best essay on neurosurgeon

So You Want to Be a Neurosurgeon

• By Kevin Jubbal, M.D.
• March 8, 2020
• Accompanying Video , Medical Student , Pre-med
• Residency , So You Want to Be , Specialty

Welcome to our next installment in So You Want to Be. In this series, we highlight a specific specialty within medicine, such as neurosurgery, and help you decide if it’s a good fit for you. You can find the other specialties on our So You Want to Be playlist. A lot of you asked for neurosurgery in our poll, so that’s what we’re covering here. If you want to vote in upcoming polls to decide what future specialties we cover, make sure you’re subscribed.

If you’d like to see what being a neurosurgeon looks like, check out my personal Youtube channel, , where I do a second series in parallel called A Day in the Life . We’ll be doing a Day in the Life of a Neurosurgeon soon and you don’t want to miss it.

What is Neurosurgery?

Neurological surgery, or neurosurgery for short, is much more than just brain surgery. The nervous system is comprised of two main components — the central nervous system, or CNS, and the peripheral nervous system, or PNS. Try saying that one 5 times as fast as you can. The CNS includes the brain and spinal cord, whereas the PNS includes all other nerves within the body. Neurosurgery deals with surgical interventions of both.

There are two overarching categories to neurosurgery: 1) Elective surgery, and 2) Emergent (i.e. non-elective) surgery. Elective surgeries take place on a non-emergent basis and generally involve treating conditions that are not immediately life-threatening. They tend to fall into one of three categories: Cranial surgery ,  spine surgery , and  peripheral nerve surgery .

Cranial Surgery

Cranial surgery, as it sounds, involves operating on structures within the head (i.e. the brain). This category can be further subdivided into a few more subcategories: tumor surgery, vascular surgery, and functional neurosurgery.

Tumors in the brain come in all shapes and sizes. They can be benign or malignant, slow or fast-growing, life-threatening or not. Some tumors can be observed without ever needing treatment, while others can be treated with radiation, but often, given the limited space afforded by the human skull, and the sensitive nature of the brain’s tissues, a neurosurgeon is called upon to surgically resect a tumor in the brain.

Vascular neurosurgery involves treating abnormalities in blood vessels of the brain. Neurosurgeons might treat an aneurysm on a vessel, or bypass a blockage or narrowing of a vessel, much the same way you would do coronary bypass in the heart. Though rather than opening the chest, of course, neurosurgeons work through a small hole in the skull.

Functional neurosurgery is the sexy stuff — the science fiction of the field. In functional neurosurgery, the brain is viewed as one large complicated electrical circuit, and neurosurgeons try to modulate the circuit to bring about a desired outcome. This might involve placing electrodes within the brain to stimulate certain structures, or creating lesions with radiation, ultrasonic energy or simple thermal ablation to effectively “turn off” structures that might be causing a problem for a patient. Functional neurosurgery addresses pathologies such as Parkinson’s disease, tremors, and obsessive-compulsive disorder, among others. Though what’s most exciting about this subset of cranial surgery is what it hopes to treat in the future – things like chronic pain, depression, PTSD, and substance addiction.

Spinal Surgery

Within spine surgery, there are a few subcategories as well: we’ll call them “degenerative”, “scoliosis”, and “tumors”.

The vast majority of spine surgery is done to treat good old fashioned wear and tear, or degenerative disease, of the spine. As you might expect, degenerative disc disease and osteoarthritis of the spine tend to occur in the cervical spine, or neck, and lumbar spine, or lower back, which are the two most mobile parts of the spine. Your thoracic spine is less mobile because of your ribs (which create additional support and limit mobility). With these degenerative processes, the spinal cord itself or nerve roots exiting the spine can become compressed, leading to pain and weakness. Surgeons often are required to decompress these structures by removing certain elements of the spine. When removing these bony arthritic spurs, or degenerated discs, the integrity of the spine can become compromised, which can require a spinal fusion to restore stability, although the fused segment has increased rigidity. Fusion is often achieved with rods and screws, and in some cases with disc replacement hardware.

Spine surgery also includes repair of scoliosis, whereby curvature of the spine can become so severe as to cause pain, difficulty breathing, or other functional deficits. It’s important to note that spinal decompression surgeries and scoliosis repair can be performed by either neurosurgeons or orthopedic surgeons. However, the removal of tumors of the spinal cord is performed exclusively by neurosurgeons. While a tumor in the liver or breast can be relatively quickly resected, removing tumors around the spine can be quite involved, and take a long time – even for small tumors – due to the care and precision required to leave the spinal cord uninjured.

Peripheral Nerve Surgery

Peripheral neurosurgery, as the name suggests, involves operating on the peripheral nervous system. This includes all nerves outside of the brain and spinal cord. These nerves can sprout tumors, or become injured in an accident. In such cases, a neurosurgeon may be called upon to remove that tumor, to reconnect severed nerves, or in some cases to connect part of a healthy, working, nerve to a damaged nerve in the hopes that a patient can regain function of that nerve over time.

Emergent/Trauma Surgery

If you’re a trauma surgeon, you take shifts and handle traumas that come in on your shift. If you’re a neurosurgeon, you have to operate on your scheduled cases but also take neurosurgery trauma call on top. It’s just part of the job. This includes traumatic injuries to both the cranium and spine. Both are very urgent.

Compared to other parts of the body, the skull is a fixed space, which results in its own set of issues. If you bleed into your abdomen, you’re concerned about exsanguination, meaning you can bleed out and die, as your abdomen can distend to accommodate a large volume of blood. In the cranium, however, a fixed space means that as you bleed, pressure increases, resulting in compression of the brain. You won’t ever exsanguinate as the skull is too small, but brain bleeds are deadly due to brain herniation, meaning compression and pushing of critical structures through the foramen magnum outside the skull. Alleviating pressure is key, and this is done with a decompressive hemicraniectomy, meaning removing part of the skull to create space for the brain to swell after it has been injured. The excised segment is kept in the freezer and the neurosurgeons can put it back weeks or months later when the brain swelling has resolved.

There are four main types of brain bleeds — epidural hematomas, subdural hematomas, subarachnoid hemorrhages, and intraparenchymal hemorrhages.  Epi-  means above and  -dural refers to the dura, the outermost layer of the meninges covering the brain. Epidural hematomas are bleeds most commonly from the middle meningeal artery in the space below the skull but above the dura. With an arterial source, these bleed quickly, and usually result from blunt trauma to the head. Subdural hematomas are below the dura and are more common amongst elderly patients on blood thinners. These are venous bleeds and slower in nature, but can be equally urgent and life-threatening Subarachnoid hemorrhages result from an aneurysm rupturing, and because it’s below the arachnoid layer of the meninges, the blood fills the sulci of the brain, meaning all the nooks and crannies, effectively coating the brain in blood, which can be toxic. Intraparenchymal hemorrhages are bleeds within the actual tissue of the brain, and this can result from long-standing hypertension resulting in arteriosclerosis, or other reasons.

Ruptured aneurysms are usually handled by neurosurgeons, but sometimes by endovascular surgeons or interventional radiologists. Treatment is either coil placement or placing a clip over the aneurysm.

Intraparenchymal hemorrhages can sometimes become large enough that they need to be evacuated. In those cases, a neurosurgeon might make an opening in the skull and work their way down to the hematoma to evacuate as much blood as safely possible without damaging surrounding structures.

If a patient fractures their spine, the spinal cord can become compressed, or even severed. In such cases, it is important to relieve pressure on the spinal cord quickly. Urgent decompression is often required, as is stabilization to reduce additional uncontrolled movement and further injury. This is why you see C-spine collars placed on trauma patients – for stability and to reduce the risk of additional spinal cord injuries.

How to Become a Neurosurgeon

To become a neurosurgeon, you’ll have to complete a neurosurgery residency after medical school. Neurosurgery has the longest residency start to finish, lasting 7 years in duration. Most residencies will include one year of dedicated research time, though not all.

In terms of competitiveness, neurosurgery is consistently in the top five, in most recent years being  ranked third , only behind dermatology and plastic surgery. Neurosurgery candidates are top students, with very high Step 1 and Step 2 scores, generally only a few points below the average dermatology or plastic surgery matriculants. But what truly sets neurosurgery applicants apart is their research. The average matriculant in 2018 pumped out over 18 publications, abstracts, or presentations by the time they applied to residency. In comparison, plastic surgery and dermatology were at 14 with orthopedic surgery at 10. Most other specialties didn’t even break 7.

Why the focus on research in neurosurgery? Neurosurgery is a highly academic field, likely due to the fact that there is so much room to improve outcomes in patients. Residencies want to train surgeon scientists who will advance the field. While treatment modalities and outcomes have improved drastically in the past 20-30 years, there are several pathologies with bleak outcomes. For example, glioblastoma multiforme, or GBM for short, had an average prognosis of about 5 months over a century ago. Despite all the technological advancement since, these days, even after aggressive surgery, radiation and chemotherapy, median survival has improved to only 14-16 months

Medical students that end up applying to neurosurgery are a unique bunch and are a self-selecting group. They take the meaning of workaholic to the next level. The award for most brutal and rigorous residency, even amongst surgical residencies, is usually reserved for neurosurgery. Despite the 80-hour workweek restrictions enacted by the ACGME, it’s not uncommon to see neurosurgery residents exceeding these limits repeatedly. The good news is that as an attending, the days of working 90 hour weeks are now behind you, but that won’t always be the case in residency.

Subspecialties within Neurosurgery

After completing residency, you can practice as a general neurosurgeon, or choose to sub-specialize further with fellowship.

Skull-base  is primarily concerned with tumors that grow along the base of the skull, which is notoriously high end real estate. It’s a shrinking field, mainly because less invasive options like radiosurgery and endovascular procedures are becoming more sophisticated and appealing for patients, but it’s still an appealing subspecialty. Those with the best hands and stamina for 18 hour-plus surgeries go here. It’s a young man’s game.

Neurovascular  is highly technical, dealing with aneurysms, hemorrhagic strokes, and bypassing blockages in the brain. Call schedule is brutal, attracting those who are gluttons for punishment. Outcomes can sometimes be particularly grim, which can take a toll over the course of one’s career. You’ll need a strong stomach.

Functional and stereotactic surgery deals with modulating the electrical circuitry of the brain. These are the nerds of the nerds, usually with Ph.D.’s after their name or computer science background.

Spine  is for the jocks and ortho bros. There’s a great deal of bony work, thus requiring a higher degree of strength and on average less finesse than other aspects of neurosurgery.

Pediatrics is for the neurosurgeons who are best at dealing with parents. A strong stomach is a prerequisite as children needing neurosurgical intervention generally don’t have rosy outcomes.

Peripheral nerve  is perhaps the smallest subspecialty within neurosurgery, partly because it’s not exclusive to neurosurgeons (you can get there through orthopedics or plastic surgery). It’s for surgeons who enjoy operating all over the body, since the peripheral nervous system exists everywhere outside of the brain and spinal cord.

Surgical neuro-oncology  tends to attract surgeons with an interest in tumor biology. These surgeons may spend up to half of their time in the research lab, studying additional methods for tumor treatment beyond simple surgical resection. This is because a large subset of brain tumors don’t respond to just surgical resection (like GBM).

Trauma/neurocritical care is for those surgeons who wish to focus on the multi-disciplinary treatment of patients with traumatic neurological injuries. Beyond performing life-saving surgeries, these folks are interested in the longer-term post-operative recovery process for patients suffering from TBI, spinal cord injury, aneurysm rupture or hemorrhagic stroke.

What You’ll Love About Neurosurgery

As a neurosurgeon, you’ll be working on arguably the most fascinating and mysterious organ of the body — the brain. Psychiatrists and neurologists deal with the brain as well but in a non-surgical capacity. You’ll get to touch, change, and augment the central nervous system right in front of you, in real-time.

It’s a highly innovative field, particularly the subspecialty of functional neurosurgery, where the line is blurred between what is you and what is hardware. It raises questions about free will, consciousness, and other questions that are bound to keep you up late at night.

Only a few specialties truly save people’s lives. Neurosurgery is one of them. At a moment’s notice, you may be called in and rush to the hospital to save someone’s life. While the surgeries may become routine, the feeling of saving someone’s life never will. Trauma and emergency medicine are some other specialties that share this aspect.

Neurological surgery is a highly academic field, satisfying even the most intellectually curious. You’ll be surrounded by driven and truly impressive colleagues cut from the same cloth. To quote my neurosurgery friend, “not to say we’re better than everyone, but we are.” He’s joking of course, but only a little.

As a doctor, you normally need to choose between honing surgical expertise and foregoing medical management, or vice versa. That’s one thing I didn’t enjoy about plastic surgery. I wasn’t managing patients medically so much, just more so surgically. As a neurosurgeon, you’ll be handling the medical side of things quite intensively — titrating sedatives to adjust for intracranial pressure abnormalities, adjusting ventilator settings, and reading EEG’s to see if someone is seizing. You won’t quite be a cardiothoracic surgeon, who are the most badass in terms of medical management while being surgeons, but you won’t miss the medical side of medicine.

In medical school, I rotated on orthopedic surgery, plastic surgery, and neurosurgery, the three specialties I was considering most seriously. One thing I loved about neurosurgery was the personalities. Some of the funniest and coolest surgeons I worked with were neurosurgeons. This isn’t uncommon. The field is very humbling, and despite the stereotype, neurosurgeons are faced daily with the reality that they are not god. You can’t take yourself too seriously and you’ll need to learn to laugh at yourself, otherwise, you won’t last.

What You Won’t Love About Neurosurgery

There were two main factors that pushed me away from neurosurgery, despite my love for neuroscience and fascination with the brain. First, think about the types of patients that need neurosurgical intervention. They’re very sick and can often have poor outcomes. Many of your patients will succumb to immense suffering or death. That may not sound so bad right now, but day after day, year after year, that sort of heaviness will weigh on you.

The other thing that pushed me away from neurosurgery was learning that it wasn’t as precise and meticulous as I would have expected brain surgery to be. Certain aspects are highly precise, like skull-base, but much of neurosurgery is surprisingly crude and more similar to orthopedic surgery than something like plastic surgery.

But wait, there’s more. Neurosurgeons face one of the most challenging lifestyles of any specialty, even beyond residency. That’s because, in addition to scheduled cases, you’ll need to take neurosurgery trauma call. In medicine, we say that neurosurgeons make the most money, but don’t have any time to enjoy it. The median salary is $680,000 per year, and they’re consistently number 1 or number 2 in terms of highest-paid specialty, duking it out with orthopedic spine surgeons.

The field is 92% men. While not as bad as orthopedic surgery, it’s one of the most male-dominated specialties, although that is slowly changing.

The neurosurgeon stereotype comes with good and bad. For online dating apps, it’s great, but beyond that, the stereotype is difficult to deal with in the hospital. Others expect you to have a god complex, to be an asshole, egotistical, emotionless, or even sociopathic.

Should You Become a Neurosurgeon?

At this point, you’ll know whether or not neurosurgery is right for you. It’s a highly self-selecting group of people. Obviously, you need to enjoy the practice of surgery and have a deep intellectual curiosity for the brain and mind.

But beyond that, you need to really want it more than anything else. You’ll need incredible stamina to endure a brutal 7-year residency and continue to work challenging and unpredictable hours as an attending.

The stakes are high, and there’s a consistently high sphincter tone and level of vigilance. That’s because, so often, patients with neurological injuries can be incredibly hard to monitor. A patient in acute organ failure, mid-heart-attack, or exsanguinating during trauma can be hard to ignore. But in neurosurgery, potentially devastating neurological complications – such as a stroke or a brain bleed – can occur with scary subtlety. Being on top of the ball is a must.

If you’re all about that, you’ll certainly get the excitement and rush from the unpredictability of trauma. You’ll also get the highly technical aspect of something like plastic surgery. If you take deep pride in your work and have perfectionistic tendencies, neurosurgery may be a good fit.

Kevin Jubbal, M.D.

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Emphasizing the Role of Neurosurgery Within Global Health and National Health Systems: A Call to Action

Jean wilguens lartigue.

1 School of Medicine and Pharmacy, State University of Haiti, Port-au-Prince, Haiti

Olaoluwa Ezekiel Dada

2 College of Medicine, University of Ibadan, Ibadan, Nigeria

Makinah Haq

3 GKT School of Medical Education, King's College London, London, United Kingdom

Sarah Rapaport

4 Johns Hopkins School of Medicine, Baltimore, MD, United States

Lorraine Arabang Sebopelo

5 Faculty of Medicine, University of Botswana, Gaborone, Botswana

Setthasorn Zhi Yang Ooi

6 Cardiff University School of Medicine, University Hospital of Wales Main Building, Cardiff, United Kingdom

Wah Praise Senyuy

7 Faculty of Health Sciences, University of Buea, Buea, Cameroon

Kwadwo Sarpong

8 Georgetown University School of Medicine, Washington, DC, United States

Anchelo Vital

9 Department of Neurosurgery, North West General Hospital and Research Center, Peshawar, Pakistan

Claire Karekezi

10 Neurosurgery Unit, Department of Surgery, Rwanda Military Hospital, Kigali, Rwanda

Kee B. Park

11 Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Harvard Medical School, Boston, MA, United States

Associated Data

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Background: Worldwide, neurological disorders are the leading cause of disability-adjusted life years lost and the second leading cause of death. Despite global health capacity-building efforts, each year, 22.6 million individuals worldwide require neurosurgeon's care due to diseases such as traumatic brain injury and hydrocephalus, and 13.8 million of these individuals require surgery. It is clear that neurosurgical care is indispensable in both national and international public health discussions. This study highlights the role neurosurgeons can play in supporting the global health agenda, national surgical plans, and health strengthening systems (HSS) interventions.

Methods: Guided by a literature review, the authors discuss key topics such as the global burden of neurosurgical diseases, the current state of neurosurgical care around the world and the inherent benefits of strong neurosurgical capability for health systems.

Results: Neurosurgical diseases make up an important part of the global burden of diseases. Many neurosurgeons possess the sustained passion, resilience, and leadership needed to advocate for improved neurosurgical care worldwide. Neurosurgical care has been linked to 14 of the 17 Sustainable Development Goals (SDGs), thus highlighting the tremendous impact neurosurgeons can have upon HSS initiatives.

Conclusion: We recommend policymakers and global health actors to: (i) increase the involvement of neurosurgeons within the global health dialogue; (ii) involve neurosurgeons in the national surgical system strengthening process; (iii) integrate neurosurgical care within the global surgery movement; and (iv) promote the training and education of neurosurgeons, especially those residing in Low-and middle-income countries, in the field of global public health.

Introduction

In 2015, the United Nations (UN) made a commitment to ensure safe and affordable access to healthcare for every person in the world through the 3rd Sustainable Development Goal (SDG3) ( 1 ). This goal will only be achievable with strong and efficient health systems that address the different categories of diseases in proportion to the epidemiological burden they represent. An article published in the same year, 2015, estimated that 5 million people worldwide do not have access to quality, safe and affordable surgical care ( 2 ). In recent years, both governmental and non-governmental agencies have developed a keen interest in promoting access to safe and reliable surgical care. The World Health Organization (WHO), an example of such organizations, has recognized the essential role of quality surgical care in global and national efforts to achieve universal health coverage (UHC) by 2030 ( 3 ).

There is a wide range of conditions that constitute surgical diseases, and many of them are debilitating. A subset of these conditions is neurologically related and require management by a neurological surgeon. Recently, many efforts have been made to improve access to surgical care in general-an example being the country-driven National Surgical, Obstetrics and Anesthesia Plans (NSOAPs) ( 4 ). However, little effort has been focused on neurosurgery despite neurosurgical diseases being a major contributor to the global burden of death and disability ( 5 ). Diseases such as traumatic brain injury, hydrocephalus and spina bifida affect millions of children and adults worldwide ( 6 ). It is, therefore, clear that UHC cannot be achieved if neurosurgical care is not integrated and prioritized through health policies and programs to strengthen health systems.

In this article, we present the major challenges in global neurosurgery and we aim to discuss the potential benefits an effective neurosurgical system can bring to healthcare systems. Finally, we launch a call to action to urge policymakers, global health leaders and country leaders to prioritize neurosurgery and integrate it into their public health and global public health interventions.

Global Burden of Neurosurgical Diseases and the Disproportional Effect on LMICs

Worldwide, neurological disorders are the leading cause of disability adjusted life years (DALYs) lost and the second leading cause of death, according to a 2016 analysis ( 5 ). Each year, 22.6 million individuals worldwide require neurological care due to diseases such as traumatic brain injury, stroke, brain tumor, and epilepsy, and 13.8 million of these individuals require surgical intervention ( 7 ). Traumatic brain injuries are common worldwide, with a prevalence between 55 to 69 million, but disproportionately affect individuals in low- and middle-income countries (LMICs) ( 8 ). This results in an increased neurosurgical burden of disease in LMICs. Yet, each year 5 million people in LMICs will require but not receive neurosurgical intervention because of limited capacity and resources, hence necessitating an additional 23,000 neurosurgeons to meet population demands ( 7 ).

Delays in accessing care for neurological diseases lead to poor outcomes for patients. The percentage of the population with access to neurosurgical services within a 2 h window is 25.26% in sub-Saharan Africa, 29.64% in East Asia and the Pacific, 52.83% in South Asia, 62.3% in Latin America and the Caribbean, 79.65% in the Middle East and North Africa, and 93.3% in Eastern Europe and Central Asia ( 9 ). These statistics highlight the large global disparities in access to timely neurosurgical care among different populations.

The unmet neurosurgical demand in LMICs not only increases unnecessary morbidity and mortality rates, but it also produces devastating economic effects. Differing models predict gross domestic product (GDP) losses of between $3–4.4 trillion (in US dollars in 2013, adjusted for purchasing power parity (PPP) in LMICs due to the unmet need for neurosurgical care, mostly as a result of stroke and traumatic brain injuries ( 10 ), while a model looking at economic loss due to unmet epilepsy surgical needs project losses of $258.95 billion ( 11 ) (in US dollars in 2016, PPP-adjusted). These economic losses hinder the ability of LMICs to reach both health and broader sustainable development goals, thus trapping citizens in a vicious cycle of poverty.

Current State of Neurosurgical Care Around the World: Workforce Deficit and Lack of Global Neurosurgery Capacity Building in Current Global Health Efforts

Despite the advocacy efforts toward, ensuring surgical equity worldwide, an estimate of “5 billion people lack access to safe and affordable surgical and anesthesia services,” and this number is predicted to increase if critical actions are not taken. To date, neurosurgery still records an overwhelming unmet need. LMICs, in particular, have the greatest unmet neurosurgical disease burden, attributed by the small ratio of neurosurgeons per capita, and the difficulty in accessing neurosurgical care ( 12 – 14 ). Poor access to neurosurgical services is a result of many factors such as insufficient infrastructure, inadequate training, limited workforce, and the geographical location of care centers ( 15 , 16 ).

The neurosurgical workforce density is yet to meet the unmet burden of neurosurgical diseases, despite increasingly growing workforce density seen in many countries around the globe ( 14 ). Africa still has the lowest neurosurgical workforce density globally, yet there are no indicative initiatives that can fill this gap by 2030 ( 17 ). Moreover, an analysis on number of neurosurgeons in east Asian countries, conducted in 2019, found that LMICs such as Indonesia, Malaysia, and the Philippines have neurosurgeon to population ratios of 1 per 731,000, 1 per 210,000, and 1 per 807,000, respectively while high-income countries (HICs) such as Japan and Taiwan have ratios of 1 per 13,000 and 1 per 37,000, respectively ( 18 ). This geographic maldistribution of neurosurgical workforce, as seen in eastern Africa and east Asia ( 12 ), is an indication that neurosurgical equity is yet to be attained globally, therefore prompting the call for action by the WFNS Global Neurosurgery Committee to ensure that neurosurgery is well established as a global health priority.

Furthermore, the lack of neurosurgical research limits the development of neurosurgery; this is seen in countries in Southeast Asia and Africa. HICs such as the United States of America and Canada produce 90 times more research about neurosurgery than Africa and Southeast Asia combined ( 19 ). Of note, a review of the state of global neurosurgery research in the world found no published literature from 113 LMICs ( 20 ). Mitigating this issue would include initiatives such as bilateral partnerships between institutions in HICs and LMICs and the provision of opportunities for capacity-building to encourage researchers to conduct and publish research that contribute to the global neurosurgery literature in LMICs ( 21 ).

Conclusively, there is still limited global neurosurgery capacity building in training allied health professionals to aid the cases done by neurosurgeons as well as to decrease their burden. There is a huge disparity between neurosurgery programs in HICs and those in LMICs in terms of surgical equipment and the suitability of facilities, and this is compounded by the paucity of literature focused on information management for neurosurgical care in LMICs. Nevertheless, although the literature is still surfacing, there is hope that the few that exist can be used to advise policy changes in order to bridge the gap.

The Inherent Benefits of Strong Neurosurgical Capability for Health Systems

The development of the SDGs have emphasized different parameters that are integral to a sustainable development that range from healthcare to ecological welfare. SDG3 (good health and well-being) introduces the narrative of global surgery which, in turn, has accumulated interest in ensuring the development of global surgical provision is effective and equitable, especially through the 2015 Lancet Commission on Global Surgery which previously focused on the lack of surgical care worldwide ( 2 ). Within this scope, there is an increasing need for physician-led management and leadership to develop these health systems on a global scale. Currently, the recent yet rapid development of global neurosurgery has demonstrated that there are many neurosurgeons who possess the sustained passion, resilience, and leadership needed to advocate for improved neurosurgical care worldwide.

Given the cross-cutting nature of neurosurgical care, developing this area in healthcare systems creates the ecosystem for the majority of other health interventions. Therefore, improving neurosurgical care will improve the whole health system in every domain, especially in terms of workforce, infrastructure and service delivery. Furthermore, the key traits necessary in effective leadership and management are uniquely developed via the process of neurosurgical training. Neurosurgical training is an arduous and competitive process which involves making difficult decisions under highly stressful situations on a daily basis. The skills and attributes seen in neurosurgeons have piqued interest about potential neurosurgeon involvement in developing health systems ( 22 ). The duties and scope of neurosurgery has been linked to 14 of the current 17 SDGs highlighting the tremendous impact neurosurgeons can have within wider development, let alone health systems ( 23 ). Andrews et al. has suggested drawing inspiration from models of neurosurgical care in certain LMICs to build response systems to natural disasters ( 24 ).

The Global Neurosurgery Movement: Purpose and Vision

The primary purpose of global neurosurgery must be to reduce disparities in global care and to allow the area of need to become independent, self-sustaining, and creative in its care. Global neurosurgeons can play a role in inspiring the next generation of students interested in neurosurgery ( 25 ). Increasing the exposure of neurosurgery to medical students will enable the interest in the specialty to be nurtured in as many individuals as possible at an early stage in their career. Training more neurosurgeons and neurosurgery capable providers will be an effective solution for closing the gap in the neurosurgeon to population ratio.

Lastly, the success of global neurosurgery can only be realized if founded on the principles of cultural sensitivity ( 26 ). It is imperative to listen to the experts and leaders in the countries of need, to let them tell us their needs, goals, and aspirations, and to champion for sustainable change and progress in solving these problems.

The significant volume of neurosurgical diseases in the global burden of disease makes their treatment essential in the marathon toward UHC. Furthermore, neurosurgical care has been linked to the SDGs and the positive impact of neurosurgeons within health systems has been reported and established. The workforce is one of the most important pillars within a health system and the great disparity between the density of the neurosurgical workforce between HICs and LMICs is one of the biggest contributors of health inequity around the world. Establishing the structures necessary for surgical care will have significant benefits for the overall health system.

Several advocates for global health have raised their voices recently to stress the fact that surgical care is neglected within overall health. Neurosurgery itself is yet to be of priority on the global health agenda despite being one of the most important disease categories in terms of disease burden and mortality. This is probably linked to the lack of involvement of neurosurgeons both globally and nationally in the decision-making spheres of public health policy. To remediate this problem, we urge policymakers, global health actors and governments to:

Increase the Involvement of Neurosurgeons Within the Global Health Dialogue

The most effective and efficient way to ensure that a topic is mentioned and meaningfully considered in a discussion is to have the actors concerned at the meeting. Global health conferences are important platforms to prioritize global health interventions and to decide, for example, the projects which will receive funding. They also make it possible to forge collaborations between actors from different countries and regions in order to advance research and interventions in the various fields of global health. Active inclusion of neurosurgeons in these high-stakes meetings is therefore essential to ensure that neurosurgical care is part of the overall health agenda. The representation of the World Federation of Neurosurgical Societies (WFNS) at the world's largest global health meeting, the World Health Assembly, is an example to be encouraged and replicated nationally and at other major global health meetings around the world ( 27 ).

It is important to stress, however, that representatives of LMICs are often under-represented at these conferences. Velin et al. have described the most important barriers to effective participation of global health actors from LMICs in global health meetings around the world ( 28 ). These barriers include high travel costs, difficulty obtaining visas, and a marginal acceptance rate for research presentations. The solutions offered to address these challenges include the relocation of conferences to countries more likely to issue visas for these conferences, the provision of travel grants for LMIC delegates, and the development of mentoring and research capacity building programs. We recognize that the involvement of neurosurgeons from LMICs will not be possible without the application of such or similar solutions.

Involve Neurosurgeons in the National Surgical System Strengthening Process

Following the recommendation of The Lancet's Global Surgery Commission, many countries have initiated the NSOAP process with the aim of strengthening their surgical systems ( 4 ). The NSOAP is a broad process that involves improving several areas of the national health system such as consolidating the workforce, constructing adequate infrastructure and enhancing service delivery.

Surgical care includes a range of subspecialties ranging from cardiothoracic surgery, transplant surgery to neurosurgery. An optimal surgical system should have all of these subspecialties available. We urge representatives of ministries and other local and international actors involved in the establishment of NSOAPs to include neurosurgeons in the team. Involving neurosurgeons will ensure that neurosurgical care is part of the discussion. The selection of a neurosurgeon as the lead of the WHO Emergency and Essential Surgical Care service has been acknowledged as a milestone for the development of the global neurosurgery field ( 29 ).

Integrate Neurosurgical Care Within the Global Surgery Movement

Global neurosurgery is a fairly new sub-discipline of global surgery which is already widespread. Global neurosurgery is defined as “the clinical and public health practice of neurosurgery with the primary purpose of ensuring timely, safe, and affordable neurosurgical care to all who need it” ( 30 ). As the global surgery movement is expanding, we must make sure that neurosurgery is fully integrated into its development. It is important to ensure that neurosurgery does not develop as a separate discipline, disconnected from the rest of the surgical community.

Promote the Training and Education of Neurosurgeons, Especially Those Residing in LMICs, in the Field of Global Public Health

National efforts are essential for the development of neurosurgical care that is safe, of quality and accessible within the recommended timeframes. However, actions taken at global and regional level have proven that they can be effective in improving access to surgical care, especially within the local workforce. The WFNS training center in Rabat is a good example. Established in 2002, within 15 years, the center has provided partial and full training to more than 58 neurosurgeons who have since been involved in the delivery of neurosurgical care in Sub-Saharan Africa (SSA) ( 31 ). The passion for training in neurosurgery, nurtured by this centre's success, has propagated a positive “ripple effect” which has led to a 5-fold increase in the number of neurosurgeons in SSA, from 79 in 1998 to 369 in 2016 ( 32 ). The long-term outcome of these initiative has been phenomenal and is worthy of replication and expansion in other populations. Such programs are golden opportunities to introduce a cluster of LMIC-based neurosurgeons to global health advocacy, particularly the global neurosurgery field.

These efforts would be similarly beneficial for other regions like Asia, particularly Southeast Asia. Published reports have described the first-ever Southeast Asian 3-day neurosurgical boot camp, held in Myanmar, which attracted 40 neurosurgery residents from 7 countries from Southeast Asia ( 33 ). An evaluation of the teaching delivered at the camp conducted 6 months after its completion found a significant improvement in the participant's knowledge, attesting to the effectiveness of these camps in increasing retained knowledge of the participants. While this is a step in the right direction, providing training beyond boot camps is critical if shortage of neurosurgeons is to be reduced. More, long-term training programs is needed to provide delegates with a wider range of skills and to boost their confidence in managing neurosurgical diseases. Sustainable North-South collaborations such as that between Mulago Hospital Department of Neurosurgery in Kampala, Uganda and Duke University Medical Center in Durham, USA should be encouraged in Southeast Asia ( 34 , 35 ). This exemplary collaboration takes a threefold approach in developing neurosurgical capacity through technology, twinning and training. Within the 2 years after the program began, there was a reported significant increase in the number and complexity of cases performed as well as the number of multiple-case days; this was promising evidence of improved productivity and efficiency of the workforce.

Of note, Dr Iftikhar A. Raja has placed a spotlight on Japan as a potential leader and host of such initiatives in the region, given the advanced state of their neurosurgical education, workforce density, access to the adequate equipment and the latest technology, and mastery of high-leveled techniques ( 36 ). This article hopes to encourage HICs such as Japan to consider developing similar programs to help improve the state of education and training for neurosurgeons in Southeast Asia.

Neurosurgeons must be provided the opportunity to navigate the world of global health in order to contribute their skills, knowledge and tenacity in expanding their role to increase access to neurosurgical care for the populations they serve. We, therefore, strongly recommend that neurosurgeons, especially those in LMICs, are given the support they need, included and valued during discussions, and likewise, for them to make the most of the opportunities given, as a step in the right direction to achieving equitable health for all across the globe.

Data Availability Statement

Author contributions.

JL: conceptualization, writing of original draft, and editing. OD, MH, SR, LS, WS, and KS: writing of original draft and editing. SO, AV, TK, and CK: reviewed the writing and editing. KP: validation, reviewed the writing, and editing. All authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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What Does a Neurosurgeon Do?

What to Expect From the Surgical Brain Specialist

What Is a Neurosurgeon?

• Conditions Treated
• What Neurosurgeons Do
• Subspecialties
• Your Appointment

A neurosurgeon, also known as a neurological surgeon, is a highly skilled medical professional who specializes in surgery of the brain, spinal cord, peripheral nerves, and cerebrovascular system.

Neurosurgeons are trained to treat a wide range of congenital brain disorders, traumas, tumors, vascular disorders, infections, stroke, and degenerative spinal diseases. A neurosurgeon is similar to a neurologist in that both treat conditions of the brain and nervous system, but only neurosurgeons perform surgery.

This article discusses neurosurgeons, how they are trained, and the different kinds of surgeries they perform.

The nervous system is a complex, sophisticated system that regulates and coordinates body activities. As a field of medicine, neurology focuses on three specific organ systems: the central nervous system (CNS), the peripheral nervous system (PNS), and the intracranial cerebrovascular system (the network of arteries and veins that deliver blood to the brain).

Neurologist vs. Neurosurgeon

Neurosurgeons are closely associated with neurologists in that both require specialized knowledge of the nervous system. While neurologists and neurosurgeons both diagnose and treat neurological disorders, only neurosurgeons perform surgery. Orthopedic surgery also frequently overlaps with neurosurgery when it involves the spine.

What Conditions Do Neurosurgeons Treat?

The conditions a neurosurgeon may be called to treat can be broadly described by their underlying cause.

These include:

• Congenital malformations , such as anencephaly , aneurysm , hydrocephalus , or spina bifida
• Traumatic injuries of the spinal cord , peripheral nerves, or brain (including skull fractures and brain hemorrhage)
• Benign or cancerous tumors of the brain or spine
• Vascular disorders , including arteriovenous malformations (AVM) and capillary telangiectasia
• CNS infections , such as meningitis , encephalitis , vertebral osteomyelitis , and epidural abscess
• Degenerative spinal disorders , including spinal stenosis and spinal disc herniation
• Epilepsy and movement disorders , such as Parkinson's disease , essential tremor, and dystonia
• Treatment-resistant psychiatric disorders , including severe obsessive-compulsive disorder (OCD), Tourette's syndrome, and major depressive disorder (MDD)
• Intractable (hard to control) pain associated with cancer, trauma, or other causes

Neurosurgery requires a high degree of technical expertise, as well as exceptional manual dexterity skills. The tools used in the trade are extensive, many of which employ cutting-edge technologies, including microsurgery and brain implants.

Key to the success of neurosurgery is the array of radiology tools used to diagnose and treat neurological disorders.

• Computed tomography (CT) , a computer-assisted X-ray technique that creates three-dimensional images of the brain or spinal cord
• Magnetic resonance imaging (MRI) , employing magnetic and radio waves to generate highly detailed images, especially of soft tissues
• Positron emission tomography (PET) , which uses a radioactive tracer to evaluate metabolic function in the nervous system
• Magnetoencephalography (MEG) , a technique for mapping the brain by recording nerves signals with magnetic receptors

Equipped with these imaging tools, a neurosurgeon can perform both conventional open surgery and minimally invasive surgical procedures.

Conventional Open Surgery

Conventional open surgery requires the neurosurgeon to open the skull. It is often used in emergencies to treat traumatic injuries. The technique, known as a craniotomy , employs specialized tools to remove a section of bone (called the bone flap), which is replaced after the brain surgery has been completed.

Endoscopic Surgery

Endoscopic surgery involves the drilling of the skull to introduce a tube-like instrument, called an endoscope , to transmit video images from deep inside the brain. Guided by the live images, the neurosurgeon can introduce surgical tools through additional holes to treat intracranial bleeds, tumors, hydrocephalus (excess fluid around the brain), and cerebrospinal fluid leaks, among other things.

Microsurgery

Microsurgery is often used to clear plaque from the carotid artery that feeds the brain (carotid endarterectomy), as well as to treat aneurysms, replace herniated spinal discs ( microdiscectomy ), or decompress the vertebras of the spine (laminectomy).

Neurosurgeons will use either an operating room microscope with images projected on a monitor or high-powered loupe magnification eyewear to aid in the surgery.

Stereostatic Radiosurgery

Stereotactic radiosurgery uses precisely targeted beams of radiation to accurately locate the position of brain tumors and other anomalies. Cameras and electromagnetic fields direct the surgical procedure.

Stereostatic radiosurgery is often used in combination with radiation therapy to treat tumors or AVM. Radiosurgical techniques include  gamma knife and cyberknife systems.

Stereotactic radiosurgery is increasingly used to precisely place brain electrodes in people with epilepsy , Parkinson's disease , or essential tremor.

Endovascular Surgery

Endovascular surgery involves the introduction of surgical tools through an opening in the femoral artery of the leg. It is used to treat brain disorders from inside a blood vessel, including stroke, AVM, aneurysm, and brain tumors.

The route of blood circulation may be surveyed beforehand with CT, MRI, or a high-resolution angiogram. The surgery itself is guided by real-time X-ray images.

Spinal Neurosurgery

Spinal neurosurgery covers the cervical (neck), thoracic (middle), and lumbar (low) spine. It may be used to treat spinal cord compression resulting from trauma, arthritis of the spinal discs, or spondylosis (characterized by bone spurs and disc degeneration).

Power drills and special instruments may be used to correct compression problems, while spinal rongeurs (scissorlike devices used to gouge out bone) can help remove herniated discs. Spinal fusions may be performed as an open or laparoscopic ("keyhole") surgery.

Psychiatric Neurosurgery

Neurosurgery may be used to treat psychiatric disorders that fail to respond to standard medications, psychotherapy, or electroconvulsive therapy (ECT). Also known as psychosurgery, it remains a controversial practice with inconsistent outcomes. Modern psychiatric neurosurgery does not employ many of the older techniques commonly used in the past, such as lobotomy.

Today, much of the focus of psychiatric neurosurgery is placed on deep brain stimulation (DBS) to treat OCD and major depression. This involves the implantation of an electrical device to stimulate parts of the brain associated with mood or anxiety disorders.

Other Surgical Techniques

Surgery for chronic pain is a sub-branch of neurosurgery. Some of the techniques used include DBS, spinal cord stimulation, peripheral nerve stimulation, and pain pumps (implanted devices that deliver pain medication over time).

Surgery of the peripheral nervous system is also possible. It may be used to decompress nerves associated with carpal tunnel syndrome (CTS) or to reposition pinched nerves that cause referred pain (felt in a different area than the injury).

What is the most common surgery for a neurosurgeon?

Neurosurgeons perform many different types of surgical procedures to treat disorders of the nervous system and brain. One of the most common is anterior cervical discectomy and fusion, a procedure that corrects a herniated disc. Other common neurosurgeries include lumbar puncture and craniotomy.

Neurosurgeon Subspecialties

Because the function of the brain and nervous system is so vast and diverse, it is not uncommon for neurosurgeons to limit the scope of their practice to specific population groups or areas of the nervous system.

Neurosurgical subspecialties include:

• Endoscopic cranial surgery
• Functional neurosurgery (used to treat movement disorders)
• Neuro-oncology (involving brain tumors and cancer)
• Neurovascular surgery
• Pediatric neurosurgery
• Peripheral nerve surgery
• Skull base neurosurgery (used to treat benign or cancerous growths on the underside of the skull and upper vertebra)
• Spinal neurosurgery
• Stereostatic neurosurgery

How to Become a Neurosurgeon

It takes around 15 years of education to become a fully board-certified neurosurgeon. Some students will embark on additional fellowships to specialize in a specific area of neurosurgery.

The education needed to become a neurosurgeon is rigorous and extensive, requiring a four-year undergraduate degree, four years of medical school, and seven years of residency training.

After receiving their state medical license, neurosurgeons need to practice for several years before they are even eligible to obtain board certification through the American Board of Neurological Surgery (ABNS).

In the United States, only 0.33% of all practicing physicians are neurosurgeons. Despite the financial rewards, there remains an alarming shortage nationwide, according to a 2017 report in the New England Journal of Medicine.

How to Prepare for Your Appointment

People are generally referred to a neurosurgeon in an emergency or when non-surgical treatments fail to provide relief.

In a non-emergency situation, you can get the most out of your appointment by documenting your symptoms in advance of your meeting. This includes noting the time, severity, duration, and location of symptoms, as well as what you were doing at the time of each event. The more accurately you can describe your symptoms, the sooner the neurosurgeon can order the correct tests and evaluations.

On the day of your appointment, bring your insurance ID card and any lab or imaging test results. You should also ask your primary care physician to forward all relevant electronic medical records (EMR) in advance of your appointment.

Be prepared to ask any questions you need to fully understand your condition and what to expect moving forward. It may help to write them down.

Questions may include:

• Why do I need this surgery?
• How exactly will it help?
• What are the chances of success?
• What are the risks?
• Have all other surgical options been exhausted?
• How long will the procedure take?
• How long will recovery be?
• What might happen if I choose not to have the surgery?
• When will I know if the surgery was successful?

The cost of neurosurgery is often extremely high. Before your appointment, it is important to check if the office accepts your insurance. If not, speak with the hospital billing department before your surgery to discuss whether no-interest payment plans or uninsured patient discounts are available. There may also be financial assistance programs for conditions like Parkinson's or brain cancer.

Even with copay or coinsurance benefits, you may find yourself paying a lot out of pocket. To help plan for your medical expenses, check the out-of-pocket maximum on your insurance policy. This is the most you have to pay for covered services in a plan year. After you meet this maximum amount, all covered services for the remainder of the year will be free.

If possible, schedule your surgery strategically so that the bulk of rehabilitation costs fall within the coverage year rather than being applied to next year's deductible.

A neurosurgeon is a surgeon who specializes in treating disorders of the nervous system and brain. Neurosurgeons perform a range of different types of surgeries including open surgery, endoscopic surgery, microsurgery, and more. 

Neurosurgeons may specialize in certain group populations or parts of the nervous system.

Neurosurgery requires an extensive education of at least 15 years, which includes a seven-year residency.

Prabhakar G, Kusnezov N, Dunn J, Cleveland A, Herzog J. Orthopaedics and neurosurgery: Is there a difference in surgical outcomes following anterior cervical spinal fusion? J Orthop . 2020;21:278-282. doi:10.1016/j.jor.2020.05.015

Donoho DA, Syed HR. Fetal neurosurgical interventions for spinal malformations, cerebral malformations, and hydrocephalus: Past, present, and future . Semin Pediatr Neurol . 2022;42:100964. doi:10.1016/j.spen.2022.100964

Robertson FC, Lepard JR, Mekary RA, et al. Epidemiology of central nervous system infectious diseases: A meta-analysis and systematic review with implications for neurosurgeons worldwide . J Neurosurg . 2018;130(4):1107-1126. doi:10.3171/2017.10.JNS17359

Berger A, Hochberg U, Zegerman A, Tellem R, Strauss I. Neurosurgical ablative procedures for intractable cancer pain . J Neurosurg . 2019:1-8. doi:10.3171/2019.2.JNS183159

Liebenthal E, Singhal T. Introduction to brain imaging . In: Miller K, et. Biomechanics of the Brain . Springer. 2019:47-70.

Shim KW, Park EK, Kim DS, Choi JU. Neuroendoscopy: Current and future perspectives . J Korean Neurosurg Soc . 2017;60(3):322-326. doi:10.3340/jkns.2017.0202.006

Yang I, Udawatta M, Prashant GN, et al. Stereotactic radiosurgery for neurosurgical patients: A historical review and current perspectives . World Neurosurg . 2019;122:522-531. doi:10.1016/j.wneu.2018.10.193

Simmons G, Gallitto M, Lee A, Baltuch G, Youngerman BE, Wang TJC. The use of stereotactic radiosurgery to treat functional disorders: A topic discussion . Pract Radiat Oncol . 2023;13(5):e395-e399. doi:10.1016/j.prro.2023.05.003

Lv X. The history and development of endovascular neurosurgery . In: Frontiers in Clinical Neurosurgery . IntechOpen. 2021. doi:10.5772/intechopen.97139

Chan AY, Lien BV, Choi EH, et al. Back pain outcomes after minimally invasive anterior lumbar interbody fusion: A systematic review . Neurosurg Focus . 2020;49(3):E3. doi:10.3171/2020.6.FOCUS20385

Müller S, van Oosterhout A, Bervoets C, Christen M, Martínez-Álvarez R, Bittlinger M. Concerns about psychiatric neurosurgery and how they can be overcome: Recommendations for responsible research . Neuroethics . 2022;15(1):6. doi:10.1007/s12152-022-09485-z

Caruso JP, Sheehan JP. Psychosurgery, ethics, and media: a history of Walter Freeman and the lobotomy . Neurosurg Focus . 2017;43(3):E6. doi:10.3171/2017.6.FOCUS17257

Schmid AB, Fundaun J, Tampin B. Entrapment neuropathies: A contemporary approach to pathophysiology, clinical assessment, and management . Pain Rep . 2020;5(4):e829. doi:10.1097/PR9.0000000000000829

Shenoy K, Adenikinju A, Dweck E, Buckland AJ, Bendo JA. Same-day anterior cervical discectomy and fusion - Oour protocol and experience: Same-day discharge after anterior cervical discectomy and fusion in suitable patients has similarly low readmission rates as admitted patients . Int J Spine Surg . 2019;13(5):479-485. doi: 10.14444/6064

University of Medicine and Health Sciences. How to become a neurosurgeon? - A step-by-step guide .

Darves, B. Physician Shortage Spikes Demand in Several Specialties. New Eng J Med . Nov. 30, 2017.

Pujara, S. and Solanki S. Foundation year one training in neurosurgery: achieving competency a 5-year review. Br J Neurosurg.  2017 Dec;31(6):718-723. doi:10.1080/02688697.2017.1339225.

Schramm, J. - Ed. (2016) Advances and Technical Standards in Neurosurgery, Volume 43. New York, New York: Springer Publishing. doi:10.1007/978-3-319-21359-0.

By Andrea Clement Santiago Andrea Clement Santiago is a medical staffing expert and communications executive. She's a writer with a background in healthcare recruiting.

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A career in neurosurgery

• Related content
• Peer review
• Dom Mahoney , second year medical student 1 ,
• Owain Davies , specialty trainee year 1 neurosurgery 2 ,
• Peter C Whitfield , consultant neurosurgeon and honorary associate professor 3
• 1 University of Bristol, UK
• 2 Southmead Hospital, Bristol, UK
• 3 Plymouth Hospitals NHS Trust, UK

Demystifying one of medicine’s most competitive specialties

Neurosurgery has consistently remained one of the most competitive specialties, 1 yet students gain little exposure to the field during most medical school courses. Neurosurgical cases are varied and patients are often at very high risk. With every operation comes the risk of severe and permanent brain or spinal cord injury. However, neurosurgical intervention can halt or even reverse debilitating neurological impairment and dramatically improve patients’ lives.

Without spending time in a neurosurgical unit, it can be difficult to get a real idea of what the specialty involves. In this article, we intend to demystify neurosurgery and help those wishing to pursue a career in the specialty to apply for training with confidence.

Box 1: Pros and cons of a career in neurosurgery

Interesting cases and pathologies

Challenging and varied types of surgery

Many opportunities for research across a broad range of subspecialties

Opportunity to dramatically improve patients’ lives with surgical treatment

High risk—neurosurgery can have a profoundly negative effect on patients if treatment does not go to plan

Neurosurgery is a competitive specialty that expects constant self improvement in trainees

Long hours and challenging on-calls

There are relatively few specialist neurosurgery centres in the UK—you may have to uproot and move to find a job

What is neurosurgery?

Neurosurgery involves the operative treatment of brain and spinal cord diseases. The field was pioneered by the American neurosurgeon Harvey Cushing (1869-1939), who conducted some of the earliest research into pituitary surgery, intracranial tumours, and the effects of increased intracranial pressure. 2 The true origins of neurosurgery are arguably much earlier than this. Skulls that have undergone a rudimentary surgical procedure (trephination) have been found at Neolithic burial sites dating back to 5100 BC. 3 However, it wasn’t until Cushing’s work that neurosurgery was widely considered a safe practice.

Neurosurgical conditions can occur at any age—in neonates to centenarians. Neurosurgery has a pivotal role in the management of traumatic brain injury, involving the measurement and treatment of elevated intracranial pressure, the evacuation of intra-axial and extra-axial haematomas, and the elevation of depressed skull fractures. Spinal surgery is also a core component of neurosurgical practice. Common spinal procedures include lumbar and cervical discectomy, spinal decompression, and vertebral column stabilisation (box 2). Unlike orthopaedic surgeons (who can also specialise in spine surgery), some neurosurgeons operate on the spinal cord itself to treat spinal cord tumours and vascular anomalies.

Box 2: Common cases in neurosurgery

Oncology—Tumour biopsy or excision including “awake” and neuronavigation surgery. Stereotactic radiosurgery.

Traumatology—Intracranial pressure monitoring, external ventricular drain placement, fracture management, haematoma evacuation, decompressive craniectomy.

Cerebrovascular—Aneurysm clipping, arteriovenous malformation excision, collaboration with interventional radiologist.

Skull base—Pituitary surgery, meningioma resection, cerebellopontine angle mass resection.

Cerebrospinal fluid flow—Hydrocephalus management, including endoscopic surgery, shunt insertion, and shunt revision.

Functional—Deep brain stimulation, epilepsy surgery, convection enhanced drug delivery.

Infections—Drainage of empyema or abscess.

Degenerative disc disease—Lumbar microdiscectomy and lumbar decompression, anterior cervical discectomy.

Oncology—Excision or biopsy of spinal tumours. Stabilisation of the vertebral column in metastatic disease.

Traumatology—Spinal fracture management, including stabilisation of the vertebral column.

Pain and spasticity—Spinal cord stimulation, baclofen pump insertion, dorsal route entry zone lesions, cordotomy.

Peripheral nerve—Ulnar and median nerve decompression.

Team members

Delivery of care in a clinical neuroscience unit is multidisciplinary, requiring close collaboration with many other departments. These include neuroradiology, neuropathology, neuro-oncology, neuro-ophthalmology, neurology, neuropsychology, neurorehabilitation, neurophysiology, pain services, and neuroendocrinology. There may also be collaboration with other surgical specialties. For example, in the management of craniosynostosis in paediatrics, a neurosurgeon often operates alongside a plastic surgeon.

Life as a neurosurgeon

Foundation year 2 (F2) doctors may undertake a four month placement in neurosurgery. Workload and intensity are high, but if you are well organised and motivated, you will learn a great deal from the cases you see, and will also get involved with procedures in theatre.

First year neurosurgical trainees (specialist training year 1 (ST1)) have longer placements in neurosurgery. During these placements, trainees attend theatre several times a week to observe and assist. When on call, ST1 and ST2 trainees will manage the ward in addition to clerking acute admissions.

Early in the training, time is also spent in allied specialties, including neurology, emergency medicine, ear, nose, and throat, and plastic surgery. Some trainees may undertake placements in neuro-intensive care or neuroradiology. Before entering ST3, trainees must pass the Membership of the Royal College of Surgeons examination.

Work patterns for ST3 vary, but generally involve placement with a specific consultant (clinical supervisor) or a group of two or three consultants. Registrars attend clinic, seeing outpatient referrals and follow-ups, have regular theatre list placements with their consultant, and also run daily ward rounds.

During on-call days, registrars carry the bleep for any neurosurgical referral, opinion, or question from hospitals within their unit’s catchment. There might be 30 or more referrals in a 12 hour period. While holding the bleep, the registrar will see all new admissions, coordinate and run the emergency theatre list, and keep the on-call consultant up to date on patients coming in. On-call rotas can be onerous, with much weekend and overnight work.

Most trainees are appointed to consultant level within a couple of years of completing training. Neurosurgical consultants are on the same salary as any NHS consultant, with limited pay supplements available under contracts for out of hours work.

Application process

The training programme takes eight years to complete full time. Over the past decade, around 20-25 posts have been advertised nationally at ST1 level each year. On average, there are between five and 10 applicants for every training post. In addition to ST1 entry, a small number of appointments at ST3 level have been made available annually since the inception of run-through training. It is not mandatory to have had a large volume of neurosurgical experience to have your application considered.

Candidates’ applications are assessed through a national selection process. You must first complete a structured application form, which asks about qualifications, previous experience, research and audit skills, quality improvement projects, publications, management skills, and practical aptitude. Since 2017, all applicants also sit the Specialty Recruitment Assessment (SRA). This comprises a clinical problem solving paper, targeted at the F2 level, and a situational judgement test. The application form score (75%) and the SRA score (25%) are then used to rank candidates. At present, the top scoring 84 ST1 applicants are invited to the selection centre for structured mini-assessment based interview. 4 5

Future of the specialty

With an ageing population, fulfilling the needs of patients with chronic subdural haematomas, normal pressure hydrocephalus, and degenerative spinal disease relies on the development of neurosurgical services. Technological advances—including developments in imaging technology (such as functional magnetic resonance imaging), intraoperative electrophysiological monitoring, minimally invasive approaches, and robotic surgery—are enabling more precise operations in increasingly difficult areas of the neuraxis. These innovations are allowing complex surgery to be performed while minimising risk to patients. Over the coming decades, there is also likely to be a considerable increase in functional neurosurgery for conditions including epilepsy, chronic pain, and movement disorders such as Parkinson’s disease. Owing to the increasing number of spinal cases that can be expected in the future, there have also been some discussions about separating spinal surgery from cranial neurosurgery and making it a standalone specialty. This is something that many neurosurgeons are opposed to, but is a conversation that may have dramatic implications for neurosurgery down the line.

Box 3:  Interviews with neurosurgeons by Alexandra Abel , third year medical student, Hull York medical school, York, UK

George spink, consultant neurosurgeon and clinical lead for spinal surgery, hull and east yorkshire nhs trust, uk.

What are the highs and lows of neurosurgery?

When you win, get it right, and help someone, it’s usually a life changing result for the patient. But the lows are incredibly low—when even with your best efforts you know the patient isn’t going to pull through. There’s no doubt or ambiguity in neurosurgery. Dealing with these emotional extremes is challenging, but rewarding.

There is also the challenge of needing to be a great communicator. When you’re telling someone the worst news they will ever hear—they have an inoperable brain tumour and weeks to live—you can make it a little easier on the patient and their family if you can do this well.

What’s the work-life balance?

The balance is difficult. You need down time to recover, because it is an emotional rollercoaster. I think because we are so driven at work—and getting into the specialty is so competitive—we seem to be driven in all aspects of our life. The phrase “work hard, play hard” was probably written with a neurosurgeon in mind.

What are the biggest challenges you face?

Keeping up with new technology. Things change a lot in spinal surgery, with new kit to use and new techniques to learn. It was this dynamic environment that I was hoping for when I started my career and I haven’t been disappointed. Keeping a balance between your surgical ego—you need a lot of self belief to carry out high risk procedures—and your humility, is also a constant challenge.

Sasha Burn, consultant paediatric neurosurgeon, Alder Hey Children’s Hospital, Liverpool, UK

Why did you choose neurosurgery?

I became interested in the brain as a child. As the youngest of four in a relatively eccentric family, the workings of the mind were always fascinating to me. I was good at cutting and sewing so surgery, as opposed to psychiatry or neurology, seemed a good option for me.

What are the highs and lows of the specialty?

The best part is the intellectual and operative challenge of tinkering with the brain. An old boss of mine used to call it “surgery of the soul.” Neurosurgery also has a huge range of subspecialties. The worst part is the on-call shifts.

I have two young children and a long suffering husband. The only solution is childcare, which is expensive. I have never considered going part time; I am not sure how it would work in a specialty like paediatric neurosurgery.

Further information

Society of British Neurological Surgeons: www.sbns.org.uk/

Royal College of Surgeons: www.rcseng.ac.uk/

NHS neurosurgical national recruitment website: www.yorksandhumberdeanery.nhs.uk/recruitment/national_recruitment/national_neurosurgery_st1__st3_recruitment/

Neurology and Neurosurgery Interest Group for medical students and junior doctors: www.nansig.org/

British Neurosurgical Trainees’ Association: http://e1v1m1.co.uk/

Originally published as: Student BMJ 2017;25:j1371

Competing interests: PCW is chairman of the Specialist Advisory Committee in Neurosurgery. This committee is responsible for the selection and appointment of neurosurgical trainees.

Provenance and peer review: Not commissioned; externally peer reviewed.

• ↵ Health Education England. Competition Ratios. 2017. http://specialtytraining.hee.nhs.uk/Portals/1/Competition%20Ratios%202016%20ST1_1.pdf .
• ↵ Bliss M. Harvey Cushing: A Life in Surgery. 1st ed . Oxford University Press, 2005 .
• ↵ Alt KW, Jeunesse C, Buitrago-Téllez CH, Wächter R, Boës E, Pichler SL. Evidence for stone age cranial surgery. Nature 1997 ; 387 : 360 . doi:10.1038/387360a0   pmid:9163419 . OpenUrl CrossRef GeoRef PubMed Web of Science
• ↵ Health Education England. Person Specifications. 2017. http://specialtytraining.hee.nhs.uk/Recruitment/Person-specifications .
• ↵ Health Education England—Yorkshire and the Humber. National Neurosurgery ST1 and ST3 Recruitment. 2017. www.yorksandhumberdeanery.nhs.uk/recruitment/national_recruitment/national_neurosurgery_st1__st3_recruitment/ .

Surviving Neurosurgery pp 275–278 Cite as

Why I Chose to Be a Neurosurgeon

• Christopher Banerjee 3  
• First Online: 08 February 2022

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In this chapter, Dr. Banerjee discusses why he chose neurosurgery as a career. Neurosurgery uniquely treats patients with conditions affecting their experience of life. Neurosurgeons need to be experts in understanding the biology that produces cognition and the mind. The philosophy of the mind–body relationship encompasses the essence of evaluating neurosurgical patients. One can become attracted to the field of neurosurgery if he/she is interested in mind/body philosophy, neuroscience, and a career in surgery.

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Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, USA

Christopher Banerjee

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Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA

Nitin Agarwal

Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA

Vamsi Reddy

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Banerjee, C. (2021). Why I Chose to Be a Neurosurgeon. In: Agarwal, N., Reddy, V. (eds) Surviving Neurosurgery. Springer, Cham. https://doi.org/10.1007/978-3-030-86917-5_52

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• Residency Application

Neurosurgery Personal Statement Examples

It is sometimes helpful to contemplate the work of others when attempting to produce your own finely tuned work, and to that end, we have provided you with these neurosurgery residency personal statement examples. Tips and advice can assist in your writing, but some people find examples more useful.

Residency personal statement examples will show you how experts write their own statements. Personal statements are an essential aspect of applying to a residency, as any residency prep course will tell you. You can use a personal statement to introduce yourself, show why you are the perfect candidate, and connect you to the discipline and program that you are applying to. Seeing example essays will also let you avoid red flags in residency personal statements .

Read on for two samples specific to applying to a neurosurgery residency.

>> Want us to help you get accepted? Schedule a free strategy call here . <<

Article Contents 8 min read

Neurosurgery residency personal statement examples, neurosurgery residency personal statement example #1.

In my high school days, I was involved with the theater program, and as everybody else talked about butterflies in their stomachs, I just felt a paradoxical relaxation and excitement. In university, I was a regular contributor to the school’s newspaper, but no matter the deadline, I never worried. Even at medical school, I always found myself stepping forward to volunteer to go first. Nerves are not a problem for me. They never have been, and as a result, I feel almost at home in the high pressure of chaos. When thinking about my residency, I naturally gravitated toward emergency medicine and surgery.

Wondering how to write a residency personal statement? Watch this video:

This dilemma – which residency to apply to – was solved for me while I was working as an assistant during medical school with Dr. Michaelson in his research into Alzheimer’s disease. This task quickly became my favorite aspect of my education. I enjoyed wrestling with complex problems, looking for solutions, and being given the freedom to explore exciting advancements in medicine using specialized equipment. The most exciting part of this research, however, was our work on the human brain. This organ that produces thoughts, mind, and consciousness itself via chemical and electric reactions is awe-inspiring and studying how our minds work fascinates and excites me. With a predilection for exploring the mind on top of my knack for handling pressure, surgery became my fits-like-a-glove choice.

My buddy Rod thought he wanted to become a surgeon, but one observation in the operating room change his mind and he abandoned the idea. My observations of surgeries while shadowing doctors have only made me more certain that this is my calling. The most memorable surgery I observed was to repair an aneurysm. The procedure was intense, taking hours, and required precision and focus for the entire time. Despite the harrowing circumstances, the surgeon and her team spoke with one another in an easy, friendly manner. I was impressed both by the work being done and the team-building respect and kindness shown in the OR. There is no space in an operating room for egos. The whole time, I wished I had the knowledge and training to help them – to join in at this crucial point in the patient’s struggle. 

My introduction to clinical rotations was at a family medicine clinic, which my supervising physician described as being on the quiet side. It was supposed to be a nice, smooth transfer to clinical work, but as I soon learned, there is really no such thing in medicine. By the end of a long, hard, first day, I was exhausted and shaken and wondering whether I should hang up my stethoscope for good.

On that first rotation, I had a family bring in their young daughter, who had very mild symptoms at first, but who rapidly progressed to what my supervising physician discovered to be a pediatric stroke. She had to be rushed to a hospital with more adequate facilities, but in the meantime, it was our job to do anything we could to stabilize the girl before the helicopter arrived. One shift in, and I was already up to my eyeballs in emergency trauma and helicopters.

But, of course, the rest of the clinic didn’t shut down, and other appointments had to be kept. It was all I could do to focus on my work while knowing that the family could do nothing but think of their little girl. I thought of them even after they were gone, and I didn’t fully relax until close to the end of my first day when my supervising physician told me, and the rest of our team, that she had received word that the girl had been treated successfully and the prognosis was very good.

She took me aside later and asked how I felt. “I don’t know if I can do this,” I told her, and she was surprised. She said she had rarely seen a person perform so well under stress. I had remained outwardly calm and professional while managing the rest of my tasks for the day. This was the first time I ever thought of myself as being calm under stress, but apparently, I am.

For more advice on writing residency personal statements, check this infographic:

In my surgery clinic, I began to appreciate what my previous supervising physician had said to me more. I noticed that no matter the pressure, my hands didn’t shake. I could always process instructions and carry out tasks. I never vomited after anything particularly intense, although I observed some very different reactions in a few of my peers. To be clear, I respect and admire my colleagues, and I would not excel at everything they are good at, either, but I discovered that I had a distinct knack for stress control. Moreover, I had success in the limited number of surgical procedures I was allowed to perform or assist with as a medical student.

At first, the brain was not my main interest. Had I simply been someone who handled stress well and enjoyed the surgery clinic, I might have picked any area of surgery – cardiac, for instance. But the nature of that little girl’s trauma – her brain needing help – made me think about the importance of the human mind. To save a mind is to save a person. We can survive anything else, can’t we? But not the loss of our minds. Perhaps it is my joint MD-PhD program that makes me philosophical about this, but there is so much to consciousness that we don’t understand – I am so intrigued by this area of medicine.

My MD-PhD research has been couched in personality discourse. Before I began my surgical rotations, I was contemplating psychology as a specialty. In my studies of personality, I was trying to learn more about how physical health affects mental health. I was involved with a sleep study, looking at how to optimize sleep habits for different demographics. We were exploring whether population subsets have different sleep requirements. I am currently involved in another study about how exercise affects mental health and personality. This connection between personality and the nervous system is what had the greatest impact on me while I considered different surgical disciplines. I recognized that I had a strong interest in how our bodies process information through the central processor of the nervous system. The related background reading and coursework in neurology, along with labs and the abovementioned research, all support my natural progression into neurosurgery. I believe that your program, with its state-of-the-art facilities and emphasis on research and development, will be ideal for making my dream a reality.

Any personal statement must have a connection to the residency you are applying to, and all personal statements will introduce you and your history as a medical student. Essentially, you are always aiming to show who you are and why you are perfect for the residency. But what should you focus on with a neurosurgery personal statement in particular?

Well, to start off with, you will want to keep in mind a list of traits that are specifically desirable for neurosurgeons.

This includes subjects such as neurology, basic neurosciences, neuroimaging, neuropsychology, and neuropathology. "}]" code="timeline1">

Ask yourself what experiences or proof you have of those traits, and whether you have knowledge of those subjects. Demonstrate that – show, don’t tell – within your application.

Additionally, neurosurgeons will need good communication skills and excellent doctor–patient relatability to deliver high levels of information about treatments and recovery to patients and their families. They also need to be able to speak to patients and their families about very difficult subjects and be able to deliver bad news in a caring but straightforward manner.

Highlight any direct or indirect experiences you have with surgery of any sort, in addition to neurosurgery.

Finally, try to give a sense of your optimal career path. This doesn’t have to be too specific but try to relate this to your residency of choice. If the hospital you are going to is known for its teamwork and you plan on working in teams, for example, this will help match you up with your ideal residency.

You can see how expertly crafted residency personal statements read now, and with these sterling examples, you should be able to craft your own statement. Remember to focus on your own journey and the fact that the primary goal of the residency personal statement is to show your unique attributes that connect you to the specific program and residency you are applying to. You are showing why you are a perfect match. Take that knowledge, focus on your goal, and take the time to write your own future.

While the statement length might vary from program to program – and you should always check for any requirements – typically a residency personal statement will be between 750 and 900 words, based on the space provided in the ERAS application.

It could take from two to six weeks, with some time each day set aside to work on your statement. Take your time writing the statement because you want to make sure you have it perfect, and you need time to re-write, edit, get feedback, and proofread your spelling and grammar. You may also wish to consider whether you need a residency application consultant to help you edit your personal statement.

Neurosurgery requires precision, manual dexterity, calm under pressure, stress management, knowledge of the brain and nervous system – including neuroscience, neurology, and other disciplines – and stamina. Surgeons also need good communication skills to speak with their patients and patients’ families – including the ability to speak clearly but compassionately about extremely difficult subjects. Experiences should highlight any or all of these qualities.

Extremely careful, as any reader will assume you have put the maximum effort into your residency application, given its importance for your future and career. If your maximum effort doesn’t include a thorough spellcheck, that will reflect poorly on said reader’s opinion of you.

Generalization, repetition, arrogance, and a failure to explain gaps in your residency CV , low test scores, or a lack of certain experiences. Most “red flags” can be avoided or handled by curating the information you include, ensuring an appropriate tone, and giving a good explanation for any problems, including what you learned and why they will never happen again.

The best information includes specifics about why you are right for the program you are applying for, why you are perfect for the specialty you are applying to, and relevant experiences that you have for your specialization.

The best criteria to use for the residency you want is deciding what you are passionate about and where you will thrive. Don’t worry about ratings – like if the place you are applying to is the “best” according to some list – worry more about whether you will fit in perfectly according to your goals and temperament.

It’s rare to find no match at all – 5%, based on NRMP data – but it does happen. If that occurs, you will want to find out how to improve residency application after going unmatched . In a nutshell, you’re going to rebuild your application and try again. Don’t give up but get working harder than ever.

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Home — Application Essay — Medical School — Why I Want to Be a Neurosurgeon

Why I Want to Be a Neurosurgeon

• University: Cornell University

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Published: Nov 1, 2021

Words: 622 | Pages: 1 | 4 min read

“Metabotropic receptors are usually found in complex particles linking the outside of the cell to enzymes inside the cell”. My finger read over the page of my textbook, not realizing that it was nearing midnight and I had school the following morning. Ever since I first completed human body coloring sheets in grade 2 I have been fascinated by biology, from the intricate ways each organ goes together like a piece of a puzzle to the mystery of everything that is still unknown. In my quest to learn as much as I can about this subject, I have pursued many avenues ranging from reading books and watching videos to even competing in biology competitions, taking courses at the Harvard Summer School and even shadowing a neurosurgeon for week. This was the first time I realized why I want to be a neurosurgeon.

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Now as a high school student on the verge of entering into university, my excitement to dive even deeper into this field of study cannot be contained. When I was making my decision about where to apply, one of the driving forces behind my decision was to find a school where I could delve even further into the field I love and develop different lenses to analyze this complex subject. I was immediately drawn to Cornell’s Biological Sciences major program through the College of Arts and Sciences due to its emphasis on academic discovery and intellectual exploration. My ultimate goal in life is to become a doctor – a neurosurgeon specifically – and to do so not only will I need a strong understanding of biology but also a greater understanding of how the natural sciences interact with society and practical experience within a laboratory setting. As such, the BIOG 1250 Biology Seminars – specifically the “Body Parts, Schemas and Images” – offered to freshmen students at Cornell was of great interest to me. By taking part in this course, I would be able to develop critical thinking skills, explore different topics related to biological sciences and delve deeper into how ethics and views of society help shape the direction of scientific study.

Furthermore, by being able to take a hands-on approach to my learning through research courses such as “Introduction to Research Methods in Biology” and “Independent Undergraduate Research in Biology” I would be able to develop essential skills required for a career in medicine. These courses would help equip me with the skills to be a successful part of a research lab and to one day be able to conduct my own independent research project on topics which interest me. I am also very keen on applying to be a part of faculty research projects at Cornell if accepted. Particularly, I would like to be involved in the research being conducted on peripheral nerve repair and the relationship between the immune response to nerve injury and nerve recovery led by Dr. Johnathan Cheetham.

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Growing up, I have also always been very fond of helping others and as such have taken part in many volunteering opportunities within my community such as through tutoring underprivileged children in elementary school and volunteering with summer camps. During my undergraduate years, I would very much like to continue this and take part in the Biology Service Leaders Program. This program would allow me to give back to the Ithaca community whilst also developing leadership and collaborative skills and furthering my knowledge of biology. I have always been very passionate about learning and am very eager to enter into my university years. I feel that the opportunities available to me at Cornell University would help me pursue my passion further and provide me with the necessary skills and support to one day fulfill my ultimate goal of becoming a neurosurgeon.

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Dagmar Turner, a violinist, during surgery to remove her brain tumour, January 2020. Photo courtesy King’s College Hospital, London

Rethinking the homunculus

When we discovered that the brain contained a map of the body it revolutionised neuroscience. but it’s time for an update.

by Moheb Costandi   + BIO

The homunculus is one of the most iconic images in neurology and neuroscience. Usually visualised as a series of disproportionately sized body parts splayed across a section of the brain, it shows how the body is systematically mapped onto the sensory and motor cortices, representing the proportion of brain tissue devoted to each part of the body.

This image has not only had a long-lasting impact on neurosurgical practice and basic brain research, but has also entered the public imagination, with three-dimensional clay models consisting of an enormous head and outsized hands attached to a tiny torso, on display at the Natural History Museum in London, and elsewhere.

The groundbreaking work that led to the homunculus was a major advance in our understanding of the structure and function of the brain, and the homunculus itself revolutionised the art of medical illustration. Yet modern research suggests that the homunculus is far more complex than originally thought, and some argue that it is incorrect and needs to be radically revised.

T he homunculus – meaning little man – is the brainchild of the Canadian neurosurgeon Wilder Penfield (1891-1976), who co-founded the Montreal Neurological Institute at McGill University in 1934 and became its first director. There, he developed a pioneering technique for identifying, and then surgically removing, abnormal brain tissue causing epileptic seizures. Using this method over the course of his career, he and his colleagues produced early detailed maps of the functions of various regions of the cerebral cortex.

Most epileptic patients respond well to anti-convulsant drugs, but for those who do not, and whose seizures become frequent, severe and debilitating, brain surgery is a last-resort treatment. Penfield’s technique involved using an electrode to electrically stimulate the surface of the patient’s brain; crucially, they remained fully conscious on the operating table during the procedure, so that the patient could describe the effects of the stimulation. This enabled Penfield to cut out, or resect , the tissue causing the seizures without damaging neighbouring tissue involved in functions such as movement and language.

With the patient’s scalp anaesthetised and their skull opened, Penfield applied small electrical currents to the exposed surface of his patient’s brain. Because the patient remained fully conscious, Penfield could not only observe the movements evoked by stimulation of a specific area, but also ask them about the sensations and perceptions they experienced.

Stimulation of the top of the brain evoked movement or sensation in the hip and torso

Penfield operated on more than 1,000 patients throughout the 1930s and ’40s, and thus comprehensively ‘mapped’ the function of each area of the cerebral cortex. Electrical stimulation of some regions elicited the recall of long-lost memories; others triggered musical or olfactory hallucinations, famously causing one patient to report: ‘I smell burnt toast!’

His most important discovery, however, was the organisation of the sensory and motor cortices, two narrow, adjacent strips of tissue that run down from the top to the bottom of the brain on either side of the central sulcus, a deep fissure separating the frontal and parietal lobes.

Here, stimulation in front of the fissure evoked small movements or muscle twitches in specific parts of the body, and stimulation just behind it evoked sensations instead. Importantly, the body appeared to be mapped in a highly organised manner in both of these regions, such that stimulation of adjacent patches in either evoked movements or sensations in adjacent body parts on the opposite side of the body.

Thus, stimulation of the top of the brain evoked movement or sensation in the hip and torso, and stimulation progressively further down along the outer surface elicited responses first in the shoulder, arm, elbow, forearm, and then the wrist. Finally, there was a large patch of both strips of tissue devoted to the hand, with each finger represented individually, and another large patch devoted to the face, tongue and throat. Crucially, although the precise size and location of the tissue devoted to each body part differed between patients, the sequence of responses elicited by progressive stimulations from the top to the bottom of the brain was always the same.

During each procedure, Penfield would place small numbered stickers on the patient’s brain, and take note of the response evoked by electrical stimulation of that particular patch of tissue (see figure below):

From Wilder Penfield and Edwin Boldrey’s 1937 paper . American Neurological Association

14. Tingling from the knee down to the right foot, no numbness. 13. Numbness all down the right leg, did not include the foot. 12. Numbness over the wrist, lower border, right side. 11. Numbness in the right shoulder. 3. Numb feeling in hand and forearm up to just above the forearm. 10. Tingling feeling in the fifth or little finger. 9. Tingling in first three fingers. 4. Felt like a shock and numbness in all four fingers but not in the thumb. 8. Felt sensation of movement in the thumb; no evidence of movement could be seen. 7. Same as 8. 5. Numbness in the right side of the tongue. 6. Tingling feeling in the right side of the tongue, more at the tip. 15. Tingling in the tongue, associated with up and down vibratory movements. 16. Numbness, back of tongue, mid-line. Precentral gyrus from above down: – (G) Flexion of knee. 18. Slight twitching of arm and hand like a shock, and felt as if he wanted to move them. 2. Shrugged shoulders upwards; did not feel like an attack. (H) Clonic movement of right arm, shoulders, forearm, no movement in trunk. (A) Extreme flexion of wrist, elbow and hand. (D) Closure of hand and flexion of his wrist, like an attack. 17. Felt as if he were going to have an attack, flexion of arms and forearms, extension of wrist. (E) Slight closure of hand; stimulation followed by local flushing of brain; this was repeated with the strength at 24. Flushing was followed by pallor for a few seconds. (B) Patient states that he could not help closing his right eye but he actually closed both. (C) Made a little noise; vocalisation. This was repeated twice. Patient says he could not help it. It was associated with movement of the upper and lower lips, equal on the two sides …

It is these findings that are immortalised in visual form as the homunculus, which first appeared in Penfield’s paper ‘Somatic Motor and Sensory Representation in the Cerebral Cortex of Man as Studied by Electrical Stimulation’ (1937), co-authored with Edwin Boldrey. The findings reveal that the motor and sensory cortices are organised in such a way that there is a point-for-point correspondence of body parts to specific regions of brain tissue, with adjacent body parts ‘represented’ by adjacent patches of tissue.

This organisation is referred to as ‘somatotopy’, and it is widely considered to be a fundamental principle of brain structure and function. Furthermore, Penfield’s technique, which came to be known as ‘the Montreal Procedure’, is still used today. Several years ago, for example, the violinist Dagmar Turner played her instrument throughout a neurosurgical procedure, so that the team performing the operation could remove a brain tumour without damaging the motor cortex.

I t’s also worth discussing what’s been called the ‘ her monculus’. The homunculus is a composite of localisation data that Penfield obtained from the presurgical evaluation of some 400 patients. Yet, while the homunculus clearly shows the cortical representation of male genitalia, female anatomical parts are conspicuously absent. The reasons for this are unclear. It may be because Penfield worked at a time when it was considered inappropriate to ask about or report certain sensations experienced by his female patients; because female patients felt embarrassed reporting genital sensations to male authority figures; or because Hortense Cantlie, the medical illustrator who drew the homunculus, may have been uncomfortable incorporating female genitalia into her illustrations.

Another possibility is that Penfield simply did not have enough data – just nine of the patients on which the homunculus is based were confirmed as female, only one of whom reported any genital sensations during presurgical evaluation. This was a 27-year-old woman referred to as ‘EC’, who had a tumour removed from her right sensory cortex. Before her surgery, the tumour caused spontaneous seizures that produced a tingling sensation that shifted between her left buttock, labium and breast, and, on the operating table, electrical stimulation of the sensory cortex produced a sensation in her left buttock and a twitching of her left foot.

Penfield and his colleagues thus assumed that the female genitals and breasts are represented in the same region as the male genitalia: adjacent to the representation of the foot, on the inner wall of the cortex, deep inside the longitudinal fissure separating the left and right hemispheres.

We need further investigation into the her munculus, and to fill in the rest of the female map

We still know very little about the neural representation of the female body. In Penfield’s time, there was only one other case study hinting at how the female genitalia map onto the cortex, that of an epileptic woman diagnosed with ‘erotomania’ (nymphomania) because she experienced vaginal sensations during her seizures; removal of the tumour causing the seizures relieved the patient of those symptoms.

Between then and 2011, there were only 10 other studies investigating the somatotopic organisation of female anatomical parts. These provided conflicting results, hinting at alternative locations for females: some scientists mapped sensations related to female anatomy onto the inner wall of the cortex, consistent with Penfield, but others mapped them further up, at the brain’s apex. Among some researchers, the call is on to resolve the matter with further, active investigation into the her munculus, and to fill in the rest of the female map. ‘What happens to bodily sensation during pregnancy, menopause … or after surgeries such as oophorectomy[?]’ the neuroscientist Paula Di Noto and colleagues asked in the journal Cerebral Cortex in 2012.

In the most recent such study to address the issue, published in 2022, Andrea Knop of Charité–Universitätsmedizin Berlin and colleagues used functional magnetic resonance (fMRI) to scan 20 women’s brains while stimulation was applied to their clitorises with an air-controlled vibrating membrane placed over disposable underwear just below the pubic mound, to show that the representation of the clitoris in the brain lies adjacent to that of the hips and upper legs, results that ‘provide independent confirmation for the revision of the original homunculus’.

Furthermore, the researchers found that the frequency of sexual intercourse within the 12 months prior to the scan was linked to the thickness of that particular area of the sensory cortex, with the more sexually active participants exhibiting thicker tissue. By contrast, the phase of the menstrual cycle was not associated with differences in thickness of the ‘genital field’.

T he sensory and motor strips of the cortex work together to control and coordinate limb movements. The sensory cortex contains cells that process touch and pain information, and the motor cortex contains cells that execute movements by sending signals down the spinal cord to ‘secondary’ cells that activate specific muscles.

But both regions also contain neurons that exhibit properties associated with spatial navigation. These navigation cells, called ‘place cells’, are located in a deep brain structure called the hippocampus. They were first identified in the 1970s in experiments performed on rats, which showed that individual place cells are activated only when the animal enters a specific place in its environment. Since then, researchers have discovered several other navigational cells in and around the hippocampus: head direction cells, which fire when the animal is moving in a specific direction, and grid cells, which fire periodically as the animal moves through an open space.

Two monkeys navigated a small room in a wheelchair controlled by a brain-machine interface to get food

These cells make up the brain’s global positioning system, working together to generate maps of the environment and contributing to formation of the spatial memories we use to find our way around. Recently, two groups of researchers have independently shown that this same spatial navigation system is also found in the brain’s sensory and motor regions.

In a study published in 2018, researchers at Duke University in North Carolina trained two rhesus monkeys to navigate a small room in a wheelchair controlled by a brain-machine interface in order to get food, while recording the activity of hundreds of cells with microelectrode arrays implanted into the animals’ sensory and motor cortices. Unexpectedly, they found that significant numbers of them exhibited place cell-like activity, firing only when the wheelchair was moved into a specific location.

These findings were confirmed in a 2021 study by researchers at Xinqiao Hospital in China, who recorded from the sensory cortex in foraging rats and identified neurons with the properties of place cells, grid cells and head-direction cells.

Although unexpected, the discovery of navigational cells in the sensory and motor cortices is not entirely surprising. Whereas in the hippocampus they function to generate maps and aid navigation, here they are likely to encode the position and orientation of the body within its surroundings.

T he discovery of navigational cells in the sensory and motor cortices allows us to expand our thinking about the function of these parts of the brain. Research into the somatotopic organisation of the female body suggests that the homunculus needs to be updated. At the same time, a team of researchers at the Washington University School of Medicine in St Louis is now arguing that the homunculus is entirely wrong and needs to be completely redrawn.

Evan Gordon, Nico Dosenbach and colleagues set out to replicate Penfield’s findings by using fMRI to scan the brains of seven volunteers at rest and as they performed various movement tasks, generating high-resolution brain maps for each. They then verified their results with data from three large, publicly available datasets, which between them contain brain-scanning data collected from some 50,000 people.

They found that movement of the feet, hands and face was associated with the parts of the motor cortex identified by Penfield, but that interspersed between these discrete regions were other areas that did not seem to be involved in movement at all. These other regions were thinner than the flanking regions associated with individual parts of the body, and were connected to each other, both within the same and between the two hemispheres of the brain, to form a chain running down the motor strip.

They argue that Penfield’s classic homunculus is wrong or at least spectacularly incomplete

Further investigation revealed that these areas are also strongly connected to distant brain regions involved in ‘executive’ functions such as thinking and planning, visual processing and the processing of touch, pain and internal bodily signals, and that they became active when the participants thought about moving.

The researchers propose that these areas form a network that integrates whole-body movements and anticipates them with appropriate changes in arousal, posture, breathing and heart function.

‘All of these connections make sense if you think about what the brain is really for,’ Dosenbach said in an interview. ‘The brain is for successfully behaving in the environment so you can achieve your goals without hurting or killing yourself. You move your body for a reason. Of course, the motor areas must be connected to executive function and control of basic bodily processes, like blood pressure and pain.’

In light of their findings, Gordon, Dosenbach and colleagues argue that Penfield’s classic homunculus is wrong or at least spectacularly incomplete, and needs to be radically revised to include the network they identified, which they have named the somato-cognitive action network (SCAN).

‘Penfield was brilliant, and his ideas have been dominant for 90 years … [but] once we started looking, we found lots of published data that didn’t quite jibe with his ideas, and alternative interpretations that had been ignored,’ Dosenbach said. ‘We pulled together a lot of different data in addition to our own observations, and zoomed out and synthesised it, and came up with a new way of thinking about how the body and the mind are tied together.’

W hat does this mean for neurosurgeons who use the homunculus to guide their scalpel? Performing surgery for epilepsy is extremely challenging due to the high risk of damaging the sensory or motor strips. Typically, the motor cortex generates seizures that are limited to certain parts of the body, but may spread to adjacent parts, and the non-movement regions identified by Gordon, Dosenbach and colleagues could, in theory, generate seizures that spread in unusual ways.

‘The likelihood that a seizure remains in this area without spreading to adjacent motor areas seems low, and I would expect typical [symptoms] in most situations,’ David Steven, professor of neurosurgery at Western University in London, Ontario, told me. With the brain regions intermingled, the surgery could be high risk, except in ‘the face area, which is usually safe as there is representation [on both sides of the brain].’

In practical terms, the little man in the brain still looms large. ‘For pre-surgical work-up and intra-operative decisions, it remains critical and very relevant,’ says Steven. ‘It may be oversimplified but, practically speaking, it remains essential.’

Mapping in finer detail will allow for prostheses that provide more realistic sensory feedback

Beyond the operating table, knowledge of how the body maps onto the motor cortex has been instrumental in the development of brain-machine interfaces that control prostheses to restore function to paralysed patients and amputees. These devices typically consist of a microelectrode array implanted into the motor cortex, which reads the brain activity associated with planning and executing movements and translates it into commands that can be used to control a wheelchair or robotic arm .

Early versions of these prostheses were cumbersome, but they are becoming more sophisticated by the day, and some of the newer devices can simultaneously stimulate the sensory cortex to provide sensory feedback. As well as restoring some sense of touch, this gives the user better control over the device, and can also reduce phantom limb pain that most amputees feel. Mapping the sensory homunculus in even finer detail will undoubtedly allow for prostheses that provide increasingly realistic sensory feedback to the user.

In the not too distant future, this knowledge, combined with a better understanding of brain activity underlying different types of touch, could also be used to develop the next generation of ‘haptic devices’, consisting of headsets that can precisely target the sensory cortex with small electrical or magnetic pulses to elicit realistic sensations of various kinds in any part of the user’s body.

From the future of artificial limbs to the future of gaming, the little man (and woman) in the brain may just be getting started – even if we’re still learning how they operate, in full.

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Time warps for a young surgeon with metastatic lung cancer

By Paul Kalanithi

Photography by Gregg Segal

In residency, there’s a saying: The days are long, but the years are short. In neurosurgical training, the day usually began a little before 6 a.m., and lasted until the operating was done, which depended, in part, on how quick you were in the OR.

audio interview

A resident’s surgical skill is judged by his technique and his speed. You can’t be sloppy and you can’t be slow. From your first wound closure onward, spend too much time being precise and the scrub tech will announce, “Looks like we’ve got a plastic surgeon on our hands!” Or say: “I get your strategy — by the time you finish sewing the top half of the wound, the bottom will have healed on its own. Half the work — smart!” A chief resident will advise a junior: “Learn to be fast now — you can learn to be good later.” Everyone’s eyes are always on the clock. For the patient’s sake: How long has the patient been under anesthesia? During long procedures, nerves can get damaged, muscles can break down, even causing kidney failure. For everyone else’s sake: What time are we getting out of here tonight?

It’s not until the last case finishes that you feel the length of the day, the drag in your step. Those last few administrative tasks before leaving the hospital, however far post-meridian you stood, felt like anvils. Could they wait till tomorrow? No. A sigh, and Earth continued to rotate back toward the sun.

There are two strategies to cutting the time short, like the tortoise and the hare. The hare moves as fast as possible, hands a blur, instruments clattering, falling to the floor; the skin slips open like a curtain, the skull flap is on the tray before the bone dust settles. But the opening might need to be expanded a centimeter here or there because it’s not optimally placed. The tortoise proceeds deliberately, with no wasted movements, measuring twice, cutting once. No step of the operation needs revisiting; everything proceeds in orderly fashion. If the hare makes too many minor missteps and has to keep adjusting, the tortoise wins. If the tortoise spends too much time planning each step, the hare wins.

The funny thing about time in the OR, whether you frenetically race or steadily proceed, is that you have no sense of it passing. If boredom is, as Heidegger argued, the awareness of time passing, this is the opposite: The intense focus makes the arms of the clock seem arbitrarily placed. Two hours can feel like a minute. Once the final stitch is placed and the wound is dressed, normal time suddenly restarts. You can almost hear an audible whoosh. Then you start wondering: How long till the patient wakes up? How long till the next case gets started? How many patients do I need to see before then? What time will I get home tonight?

But the years did, as promised, fly by. Six years passed in a flash, but then, heading into chief residency, I developed a classic constellation of symptoms — weight loss, fevers, night sweats, unremitting back pain, cough — indicating a diagnosis quickly confirmed: metastatic lung cancer. The gears of time ground down. While able to limp through the end of residency on treatment, I relapsed, underwent chemo and endured a prolonged hospitalization.

I emerged from the hospital weakened, with thin limbs and thinned hair. Now unable to work, I was left at home to convalesce. Getting up from a chair or lifting a glass of water took concentration and effort. If time dilates when one moves at high speeds, does it contract when one moves barely at all? It must: The day shortened considerably. A full day’s activity might be a medical appointment, or a visit from a friend. The rest of the time was rest.

With little to distinguish one day from the next, time began to feel static. In English, we use the word time in different ways, “the time is 2:45” versus “I’m going through a tough time.” Time began to feel less like the ticking clock, and more like the state of being. Languor settled in. Focused in the OR, the position of the clock’s hands might seem arbitrary, but never meaningless. Now the time of day meant nothing, the day of the week scarcely more so.

Yet there is dynamism in our house. Our daughter was born days after I was released from the hospital. Week to week, she blossoms: a first grasp, a first smile, a first laugh. Her pediatrician regularly records her growth on charts, tick marks of her progress over time.  

Verb conjugation became muddled. Which was correct? “I am a neurosurgeon,” “I was a neurosurgeon,” “I had been a neurosurgeon before and will be again”? Graham Greene felt life was lived in the first 20 years and the remainder was just reflection. What tense was I living in? Had I proceeded, like a burned-out Greene character, beyond the present tense and into the past perfect? The future tense seemed vacant and, on others’ lips, jarring. I recently celebrated my 15th college reunion; it seemed rude to respond to parting promises from old friends, “We’ll see you at the 25th!” with “Probably not!”

Yet there is dynamism in our house. Our daughter was born days after I was released from the hospital. Week to week, she blossoms: a first grasp, a first smile, a first laugh. Her pediatrician regularly records her growth on charts, tick marks of her progress over time. A brightening newness surrounds her. As she sits in my lap smiling, enthralled by my tuneless singing, an incandescence lights the room.

Time for me is double-edged: Every day brings me further from the low of my last cancer relapse, but every day also brings me closer to the next cancer recurrence — and eventually, death. Perhaps later than I think, but certainly sooner than I desire. There are, I imagine, two responses to that realization. The most obvious might be an impulse to frantic activity: to “live life to its fullest,” to travel, to dine, to achieve a host of neglected ambitions. Part of the cruelty of cancer, though, is not only that it limits your time, it also limits your energy, vastly reducing the amount you can squeeze into a day. It is a tired hare who now races. But even if I had the energy, I prefer a more tortoiselike approach. I plod, I ponder, some days I simply persist.

Everyone succumbs to finitude. I suspect I am not the only one who reaches this pluperfect state. Most ambitions are either achieved or abandoned; either way, they belong to the past. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described, hold so little interest: a chasing after wind, indeed.

Yet one thing cannot be robbed of her futurity: my daughter, Cady. I hope I’ll live long enough that she has some memory of me. Words have a longevity I do not. I had thought I could leave her a series of letters — but what would they really say? I don’t know what this girl will be like when she is 15; I don’t even know if she’ll take to the nickname we’ve given her. There is perhaps only one thing to say to this infant, who is all future, overlapping briefly with me, whose life, barring the improbable, is all but past.

That message is simple: When you come to one of the many moments in life when you must give an account of yourself, provide a ledger of what you have been, and done, and meant to the world, do not, I pray, discount that you filled a dying man’s days with a sated joy, a joy unknown to me in all my prior years, a joy that does not hunger for more and more, but rests, satisfied. In this time, right now, that is an enormous thing.

Editor’s note: Paul Kalanithi, MD, an instructor in Stanford’s Department of Neurosurgery and a fellow at the Stanford Neurosciences Institute, died March 9, 2015, at age 37.  Here is our obituary.

Email the magazine editor at [email protected]

Online Extra:

Announcing the NeurIPS 2023 Paper Awards 

Communications Chairs 2023 2023 Conference awards , neurips2023

By Amir Globerson, Kate Saenko, Moritz Hardt, Sergey Levine and Comms Chair, Sahra Ghalebikesabi 

We are honored to announce the award-winning papers for NeurIPS 2023! This year’s prestigious awards consist of the Test of Time Award plus two Outstanding Paper Awards in each of these three categories: 

• Two Outstanding Main Track Papers 
• Two Outstanding Main Track Runner-Ups 
• Two Outstanding Datasets and Benchmark Track Papers  

This year’s organizers received a record number of paper submissions. Of the 13,300 submitted papers that were reviewed by 968 Area Chairs, 98 senior area chairs, and 396 Ethics reviewers 3,540  were accepted after 502 papers were flagged for ethics reviews . 

We thank the awards committee for the main track: Yoav Artzi, Chelsea Finn, Ludwig Schmidt, Ricardo Silva, Isabel Valera, and Mengdi Wang. For the Datasets and Benchmarks track, we thank Sergio Escalera, Isabelle Guyon, Neil Lawrence, Dina Machuve, Olga Russakovsky, Hugo Jair Escalante, Deepti Ghadiyaram, and Serena Yeung. Conflicts of interest were taken into account in the decision process.

Congratulations to all the authors! See Posters Sessions Tue-Thur in Great Hall & B1-B2 (level 1).

Outstanding Main Track Papers

Privacy Auditing with One (1) Training Run Authors: Thomas Steinke · Milad Nasr · Matthew Jagielski

Poster session 2: Tue 12 Dec 5:15 p.m. — 7:15 p.m. CST, #1523

Oral: Tue 12 Dec 3:40 p.m. — 4:40 p.m. CST, Room R06-R09 (level 2)

Abstract: We propose a scheme for auditing differentially private machine learning systems with a single training run. This exploits the parallelism of being able to add or remove multiple training examples independently. We analyze this using the connection between differential privacy and statistical generalization, which avoids the cost of group privacy. Our auditing scheme requires minimal assumptions about the algorithm and can be applied in the black-box or white-box setting. We demonstrate the effectiveness of our framework by applying it to DP-SGD, where we can achieve meaningful empirical privacy lower bounds by training only one model. In contrast, standard methods would require training hundreds of models.

Are Emergent Abilities of Large Language Models a Mirage? Authors: Rylan Schaeffer · Brando Miranda · Sanmi Koyejo

Poster session 6: Thu 14 Dec 5:00 p.m. — 7:00 p.m. CST, #1108

Oral: Thu 14 Dec 3:20 p.m. — 3:35 p.m. CST, Hall C2 (level 1) 

Abstract: Recent work claims that large language models display emergent abilities, abilities not present in smaller-scale models that are present in larger-scale models. What makes emergent abilities intriguing is two-fold: their sharpness, transitioning seemingly instantaneously from not present to present, and their unpredictability , appearing at seemingly unforeseeable model scales. Here, we present an alternative explanation for emergent abilities: that for a particular task and model family, when analyzing fixed model outputs, emergent abilities appear due to the researcher’s choice of metric rather than due to fundamental changes in model behavior with scale. Specifically, nonlinear or discontinuous metrics produce apparent emergent abilities, whereas linear or continuous metrics produce smooth, continuous, predictable changes in model performance. We present our alternative explanation in a simple mathematical model, then test it in three complementary ways: we (1) make, test and confirm three predictions on the effect of metric choice using the InstructGPT/GPT-3 family on tasks with claimed emergent abilities, (2) make, test and confirm two predictions about metric choices in a meta-analysis of emergent abilities on BIG-Bench; and (3) show how to choose metrics to produce never-before-seen seemingly emergent abilities in multiple vision tasks across diverse deep networks. Via all three analyses, we provide evidence that alleged emergent abilities evaporate with different metrics or with better statistics, and may not be a fundamental property of scaling AI models.

Outstanding Main Track Runner-Ups

Scaling Data-Constrained Language Models Authors : Niklas Muennighoff · Alexander Rush · Boaz Barak · Teven Le Scao · Nouamane Tazi · Aleksandra Piktus · Sampo Pyysalo · Thomas Wolf · Colin Raffel

Poster session 2: Tue 12 Dec 5:15 p.m. — 7:15 p.m. CST, #813

Oral: Tue 12 Dec 3:40 p.m. — 4:40 p.m. CST, Hall C2 (level 1)  

Abstract : The current trend of scaling language models involves increasing both parameter count and training dataset size. Extrapolating this trend suggests that training dataset size may soon be limited by the amount of text data available on the internet. Motivated by this limit, we investigate scaling language models in data-constrained regimes. Specifically, we run a large set of experiments varying the extent of data repetition and compute budget, ranging up to 900 billion training tokens and 9 billion parameter models. We find that with constrained data for a fixed compute budget, training with up to 4 epochs of repeated data yields negligible changes to loss compared to having unique data. However, with more repetition, the value of adding compute eventually decays to zero. We propose and empirically validate a scaling law for compute optimality that accounts for the decreasing value of repeated tokens and excess parameters. Finally, we experiment with approaches mitigating data scarcity, including augmenting the training dataset with code data or removing commonly used filters. Models and datasets from our 400 training runs are freely available at https://github.com/huggingface/datablations .

Direct Preference Optimization: Your Language Model is Secretly a Reward Model Authors: Rafael Rafailov · Archit Sharma · Eric Mitchell · Christopher D Manning · Stefano Ermon · Chelsea Finn

Poster session 6: Thu 14 Dec 5:00 p.m. — 7:00 p.m. CST, #625

Oral: Thu 14 Dec 3:50 p.m. — 4:05 p.m. CST, Ballroom A-C (level 2)  

Abstract: While large-scale unsupervised language models (LMs) learn broad world knowledge and some reasoning skills, achieving precise control of their behavior is difficult due to the completely unsupervised nature of their training. Existing methods for gaining such steerability collect human labels of the relative quality of model generations and fine-tune the unsupervised LM to align with these preferences, often with reinforcement learning from human feedback (RLHF). However, RLHF is a complex and often unstable procedure, first fitting a reward model that reflects the human preferences, and then fine-tuning the large unsupervised LM using reinforcement learning to maximize this estimated reward without drifting too far from the original model. In this paper, we leverage a mapping between reward functions and optimal policies to show that this constrained reward maximization problem can be optimized exactly with a single stage of policy training, essentially solving a classification problem on the human preference data. The resulting algorithm, which we call Direct Preference Optimization (DPO), is stable, performant, and computationally lightweight, eliminating the need for fitting a reward model, sampling from the LM during fine-tuning, or performing significant hyperparameter tuning. Our experiments show that DPO can fine-tune LMs to align with human preferences as well as or better than existing methods. Notably, fine-tuning with DPO exceeds RLHF’s ability to control sentiment of generations and improves response quality in summarization and single-turn dialogue while being substantially simpler to implement and train.

Outstanding Datasets and Benchmarks Papers

In the dataset category : 

ClimSim: A large multi-scale dataset for hybrid physics-ML climate emulation

Authors:  Sungduk Yu · Walter Hannah · Liran Peng · Jerry Lin · Mohamed Aziz Bhouri · Ritwik Gupta · Björn Lütjens · Justus C. Will · Gunnar Behrens · Julius Busecke · Nora Loose · Charles Stern · Tom Beucler · Bryce Harrop · Benjamin Hillman · Andrea Jenney · Savannah L. Ferretti · Nana Liu · Animashree Anandkumar · Noah Brenowitz · Veronika Eyring · Nicholas Geneva · Pierre Gentine · Stephan Mandt · Jaideep Pathak · Akshay Subramaniam · Carl Vondrick · Rose Yu · Laure Zanna · Tian Zheng · Ryan Abernathey · Fiaz Ahmed · David Bader · Pierre Baldi · Elizabeth Barnes · Christopher Bretherton · Peter Caldwell · Wayne Chuang · Yilun Han · YU HUANG · Fernando Iglesias-Suarez · Sanket Jantre · Karthik Kashinath · Marat Khairoutdinov · Thorsten Kurth · Nicholas Lutsko · Po-Lun Ma · Griffin Mooers · J. David Neelin · David Randall · Sara Shamekh · Mark Taylor · Nathan Urban · Janni Yuval · Guang Zhang · Mike Pritchard

Poster session 4: Wed 13 Dec 5:00 p.m. — 7:00 p.m. CST, #105 

Oral: Wed 13 Dec 3:45 p.m. — 4:00 p.m. CST, Ballroom A-C (level 2)

Abstract: Modern climate projections lack adequate spatial and temporal resolution due to computational constraints. A consequence is inaccurate and imprecise predictions of critical processes such as storms. Hybrid methods that combine physics with machine learning (ML) have introduced a new generation of higher fidelity climate simulators that can sidestep Moore’s Law by outsourcing compute-hungry, short, high-resolution simulations to ML emulators. However, this hybrid ML-physics simulation approach requires domain-specific treatment and has been inaccessible to ML experts because of lack of training data and relevant, easy-to-use workflows. We present ClimSim, the largest-ever dataset designed for hybrid ML-physics research. It comprises multi-scale climate simulations, developed by a consortium of climate scientists and ML researchers. It consists of 5.7 billion pairs of multivariate input and output vectors that isolate the influence of locally-nested, high-resolution, high-fidelity physics on a host climate simulator’s macro-scale physical state. The dataset is global in coverage, spans multiple years at high sampling frequency, and is designed such that resulting emulators are compatible with downstream coupling into operational climate simulators. We implement a range of deterministic and stochastic regression baselines to highlight the ML challenges and their scoring. The data (https://huggingface.co/datasets/LEAP/ClimSim_high-res) and code (https://leap-stc.github.io/ClimSim) are released openly to support the development of hybrid ML-physics and high-fidelity climate simulations for the benefit of science and society.   

In the benchmark category :

DecodingTrust: A Comprehensive Assessment of Trustworthiness in GPT Models

Authors: Boxin Wang · Weixin Chen · Hengzhi Pei · Chulin Xie · Mintong Kang · Chenhui Zhang · Chejian Xu · Zidi Xiong · Ritik Dutta · Rylan Schaeffer · Sang Truong · Simran Arora · Mantas Mazeika · Dan Hendrycks · Zinan Lin · Yu Cheng · Sanmi Koyejo · Dawn Song · Bo Li

Poster session 1: Tue 12 Dec 10:45 a.m. — 12:45 p.m. CST, #1618  

Oral: Tue 12 Dec 10:30 a.m. — 10:45 a.m. CST, Ballroom A-C (Level 2)

Abstract: Generative Pre-trained Transformer (GPT) models have exhibited exciting progress in capabilities, capturing the interest of practitioners and the public alike. Yet, while the literature on the trustworthiness of GPT models remains limited, practitioners have proposed employing capable GPT models for sensitive applications to healthcare and finance – where mistakes can be costly. To this end, this work proposes a comprehensive trustworthiness evaluation for large language models with a focus on GPT-4 and GPT-3.5, considering diverse perspectives – including toxicity, stereotype bias, adversarial robustness, out-of-distribution robustness, robustness on adversarial demonstrations, privacy, machine ethics, and fairness. Based on our evaluations, we discover previously unpublished vulnerabilities to trustworthiness threats. For instance, we find that GPT models can be easily misled to generate toxic and biased outputs and leak private information in both training data and conversation history. We also find that although GPT-4 is usually more trustworthy than GPT-3.5 on standard benchmarks, GPT-4 is more vulnerable given jailbreaking system or user prompts, potentially due to the reason that GPT-4 follows the (misleading) instructions more precisely. Our work illustrates a comprehensive trustworthiness evaluation of GPT models and sheds light on the trustworthiness gaps. Our benchmark is publicly available at https://decodingtrust.github.io/.

Test of Time

This year, following the usual practice, we chose a NeurIPS paper from 10 years ago to receive the Test of Time Award, and “ Distributed Representations of Words and Phrases and their Compositionality ” by Tomas Mikolov, Ilya Sutskever, Kai Chen, Greg Corrado, and Jeffrey Dean, won. 

Published at NeurIPS 2013 and cited over 40,000 times, the work introduced the seminal word embedding technique word2vec. Demonstrating the power of learning from large amounts of unstructured text, the work catalyzed progress that marked the beginning of a new era in natural language processing.

Greg Corrado and Jeffrey Dean will be giving a talk about this work and related research on Tuesday, 12 Dec at 3:05 – 3:25 pm CST in Hall F.  

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Guest Essay

The Best Way to Find Out if We Can Cool the Planet

By Jeremy Freeman

Dr. Freeman is the executive director of CarbonPlan, a climate research nonprofit.

A few years ago, the idea of deliberately blocking the sun to combat climate change was taboo for scientists. But a lot can change in a short time .

As the disastrous effects of climate change mount, Congress has asked federal scientists for a research plan , private money is flowing and rogue start-ups are attempting experiments — all signs that momentum around solar geoengineering is building fast. The most discussed approach involves spraying tiny particles into the stratosphere to reflect sunlight and cool the planet. Other proposals include injecting sea salt into clouds to increase their reflectivity or using giant space parasols to block the sun .

It might all sound like dystopian science fiction, but some techno-futurists, like OpenAI’s chief executive, Sam Altman, are already normalizing it: “We’re going to have to do something dramatic with climate like geoengineering as a Band-Aid, as a stopgap,” he said in January at the World Economic Forum in Davos.

No one fully understands the risks of these technologies — which could include calamitous disruptions in weather — or how significant the benefits could be. I’m increasingly convinced that we should do more research on solar geoengineering . But such high-stakes science requires extraordinary levels of transparency and accountability to the global public. The alternative is clandestine research controlled by corporations or autocratic regimes, lurching toward deployment without knowing — or knowing and not sharing — the true risks.

The potential risks of solar geoengineering are serious. Spraying reflective particles in one place, for example, could significantly change rainfall patterns elsewhere. What’s more, once anyone starts solar geoengineering at a larger scale, suddenly stopping it could lead to “ termination shock ” — global temperatures rapidly readjusting to where they would have been without geoengineering. With such terrifying points of no return, every accelerating step of research requires global public participation and deliberation.

Most research so far has been tentative and contained to computer simulations . But to know what will happen in the real world, we also need outdoor experiments. By launching an instrument-laden balloon into the stratosphere, for example, researchers could release a tiny amount of particles and measure how they interact with the atmosphere, with minimal environmental risk.

But already we’ve seen a backlash to these kinds of experiments: Harvard geoengineering researchers planned a dry run of their instruments in Sweden in 2021 only to be shut down after the Indigenous Saami Council and local environmental groups protested the tests. A key concern was how such research could redirect attention and investment from more pressing efforts to reduce emissions, thereby becoming a moral hazard . More recently, Mexico banned geoengineering experiments after discovering an American tech entrepreneur had launched a balloon test without permission. And a startup out of Israel has now raised millions of dollars and is planning experiments with little to no transparency. Some assessments suggest that more experiments, and even larger deployments, are increasingly likely. It would be far better if they happened in the open, as in Sweden, rather than in secret.

Even in places where no experiments have been planned, the public is wary. Most people haven’t heard of geoengineering in the United States, but of those who have, 72 percent reported being very concerned we’ll use it before understanding its impact. More broadly, while there’s evidence of support for research , that support is reluctant and conditional. Without transparency and trust, public debate on geoengineering could devolve into conspiracy theories and partisan ideology.

A reluctance to trust scientists is understandable. Science as a profession has for too long pursued prestige at the expense of integrity, and public scientific institutions have been increasingly privatized with minimal accountability. With a long, troubled history that includes eugenics and weapons of war, we cannot pretend that science is either pure or infallible.

But science is fallible precisely because it is a practice , a cooperative human activity. And as the moral philosopher Alasdair MacIntyre reminds us, engaging in a practice well requires exercising its virtues — which for science include transparency, honesty, humility, skepticism and collaboration. For geoengineering, that means disclosing all funding and effectively managing potential conflicts of interests, ensuring the participation of stakeholders from around the world in decision making , avoiding groupthink, sharing early-stage results and data to accelerate research and engaging in radically open science .

Transparency on its own may not lead to the widespread adoption of a new technology. A study on Covid-19 vaccine communication showed that increased transparency, especially about negative outcomes, led to lower vaccine acceptance — but it did increase trust in public health. A potential lesson for solar geoengineering is that transparency is important even when or perhaps especially when it doesn’t result in an outcome scientists initially imagine.

We should be especially wary of ceding control over geoengineering research to the tech industry. Often under the guise of virtue, techno-futurists capitalize on the power that comes from scientific knowledge while exploiting people and the environment, a pattern The Atlantic’s Adrienne LaFrance diagnoses as techno-authoritarianism. We cannot allow private for-profit entities to steer, or covertly fund, solar geoengineering research.

Instead, any research must be done by institutions acting in the public’s interest. If private funding is the only option, scientists will need to choose carefully where they work and defend their integrity against external pressures. They must clearly communicate research findings, positive and negative, and educate the public about what’s possible and what’s at stake. That way the public can in turn hold policymakers, regulators and scientists to account, with everyone working together in pursuit of a common good.

When confronted with the prospect of solar geoengineering, we may wish it had never come to this point. But we can still decide how to move forward responsibly, with and for the public.

Jeremy Freeman is the executive director of CarbonPlan, a climate research nonprofit. Much of CarbonPlan’s work has focused on carbon dioxide removal, another controversial climate technology.

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