AANS Neurosurgeon | Volume 27, Number 4, 2018


Training the Next Generation: Initiating the Process for Starting a Residency

Many hospitals and neurosurgery programs have set their sights on taking the leap into training the next generation of neurosurgeons. Where one is in this process, experience Graduate Medical Education (GME) processes as well as institutional history will influence the journey and chance of success. Having recently traveled this road, we present key concepts that could help others.

The first step in the process of applying for a neurosurgery residency is meeting with institution administration and ACGME Designated Institutional Official (DIO) to gauge the institutional level of commitment. There should be a program and institution-wide understanding that the motivation for starting a residency is to contribute to the future of the profession, not to improve manpower or finances. An appropriately executed residency program will require significant upfront time and financial resources. It is important that the institution makes a written commitment to providing the financial resources and clinician time necessary.

The institution’s DIO is vital to the application process, not only because she or he will submit the final application, but also because they will serve as a resource concerning the GME environment and community within the institution. The basic requirements of a neurosurgery residency are available online. This document is a basic overview of the requirements, but it does not give a full picture of the complexity involved in completing the actual application for a residency. The GME community at the institution is very important to the process. Neurosurgery residencies have relatively few residents, typically starting with one per year. There are many resident training requirements beyond clinical care. An active and collaborative GME community can facilitate the achievement of these requirements through shared conferences and educational experiences, especially when the neurosurgery residency is small and still growing. 

Fundamental Clinical Experience

A fundamental requirement for training neurosurgery residents is the clinical experience. This does not simply mean a high volume of surgical cases and patient encounters, but also comprehensive experience in neurosurgery that includes all subspecialty areas. Demonstration of required case numbers for all procedure types is a good starting point. Fellowship-trained neurosurgery faculty in all subspecialty areas will help with the application as well. But clinical volume and breadth is only the starting point in developing the neurosurgery residency application.

The ACGME addresses the need for other residencies at the institution. A core requirement is that “ACGME-accredited programs in anesthesiology, diagnostic radiology, internal medicine, neurology, pediatrics and surgery, should be available at either the primary clinical site or a participating site.”(1) The requirement reads “should,” not “must,” but the greater the number of these residencies at the primary institution, the stronger the neurosurgery residency application will be. Collaboration with another site under a program letter of agreement (PLA) is a way to mitigate for occasional deficiencies in an area. 

Teaching and Conferences are a Priority

Many of the requirements for the residency application, the application review process and subsequent residency reviews will focus on conference and research participation by both the residents and the faculty. Detailed plans on how these components of the residency are guaranteed should be included in the application. Compared to patient care, which is the lifeblood of practice and is unlikely to disappear, conferences and research often fall victim to the demands of clinical responsibilities. Because of this concern, information from the institution that supports the robustness of conferences and research should be included in the application.  At a minimum, a detailed plan of all conferences should be submitted, including who will lead them (faculty preferred, an application that relies too heavily on residents will suggest a lack of faculty commitment) as well as when and where they will take place and a detailed plan for research mentoring with similar specifics of people, place and time. It is also good to have a written commitment from the institution to provide financial and time resources for conferences and research. The best approach is to have these programs already funded, in place and operating successfully. An institution that can show faculty regularly attend a comprehensive conference schedule and are actively involved in productive research with PubMed ID published articles will have a much better chance for a successful application. 

A record of accomplishment in resident education also helps demonstrate that resident education will take precedence over service. Positive experience with rotating residents from other programs and demonstration that the service is adequately resourced with advanced practice providers (APPs) will go a long way in this regard. Fellows may work against the program application as they represent additional learners with a competitive advantage over residents for clinical experience. 

Be Ready Already

The most important part of starting the neurosurgery residency application process is establishing as much of the program as possible before the application is submitted. If the neurosurgery department is already completing the requirements for a strong residency program, communicating this clearly through the residency application will lead to the best chance for success.



Accreditation Council for Graduate Medical Education (ACGME). (2017). Common Program Requirements Frequently Asked Questions. 

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