To show is better than to tell. The first time I received this advice was in my fifth grade English class. As I enter my fourth year of medical school, my residency application will show many things: years of labor compressed down onto a few pages and then further summarized into a handful of relevant numbers. I am more than a handful of numbers. But how can I demonstrate this to neurosurgery programs? In the past, away rotations have allowed students to do just this, while at the same time providing exposure to the wider world of neurosurgery regardless of their medical school. For the many students who attend medical schools without neurosurgery departments or affiliated residency programs, away rotations will be their only chance to interact with neurosurgeons long enough to allow for meaningful letters.
Current medical school curricula are designed in a way that rarely lets students explore neurosurgery until their fourth year. This is especially true for students without home neurosurgery programs. For them, an away rotation may represent the only opportunity to see if they have the personality to one day practice neurosurgery. Most people find the subject interesting, but it is another thing entirely to care for neurosurgical patients, to round on NICU patients that are waking up from technically perfect surgeries with new deficits, to explain to a family whose loved one was fully independent before their intracerebral hemorrhage will never again be the same person and then get up the next day and face the same challenges – all while attempting to be a ray of hope for your patients and their loved ones. The proximity to tragedy and the enormous responsibility given to neurosurgeons by their patients is too heavy a burden for most people. Away rotations provide students with the breadth of exposure to neurosurgery necessary to assess how well they might handle that responsibility.
COVID-19 has disrupted these subinternships. Even as most medical students were receiving their second doses of the vaccine, the Coalition for Physician Accountability recommended that away rotations would again be limited. Furthermore, there is discussion of continuing to limit these subinternships in the future. As a student, let me defend this means to prove ourselves. Nothing read from a personal statement demonstrates endurance like seeing a student arrive to the hospital first and leave last. No story I can tell will convey my adaptability or problem solving as effectively as witnessing me spontaneously create a solution. Only in person can my patient rapport be observed. These are not experiences that will adequately translate to Zoom.
The Digital World
Without the in-person experiences of away rotations, it is difficult for potential applicants to evaluate programs. Much like the applicants themselves, residency programs put their best foot forward during interviews. It is much more compelling for me to witness a program first-hand than to be told about its ethos. As a soon-to-be applicant, seeing how current residents and senior staff handle disagreements will be an important consideration when applying to a program or forming my rank list.
A subinternship is not only a way to secure meaningful letters or audition at a program, but also offers a wider exposure to neurosurgical techniques, research and potential future collaborators. Many procedures, whether in research or the operating room, are only performed at a handful of major centers. Although cutting edge technology plays its role, the true value of rotating at a variety of centers is being able to observe and build professional relationships with uniquely experienced surgeons and researchers.
Those calling to amend or discontinue away rotations want to create a more equitable process for students applying into neurosurgery. They offer a salient critique: away rotations may be cost prohibitive to those who do not come from significant wealth and privilege. As a student who came from a single parent household, whose mother is a hairdresser, someone who has only attended school through scholarships and has set aside some of that money in anticipation of the costs of away rotations, I say they are a net positive for equity. Rather than moving to write-off away rotations, schools, the AAMC and organized neurosurgery could work to reduce the costs incurred by creating institutional supports, like facilitating apartment swapping between rotators or outright offering low-cost housing.
Taken in whole, away rotations offer students not already at top programs a means to make themselves stronger candidates and demonstrate their existing merits.
