AANS Neurosurgeon | Volume 29, Number 2, 2020


Neurosurgery Response to Resident Application Challenges During the 2020-2021 Cycle

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The residency application cycle has changed dramatically in response to the COVID-19 pandemic. Neurosurgery has prioritized safety, education and equity during the development of our specialty’s national response and planning. External sub-internship rotations, or Acting-Internships (AIs), the interview process and ERAS and Match dates have all been affected. There are significant implications for applicants as well as for programs. What follows are the recommendations made by national medical leadership bodies as well as policies specifically developed by organized neurosurgery to help navigate this extraordinary time.

The Coalition for Physician Accountability (CPA), representing all major national stakeholders in medical education and training, including the AACOM, AAMC, ACCME, ACGME, AMA, AOGME, AOA, CMSS, ECFMG, FSMB, LCME, NBME and NBOME, has developed four national guidelines for the 2020-2021 residency application cycle in all specialties. Although this guidance does not supersede requirements imposed locally by medical schools, sponsoring institutions, and residency programs, it has been widely adopted by most institutions and programs. Of highest importance is ensuring that core competencies are met by all students and that the residency selection process remains as equitable and transparent as possible for applicants and training programs. The CPA recommendations 1) discourage away rotations (with rare exceptions), 2) encourage online interviews in all cases, 3) commit to delayed opening of the ERAS application platform (with likely delays in the National Residency Match Program), and 4) plan transparent communication around all forthcoming changes. The full recommendations can be viewed at https://mk0nrmp3oyqui6wqfm.kinstacdn.com/wp-content/uploads/2020/05/2020.05.06-Final-Recommendations_Final.pdf.

In parallel with these recommendations, the SNS Medical Student Committee has developed a policy for the current neurosurgery residency application cycle. That policy was distributed for comment to all U.S. residency programs, approved by the SNS Executive Council and individually endorsed by leadership representatives to the One Neurosurgery Summit from the following organizations: the SNS, AANS, CNS, ABNS, RRC for Neurological Surgery, American Academy of Neurological Surgery and the AANS/CNS Washington Committee.

SNS Policy on Away Rotations for Medical Students

External rotations for medical students are integral to the application process for:

1. The student to experience the specialty of neurosurgery in its depth and breadth prior to committing to a specialty.

2. Education in preparation for internship.

3. Letters of recommendation to assist programs in the evaluation of medical student applicants. 

External rotations require travel, which increases potential spread of disease. Additionally, given differing levels of disease impact in different regions, many institutions are not allowing medical students to rotate in or out during the months of May-September, when external rotations would usually occur. This disadvantages many students and programs who would not be able to participate in these external rotations. In order to minimize disease spread and financial burden and to ensure the most equitable experience for all students and all programs during this pandemic, the following recommendations have been issued by the leadership of the specialty of neurological surgery:

1. All external medical student rotations in neurological surgery will be deferred in 2020.

2. Given the importance of the applicant experience in neurological surgery prior to committing to a career path, each student should have at least eight weeks (two rotations) of neurological surgery experience at their home institution.

a. For students without a home program, they should have eight weeks (two rotations) of neurological surgery experience at the closest ACGME accredited program, in order to minimize travel and keep within regional disease demographics.

3. Letters of recommendation should come from the student’s home institution, including at least two from neurosurgical faculty members and one from a general surgery faculty member (i.e. a program director, clerkship director or surgical faculty mentor).

a. Letter templates will be provided on the SNS website under the medical student section.

b. Letters of recommendation from external rotations will be looked upon unfavorably (with the exception of those students without a home program, see 2a).

  1. FAQs

There is no perfect policy for every circumstance, such that both applicants and programs must approach this with an appropriate degree of flexibility, while respecting the core principles of the recommendations and their underlying rationale. For example:

  • At medical schools that have shortened rotations to three weeks, a student could supplement two neurosurgery rotations with a neuroscience ICU or interventional neuroradiology elective rotation.
  • For both safety and equity, we ask students with multiple hospitals affiliated with their medical school to complete both neurosurgery rotations at a single affiliate.
  • Some residency programs have begun to offer remote academic experiences (RAEs), which include opportunities to attend conferences remotely, meet faculty and residents, and participate in clinical research. While valuable to both programs and to applicants, these RAEs should not be considered equivalent to hands-on patient care sub-internships. ERAS application letters should come only from in-person sub-internships.
  • Input from a general surgery clerkship leader, mentor or other rotation faculty member provides an external source of evaluation that is consistent across applicants and relevant to the basic surgical skills, work ethic and professionalism necessary for neurosurgical training.
  • To improve the quality and consistency of applicant evaluations, faculty recommenders should use templated forms. Neurosurgery-specific forms are under development and will be available on the SNS website soon.

The neurosurgery policy, answers to these and other FAQs and general objectives for neurological surgery sub-internship rotations are all available on the SNS website https://www.societyns.org/medical-students/external-medical-student-rotations, and will continue to be updated as the situation unfolds. Neurosurgery’s policy is posted on the AAMC website.

Interview Season

The SNS Medical Student Committee and other stakeholders continue to actively monitor developments and discuss a policy regarding the 2020-2021 neurosurgery match season interview process. We recognize, however, that external developments, local conditions and the decisions of CPA members and other national stakeholders are likely to make any specialty-specific policy a fait accompli. At this point in time, we strongly encourage all programs to prepare for the eventuality of an entirely remote interview process. To preserve equity, local candidates should also complete interviews virtually, following the same process as candidates from other medical schools and geographic locations. It is therefore vitally important to develop ways now to showcase your program online, possibly including:

  • Virtual tours of clinical, research and academic learning environments.
  • Updated websites with granular information such as resident publications, awards and other accomplishments.
  • Taped resident and faculty interviews.
  • Virtual attendance at departmental didactic conferences and teaching sessions (with attention to institutional HIPAA guidelines).
  • Research and writing experiences.
  • Resident mentoring of applicants.
  • Virtual gatherings of applicants and residents to help transmit program culture, expectations and training methods.
  • Effective interview forums for applicants with current residents, advanced practice providers, faculty and affiliate faculty.

Working Together to Sustain a Strong Future

The SNS has worked diligently to make all neurosurgical policies and recommendations actionable and specialty specific, given the distinct nature of neurosurgical training. To do so, we have depended on the collective wisdom of neurosurgery program leadership around the country in order to enhance the application process despite the unique challenges posed by the COVID-19 pandemic. We anticipate that the present challenges will drive innovation and even closer collaboration between programs across the nation that will outlast the present challenges and better serve our specialty and, ultimately, our patients.

During the pandemic, the SNS remains committed to and focused on its core mission of supporting the educational and governance functions of U.S. academic neurosurgery departments and ACGME-accredited programs. We recognize that the success of our specialty will depend for decades to come on the quality and accomplishments of the residents we recruit and begin to train during this pandemic.


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