A career in neurosurgery: selection, training, and beyond
Authors: Jonathan Ellenbogen, Ian Kamaly-Asl
Publication date: 01 Oct 2014
Jonathan Ellenbogen and Ian Kamaly-Asl outline the process for national selection and training in neurosurgery
Neurosurgery is a fascinating and evolving specialty that offers the prospect of curing patients who have a wide range of benign pathologies, as well as improving and prolonging the quality of life for patients with debilitating neurological diseases.
The specialty encompasses all aspects of the diagnosis, assessment, and surgical management of brain, central nervous system, and spinal pathologies. There are several subspecialties within the field (box 1), and advances in our understanding of neurophysiology and neuroanatomy, as well as continual improvements in microsurgical techniques, neuroradiology, image guided surgery, and interventional radiology, further change and extend the variety of neurosurgical practice.
Entry to specialty
Since 2008, entry into the specialty has been through a national selection process that takes place once a year. The Neurosurgical National Selection Board leads this process, and is hosted by the Yorkshire and Humber Deanery. The aims of the national selection process are to enable equity of access and consistency in the application of selection standards, to enhance open competition, to remove local bias, and to improve the specialty specific aspects of selection. The board has representatives from the specialist advisory committee in neurosurgery, the Society of British Neurological Surgeons, the British Neurosurgical Trainees’ Association, and each of the neurosurgical training programmes in England, Scotland, and Wales.
Entry into the national run-through training programme occurs between the first and third year of specialty training (ST1 and ST3). Candidates are shortlisted based on scoring of an online application form using standardised criteria, which are available on the Yorkshire and Humber Deanery’s website. Evidence of undergraduate work, research, publications, presentations, career progression, higher degrees, and organisational and psychomotor skills are among the categories scored. Each application is independently scored by two assessors. Shortlisted candidates are then invited to the selection centre. There are 96 slots for candidates at all levels over two days at the selection centre.
The selection centre has five 20 minute face to face stations (CV, clinical scenario, management scenario, telephone exercise, and simulated patient), as well as a portfolio review and practical skills assessments. The stations assess judgment under pressure, communication skills, problem solving, professional integrity, technical knowledge, and clinical expertise.
Pairs of selectors again independently assess performance at each station. The shortlisting score accounts for 20% of the final selection centre score. Candidates are ranked based upon their overall score and are then matched to their preferred posts.
Neurosurgery has consistently been a highly competitive specialty. In 2012 it had a competition ratio for run-through training of 15.9:1. In 2013 there were 159 applications for 21 ST1 run-through posts, 36 applications for two ST2 run-through posts, and 46 applications for eight ST3 run-through posts.
The UK neurosurgical specialty training programme consists of eight training years in four stages from ST1 to ST8. Access is available into ST1 to ST3 only for those who meet the person specifications at these levels. Entry to the programme is usually at ST1 for trainees who will have completed the two year UK foundation programme, or equivalent. As specialty training in neurosurgery is a run-through programme there is no additional competitive step when a programme has been entered.
Academic neurosurgical training is different in England from that in Scotland and Wales. In England the training is split into academic clinical fellow and clinical lecturer posts, both of which are recruited through a separate application process. Academic clinical fellows are recruited to early years training (ST1-3) and will have a 3:1 split between clinical and research time. The aim of the posts is to allow trainees to do some initial research with the aim of subsequently taking time out of programme to undertake a full time higher degree (usually a PhD) as well as ideally securing grant funding for this research. Following a PhD there is a second application process for the clinical lecturer posts, which have a 1:1 split in clinical and research time, and the aim of the posts is to continue postdoctoral research and to apply for clinician scientist awards to move into an academic consultant post. If an academic trainee leaves his or her research post then they are automatically allocated a clinical run-through training number.
The initial stage of neurosurgical training (ST1-3) incorporates a first year of core knowledge in the clinical neurosciences. This initial year of core neuroscience training includes a six month attachment in neurosurgery and a six month attachment in an acute neurology specialty. It incorporates experience in clinical neurophysiology and neurorehabilitation, or four month attachments in neurosurgery, neurology, and neuro-intensive care (box 2).
During ST2 and ST3 trainees will undertake one or more placements in complementary surgical disciplines to acquire core surgical skills and knowledge. By the end of ST3 all trainees will have had a minimum of 12 months’ full time training in basic neurosurgery. The intermediate stage (ST4 to ST5) provides two years in full time general neurosurgical training. The final stage (ST6 to ST7) encompasses advanced neurosurgical training to achieve all the generic neurosurgical competences, and this is followed by a final year (ST8) of special interest training in one of the neurosurgical subspecialties.
Working time restrictions have had a negative effect on training in neurosurgery and have limited the time available for trainees to gain experience in all aspects of the specialty. As such, in future, training may be prolonged to enable all competences required of a consultant to be fully met.
Progress through the programme depends on acquisition of the necessary competences (clinical, operative, and generic) as described in the curriculum, receiving satisfactory workplace based assessments (box 3) and other assessments of competence to satisfy the annual review of competence progression (ARCP). Passing the membership of the Royal College of Surgeons (MRCS) examination is obligatory for progression to ST3, and passing the joint intercollegiate exit examination, the FRCS(SN), is required for a certificate of completion of training and entry on to the specialist register. You will also have to demonstrate a portfolio of experience to include such activities as formal teaching, leadership and management, research, and audit.
The full requirements for the certificate of completion of training are available on the Joint Committee on Surgical Training’s website (box 4). Consultants are expected to continue developing their professional skills throughout their working lives (box 5).
As with all the surgical specialties, simulation is becoming an increasingly important part of neurosurgical training and the revised neurosurgical curriculum including simulation has now been accepted by the General Medical Council for imminent incorporation into the Intercollegiate Surgical Curriculum Programme.
Competition for consultant posts is becoming fierce. Most senior trainees will have several papers as first named authors and/or a higher degree (PhD/MD) to make themselves more employable for consultant posts. Although a fellowship post is not a prerequisite to attaining a consultant position many senior trainees will also take one up in other units in the UK or abroad to broaden their experience and increase their employability.
Neurosurgical services are usually provided in tertiary regional neuroscience centres serving populations of between 1 million and 3.5 million. Neurosurgery units are situated in most major cities so you might be limited if you want to work in a rural environment. There are 34 neurosurgical units in the United Kingdom. Some of these are part of standalone neuroscience centres, and others are incorporated into larger teaching hospitals. Neuroscience units include neurology, neuropsychology, neuroradiology, neuropathology, and neurorehabilitation services.
Neurosurgery is both a consultant led and a consultant provided service, with fewer than 5% of trained neurosurgeons working in the specialty and associate specialist grades. Most consultant neurosurgeons spend four to five programmed activities operating a week, with one to two outpatient clinic sessions a week. The remainder of their time is spent on preoperative and postoperative ward care, teaching, and other management and leadership duties.
Emergency and unscheduled referrals from hospitals within the regional catchment area account for more than 50% of the neurosurgical caseload. Out of hours activity is commonplace and mainly delivered by consultants. Neurosurgical consultants must be competent to manage a diverse range of adult emergency conditions and able to provide basic emergency paediatric care (box 3).
Subspecialty elective care, referred from other hospital specialties or general practice, is provided by neurosurgeons with special interest training working within multidisciplinary teams with colleagues in clinical neurosciences, neuro-oncology, endocrinology and otolaryngology, maxillofacial, plastic, and orthopaedic surgery. Spinal surgery is the largest subspecialty, contributing 50% of the operative workload of some departments. Paediatric neurosurgery accounts for 10-15% of all neurosurgical activity.
Neurosurgery is an increasingly popular career choice. It has traditionally been a male dominated specialty, but more women are choosing it as a career, and in the US consultation is underway to actively encourage females into the specialty. In the UK, from 2001 to 2011, 20% of the overall neurosurgical workforce were women and 6.5% of consultants were women. The introduction of working time restrictions, together with flexible training, may encourage more women to enter the specialty.
The work is diverse, with daily diagnostic challenges and varying management plans that bring together many different treatment modalities within a multidisciplinary setting (box 6). There are numerous opportunities to get involved in research and academic work and the opportunity to be at the forefront of our understanding of how the brain works and the surgical correction of its pathological processes.
Box 1: Neurosurgical subspecialties
Functional neurosurgery (surgical management of intractable pain, epilepsy, and movement disorders)
Box 2: Day to day life of a trainee
There is no standard day for an initial stage neurosurgical trainee. The day starts at around 7.45 am gathering patient lists and outstanding results in preparation for the ward rounds. A handover meeting takes place at 8 am and all patients referred in the preceding 24 hours are discussed and the imaging reviewed. This is a good opportunity to learn how to interpret computed tomography and magnetic resonance imaging scans and also to understand patient management.
A neurosurgical ward round is usually a rapid affair, and there may be multiple ward rounds throughout the day if you look after a number of different consultants’ patients. After the ward round, tasks are collated, patients’ notes are written up, outstanding investigations and results are organised, and emergency and elective patient admissions are managed. There may be a teaching session in the middle of the day for an hour. Patients are generally medically unwell, either with medical comorbidities or with sequelae of their neurological pathology, and they require a lot of medical care; days are invariably very busy. If you are organised, efficient, and work as a team with your other junior colleagues it is possible to gain theatre and clinic experience. The experience can be very rewarding, but as with any job you only get out as much as you put in.
Box 3: Workplace based assessments
Assessment of audits
Case based discussion
Clinical evaluation exercise
Direct observation of procedural skills in surgery
Mini peer assessment tool
Observation of teaching
Procedure based assessment
Box 4: Neurosurgical conditions that neurosurgical consultants manage
Spontaneous intracranial haemorrhage
Central nervous system infections
Benign intradural tumours
Malignant spinal cord compression
Degenerative spinal disorders
Emergency paediatric care
Box 5: Qualities of a neurosurgeon
Effective time management and organisation
Comfortable managing acutely unwell patients
Highly self motivated, willingness to learn and keep abreast of new developments
Ability for analytical thinking, problem solving, decision making
Ability to handle stress and perform under pressure
Excellent communication skills
Good manual dexterity
Ability to deal with emotional stress constructively
Box 6: Advantages and disadvantages of a career in neurosurgery
Forefront of medical and surgical advances, especially high-end technologies
Ability to vastly improve a patient’s quality of life
Varied and interesting patients and disease processes
Onerous on-call duties with resident on calls for ST4-8
Units can be far apart, with the need to travel for rotational posts and move for consultant posts
Units in large cities, so not particularly suitable if you like the country life
Constant patient load and pressure on beds means there is never a let up in work
Further information: useful websites
Medical and Dental Recruitment and Selection— [Link]
York and Humber Deanery— [Link]
General Medical Council postgraduate training pages— [Link]
Joint Committee on Surgical Training— [Link]
Intercollegiate Surgical Curriculum Programme— [Link]
NHS Medical Careers— [Link]
Royal College of Surgeons of England— [Link]
Society of British Neurological Surgeons— [Link]
Neurology And Neurosurgery Interest Group— [Link]
We have read and understood BMJ’s policy on declaration of interests and declare the following interests: None.
- Yorkshire and Humber Deanery. National neurosurgery ST1, ST2 & ST3 recruitment. Vacancies. January 2014. [Link] .
- Medical and Dental Recruitment and Selection. Competition ratios. January 2014. [Link] .
- Royal College of Surgeons of England. Intercollegiate surgical curriculum programme. 7 August 2013. [Link] .
- Joint Committee on Surgical Training document: CCT guidelines for neurosurgery. [Link] .
- Myles ST, McAleer S. Selection of neurosurgical trainees. Can J Neurol Sci 2003;30:26-30.
- Royal College of Surgeons of England. Surgical careers: what kind of surgeon do I want to be? [Link] .
- Benzil DL, Abosch A, Germano I, Gilmer H, Maraire JN, Muraszko K, et al. The future of neurosurgery: a white paper on the recruitment and retention of women in neurosurgery. J Neurosurg 2008;109:378-86.
- Health & Social Care Information Centre. NHS staff—2001-2011, medical and dental. 21 March 2012. [Link] .
Jonathan Ellenbogen ST7 neurosurgery
Walton Centre for Neurology and Neurosurgery, Liverpool, UK
Ian Kamaly-Asl consultant neurosurgeon and secretary to the Neurosurgical National Selection Board Royal Manchester Children’s Hospital, Manchester, UK