ne plus ultra / plus ultra


The phrase ne plus ultra (latin, literally – no more beyond, in common usage – the epitome, the finest example, the ultimate) was first immortalized on the medieval Spanish coat of arms. The Spaniards believed that they sat at the edge of the knowable world – the Atlantic ocean was an uncrossable barrier. Accordingly, there was literally nothing more beyond Spain. Eventually, they sent an exploration to test that theory, discovered (from their perspective) a new continent, and the coat of arms promptly sacrificed the “ne” to become simply plus ultra, more beyond. Spain became the portal to the new world.

Many people have written to ask me why I chose Neurosurgery. I enjoy extremely immersive, obsessive pursuits. I feel gratified when I have very difficult, dire challenges that demand my full attention. I want to be on a team of people who felt the same way I do, who seek challenge and difficulty. Accordingly, I decided to consider surgical fields as a career.

In surgery, there are other operations which require dextrous hands, which last longer, and which are physically more challenging. But there is no operation where each action is more consequential. In our world, every time we intervene on someone’s central nervous system, our movements are forever etched upon their consciousness, on their very sense of self and their perception of reality. If we excise eloquent cortex, stretch the optic nerve too far, or occlude blood flow to the motor cortex for too long, we cannot “fix” that problem or undo it. Perhaps we get lucky, but there is no return and there are no second chances. Accordingly, I came to see neurosurgery as the ne plus ultra of surgery.

Neurosurgery is the modern medical equivalent of the medieval Spanish Empire. Much as the Spaniards sat at the edge of the old world, dipping their toes into the Atlantic ocean, we are the only humans with direct physical access to the central nervous system. We are explorers. We enable the future of neuroscience to come into being. It is exciting to be out on the frontiers of human knowledge, surrounded by opportunities for discovery. There is no other field in surgery which is similarly positioned to propel scientific progress forward.


plus ultra indeed.

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International Medical Schools, Part II (for the FMG/IMG)

International Medical Schools, Part II (for the current medical student)

“Can an international medical graduate (IMG) match into neurosurgery?”

“Can a foreign medical graduate (FMG) match into neurosurgery?”


The short answer is: no.


The long answer is: if you’re not dissuaded by the short answer, then keep reading.


I’ll share my thoughts for IMG and FMG who are applying to neurosurgery based on my recent experience as an applicant and my current experience on the other side of the residency application process.

First, lets show some data. How many FMG, IMG, DO and US MD postgraduate  (“Other”) applicants match in neurosurgery each year, compared to US Seniors (“MS4”)?

Year  Total  #MS4 #Other

2014: 206: 189 + 17

2013: 203: 190 + 13

2012: 194: 170 + 24

2011: 191: 174 + 17 *Charting Outcomes*

2010: 188: 173 + 15

2009: 191: 172 + 19

Thus, in a typical year, approximately 10% of the neurosurgery spots are filled by these “other” applicants. Keep in mind that from the (anecdotal) information that I am aware of, most of these spots are filled with US MD postgraduate applicants (i.e. folks who didn’t match the previous year), followed by US DO applicants, FMG and IMG. Definitely fewer than 10, probably five or fewer FMG/IMG applicants match in neurosurgery each year.


We can drill down further into the last “Charting Outcomes” release from 2011. I had hoped that NRMP would release one from 2013, but apparently they have not yet done so. There are a few factors that clearly matter based on this data: # of contiguous ranks, Step 1/2 scores, AOA, and # of research publications. Most of the other stuff is noise.


Looking at the distribution for contiguous ranks, the distribution of ranks of US seniors and other applicants are almost complete opposites.  Other applicants who matched ranked a mean of 6.3 programs, those who did not match ranked 3.3 programs, whereas matched US applicants ranked 15.2 programs and unmatched ranked 7.5 programs. Of the four independent applicants who ranked >10 programs, three of those matched! So, the goal for any independent applicant has got to be to get as many interviews as possible. The only truly modifiable factor you have as a fourth year FMG/IMG is the # of applications you send out, so apply to every single program.


Step 1/2: Whereas US senior applicants have a match rate exceeding 80% with even an average Step 1 score (>221), there is not enough data to speak conclusively about this heterogeneous population. Still, with screening for most programs at either 230 or 240, I would say that IMG/FMG should shoot for 250+ on Step 1. You need to stack the deck in your favor. Again, step 2 scores being much less important for US seniors than for IMG/FMG, you should aim to score 250+ on Step 2 as well. However, these scores are only rarely attained by IMG/FMG according to the 2011 data.


AOA: unfortunately not available to IMG/FMG.


Research publications: sure, can’t hurt. Make sure they are in neuroscience/neurosurgery, use them to build relationships with mainland US faculty.


FMG/IMG will also need to build political connections and get letters from well known US neurosurgeons and US department chairmen. Letters from elsewhere probably just wont help enough. Ideally, you need a senior US neurosurgeon / department chairman who can advocate for you because you are starting off quite far behind all of the US seniors. Obtain these letters by doing away rotations as a fourth year medical student. Maybe you can extend your fourth year and do four or five rotations in Neurosurgery, specifically choosing departments that may be relatively slightly less competitive or who have taken IMG/FMG in the past (peruse their websites and Keep in mind that during those rotations you will have to excel individually and be found to be an excellent and enjoyable team member. This is not easy.


Unfortunately, based on the numbers, you have to prepare from the beginning of your ERAS application for the possibility you wont match.


There are two basic options for backup plans:

  1. If you are absolutely certain you want to pursue neurosurgery, I would strongly recommend considering trying to find a bona fide research job in a US Neurosurgery department if you don’t match the first year. You’re looking for a job that is paid, ideally full-time, (so that someone takes an active interest in your success), with a clinical neurosurgeon as your direct boss (not a basic science research PhD). If you find such a job, you will have to devote yourself 110% to it without compromise. The most likely place to take you on as a resident is the place that knows you best. Plan on spending 2-3 years working before applying again.
  2. Apply to general surgery or other backup programs, and then scramble (“SOAP”) if you don’t match into those. You will most likely be forgoing your shot at neurosurgery. if you want to still keep the faintest dream alive, take a spot at a university hospital which has neurosurgery residents and keep your ears open during PGY1, 2 and 3. If you decide this then you should be applying to backup programs from the beginning of your ERAS application.


So, in summary, if you are an FMG/IMG and want to be a neurosurgeon in America, then:

  1. Apply to every program listed in ERAS.
  2. Score as highly as possible on Step 1 and 2, aiming for over 250
  3. Rotate and build relationships with US neurosurgery departments, faculty and department chairmen.
  4. Consider taking an extra year / modifying your medical school curriculum to do more rotations in the US before applying.
  5. Decide on a backup strategy BEFORE applying to neurosurgery (either get a research job or apply to backup fields/SOAP).

All the best, and email me with any questions through the link at the top of the blog.

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International Medical Schools, Part I (for the pre-medical student)

As a “non-traditional” applicant with several years of work under my belt, I considered applying to US MD, US DO, non-US Caribbean MD and non-US International MD schools.

In retrospect, I would simply say this: the freedom to choose my field of medical practice, without additional stigma or obstacles, has been worth every ounce of struggle. It would have been almost impossible for me to become a neurosurgeon if I attended any of the alternatives. So, too, with almost any highly competitive field (see part II for more on this).

Yes, it may take additional time, effort, and even money – one of my dear friends applied three times (rejected twice), obtained a pre-medical school masters degree and retook the MCATs twice before being accepted to our school. He was elected to junior AOA above many other “traditional” students with Ivy League backgrounds and matched at one of his top two choices in the most competitive field (by the numbers) in our year’s match. His reward is a lifetime of medical practice doing precisely what he wants.

If you’re reading this blog and considering neurosurgery as a career, that line of reasoning probably resonates strongly with you. Whether you end up deciding on neurosurgery or not – having that choice is worth all the time in the world. Some roads are harder, some are easier, but my friend’s story illustrates that even great obstacles can be overcome.

Lastly, this: investing extra time and years to improve your application to medical school is not “time off” or “time wasted” if approached correctly. If you can gain new skills, strengthen your knowledge, build connections and (maybe even) enjoy your years, you will be grateful for the opportunity. Your experience will make you a better physician, a better scientist, and a better person compared to those who went “straight though”.

To pre-medical students considering non-US MD programs because of difficulty gaining admission to US-MD programs, I would strongly encourage you to invest time and energy in your future before closing off opportunities that you do not fully comprehend. If you have applied to medical school and been rejected, determine the cause(s), invest time in shoring up your weaknesses*, and then reapply once your application has materially improved**. If that fails, then reassess again, improve your application and try again. As long as you have the will to continue, try again.


* and **: The most common reason for failure in re-applicants, among the students who I have spoken with, is a failure to materially change the application. Examples: applying again three months after being rejected, applying before results of research years have been published, applying before new MCAT score released (or applying with the same low MCAT score), applying before GPA has changed significantly, applying before new letters can be written.

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The days are long, but the years are short.

At the beginning of this year, a very wise individual gave me the following advice: “The days are long, but the years are short.”

As for the days being long, I couldn’t agree more. As a surgical intern, my job is to provide sweat and blood to lubricate the machinery of modern medicine. To do everything that no one else wants to do – filling out mountains of paperwork, mollifying angry families, removing feces from rectums, verifying that the orders of others have been carried out, spending hours with the most tedious patients in the clinic, checking endless checkboxes – and facing the wrath of all at the slightest mis-step.

On one particular day, I was paged over 70 times between the hours of 6 am and 6 pm. Since each page requires an average of four minutes of time to address (usually at least 2 minutes just to get the nurse who paged me back on the phone), I spent almost five hours of my day just responding to pages. I had to write forty notes on patients, which is a process that takes approximately 3-5 minutes per patient (again, an average of 4 minutes), for another two and a half hours. All told, I spent nearly eight hours of that particular day either responding to pages or writing notes. In 2014, this is what modern medicine feels like.

Being beneath everyone in the hospital hierarchy – either by virtue of rank or the complete apathy of others- is a daily challenge. When a nurse or technician does not care about their job or their patient, they are never blamed for oversights or errors, but it is always the intern’s fault for not being vigilant, not knowing, or being inexperienced. And it is not worth scolding someone who is truly and completely uncaring.

I’ve learned very quickly to accept responsibility for everything bad that happens, offer no excuses and only give the briefest apologies. One attending surgeon explained it thusly:

The only thing worse than an intern who makes a mistake is an intern who wastes my time telling me why [they did it]. I don’t want to hear that – don’t you think I have more important things to think about? Just take care of it.

It’s not that the job is thankless – because people are constantly thanking you and even blessing you – its just that you are never thanked for doing the things that actually warrant an expression of gratitude. All the behind the scenes hard work is taken for granted – the really tough stuff is never seen. Conversely, families of the sickest patients will effusively thank and praise you for your mistakes, and for their bad outcomes, even after you explain precisely what had happened.

Oh and while all of these things are going on, every once in a while you actually have to practice real high stakes medicine. A few times I’ve been the first physician to arrive at a patient in acute cardiovascular collapse (“code blue”), the principal surgeon in the operating room, the sole doctor taking care of a patient, formulating a treatment plan, and obtaining rubber-stamp approval from an overworked superior.  But those times are indeed far between.

I can also confirm that the years are indeed short. I was recently teaching one of our fourth year medical students about some inpatient diabetes management methods, when I experienced a new feeling. I asked him a question I thought to be so basic that everyone must know the answer – but he in fact had no idea what I was talking about. He was three months away from his medical school graduation, 95% of an MD degree completed, and precisely one year behind me in his training. I could not remember a time when I did not know the answer to the question I had asked him – I could no longer put myself in his shoes.  It was a great experience for me because I had to stop, think, and remember how to teach this particular concept from the bottom up. For me, it was also clear evidence that this year has passed by with stunning pace.


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The best medical and surgical writing on the internet

… can be found at

Specifically, the last post, titled “thumbs up“.

Although still early in my PGY-1 year, I have already pronounced a dozen or two patients, called the coroner and talked to families. I’m not really sure how to write about it, or what to say in these circumstances, but when I figure it out I’ll let you know.

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The Tebowing Neurosurgeon

So, after successfully matching and a relatively awesome weekend, things are starting to calm down a bit and I’m hoping to blog a bit more. (I have said this before …)

The Atlantic recently ran a piece about a neurosurgeon who “2-Corinthianed” an atheistic patient before taking him to the OR, dropping a lot of “jesus-this” and “christ-that”. The post concludes “It was wrong for that neurosurgeon to preach at his patient’s bedside without first inquiring about his patient’s spirituality.” To me this seems like much ado about nothing.

I have several very religious (non-physician) friends who have explicitly told me that they will pray for me (for instance, during the match week) or for my family. Frankly, even though we don’t share common religious beliefs, I don’t mind. They are going to pray anyway, and for them, prayer is one expression of love and friendship, so hey – I send flowers, they talk to JC. I’m grateful to them for that expression of friendship. For what it’s worth, apparently the professor had a similarly bemused reaction.

I have only been on the receiving end of requests for prayer, which I accepted even though the patients often said things that I don’t theologically agree with. While I tell the patients that I’m happy for any help that I can get, the truth is that I agree to these requests solely out of respect for the patient and because their spiritual and mental strength may have some positive effect on their outcome. Lastly, (given that the patient and I have made the decision to have an operation) anything that will steady their nerves on the day is a win-win.

I do think that in a perfect world of rainbows and unicorns, the neurosurgeon could have developed a better routine for this situation. One might imagine a perfect surgeon saying something like “Faith is an important part of my life and I pray several times each day. I am going to pray now and you are welcome to join me.” followed by a short pause to allow objections, followed by the prayer du jour.

Although I think that there could be some grossly overbearing theists out there, for the most part I find these gestures to be benign. It is not my personal style to Tebow at the bedside, but I think we have bigger things to worry about in healthcare than these well-intentioned gestures of faith. Maybe an aspiring Christopher Hitchens out there can comment and disagree, but given that our life and time is finite, I would rather invest in better communication in counseling patients regarding indications for surgery, risks, benefits and alternatives, rather than prayer styles.

If I’m ever on the other side and a physician wants to “2-Corinthians” me, I would nod, smile, and be grateful for their well wishes.

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More to follow …

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