How to Match Neurosurgery in 2026!

This is the Neurosurgery Podcast. Welcome back to the podcast. I am super excited. I happen to be in Rick Cometar's office right here at Epic Space. Welcome. Obviously we're in Miami and I thought we ought to do an episode because it's May, early May. The next cycle for 2027 applications is people starting to do sub-eyes. We got to talk about this 2026 match. This was a crazy year. You're our program director. You have visibility on this. Tell us about what happened in the last six months. This was by far the most competitive year of the match in the last decade. The numbers when you look at them are certainly shocking. There's only 280 spots in the country, 120 programs and nearly 500 applicants. This year had the highest number of unmatched applicants in recent memories. A lot of disappointed, very qualified candidates. I think that's what really got me was that every year people don't match but a lot of those people are questionable going in. I think this year, at least in my opinion, there were several. I would say at least a dozen candidates that I know who should have matched, who were elite in every way in terms of quality of medical school, number of publications, letters of recommendation, all the above. They still didn't match. I think that's what took me back when I looked at this year. Yeah, JP and I are going to do a deeper dive on this as the months go on but we wanted to be timely because folks want to prepare now. This reminds me of when you and I were interviewing in the old days with early match where it was super competitive and early matches so people know, commits you to ranking and matching early so in case you didn't match, you'd go in another field and still have a chance. Now we've gone into general match for mostly financial reasons. Unfortunately, who does early match? I think it's just the ophthalmology. I think those are the only two that I am aware of but yes, it was a benefit when neurosurgery had the early match in January and that provided you another buffer. That was called the San Francisco match and it was expensive for organized neurosurgery. Derm by the way does late match to penalize you for trying to rank them because they only want serious people. Right, obviously Derm is very desirable. These numbers, basically we're talking about a lot of folks out there who have to go through soap. Maybe you could describe what soap is. Yeah, soap is the process when people don't match and then it used to be called scramble where there's open spots around the country. This year there were zero open spots in neurosurgery. Usually there's five or less but this year there was actually none. People who don't match scramble or go in the soap and they look for open spots. Again, there was none this year so the soap was all directed into other specialties where they're unmatched spots in general surgery, emergency room, radiation oncology, orthopedics potentially and those spots are also limited and that's a three day process. So there's a lot of chaos, a lot of anxiety that's caused by obviously not matching people have to change their entire careers. The soap process has organized as it is still creates a lot of anxiety for all the applicants. So before we go into what people can start to do now today in May of 2026, let's talk about maybe theories. Of course, they're all theoretical hypotheses of why this is happening. Why is this year, I mean it was a big change, right? Yeah. I think the number of spots is always the same. The same number of programs, potentially even more because there are more programs opening up around the country. But I think the not only are the number of applicants going up in neurosurgery slowly, I think the quality of applicants is going up overall. I think in prior years you would have more borderline candidates and I think this year in particular again, I was shocked at the average quality was definitely above the average quality of years in the past, which makes it inherently more competitive. I also think what's changed is that the medical schools overall are trying to what they say help the students by making the grades pass fail. Let's make step one pass fail. And what that has done is it takes away the ability of the underdogs, people who come from smaller medical schools, foreign medical graduates potentially, they have no way to differentiate themselves. And so what he used to do back when you and our applying was you could, if you crushed step one, you got looked at. Now step one is pass fail. Step two is important but not nearly as important as step one used to be. So step one is out of the picture essentially, which really hurts the lower tier medical schools and the foreign medical graduates. Research is now the number one priority. If you're going to differentiate yourself, you need to publish, publish quantity and quality. So people are starting earlier. People instead of doing research back like you and I did when we were third or fourth years back when we were applying, people are starting an undergraduate which is crazy. But again, it's gotten so competitive to build that research portfolio. Might as a recommendation or still standard. Let's come back to that topic of what people can do now, but let's finish this part which is I've heard that it's AI. I've heard that the fear of AI, the robots come later than the cognitive, so nobody wants to go into cognitive field. They're all trying to be surgeons now because they think there's a little bit of a runway there. Otherwise Elon Musk already said don't even bother, right? So do you think that's part of it? Because this is a big change. Yeah, I honestly hadn't thought about it until you mentioned it. But of course, if you are a medical student and you're thinking about going into a field that's pattern recognition, pathology, radiology, those two obviously come to mind. Without any doubt, if you look at it, that field is going to be dominated by AI. There's no way you could argue that a human being can do pattern recognition as well as AI. And that's using the current AI, let alone what's going to happen in five or ten years. So if I had a friend who was doing one of those two fields, radiology, pathology, I would say certainly don't because that field is either going to be extinct or your role in that field is going to be trivial. So now that you say it, I do think that certain fields are going to be not obsolete but are going to be a lot less attractive to medical students in the near future. You know, another element, when we started podcast in 2019, one of our early substances, I think it was episode five or something like that, we had Matthew Comet who's down on faculty here debating the value of a resident versus an APP in our practices. And it was Alice who came from New Jersey. They were working together and who's more powerful. They wouldn't engage as much as I wanted. But that's the other thing, right, that there's a fear that APPs take over primary care, because they're cheaper. And they say they do a better job, patients like them more versus surgery. It's a little bit harder for them to access what we do, right? Correct. And there's, you know, the nice thing that I've heard about APPs is that you don't have that learning curve. So a lot of attendings that I know who work with APPs, they always say that whenever you work with residents, yes, the ceiling is higher once you teach a resident to do the surgery, but there's a, there's this learning curve. And then the resident leaves and then there's a learning curve again. And so you have to deal with investing that time and energy to get the ROI every time you have a new resident and a new fellow. But with APPs, you teach them and then they're there for five years, 10 years, 15 years. And so you don't have this constant cycling of learning curves. And I think that is certainly an advantage to the APPs. Yeah. So I think that threat has driven people because politically they've gotten a lot of power lately, a lot of legislation lately at the state level that give them more independence, right? So I want to cover that maybe to just prime on it, the more the areas you mentioned them already where people can start to get their application ready too late about the scores because if you're, if you're applying now, right, it's too late. So let's talk about papers or research. Let's talk about sub-eyes. Let's talk about rec letters and let's talk about interviewing in that order, okay? Absolutely. So, so, so a lot of folks listening, they're maybe they're not in this cycle, but they're thinking, oh my god, papers like you said, I already finished undergrad, I lost those years. But do you know, how do I get started in doing some research? So I tell everyone, since the boards are now pass fail, the number one way that you can differentiate yourself going into the matches research, you have to put yourself in the shoes of the program director and I'll just tell you my role, we interview 40 applicants for four spots and we literally get 500 applications of which at least half signal us. You cannot look at every single application. It's physically impossible. You're going to miss a couple of diamonds in the roughs, but you cannot look at every application. So you have to have some way to screen people out and research will get you seen. So for example, you come out of a smaller school, foreign medical graduate, the number of pubs and the quality of pubs, if you can do both of those, we'll get you seen. So I tell students here, you know, from Miami, start often on research, say note in any project, work on cranial spine, any project, you don't have to necessarily say, don't say don't say no to no one. Let's put it that way. And I would say that the more publications you have, you need quality and quantity. And this is where students sometimes get into trouble because they focus on just quantity and then they have no quality and they have 15 case reports. And while that's nice, it shows you're productive, that's not what we're looking for. for. The other side of that spectrum is people working to lab, they want to get a nature paper or a cell paper. They spent three years doing that and the paper gets rejected and they have come out with nothing. Again, great effort, but nothing to show for it. So you got to do quality and quantity and start as early as possible. Doesn't matter if you're a first year, a third year, get those numbers up because that's what's going to differentiate you in the long run, especially if you come out of potentially a non-top 25 program. Yes, I've started to see residents worry about their H-index, which is fascinating. You used to be only faculty. So if you don't know what H-index is, go look it up. So next, let's go to sub-Is. So now people are starting their sub-Is. We can talk all day about it, but some input on how to do that. Correct. So again, meet with your program director or your APD. I meet with all the students in my area. What if you have no program director? You got to find a mentor. If you have a program that doesn't have a neurosurgery program, then you need to find a neighboring program. We have, for example, FIU, FAU, we have neighboring medical schools that always reach out to me, "Hey, we don't have our home neurosurgery program. Can you mentor me?" We obviously are very happy to mentor anyone. So regardless of where you are, you have to find someone who's either a program director or an APD who someone who has experience in the field to mentor you through the process. Picking sub-Is is absolutely critical. The way I summarize it for our students is it's a one-month try-out. And so I always ask them, "Okay, what do your pubs look like? What type of medical school are you coming out of? What has been your extracurriculars?" And I gauge what type of applicant are they? Are they elite? Are they average? Are they inferior? And so if someone is an elite applicant, they're coming out of a top 25 med school. They've got 10 plus pubs. Their step two score is good. They've done all the prerequisites. Those people should aim for the stars. Meaning, "Hey, you want to go to the West Coast? Look at UCSF, USC, Stanford. You want to go to the East Coast. Look at Miami, Vanderbilt, Penn. I'm just throwing out names." The other side of that is if someone comes out and they come out of maybe a foreign medical school or a lesser-known medical school, they've got three publications, all case reports. They should not be applying to those programs because you're not going to match there. And so you have to temper your expectations if your application's not going to be super strong. So for example, if someone's going to look at the West Coast, you're going to dial it down. You're not going to look at those elite programs because more often than not, you're going to be wasting your time and you're wasting the programs time. So I think meeting with a mentor who can tell you what programs are in your strike zone so that those sub-eyes are your best chance to match. And especially if someone is a borderline candidate, someone comes again, lower tier medical school, just a few pubs. You're questionable if you're going to match it all. You have to be your sub-eyes at lower tier schools because that's your best shot of making a good impression and then matching that. Yeah, be careful. The best mentor is not the person who tells you what you want to hear is what you're saying, pick carefully and be realistic. Yeah. There are students who come to me all the time that like I want to do sub-eyes at these three programs. They're all top 10 programs and I look at their application. I'm like, you're never going to match there. Don't waste your time. Don't waste their time. Let's just temper the expectations. Go to a program a little bit further down on the tier scale and that gives you a better chance of matching. And we've said on this podcast for a long time in neurosurgery, at least for now, there really aren't any bad programs. Like in general surgery, there are a lot of bad programs. And I don't mean to be disparaging, but their programs in little hospitals who just happen to have residents and all that. There are surgery doesn't allow that. So let's go to the third tranche. Also signaling. Signalling is critical. That's also like doing sub-eyes. Where you signal is critical. So you think it matters? Oh, 100%. So for example, the way we screen programs, right? Again, we've got 500 applications. We screen applicants. Yes, sorry. We don't look at any application of someone who has not signal. You don't even look at it. Don't even look at it because people get 25 signals. If someone doesn't signal us, that means you're outside of their top 25. That means they have no interest in coming to your program essentially. So if they have no interest, we have no interest, which kind of makes sense to seven year marriage. So if someone doesn't signal us, we don't look at them. Then that narrows it down to from 500 on to about 253 100. Then we look at top 25 medical schools, 10 plus pubs. And that gives it down to about 120. Then it comes down to fit extracurriculars, athletics potentially, high achieving endeavors that might show that someone is a leader in the field. But anyway, signaling is important because if you are a top tier applicant and you signal the top programs, that's the way it should be. If you're an inferior applicant potentially and you're signaling only the top tier programs, you're not going to get many interviews. I feel like there's too many options. 25 is too big, but use it as a first screen. Well, 25 means that if someone doesn't signal you, you're not on their list. Because people come up to you, like, you know, I signal to you and signal to you. We're like, okay, like, I mean, there's 25 signals. Yeah, it's a lot. It's like hitting on 25 people to bar. It's like it's, anyways, okay, let's go to an estimate, which is important. Rec letters. Yeah. How many, how do you get them? How do you approach, you know, what's the right? Yeah. Right way. Right letters have become, I mean, they've always been important, but now that step one is obsolete, they become even more important. So number one, you need four. Number two, they have to come from neurosurgeons. I get asked this every year, oh, my mentor who's a cell biologist and the undergraduate who really knows me great, but no one cares. If it's true, if I get a letter, and it's from someone who I don't recognize the name, I don't know neurosurgery, that letter doesn't care. But I know, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, no, it might be a little bit different. I agree. But I'm saying, barring those situations, I think a letter from someone that doesn't have name or brand recognition is not going to be nearly as powerful. So you want to have a letter such that if someone's reading it and they want to call that person, they can quickly call them, hey, is this applicant legit? So four letters, make sure they're all from neurosurgeons or a Nobel laureate. And you want to cover all your sub-Is. So your home institution, one or two, and then most people do two away sub-Is, get a letter from each. If you do a sub-I and don't get a letter from that program, it is a red flag. People will be like, well, why didn't you get a letter? Even if your sub-Is late, September, October, you can get the letter and then add it in later on. So those are really the four premises, four letters, all neurosurgeons, home institution, typically two, and then your two away sub-Is. You want to make sure that both sub-Is are covered. So let me ask you an important question because this comes up often, right? Let's say you have two options for a letter writer and you're, you know, it's not limitless to number of letters. So you're going to pick between these two individuals. One person is more prestigious or better known, but the other person you have a suspicion is going to write a stronger letter. What's the right way to calculate on this? Yeah, you want the stronger letter, for sure. You could potentially, in a situation what I've seen is people ask for a dual letter. They get the letter written by the person who knows them better, is going to write them a stronger letter, and then they ask, can the chair or the program director or the full professor co-sign that letter? And that's definitely done at a lot of programs. So I think there's a fine line. You definitely don't want just the name on the letter, and then it's a crappy letter. So definitely take the stronger letter, but if you can get the senior person to co-sign it, it's even better. I don't want to game a fight, but I've experienced this, which is almost like if you have a luke warm, which is negative letter from someone powerful, it's almost more damning. Agreed, right? It's like, oh, well, someone wrote this letter. It's not so great, but we don't really know. But you get a letter from someone important like you, and it's like, whoa, I want to stick stuff back, right? You also have to know who's writing the letter. It's very hard for applicants to know this, but at least in the small community, people know who's letters mean something and who's don't. There are a lot of neurosurgeons that write the greatest letters for every single applicant every year, year in and year out, which makes no sense, right? Not every applicant is God's greatest gift in neurosurgery, but there are certainly neurosurgeons that literally write that for every single letter. So you just discard that. Everybody's in the top three. Oh, exactly. And so it makes no sense. So there's a handful of us that are very honest. I personally think I'm very honest in my letters, because you never want to lose that kind of credibility. If someone is great and you put great, people need to know that, okay, this person is great. Or if someone's average, you put their average, they need to know that you're telling the truth. And so when you're picking your letters, you need seniority, but you also need someone who's going to write you a good letter and something that's going to be genuine, insincere, and people are actually going to give credibility to. Let's wrap it up. I want to be respectful of your time about the interview process. This again could be an entire eight hour discussion, key points interview. So now you've got the interview. Maybe you've done a sub-eye there. Now you're there on interview day. All the programs do it differently, right? Mm-hmm. So first of all, this is such an important topic that my time, this is great. So I can be here all day talking about it because it's so near and dear to my heart. But when it comes to interviewing, you have to put yourself in the shoes of the interviewer, right? As neurosurgeons, as professors, as program directors, as chairs, what we want to see is leadership. Someone who has has strive to be excellent and has achieved that at every single phase of the game. And so what I'm talking about is, and we all know who these applicants are. They were captain of their varsity. team in high school. They were valedictorian in college. They did high level athletics and accomplished great things. Everything that they've touched, everything that they've done, they've not only been successful, but they've been the best at. And you see that translation and you know that person's not going to fail. And so what I always tell applicants is that when you're interviewing, obviously everyone says it and it's pretty contripe, but basically be yourself kind of makes sense. But you have to portray that leadership ability and the understanding of okay, I know this is going to be hard. It's seven years. It's very, very difficult, but I want that challenge. I need that challenge and I'm going to succeed. And I think portraying that there's no recipe for portraying that. But when you see it, when you see that leadership and that confidence and that mojo, I call it, it's very, very apparent. And it doesn't mean you definitely don't want to be cocky in the interview because you have to be respectful of understanding what you're up against. But being confident, understanding the challenge and thriving off of adversity. And also I think the big thing is people who can bounce back from failures because life is hard, neurosurgery is even harder. You're going to fail not once, not twice all the time. And the people that are successful and Mike and I included have failed, have failed, have failed. And they use that as a growth opportunity. So every now and then you see an applicant who has been through multiple life adversities and they've succeeded. Those are the ones that really impress you the most because you know they've been through something super difficult. Neurosurgery is not going to be a problem for them. Wow, fantastic. Pure gold in 30 minutes. You heard it from Rick Comattar here in Miami. Good luck. Those applying don't be discouraged. The numbers reflect the reality neurosurgery is a very hot specialty. Hope to see on the trail. Throughout the year. For you. That's right. Great man. Talk soon.