Tips to Excel on a Neurosurgery Sub-I
Written by Sam Spellicy, Ph.D. (Class of 2022 MD graduate)
Congrats! You were offered a Neurosurgery Sub-I position. You just crushed another hurdle on your way to being a neurosurgeon! After the elation wears off, feelings of anxiety, hesitancy, and even imposter syndrome may start to creep in. Hopefully, we can work to assuage some of those fears with some tips to review before Day 1.
Prepare
First, prepare, prepare, prepare. This is the one step I could have probably done better myself. I concentrated my preparation on staring at neuroanatomy diagrams, throwing stitches on suture kits until midnight, and googling "most common neurosurgery PIMP questions." Wrong. While it is important to cover those bases, more specific preparation should be spent on the actual program itself. Know the faculty, their sub-specialties, and, at a minimum, a cursory understanding of their research. If you are interested in a specific area of research or sub-specialty, really focus on those individuals, and make it known from day one that is what you are interested in. It will not only make you better prepared when you scrub in with them, but also may facilitate more interactions with those individuals during your short time.
Your Advocates
The program coordinator is the real MVP of this entire operation. They will be your primary source of contact before your Sub-I, throughout your Sub-I, and then during interview season. They will most likely be more than willing to help answer any questions you have before you begin or help facilitate obtaining letters of recommendation from faculty members during your sub-I. Really utilize this relationship to showcase how professional, personable, and respectful you are with everyone.
Want to have a bad time during your rotation? Get on the bad side of the Scrub Techs and OR nurses. Honestly, they can be some of the most helpful, insightful people during your rotation. Often while the residents are finishing up notes after rounds or coming from morning conferences, it might just be you, the scrub techs, OR nurse, and anesthesia in the OR. Make sure to introduce yourself on Day 1 and to anyone you have not met yet. I honestly wasn't great at this myself, because I often felt like I was interrupting or in the way. Before the case, they are often busy doing the count, prepping the table, and handling other pre-op tasks. Sometimes, it seems easier to just shy away in a corner until someone you recognize comes into the OR. Instead, work on social awareness and look for a good opening to introduce yourself. I found that first asking, "Is it okay if I give you my gloves now?" was a good way to start, and then I would introduce myself while sterilely handing them over.
What to keep in your pocket
With all those neuro tools rattling around, I know adding more stuff to your pockets sounds impossible but hear me out. Some items get used constantly on rounds, and in the OR, so you can look like a rockstar if you have them at the ready.
1. Marking pen – Grab a few, actually. On morning rounds, these will come in handy, and you churn through them pretty quickly while marking pre-op patients.
2. Tape – From picking up loose hairs after shaving patients to helping secure things in the OR, you will need tape constantly. Just have a roll within reach.
3. Pair of nonsterile gloves – I always kept a pair of nonsterile gloves in the back pocket of my scrub pants. Often, you'll need to jump in quickly to either help transfer a patient, pick up things on the floor of the OR (when you are not scrubbed, of course), or grab equipment. Rather than spinning in circles in unfamiliar ORs trying to find gloves on the wall or anesthesia cart, it was easy to just grab some out of my pocket without even thinking about it.
Suture removal/Staple removal kits -These are for bonus points. If you have room in your white coat for these, I need to know what company makes your white coat because, honestly, I am impressed. Really, though, these tools just make it easier for you. If you are asked after rounds or during rounds to pull some sutures or staples, it saves you a trip to the supply closet if you already have them on hand.
Bonus, if you are looking for an efficient way to make some pocket room, try out this white coat hack I made to keep my neuro tools together. All you need is some elastic fabric and thread.
The three questions
As neurosurgery applicants, I know we all stress about the details and want to be absolutely perfect. We want to know all the anatomy, knock every PIMP question out of the park, and be technically exquisite. While that is a portion of what is assessed during your Sub-I, the elements most programs really want to know are 1. Are you teachable, 2. Do you work well with others, and 3. Do you add to the team?
1. Are you teachable?
a. If you don't know an answer, go home and review and come back ready the next day. While getting a question wrong 1x might feel bad, just imagine how bad getting it wrong 2x feels.
b. Do you prep for cases? Ideally, you will know what case you will be in the next day, which gives you the evening before to prepare. Sometimes, cases get bumped, canceled, or moved around, which means you might have a different case than you originally planned for. It happens. On the way to the OR, just use your phone to quickly scan through relevant anatomy and approaches. Anything to re-jog your memory on things you might not have seen in a while.
c. Pay attention in the OR. If you see a case a couple of times, you should start to recognize what instruments are needed, when, and what steps come next. For example, if the team is getting ready to close dura, you can ask if they would like you to prep the bone flap. While some programs may allow Sub-Is more or less freedom in the OR, at whatever level of involvement is permitted, you can still show you are paying attention and know what steps come next.
2. Do you work well with others?
a. This goes for the residents, faculty, NPs, PAs, OR staff, other departments, AND other Sub-Is. Most likely, there will be other Sub-Is during your rotation. That's great! This is the person you can text when you inevitably get lost in the hospital or locked in a stairwell without feeling too embarrassed (looking at you, stairwells with ID badge locks). You can prepare for cases together, explore the city together, and be a resource for each other. My Co-Sub-I and I even helped each other with our ERAS applications.
b. Always lift others up. If a resident is asked a question and you know the answer, it might be best to just keep it to yourself. You don't want to butt in and make anyone look bad, even if it is unintentional. This one might be hard because you are ready to impress, and you always want to demonstrate your knowledge the best you can. If there’s any way to help the resident that’s usually the better course.
c. Always be humble. No matter who you are interacting with and when. This is essential.
3. Do you add to the team?
a. Unless told otherwise, always help with pre-op and post-op tasks. Helping to move the patient, helping pick up things in the OR, etc. While others are busy catching up on pages and patient notes or scrambling to another case, this is one way you can help the team. If you have this handled, they can focus on tasks you may not be able to help with, which is always a good look. The same goes for pulling up images before the case starts, moving patients to imaging, running down samples to the lab or path, and pulling drains/staples.
b. Teach others when appropriate. Is there an M1-M3 student in the OR, too? Do they have questions they might not feel comfortable asking an attending/resident? This is a good time to really practice your own teaching skills and convey what you know about the case, what anatomy you are currently looking at, and what the goals of the procedure are. It’s a great way to demonstrate your own knowledge and find gaps in your understanding, while also letting the rest of the team concentrate on other tasks at hand. Hey, who knows, you might even get some brownie points if you are within earshot of the team.
Presentations
Often, Sub-Is are asked to give a short presentation during their time with the department. These presentations can range from research you have done to a case report you find interesting. While it may differ from program to program, these are typically short, 15–20-minute presentations. If you have more substantial research, such as a Ph.D., you may be asked to present longer. Really, this is something you should absolutely knock out of the park. Since you know this is coming, you could start putting something together now, even before your Sub-I starts. I know this part can be anxiety-inducing, especially if you aren't a fan of public speaking, but the goal really isn't to make you uncomfortable. The goal is usually to try to teach the Dept. something interesting, show how you convey information, and show how you prepare. You can give yourself a boost on this by knowing your presentation inside and out. Practice it with friends, your co-Sub-I, or anyone willing to listen (Heck, even send it to me – if I have time, I'll try to help). While practicing, stop on each slide and try to come up with questions you could be asked about each one. It's always easier to answer a question during the real thing if you have already answered it while practicing.
Other resources to review before and during your Sub-I
Hey, no one is perfect, and I certainly wasn’t and don’t know it all. While these tips are based on my personal experience, the best way to really be prepared is to leverage as many resources as possible. Below are some other resources I used while preparing for my Sub-I that could also be helpful.
1. Podcasts
a. Inside the Match – Hopefully you are already familiar with this one, but if not, it is a TROVE of information all things concerning the Residency Application Process. Better yet, there is specialty- specific and more general content available as well!
b. The Neurosurgeon's Journey – A podcast hosted by immediate past-chair of the Young Neurosurgeon's Committee (YNC), Dr. Jeremiah Johnson, and Senior Student Director of Education Resources for the Medical Student Neurosurgery Training Center, Michael Kurtz. All episodes are a great resource if you have the time, and they routinely ask their interviewees about ways to excel on Sub-Is. Episode 2 Is specifically about Sub-internships.
c. Neurosurgery Podcast- A catalog of over 60 program directors and faculty have given short 15–20-minute spiels on their program starting around episode 84. I would say it's a must-listen if you are about to go to one of those programs for a sub-I and then a great resource right before an interview during interview season. It goes a long way to hear from the PDs themselves, what the program's culture is, what they are looking for in applicants and Sub-Is, and what they think sets their programs apart.
2. Associations
a. Medical Student Neurosurgery Training Center (MSNTC)
b. AANS Young Neurosurgeon's Committee
Lastly, be proud of yourself. This is a rite of passage and an honor to get this far. A lot of anxiety may come from not knowing exactly how you fit in on the team or where you can help. Always try to be conscientious of what needs to be done when and who might look like they have their hands full. There are always opportunities to step up, and it doesn't hurt to ask if you can help someone. Best of luck in this journey, and feel free to reach out.
If you don't have time to read or remember anything else, here are my top 3 take homes.
1. Demonstrate you are teachable and have a high social/emotional IQ
2. Don't wait for someone to ask for help, offer first
3. Be humble
