AANS Neurosurgeon | Volume 29, Number 2, 2020

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This Crisis is an Opportunity

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Academic medicine faces extraordinary times. A global pandemic has shaken many of our strongest institutions, invoking fear of both illness and economic devastation within our communities. While this new threat temporarily captured the full attention of the world, the “preexisting conditions” of our culture: inequality, racism, mistrust in science and political polarization, quickly impacted our ability to respond to the pandemic and complicated the lives of physicians even further. The most vulnerable of our ranks – future neurosurgeons and those in training – bear a disproportionate share of this burden. Perhaps it is surprising, then, to imagine that the effect of COVID-19 on the Neurosurgery match has the potential to be a very positive one.

The goal of the match is to maintain the neurosurgical work force by placing well-qualified students in appropriate training programs with minimal attrition. In theory, the match serves two populations: programs, and the students who hope to join them.  In reality, neither group has been particularly well-served in recent times. Program directors (PDs) are now accustomed to rapidly sorting through hundreds of applications with very few objective academic yardsticks. Research productivity is commonly considered an important measure of preparation, but misrepresentation can occur and productivity may reflect not just hard work but luck, the opportunities within a given school, and the student’s own financial flexibility.  These challenges often force us to resort to recommendations to form the basis of our assessment of a student’s suitability for a career in neurosurgery. This of course dramatically biases the process, favoring students who are fortunate enough to have well-connected and vocal mentors, and further marginalizing students who by chance or lack of opportunity may be unable to build those relationships.

If this situation is difficult for PDs, our struggles pale in comparison to those of medical student applicants. Seeking to stand out in a cluttered field of candidates, they routinely spend tens of thousands of dollars on the interview trail. They may vacate their other educational goals to pursue month after month of visiting sub-internships, a process particularly challenging for students lacking substantial familial and financial support. In most cases the entire 4th year, and often much of the 3rd, are devoted strategically to matching in neurosurgery. The educational, financial, and psychological costs of this system are high. This process is outdated and has failed to evolve despite technological advances, revolutions in hiring practices in other industries, and our own recognition of the heavy weight of implicit bias in our culture. In other words, the neurosurgery match is ripe for disruption, and COVID-19 could be the catalyst.

Neurosurgeons are innovators, and this global crisis has stoked innovation in our community. The Medical Student Education Committee of the Society of Neurological Surgeons, led by Dr. Stacey Q. Wolfe, MD, recognized the need for a centralized response to this crisis.  They have taken the unprecedented step, with the support of all organized neurosurgery leaders, to create a specialty-specific structure for this match which programs and applicants can trust.  Their guidelines are unlikely to perfectly suit any individual, but taken as a whole they are as equitable as possible. They balance the need for students to have a robust experience in neurosurgery within the logistical constraints of travel and credentialing. The introduction of templates for letters of recommendation has the potential to dramatically reduce the bias in that portion of the application, and will likely become a fixture of our process in years to come. Neurosurgeons may chafe at the idea of a one-size-fits-all approach, but our commitments to our students and our colleagues demand that we approach the unique 2021 match with the same team-based spirit we use when we approach a complex surgical problem. Unified processes amongst programs will be critical to helping our students navigate the match successfully.

Innovation is happening on smaller scales as well. Groups of residents have worked together to host informal “meet and greet” sessions with applicants where they can talk about the characteristics of their program. Medical student boot camps have gone online, which has allowed them to draw faculty from around the country and reduced the financial barriers to participation. Students are offered new opportunities, like a half day “virtual sub-I” or the chance to participate regularly in Zoom journal clubs. Why have we never done these things before? We didn’t have to. Not all of these new ideas will persist, but some will become intrinsic to the fabric of the neurosurgery match in the next decade, and we will be thankful that we were pushed to develop these concepts.

We know that the 2021 match will be very unusual. The unanswered question is: how will we approach the 2025 match?  Will we use virtual interview techniques to reduce the cost of travel for applicants?  Will we enforce the use of recommendation templates nationally to reduce implicit bias?  Will we, as a specialty, recognize the importance of non-neurosurgical clinical rotations and put an end to the arms race of sub-Is? What about this year, which takes us back to the essence of what matters, will inform our future practices to ensure that we promote accessibility, equity, and excellence when we someday interview those students just starting their medical educational journey this fall? 

We have before us an unprecedented opportunity to study, learn, and reform. For educator/scientists, this is a thrilling opportunity to disrupt an outdated process and build something better. Our responsibility is to ensure that we do so in a way that is student-centric to protect the most vulnerable among us. That notion is familiar to us as physicians in this pandemic and it seems certain that we can approach this disruption to our educational process with the same integrity, bravery and leadership neurosurgeons have demonstrated in hospitals around the world this year.

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