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

Abbreviations used in this paper: AAP = American Academy
of Pediatrics; ABNS = American Board of Neurological Surgery;
ABPNS = American Board of Pediatric Neurological Surgery;
ACPNF = Accreditation Council for Pediatric Neurosurgical Fel-
lowships; ASPN = American Society of Pediatric Neurosurgeons;
CAST = Committee on Accreditation of Subspecialty Training;
PGY = postgraduate training year; PNS = pediatric neurosurgery.
I
n 1991 the American Board of Pediatric Neurological
Surgery (ABPNS) began certifying pediatric neuro-
surgeons, and, in 1992, the Accreditation Council for
Pediatric Neurosurgical Fellowships (ACPNF) began for-
mally accrediting fellowship training programs in pediat-
ric neurosurgery (PNS) in an effort to ensure high quality
of neurosurgical care for children in the United States. Be-
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
143 met ABPNS eligibility criteria. Moreover, fully one-
third of these graduates did not become ABPNS certified
or pursue a pediatric neurosurgical career.8 This leaves an
average of only 6 new board-eligible pediatric neurosur-
geons per year in the US.
At the same time, a survey of practicing pediatric
neurosurgeons in the US revealed that nearly two-thirds
planned to recruit additional individuals to their practices,
and another study confirmed that pediatric neurosurgical
care in the US is increasingly being assumed by dedicated
pediatric neurosurgeons, with less than 50% of neurosur-
geons providing routine neurosurgical care for children
and only 22% providing emergency care.3 Children’s hos-
pitals increasingly recognize the value of dedicated pedi-
atric neurosurgical training, and most demand ACPNF-
accredited fellowship training and board certification or
eligibility for new recruits. Nationwide, pediatric neuro-
surgeons are increasingly assuming care for adults with
developmental neurosurgical disorders (for example, dys-
raphic malformations), complex hydrocephalus, and con-
ditions requiring endoscopy. Finally, it is anticipated that
recent legislation, such as the Affordable Care Act, will
significantly expand the population (including children)
covered by medical insurance; how this will impact the
workforce needs for pediatric neurosurgeons has yet to be
analyzed. These factors raise concern over whether de-
mand for pediatric neurosurgeons will outstrip supply in
the near future. It therefore becomes important to under-
stand what factors attract trainees to, or discourage them
from, pursuing a career in PNS. We undertook a survey
of US neurosurgical residents to assess their perceptions
about barriers and benefits to a career in PNS.
Methods
A survey was developed to query residents’ interest in
PNS and to assess their perceptions about benefits of, and
deterrents to, a PNS career. The survey was divided into
4 sections. The first section compiled simple demographic
information from residents, including sex; race; marital
status; whether they had or planned to have children; their
level of educational indebtedness; their postgraduate train-
ing year (PGY); the geographic location of their residency
training program; and details about how pediatric care in
general, and PNS training in particular, is provided within
their institution. The second section sought information
about mentorship, potential career planning and subspe-
cialization within neurosurgery, and pursuit of post-res-
idency fellowship training. The third and largest section
asked respondents to rate their perceptions about each of
40 characteristics as either enticements or deterrents to a
PNS career; responses were scored from 2 to -2 using a
Likert scale, with a score of 2 signifying “strong entice-
ment,” 1 signifying “moderate enticement,” 0 signifying
“neutral,” -1 signifying “moderate deterrent,” and -2 sig-
nifying “strong deterrent.” Mean scores were calculated
for each of these factors. Residents were also asked which
of 5 general categories—the inherent nature or practice
of PNS, the additional training required, financial issues,
time demands and coverage issues, and medicolegal is-
J Neurosurg: Pediatrics / Volume 12 / November 2013
sues—they felt was the single greatest obstacle to a PNS
career. The fourth section sought residents’ views con-
cerning the importance or necessity of post-residency PNS
fellowship or certification by ABPNS for treating various
pediatric neurosurgical conditions.
The research was approved by the Human Subjects
Protection Office at Penn State University College of Med-
icine. The residents’ e-mail addresses were obtained from
the American Board of Neurological Surgery (ABNS). A
total of 1263 trainees participating in postgraduate train-
ing programs in the US and Canada during the academic
year 2008–2009 were sent e-mails requesting their par-
ticipation and providing a private link to an Internet-based
survey site (www.surveymonkey.com) to complete the
survey. A drawing for 2 iPods (Apple Inc.) was offered
as an enticement for participating. All responses were
de-identified and analyzed. Between-group comparisons
were analyzed using chi-square analysis; p < 0.05 was
considered significant.
Results
A total of 496 responses (representing 39% of US
and Canadian trainees) were obtained from residents and
fellows in 43 states as well as Puerto Rico and Canada.
Since only 8 PNS fellows responded, their answers were
included in the total, but no attempt was made to compare
their responses with those of residents. The demographic
characteristics are listed in Table 1. Overall, 89% of re-
spondents were male and 63% were married. Analysis by
sex shows that more male respondents (65%) were mar-
ried compared with female respondents (49%, p = 0.03).
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
at the time of the survey, 53% planned on having children
sometime during residency. However, there were signifi-
cant sex differences, with 65% of married male respon-
dents but only 13.3% of female respondents planning to
have children during residency (p = 0.03). Half of respon-
dents currently owed $100,000 or more in student loans,
and 14% owed over $200,000. Three-quarters of respon-
dents were currently at a PGY 3 level or higher.
The extent and character of PNS training is outlined
in Table 2. Sixty-one percent of respondents were being
trained within a dedicated children’s hospital, 29% were
being trained within a “children’s hospital within a hos-
pital,” 8% were being outsourced to another program for
PNS training, and only 2% reported no significant PNS
training experience. Over half (56%) of respondents re-
ported 6–11 months of dedicated PNS rotations—44%
during their junior years (PGY 1–2), 86% during their se-
nior years (PGY 3–5), and 25% during their chief resident
year (PGY 6–7). At the time of the survey, 70% of re-
spondents had already completed at least 2 months of PNS
training. Eighty-eight percent were trained in programs
having at least 1 dedicated PNS faculty member, with
65% having 2 or more dedicated PNS faculty members
(defined as spending more than 75% of their time treating
children). Seventy-two percent described a separate PNS
rotation having at least 1 dedicated PNS faculty member,
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-
es in intragroup responses (both Group 1 vs Group 4 as
well as Groups 1 and 2 vs Groups 3 and 4) to 35 of the 40
factors examined (Table 12). The only factors for which
there were no significant differences were 1) fast healing
and lack of secondary comorbidities in children, 2) ease
of finding employment and greater hiring potential, 3) job
pressure, 4) total working hours, and 5) work-hour flex-
ibility. There were no statistically significant differences
in the responses from those with less than 2 months of
PNS training compared with those from respondents with
≥ 2 months of PNS training at the time of the survey.
Finally, a number of residents provided further writ-
ten commentary. Several residents explicitly expressed
conflict with children’s hospital personnel; one resident
commented that working with pediatric nurses was “the
emotional equivalent of trigeminal neuralgia”! One trou-
TABLE 5: Interest in PNS as a career choice
bling theme was the perception among residents that pe-
diatric neurosurgeons garnered less respect from their
“adult” colleagues in other neurosurgical subspecialties,
both within their own departments as well as within the
neurosurgical community at large. Some respondents felt
that pediatric neurosurgeons were “looked down upon” by
colleagues and that PNS faculty should “stand up” to these
attitudes.
Discussion
Whether the present or future need for pediatric neu-
rosurgeons is, or will be, matched to the present supply
and future trajectory of the workforce is not clear. Both
general pediatrics and some pediatric medical and surgi-
cal specialties are experiencing a widening gap between
supply and demand for their services, although there are

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

J Neurosurg: Pediatrics / Volume 12 / November 2013 427


TABLE 7: Single greatest obstacle to recruiting residents to PNS
career
Obstacle % rosurgeon.
intrinsic nature of PNS practice 46.4
financial or reimbursement issues 25.3
additional training required 12.4
medicolegal issues/lawsuits 3.9
Finally, a significant number of ACPNF-accredited fel-
lowship slots are either not filled or are filled by trainees
who are ineligible for ABPNS certification (most by virtue
of foreign residency training).4
Residents’ Perceptions of PNS as a Career Choice
This study reveals that a significant proportion of
neurosurgical residents—perhaps as many as 42%—are
considering a PNS career. Whereas the decision to pursue
neurosurgery is made by most residents during medical
school, most of the residents who do decide to pursue PNS
do not make that decision until their senior resident years.
This affords an opportunity for pediatric neurosurgeons
to develop mentoring relationships with medical students
and younger residents. Unfortunately, only 40% of survey
respondents were exposed to PNS and only 7.4% identi-
fied a PNS faculty mentor during medical school. A sig-
nificantly higher proportion (11%) of those expressing an
interest in PNS had been exposed to a PNS mentor com-
pared with those who were not (2.4%) (p < 0.05). Which
came first—exposure to a mentor or interest in PNS—can-
not be determined by this study. In any event, this repre-
sents a missed opportunity to identify and recruit medical
students and residents into PNS early in their careers. On
M. S. Dias et al.
the other hand, most respondents had significant PNS ex-
posure during residency, with the majority having at least
6 months of PNS training under a dedicated pediatric neu-
There are a number of factors that neurosurgery resi-
dents might consider in making a decision about a career
in PNS (Table 6). Among these, the opportunity to care
for children was perceived as the strongest benefit while
the inherent nature of pediatric neurosurgical practice—in
particular the challenges of complex hydrocephalus and
shunt complications and the interpersonal challenges of
interacting with parents and other pediatric healthcare
providers—was the most significant deterrent.
This study also suggests that there are 2 distinct pop-
ulations of residents with respect to attitude toward PNS
(Tables 11 and 12). To the extent that these differences
are innate or learned is analogous to the nature-versus-
nurture debate. Some differences, such as a desire to work
with children and their parents, altruism and a desire to
help children, or an inherent interest in pediatric neurosur-
gical disorders, likely reflect innate traits. Other factors,
such as an interest in pediatric neurosurgical disease, at-
titudes toward shunts and shunt complications, and inter-
personal relationships between surgical and pediatric phy-
sicians and staff, are more likely learned from peers and
mentors. Since many of these issues apply to all surgical
subspecialties, this is also a globally important issue for
all pediatric surgical subspecialties. The extent to which
any of these factors is modifiable through changes in the
training experience provides opportunities to improve that
experience. There were no significant differences in the
responses of those having received at least 2 months of
PNS exposure compared with those having less than 2
months, suggesting that either these attitudes are innate or
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
innate interest in PNS.
A number of theoretical models have been advanced
to explore what factors influence career choice.22 Trait
factor theories propose that career seekers seek and ulti-
mately match with careers that align with their individual
skills and wants. Developmental (or self-concept) theories
propose that individuals use their own life experiences to
build both self-concepts and occupational concepts, merg-
ing the two to make final career choices. Vocational choice
and personality theories propose that individuals seek out
careers that “fit” their own personalities. Behavioral theo-
ries combine personal attributes, environment, and self-
experiences that interact, through subsequent positive and
negative feedback, to lead individuals toward particular
career choices. Finally, society and career choice theo-
ries propose a combination of societal circumstances and
sheer chance that combine to lead people toward career
choices. Osipow and Fitzgerald propose that all 5 of these
theories are involved at some level in determining an in-
dividual’s ultimate career path.22 With respect to medical
students’ decisions about subspecialty choice, a combina-
tion of personality traits, medical school environment,
learning experiences, and economic factors may all influ-
ence these decisions.9,10,16 The relative influence of each
TABLE 10: Degree of confidence/comfort regarding treatment of
PNS disorders after residency
Response
well prepared to treat all PNS conditions
prepared to treat most common or simple PNS conditions
prepared to treat some common or simple PNS conditions
largely unprepared to treat PNS conditions
completely unprepared to treat PNS conditions
of these factors appears to have changed somewhat over
time; in a 1996 article, Dohn identified 3 distinct epochs in
which factors influencing medical student career choices
changed. From 1950 to 1970 personality, socio-economic
status and values predominated. From 1970 to 1985, the
medical school environment assumed greater signifi-
cance. From 1985 to 1995, lifestyle and amount of debt
eclipsed other factors.6
More recent studies have examined how individual
factors influence medical students’ career choices, includ-
ing perceived career satisfaction (even if the perceptions
were incorrect), amount of debt, sex, race and ethnicity,
income, lifestyle, malpractice costs, medical education,
personality, and perhaps most importantly, a clinical ro-
tation and/or exposure to a mentor or role model during
medical school.5,14 These last factors may play an impor-
tant role in the medical student’s ultimate career path. Ef-
fective faculty and surgical resident mentors can strongly
influence medical students’ career decisions.2,17 A number
of studies have demonstrated that surgical rotations are
highly correlated with surgical subspecialty selection and
that seemingly random assignments to particular surgi-
cal subspecialties during surgical rotations may strongly
influence a student’s ultimate career path.5,17–19 Engaging
students during their surgical rotations, or even residents
in the early years of their training, by establishing informal
or formal dedicated mentorship programs that introduce
trainees to PNS, inviting them to shadow faculty, discuss-
ing some of their concerns about PNS, and/or involving
% them in research projects, may afford an important oppor-
11.9 tunity to direct their interests toward PNS.
61.8 How Can We Attract Residents Into PNS?
24.6
1.0
The results of this survey suggest that academic pe-
diatric neurosurgeons should seek ways to improve both
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-
dividually take several proactive steps to improve resident
education, such as maintaining positive attitudes toward
shunts and shunt complications; focusing on other aspects
of pediatric neurosurgical practice while seeking to mini-
mize shunt revisions and infections; modeling good in-
terpersonal relationships with children, their parents, and
other pediatric care providers; teaching residents how to
deal effectively with difficult families; educating pediat-
ric health care providers about neurosurgical issues; and
providing opportunities for surgical residents to positively
interact with pediatric personnel at all levels (for example,
attending pediatric grand rounds as a team, having resi-
dents attend and/or present at children’s hospital confer-
ences, involving residents in children’s hospital commit-
tees); and engaging both medical students and residents
in clinical research projects. Comments by some respon-
dents suggest that PNS in some training programs is cast
in a negative light as less challenging or more mundane;
pediatric neurosurgeons should work proactively with
their colleagues and department chairs to recognize and
address negative stereotypes so they are not passed on to
trainees.
On an institutional level, children’s hospitals can im-
prove interpersonal relationships between surgical resi-
dents and children’s hospital staff. The itinerant position of
surgical residents, who may rotate to the pediatric surgical
services for only a few months at a time, creates fewer op-
portunities for them to develop interpersonal relationships
with children’s hospital staff. Surgical residents may even
feel ostracized as evidenced by the negative scores for
“working in a children’s hospital environment,” “working
with pediatricians,” and “working with pediatric nurses”
(even among those planning a career in PNS) as well as
some of the respondents’ specific comments. Many sur-
gical residents have little prior experience handling even
routine pediatric care issues and some may harbor anxi-
ety, self-doubt, or even fear of caring for children. These
emotions may be misperceived by others in the children’s
hospital as detachment, defensiveness, anger, or even ar-
rogance, further alienating surgical residents from the
very people who could help them. Children’s hospital
leadership should recognize these challenges, work col-
laboratively to create a welcoming and nonthreatening
environment for all trainees and particularly for surgical
residents, and promote positive relationships with chil-
dren’s hospital staff. Formal educational conferences for
both pediatric and surgical residents (as well as pediatric
nursing staff) could cover topics such as fluid, electrolyte,
and caloric needs; postoperative surgical care; assessment
and treatment of pain and anxiety in children; treatment
for common pediatric diseases; techniques for examining
children at various developmental ages; subspecialty care
issues for the surgical patient; promoting family-centered
care; and dealing positively with difficult parents. Such
a program would enhance surgical residents’ knowledge
about pediatric issues, improve pediatric residents’ and
nurses’ knowledge about surgical issues, and provide an
opportunity to develop collaborative relationships.
There are also broader opportunities for organized
PNS to attract trainees to PNS. The Joint Section on Pedi-
atric Neurosurgery currently encourages medical students
and residents to present research at the national meeting
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
and/or the American Society of Pediatric Neurosurgeons
(ASPN) could undertake a national recruiting campaign to
identify and engage medical students and residents having
an identified interest in PNS and coordinate formal men-
torship opportunities for them. The section could develop
a formal student/resident subsection. There are also oppor-
tunities to address financial disparities and other economic
and medicolegal issues on a national level. The American
Academy of Pediatrics (AAP) is already actively engaged
with federal and state legislators on behalf of both primary
care pediatricians and pediatric medical and surgical sub-

J Neurosurg: Pediatrics / Volume 12 / November 2013 431


specialists; the Joint Section on Pediatric Neurosurgery
and the ASPN, together with the Section on Pediatric Neu-
rosurgery of the AAP, should seek ways to more actively
collaborate and support the AAP in these efforts.
The most controversial issue is whether to allow en-
folded PNS fellowship training. In the early 1990s, PNS
was the first neurosurgical subspecialty to develop inde-
pendent accreditation and certification bodies to improve
the quality of pediatric neurosurgical training and care in
North America. Organized neurosurgery has subsequent-
ly recognized the concept of enfolded fellowships in other
subspecialty areas through the Committee on Accredita-
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-
ed PNS fellowships. A structured CAST fellowship might
attract more residents to PNS without expanding the over-
all length of training. However, at least at the present time,
organized PNS (including the Section on Pediatric Neuro-
surgery, the ASPN, the ACPNF, and the ABPNS) remains
committed to post-residency fellowships as the only path-
way to PNS board certification.
A somewhat surprising result of this survey is resi-
dents’ perception that their residency training alone would
prepare them to treat most PNS problems and their opin-
ion that PNS fellowship training and ABPNS certification
should be required only for complex (coronal, metopic, or
multisutural) craniosynostosis. Although American Board
of Neurological Surgery (ABNS) certification confers au-
thority to treat both adults and children, this practice is
declining among general neurosurgeons,3 and children’s
hospitals are increasingly seeking fellowship-trained and
ABPNS-eligible or ABPNS-certified individuals for em-
ployment. Whereas residents might feel competent to care
for children at the conclusion of their training, long-term
interest and dedication are other factors to consider. Main-
taining the knowledge, experience, volume, and skill set
to optimize outcomes; working with other pediatric care
providers within the holistic and family-centered frame-
work of a children’s hospital; attending time-consuming
multidisciplinary specialty clinics; and caring for adult
survivors of pediatric neurosurgical diseases are all sig-
nificant commitments that practicing neurosurgeons are
increasingly unwilling to make.3 The “added value” of
dedicated pediatric neurosurgical training and experience
has been demonstrated (for example, for the treatment of
pediatric brain tumors).1,23 Involvement of pediatric sur-
geons (neurosurgery, orthopedic, and urological) within
the context of multidisciplinary, disease-specific clinics,
such as spina bifida clinics, has both improved care and
reduced overall health care costs;13 it is likely that similar
clinics for such areas as neuro-oncology, craniofacial sur-
gery, spasticity management achieve similar results.
One limitation to this study is that the response rate
of 39%, although in line with most survey-based studies,
raises the potential for selection bias. In particular, over
one-third of respondents report being in residencies that
have accredited PNS fellowships, although there are cur-
rently only 23 accredited PNS fellowships in the US and
Canada. Another limitation is that cause-and-effect rela-
tionships were not specifically sought in this study.
432
M. S. Dias et al.
Conclusions
To summarize, although this study has identified
many issues, both intrinsic and extrinsic to the practice
of PNS, that influence residents’ career decisions, it is
primarily the intrinsic nature of PNS practice that most
importantly impacts the decisions. We have suggested a
number of ways to address these issues individually, lo-
cally, and nationally. We recommend that a committee of
dedicated pediatric neurosurgeons, along with fellows and
residents (both with and particularly without an interest
in PNS) should examine these and other ways to further
attract residents to PNS careers.
Disclosure
This study was funded in part by the Joint Section on Pediatric
Neurological Surgery of the American Association of Neurological
Surgeons and the Congress of Neurological Surgeons.
Author contributions to the study and manuscript preparation
include the following. Conception and design: Dias, Sussman, Dur-
ham. Acquisition of data: Dias, Sussman. Analysis and interpretation
of data: Dias, Sussman. Drafting the article: Dias. Critically revising
the article: all authors. Reviewed submitted version of manuscript: all
authors. Approved the final version of the manuscript on behalf of all
authors: Dias. Study supervision: Dias.
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Manuscript submitted February 3, 2013.
Accepted July 30, 2013.
Please include this information when citing this paper: pub-
lished online August 30, 2013; DOI: 10.3171/2013.7.PEDS12597.
Address correspondence to: Mark S. Dias, M.D., Department of
Neurosurgery, Penn State Hershey Medical Center, EC 2750, 30
Hope Dr., Hershey, PA 17033. email: mdias@hmc.psu.edu.
433