During the seven-year Neurologic Surgery Residency, trainees receive advanced education in all aspects of neurosurgery, including both outpatient and hospital settings, with a full six months of dedicated intensive care unit (ICU) training. Trainees will participate in the care and surgery of all neurosurgery patients as an integral member of the neurosurgical team.
Progressive responsibility and surgical experience under the direction of the neurosurgical faculty is assured throughout the residency. Each clinical rotation has specific competencies, goals and learning objectives, in addition to the general departmental academic requirements.
Opportunities for enhanced training in a subspecialty area can be enfolded within the seven-year curriculum; present options include complex spine, peripheral nerve and skull base.
Each resident is required to spend a minimum of 54 months of clinical neurosurgery training prior to graduation. A unique feature of the neurosurgery training at Mayo is our mentorship model, in which residents complete dedicated clinical rotations on the services of one to three faculty members for three-month periods of time. This provides for the development of a longitudinal relationship between the resident and staff, as well as an opportunity for true immersion in a particular practice model, and complete continuity of care for the patients and families on those services.
Two years of dedicated research and career development time are afforded during senior residency. Supplemental clinical rotations, enfolded fellowships and visiting electives may be arranged during this period. Additional provisions are allowed for residents desiring to expand their training by an additional year or longer, so as to obtain a doctorate in neurosciences through Mayo Clinic Graduate School of Biomedical Sciences.
The typical rotation sequence for Mayo Clinic neurosurgery residents is:
During their first year, neurosurgery residents spend five months on the medical neurology services, including two months as junior residents in the neurosciences intensive care unit. Additionally, residents spend one month on the critical care service ICU, one month on neuro-anesthesia, three months on the chief resident service, and one month on the service of Frederic B. Meyer, M.D., the neurologic surgery enterprise chair at Mayo Clinic and the executive dean of education for Mayo Clinic College of Medicine and Science.
By the end of this first year, the PGY-1 resident will have a basic understanding of neurological disease and be competent to perform a neurological history and examination. The resident will have a strong knowledge base for evaluating and caring for the critically ill patient in an intensive care setting. In addition, the resident will have performed basic neurosurgical procedures including intracranial pressure (ICP) monitor placement, external ventricular drain, laminectomy exposures and basic craniotomies.
This first year is expected to lay the foundation of knowledge and skills required for a superlative career in neurosurgery.
During this year, neurosurgery residents spend an additional three months on the medical neurology services, including two months as senior residents in the neurosciences intensive care unit and one month on outpatient neuro-oncology. By the completion of PGY-2, all residents will have completed six months of dedicated ICU training.
PGY-2 residents additionally spend six to nine months as first assistant on the chief resident services, mastering the fundamentals of operative neurosurgery and care of acutely ill neurosurgical and trauma patients. During this time, the resident also enjoys ample opportunity to work one-on-one with staff neurosurgeons as first assistant in the operating room.
During this year, residents are assigned to quarterly rotations on the clinical neurosurgery services of the various consultants. The clinical assignment system is unique in that trainees work one-on-one with each staff neurosurgeon for three-month intervals before rotating. This allows the evolution of a strong teaching mentorship.
During this PGY-3 year, resident surgical skills significantly advance. It is expected that during this time, depending on an individual resident's skill set, the trainee will perform critical portions of each operation with the staff surgeon serving as an assistant and coach. Therefore, trainee surgical skills improve dramatically during this year. It is also expected that residents will better define their clinical interests and begin to formalize their career goals during this year.
During the PGY-4 year, residents typically complete three-quarters of advanced staff rotations, including complex cranial, complex spine, cerebrovascular and endovascular surgery. Additionally, three months are reserved for a dedicated neuropathology rotation. During this time, residents prepare for and take for credit the American Board of Neurological Surgery written examination. A score at or above 75 percent is considered requisite for advancement to chief residency.
A formal, required curriculum of skull base, microvascular and peripheral nerve techniques is simultaneously completed, both to facilitate anatomic study and to prepare residents for senior-level roles. Final planning decisions are made for upcoming career development years.
PGY-5 and PGY-6
Up to 24 months are allocated for career development, typically taken as a single block during the PGY-5 and PGY-6 time frame. Dedicated laboratory research, enfolded fellowships, visiting electives at Mayo Clinic's campuses in Florida and Arizona, and acquisition of advanced degrees are common academic pursuits during this time. But flexibility and adaptability to the needs of each individual resident's career are emphasized.
For residents who are pursuing a one- or two-year research block, application for a Neurosurgery Research and Education Foundation (NREF) training grant is highly encouraged. If basic research is chosen, a research plan should have been developed the preceding year with a mentor identified. Clinical research projects also may be chosen, and potentially pursued via the Clinician-Investigator Training Program or a master's degree.
The emphasis during the research year is toward the development of critical scientific methodology and production of meaningful contributions to basic science or clinical knowledge. For those pursuing additional clinical neurosurgery training, the goal is to develop advanced surgical training in a subspecialty area of interest.
Within these two years, both research and advanced clinical training can be combined. Furthermore, each resident is strongly encouraged to rotate to Mayo Clinic in Jacksonville, Florida, or Mayo Clinic in Phoenix/Scottsdale, Arizona, for advanced clinical training, notably in endovascular surgery, complex adult spine surgery or minimally invasive spine surgery.
PGY-7 (chief resident)
During the final 12 months of training, chief residents have responsibility for managing their own clinical service and operating room. This is unique among training programs.
Perhaps the greatest strength of our singular training program is that the Mayo Clinic chief residency allows senior trainees to function as junior faculty with the privileges of an autonomous starting operating room in which they are the primary surgeons. Chief resident cases are booked on an elective basis from their own active clinical practices. Further, the chief residents manage all emergency neurosurgery cases and in-house consultations, providing for consultant-level decision-making and management across the full breadth of neurosurgery.
During this time, the chief resident alternates emergency call, elective surgery and outpatient consultation on a daily basis with a chief resident partner — a schedule akin to that of our full-time faculty. Chief residents are given the opportunity to rotate again for three to six months acting as primary residents on senior faculty services to acquire additional expertise in areas of subspecialty training such as spine, cerebrovascular, endovascular, skull base, tumor, epilepsy, peripheral nerve, stereotactic surgery or radiosurgery.
Residents work with these specialists:
- Nicholas M. Wetjen, M.D., and David J. Daniels, M.D., Ph.D. Pediatric neurosurgery rotations concentrate on pediatric brain tumors, epilepsy and intraventricular endoscopy, in addition to other pediatric cases and patient care.
- Fredric B. Meyer, M.D. Brain tumors and vascular and epilepsy surgery.
- W. Richard Marsh, M.D. Epilepsy and spine surgery.
- John L. D. Atkinson, M.D. Pituitary tumors, spine and sympathectomy.
- Robert J. Spinner, M.D. Peripheral nerve surgery.
- Ian F. Parney, M.D., Ph.D., and Terrence (Terry) C. Burns, M.D., Ph.D. Intra-axial brain tumors, Gamma Knife and awake brain surgery.
- William E. Krauss, M.D. Spine tumor and complex spine surgery.
- Bruce E. Pollock, M.D. Gamma Knife, trigeminal neuralgia and brain tumors.
- Michael J. Link, M.D. Skull base, acoustic neuromas, Gamma Knife and vascular surgery.
- Giuseppe Lanzino, M.D. Endovascular and open vascular surgery.
- Kendall H. Lee, M.D., Ph.D. Deep brain stimulation, pain and functional neurosurgery.
- Jeremy L. Fogelson, M.D. Complicated spinal deformity correction.
- Michelle (M.J.) J. Clarke, M.D. Spinal oncology and complicated spine surgery.
- Jamie J. Van Gompel, M.D. Skull base, endoscopic pituitary surgery and epilepsy.
- Mohamad Bydon, M.D. Spinal oncology and minimally invasive spine surgery.
Neurosurgery residents may choose to complete clinical rotations at Mayo Clinic in Jacksonville, Florida, or Mayo Clinic in Phoenix/Scottsdale, Arizona. Mayo Clinic fully funds all incumbent costs, including travel, housing, automobile rental and licensure fees.
These rotations have been approved by the American Board of Neurological Surgery as containing significant educational merit, and Mayo Clinic encourages trainees to take advantage of the associated opportunities, including advanced exposure to additional subspecialty training, notably in vascular and complex spine surgery. The cumulative case volume available for training at Mayo Clinic's campuses in Florida and Arizona is approximately 3,500 cases.
Didactic conferences are held on a daily basis for one hour, prior to the initiation of the day's operative calendar. Conferences are held in the neurosurgery department at Mayo Clinic Hospital — Rochester, Saint Marys Campus, and resident attendance is mandatory.
The typical weekly schedule is:
Neurosurgery Grand Rounds — Monday
The administrative chief resident organizes this conference. There is an alternating form, which includes case presentations and discussion, a monthly morbidity and mortality conference dedicated to discussion of complications and quality assurance issues, and a cerebrovascular conference. Didactic lectures and presentations by visitors, Mayo staff and residents also complement this forum. All faculty and residents attend this conference.
Cranial Board Preparation Clinical Conference — Tuesday
Complex cases are presented by Drs. Meyer, Van Gompel, Link and Parney, in which preoperative diagnosis, surgical approaches technical pearls and postoperative complications are discussed.
Spine Board Preparation Clinical Conference — Wednesday
This is a rotating conference focusing on spinal disorders. The agenda alternates between spine journal club, spine trauma case conference, nontrauma case conference and didactic lectures. The course is taught by joint faculty from the orthopedic surgery and neurological surgery departments. Case conferences are resident driven, whereas didactic lectures are consultant driven.
Core curriculum — Thursday
The first Thursday of every month is a resident-led, board-focused didactic lecture. The second Thursday is Research Grand Rounds, where investigators present their research to the residents to help inform them of opportunities available for pursuit during their career development years. The third Thursday is dedicated to cranial journal club, the fourth Thursday is dedicated to pediatric journal club, and the fifth Thursday is a chairman's conference, during which Dr. Spinner meets with the residents to discuss a broad range of academic, administrative or other salient topics.
Neuro-Oncology Conference — Friday
This is a multispecialty-combined conference in which four interesting brain tumor cases are presented and discussed. The faculty from all the neuroscience specialties including neurology, medical oncology, neuropathology and neuroradiology are in attendance. The format of this conference is standardized and educationally targeted, incorporating the case presentation, pertinent radiology, surgical approach, pathology and adjunctive treatment with an open forum for discussion and analysis as required and appropriate.
Multiple subspecialty conferences are held daily throughout Mayo Clinic, which are all open to neurosurgery residents. These include a neuroradiology conference, surgical epilepsy conference, pediatric neuro-oncology conference and many others.
The mandatory one-hour teaching conferences five days a week from 7 to 8 a.m. focus on both general and subspecialty neurosurgery. The subspecialty conferences include vascular, spine, epilepsy, neuro-oncology and neuroradiology. These are held in conjunction with the appropriate medical and radiological services.
Neurosurgery residents regularly contribute to the educational process, preparing case presentations, journal clubs and didactic lectures.
Call schedules vary by individual rotation. Mayo Clinic's Department of Neurologic Surgery follows the duty hour guidelines of the Accreditation Council for Graduate Medical Education (ACGME).
All residents share the in-house emergency call assignments equally during the time that they are assigned to clinical neurosurgery service, as well as during certain elective and basic science rotations. Therefore, the frequency of a resident actually being in the hospital overnight to cover trauma and the emergency room is modest.
Residents on clinical neurosurgery services are expected to respond to calls regarding their own patients throughout the day and night. In-hospital night call covering emergencies occurs on average one out of every 10 to 13 days, as does "backup call," which is typically taken from home.
Neurosurgery residents have the opportunity to teach Mayo Clinic School of Medicine students and visiting students from other medical schools, through bedside instruction, formal didactic lectures and voluntary participation in the anatomy curriculum.
Neurosurgery residents are expected to engage in scholarly pursuits, including clinical research projects, and during the elective research year, to participate in dedicated study and basic laboratory investigation under the direction of a research mentor. Members of the Department of Neurologic Surgery and other established investigators within Mayo Clinic's research departments serve as mentors and also assist the resident in developing the research proposal well in advance of the research year.
Financial support and call coverage is generally made available to residents whose research is accepted for presentation to national or regional neurosurgery meetings.
Neurosurgical oncology laboratory
This laboratory focuses on the cellular and immunological characteristics of malignant brain tumors. Particular areas of interest include immunotherapy, brain tumor stem cells and mouse models of malignant gliomas. Our laboratory has demonstrated that an interrelated cellular network mediates immunosuppression in patients with malignant gliomas, including glioma cells (differentiated and stem cell phenotypes), tumor-infiltrating monocytes-microglia, circulating myeloid-derived suppressor cells and regulatory T cells.
Multiple molecular mechanisms contribute to these cells' effects, but evidence from our lab has implicated a central role for the immunosuppressive T cell costimulatory molecule homologue B7-H1. Much of our work is aimed at disrupting this network to facilitate immunotherapies and develop appropriate murine models of glioma-mediated immunosuppression to allow preclinical testing.
A major aim of our work is to translate discoveries to the clinic through glioma vaccine clinical trials, an effort that is facilitated by the presence of a Good Manufacturing Practices (GMP) laboratory for generating clinical-grade cellular therapy reagents at Mayo Clinic. Additionally, members of the Mayo Clinic Brain Cancer SPORE work closely with this laboratory. Specialized Program of Research Excellence (SPORE) grants are highly competitive group grants awarded by the National Cancer Institute for translational cancer research programs. Only three Brain SPOREs have been awarded nationwide, underscoring Mayo Clinic's exceptional capacity to perform translational research in neuro-oncology.
Neurosurgery regenerative laboratory
This group engages in advanced research in regenerative neuroscience from the molecular to cell biological and integrative levels. Specific topics under investigation include: molecular analysis of receptors and signal transduction mechanisms; axon guidance, target recognition and regeneration; formation and plasticity of synapses; control of neural cell fate; development of neural networks; regulation of glioma cell motility; and mechanisms controlling vascular development and regeneration.
The lab offers an integrated approach to training in modern neurobiology, utilizing molecular, biochemical and cell biological techniques as well as advanced optical imaging. Members of the lab have the opportunity to work closely with the spinal cord injury research team at Mayo.
Neural Engineering Laboratory
High-frequency deep brain stimulation (DBS) is an effective treatment for Parkinson's disease, tremor, epilepsy, dystonia and depression. However, the precise mechanisms of action for the therapeutic effects of DBS are unknown. Since both DBS and lesionectomy target similar brain regions, it has been thought that electrical stimulation works through neuronal inhibition. However, our lab has found that DBS results in excitation of neuronal and glial elements, suggesting that electrically excited neurotransmitter release may be the mechanism of action of DBS.
Accordingly, the Neural Engineering Laboratory is studying how DBS affects changes in neuronal action potential firing and modifies neural network activities. To study the mechanism of action of DBS, we perform fluorescent microscopy along with intracellular and extracellular electrophysiological recordings. In addition, our lab also utilizes electrochemical techniques of constant potential amperometry to measure neurotransmitter levels both in the in vivo and in vitro setting.
Through this research, our lab hopes to combine sophisticated electrophysiological recordings with miniaturized analytical elements (microprocessors) to augment and repair disrupted brain functions. Thus, we are actively involved with biomedical engineers to develop the next generation of DBS devices.
Multidisciplinary neural regeneration laboratory
This laboratory effort focuses on developing synthetic polymeric scaffolds and controlled delivery of bioactive molecules for peripheral nerve and spinal cord repair and regeneration. This National Institutes of Health (NIH)-funded research endeavor combines strong collaborative efforts of neurosurgeons, neuroscientists, orthopedists, tissue engineers, and cellular neurobiologists and polymer chemists. The goal of this project is to introduce and commercialize biodegradable conduits for clinical use.
Additional training opportunities
The Clinician-Investigator Training Program is available to residents who wish to prepare for an academic career involving a significant research component. This competitive program provides support for an additional one to two years of research outside of the usual scheduled resident rotations.
Upon completion, a certificate in clinical investigation for a master's degree in neurosurgery is awarded.
Clinical research training program
The Center for Clinical and Translational Science offers programs designed to train future investigators in clinical research through a curriculum focused on research methodology, complemented by mentor-based training in the research environment.
Options include a master's degree in clinical research, or a shorter program awarding a certificate in clinical research.
There is a formalized pathway available to neurosurgery residents for obtaining a doctorate in molecular neuroscience, biomedical engineering or molecular physiology, which requires a minimum of two to three years of study and research, culminating in a dissertation.
The in-residency doctoral program has been designed to maximize flexibility, allowing for an individualized curriculum, with appropriate oversight from an advisory and mentorship committee.
This program, offered in conjunction with Mayo Clinic Graduate School of Biomedical Sciences, should be strongly considered by neurosurgical residents interested in obtaining advanced basic science experience for a career in academic neurosurgery.
Residents are encouraged to meet formally and informally with the department chair, program director and individual mentors on a regular basis to discuss career goals. The program director takes a sincere interest in tailoring a resident's training program to career objectives and actively participates in job searches on behalf of the residents.
Mayo Clinic neurosurgery residents have been highly successful in competing for both academic and private practice positions, consistent with their individual goals.
Performance is carefully monitored throughout the course of the Neurologic Surgery Residency with an eye toward operative skill, clinical judgment, academic productivity and career development. After each three-month clinical rotation, residents are evaluated formally by their supervising faculty.
Additionally, residents meet individually with the program director on a semiannual basis to review their performance and discuss career goals in detail to dynamically individualize their training program.
All residents sit for the American Board of Neurological Surgery written examination during their PGY-2 and PGY-3 years for self-assessment, and for credit during their PGY-4 year. A three-month neuropathology rotation provides supplemental basic science education and opportunity for independent study immediately prior to formal examination. Residents are expected to pass at a 75 percent or higher level before being qualified for the chief resident year.
As part of our regular examination of residents to monitor their progress and also help prepare for the future oral board examination, annual oral examinations in clinical neurosurgery and neurology are administered. The format is similar to that of the certifying oral examination given by the American Board of Neurological Surgery after completion of training. Feedback from the program director and director of resident education is provided.
An electronic case log program tracks all resident operative cases, with salient details auto-populated from the operative report and prepared for review and submission to ACGME case log. The case volume and mixture is carefully analyzed to ensure that each resident is obtaining in-depth expert training in all areas of neurosurgery. If areas of deficiency are identified, the resident's rotations are adjusted accordingly to provide an appropriately balanced education.