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Neurosurgery or Plastic surgery
Posted: 12 June 2009 02:01 PM  
Total Posts  16
Joined  2009-06-12

I’m an early 3rd year med student trying to decide what to do here. Since childhood, I’ve been set on pursuing neurosurgery, but it has recently dawned upon me that I might be more fascinated by “being a neurosurgeon” than “doing neurosurgery.” Clearly, there is a dichotomy between public and even self-perception of this job and one’s actual duties. Pros for me: I love the ideas of being an expert in one field, working with cutting edge technology, a high guaranteed salary, and admittedly “playing God” (to some extent - and this is me just being honest, not facetious). Cons to me: Limited to CNS (PNS, I’ve been told, is rarely pursued by neurosurgeons - and if pursued only at highly academic centers), surgeries limited to minimally invasive prodding of jello-like substance for hours on end, work hours, minimal international work (is that truth?)? can I handle the sickest of the sick all day every day (I don’t know, does it make you happy?)?

I’ve done plastic surgery research for 2 years now (which ironically I did not seek out, long story) and have a solid application in line. However, I have absolutely no inclination to do cosmetics work. I’ve been told by a senior plastic surgeon that neurosurgery is “just poking around in goo,” which sounds flip, but does not seem far from the truth. He said plastic surgery, on the other hand, is a great field because of good outcomes, working on every part of the body including muscle, bone, nerve, and blood vessels, capacity for international work, and ability to mold one’s career path in any way (in terms of options to sub-specialize, although this quality is not unique to plastics). He mentioned that in the academic setting, there is very little cosmetic work. Pros to me are all of the aforementioned. Cons to me: Cosmetics, public/colleague perception of plastic surgeons, regret for not pursuing neurosurgery, lack of CNS research, don’t care for many topics in plastics (intimidated by need for extensive knowledge of anatomy. Don’t care for wound healing, dealing with pressure sores, breast reconstruction, cosmetics; things that I more or less consider “menial"), some part of me wants to handle life and death situations (is that ego and self-righteousness or genuine compassion? Don’t know, probably the former)

So I guess my question is, how did you all come to a decision (not necessarily even between plastics and neurosurgery, but any other field you were considering)? Was your decision immediately apparent to you from the get-go? I have heard that it comes down to being able to tolerate bread and butter cases in whatever field you do. What is bread and butter plastics/neurosurgery? What can I do to help myself answer these questions? I’ve shadowed 2-3 cases in each field but was not particularly impressed (probably since I was just standing in the background for several hours, neither seemed to “click” but then again NOTHING has seemed to “click” for me up to this point). I definitely have the dedication to pursue whatever I decide on, but things at this stage in the game seem clear as mud. ANY insight would be appreciated.

Thanks for the thoughts!

PS I am qualified to match in either specialty, if that is something that might cause hangups.

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Posted: 12 June 2009 02:16 PM  
Total Posts  16
Joined  2009-06-12

Just for extra info, the two things that REALLY drive me to neurosurgery are Radiosurgery/stereotactic surgery and Endovascular surgery. I am absolutely in love with those fields, but I don’t know why because I haven’t seen either (I think it’s the high-tech, cutting edge aspect).

But the 12 hr craniotomies and spine surgeries (minus the $$$, obviously) seem a little mundane to me. One could argue that my faves aren’t even really surgery… Should this play any role in my decision? In other words, would one be able to deal with the long residency if he/she were not 100% engaged by “typical brain surgery”? Thanks, I know my posts are ridiculously long…

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Posted: 12 June 2009 02:55 PM  
Total Posts  161
Joined  2008-04-03
bobsagetman - 12 June 2009 02:16 PM

Just for extra info, the two things that REALLY drive me to neurosurgery are Radiosurgery/stereotactic surgery and Endovascular surgery. I am absolutely in love with those fields, but I don’t know why because I haven’t seen either (I think it’s the high-tech, cutting edge aspect).

But the 12 hr craniotomies and spine surgeries (minus the $$$, obviously) seem a little mundane to me. One could argue that my faves aren’t even really surgery… Should this play any role in my decision? In other words, would one be able to deal with the long residency if he/she were not 100% engaged by “typical brain surgery”? Thanks, I know my posts are ridiculously long…

Some advice:
- Do rotations in the fields you are interested in
- Know what bread and butter cases are for each field
- If you don’t enjoy the field’s bread and butter cases, don’t go into the specialty
- Neurosurgery is over 70% spine. Do you like spine?
- Radiosurgery is a small part of neurosurgery; if you like it check out Radiation Oncology, a very different specialty.
- Extra training is required for endovascular neurosurgery; are you willing to train for 9-10 years?
- Spine surgery reimbursment will inevitably decrease, and will not be as lucrative in the future
- Lifestyle is remarkably different between plastics and neurosurgery. How much do you want to work?
- If you are on the fence, go with plastics, not neurosurgery. Its too big a commitment to chance it.

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Posted: 12 June 2009 03:55 PM  
Total Posts  76
Joined  2008-12-11

I entered medical school thinking neurosurgery but during my 3 month MS3 surgery clerkship, I also briefly considered plastics. Disclaimer that by this time, I had spent one month on the neurosurgery service but had no experience rotating on the plastics service (all I saw was what I observed on their rounds, or if they came in to assist in certain procedures).

I figured that plastics would give a better life outside the hospital, that reconstructive seemed pretty neat, and the idea of being purposefully meticulously trained in various technical abilities seemed appealing. However, as time went by, I realized that there was nothing about the plastics cases that personally fascinated me. For me, I found that the neurosurgical patient population (tumor, CNS vascular, functional, etc.) is an intellectually stimulating field that would keep me coming back. And although I readily admit that my exposure to plastics had been extremely limited, extensive knowledge of human anatomy + wound healing + superb technical ability wasn’t enough for me personally to switch. And although neurosurgery could be condensed down to prodding goo, to my untrained eye, plastics seemed to boil down to wound care and wound vacs.

But as latin said, this is a very personal decision. Spend some time on both services. If you feel like you could be happy doing either, I’d say go for plastics—your quality of life will probably be much better! But if you feel like there’s really nothing else for you but neurosurgery, well… that one’s self-explanatory.

PS—Stereotactic radiosurgery is a very small part of neurosurgery and although its description sounds very wrapped in technology (i.e., knifeless coalescing of multiple points of radiation), what it really boils down to is computer screen mapping and pushing a button. Likewise, if you only purely like endovascular (vs. vascular all-comers), you could do that all day via a neurointerventional radiology route. Goodluck though, this is only one anonymous poster’s opinion, but hope it helps.

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Posted: 12 June 2009 04:52 PM  
Total Posts  16
Joined  2009-06-12

Thank you both for the great advice...I will definitely attempt to schedule some Sub-Is to gain more hands-on exposure!

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Posted: 12 June 2009 05:57 PM  
Total Posts  14
Joined  2008-10-08

I came to medical school wanting to be a neurosurgeon.  My first experience with a neurosurgical patient was as a young child and I was driven to be able to intervene at the worst of times in my patients’ lives.  Now matched, I am glad I stuck with neurosurgery--even though I seriously considered other specialties in medical school.

A few thoughts . . . first, neurosurgery requires more knowledge of detailed anatomy than almost any other field.  If plastics scares you in this regard, neurosurgery should completely freak you out.  Secondly, neurosurgery owned spine, peripheral nerve and neuro-vascular surgery.  These fields were given up to other specialties because neurosurgeons wanted to do sophistocated, sexy tumor and skull-based surgery.  However, neurosurgeons have realized that their expertise benefits patients requiring these types of procedures, and it is adventageous for neurosurgeons to be involved in advancing the treatment of these disorders. 

So neurosurgeons are taking back these fields, and really not having a problem doing so.  While, as you point out, radiosurgery and endovascular procedures are not “surgery” in a classic sense, to a neurosurgeon they are tools to round out a armamentarium for treating neurological disease.  Neurosurgeons have the advantage of going into consults without bias because they can do open or minimally invasive procedures.  This, when it comes to doing right by the patient, is critical and fun.  Therefore, as a neurosurgeon, the doors are open as wide as you want them to be. 

Plastics is completely different.  If you like technology, pushing boundaries and being up against the wall neurosurgery wins out, no contest.  If you want something more controlled, more artistic and more predictable go with plastics.  As a medical student, you rarely get a great feel for what it is like to “be a neurosurgeon” or to “be a plastic surgeon.” Try to do as much as you can, but also look at the type of people you encounter while trying out these fields.  Which group of people are you more like? Ultimately, not only will this give you a clue as to which field you might like best, but it will also show you what type of people you will team up with to tackle and advance the field you eventually choose. 

Good luck.

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Posted: 13 June 2009 05:16 PM  
Total Posts  6
Joined  2009-04-19

My first response upon reading your post was to be amazed by how incredibly cocky you sound.  Now on to a bit more constructive of a response.  To be completely honest, I don’t think any of your reasons for potentially pursuing neurosurgery sound like very good ones.  There are many fields of medicine where you could be an expert in one thing.  There are far easier ways to make a high salary both inside and outside of medicine.  Multiple fields have cutting edge technology.  And as for the “playing God” aspect - While there are definitely some neurosurgeons who think they are “God,” it’s actually a really humbling field in many ways - there are many patients who despite everyone’s best efforts just can’t be saved and mistakes (which lets face it, everyone is human) can have devastating consequences. 

I think if you talk to most neurosugeons that enjoy their career, they find the brain/nervous system fascinating, enjoy dealing with really sick patients and potentially having a huge impact on their lives, and love operating.  You have to love this field to have any hope of getting through the challenges of training.  It doesn’t really sound like you like the brain or find the field very interesting.  If you do neurosurgery just because you think it sounds cool and you could one day make a good living, I think you’ll be miserable.  It doesn’t sound like you are really that interested in plastics either, and it’s a bit hard to love a field (you mentioned radiosurgery and endovascular) without having even seen them. 

My advice to you would be to try to keep an open mind as you go through the rest of your third year.  It sounds like you’ve sort of focused in on somewhat flashy fields.  You may end up actually liking something totally different if you keep an open mind.  I agree with the advice above about seeing what bread and butter you like and also seeing what personality types are in different fields to see where you would fit.  It is sometimes hard to get a good sense of surgical fields if you aren’t able to really be involved in the case much as a student; however, if you repeatedly shadow the same attending or resident, they may gradually allow you to be more involved.  it sounds like you’ve found a mentor in plastics, so you may want to go to the OR with him or her.  I’d also suggest talking to as many people in the fields you are considering as possible.  Talk to both residents and attendings since they may have different viewpoints.  Find out what drives them and whether you share these interests or not.  Ask why they chose the field they are in - what do they like about it; what don’t they like.

I think there is some great advice in the posts above as well and I definitely have to second what harley-davidson said about being drawn to the field in part because of the ability to intervene at the worst times.  I think this really is a critical point.  Neurosurgery patients are often incredibly sick and while there are some incredible saves there are also many patients who don’t do well.  For some, the saves carry them through; for others, it’s not enough.  In addition to the bread and butter cases advice it’s important to consider the types of patients that will be the best fit for you. 

Lastly, enjoy your third year and the opportunity to see lots of different fields so you can find the right match for you.

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Posted: 13 June 2009 06:44 PM  
Total Posts  16
Joined  2009-06-12

Didn’t mean to sound cocky, sorry if it came off that way. Anyways, I loved my second year neuropath and neuroanatomy, and I was a neuroscience major in undergrad. I didn’t fall in love with neurosurgery just because of the “flash,” I’ve done a lot of reading over the course of years. A big part of my draw to neurosurgery is helping people in the worst of worse conditions, I only question whether this would wear down on me as the years progressed.

And plastic surgery, as I alluded to before, wasn’t even on my radar I picked up this research job. The more I read about it the cooler it sounded. You’re right though, an open mind throughout this year and more exposure might clear some of the issues up.

I posted my questions and concerns in the first place because I know it is incredibly difficult to match into a respectable neurosurgery or plastics program. I think it’s a little crazy to be thinking about this stuff at this point, but I know I need to start planning now to be a competitive applicant.

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Posted: 13 June 2009 08:33 PM  
Total Posts  20
Joined  2009-05-24
bobsagetman - 13 June 2009 06:44 PM

Didn’t mean to sound cocky, sorry if it came off that way. Anyways, I loved my second year neuropath and neuroanatomy, and I was a neuroscience major in undergrad. I didn’t fall in love with neurosurgery just because of the “flash,” I’ve done a lot of reading over the course of years. A big part of my draw to neurosurgery is helping people in the worst of worse conditions, I only question whether this would wear down on me as the years progressed.

And plastic surgery, as I alluded to before, wasn’t even on my radar I picked up this research job. The more I read about it the cooler it sounded. You’re right though, an open mind throughout this year and more exposure might clear some of the issues up.

I posted my questions and concerns in the first place because I know it is incredibly difficult to match into a respectable neurosurgery or plastics program. I think it’s a little crazy to be thinking about this stuff at this point, but I know I need to start planning now to be a competitive applicant.

Don’t apologize for something you did not do, and for something you should not apologize for. You better be cocky if you want to complete a 7 year residency program with your best ability.  smile

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Posted: 14 June 2009 07:10 AM  
Total Posts  22
Joined  2009-05-07

if one isn’t a masochistic workoholic psycho, one better not take up NS.

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Posted: 14 June 2009 08:36 AM  
Total Posts  6
Joined  2009-04-19

That’s great to hear that you enjoyed neuroanatomy and neuroscience and like the idea of working with really sick patients.  Neurosurgery may be the right field.  In terms of advice, my usual advice is to try to shadow people since this gives a much better sense of what the field entails than reading about it ever can.  That being said, it’s pretty difficult to fit shadowing into your schedule as a third year since you really need to focus on whatever rotation you are on.  As a third year though one great thing is that you have exposure to a ton of people in a broad range of fields.  My guess is that as you get closer to the end of third year after having rotated through plastics, neurosurgery, and a whole bunch of other fields things will become clear - you will see that you really don’t fit in certain areas and do fit in others and will be able to pick out the common threads in things you like. 

The three things that I think are most important to pay attention to are: what are the cases/medical problems like in this field? what is the patient population like in this field? and what are the types of clinicians in this field like?  The key is to find the field where all 3 fit you, and you usually can find a field where they do since often similar people tend to like similar things and be drawn to similar types of patients - ie some people like to know a little about a lot, some people like you expressed and like most neurosurgeons like to know a lot about a very specific area; some people like dealing with reasonably healthy patients, some people like dealing with really sick ones. 

While you are going through this, I would definitely take the opportunity to talk to as many people as possible.  If you happen to be on a lighter rotation and can squeeze in going to a conference or two in neurosurgery, that may also give you a better sense of the field.  Just having some idea of what areas you may be interested in, puts you ahead of many third years.  In terms of other fields to think about if you like neuroscience - neurology, radiation oncology, interventional radiology, and opthalmology are all fields that you may also want to consider.  You will notice though that these fields all have very different types of people, patient populations, and lifestyles, and only you can figure out which one will be the best fit. 

Also, if you have the opportunity to do electives, this will help you check out different fields.  Some schools will let you do two week electives or take a month off where you could independently set up a few different shadowing experiences.  You may want to talk to your registrar about what options you have for taking time away from the standard rotations to check out things you think you may like.  Ultimately, you will also do sub-I’s which really help you know whether the field is a good fit.  It’s great that you are thinking about things early, but don’t worry if you don’t have it sorted out until a bit later.  I’m sure it will become clear what the right path is for you.

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Posted: 07 July 2009 08:02 AM  
Total Posts  22
Joined  2007-10-19

That last line says it all...It’s just too big a commitment to chance it. Sigh....

latin - 12 June 2009 02:55 PM

bobsagetman - 12 June 2009 02:16 PM
Just for extra info, the two things that REALLY drive me to neurosurgery are Radiosurgery/stereotactic surgery and Endovascular surgery. I am absolutely in love with those fields, but I don’t know why because I haven’t seen either (I think it’s the high-tech, cutting edge aspect).

But the 12 hr craniotomies and spine surgeries (minus the $$$, obviously) seem a little mundane to me. One could argue that my faves aren’t even really surgery… Should this play any role in my decision? In other words, would one be able to deal with the long residency if he/she were not 100% engaged by “typical brain surgery”? Thanks, I know my posts are ridiculously long…

Some advice:
- Do rotations in the fields you are interested in
- Know what bread and butter cases are for each field
- If you don’t enjoy the field’s bread and butter cases, don’t go into the specialty
- Neurosurgery is over 70% spine. Do you like spine?
- Radiosurgery is a small part of neurosurgery; if you like it check out Radiation Oncology, a very different specialty.
- Extra training is required for endovascular neurosurgery; are you willing to train for 9-10 years?
- Spine surgery reimbursment will inevitably decrease, and will not be as lucrative in the future
- Lifestyle is remarkably different between plastics and neurosurgery. How much do you want to work?
- If you are on the fence, go with plastics, not neurosurgery. Its too big a commitment to chance it.

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Posted: 08 July 2009 02:05 PM  
Total Posts  115
Joined  2007-06-07

I think the only way you will find out the types of things that have been very aptly described in the aforementioned posts (regarding specialty suitability) will be to do a subI in both neurosurg and plastics.

Though I spent time shadowing and reading about the field (neurosurgery) in all my spare moments for the first three years of medical school, I only realized after my subI just how little I really knew, and that the one month of q2 call and working like an animal taught me more about being a neurosurgeon than anything I could have done over those three years.

good luck.

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Posted: 25 January 2012 12:40 PM  
Total Posts  8
Joined  2010-10-09

I’m a M4 hoping to match into neurosurgery this year. I initially got interested in medicine because I wanted to work overseas; when I became interested in neurosurgery, I started looking into whether international work is possible. As a field, neurosurgery has been active in international work at least since 1969 with the start of the Foundation for International Education in Neurological Surgery (FIENS).  However, over the past decade, I think there’s been an increase in the number of neurosurgeons working overseas; as evidence of this, FIENS started a journal in 2010 called “World Neurosurgery,” described as “the specialty’s first publication acting as a global forum for not only high level peer reviewed, clinical and laboratory science, but also the social, political, economic, cultural and educational issues that affect research and care delivery regionally and from a global perspective.”

East Africa in particular has had a lot of activity lately and is the area that I’m most familiar with. There are at least four different neurosurgeons working on projects there: Dr. Benjamin Warf, Dr. Michael Haglund, Dr. Dilan Ellegala, and Dr. Leland Albright.  Dr. Warf spent around 5 years in Uganda founding CURE International’s Pediatric Neurosurgery Hospital. He has a great series of articles in the Journal of Neurosurgery that mostly focus on his prospective series of ETVs for hydrocephalus. Currently, Dr. Warf is on faculty at Brigham, but is still involved in the research portion of CURE. The hospital itself is very active and is staffed completely by Africans.  I spent September of last year there and it was a fantastic experience.

Dr. Michael Haglund at Duke is currently working in the capital cities of Uganda (Kampala) and Rawanda (Kigali) to train neurosurgeons and build the capacity of the hospitals to treat neurosurgical patients. He has an insightful article recently published in World Neurosurgery that talks about the concept of “twining” hospitals in developed nations with hospitals in developing countries to supply training and usable surplus.

Dr. Dilan Ellegala founded PTP Africa, an organization that started in Tanzania and is trying to build neurosurgical capacity in that country. Dr. Leland Albright is working at the Kijabe Medical Center in Kenya where he does a lot of pediatric neurosurgery cases.

In addition, a few neurosurgery programs even have built-in international experience. Residents at Duke can spend at least one month in either Uganda or Rawanda. Residents at Michigan have been participating in a yearly trip to Guatemala since 1996. Though I do not know the actual involvement, the residences at MUSC, Barrow Neurological Institute, Cornell, Harvard’s Brigham and Women’s Hospital, and the University of Colorado have a connection with PTP Africa.

All this is to say that in my opinion there are plenty of opportunities to work in neurosurgery internationally, especially with regard to pediatric neurosurgery and trauma. I do think that it’s probably not as easy as popping into a country and doing a lot of cleft lip and palates and then heading back home. But in the end, the point is there is precedence in the field and if you want to make it part of your practice, residency, or even medical school experience, it’ll just take some extra effort.

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