Does the typical neurosurgeon have an informed opinion on adult ADHD? We’re about to find out. In the process, we’ll learn something about medical education.

A poster on Reddit recently complained about his neurosurgeon telling him he didn’t need ADHD treatment with medication. As a public service, I’m writing this article to let you know exactly how much a typical neurosurgeon’s training includes the management of ADHD, particularly in adults.

The r/ADHD post was this:

We assume neurosurgeons are brilliant. So do they (I just love this sketch):

Neurosurgery might as well be medicine’s answer to the question: “What if medicine was a monastic order?” They need to be exceptional at cutting into brains safely. The training reflects this. There is little room for practical experience working in child psychiatry—where the most ADHD management takes place. What follows is the story of how medical training functions to both enable expert care and limit general experience.

Medical Education for All U.S. Allopathic Physicians

For both child psychiatrists and neurosurgeons, medical school starts the same. Most medical schools follow a four-year curriculum, in which the first two years are largely basic science, and the second half is clinical rotations across disciplines. Every doctor has to pass multiple licensing exams in order to get that medical license. We all have to learn a lot of the same stuff.

Before you even get to medical school, you’re expected to complete college coursework that includes biology, physics, chemistry, organic, chemistry, and now, psychology, social science, and humanities. You also have to be able to read complex things and answer fiendishly difficult questions about them. The AAMC will even sell you a helpful guide of what the medical school admission requirements are1. They also publish this official guide for free. All of that is course work you must do before you even walk into the door to a medical school in the US.

How Hard Is It to Get Into Medical School in the U.S.?

The acceptance rate for all U.S. Medical Schools schools is 7%. To compare, acceptance rate to Harvard undergraduate is 4.7%. Harvard Medical School has an acceptance rate of 3.5% and an average GPA2, in undergraduate education, of 3.9. Virtually everyone doing that application process has to take the MCAT, and spend up to a year of their life studying for it.3

Medical schools are strongly selecting for individuals who have trained, like goddamn Olympic athletes, to get the right answer on tests. This is not good enough to get in. Applicants need to demonstrate effort over many years to care for humans, through volunteer activities and other experiences. Being a decent human, even being remarkable human, is not enough. You need to get the right answer on tests reliably. We are selecting for individuals obsessively dedicated to knowing from memory the right answer— and being able to click it off on a timed test.

The American Association of Medical Colleges (AAMC) sets the standards for accredited programs.

The Basic Science Curriculum in Medical School

The first two years includes the following, in brief outline format (this is not exhaustive list):

Anatomy
Physiology
Histology
Microbiology
Biochemistry
Molecular biology
Genetics
Embryology
Human development
Medical Ethics
Statistics
Trial design
Neuroanatomy
Neuroscience
Pathophysiology
Pharmacology
Psychopharmacology
Social determinants of health
Pathology
Radiology
History of medicine

As a medical student, you are not just going to class, you’re spending time in the emergency room and in doctors offices. You’re learning the craft, and the art, of medicine.4

This includes a tremendous degree of acculturation—we learn about 6,000 new words in the first 2 years. You have to learn them to be part of the club, and then you have to unlearn them to be understandable to your patients.

Many schools, including mine, make these classes pass/fail. It doesn’t matter, because the exam that matters is at the end of your first two years, and it’s a licensing exam which includes a score. The pressure is to learn the “facts” in a way that answers the test questions you need to get right to succeed. And now here is the rub:

About half of what you learn will turn out to be wrong, later; because science progresses. You just don’t know which half.

The First U.S. Medical Licensing Exam Doctors Take

Armed with half-wrong answers crammed into one’s head, student-doctors take the US Medical Licence Exam (USMLE) Step 1. This test is about 10 hours long. Not only do you have to pass, but the score you get is going to determine what kind of doctor you are able to be, because some programs, like neurosurgery, have extremely high cut off scores before they consider applicants. The passing score on that exam is 194, and the average is 232. For neurosurgery, the average is 245. Psychiatry is 226. I passed, but was average for psychiatry. On the upside, I believe in lifelong learning, so if you’re looking to get a better USMLE score, I’m here to help:

It is worth remembering that the competition, if you’re taking this exam, is composed of all the people who already got into medical school, because they did so well in high school, college, and on the MCAT. And some of them are “gunners.” Gunners are medical students who are ambitious to a fault. They work their ass off to look good to neurosurgery residency programs.

All that time is spend learning WHAT and WHY, not how. This is on purpose. To quote one of my favorite medical school teachers:

“We not teaching you so that you can follow protocol. We are teaching you to understand why, so you know when to break protocol.”

Doctors are learning how to assess the practice of medicine. It’s a practice that they haven’t learned yet, so that they can be an effective critic when the protocol isn’t working. It’s a brutal way to learn this skill set. It is mostly about what you should do in edge cases. I’m letting readers draw their own conclusions here as the wisdom of this approach.

Clinical Rotations Eat What’s Left of Your Life for Two Years

All physicians trained in the US at allopathic medical schools—those that grant MD degrees—have clinical rotations that need to be completed as well as elective time. But you’re not done taking exams! No, you’re taking exams, the whole time, studying the whole time, and have another medical licensing exam at the end. The USMLE step 2. This used to be two tests, the USMLE step 2 CK and the USMLE step 2 CS, but the pandemic got rid of that in person “clinical skills” exam, which was kind of BS anyway.

Whether you’re going to be a child psychiatrist or a neurosurgeon, you’re doing the same rotations and taking the same exams.

The Association of American Medical Colleges and the American Osteopathic Association require (with back of the envelope guess as to how much time I spent doing these things myself):

Obstetrics and gynecology (6-8 weeks)
Internal medicine (8-12 weeks)
Family medicine (Don’t remotely remember, maybe the 1st 2 years counted?)
Pediatrics (4 weeks)
Psychiatry (4 weeks — roughly 1/8th of my class had child psychiatry as their core rotation.)
Neurology (4 weeks)
Surgery (8 weeks — I did neurosurgery and trauma surgery.)
There is elective time as well. (Electrophysiology was my most useful one!)

Medical students spend four to eight weeks on each rotation as an “integral member” of the team.5

Share The Frontier Psychiatrists

Let’s Compare the Neurosurgeon and Child Psychiatrist Experience Thus Far…

Neurosurgeons do zero rotations in child psychiatry on average (you can graduate medical school with only 4 weeks in psychiatry). For a neurosurgeon, in practice, they have likely seen a stimulant on a med list and answered questions above them correctly on tests. That is it.

Neurosurgery residency has no psychiatric rotations. It’s not part of ACGME requirements.

I did 8 weeks of surgery and 6 of those in neurosurgery in medical school.

Bizarrely, your author, a psychiatrist, has more experience working in a neurosurgery operating room than virtually any neurosurgeon has in child psychiatry, as part of medical training.

I spent 2 years learning how to manage ADHD in fellowship.

Neurosurgeons may have heard of stimulant medications in school, but it’s entirely plausible they have NEVER managed an ADHD patient. Much less learned how to prescribe those meds in the any detail past memorizing was was mandated for tests about about it.

Being a physician is a strange job. We learn a lot of what. We learn a lot of why. We don’t do most of the things we’re learning about on a day-to-day basis, because for procedures to go well, they need to be done by procedural specialists: people who do the thing all day long. We are trained as exception-ists. The training of physicians is specifically geared towards dealing with the unusual. We are trained to know when to break protocol in medical school. But we don’t learn how to actually treat a medical condition in real time with a patient until residency training. There are some extremely common conditions that every doctor has experience managing. Virtually all psychiatric conditions don’t fall into this bucket. Anything you’re going to learn about how to manage a psychiatric condition, you learn in the context of your residency training. Primary care doctors will learn the basics of managing depression, and will learn even more when they have to do so every day. Neurosurgeons won’t. Because it’s never crucial for a neurosurgeon to manage your ADHD. So they won’t know how to do it.

It’s tempting to imagine that knowing everything about how ADHD could or should be managed is the same as performing the actual skills of doing so. My medical license says that I am allowed to perform medicine and surgery. To be very clear: don’t ever let me cut you. Just because I’ve passed enough exams to answer the right questions about where to cut and when doesn’t mean I know how to do it. The appropriate management of ADHD is not less complicated than neurosurgery. It’s a different skill set entirely. General knowledge and competence in specific applied domains are different things: come on people, this isn’t brain surgery.

1

This seems like some real bloodsucking vampire stuff, but whatever. At least they’re not private equity.

2

For reference, at Amherst College, my GPA was 3.6. I later did my post-baccalaureate pre-medical education, and I got a 3.96 GPA. To keep up a 3.9, you can only get three Bs in all of college.

3

As one of the top 10 MCAT instructors for Kaplan in North America, 2 years running, I know how hard this is. Most of the people who take that test will not get into medical school.

4

You will notice, if you read the Substack, that there’s kind of a gaping hole there, and it’s in healthcare economics. Business is also not really included. You don’t learn why private equity is going to buyer clinic later, or why it’s a terrible idea to have anything to do with that. But whatever. So much to learn. No time for the small stuff.

5

Your ability to convince the other team members that you’re pretty integral is what will get you a good grade.

The Frontier Psychiatrists

How Much Do Neurosurgeons Learn About Adult…