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AANS Neurosurgeon | Volume 26, Number 4, 2017



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The email arrives Monday morning of Match week; the news is not good. In fact, it is a gut punch, a catastrophe, an embarrassment – you did not secure a neurosurgery residency position. You have prepared, studied, taken test after test, traveled for sub-internships and spent a large amount of time and money traveling to interviews. You have answered the same questions over and over, gotten a haircut, picked out a professional outfit and put your best foot forward. After all this effort, perhaps for the first time in your life, you have failed spectacularly and publicly. Do not panic.

The odds of obtaining a neurosurgery residency position through the National Residency Matching Program® (NRMP® or The Match®) is high for graduating seniors from U.S. allopathic medical schools (greater than 90 percent), and has been for many years. This likely reflects the motivation, active mentor relationships and realistic expectations of most aspiring neurosurgeons. For graduates of U.S. osteopathic and foreign medical schools, the odds are more challenging; in the 2018 Match®, and ten successfully applied from each group respectively. Collectively, 15 percent of applicants who are not current seniors from U.S. allopathic medical schools obtained a position through The Match®.

Now is a time for re-evaluation. First, is neurosurgery a realistic goal? If so, there are options and roads to success. Admittedly, these roads may have a daunting upward inclination.

The NRMP® system for matching unfilled residency positions, called the Supplemental Offer Acceptance Program® (SOAP®), operates during Match Week (watch an informative video here). Although there are often few or no unfilled neurosurgery residency positions, some years there are positions available. Let’s walk through the steps:

  • Monday of Match Week, notifications of failure to match are sent (11 a.m.).
  • Later that day, through the Electronic Residency Application Service (ERAS®), unmatched applicants are able to direct their applications to residency programs with available positions (2 p.m.). Applicants do not submit a rank list.
  • One hour later, programs are able to view the applications.
  • Offer rounds begin the following Wednesday at noon.

Offers may be made only through the Registration, Ranking and Results (R3®) system. The process is repeated at 3:00 p.m. and again at 9:00 a.m. the following day. The SOAP® has strict prohibitions against programs contacting applicants outside of the R3® system.

If completion of both The Match® and SOAP® routes to neurosurgery residency fail, the next option bifurcates into clinical and research paths. Clinical options include training in an alternative specialty or in a non-ACGME accredited pre-residency fellowship. Research opportunities are widely available, but the area of focus, mentors and goals should be carefully considered and have direct applicability to the clinical neurosciences. 

The pursuit of an ACGME accredited residency position has many advantages. This approach potentially keeps the applicant on the desired timeline for training. By beginning PGY1, at least some of the required rotations for neurosurgery can be fulfilled during a preliminary general surgery position or a formal transitional year – they may provide the best fit. For example, after the SOAP® process concluded for general surgery in 2018, 44 preliminary residency positions remained unfilled and would be available to follow this pathway.

Neurosurgery residency has a significant attrition rate, as do most other challenging residencies. Attrition rates are highest during the first two years of residency. After initial exposure to the time demands of surgical training, psychological challenges and other considerations, some promising individuals simply conclude that a life and career in neurosurgery is not for them. By initiating clinical training, a candidate who is clinically active in a GME program may be ready to fill a newly vacant PGY2 position and hit the ground running.

These alternative PGY1 positions also serve as a prolonged audition. Performance at a high level, the demonstration of reliability, conscientiousness, professionalism and dedication to clinical care will enhance the applicants appeal to programs seeking to fill vacancies. They also provide an opportunity for meaningful letters of recommendation.

Navigating this difficult pathway requires help – now is the time to seek assistance and advice from faculty mentors and neurosurgery residents, along with psychological and emotional support from friends and family. Not every successful practicing neurosurgeon’s path to – and through – residency training was a straight line, free of obstacles and challenges. We “do” neurosurgery, not because it is easy or even because it is difficult. We do it because our patients and their families need their neurosurgeons to be resilient – sometimes that resilience needs to be demonstrated at the earliest career stages.


The Match® National Residency Matching Program® Results and Data 2018 Main Residency Match®

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