An Academic Neurosurgeon Discusses What His Job is Like

Session 20

Dr. Stephen Grupke is an attending Neurosurgeon at the University of Kentucky. In our episode today, he discusses the residency path to neurosurgery, what makes you a competitive applicant, his typical day, the types of patients and cases he serves, what he likes best and least about his subspecialty, and more.

Stephen and I went to New York Medical College together. Currently, he is a neurosurgeon in an academic facility, being an assistant professor at the University of Kentucky.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:30] Choosing Neurosurgery

Stephen knew he wanted to be a neurosurgeon when he was in graduate school. Being a chem major in undergrad, he was working in a lab in grad school. A neurosurgery resident at New York Medical College was doing research and took Stephen under his wing. He was doing experiments and showing him different amazing stuff. Stephen was just taken by it right there. That was actually the first time he saw what it’s like to be a neurosurgeon. That was what sold him to be a doctor.

[04:33] Traits that Lead to Being a Good Neurosurgeon

Stamina is a major key in being a good neurosurgeon. Taking out a brain tumor can take hours and hours, and that can be very physically and mentally taxing. You can have long clinic hours with a lot of patients with varied problems, so you have to think every one of them through, giving a genuine, concerted effort to every single person.

The longest case Stephen has been in was a brain tumor case as a resident—it went fourteen hours. He’s also been a part of spine operations that ended up being broken up in a couple of days, such as a long, complex scoliosis case.

Emotional Ups and Downs in Neurosurgery

Emotionally, the level of acuity in what neurosurgeons see is profound, having several highs and lows in one day. You could see pretty horrible things like abused children coming in with brain traumas and people being diagnosed with brain tumors. Then you have to relay this information to the family.

On the same day, you could bring somebody back from the brink of death or give somebody function back with a simple spine surgery that enables them to live without pain. In short, there are a lot of emotional highs and lows. You just have to focus on the highs and move on to the next thing, doing the best you can for every person that comes to your door.

There are a lot of emotional highs and lows, and to just deal with that day in and day out is kind of tough.Click To Tweet

Other Specialties Besides Neurosurgery That He Considered

Besides neurosurgery, the other main specialty that crept into his mind was neurology, being cerebral and focused on the central nervous system. He likes having to work through esoteric pathology. Internal medicine was another specialty of interest for Stephen, as it shares a lot of things with neurosurgery in terms of the complexity and diversity of cases you see. There’s a lot of detective work involved.

One of the things that led Stephen to neurosurgery is how connected it is with other specialties such as endocrinology for pituitary tumors or traumatic brain injury cases. You have to be adept at critical care management, as well as fluid and electrolyte maintenance. There is so much intermingling with other specialties since the brain is ultimately involved in every other system of the body.

[10:10] Types of Patients Seen in Academic Neurosurgery

As a neurosurgeon, Stephen sees all sorts of pathology. In his practice, he tries to focus on cerebral and vascular neurosurgery like aneurysms, arteriovenous malformations, etc. But when you’re on call, you have to be willing to take whatever is thrown at you and treat everybody from premature babies all the way up to the very elderly and all different socioeconomic classes.

You end up treating all kinds of pathology, taking out a tumor in a peripheral nerve, spine surgeries, open surgeries, and endovascular surgery. The variety keeps things interesting.

Typical Day for an Academic Neurosurgeon

Stephen’s typical day is getting into the office at 6 in the morning to give him breathing room to go over some of the labs and images of the patients from the day before.

He spends one day in clinic each week from 8am to 5pm, which consists of seeing new patients and operative followups. A couple of days per week are spent in the operating room treating patients.

Another couple of days per week would be spent in the endovascular suite doing things like diagnostic cerebral angiograms, treating aneurysm cases, angioplasty and stenting to treat coronary stenosis, or treating arteriovenous malformations with glue embolization.

As a resident, Stephen did several hundred cases as part of an enriched curriculum that focuses on endovascular treatment of cerebrovascular disease. Now, he’s doing another year under the tutelage of a group of physicians at the University of Kentucky who also serve as his mentors, so he can get a certification in cerebrovascular intervention. So Stephen does this for two days a week.

Turf Wars Between Neurosurgery and Other Specialties

Some specialties like interventional radiology and neurology are also doing these fellowships to become adept at this intervention. Stephen doesn’t really see any turf war going on in his institution. One of his mentors is an interventional radiologist and is grooming him to be a partner in his practice.

In general, however, Stephen is seeing a little bit of turf war across industries that are trying to get in on it. Moreover, there is a move for interventional surgery to standardize fellowships to make sure that everybody coming out of these other specialties are providing an essentially comparable product.

[15:15] Taking Call and Procedures

As far as interventional call, Stephen takes one-third of the call, which they do a week at a time. This is much less rigorous than primary neurosurgery call. Procedures they get called in for include endovascular treatment for aneurysm or stroke. Being a comprehensive stroke center, they’ve always got somebody on call to do thrombectomies for stroke. They don’t get calls every night by any stretch, and it is totally manageable and doable.

Considering he spends one day a week at the clinic, only a small percentage of those patients are being brought to the operating room. Some people are queued up to come in who have been sent to him from pain clinics and anesthesiologists to have interventional pain procedures done. These are people who have already been worked up and already know they’re getting surgery.

Primary care doctors refer many patients to him for back pain, but only one-tenth of them or less is worth taking to the operating room. In general, 20% of the people he sees in clinic end up getting into surgery, and the rest involve counseling in terms of pathology and management.

[18:56] Work-Life Balance: What Kind of Lifestyle Do You Have as a Neurosurgeon?

Stephen doesn’t think any neurosurgeon has work-life balance. Neurosurgeons have a workaholic stereotype, and he sees it as true to some extent. Stephen has a nasty habit of bringing work home with him.

He has three small children, and he’s happy he gets to spend a lot of time with them. He is fortunate to have a program that emphasizes a good home-work balance since their chairman wants to make sure they are happy at work, and a big part of that is making sure you have a good balance in life.

There is a stereotype that neurosurgeons are workaholics, and Stephen sees this as true to some extent.Click To Tweet

There are many nights spent signing notes, reading upcoming cases, or writing papers at home. Still, he makes it a point to take time out of his day for as much family time as he can.

[20:52] Academic vs. Community Neurosurgery

One of the biggest benefits Stephen sees being in an academic center is being surrounded by a great group of residents. He gets to play a part in teaching them and helping them to become the next generation of neurosurgeons. Being able to walk them through the same steps his predecessors did for him is fulfilling.

The academic setting also puts him at the forefront of what’s going on in neurosurgery, which is a wide open field. There is so much that’s not known about the brain, and there’s so much research going on. It’s really exciting to be at the forefront of that and seeing that happen in real time.

They also get to see a lot of unusual pathology being sent to them since only a big university that has resources and experts such as theirs that can deal with it.

There is so much that's not known about the brain, and there's so much research going on. It's really exciting to be on the forefront of that.Click To Tweet

[23:00] Neurosurgery Residency and Matching

The ACGME requires you get a certain number of different procedures under your belt while being a resident, and you have to spend so much time in the ICU and such.

For Stephen, he spent a year doing an internship that was part general surgery and part neurosurgery and neurology. (Today, they’re more focused on neurosurgery and neurointensive care.) Then Stephen had to go through six years of neurosurgery residency. Typically, it’s a total of seven years of residency training for neurosurgery.

As a junior resident, he did a lot more carrying the call pager, dealing with the ER, seeing new consults, helping staff clinics, and helping taking care of the patients on the floor and in-patients.

As he went on, he spent more time in the operating room and doing academic stuff. He spent more time on the lab and molded his curriculum to enrich himself in certain subspecialties once he met his prereqs. As he got on towards the fifth to seventh year, he took on more administrative roles, working with scheduling junior residents, and juggling taking care of the operating rooms. He was also the chief on call, helping junior residents on the floor and being a resource for the younger residents.

How Competitive Is It to Match into Neurosurgery?

Neurosurgery is competitive when it comes to matching, and it will likely get more and more competitive. Stephen met some really smart, capable, and qualified folks over the last couple of years who unfortunately ended up in the scramble (SOAP).

It’s competitive because there are not that many spots and there’s a lot of very smart, capable, and qualified applicants. Despite the specialty having a very tough and rigorous lifestyle, there are a lot of people who are up to meet that challenge and want to face it head on.

[28:00] What Makes a Competitive Applicant for Neurosurgery?

Stephen has been on the committee that goes over all of the residency applicants. While everybody who gets on his table has great boards scores and good grades, that’s not what seals it for you. You need to show in the interview that you’re a reasonable person. There are smart people who are capable of creating a hostile work environment. If everybody can get along, that makes life nice, and that’s what their resident group strives to achieve.

Ten or fifteen points on your boards are not what seals the match for you. I think it's in the interview, you need to show that you're a reasonable person.Click To Tweet

Having said that, their match system is difficult in that they interview applicants for a day, similar to speed dating. One of the best ways to see if you would fit into a particular residency program is to do a sub-internship there, whether for a month of medical school or just a week. Go back for a second look after you’ve done your interview and spend some more time with them.

Any residency program can really put on a good face for a day, so it’s important to be able to see how everybody is on a day-to-day basis.

Any residency program can put on a good face for a day.Click To Tweet

[30:58] DOs in Neurosurgery

Unfortunately, Stephen doesn’t know a lot of DO neurosurgeons, probably because he has not been out of the academic world for a long time. He also went to an allopathic school and residency. But he knows there are some designated DO neurosurgery programs.

Subspecialties in Neurosurgery

After seven years of residency training, subspecialties available include pediatric neurosurgery or cerebrovascular neurosurgery. Today, physicians can get a CAST or Certificate of Advanced Surgical Training. This requires them to meet certain criteria and complete a certain number of cases. Then you’ll have a certification for spine, epilepsy, peripheral nerve, or other subspecialties.

To be able to do this, Stephen suggests working in an academic center where you have other folks who can cover the rest of the subspecialties. While you want to subspecialize in one particular thing, they still have a good complement of attendings in their group.

What Primary Care Physicians Should Know About Neurosurgery

Stephen has a good relationship with the primary care physicians in his area. The important thing is for them to know that neurosurgeons are always available to help them with things. Neurosurgeons can even help with non-surgical stuff, such as back pain and neck pain.

It can be hard to tell which cases are surgical and which are not. Neurosurgeons are more than happy to go over the issue with a patient and help them understand what’s going on. It’s worth your time to explain things carefully to patients.

Other Specialties That Neurosurgeons Commonly Work With

Neurosurgeons work closely with include oncology (for tumors in spinal cord, brain, or peripheral nerves), physical medicine and rehabilitation (for brain pathology due to stroke), hospitalists, vascular surgeons (for carotid artery pathology), trauma surgery, and endocrinology (for Cushing’s disease and pituitary tumors). Neurologists are their closest colleagues, sharing management on stroke patients and epilepsy.

[38:40] Opportunities for Neurosurgeons Outside of Clinical Medicine

You can take part in academics and research in the lab. You can take things from the bench to the bedside since you have access to the patient base. Some neurosurgeons also end up doing stuff on the administrative side of things.

Many neurosurgeons are clinically and academically busy between teaching, writing, and fulfilling their clinical duties. You can do pretty much anything, according to Stephen.

[40:12] The Best and Worst Parts of Neurosurgery

A lot of times, things can get tough and it wears on you physically and mentally. But literally being able to take care of people in their darkest hour and be there—being involved in the most important part of a lot of people’s lives—is hugely fulfilling.

The same goes academically. It is very fulfilling in that you can do detective work while you get to teach the next generation of neurosurgeons. He gets tired. But he’s never felt that feeling of dragging yourself off to work just for the paycheck. Stephen finds his profession to be very fulfilling.

Being able to take care of people in their darkest hour and be there—being involved in the most important part of a lot of people's lives—is hugely fulfilling.Click To Tweet

There are bad days, and sometimes you’ll have a streak of patients you’re not able to help. Or you think you did a case by the book and did everything right, but the patient has a bad outcome. So there’s that feeling of hopelessness. You present that case in M&M and maybe if you had the chance to do it again, you’d do it the same way, but it keeps you up at night.

[43:46] What is M&M?

M&M stands for Morbidity and Mortality. It is a conference where you and your colleagues present difficult cases you’ve encountered. The purpose of M&M is to prevent errors in the future and to identify where mistakes were made in the care and management of patients.

It’s stressful, and it’s rough on you if it’s your case. But it’s important to make sure everybody is treated appropriately in the future, for accountability, and for teaching the residents.

[45:30] The Future of Neurosurgery

There is so much more we don’t know about the brain and the central nervous system. Some exciting new things are going on. One example is neuromodulation and deep brain stimulation for all sorts of different pathologies. It’s commonplace for Parkinson’s disease and tremors, but there is a lot more potential use for it in the future. There are also implantable devices help detect seizures and extinguish them before they become a problem.

There’s a lot of interesting technology on the horizon, as well as new uses for old technology. These include stimulators for spasticity and stroke, and stem cells implanted for stroke, Parkinson’s disease, and neurodegenerative diseases in general.

We're coming up with ways to help patients who were once thought to just have progressive neurodegenerative disorders.Click To Tweet

We’re coming up with ways to help patients who were once thought to just have progressive neurodegenerative disorders. We’re developing promising interventions such as treatments for traumatic brain and spine injury, and using neural computer interfaces for moving appendages. He doesn’t see it being too off before you’re going to be able to use an artificial limb to perform complicated maneuvers. It’s close to being a thing, so we’re in really exciting times.

[48:00] Final Words of Wisdom

If he had to do it all over again, Stephen would still choose the same residency, as he had a great time making friends, and he had great teachers. The field of neurosurgery is still what he picks up to read, and it’s what he’s drawn to. So he definitely still has a fire for it, and it’s been great so far.

If neurosurgery is something you’re considering, Stephen recommends to look into yourself and make sure it’s something you want to do. And if it is, then you should do it. It’s rewarding and interesting.

TV glamorizes neurosurgery more so than the other surgical subspecialties, even though the others require just as much scholastic aptitude and manual dexterity. So look inside yourself, and make sure this is what you want to do.

Maintain Balance on Your Path

Plan it out and keep a balance in your life. Go out and get some fresh air. Do the recreational activities you like. Spend time with your family. You should maintain that balance. It may take a little more effort than it did before when you were able to sleep in. But try to keep a balance.

Lastly, Stephen wants to emphasize that you’ve chosen a great field no matter what subspecialty of medicine you go into. Congratulations on getting this far!

[51:28] My Closing Thoughts

Neurosurgery is one of those more rigorous paths to becoming an attending, and it’s still very rigorous as an attending. As Stephen said, it’s very competitive to get into. If you’re interested in neurosurgery, reach out to some programs and find some mentors.