See the corresponding editorial in this issue, pp 419–421.

J Neurosurg Pediatrics 12:422–433, 2013

©AANS, 2013

Perceived benefits and barriers to a career in pediatric

neurosurgery: a survey of neurosurgical residents
Clinical article

Mark S. Dias, M.D.,1,4 Jeffrey S. Sussman, M.P.H., M.A., 2 Susan Durham, M.D., M.S., 3
and Mark R. Iantosca, M.D.1

Departments of 1Neurosurgery and 4Pediatrics, Penn State University College of Medicine, Hershey,
Pennsylvania; 2Heller School for Public Policy and Management, Brandeis University, Waltham,
Massachusetts; and 3Dartmouth University School of Medicine, Lebanon, New Hampshire

Object. Research suggests that there may be a growing disparity between the supply of and demand for both
pediatric specialists and neurosurgeons. Whether pediatric neurosurgeons are facing such a disparity is disputable,
but interest in pediatric neurosurgery (PNS) has waxed and waned as evidenced by the number of applicants for PNS
fellowships. The authors undertook a survey to analyze current neurosurgical residents’ perceptions of both benefits
and deterrents to a pediatric neurosurgical career.
Methods. All residents and PNS fellows in the United States and Canada during the academic year 2008–2009
were invited to complete a Web-based survey that assessed 1) demographic and educational information about resi-
dents and their residency training, particularly as it related to training in PNS; 2) residents’ exposure to mentoring
opportunities from pediatric neurosurgical faculty and their plans for the future; and 3) residents’ perceptions about
how likely 40 various factors were to influence their decision about whether to pursue a PNS career.
Results. Four hundred ninety-six responses were obtained: 89% of the respondents were male, 63% were mar-
ried, 75% were in at least their 3rd year of postgraduate training, 61% trained in a children’s hospital and 29% in
a children’s “hospital within a hospital,” and 72% were in programs having one or more dedicated PNS faculty
members. The residencies of 56% of respondents offered 6–11 months of PNS training and nearly three-quarters of
respondents had completed 2 months of PNS training. During medical school, 92% had been exposed to neurosurgery
and 45% to PNS during a clinical rotation, but only 7% identified a PNS mentor. Nearly half (43%) are consider-
ing a PNS career, and of these, 61% are definitely or probably considering post-residency fellowship. On the other
hand, 68% would prefer an enfolded fellowship during residency. Perceived strengths of PNS included working
with children, developing lasting relationships, wider variety of operations, fast healing and lack of comorbidities,
and altruism. Perceived significant deterrents included shunts, lower reimbursement, cross-coverage issues, higher
malpractice premiums and greater legal exposure, and working with parents and pediatric health professionals. The
intrinsic nature of PNS was listed as the most significant deterrent (46%) followed by financial concerns (25%), addi-
tional training (12%), longer work hours (12%), and medicolegal issues (4%). The majority felt that fellowship train-
ing and PNS certification should be recommended for surgeons treating of all but traumatic brain injuries and Chiari
I malformations and performing simple shunt-related procedures, although they felt that these credentials should be
required only for treating complex craniosynostosis.
Conclusions. The nature of PNS is the most significant barrier to attracting residents, although reimbursement,
cross-coverage, and legal issues are also important to residents. The authors provide several recommendations that
might enhance resident perceptions of PNS and attract trainees to the specialty.
(http://thejns.org/doi/abs/10.3171/2013.7.PEDS12597)

Key Words      •      pediatric neurosurgery      •      medical education      •      residency      •

postgraduate training       •      workforce      •      career choice

I
n 1991 the American Board of Pediatric Neurological
Surgery (ABPNS) began certifying pediatric neuro-
Abbreviations used in this paper: AAP = American Academy surgeons, and, in 1992, the Accreditation Council for
of Pediatrics; ABNS = American Board of Neurological Surgery;
ABPNS = American Board of Pediatric Neurological Surgery; Pediatric Neurosurgical Fellowships (ACPNF) began for-
ACPNF = Accreditation Council for Pediatric Neurosurgical Fel- mally accrediting fellowship training programs in pediat-
lowships; ASPN = American Society of Pediatric Neurosurgeons; ric neurosurgery (PNS) in an effort to ensure high quality
CAST = Committee on Accreditation of Subspecialty Training; of neurosurgical care for children in the United States. Be-
PGY = postgraduate training year; PNS = pediatric neurosurgery. tween the years 1992 and 2008, the 22 accredited PNS fel-

422 J Neurosurg: Pediatrics / Volume 12 / November 2013

Residents’ perceptions of careers in pediatric neurosurgery

lowship programs graduated 193 trainees, of whom only sues—they felt was the single greatest obstacle to a PNS
143 met ABPNS eligibility criteria. Moreover, fully one- career. The fourth section sought residents’ views con-
third of these graduates did not become ABPNS certified cerning the importance or necessity of post-residency PNS
or pursue a pediatric neurosurgical career.8 This leaves an fellowship or certification by ABPNS for treating various
average of only 6 new board-eligible pediatric neurosur- pediatric neurosurgical conditions.
geons per year in the US. The research was approved by the Human Subjects
At the same time, a survey of practicing pediatric Protection Office at Penn State University College of Med-
neurosurgeons in the US revealed that nearly two-thirds icine. The residents’ e-mail addresses were obtained from
planned to recruit additional individuals to their practices, the American Board of Neurological Surgery (ABNS). A
and another study confirmed that pediatric neurosurgical total of 1263 trainees participating in postgraduate train-
care in the US is increasingly being assumed by dedicated ing programs in the US and Canada during the academic
pediatric neurosurgeons, with less than 50% of neurosur- year 2008–2009 were sent e-mails requesting their par-
geons providing routine neurosurgical care for children ticipation and providing a private link to an Internet-based
and only 22% providing emergency care.3 Children’s hos- survey site (www.surveymonkey.com) to complete the
pitals increasingly recognize the value of dedicated pedi- survey. A drawing for 2 iPods (Apple Inc.) was offered
atric neurosurgical training, and most demand ACPNF- as an enticement for participating. All responses were
accredited fellowship training and board certification or de-identified and analyzed. Between-group comparisons
eligibility for new recruits. Nationwide, pediatric neuro- were analyzed using chi-square analysis; p < 0.05 was
surgeons are increasingly assuming care for adults with considered significant.
developmental neurosurgical disorders (for example, dys-
raphic malformations), complex hydrocephalus, and con-
ditions requiring endoscopy. Finally, it is anticipated that Results
recent legislation, such as the Affordable Care Act, will A total of 496 responses (representing 39% of US
significantly expand the population (including children) and Canadian trainees) were obtained from residents and
covered by medical insurance; how this will impact the fellows in 43 states as well as Puerto Rico and Canada.
workforce needs for pediatric neurosurgeons has yet to be Since only 8 PNS fellows responded, their answers were
analyzed. These factors raise concern over whether de- included in the total, but no attempt was made to compare
mand for pediatric neurosurgeons will outstrip supply in their responses with those of residents. The demographic
the near future. It therefore becomes important to under- characteristics are listed in Table 1. Overall, 89% of re-
stand what factors attract trainees to, or discourage them spondents were male and 63% were married. Analysis by
from, pursuing a career in PNS. We undertook a survey sex shows that more male respondents (65%) were mar-
of US neurosurgical residents to assess their perceptions ried compared with female respondents (49%, p = 0.03).
about barriers and benefits to a career in PNS. Twelve percent of respondents had previously had chil-
dren during medical school and one-third had previously
had children during residency. Of those who were married
Methods
at the time of the survey, 53% planned on having children
A survey was developed to query residents’ interest in sometime during residency. However, there were signifi-
PNS and to assess their perceptions about benefits of, and cant sex differences, with 65% of married male respon-
deterrents to, a PNS career. The survey was divided into dents but only 13.3% of female respondents planning to
4 sections. The first section compiled simple demographic have children during residency (p = 0.03). Half of respon-
information from residents, including sex; race; marital dents currently owed $100,000 or more in student loans,
status; whether they had or planned to have children; their and 14% owed over $200,000. Three-quarters of respon-
level of educational indebtedness; their postgraduate train- dents were currently at a PGY 3 level or higher.
ing year (PGY); the geographic location of their residency The extent and character of PNS training is outlined
training program; and details about how pediatric care in in Table 2. Sixty-one percent of respondents were being
general, and PNS training in particular, is provided within trained within a dedicated children’s hospital, 29% were
their institution. The second section sought information being trained within a “children’s hospital within a hos-
about mentorship, potential career planning and subspe- pital,” 8% were being outsourced to another program for
cialization within neurosurgery, and pursuit of post-res- PNS training, and only 2% reported no significant PNS
idency fellowship training. The third and largest section training experience. Over half (56%) of respondents re-
asked respondents to rate their perceptions about each of ported 6–11 months of dedicated PNS rotations—44%
40 characteristics as either enticements or deterrents to a during their junior years (PGY 1–2), 86% during their se-
PNS career; responses were scored from 2 to -2 using a nior years (PGY 3–5), and 25% during their chief resident
Likert scale, with a score of 2 signifying “strong entice- year (PGY 6–7). At the time of the survey, 70% of re-
ment,” 1 signifying “moderate enticement,” 0 signifying spondents had already completed at least 2 months of PNS
“neutral,” -1 signifying “moderate deterrent,” and -2 sig- training. Eighty-eight percent were trained in programs
nifying “strong deterrent.” Mean scores were calculated having at least 1 dedicated PNS faculty member, with
for each of these factors. Residents were also asked which 65% having 2 or more dedicated PNS faculty members
of 5 general categories—the inherent nature or practice (defined as spending more than 75% of their time treating
of PNS, the additional training required, financial issues, children). Seventy-two percent described a separate PNS
time demands and coverage issues, and medicolegal is- rotation having at least 1 dedicated PNS faculty member,

J Neurosurg: Pediatrics / Volume 12 / November 2013 423

 M. S. Dias et al.
TABLE 1: Demographics of respondents rotation, but only 7.4% of respondents identified a PNS
mentor. When asked what they thought were the most im-
% of Total No. of portant characteristics of a mentor, the top 3 choices were
Characteristic Responses Responses* “being a good teacher,” “telling the truth,” and “being an
sex 495
excellent clinician.”
Selecting neurosurgery as a career was accomplished
 male 88.5 during college or earlier by 25% of respondents, during
 female 11.5 the preclinical medical school years by 21%, and during
ethnicity 494 the clinical medical school years by 50% (Table 4). In
 Hispanic 7.9 contrast, among respondents interested in PNS, only 25%
 non-Hispanic 92.1 made the decision before entering residency, and over
half made the decision during or after their PGY 3 year.
race 477
Nearly half (43%) of respondents expressed some interest
 white 75.5 in PNS as a career, including 17% who were definitely in-
 African-American 3.4 terested and 24% who were perhaps interested; only 26%
 Asian 19.9 were definitely not interested (Table 5). Of those express-
  Hawaiian/Pacific Islander 0.4 ing interest in PNS, 83% expressed some interest in a fel-
marital status 494
lowship, but 63% would more strongly consider PNS if
enfolded pediatric neurosurgical fellowships were offered
  married 62.8 as an alternative to a post-residency fellowship. A break-
  engaged 5.3 down of other fellowships being considered by residents
 single 29.1 is also listed in Table 5; spine, endovascular, cerebrovas-
  divorced 2.8 cular, neuro-oncology, and skull base were the most fre-
children 494 quently cited.
Table 6 displays residents’ ratings of 40 various fac­
  during college 4.4
tors as benefits or barriers toward a PNS career. To sum-
  during medical school 12.2 marize a few key features, residents identified working
  during residency 32.8 with children as a strong enticement, whereas working
  no children 50.6 with parents and families, as well as with pediatricians
educational indebtedness 493 and pediatric nurses, were all seen as relative deterrents.
  ≤$50,000 36.3 The precision and delicate nature of PNS operations, the
wider variety of procedures, and fast healing and lack
 $50,001–100,000 14.0
of secondary comorbidities were seen as enticements,
 $100,001–150,000 16.2 whereas dealing with shunts was seen as a strong deter-
 $150,001–200,000 19.7 rent. Altruism, the ability to have an academic career
 >$200,000 13.8 and to do research, and the potential for higher career
PGY 495 satisfaction were also seen as enticements, whereas re-
  PGY 1 5.1
imbursement, on-call schedules and lack of on-call cov-
erage, cost of malpractice insurance, and the prolonged
  PGY 2 14.5 exposure to potential malpractice actions were seen as
  PGY 3 15.4 deterrents. Somewhat surprisingly, the number of work-
  PGY 4 20.4 ing hours, work-hour flexibility, and job pressure were not
  PGY 5 19.6 viewed as significant negatives. When asked what they
  PGY 6 12.5 perceived overall as the single greatest obstacle to recruit-
ing residents into a career in PNS, respondents identified
  PGY 7 or greater 7.1
the intrinsic nature or practice of PNS (46%) as the most
  fellow in PNS 1.6 common issue; in contrast, the additional training and
  fellow in another neurosurgical specialty 3.4 medicolegal issues were less frequently seen as the most
important barriers (Table 7).
*  Total number of responses to the given survey question. Tables 8 and 9 review residents’ perceptions about
whether post-residency fellowship training or ABPNS
certification (or eligibility) should be considered in decid-
and an additional 20% described mixed adult and pediat- ing who should treat various conditions in children. Fel-
ric rotations having at least 1 dedicated PNS faculty mem- lowship training and ABPNS certification or eligibility
ber. Over one-third (36%) of respondents were training in were thought to be unnecessary only for the treatment of
residency programs having post-residency PNS fellows. traumatic brain injuries, simple (1 shunt) hydrocephalus,
The frequency and types of medical school exposures and Type I Chiari malformations, and required only for
to neurosurgery, PNS, and pediatric surgery are illustrat- complex (coronal, metopic, or multisutural) craniosyn-
ed in Table 3. Only 1.4% of respondents had no exposure ostosis. For all other conditions, residents viewed fellow-
to neurosurgery during medical school, but 40% had no ship training and ABPNS certification as recommended
PNS exposure. Of those respondents having PNS expo- but not required. Nearly three-quarters of respondents felt
sure, 45% reported this exposure during a neurosurgical that their training prepared them to treat most common

424 J Neurosurg: Pediatrics / Volume 12 / November 2013

Residents’ perceptions of careers in pediatric neurosurgery
TABLE 2: Description of pediatric neurosurgical training

Characteristic % of Responses Total No. of Responses

type of pediatric hospital for training 495
  dedicated (free-standing/connected) children’s hospital 61.4
  children’s hospital w/in a hospital 29.1
  referred to another program for training 7.7
  no significant pediatric training 1.8
type of PNS training 495
  separate PNS rotation w/ at least 1 dedicated PNS faculty member 72.1
  combined adult & pediatric rotations w/ at least 1 dedicated PNS faculty member 20.0
  combined adult & pediatric rotations w/ no dedicated PNS faculty member 5.9
  little or no PNS training 2.0
level of training when PNS rotations occur 471
  PGY 1–2 (junior resident) 43.9
  PGY 3-5 (senior resident) 85.6
  PGY 6–7 (chief resident) 24.6
time spent on PNS rotations 472
  ≤1 mo 2.5
  2–3 mos 14.2
  4–5 mos 14.6
  6–11 mos 55.5
  ≥12 mos 13.1
number of dedicated PNS faculty members 495
 0 12.3
 1 23.2
 2 26.7
 3 19.6
 >3 18.2
training program offers PNS fellowship training 495
 yes 35.8
 no 61.8
 unsure 2.4

or simple PNS disorders, but only 11% felt their training

prepared them to treat all PNS disorders (Table 10).
TABLE 3: Exposure to mentors during training
Trainees’ responses were divided into 4 groups based
upon their answer to one question concerning their plans
% of Total No. of for a future career in PNS: 1) definitely yes, 2) maybe yes,
Characteristic Responses Responses 3) probably no, and 4) definitely no. Two comparative
exposure to specialty 434 analyses were performed using chi-square analysis with a
 neurosurgery 98.6 Type I error rate of 0.05. In the first analysis, the character-
istics and responses of Group 1 were compared with those
 PNS 60.4
of Group 4, and in the second, the combined responses
  pediatric surgery 55.5 of Groups 1 and 2 were compared with the combined re-
identified mentor during medical school* 433 sponses from Groups 3 and 4. There were significant dif-
 neurosurgeon 55.0 ferences between the responses of those who expressed
  pediatric neurosurgeon 7.4 a desire to pursue a PNS career and those who did not;
 surgeon 14.1
these are listed in Tables 11 and 12. As a group, trainees
planning to pursue a career in PNS were statistically more
  pediatric surgeon 1.6 likely to be female, to have less than $100,000 in loan in-
  medical specialist 4.2 debtedness, to be in the earlier stages of residency, and
  obstetrician/gynecologist 0.7 to have had prior exposure to a PNS mentor. Not surpris-
  pediatrician 0.5 ingly, this group was significantly less likely to view the
intrinsic practice of PNS, length of training, and financial
*  Refers to mentors identified by respondents. issues as obstacles to a PNS career (Table 11).

J Neurosurg: Pediatrics / Volume 12 / November 2013 425

 M. S. Dias et al.

TABLE 4: Timing of decisions concerning career choice

Med School Yrs Med School Yrs

Choice College or Earlier 1–2 3–4 PGY 1–2 PGY 3–5 No. of responses
neurosurgery 24.7% 21.2% 50.1% 3.0% 0.2% 433
PNS 9.4% 3.1% 13.0% 22.0% 53.0%  96

The analyses also demonstrated significant differenc- bling theme was the perception among residents that pe-
es in intragroup responses (both Group 1 vs Group 4 as diatric neurosurgeons garnered less respect from their
well as Groups 1 and 2 vs Groups 3 and 4) to 35 of the 40 “adult” colleagues in other neurosurgical subspecialties,
factors examined (Table 12). The only factors for which both within their own departments as well as within the
there were no significant differences were 1) fast healing neurosurgical community at large. Some respondents felt
and lack of secondary comorbidities in children, 2) ease that pediatric neurosurgeons were “looked down upon” by
of finding employment and greater hiring potential, 3) job colleagues and that PNS faculty should “stand up” to these
pressure, 4) total working hours, and 5) work-hour flex- attitudes.
ibility. There were no statistically significant differences
in the responses from those with less than 2 months of Discussion
PNS training compared with those from respondents with
≥ 2 months of PNS training at the time of the survey. Whether the present or future need for pediatric neu-
Finally, a number of residents provided further writ- rosurgeons is, or will be, matched to the present supply
ten commentary. Several residents explicitly expressed and future trajectory of the workforce is not clear. Both
conflict with children’s hospital personnel; one resident general pediatrics and some pediatric medical and surgi-
commented that working with pediatric nurses was “the cal specialties are experiencing a widening gap between
emotional equivalent of trigeminal neuralgia”! One trou- supply and demand for their services, although there are
TABLE 5: Interest in PNS as a career choice

Characteristic % of Responses Total No. of Responses

level of interest in PNS career 435
  definitely yes 16.8
  maybe 26.4
  probably not 30.6
  definitely not 26.2
If interested in PNS, do you have plans for PNS fellowship? 211
  definitely yes 37
  probably yes 23
  maybe 23
  probably not 9
  definitely not 8
Would you have a greater interest in enfolded PNS fellowship? 361
 yes 53
  maybe 20
 no 28
Which other fellowships are you considering? 421
 spine 38.0
  endovascular/interventional neuroradiology 33.0
  cerebrovascular 27.8
 neuro-oncology 27.6
  skull base 27.3
  stereotactic and functional 20.0
 epilepsy 16.4
  neurotrauma/critical care 14.0
  radiosurgery 9.3
  peripheral nerve 6.9
 none 11.9

426 J Neurosurg: Pediatrics / Volume 12 / November 2013

Residents’ perceptions of careers in pediatric neurosurgery
TABLE 6: Perceived benefits and barriers to PNS career*

% of Respondents
Factor Strong Benefit Moderate Benefit Neutral Moderate Barrier Strong Barrier Mean Score
working in children’s hospital 7.8 26.9 43.9 17.0 4.4 0.17
developing long-term relationships w/ pts 19.3 40.7 33.1 5.3 1.6 0.71
working w/ children 43.2 32.4 18.4 3.9 2.1 1.11
working w/ parents/families 12.0 15.4 23.9 33.3 15.4 −0.25
working w/ pediatricians 3.7 13.8 44.1 26.0 12.4 −0.32
working w/ pediatric nurses 4.1 14.5 43.9 23.4 14.0 −0.29
absence of malingering 22.3 37.5 38.4 1.8 0 0.57
working w/ pediatric tissues 15.4 32.2 47.1 4.1 1.1 0.57
developmental disorders 17.7 33.8 34.0 11.7 2.8 0.52
precision/delicacy of operations 36.1 42.8 20.2 0.5 0.5 1.14
wider variety of cases 34.9 41.4 21.6 1.8 0.2 1.09
working w/ shunts 2.8 9.4 23.9 36.6 27.4 −0.76
fast healing & lack of comorbidities 33.6 44.8 19.8 1.4 0.5 1.1
PNS research 12.9 27.2 53.8 4.8 0.9 0.4
relationship w/ mentor 12.2 25.7 59.8 1.4 0.9 0.2
faculty quality 15.9 33.1 48.3 2.1 0.7 0.53
length of training 1.8 7.1 56.1 30.3 4.6 −0.29
opportunity to do fellowship 8.0 20.5 54.0 12.9 4.6 0.14
fellowship location 8.3 18.6 69.0 3.2 0.9 0.3
greater opportunity for academic practice 11.0 31.5 53.6 3.2 0.7 0.49
prestige of subspecialist 5.1 17.5 71.7 4.4 1.4 0.2
perception of pediatric neurosurgeons 2.5 12.9 70.8 12.4 1.4 0.03
altruism/desire to help children 21.8 46.4 30.8 0.5 0.5 0.89
higher career satisfaction 20.5 37.2 40.5 1.1 0.7 0.76
serve as resource for group practice 7.6 39.3 52.0 0.9 0.2 0.53
greater hiring potential 5.7 32.2 59.1 2.3 0.7 0.4
amount of trauma 2.8 15.6 70.6 10.3 0.7 0.09
being named in lawsuit 1.1 2.5 55.2 29.2 12.0 −0.48
job pressure 1.1 12.2 71.1 13.6 2.1 −0.03
amount of clinic time 2.3 8.7 64.1 22.3 2.5 −0.14
concern about lack of hospital resources 1.4 6.2 73.3 17.7 1.4 −0.11
OR environment (e.g., temperature) 2.3 9.0 65.3 20.9 2.5 −0.12
parity in reimbursement 0.7 6.0 48.3 34.0 11.0 −0.49
cost of malpractice insurance 1.4 4.1 57.5 27.4 9.7 −0.4
salary/earning potential 1.1 7.8 49.2 34.3 7.6 −0.39
small group cross-coverage 1.4 6.7 49.8 32.4 9.7 −0.42
on-call coverage 1.6 7.1 51.5 33.1 6.7 −0.36
ability to have family 4.6 13.6 69.7 10.3 1.8 0.09
total working hours 2.8 10.1 74.3 11.3 1.6 0.01
work hour flexibility 2.5 11.5 71.5 12.6 1.8 0.002

*  Gray shading indicates factors that overall were viewed as barriers. OR = operating room; pts = patients.

conflicting data.15,20,21,24 With respect to neurosurgery, a were fewer than 200 practicing pediatric neurosurgeons
2005 study by Gottfried et al. predicted an overall short- (defined as those whose practice consists of at least 75%
age of neurosurgeons in general,12 and a 1998 pilot study pediatric cases), of whom almost two-thirds surveyed in
by Flannery suggested that the growing demand for pe- 2009 planned to recruit additional faculty members with-
diatric neurosurgical services will ultimately generate a in 5 years. An average of only 9 trainees finish accredited
shortage of PNS providers.11 Recent studies by Durham PNS fellowships each year, and one-third do not ultimate-
and colleagues7,8 reported in 2008 and 2009 that there ly practice as pediatric neurosurgeons (as defined above).7

J Neurosurg: Pediatrics / Volume 12 / November 2013 427

 M. S. Dias et al.
TABLE 7: Single greatest obstacle to recruiting residents to PNS the other hand, most respondents had significant PNS ex-
career posure during residency, with the majority having at least
6 months of PNS training under a dedicated pediatric neu-
Obstacle % rosurgeon.
intrinsic nature of PNS practice 46.4 There are a number of factors that neurosurgery resi-
dents might consider in making a decision about a career
financial or reimbursement issues 25.3
in PNS (Table 6). Among these, the opportunity to care
additional training required 12.4 for children was perceived as the strongest benefit while
medicolegal issues/lawsuits 3.9 the inherent nature of pediatric neurosurgical practice—in
particular the challenges of complex hydrocephalus and
shunt complications and the interpersonal challenges of
Finally, a significant number of ACPNF-accredited fel- interacting with parents and other pediatric healthcare
lowship slots are either not filled or are filled by trainees providers—was the most significant deterrent.
who are ineligible for ABPNS certification (most by virtue This study also suggests that there are 2 distinct pop-
of foreign residency training).4 ulations of residents with respect to attitude toward PNS
(Tables 11 and 12). To the extent that these differences
Residents’ Perceptions of PNS as a Career Choice
are innate or learned is analogous to the nature-versus-
This study reveals that a significant proportion of nurture debate. Some differences, such as a desire to work
neurosurgical residents—perhaps as many as 42%—are with children and their parents, altruism and a desire to
considering a PNS career. Whereas the decision to pursue help children, or an inherent interest in pediatric neurosur-
neurosurgery is made by most residents during medical gical disorders, likely reflect innate traits. Other factors,
school, most of the residents who do decide to pursue PNS such as an interest in pediatric neurosurgical disease, at-
do not make that decision until their senior resident years. titudes toward shunts and shunt complications, and inter-
This affords an opportunity for pediatric neurosurgeons personal relationships between surgical and pediatric phy-
to develop mentoring relationships with medical students sicians and staff, are more likely learned from peers and
and younger residents. Unfortunately, only 40% of survey mentors. Since many of these issues apply to all surgical
respondents were exposed to PNS and only 7.4% identi- subspecialties, this is also a globally important issue for
fied a PNS faculty mentor during medical school. A sig- all pediatric surgical subspecialties. The extent to which
nificantly higher proportion (11%) of those expressing an any of these factors is modifiable through changes in the
interest in PNS had been exposed to a PNS mentor com- training experience provides opportunities to improve that
pared with those who were not (2.4%) (p < 0.05). Which experience. There were no significant differences in the
came first—exposure to a mentor or interest in PNS—can- responses of those having received at least 2 months of
not be determined by this study. In any event, this repre- PNS exposure compared with those having less than 2
sents a missed opportunity to identify and recruit medical months, suggesting that either these attitudes are innate or
students and residents into PNS early in their careers. On learned very early in training. It may therefore be impor-

TABLE 8: Need for post-residency fellowship training to treat PNS disorders*

Condition Unnecessary (%) Recommended (%) Required (%)

mild TBI 86.9 11.5 1.6
moderate/severe TBI 61.4 32.4 6.2
primary brain/spinal cord tumors 27.6 48.7 23.7
sagittal synostosis 18.2 45.5 36.3
coronal, metopic, or multisutural synostosis 7.1 40.5 52.4
myelomeningocele closure 21.6 45.5 32.9
other congenital dysraphic malformations/untethering 21.1 47.6 31.3
simple hydrocephalus/one shunt 85.3 12.6 2.1
complex hydrocephalus 22.8 55.6 21.6
endoscopy 36.6 44.8 18.6
CM-I 67.8 25.3 6.9
CM-II 35.4 45.3 19.3
syringomyelia 41.6 44.8 13.6
birth brachial plexus palsy 11.7 48.0 40.2
epilepsy surgery 23.0 40.9 36.1
pt age <10 yrs 33.8 56.1 10.1
pt age <3 yrs 17.9 43.2 38.9

*  CM = Chiari malformation; CM-I = CM Type I; CM-II = CM Type II; TBI = traumatic brain injury.

428 J Neurosurg: Pediatrics / Volume 12 / November 2013

Residents’ perceptions of careers in pediatric neurosurgery
TABLE 9: Need for PNS certification to treat PNS disorders

Condition Unnecessary (%) Recommended (%) Required (%)

mild TBI 75.2 20.0 4.8
moderate/severe TBI 53.3 37.2 9.4
primary brain/spinal cord tumors 30.6 46.7 22.8
sagittal synostosis 22.8 49.0 28.3
coronal, metopic, or multisutural synostosis 11.7 49.2 39.1
myelomeningocele closure 22.3 45.5 32.2
other congenital dysraphic malformations/untethering 21.1 49.9 29.0
simple hydrocephalus/one shunt 71.3 21.6 7.1
complex hydrocephalus 25.7 52.6 21.6
endoscopy 38.2 46.0 15.9
CM-I 59.5 29.9 10.6
CM-II 34.7 44.8 20.5
syringomyelia 37.2 46.7 16.1
birth brachial plexus palsy 19.8 48.3 32.0
epilepsy surgery 26.4 48.3 25.3
pt age <10 yrs 32.4 54.7 12.9
pt age <3 yrs 18.4 46.2 35.4

tant to also identify and recruit resident applicants with an of these factors appears to have changed somewhat over
innate interest in PNS. time; in a 1996 article, Dohn identified 3 distinct epochs in
A number of theoretical models have been advanced which factors influencing medical student career choices
to explore what factors influence career choice.22 Trait changed. From 1950 to 1970 personality, socio-economic
factor theories propose that career seekers seek and ulti- status and values predominated. From 1970 to 1985, the
mately match with careers that align with their individual medical school environment assumed greater signifi-
skills and wants. Developmental (or self-concept) theories cance. From 1985 to 1995, lifestyle and amount of debt
propose that individuals use their own life experiences to eclipsed other factors.6
build both self-concepts and occupational concepts, merg- More recent studies have examined how individual
ing the two to make final career choices. Vocational choice factors influence medical students’ career choices, includ-
and personality theories propose that individuals seek out ing perceived career satisfaction (even if the perceptions
careers that “fit” their own personalities. Behavioral theo- were incorrect), amount of debt, sex, race and ethnicity,
ries combine personal attributes, environment, and self- income, lifestyle, malpractice costs, medical education,
experiences that interact, through subsequent positive and personality, and perhaps most importantly, a clinical ro-
negative feedback, to lead individuals toward particular tation and/or exposure to a mentor or role model during
career choices. Finally, society and career choice theo- medical school.5,14 These last factors may play an impor-
ries propose a combination of societal circumstances and tant role in the medical student’s ultimate career path. Ef-
sheer chance that combine to lead people toward career fective faculty and surgical resident mentors can strongly
choices. Osipow and Fitzgerald propose that all 5 of these influence medical students’ career decisions.2,17 A number
theories are involved at some level in determining an in- of studies have demonstrated that surgical rotations are
dividual’s ultimate career path.22 With respect to medical highly correlated with surgical subspecialty selection and
students’ decisions about subspecialty choice, a combina- that seemingly random assignments to particular surgi-
tion of personality traits, medical school environment, cal subspecialties during surgical rotations may strongly
learning experiences, and economic factors may all influ- influence a student’s ultimate career path.5,17–19 Engaging
ence these decisions.9,10,16 The relative influence of each students during their surgical rotations, or even residents
in the early years of their training, by establishing informal
TABLE 10: Degree of confidence/comfort regarding treatment of or formal dedicated mentorship programs that introduce
PNS disorders after residency trainees to PNS, inviting them to shadow faculty, discuss-
ing some of their concerns about PNS, and/or involving
Response % them in research projects, may afford an important oppor-
well prepared to treat all PNS conditions 11.9 tunity to direct their interests toward PNS.
prepared to treat most common or simple PNS conditions 61.8 How Can We Attract Residents Into PNS?
prepared to treat some common or simple PNS conditions 24.6
largely unprepared to treat PNS conditions 1.0
The results of this survey suggest that academic pe-
diatric neurosurgeons should seek ways to improve both
completely unprepared to treat PNS conditions 0.6 residents’ experience in PNS and their perceptions of PNS

J Neurosurg: Pediatrics / Volume 12 / November 2013 429

 M. S. Dias et al.
TABLE 11: Residents with and without an interest in a PNS career: selected respondent characteristics*

Characteristic Group 1 Group 4 p Value† Groups 1 & 2 Groups 3 & 4 p Value‡

sex (% males) 75 90 0.006 84 91 0.036
marital status (% married) 70 68 0.740 62 63 0.878
children (% having)
  during college 3.7 5.7 0.437 4.7 4.7 0.977
  during medical school 11.4 13.6 0.665 11.2 13.0 0.579
  during residency 35 40 0.497 32 33 0.842
loan indebtedness (% w/ loans >$100K) 41 42 0.891 44 55 0.018
postgraduate year (% <PGY 4) 36 19 0.016 44 30 0.004
type of training hospital (% w/ dedicated CH) 67 59 0.280 62 59 0.437
type of PNS training (% w/ at least 1 dedicated PNS faculty member) 89 90 0.772 93 92 0.802
time spent on PNS rotation (% ≥6 mos) 71 71 0.968 70 69 0.751
% w/ PNS fellowship 43 35 0.276 38 36 0.627
% w/ PNS mentor in medical school 68 54 0.058 65 57 0.075
greatest obstacle to PNS career (%)
  intrinsic nature of PNS 34 65 <0.001 67 39 <0.001
  financial issues 34 12 0.0003 34 19 0.002
  additional training 16 7 0.042 11 13 0.660
  medicolegal issues 4 3.5 0.833 6 7 0.878

*  CH = children’s hospital.
†  For comparison of Group 1 versus Group 4.
‡  For comparison of Groups 1 and 2 (combined responses) versus Groups 3 and 4.

as a career choice. Pediatric neurosurgical mentors can in- with pediatricians,” and “working with pediatric nurses”
dividually take several proactive steps to improve resident (even among those planning a career in PNS) as well as
education, such as maintaining positive attitudes toward some of the respondents’ specific comments. Many sur-
shunts and shunt complications; focusing on other aspects gical residents have little prior experience handling even
of pediatric neurosurgical practice while seeking to mini- routine pediatric care issues and some may harbor anxi-
mize shunt revisions and infections; modeling good in- ety, self-doubt, or even fear of caring for children. These
terpersonal relationships with children, their parents, and emotions may be misperceived by others in the children’s
other pediatric care providers; teaching residents how to hospital as detachment, defensiveness, anger, or even ar-
deal effectively with difficult families; educating pediat- rogance, further alienating surgical residents from the
ric health care providers about neurosurgical issues; and very people who could help them. Children’s hospital
providing opportunities for surgical residents to positively leadership should recognize these challenges, work col-
interact with pediatric personnel at all levels (for example, laboratively to create a welcoming and nonthreatening
attending pediatric grand rounds as a team, having resi- environment for all trainees and particularly for surgical
dents attend and/or present at children’s hospital confer- residents, and promote positive relationships with chil-
ences, involving residents in children’s hospital commit- dren’s hospital staff. Formal educational conferences for
tees); and engaging both medical students and residents both pediatric and surgical residents (as well as pediatric
in clinical research projects. Comments by some respon- nursing staff) could cover topics such as fluid, electrolyte,
dents suggest that PNS in some training programs is cast and caloric needs; postoperative surgical care; assessment
in a negative light as less challenging or more mundane; and treatment of pain and anxiety in children; treatment
pediatric neurosurgeons should work proactively with for common pediatric diseases; techniques for examining
their colleagues and department chairs to recognize and children at various developmental ages; subspecialty care
address negative stereotypes so they are not passed on to issues for the surgical patient; promoting family-centered
trainees. care; and dealing positively with difficult parents. Such
On an institutional level, children’s hospitals can im- a program would enhance surgical residents’ knowledge
prove interpersonal relationships between surgical resi- about pediatric issues, improve pediatric residents’ and
dents and children’s hospital staff. The itinerant position of nurses’ knowledge about surgical issues, and provide an
surgical residents, who may rotate to the pediatric surgical opportunity to develop collaborative relationships.
services for only a few months at a time, creates fewer op- There are also broader opportunities for organized
portunities for them to develop interpersonal relationships PNS to attract trainees to PNS. The Joint Section on Pedi-
with children’s hospital staff. Surgical residents may even atric Neurosurgery currently encourages medical students
feel ostracized as evidenced by the negative scores for and residents to present research at the national meeting
“working in a children’s hospital environment,” “working and awards the Matson and Hydrocephalus Research

430 J Neurosurg: Pediatrics / Volume 12 / November 2013

Residents’ perceptions of careers in pediatric neurosurgery
TABLE 12: Comparing residents with and without an interest in a PNS career: respondents’ perceptions of benefits and barriers (group
values are the percentage of respondents)

Factor Group 1 Group 4 p Value* Groups 1 & 2 Groups 3 & 4 p Value†

working in children’s hospital 73 14 <0.0001 57 17 <0.001
developing long-term relationships w/ patients 74 44 <0.001 69 53 0.001
working w/ children 99 52 <0.001 95 61 <0.001
working w/ parents/families 69 10 <0.001 47 42 0.241
working w/ pediatricians 37  8 <0.001 29  9 <0.001
working w/ pediatric nurses 38  9 <0.001 29 11 <0.001
absence of malingering 75 43 <0.001 68 54 0.004
working w/ pediatric tissues 59 38 <0.001 56 41 0.003
developmental disorders 80 26 <0.001 75 34 <0.001
precision/delicacy of operations 86 67 0.003 86 73 0.001
wider variety of cases 90 61 <0.001 86 69 <0.001
working w/ shunts 34  3 <0.001 25  3 <0.001
fast healing & lack of comorbidities 81 70 0.104 85 74 0.006
PNS research 81 16 <0.001 65 35 <0.001
relationship w/ mentor 62 19 <0.001 55 25 <0.001
faculty quality 63 31 <0.001 64 48 0.001
length of training  6  2 0.009 16  4 <0.001
opportunity to do fellowship 59  9 <0.001 48 13 <0.001
fellowship location 40 14 <0.001 39 18 <0.001
greater opportunity for academic practice 70 23 <0.001 60 29 <0.001
prestige of subspecialist 34  9 <0.001 35 13 <0.001
perception of pediatric neurosurgeons 23 11 0.019 23 10 0.002
altruism/desire to help children 90 44 <0.001 84 56 <0.001
higher career satisfaction 89 30 <0.001 81 40 <0.001
serve as resource for group practice 60 35 0.001 60 37 <0.001
greater hiring potential 33 31 0.755 30 34 0.416
amount of trauma 29 14 <0.001 27 12 0.001
being named in lawsuit  8  2 0.033  6  2 0.009
job pressure 16  9 0.112 19  9 0.002
amount of clinic time 19  4 0.001 18  6 <0.001
concern about lack of hospital resources 16  4 0.002 13  3 <0.001
OR environment (e.g., temperature) 18  6 0.012 18  7 0.001
parity in reimbursement 23 11 0.019 23 10 0.002
cost of malpractice insurance 14  2 0.001 11  2 <0.001
salary/earning potential 12  3 0.008 13  6 0.006
small group cross-coverage 14  2 0.001 12  5 0.015
on-call coverage 16  3 0.001 14  5 0.001
ability to have family  8  2 0.033 27 121 <0.001
total working hours 15  7 0.076 15 11 0.166
work hour flexibility 16  9 0.112 17 12 0.196

*  For comparison of Group 1 versus Group 4.

†  For comparison of Groups 1 and 2 (combined responses) versus Groups 3 and 4.

Awards for the best research presentations. The section a formal student/resident subsection. There are also oppor-
and/or the American Society of Pediatric Neurosurgeons tunities to address financial disparities and other economic
(ASPN) could undertake a national recruiting campaign to and medicolegal issues on a national level. The American
identify and engage medical students and residents having Academy of Pediatrics (AAP) is already actively engaged
an identified interest in PNS and coordinate formal men- with federal and state legislators on behalf of both primary
torship opportunities for them. The section could develop care pediatricians and pediatric medical and surgical sub-

J Neurosurg: Pediatrics / Volume 12 / November 2013 431

 M. S. Dias et al.

specialists; the Joint Section on Pediatric Neurosurgery Conclusions

and the ASPN, together with the Section on Pediatric Neu-
rosurgery of the AAP, should seek ways to more actively To summarize, although this study has identified
many issues, both intrinsic and extrinsic to the practice
collaborate and support the AAP in these efforts.
of PNS, that influence residents’ career decisions, it is
The most controversial issue is whether to allow en- primarily the intrinsic nature of PNS practice that most
folded PNS fellowship training. In the early 1990s, PNS importantly impacts the decisions. We have suggested a
was the first neurosurgical subspecialty to develop inde- number of ways to address these issues individually, lo-
pendent accreditation and certification bodies to improve cally, and nationally. We recommend that a committee of
the quality of pediatric neurosurgical training and care in dedicated pediatric neurosurgeons, along with fellows and
North America. Organized neurosurgery has subsequent- residents (both with and particularly without an interest
ly recognized the concept of enfolded fellowships in other in PNS) should examine these and other ways to further
subspecialty areas through the Committee on Accredita- attract residents to PNS careers.
tion of Subspecialty Training (CAST) system developed
by the Society of Neurological Surgeons. The majority of
respondents to our survey expressed an interest in enfold- Disclosure
ed PNS fellowships. A structured CAST fellowship might
This study was funded in part by the Joint Section on Pediatric
attract more residents to PNS without expanding the over- Neurological Surgery of the American Association of Neurological
all length of training. However, at least at the present time, Surgeons and the Congress of Neurological Surgeons.
organized PNS (including the Section on Pediatric Neuro- Author contributions to the study and manuscript preparation
surgery, the ASPN, the ACPNF, and the ABPNS) remains include the following. Conception and design: Dias, Sussman, Dur-
committed to post-residency fellowships as the only path- ham. Acquisition of data: Dias, Sussman. Analysis and interpretation
way to PNS board certification. of data: Dias, Sussman. Drafting the article: Dias. Critically revising
A somewhat surprising result of this survey is resi- the article: all authors. Reviewed submitted version of manuscript: all
authors. Approved the final version of the manuscript on behalf of all
dents’ perception that their residency training alone would authors: Dias. Study supervision: Dias.
prepare them to treat most PNS problems and their opin-
ion that PNS fellowship training and ABPNS certification
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