AANS Neurosurgeon | Volume 28, Number 4, 2019


Point: In Defense of the Enfolded Fellowship: A Case Study

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For some, opportunity knocks upon completion of residency, but some of us can hear a faint knocking during residency. Of course, it is sometimes hard to perceive, with the sleep-deprivation-induced delirium. Was that knocking I heard, or the rattling of the chains of residency? Is there even a knocker on my door? It is starting to transform into my chair’s face. Levity aside, you should make no mistake: Opportunity knocks but once. I do not believe that post-residency fellowships are superior to enfolded fellowships, nor vice versa. I am prepared to demonstrate through my own experiences that the choice is personal and should be made upon rigorous evaluation of your situation and opportunities that may be presenting themselves.

At New Jersey Medical School, where I did my residency training, we have the option to use the PGY-5 year for an enfolded fellowship. By my PGY-4 year, I was gaining interest in movement disorders based on interactions at the neurology clinics at away rotations. We had no program in functional neurosurgery in Newark, N.J. I began to consider my options. Do I blindly commit to this subspecialty and wait for the PGY-8 year to delve into it?  What is the value of a year of your life? Could I potentially use my PGY-5 year to do a fellowship in functional? Worst case scenario: I learn a core topic in neurosurgery; best case scenario: I realize that this is for me and strategize accordingly. I explored both options and began talking to functional neurosurgeons to see what opportunities were available. 

If only the decision was simple black and white, but, alas, reality adds a splash of color and a monkey wrench or two. I found an outstanding out-of-state fellowship that was welcoming of enfolded fellows: problem solved. Shortly after I committed to this fellowship, it disappeared, as the surgeon moved to a different program. At the time I received this news, my wife was pregnant, and we had packed up our little studio apartment outside of Newark. On the bright side, at least this was happening during my PGY-4 year and not during my chief year. If things did not work out, I could try again for PGY-8 fellowship.

Things did work out, though. While at a cocktail part in New Jersey, a private practice neurosurgeon recommended I speak to Alon Y. Mogilner, MD, PhD, FAANS, at North Shore Hospital in Manhasset, N.Y. I followed that lead, and, before long, Dr. Mogilner had set up an enfolded fellowship for me. My goals were to learn about deep brain stimulation (DBS) and to publish good work. However, when I was asked if I had any interest in chronic pain, I did not realize that my life was about to change.

Time for a Change
Back at home, things were looking up. My pregnant wife was beginning to grow weary of the daily subway rides from Newark to Queens, N.Y. to teach inner-city kids. She grew up in Astoria, a neighborhood in New York, and though we had been living in New Jersey for a few years, New York was always home for both of us. “What an opportunity to buy in Astoria,” she said “After all, Manhasset isn’t too far.”  By this time, opportunity had taken the knocker off the door and was using the battering ram. I committed to the fellowship. My wife bought a house in Astoria, just as the New York housing bubble burst in 2010. Suddenly, both her parents and my parents were within walking distance. In June 2010, we had our first daughter, and in July, my enfolded fellowship began.

My PGY-5 year was the most valuable year of my residency, and Dr. Mogilner taught me, by example, how to be an excellent functional neurosurgeon. I learned DBS, published quite a bit and saved a year of training. These are some obvious benefits of the enfolded fellowship, but now we will examine the subtleties. I learned a great deal about neuromodulation therapies for chronic pain, a topic I was naïve to but grew to embrace. Ultimately, it is the discipline that would solidify my career.

Don’t Miss Out on Opportunities
My PGY-6 year was spent back in Newark where I laid the foundations for a program in neuromodulation. I met with key people who could help, built a business proposal and took it to my chair. I interviewed for a position with my home program to stay on as faculty and build neuromodulation. It was one of only a handful of jobs available for academic functional neurosurgeons that year. There were even less the following year and even less the year after. This market analysis is not something to be left for the PGY-7 year. Rather, it should be started early and should help guide your decision. Upon graduation, I stayed on as assistant professor and director of the Center for Neuromodulation. What started out as some personal questions and introspective analysis, turned out to be great opportunities I would have missed if I held out for a PGY-8 fellowship.

Where does this bring our story, now four years later? I still commute from Astoria (the market here has changed dramatically since 2010) to Newark, and as of the time of this article, we are expecting baby No. 4. New Jersey Medical School is now under the umbrella of Rutgers University, which has opened up unprecedented academic collaborations. Our fledgling functional neurosurgery program has become one of the busiest programs in the northeast. I have been blessed to work with colleagues who are leaders in their respective fields and with residents and students who are a joy to teach. 

In conclusion, I can neither say enfolded fellowships are better than post-residency fellowships nor can I say that post-residency is better than enfolded. Furthermore, there are no guidelines that can be etched in stone. Clearly, in my situation, an enfolded fellowship not only got me a job but was important in promoting balance in my family life, home life and overall well-being. I would advise that one keep an open mind, pay attention listening for that knock.

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