The Current State of the Neurosurgical Match

Sifting the match statistics published by the National Residency Matching Program (NRMP) since 2009 (and those published by the San Francisco Match in preceding decades), it is evident that the arduous nature of matching into neurosurgery has long been established. While similarly competitive specialties such as plastic and orthopedic surgery have analyzed the NRMP data to distill the characteristics of successful applicants in each of their respective fields^1,2, neurosurgery lacks such literature. The obscurity regarding the makings of a successful neurosurgical residency applicant has incited a highly neurotic process. The steady upsurge of applications submitted per applicant/fielded per program, the snowballing number of interviews attended per applicant and unprecedented application costs accrued by a neurosurgical applicant relative to his or her peers underscore a feedforward process that is actively accelerating.

In 2014, a survey of neurosurgery training programs concluded that one’s interview performance, letters of recommendation (LORs) and USMLE Step 1 score were most influential in determining his or her ultimate rank.³ While this insight is valuable, board scores were the only objective metric. Moreover, considering the variability of the application review process across institutions – spanning appraisal by a single program director to a highly democratic process comprised by amalgamating feedback from the majority of a department – a more formulaic appraisal of the data was needed.

Since May, there have been four articles published intended to help decrypt this process. To determine the variables most predictive of a successful match, Leschke et al.⁴ and Dossani et al.⁵ examined the NRMP data from 2009 to 2016 and 2009 to 2017, respectively and with convergent results. Since the NRMP does not report demographic data, Durham et al. scrutinized the San Francisco data from 1990 to 2007 to help elucidate why females have been, and continue to be, underrepresented in neurosurgery.⁶ Finally, Pittman, in a commentary piece, provided a thoughtful criticism of the current state of the process and a proposal for its reformation.⁷

According to the NRMP data, 2009-2017 saw a significant increase in the number of programs (from 97 to 107) as well as in annually available residency positions (from 191 to 218). Over this same interval, the number of applicants has remained in a narrow range between 309 and 354, saving 2011 (n=283). The preponderance of available seats has been filled by graduating seniors from U.S. allopathic medical schools (>90% in each year, except 2012 (87%) and 2017 (84%)). The great majority of remaining seats have been filled by a mix of international medical graduates and reapplying U.S. allopathic graduates (only 10 U.S. osteopathic graduates have matched in ACGME neurosurgical residencies since 2009).⁵

Both Leschke et al. and Dossani et al. found that, on average, compared to applicants that failed to match, successfully matched allopathic seniors had:

• Higher USMLE Step 1 scores (Leschke et al. also found a positive significant positive correlation with USLME Step 2 Clinical Knowledge);
• Ranked more programs;
• A higher proportion of students elected to the Alpha Omega Alpha Honors Society;
• More students with PhD degrees (not significant for “other degrees”); and
• A higher percentage of students from schools ranked in the top 40 in NIH funding.

Interestingly, while Dossani et al. found the number of abstracts, presentations and publications to be a significant predictor of match success, Leschke et al. did not find the number of publications and presentations to be a significant predictor of match success; however, they did find an applicant’s number of research projects to be a significant positive predictor of a fruitful match. This discrepancy may reflect the programs’ affinity for PhD students where thorough, plodding research pervades over superficial, swift publications.

Despite anecdotal claims that neurosurgery is becoming increasingly competitive, match rates for graduating allopathic students have actually remained remarkably stable over the past decade, with the highest match rate appearing in 2017 (87.1%).⁵ Moreover, in the face of a burgeoning applicant pool (209 in 1990 versus 311 in 2017), the increase in residency positions has more than offset this surge (124 in 1990 versus 159 in 2007 versus 218 in 2017), resulting in a dramatic increase in match rate (59.1%, 84.1% and 87.1%, respectively).^5,6

While competitiveness has remained steady over time, Durham et al. discovered an alarming finding: the current paucity of female neurosurgeons may stem from historical bias against female applicants. At the attending level, only 7.8% of all practicing neurosurgeons are female, with a staggering 23% of neurosurgery residency training programs lacking female faculty altogether. At the resident level, females account for merely 17% of all neurosurgical residents – the second lowest representation of all specialties – without a single female resident in 12% of all programs.⁶ Delving into the San Francisco match data, the authors found that from 1990 to 2007, only 13.8% of the applicant pool was female. Over this period, a significantly lower percentage of female applicants were accepted than male applicants (62% versus 73%), a disparity that remained significant after controlling for board scores, AOA status and school ranking. In 1990, just over a third of medical school classes were comprised of females. In 2017, for the first time ever, females made up the majority of students matriculating to U.S. allopathic medical schools. Needless to say, change needs to come.

Although the absence of demographic information in NRMP data prevents repeating this analysis for more contemporary years, a similar study aimed at understanding the reasons for this disparity is imperative. As one embarks toward a career in neurosurgery, having relatable faculty and residency mentors is invaluable. Although this certainly does not require mentors to match the gender of the mentee, with nearly a quarter of programs lacking female faculty and better than one in ten lacking female residents, a glaring problem exists. It is conceivable that without increasing the number of women neurosurgeons to scale with the proportion of women graduating medical school today, these inexcusably low numbers may continue.

I have been fortunate to attend an institution with a robust neurosurgery department, replete with faculty and residents eager to help me along the way. With a program director and chair deeply invested in medical student education, they have treated my medical education as a journey toward neurosurgical training – not as a race toward a hurdle veiled as the match. Having experienced such a supportive environment, I cannot imagine this process without the insight I have gleaned from our sage residents and faculty or without having a phenomenal program director, who, after a decade at the helm, appreciates the process and genuinely cares about the success of his medical students. To this point, the positive correlation between an applicant’s match success and whether he or she graduated from an institution that incidentally falls within the top 40 in NIH funding can be partially explained by the following points.

Each of the top 40 medical schools have an associated neurosurgical residency program. For the rest of the top 100 medical schools, 20% of the next forty and 80% of the final 20 lack associated neurosurgery programs. As such, this correlation would feasibly persist if the analysis were extended to the top 50 or 60 most generously funded NIH institutions, where neurosurgical training programs are ubiquitous and opportunities for medical student engagement are abounding. As a medical student aspiring to match into a neurosurgical residency, the benefits of having a home program cannot be overstated:

• The field is readily accessible to students, allowing them to interface with the specialty and identify mentors early on in their medical education.
• The convoluted match process is simplified by the help of residents privy to its nuances.
• Letters of recommendation, one of the three most highly regarded factors according to surveyed program directors,³ are authored by individuals recognized by the eyes that read them.
• Engagement in neurosurgical research, a significant predictor of match success, lies at students’ fingertips.
• Medical schools that rank higher in NIH funding tend to require higher MCAT scores for admission. MCAT performance has been shown to correlate with one’s performance on USMLE Step 1, a test that was neither intended to predict nor has been shown to correlate with resident proficiency.⁸

Taken together, these factors, none of which have been shown to measure one’s potential for success in neurosurgical training or practice, govern much of the current match process.

As outlined by Pittman, the average cost to apply for neurosurgical residency five years ago was $10,255. Contemporaneously, plastics and orthopedics, specialties that also require away rotations, averaged $6,262 and $5,415, respectively.^10,11 Since this time, the average number of applications submitted per neurosurgical applicant has increased from 40 to 65,¹² as interviews attended has increased from 15 to 18,¹⁰ resulting in proportional increases in the already exorbitant costs. Such a feedforward process is precarious. To counter the mounting number of applications that are attenuating the quality of the review and interview processes, he proposes limiting:

1. The number of applications an applicant can submit (i.e., 35 to allow for thorough review by every program);
2. How many interviews can be accepted (i.e., prior to switching from the San Francisco Match to the NRMP, students typically interviewed at 10 programs and experienced similar match rates); and
3. The number of applicants a program can interview (i.e. 10 to demonstrate sincere interest in each interviewee).

In summary, neurosurgery’s competitiveness is stable. The usual suspects – USMLE performance, research engagement and sound academics – are in fact predictive of a favorable outcome on match day. However, there are facets to this process that elude these data. The resultant uncertainty has precipitated the currently frenzied state of the neurosurgical match. Undoubtedly, there are numerous medical students every year that would make outstanding neurosurgical residents who are either caught in the abyss of never discovering neurosurgery or the crosshairs of finding this path, but lacking mentors and resources to traverse it. Herein lies an opportunity for the YNC to help rectify these shortcomings to ensure that the future of neurosurgery is steered by the most passionate and capable, irrespective of circumstance.

Robert Gramer
Medical Student
Duke University

Samuel Tomlinson
Medical Student
University of Rochester

References