The arrival of COVID-19 in the U.S. heightened concerns for public health, resulting in medical institutions limiting in-person curricular activities. Notably, residency program outreach and application processes are now much more dependent on online communications. For neurosurgery program applicants, there has been increasing concern regarding virtual interviews, limited research opportunities, and indefinite suspensions of external internships and sub-internship rotations, all of which have traditionally contributed to a prospective applicant’s thorough exploration of neurosurgery programs and consequently a successful match [25, 27, 30]. For virtual interviews, specifically, residency applicants are concerned with the relative lack of tangible components, hampered capacity to present themselves accurately, and reduced ability to accurately gauge their compatibility with residency programs [26, 30].
Nonetheless, with the increase in public health efforts to decrease the transmission of COVID-19, it is expected that neurosurgery programs will integrate more intensive utilization of virtual conferencing into curriculum and recruitment over time [25, 31]. A pioneer virtual event that was implemented to address applicant concerns with COVID-19 limitations on rotations and in-person interactions was the 2020 National Virtual Medical Student Symposium, held by the Congress of Neurological Surgeons (CNS). Post-attendance survey data indicated a unanimous approval to establish the symposium as an annual event and overall satisfaction with an improved understanding of neurosurgery residency and the increased opportunities presented by the virtual format of the symposium to connect with more programs and the broader neurosurgical community . It is also significant that over the past decade, neurosurgery program rankings by applicants have consistently taken into consideration educational aspects, such as the academic reputation of the program and established faculty, but are also increasingly prioritizing the resources that the programs offer to address applicant concerns and support resident wellbeing . Additional studies focusing on the current development of virtual communications by individual neurosurgery programs to increase resident recruitment and promote community may provide essential insight for how neurosurgery residency programs can continue to address concerns with the loss of traditional in-person opportunities and adapt their residency recruitment efforts moving forward.
In addition to novel challenges presented by the COVID-19 pandemic to a successful neurosurgery match in current times, certain difficulties associated with the match process are inherent to the established factors of a successful match. We detail in the following sub-sections the longstanding challenges of the neurosurgery match process and relevant focuses for facilitating a more equitable and successful process in current times.
Medical Student Recruitment and Interest Groups
Recently, more studies have focused on potential areas of improvement for neurosurgery resident recruitment and retention. One significant factor that contributes to current recruitment of residents is the presentation and accessibility of relevant information on neurosurgery departmental websites. Larger and higher ranked neurosurgery programs were found to have an overall larger online presence and more easily accessible information on their websites . Other factors for applicant rank list consideration include surgical caseload, team collaboration, current residents, the interview day, and information regarding their particular rank by the program . AANS Medical Student Chapters have spearheaded current efforts to facilitate the neurosurgery residency match process for medical students. Studies have investigated the influence of these groups on future neurosurgery residency match outcomes, research output, and overall medical student neurosurgical learning .
These studies provide further evidence that presence of neurosurgical mentorship during the preclinical and clinical years of medical school, accessible information regarding residency programs and applications, access to a home neurosurgery residency program, a “bioscientific orientation”, along with ample research and publication opportunities can increase neurosurgical interest and improve the prospects of a successful match [9, 10, 12, 14, 15, 34–37].
Academic Performance and Academic Prestige
Multiple studies have indicated that academic performance, as measured through the United States Medical Licensing Exam (USMLE) Step 1 score or clinical clerkship grades and academic prestige, may influence match success . A study by Durham and colleagues investigated pre-residency factors influencing match success. The authors observed that from 1990–2007, students scoring > 245 had a 21-fold increase in matching into neurosurgery compared to students scoring < 215, with a mean USMLE Step 1 match score of 233 ± 18.5 As USMLE Step 1 scores continue to trend upwards, even higher scores are likely required to be a competitive applicant. Moreover, they observed that students from top-40 medical schools matched at a significantly higher rate (2-fold increase) than students at non-top-40 medical schools . A more recent analysis on factors influencing match success for the years 2009, 2011, 2014, and 2016, similarly demonstrated that USMLE Step 1, Step 2, graduating from a top-40 medical school, and AOA status were significantly correlated with matching into a neurosurgery residency program .
The recent decision to change score reporting of USMLE Step 1 from a three-digit numeric score to a pass/fail outcome is believed to significantly impact the neurosurgery residency selection process [38, 39]. Specifically, this change poses a challenge to program directors, who previously used Step 1 as a key objective criterion in distinguishing highly competitive applicants. Without this metric, the focus may be shifted to Step 2CK scores. Though this does offer an objective numerical data point, Udawatta and colleagues found that Step 2CK performance is not a reliable predictor of neurosurgical board performance . Ultimately, the forthcoming change in Step 1 score reporting presents a novel challenge for the resident recruitment process moving forward.
Publications and Grants
Most notably, the relationship of publications, including neurosurgery specific, basic, translational, and clinical science topics, to an applicant’s neurosurgery match success has been extensively researched [16, 17, 19, 37]. Neurosurgery-matched applicants have significantly greater overall research productivity compared to other specialties . However, evidence regarding the association between number of publications and match success is conflicting [19, 41]. Although one study found no association , Kashkoush and colleagues demonstrated that h-index was the only factor associated with the residency tier of the matched program . Moreover, h-index was significantly influenced by years since first publishing original research articles .
Wadhwa and colleagues found that publication volume of post-graduate year 1 (PGY-1) neurosurgery residents increased from 2009 to 2018 . Moreover, in 2018, PGY-1s at top-40 programs had a significantly higher volume of neurosurgery, first/senior author, basic science, and clinical research publications compared to PGY-1s at non-top-40 programs. A separate study observed that PGY-1s at top-25 programs had a significantly higher volume of overall publications, neuroscience-specific publications, and average citation quantity per publication than PGY-1s at non-top-25 programs . Overall, both studies demonstrate that publication volume is increasing overtime for prospective neurosurgery applicants. On the other hand, the increased quantity of research may be attributed in part to nonindexed works and/or the growing increase in publication misrepresentation amongst neurosurgery applicants . Misrepresentation is common, particularly among medical students applying into neurosurgery from unranked medical schools . Future studies are warranted to both investigate the specific factors within research experience that distinguish applicants to program directors, and to characterize the influence of publication record on matching into neurosurgery.
In addition to publications, medical student grants have also been implicated as a potential factor influencing an applicant’s prospects of matching into neurosurgery. Awad and colleagues determined that 51% of grant awardees between 2007–2016 successfully matched into neurosurgery residencies . The majority of grant awardee medical students were from University of Toronto, Harvard University, University of Rochester, and Columbia University, which may be due to the propensity of these universities to accommodate their students’ research interests. Grant awardees may have a slight advantage for matching successfully into neurosurgery, potentially through increased contact with neurosurgical mentors and research opportunities. However, further studies should assess the impact of these grant awards, as well as the impact of institutional T32 awards, MSTP status, and F30/F31 awards on the match success rate for neurosurgery applicants.
Letters of Evaluation
Another aspect of potential neurosurgery match success is the value and impact of letters of recommendation (LOR). In a 16-question survey with a 7-point Likert scale sent to all US neurosurgery program directors, LOR was ranked as the highest factor for selecting applicants to interview . Although the response rate was less than 50%, more than half of the program directors that responded found the LOR essential in their residency applicant selection process. A related finding from this study was that the majority of responses indicated support for a shift towards more objective LORs, provided the potential of a standardized LOR and inclusion of statements focused on an applicant’s professionalism, collaborative abilities, communication, and work ethic.
Rotations and In-Person Interviews
Although rotations and in-person interviews are an important aspect of the match process, significant financial costs are often incurred. All neurosurgery applicants tend to have at least one away rotation, and roughly one-third match at one of the institutions at which they performed their away rotation(s) . The away rotation can often be an essential component of the successful match, but the opportunity to participate in at least one of these programs is not equally available to all applicants: across all specialties surveyed, financial cost was the main determining factor for not performing an away rotation, meaning that applicants who cannot afford to attend away rotations may be placed at a significant disadvantage. On average, applicants spend $10,255 on the neurosurgery residency match process, with nearly 70% of that cost being comprised of interview fees and commuting expenses. Interestingly, students who match at their home institution encounter the same cost burden as others.
Potential solutions to high costs include coordination of cost-sharing efforts, such as pooling hotel or transportation or staying with a current local medical student or resident . Another potential solution is virtual interviews , which has been found to not significantly affect applicant ranking when compared to in-person interviews and has grown in importance during the COVID-19 pandemic . However, one caveat concerning virtual interviews is the difficulty in deciphering key personality characteristics known to correlate with standard residency selection without in-person cues .
International Medical Student Graduates
IMGs are facing increasing competition for U.S. neurosurgery residency spots with no changes in IMG match success over the last decade [3, 47]. Most IMGs have come from the Middle East, specifically Lebanon, and most match into programs in New York, Texas, and Kentucky . A recent study comparing USGs to IMGs demonstrated that the match rates were lower for IMGs despite greater age, percent taking a research gap year, volume of publications, and h-index. Moreover, IMGs are less likely to match into National Institutes of Health top-40 or Doximity top-20 programs, except when previously affiliated with a US neurosurgical department .