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My first part of this topic received tremendous amount of viewers, reaching almost 1500 views/day since 07/01/2013. That shows how many were interested in the topic. I am sure by now they would have got the true picture of the pathway to become a Cardiothoracic surgeon and why there are so few of them in the country. I am not sure how many budding doctors would still want to become one after reading the article. It is always better to decide after you start working when you know the reality of a medical life.

Now, let’s look at Neurosurgery. This is another common question that I am always asked by budding doctors. Again, TV programs showing glamorous and rich lifestyles of neurosurgeon get them carried away without knowing the reality. Whenever someone ask me about neurosurgery, I always ask them to take a walk into any neurosurgical ward in any state hospitals and let me know after that, what you felt when you were walking through. Personally, it is depressing. Many budding doctors think that they are going to be operating on brain tumors and do wonders! Well, that is not the reality. Recently there was a comment in my blog of a budding doctor (just finished SPM) who wanted to become a neurosurgeon just because she heard that neurosurgeon are the highest earners!! Gosh, what kind of students are we producing? They really got no idea about the world out there. In government service, all specialists are paid the same based on your grade.

Brain tumors account for less than 1% of all cancers and 1/3 of it are malignant cancers. Most of these malignant cancers have poor outcome despite surgeries. The incidences are also low with less than 7 per 100 000 population. So, from here, you will know that these are NOT the bulk of cases that neurosurgeons are dealing with. The major bulk is actually motor-vehicle accidents with head injuries! Malaysia has the highest number of road accidents in this region. Thus, head injuries contribute to almost 70-80% of patients in neurosurgical units. The remaining are contributed by Intracranial bleeds (bleeding in brain) and finally brain tumors. BTW, most surgeries involving brain tumors will end up with neurological complications like epilepsy, limb weaknesses etc, even in good hands. Brain tumours involving children is the most depressing. I know a Neurosurgeon whose own child died of brain tumour!

Most intracranial bleeds have poor outcome as well. That’s the reason when you walk into any neurosurgical unit, you will see many patients who are bedbound, speechless and comatose. Many of them end up going back as a “vegetable”. Very few survive and go back fully conscious. However, there are some intracranial bleeds such as Subdural, Subarachnoid and Extradural bleed that have good prognosis if early intervention is done. This is where most satisfaction occurs. The procedures involved are usually simple, like burr hole, craniotomy and EVD. To be frank, these procedures are done by neurosurgical MOs in government hospitals and sometimes by general surgeons. So, you really do not need a Neurosurgeon to do these simple procedures. Nowadays, even interventional radiologists are trained to do cerebral angiogram and clipping of aneurysm !

Neurosurgery involves a lot of training and skills. This is needed mainly for surgeries involving brain tumors and spinal surgeries. These are delicate surgeries. There are a lot of advancement in microsurgery involving the brain and spinal cord. However, most of the time there is nothing much that can be done and the outcome is generally poor. I remember once I was talking to a Neurosurgeon about a patient who had massive intracranial bleed. The GCS was below 7. The neurosurgeon said that ventilating and doing cerebral resuscitation could save him. I asked him what would be his neurological recovery. The answer: well not much, his GCS likely will remain low and he will go back bed bound! So, what is the point? I am not undermining neurosurgeons but the budding doctors should understand that being a neurosurgeon is not about doing wonders. I know many who even dropped out while in training as they felt it is not worth it.

The entire state of Johor has only 2 Neurosurgeons in private sector and that’s all you need. In fact, the 2^nd Neurosurgeon just started 1 year ago. Since 1980s, there was only 1 Neurosurgeon in private sector for the entire state of Johor. There was only 1 Neurosurgeon in JB Government hospital till about 2 years ago when another 2 joined him. It is a stressful job and in private sector, you need to come and see the patient at any time of the day as long as the patient has head injury. Looking at the road accident rate in Malaysia, likely you would be called almost every other day. I also know neurosurgeons in private hospitals who do unnecessary procedures just to get some money even though they know the outcome/prognosis is poor. You can save lives in the expense of poor neurological outcome aka “going back as a vegetable” to the dismay of the relatives who had spent so much of money. That’s the reality in medicine.

Now, let’s come to the pathway. There are 2 pathways to become a Neurosurgeon in Malaysia, the shorter route and the longer route:

a)    Longer route

–       2 years Housemanship

–       2-3 years MOship

–       4 years Master’s in Surgery

–       6 months gazettment

–       1-2 years waiting period

–       4 years Neurosurgical subspecialist training

–       another 3-5 years experience before being able to perform surgeries on your own.

b)   Shorter route

–       2 years housemanship

–       2-4 years waiting period (min of 6 months experience in General surgery and 18 months experience in any other recognized field after housemanship)

–       4 years Master’s in Neurosurgery by USM

–       6 months gazettment

–       4-5 years experience before being able to perform surgeries on your own

Master’s in Neurosurgery by USM has a very limited number of posts offered, usually less than 10. So, the chances of you getting into this program are slim on first try. You also need strong cables and preference is given to those who are working in neurosurgical units.

Whatever said, we still need a lot of neurosurgeons in Malaysia. BUT, please remember that the working life is not as simple and grand as what is shown on TV programs. The reality is different. It is a hectic life, needs a lot of skills and training, depressing and generally have poor outcome except for some instances.