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Neurologic Surgery Residency (Minnesota)

Curriculum

Mayo Clinic neurologic surgeon in the operating room

During the seven-year Neurologic Surgery Residency, you will receive advanced education in all aspects of neurosurgery, including both outpatient and hospital settings, with a full six months of dedicated intensive care unit (ICU) training. As a trainee, you will participate in the care and surgery of all neurosurgery patients as an integral member of the neurosurgical team.

Progressive responsibility and surgical experience under the direction of the neurosurgical faculty is assured throughout the residency. Each clinical rotation has specific competencies, goals, and learning objectives, in addition to the general departmental academic requirements.

Opportunities for enhanced training in a subspecialty area can be enfolded within the seven-year curriculum; present options include complex spine, oncology, peripheral nerve, critical care, and skull base.

Clinical training

As a resident, you will be required to spend a minimum of 54 months of clinical neurosurgery training prior to graduation. A unique feature of the neurosurgery training at Mayo Clinic is our mentorship model, in which residents complete dedicated clinical rotations working directly under faculty members for two to three-month rotations. This provides for the development of a longitudinal relationship between the resident and staff, as well as an opportunity for true immersion in a particular practice model, and complete continuity of care for the patients and families on those services.

Two years of dedicated research and career development time are afforded during senior residency. Supplemental clinical rotations, enfolded fellowships, and visiting electives may be arranged during this period. Additional provisions are allowed for residents desiring to expand their training by an additional year or longer, so as to obtain a doctorate in neurosciences through Mayo Clinic Graduate School of Biomedical Sciences.

The capstone of our program is the chief resident experience. During that year, the chief runs an independent service in a transition to practice role taking on the privilege of responsible patient management and patient care in a one to one relationship with the patient.

Another key aspect to our program is the ability to rotate at other sites during your time in the program. We have pediatric rotation alternatives at Phoenix Children's hospital as well as the Mayo Clinic campuses in Arizona and Florida.

The typical rotation sequence for Mayo Clinic neurosurgery residents is:

PGY-1

During your first year, you will spend five months on the medical neurology services, including one month as junior and two months as senior residents in the neurosciences ICU. You will spend one month on the critical care service ICU, one month on neuro-anesthesia, four months on the chief resident service, one month in neurosurgery outpatient clinic, and one month on the services of Jamie Van Gompel, M.D., the neurologic surgery program director and department vice chair of education, as well as Frederic Meyer, M.D., the neurologic surgery enterprise chair at Mayo Clinic and the executive dean of education for Mayo Clinic College of Medicine and Science.

By the end of this first year, you will have a basic understanding of neurological disease and be competent to perform a neurological history and examination. You will have a strong knowledge base for evaluating and caring for critically ill patients in an intensive care setting. In addition, you will have performed basic neurosurgical procedures including intracranial pressure (ICP) monitor placement, external ventricular drain, laminectomy exposures, and basic craniotomies.

This first year is expected to lay the foundation of knowledge and skills required for a superlative career in neurosurgery.

PGY-2

During this year, you will spend additional time in the ICU as well as serve a junior role on our chief service and perform stereotactic and functional surgery rotations. You will also enjoy ample opportunity to work one-on-one with staff neurosurgeons as a first assistant in the operating room.

PGY-3

You are assigned to rotations on the clinical neurosurgery services of the various neurosurgery consultants during your third year. The clinical assignment system is unique in that you work one-on-one with each staff neurosurgeon for intervals of several months' time before rotating. This allows the evolution of a strong teaching mentorship.

Throughout this PGY-3 year, your surgical skills will significantly advance. It is expected that during this time, depending on your individual skill set, you will perform critical portions of each operation with the staff surgeon serving as an assistant and coach. Therefore, your surgical skills improve dramatically during this year. It is also expected that you will better define your clinical interests and begin to formalize your career goals. PGY-3 rotations concentrate on spine, intraaxial brain tumors, peripheral nerve, and epilepsy.

PGY-4

Over the course of fourth year, residents typically complete additional rotations on complex cranial, complex spine, cerebrovascular, skull base, and endovascular surgery. Additionally, a block of neuropathology is used to prepare for the ABNS board exam.

A formal, required curriculum of skull base, microvascular, and peripheral nerve techniques is simultaneously completed, both to facilitate anatomic study and to prepare you for senior-level roles. Final planning decisions are made for upcoming career development years.

PGY-5 and PGY-6

Up to 24 months are allocated for career development, typically taken as a single block during the PGY-5, PGY-6, and PGY-7 time frame. Dedicated laboratory research, enfolded fellowships, visiting electives at Mayo Clinic's campuses in Florida and Arizona, and acquisition of advanced degrees are common academic pursuits during this time. Flexibility and adaptability to the needs of each individual resident's career are emphasized.

For residents who are pursuing a one- or two-year research block, application for a Neurosurgery Research and Education Foundation (NREF) training grant is highly encouraged. If basic research is chosen, a research plan should be developed the preceding year with a mentor identified. Clinical research projects also may be chosen, and potentially pursued, via the Clinician-Investigator Training Program or a master's degree.

The emphasis during the research year is toward the development of critical scientific methodology and production of meaningful contributions to basic science or clinical knowledge. For those pursuing additional clinical neurosurgery training, the goal is to develop advanced surgical training in a subspecialty area of interest.

Within these two years, both research and advanced clinical training can be combined. Furthermore, you are strongly encouraged to rotate to Mayo Clinic in Jacksonville, Florida, or Mayo Clinic in Phoenix/Scottsdale, Arizona, for advanced clinical training, notably in endovascular surgery, complex adult spine surgery, or minimally invasive spine surgery.

PGY-7 (chief resident)

During the final 12 months of training, chief residents have responsibility for managing their own clinical service and operating room. This is unique among training programs.

Perhaps the greatest strength of our singular training program is that the Mayo Clinic chief residency allows senior trainees to function as junior faculty with the privileges of an autonomous starting operating room in which they are the primary surgeons. Chief resident cases are booked on an elective basis from their own active clinical practices. Further, the chief residents manage all emergency neurosurgery cases and in-house consultations, providing for consultant-level decision-making and management across the full breadth of neurosurgery.

During this time, the chief resident alternates emergency call, elective surgery, and outpatient consultation on a daily basis with chief resident partners — a schedule akin to that of our full-time faculty.

Rotation descriptions

You will work with these specialists:

  • Edward Ahn, M.D. Pediatric neurosurgery concentrating on Shunts, Intrauterine surgery, cranial vault remodeling, and general pediatric surgery

  • John Atkinson, M.D. Pituitary tumors, spine surgery, and sympathectomy

  • Terry Burns, M.D., Ph.D. Intra-axial brain tumors, Gamma Knife, and awake brain surgery

  • Mohamad Bydon, M.D. Spinal oncology and minimally invasive spine surgery

  • M.J. Clarke, M.D. Spinal oncology and spine surgery

  • David Daniels, M.D., Ph.D. Pediatric neurosurgery with emphasis on brain tumors and intraventricular endoscopy

  • Benjamin D. Elder, M.D., Ph.D. Normal Pressure Hydrocephalus and complex spine surgery

  • Jeremy Fogelson, M.D. Complicated spinal deformity correction

  • William Krauss, M.D. Spine tumor and spine surgery

  • Giuseppe Lanzino, M.D. Endovascular and open vascular surgery

  • Kendall Lee, M.D., Ph.D. Deep brain stimulation, pain, and functional neurosurgery

  • Michael Link, M.D. Skull base, acoustic neuromas, Gamma Knife, and vascular surgery

  • W. Richard Marsh, M.D.  Epilepsy and spine surgery

  • Fredric Meyer, M.D. Brain tumors, vascular, and epilepsy surgery

  • Kai Miller, M.D., Ph.D. Epilepsy and pediatric neurosurgery

  • Ian Parney, M.D., Ph.D. Intra-axial brain tumors, Gamma Knife, and awake brain surgery

  • Bruce Pollock, M.D. Gamma Knife, trigeminal neuralgia, and brain tumors

  • Luis Savastano, M.D., Ph.D. Endovascular and open vascular surgery

  • Robert Spinner, M.D. Peripheral nerve surgery

  • Jamie Van Gompel, M.D. Skull base, endoscopic pituitary surgery, and epilepsy

Extramural rotations

You may choose to complete clinical rotations at Mayo Clinic in Jacksonville, Florida, or in Phoenix/Scottsdale, Arizona. Mayo Clinic fully funds all incumbent costs, including travel, housing, automobile rental, and licensure fees.

These rotations have been approved by the Accreditation Council for Graduate Medical Education and American Board of Neurological Surgery as containing significant educational merit. Mayo Clinic encourages trainees to take advantage of the associated opportunities, including advanced exposure to additional subspecialty training, notably in vascular and complex spine surgery. The cumulative case volume available for training at Mayo Clinic's campuses in Minnesota, Florida, and Arizona is approximately 7,000 cases annually.

Conferences

Didactic conferences are held on a daily basis for one hour, prior to the initiation of the day's operative calendar. Conferences are held in the neurosurgery department at Mayo Clinic Hospital — Rochester, Saint Marys Campus, and resident attendance is mandatory.

The typical weekly schedule is:

Neurosurgery Grand Rounds — Monday

A monthly conference, held every first Monday. The rest of Monday grand rounds conferences alternate between research grand rounds, visiting professor lectures, and a monthly morbidity and mortality conference dedicated to discussion of complications and quality assurance issues. Didactic lectures and presentations by visitors, Mayo staff, and residents also complement this forum. All faculty and residents attend grand rounds conference.

Administrative and Clinical Conferences — Tuesday

Complex cases are presented by Drs. Meyer, Van Gompel, Link, Lanzino, and Parney, in which preoperative diagnosis, surgical approaches, technical pearls, and postoperative complications are discussed. Additionally, program leadership meets monthly with residents to communicate any changes or updates and receive frequent feedback.

Spine Board Preparation Clinical Conference — Wednesday

Wednesdays are rotating spine conferences focusing spinal disorders. The agenda alternates between spine journal club, spine trauma case conference, non-trauma case conference, and didactic lectures. The course is taught by joint faculty from the orthopedic surgery and neurological surgery departments. Case conferences are resident-driven, whereas didactic lectures are consultant-driven.

Core curriculum — Thursday

Thursdays of every month rotate between resident-led, board-focused didactic lectures, pediatric journal club, cranial journal club, and conferences hosted by investigators presenting their research to help inform you of opportunities available for pursuit during your career development years. Once per quarter, the chairman holds a conference, during which Dr. Spinner meets with the residents to discuss a broad range of academic, administrative, or other salient topics.

Neuro-Oncology Conference — Friday

The conference every Friday is a multispecialty-combined gathering in which four interesting brain tumor cases are presented and discussed. The faculty from all the neuroscience specialties including neurology, medical oncology, neuropathology, neurosurgery, and neuroradiology are in attendance. The format of this conference is standardized and educationally targeted, incorporating the case presentation, pertinent radiology, surgical approach, pathology, and adjunctive treatment with an open forum for discussion and analysis as required and appropriate.

Additional conferences

Multiple subspecialty conferences are held daily throughout Mayo Clinic, which are all open to neurosurgery residents. These include a neuroradiology conference, surgical epilepsy conference, pediatric neuro-oncology conference, skull base tumor board conference, and many others.

Case conferences

The mandatory one-hour teaching conferences five days a week from 7 to 8 a.m. focus on both general and subspecialty neurosurgery. The subspecialty conferences include vascular, spine, epilepsy, neuro-oncology, and neuroradiology. These are held in conjunction with the appropriate medical and radiological services.

You will regularly contribute to the educational process, preparing case presentations, journal clubs, and didactic lectures.

Call frequency

Call schedules vary by individual rotation. Mayo Clinic's Department of Neurologic Surgery follows the duty hour guidelines of the Accreditation Council for Graduate Medical Education (ACGME).

All residents share the in-house emergency call assignments equally during the time that they are assigned to clinical neurosurgery service, as well as during certain elective and basic science rotations. Therefore, the frequency of a resident being in the hospital overnight to cover trauma and the emergency room is modest.

Residents on clinical neurosurgery services are expected to respond to calls regarding their own patients throughout the day and night. In-hospital night call covering emergencies occurs on average one out of every 10 to 13 days, as does "backup call," which is typically taken from home. Residents are provided with meal allowance funds in accordance with call coverage.

Teaching opportunities

You will have the opportunity to teach Mayo Clinic Alix School of Medicine students and visiting students from other medical schools, through bedside instruction, formal didactic lectures, and voluntary participation in the anatomy curriculum.

Research training

Neurosurgery residents are expected to engage in scholarly pursuits, including clinical research projects. During the elective research year, you will be required to participate in dedicated study and basic laboratory investigation under the direction of a research mentor. Members of the Department of Neurologic Surgery and other established investigators within Mayo Clinic's research departments serve as mentors and will also assist you in developing your research proposals well in advance of your research year.

Financial support and call coverage are generally made available to residents whose research is accepted for presentation to national or regional neurosurgery meetings.

Applied Computational Neurophysiology and Neuromodulation Laboratory

Working closely with Dr. Luis Lujan, Ph.D., M.S., the Applied Computational Neurophysiology and Neuromodulation Laboratory combines pre-clinical and clinical neurophysiological (electrophysiological, neurochemical, and optical) data collection and analysis with computational modeling strategies to advance neuromodulation interventions for the treatment of neurologic and psychiatric conditions.

Cybernetics and Motor Physiology Laboratory

As a dedicated physician-scientist, Kai Miller, MD, PhD., is interested in developing therapeutic cybernetics, neurosurgical, stereotaxy, and large-scale brain dynamics with a focus on enhancing the effectiveness of brain-computer interface for patients with Amyotrophic Lateral Sclerosis (ALS), sensory-motor cortex research for patients with Parkinson’s disease, and deep brain stimulation for movement disorders such as epilepsy.

The goal of his research in the Cybernetics and Motor Physiology Laboratory is to translate his expertise in electrophysiological neuroscience to therapeutic technologies that can improve patients’ clinical care as well as meaningfully improve quality of life for patients suffering from neurologic diseases.

The lab team is committed to improving existing methods and developing innovative techniques to measure the electrophysiology of the brain. They want to create more precise closed-loop stereotactic procedures that take advantage of new emerging hardware. The team hopes to develop new devices that can induce brain plasticity after injury, control cybernetic prostheses, and intervene with distributed circuits in neuropsychiatric disease and movement disorders. 

Device Development and Experimental Therapeutics Lab

Research in Mayo Clinic's Device Development and Experimental Therapeutics Lab focuses on the advancement of neurosurgery in techniques and technology to assist surgery. Most work concentrates on expanding indications for the treatment of disease for neurosurgery and using brain stimulation for the treatment of epilepsy.

The lab works on mechanical aspects of devices to improve current operative procedures and innovates new ways to treat diseases relevant to neurosurgery. Most treatments are focused on diseases relevant to our clinical practice of benign skull base tumors and epilepsy.

In addition, the lab employs outcome analysis, advanced imaging, and techniques for benign skull base tumors, such as pituitary adenomas, vestibular schwannomas, and meningiomas, as well as malignant skull base tumors, such as esthesioneuroblastoma and chordoma.

Multidisciplinary Neural Regeneration Laboratory

This laboratory team focuses on developing synthetic polymeric scaffolds and controlled delivery of bioactive molecules for peripheral nerve and spinal cord repair and regeneration. This National Institutes of Health (NIH)-funded research endeavor combines strong collaborative efforts of neurosurgeons, neuroscientists, orthopedists, tissue engineers, and cellular neurobiologists and polymer chemists. The goal of this project is to introduce and commercialize biodegradable conduits for clinical use.

Neural Engineering Laboratory

High-frequency deep brain stimulation (DBS) is an effective treatment for Parkinson's disease, tremor, epilepsy, dystonia, and depression. However, the precise mechanisms of action for the therapeutic effects of DBS are unknown. Since both DBS and lesionectomy target similar brain regions, it has been thought that electrical stimulation works through neuronal inhibition. However, the lab has found that DBS results in excitation of neuronal and glial elements, suggesting that electrically excited neurotransmitter release may be the mechanism of action of DBS.

Accordingly, the Neural Engineering Laboratory is studying how DBS affects changes in neuronal action potential firing and modifies neural network activities. To study the mechanism of action of DBS, the lab performs fluorescent microscopy along with intracellular and extracellular electrophysiological recordings. The lab also utilizes electrochemical techniques of constant potential amperometry to measure neurotransmitter levels both in the in vivo and in vitro setting.

Through this research, the members of the lab hope to combine sophisticated electrophysiological recordings with miniaturized analytical elements (microprocessors) to augment and repair disrupted brain functions. Thus, the lab members are actively involved with biomedical engineers to develop the next generation of DBS devices.

Neuro-Informatics Laboratory

The Neuro-Informatics Laboratory is dedicated to advancing patient care and safety, with a specific focus in the following areas:

  • Surgical outcomes. Working closely with the Mayo Clinic Robert D. and Patricia E. Kern Center for Science of Health Care Delivery and other departments, the Neuro-Informatics Laboratory mines national databases and utilizes machine learning to track and model the impact and safety of surgical and nonsurgical interventions.
  • Spinal biomechanics and novel spinal devices. The Neuro-Informatics Laboratory works with the Mayo Clinic Division of Engineering and the Orthopedic Biomechanics Laboratory to study the impact of spinal surgeries on the biomechanics of the spine and develop devices that can make spinal surgery safer and provide alternatives to fusion.
  • Spinal cord injury and spinal disk degeneration. The Neuro-Informatics Laboratory's multidisciplinary team investigates the molecular underpinnings of spinal disease intending to establish new treatments. These treatments utilize stem cell interventions for patients with low back pain and spinal cord injury as well as genomic treatments for degenerative disk disease.

Neurogenesis and Brain Repair Laboratory

The Neurogenesis and Brain Repair Laboratory of Mi Hyeon Jang, Ph.D., develops novel therapeutic strategies for treating neurological diseases associated with cognitive function.

Recent advances in neuroscience have given researchers unprecedented insight into normal brain function and the pathology of neurological diseases. The knowledge still has to be brought into clinical application due to an inadequate understanding of how such pathologies may be targeted for actual patient outcomes.

Aided by multiple approaches — including mouse genetics, shRNA-mediated genetic manipulations, imaging, and animal behaviors — research in this lab is focused on the following areas:

  • Adult neurogenesis. The process of generating new neurons from neural stem cells is called neurogenesis. In the mammalian brain, neurogenesis continues to occur well into adulthood in discrete regions — namely the hippocampus and olfactory bulb. Dr. Jang's lab focuses on the cellular and molecular mechanisms regulating adult hippocampal neurogenesis that play significant roles in regeneration, memory, and mood regulation.
  • Remyelination. New axonal myelin sheaths are generated in the central nervous system by the process of remyelination. Although remyelination has been posited as a promising therapeutic target for myelin-related disorders such as multiple sclerosis, no effective therapies exist for myelination-related disorders. This is due to the limited understanding of the causative pathology mediating myelination. Dr. Jang's laboratory aims to identify the molecular targets that mediate remyelination so that effective therapeutic strategies capable of promoting myelin regeneration can be realized.

Neurosurgical Oncology Laboratory

The Neurosurgical Oncology Laboratory focuses on the cellular and immunological characteristics of malignant brain tumors. Particular areas of interest include immunotherapy, brain tumor stem cells, and mouse models of malignant gliomas. The laboratory has demonstrated an interrelated cellular network mediates immunosuppression in patients with malignant gliomas. This includes glioma cells (differentiated and stem cell phenotypes), tumor-infiltrating monocytes-microglia, circulating myeloid-derived suppressor cells, and regulatory T cells.

Multiple molecular mechanisms contribute to these cells' effects, but evidence from the lab has implicated a central role for the immunosuppressive T cell costimulatory molecule homologue B7-H1. Much of the lab’s work is aimed at disrupting this network to facilitate immunotherapies and develop appropriate murine models of glioma-mediated immunosuppression to allow pre-clinical testing.

A significant aim of the lab’s work is to translate discoveries to the clinic through glioma vaccine clinical trials. This effort is facilitated by the presence of a Good Manufacturing Practices (GMP) laboratory for generating clinical-grade cellular therapy reagents at Mayo Clinic. Additionally, members of the Mayo Clinic Brain Cancer SPORE work closely with this laboratory. Specialized Program of Research Excellence (SPORE) grants are highly competitive group grants awarded by the National Cancer Institute for translational cancer research programs. Only three Brain SPOREs have been awarded nationwide, underscoring Mayo Clinic's exceptional capacity to perform translational research in neuro-oncology.

Neurosurgery Regenerative Laboratory

The Neurosurgery Regenerative Laboratory engages in advanced research in regenerative neuroscience from the molecular to cell biological and integrative levels. Specific topics under investigation include molecular analysis of receptors and signal transduction mechanisms; axon guidance, target recognition, and regeneration; formation and plasticity of synapses; control of neural cell fate; development of neural networks; regulation of glioma cell motility; and mechanisms controlling vascular development and regeneration.

The lab offers an integrated approach to training in modern neurobiology, utilizing molecular, biochemical, and cell biological techniques as well as advanced optical imaging. Members of the lab have the opportunity to work closely with the spinal cord injury research team at Mayo.

Pediatric Brain Tumor Laboratory

In the past decades, brain cancer has replaced leukemia as the most common cancer-causing death among children and adolescents. The Experimental Drug and Therapeutics for Pediatric Brain Tumor Lab of David J. Daniels, M.D., Ph.D., aims to improve the prognosis of children with malignant brain tumors through early diagnosis, novel strategies, and targeted therapies based on the unique molecular underpinnings of individual brain tumors.

Malignant brain tumors, including glioblastomas, diffuse intrinsic pontine gliomas (DIPGs), medulloblastomas, and ependymomas, are among the most lethal cancers and inflict a disproportionate impact on younger populations. Effective new therapies are needed to alleviate the suffering and improve the prognosis of children facing these central nervous system tumors. Dr. Daniels' focus is on the diagnosis and treatment of these tumors.

Dr. Daniels and his colleagues seek to develop and rigorously test methods that facilitate aggressive surgical resection for pediatric brain tumors while maintaining or improving safety. The techniques include integrating functional imaging, including functional MRI and diffusion tensor imaging tractography, into image-guidance systems, and intraoperative MRI. They are also pursuing novel strategies such as fluorescence-guided resection and ultra-early diagnosis of tumor types.

Additional training opportunities

Clinician-investigator

The Clinician-Investigator Training Program is available to residents who wish to prepare for an academic career involving a significant research component. This competitive program provides support for an additional one to two years of research outside of the usual scheduled resident rotations.

Upon completion, a certificate in clinical investigation for a master's degree in neurosurgery is awarded.

Clinical research training program

The Center for Clinical and Translational Science offers programs designed to train future investigators in clinical research through a curriculum focused on research methodology, complemented by mentor-based training in the research environment.

Options include a master's degree in clinical research, or a shorter program awarding a certificate in clinical research.

Doctoral degrees

A formalized pathway is available to neurosurgery residents for obtaining a doctorate in molecular neuroscience, biomedical engineering, or molecular physiology, which requires a minimum of two to three years of study and research, culminating in a dissertation.

The in-residency doctoral program has been designed to maximize flexibility, allowing for an individualized curriculum, with appropriate oversight from an advisory and mentorship committee.

This program, offered in conjunction with Mayo Clinic Graduate School of Biomedical Sciences, should be strongly considered by neurosurgical residents interested in obtaining advanced basic science experience for a career in academic neurosurgery.

Career development

Residents are encouraged to meet formally and informally with the department chair, program director, and individual mentors on a regular basis to discuss career goals. The program director takes a sincere interest in tailoring a resident's training program to career objectives and actively participates in job searches on behalf of the residents.

Mayo Clinic neurosurgery residents have been highly successful in competing for both academic and private practice positions, consistent with their individual goals.

Evaluation

Performance is carefully monitored throughout the course of the Neurologic Surgery Residency with an eye toward operative skill, clinical judgment, academic productivity, and career development. After each clinical rotation, you will be evaluated formally by your supervising faculty.

Additionally, you will meet individually with the program director on a semiannual basis to review your performance and discuss career goals in detail to dynamically individualize your training program.

You will sit for the American Board of Neurological Surgery written examination during your PGY-2 and PGY-3 years for self-assessment, and for credit during their PGY-4 year. A three-month neuropathology rotation provides supplemental basic science education and opportunity for independent study immediately prior to formal examination. You are expected to pass at a 75 percent or higher level before being qualified for the chief resident year.

As part of our regular examination of residents to monitor their progress and also help prepare for the future oral board examination, annual oral examinations in clinical neurosurgery and neurology are administered. The format is similar to that of the certifying oral examination given by the American Board of Neurological Surgery after completion of training. Feedback from the program director and director of resident education is provided.

An electronic case log program tracks all resident operative cases, with salient details auto-populated from the operative report and prepared for review and submission to ACGME case log. The case volume and mixture is carefully analyzed to ensure that each resident is obtaining in-depth expert training in all areas of neurosurgery. If areas of deficiency are identified, the resident's rotations are adjusted accordingly to provide an appropriately balanced education.