An analysis of cross-continental scholarship requirements during neurosurgical training and national research productivity

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OBJECTIVE

Engagement in research and scholarship is considered a hallmark of neurosurgical training. However, the participation of neurosurgical trainees in this experience has only recently been analyzed and described in the United States, with little, if any, data available regarding the research environment in neurosurgical training programs across the globe. Here, the authors set out to identify requirements for research involvement and to quantify publication rates in leading neurosurgical journals throughout various nations across the globe.

METHODS

The first aim was to identify the research requirements set by relevant program-accrediting and/or board-certifying agencies via query of the literature and published guidelines. For the second part of the study, the authors attempted to determine each country’s neurosurgical research productivity by quantifying publications in the various large international neurosurgical journals—World Neurosurgery, Journal of Neurosurgery, and Neurosurgery—via a structured search of PubMed.

RESULTS

Data on neurosurgical training requirements addressing research were available for 54 (28.1%) of 192 countries. Specific research requirements were identified for 39 countries, partial requirements for 8, and no requirements for 7. Surprisingly, the authors observed a trend of increased average research productivity with the absence of designated research requirements, although this finding is not unprecedented in the literature.

CONCLUSIONS

A variety of countries of various sizes and neurosurgical workforce densities across the globe have instituted research requirements during training and/or prior to board certification in neurosurgery. These requirements range in intensity from 1 publication or presentation to the completion of a thesis or dissertation and occur at various time points throughout training. While these requirements do not correlate directly to national research productivity, they may provide a foundation for developing countries to establish a culture of excellence in research.

ABBREVIATIONS COSECSA = College of Surgeons of East, Central and Southern Africa; JRAAC = Joint Residency Advisory and Accreditation Committee; WFNS = World Federation of Neurosurgical Societies.

OBJECTIVE

Engagement in research and scholarship is considered a hallmark of neurosurgical training. However, the participation of neurosurgical trainees in this experience has only recently been analyzed and described in the United States, with little, if any, data available regarding the research environment in neurosurgical training programs across the globe. Here, the authors set out to identify requirements for research involvement and to quantify publication rates in leading neurosurgical journals throughout various nations across the globe.

METHODS

The first aim was to identify the research requirements set by relevant program-accrediting and/or board-certifying agencies via query of the literature and published guidelines. For the second part of the study, the authors attempted to determine each country’s neurosurgical research productivity by quantifying publications in the various large international neurosurgical journals—World Neurosurgery, Journal of Neurosurgery, and Neurosurgery—via a structured search of PubMed.

RESULTS

Data on neurosurgical training requirements addressing research were available for 54 (28.1%) of 192 countries. Specific research requirements were identified for 39 countries, partial requirements for 8, and no requirements for 7. Surprisingly, the authors observed a trend of increased average research productivity with the absence of designated research requirements, although this finding is not unprecedented in the literature.

CONCLUSIONS

A variety of countries of various sizes and neurosurgical workforce densities across the globe have instituted research requirements during training and/or prior to board certification in neurosurgery. These requirements range in intensity from 1 publication or presentation to the completion of a thesis or dissertation and occur at various time points throughout training. While these requirements do not correlate directly to national research productivity, they may provide a foundation for developing countries to establish a culture of excellence in research.

ABBREVIATIONS COSECSA = College of Surgeons of East, Central and Southern Africa; JRAAC = Joint Residency Advisory and Accreditation Committee; WFNS = World Federation of Neurosurgical Societies.

Engagement in research and scholarship is considered a hallmark of neurosurgical training. This academic pursuit is fundamental to the advancement of the field. However, the participation of neurosurgical trainees in this experience has only recently been analyzed and described in the United States,18,19 with little, if any, data available regarding the research environment in neurosurgical training programs across the globe.

Throughout the United States, participation in research during neurosurgical training is nearly universal, despite a lack of explicit requirements set by residency-accrediting organizations and board-certifying agencies.1,3,19 A recent analysis of 1506 residents in 117 distinct neurosurgical training programs identified the average productivity of individual residents as 5 publications in total, with 3 published during residency.19 Moreover, one’s involvement in neurosurgical research typically begins early, with 1st-year residents averaging at least 1 publication prior to the start of residency.18 This is likely attributable to both the academic nature of neurosurgery as a specialty and the high value placed on applicant involvement in research by residency program directors. Indeed, according to data presented by the National Resident Match Program, neurological surgery ranked as the highest in mean number of abstracts, presentations, and publications among allopathic seniors who matched into the specialty in 2018.24 One of the most significant factors in determining the productivity of these trainees is the extent of support offered by their institutions. Institutions can foster supporting educational environments via the provision of protected research time, funding, medical editorial assistance, and travel stipends.19 In fact, the lack of protected time and institutional resources, including training in research design and conduct, has been identified as one of the greatest barriers to research involvement among physicians in various specialties.9,21 Notably, however, a program’s designation of a “research requirement” was not shown to have a significant impact on departmental productivity in the large neurosurgery resident cohort mentioned above. Authors of that study reasoned that research is engrained in the culture of many of the highly productive programs and does not require formal designation, while programs with an explicit requirement may be in the early stages of such a culture change.19

The translation of these findings to the global arena of neurosurgery is unclear and likely influenced by various country- or region-specific factors including socioeconomic status, density of neurosurgeons, and research infrastructure and support. At present, there is limited literature on identifying and evaluating research requirements during neurosurgical training in nations outside of North America. In an important study focused on identifying requirements for neurosurgery certification across the globe, Gasco et al. reported that 3.8% of responding international societies require involvement in a research project, with publication, prior to oral examination eligibility.15 However, this analysis was limited to member societies of the World Federation of Neurosurgical Societies (WFNS) and did not explore in depth the impact of the requirement, nor other factors on research productivity in the responding countries. In appreciation of the great value of participation in the pursuit of knowledge via research and/or scholarship, our group has set out to identify research requirements established by relevant accrediting and/or certifying bodies across the globe. Additionally, we seek to understand how these requirements correspond to productivity.

Methods

Data Extraction

A list of countries was compiled from the WFNS Global Neurosurgical Workforce Map (https://www.wfns.org/menu/61/global-neurosurgical-workforce-map). Our first aim was to identify research requirements set by relevant program-accrediting and/or board-certifying agencies within each country. This search was conducted using a general query of Google and the PubMed database to obtain the above described information from agency/society guidelines and previously reported literature. Search terms for these queries included various combinations of the country name AND “neurosurgery” AND “residency” OR “training” OR “education” AND “research.” These queries returned results including websites of national/regional neurosurgical certification organizations and previously published scholarly literature, which facilitated our determination of research requirements during training. Required research was defined as any compulsory research activity during residency, such as mandatory publications, presentations, thesis/dissertation, or research time. Explicit requirements including number of publications and/or presentations, when listed, were recorded for analysis. Undefined scholarly requirements were excluded from our analysis.

For the second part of the study, we aimed to determine each country’s neurosurgical research productivity, which was assessed by quantifying a given country’s publications in the various large international neurosurgical journals: World Neurosurgery, Journal of Neurosurgery, and Neurosurgery. These data were collected by performing a query of the PubMed database using the name of each country as the term in the “affiliation” search field in combination with the title of each journal in the “journal” search field. Our final PubMed query was as follows: “<journal>”[Journal] AND “<country>”[Affiliation] with no restriction on time.

Data Analysis

We performed a descriptive analysis of the research requirements and productivity across the countries for which data were available. These countries were grouped into 3 categories based on the nature of their requirements: 1) no stated requirement; 2) partial requirement, defined as a guideline lacking explicit details and/or only requiring education on research methodology; and 3) specific requirement, defined as a guideline with details on the type of research required and/or number of publications/presentations. The number of publications for countries within each group was averaged, with descriptive statistics reported as the mean and range.

Results

We identified a total of 192 countries from the WFNS Global Neurosurgery Workforce Map. A complete list of countries and research output is included in Table 1, which displays each country along with information regarding that country’s continent and geographic region as well as its number of publications in the aforementioned journals. Data regarding neurosurgical training requirements for research were available for 54 (28.1%) of the 192 countries. Specific research requirements, as defined above, were identified for 39 countries, partial requirements for 8, and no requirements for 7 (Table 2). The most frequently occurring reporting body was the College of Surgeons of East, Central and Southern Africa (COSECSA), which oversees surgical training in 14 African countries. In Europe, such data were primarily reported by the Joint Residency Advisory and Accreditation Committee (JRAAC), which is an agency that accredits residency programs throughout the various countries in the European Union. Finally, requirements in several nations were set by board-certifying agencies, such as the Japan Neurosurgical Society, making research obligatory in order to be board certified, although it was not required as a component of training. The average number of publications in World Neurosurgery, Journal of Neurosurgery, and Neurosurgery for each category of requirements is summarized in Fig. 1. Surprisingly, we observed a trend of increased average research productivity with the absence of designated research requirements. Similar results have been observed in a previous bibliometric analysis of research productivity among specific neurosurgical residency programs within the United States19 and will be discussed later. The heterogeneity of our results, especially the variance in research productivity among nations, unfortunately prevented statistical analysis of the relationship between research requirements and national research productivity. In addition, when we averaged publications in each journal among all countries, we found that World Neurosurgery had the highest number of publications (69.3, range 0–4375 vs 52.7, range 0–4200 and 53.4, range 0–3724 for Neurosurgery and Journal of Neurosurgery, respectively). This finding is consistent with the mission of World Neurosurgery to provide an “international forum” and “two-way dialogue” for neurosurgeons and those caring for neurosurgical patients.10 Once again, statistical analysis was not possible because of the high heterogeneity of the data. The breakdown of research productivity in these journals across continents is summarized in Fig. 2. Publication in these journals appears biased toward developed countries in North America, Europe, and Asia. Overall, we have been able to obtain and report interesting descriptive data regarding the types of research mandates imposed during training and/or prior to board certification via a global review of training curricula and requirements.

TABLE 1.

Summary of countries, with information regarding their geographic location and research output in three neurosurgical journals

No. of Publications
CountryContinentRegionWorld NeurosurgNeurosurgJ Neurosurg
AfghanistanAsiaSouth Asia000
AlbaniaEuropeBalkan Peninsula403
AlgeriaAfricaNorth Africa301
AngolaAfricaSouth-Central Africa100
Antigua & BarbudaNorth AmericaCaribbean000
ArgentinaSouth AmericaSouthern South America371921
ArmeniaEurasiaCaucasia100
AustraliaOceania140140117
AustriaEuropeCentral Europe756581
AzerbaijanEurasiaCaucasia100
BahamasNorth AmericaCaribbean000
BahrainAsiaGulf000
BangladeshAsiaSouth Asia501
BarbadosNorth AmericaCaribbean000
BelarusEuropeEastern Europe001
BelgiumEuropeWestern Europe6510075
BelizeNorth AmericaCentral America000
BeninAfricaWest Africa200
BhutanAsiaSouth Asia000
Bosnia & HerzegovinaEuropeBalkan Peninsula500
BotswanaAfricaSouth Africa000
BrazilSouth America234110103
Brunei DarussalamAsiaMaritime Southeast Asia000
BulgariaEuropeSoutheast Europe440
Burkina FasoAfricaWest Africa100
BurundiAfricaEast Africa000
Cabo VerdeAfricaWest Africa000
CambodiaAsiaSoutheast Asia1000
CameroonAfricaCentral Africa000
CanadaNorth America342570682
Cayman IslandsNorth AmericaCaribbean000
Central African RepublicAfricaCentral (Middle) Africa000
ChadAfricaNorth-Central Africa000
ChileSouth AmericaWestern South America3580
ChinaAsiaEast Asia1946235336
ColombiaSouth AmericaNorthern South America35148
ComorosAfricaEast Africa000
Costa RicaNorth AmericaCentral America010
Côte d’IvoireAfricaWest Africa001
CroatiaEuropeBalkan Peninsula1238
CubaNorth AmericaCaribbean210
CyprusEuropeMediterranean Basin400
Czech RepublicEuropeCentral Europe201633
Democratic People’s Republic of KoreaAsiaKorean Peninsula100
Democratic Republic of the CongoAfricaCentral Africa000
DenmarkEuropeScandinavia253136
DominicaNorth AmericaCaribbean100
Dominican RepublicNorth AmericaCaribbean202
EcuadorSouth AmericaWestern South America300
EgyptAfricaNortheast Africa921934
El SalvadorNorth AmericaCentral America000
Equatorial GuineaAfricaCentral (Middle) Africa000
EritreaAfricaEast Africa000
EstoniaEuropeNorthern Europe011
eSwatiniAfricaSouth Africa000
EthiopiaAfricaEast Africa1300
Federated States of MicronesiaOceaniaMicronesia000
FijiOceaniaMelanesia000
FinlandEuropeNorthern Europe10210653
FranceEurope273365366
GabonAfricaWest-Central Africa000
GeorgiaEurasiaCaucasia000
GermanyEuropeWestern Europe586754644
GhanaAfricaWest Africa400
GreeceEuropeBalkan Peninsula716161
GrenadaNorth AmericaCaribbean5875
GuatemalaNorth AmericaCentral America100
GuineaAfricaWest Africa000
Guinea-BissauAfricaWest Africa000
GuyanaSouth AmericaNorthern South America000
HaitiNorth AmericaCaribbean501
HondurasNorth AmericaCentral America300
HungaryEuropeCentral Europe171419
IcelandEuropeNorth Atlantic110
IndiaAsiaSouth Asia448121136
IndonesiaAsiaMaritime Southeast Asia1204
IranAsiaWest Asia1222236
IraqAsiaWest Asia610
IrelandEuropeBritish Isles221914
IsraelAsiaWest Asia149123124
ItalyEuropeSouthern Europe698432303
JamaicaNorth AmericaCaribbean000
JapanAsiaEastern Asia110812301685
JordanAsiaWestern Asia722
KazakhstanAsiaCentral Asia301
KenyaAfricaEast Africa1500
KiribatiOceaniaMicronesia000
KosovoEuropeBalkan Peninsula000
KuwaitAsiaArabian Peninsula822
KyrgyzstanAsiaCentral Asia000
Lao People’s Democratic RepublicAsiaMainland Southeast Asia000
LatviaEuropeNorthern Europe000
LebanonAsiaWestern Asia485647
LesothoAfricaSouth Africa000
LiberiaAfricaWest Africa000
LibyaAfricaNorth Africa010
LithuaniaEuropeNorthern Europe421
LuxembourgEuropeWestern Europe200
MadagascarAfricaEast Africa000
MalawiAfricaSoutheast Africa200
MalaysiaAsiaMaritime Southeast Asia1044
MaldivesAsiaSouth Asia000
MaliAfricaWest Africa000
MaltaEuropeMediterranean Basin000
Marshall IslandsOceaniaMicronesia000
MartiniqueNorth AmericaCaribbean000
MauritaniaAfricaNorthwest Africa000
MauritiusAfricaEast Africa000
MexicoNorth America1046158
MongoliaAsiaEast Asia301
MontenegroEuropeSoutheast Europe021
MoroccoAfricaNorth Africa2263
MozambiqueAfricaSoutheast Africa200
MyanmarAsiaMainland Southeast Asia300
NamibiaAfricaSouth Africa000
NauruOceaniaMicronesia000
NepalAsiaSouth Asia2001
New ZealandOceaniaPolynesia18149
NicaraguaNorth AmericaCentral America400
NigerAfricaWest Africa000
NigeriaAfricaWest Africa2425
North MacedoniaEuropeBalkan Peninsula040
NorwayEuropeScandinavian Peninsula558461
OmanAsiaArabian Peninsula201
PakistanAsiaSouth Asia3532
PalauOceaniaMicronesia000
PanamaNorth AmericaCentral America200
Papua New GuineaOceaniaMelanesia100
ParaguaySouth AmericaCentral South America000
PeruSouth AmericaWestern South America501
PhilippinesAsiaMaritime Southeast Asia907
Plurinational State of BoliviaSouth AmericaWestern South America401
PolandEuropeCentral Europe36916
PortugalEuropeIberian Peninsula17157
Puerto RicoNorth AmericaCaribbean10715
QatarAsiaArabian Peninsula502
Republic of KoreaAsiaKorean Peninsula25275100
Republic of MoldovaEuropeEastern Europe000
Republic of the CongoAfricaCentral Africa000
RomaniaEuropeBalkan Peninsula1825
Russian FederationEuropeEastern Europe61514
RwandaAfricaCentral Africa600
Saint Kitts & NevisNorth AmericaCaribbean000
Saint LuciaNorth AmericaCaribbean000
SamoaOceaniaPolynesia000
São Tomé and PríncipeAfricaWest Africa000
Saudi ArabiaAsiaArabian Peninsula711522
SenegalAfricaWest Africa100
SerbiaEuropeBalkan Peninsula1583
SeychellesAfricaEast Africa000
Sierra LeoneAfricaWest Africa000
SingaporeAsiaMaritime Southeast Asia322622
SlovakiaEuropeCentral Europe403
SloveniaEuropeSouthern Central Europe077
Solomon IslandsOceaniaMelanesia000
SomaliaAfricaEast Africa000
South AfricaAfricaSouth Africa273021
South SudanAfricaEast-Central Africa000
SpainEuropeSouthwestern Europe169110144
Sri LankaAsiaSouth Asia000
State of PalestineAsiaWestern Asia1300
SudanAfricaNortheast Africa300
SurinameSouth AmericaNortheastern South America000
SwedenEuropeScandinavian Peninsula53135149
SwitzerlandEuropeCentral Europe190134140
Syrian Arab RepublicAsiaWest Asia100
TajikistanAsiaCentral Asia000
TanzaniaAfricaEast Africa1311
ThailandAsiaMainland Southeast Asia2886
The GambiaAfricaWest Africa000
The NetherlandsEuropeNorthwest Europe123197192
Timor-LesteAsiaMaritime Southeast Asia000
TogoAfricaWest Africa000
TongaOceaniaPolynesia000
Trinidad & TobagoSouth AmericaCaribbean000
TunisiaAfricaNorth Africa1512
TurkeyEuropeEastern Europe281169158
TurkmenistanAsiaCentral Asia000
TuvaluOceaniaPolynesia000
UgandaAfricaEast Africa1236
UkraineEuropeEastern Europe001
United Arab EmiratesAsiaArabian Peninsula803
United KingdomEuropeBritish Isles237127273
United StatesNorth America437542003724
UruguaySouth AmericaSoutheastern South America303
UzbekistanAsiaCentral Asia100
VanuatuOceaniaMelanesia000
VenezuelaSouth AmericaNorthern South America110
VietnamAsiaIndochina Peninsula603
YemenAsiaArabian Peninsula000
ZambiaAfricaSouth-Central Africa000
ZimbabweAfricaSouth Africa200
J Neurosurg = Journal of Neurosurgery; Neurosurg = Neurosurgery; World Neurosurg = World Neurosurgery.The table is organized alphabetically by country.
TABLE 2.

Summary of research requirements and output for countries

No. of Publications
CountryContinentRegionRequirement TypeRequirement(s) or Comment(s)Requiring or Reporting AgencyWorld NeurosurgNeurosurgJ Neurosurg
BotswanaAfricaSouth AfricaSpecificComplete dissertationCOSECSA000
BurundiAfricaEast AfricaSpecificComplete dissertationCOSECSA000
EgyptAfricaNortheast AfricaSpecificMultiple degrees available to neurosurgeons, 1 pathway requires thesis defenseEgyptian Society of Neurological Surgeons921934
EthiopiaAfricaEast AfricaSpecificComplete thesisCOSECSA1300
GhanaAfricaWest AfricaSpecificComplete dissertationGhana College of Physicians & Surgeons400
KenyaAfricaEast AfricaSpecificComplete dissertationCOSECSA1500
MalawiAfricaSoutheast AfricaSpecificComplete dissertationCOSECSA200
MoroccoAfricaNorth AfricaSpecificUnspecified no. publications & presentationsWFNS Rabat Reference Center2263
MozambiqueAfricaSoutheast AfricaSpecificComplete dissertationCOSECSA200
NamibiaAfricaSouth AfricaSpecificComplete dissertationCOSECSA000
NigeriaAfricaWest AfricaSpecificComplete dissertationWest African College of Surgeon2425
RwandaAfricaCentral AfricaSpecificComplete dissertationCOSECSA600
South SudanAfricaEast-Central AfricaSpecificComplete dissertationCOSECSA000
SudanAfricaNortheast AfricaSpecificComplete dissertationCOSECSA300
TanzaniaAfricaEast AfricaSpecificComplete dissertationCOSECSA1311
UgandaAfricaEast AfricaSpecificComplete dissertationCOSECSA1236
ZambiaAfricaSouth-Central AfricaSpecificComplete thesis & 1 publicationSchool of Medicine, University of Zambia; COSECSA000
ZimbabweAfricaSouth AfricaSpecificComplete dissertationCOSECSA200
BahrainAsiaPersian GulfSpecificPublish 1 articleABNPE000
ChinaAsiaEast AsiaNoneNeurosurgical training standardized nationwide in 2015; will not be fully implemented till 2020; new program does not appear to have specific research requirements or provide dedicated research timeChinese Congress of Neurological Surgeons1946235336
IndiaAsiaSouth AsiaSpecificComplete dissertationMedical Council of India448121136
IraqAsiaWest AsiaSpecificPublish 1 articleABNPE610
JapanAsiaEastern AsiaSpecific>1 presentation & 1 publicationJapan Neurosurgical Society110812301685
JordanAsiaWestern AsiaSpecificPublish 1 articleABNPE722
KuwaitAsiaArabian PeninsulaSpecificRequired to take 3 mos dedicated research timeMinistry of Health, Kuwait822
LebanonAsiaWestern AsiaSpecificPublish 1 peer-reviewed article & 1 presentationABNPE485647
MalaysiaAsiaMaritime Southeast AsiaSpecificComplete thesisNeurosurgical Association of Malaysia1044
MyanmarAsiaMainland Southeast AsiaNoneNew surgical program in conjunction w/ Switzerland, but no mention of research in curriculumSwiss Neurosurgeons International300
PakistanAsiaSouth AsiaSpecificComplete independent research projectCollege of Physicians & Surgeons of Pakistan3532
QatarAsiaArabian PeninsulaSpecificPublish 1 articleABNPE502
Saudi ArabiaAsiaArabian PeninsulaSpecificPublish 1 articleABNPE711522
SingaporeAsiaMaritime Southeast AsiaPartialResearch principles must be taught, but no specific requirements on research projectsSpecialists Accreditation Board322622
Sri LankaAsiaSouth AsiaSpecificComplete dissertationPostgraduate Institute of Medicine000
Syrian Arab RepublicAsiaWest AsiaSpecificPublish 1 articleABNPE100
AlbaniaEuropeBalkan PeninsulaSpecificPresent research thesisSchool of Neurosurgery403
CroatiaEuropeBalkan PeninsulaPartialNDA on national requirements, but JRAAC accredited 2 neurosurgical programs in Croatia, & per JRAAC, residents must be trained on research methodology, but no specific requirementsJRAAC1238
Czech RepublicEuropeCentral EuropePartialNDA on national requirements, but JRAAC accredited 2 neurosurgical programs in Czech Republic, & per JRAAC, residents must be trained on research methodology, but no specific requirementsJRAAC201633
DenmarkEuropeScandinaviaPartialNDA on national requirements, but JRAAC accredited 1 neurosurgical program in Denmark, & per JRAAC, residents must be trained on research methodology, but no specific requirementsJRAAC253136
GermanyEuropeWestern EuropePartialNDA on national requirements, but JRAAC accredited 4 major neurosurgical programs in Germany, & per JRAAC, residents must be trained on research methodology, but no specific requirementsJRAAC586754644
IrelandEuropeBritish IslesSpecificPublish 1 peer-reviewed article & 1 presentationJoint Committee on Surgical Training221914
LithuaniaEuropeNorthern EuropePartialNDA on national requirements, but JRAAC accredited 1 neurosurgical program in Lithuania, & per JRAAC, residents must be trained on research methodology, but no specific requirementsJRAAC421
MaltaEuropeMediterranean BasinSpecificPublish 2 articles & conduct 2 clinical auditsSpecialist Accreditation Committee000
PolandEuropeCentral EuropePartialNDA on national requirements, but JRAAC accredited 1 neurosurgical program in Poland, & per JRAAC, residents must be trained on research methodology, but no specific requirementsJRAAC36916
PortugalEuropeIberian PeninsulaPartialNDA on national requirements, but JRAAC accredited 1 neurosurgical program in Portugal, & per JRAAC, residents must be trained on research methodology, but no specific requirementsJRAAC17157
Russian FederationEuropeEastern EuropeNoneNANA61514
SpainEuropeSouthwestern EuropeSpecificTraining on research methodology & involvement in research project resulting in presentation/publicationComisión Nacional de Neurocirugía169110144
TurkeyEuropeEastern EuropeSpecificComplete thesisTurkish Neurosurgical Society281169158
United KingdomEuropeBritish IslesSpecificResearch encouraged but no specific requirementsJoint Committee on Surgical Training237127273
CanadaNorth AmericaNoneNARoyal College of Physicians & Surgeons of Canada342570682
HaitiNorth AmericaCaribbeanNoneNAHaitian Ministry of Health, Hospital Bernard-Mevs/Project Medishare501
United StatesNorth AmericaNoneNAAmerican Board of Neurological Surgeons437542003724
AustraliaOceaniaSpecific1 presentation & 1 publicationNeurosurgical Society of Australasia140140117
New ZealandOceaniaPolynesiaSpecificPublish 1 article & 1 presentationNeurosurgical Society of Australasia18149
ColombiaSouth AmericaNorthern South AmericaNoneNANo centralized certification system35148
ABNPE = Arab Board of Neurosurgical Programs and Examinations; COSECSA = College of Surgeons of East, Central and Southern Africa; JRAAC = Joint Residency Advisory and Accreditation Committee; NA = not applicable; NDA = no data available; WFNS Rabat Reference Center = WFNS Rabat Reference Center for Training Young African Neurosurgeons.
FIG. 1.
FIG. 1.

Quantification of publications in World Neurosurgery, Neurosurgery, and Journal of Neurosurgery among countries detailing no research requirements, partial research requirements, or specific research requirements.

FIG. 2.
FIG. 2.

Quantification of publications in World Neurosurgery, Neurosurgery, and Journal of Neurosurgery across continents.

Discussion

The goal of our study was to identify and describe research requirements during neurosurgical training and/or prior to board certification across the globe. In addition, we sought to quantify research output across various nations via publication in 3 of the most prominent journals in the field: World Neurosurgery, Neurosurgery, and Journal of Neurosurgery. Notably, specific research requirements were identified in countries in Africa, Asia, Europe, and Oceania. Countries for which requirement information was available in North America and South America identified no mandatory research requirements. We did not find a positive correlation between the presence of a research requirement and research output, as may have been intuited. In fact, our rudimentary analysis suggested that countries lacking research requirements had higher rates of research productivity, although this analysis did not account for other factors such as density of neurosurgeons, size, etc. A similar result was shown in a recent analysis of American residency program research output, in which mandated research did not correlate with improved productivity.19 Authors of that study postulated that this finding may be attributable to a culture in which research is informally established in many of the high-output institutions, thereby making a requirement unnecessary. However, for programs seeking to establish the culture, such a requirement may be useful.

While some countries detail explicit requirements for research experience during neurosurgical training, such as a minimum number of publications or presentations, others make broad recommendations or requirements, with individual programs then determining their own explicit guidelines. This is characteristic of the United States, in which the American Board of Neurological Surgery encourages resident involvement in research, and individual programs make subsequent decisions about the requirement for, and the timing of, research within the training program.3 We discuss below the research requirements of selected countries across the continents mentioned above, with a focus on the types of requirements and the timing of research involvement during training, as available.

Africa

African countries specifying research requirements spanned the continent in terms of regional representation; however, the majority fell within Eastern, Central, and Southern Africa in territories under the purview of the COSECSA, which has been instrumental in the development and standardization of surgical training curricula in a variety of surgical subspecialties, including neurosurgery, throughout Sub-Saharan Africa. COSECSA currently represents 14 countries,7 although according to the most recently available data, accredited programs are only present in Kenya, Uganda, Tanzania, Ethiopia, Zambia, Rwanda, and Malawi.14,31 In the training guidelines established by COSECSA, trainees who have earned a doctorate in medicine are registered as members of the COS (MCS) after they complete 2 years of training and subsequently complete 4 years of training in neurosurgery, culminating in the Fellow of the COS (FCS) certification.6 Participation in research projects during this training period is expected, including completion of a dissertation14 and preparation of a presentation for an international surgical conference.6 Additionally, 1 non-thesis research paper must be submitted at least 3 months prior to sitting for the oral/clinical FCS examination.6 Individual programs within Africa have also implemented research requirements, including the newly developed University of Zambia School of Medicine Neurosurgery Training Program, developed in partnership with the University of Cambridge. This program, spanning 5 years and 3 stages (initial, intermediate, and final), requires registrars to complete a thesis for the Master of Medicine degree, with research beginning in the first 2 years and completed in the 3rd or 4th years. Publication of at least 1 peer-reviewed article is required prior to progression to the chief registrar year. During this final year, registrars take on additional scholarly responsibility including delivering student lectures and running morbidity and mortality conferences.30

Asia

Once again, the specification of research requirements traverses regional boundaries across the Asian continent. Within the Middle East and Gulf region, neurosurgical training and certification is overseen by the Arab Board of Neurosurgical Programs and Examinations and includes the countries of Iraq, Jordan, Bahrain, Saudi Arabia, Lebanon, Qatar, and Syria. In the 5th or 6th years of the training program, trainees take the final examination for certification including written, clinical, and oral portions. Prior to this examination, trainees must complete and publish 1 research project, as well as maintain a log of attendance at scientific sessions.4,14 Kuwait is one of the few countries whose Ministry of Health mandates the completion of a dedicated research period during neurosurgical training. This dedicated time occurs during the 3rd year of a 5-year program,20 resembling the timing of the research year that is typical of many programs within the United States. Japan is one of the most productive countries in neurosurgical research that utilizes a research requirement. The Japan Neurosurgical Society requires an individual to present at an academic conference more than once and write research papers, at least one of which must be accepted into a peer-reviewed journal to obtain eligibility for the board certification examination. Additionally, recertification is contingent upon continued scholarly work in the form of academic presentations and/or publications.16 According to our analysis, Japan ranks just second to the United States in research output in the American literature, suggesting that its requirements place an appropriate emphasis on lifelong scholarship, which translates into exceptional productivity. Notably, a similarly industrialized nation, China, bears no research requirement in its newly developed standardized training program, which is set for nationwide adoption by 2020. But a lack of flexibility in the training schedule, limiting the time for research and/or enfolded fellowships, is considered a limitation of this program.32 While China ranks highly at present in terms of research output, the impact of the program’s design may perturb this. Finally, in Singapore, while no specific requirements for research involvement exist, programs are required to teach principles of research within the training curriculum. Residents are encouraged to participate in scholarly activity, although this is undefined, and sponsoring institutions are encouraged to provide adequate resources for such involvement.29

Europe

The JRAAC is the central monitoring body for the field of neurosurgery within Europe and is a joint committee between the European Association of Neurosurgical Societies (EANS) and the European Union of Medical Specialists (UEMS). There are currently 16 JRAAC-accredited programs in Turkey, Germany, Czech Republic, Denmark, Lithuania, Poland, Spain, Portugal, and Croatia.11 Guidelines released from the UEMS in 2015 recommend that neurosurgical training programs provide training in research methodology, as well as the opportunity for protected research time during the 6-year training program.12 However, these recommendations do not represent explicit requirements for compulsory participation in research as a trainee. Despite the lack of requirements by this multinational organization, individual nations within Europe do maintain prerequisites for research participation during training. For example, in the United Kingdom (UK) and Republic of Ireland, where neurosurgical training is overseen by the Joint Committee on Surgical Training, research requirements are quite extensive: trainees must publish 1 peer-reviewed paper covering a laboratory experiment and a case series or systematic audit, as well as deliver 2 verbal presentations at national or international conferences, with attendance at a minimum of 4 conferences in total during training.17 Furthermore, in Albania, presentation of one’s research thesis is, in fact, a component of the final board-certifying examination.27

Oceania

Neurosurgical training in Australia and New Zealand is overseen by the Neurosurgical Society of Australasia, an organization founded in 2014, which currently boasts a membership of 95% of neurosurgeons within the 2 countries.25 The neurosurgical training program guided by the society involves 3 phases: basic, constituting 1–2 years; intermediate, constituting 2–3 years; and advanced, constituting 1–3 years. Research requirements are primarily restricted to the intermediate years including participation in the Critical Literature Evaluation and Research course and completion, presentation, and publication of an approved research project. In fact, prior to 2012, all trainees in neurosurgical training programs were required to complete a compulsory research year during the 4th year of training.26

Barriers to Trainee Research Involvement

Studies identifying barriers to resident/trainee research involvement have been conducted in several countries, identifying results similar to those within the United States: a lack of protected time for both trainees and faculty, a lack of mentorship, and unfamiliarity with research methodologies continue to be reported as the greatest obstacles.5,22 But research requirements that are instituted in environments conducive to research and offering the necessary training, resources, and protected time are likely to be more fruitful than similar requirements without the necessary support. International collaboration may provide an important avenue to enhance the research involvement of trainees from institutions without a strong research infrastructure, especially those within low- and middle-income countries. Various models for collaboration exist, often with the primary goal of enhancing clinical productivity within developing countries, although opportunities for involvement in research exist as well. One of the most common models involves integration of a visiting neurosurgeon within the department of a host institution for a short- or long-term fellowship, during which the visiting fellow trains in clinical and operative care while also participating in clinical research projects.2 Trainees can also seek involvement in research collaboratives by partnering their home countries with large international institutions. For example, the UK-based Global Health Research Group on Neurotrauma is conducting a multinational research project to identify optimal strategies for the management of patients with traumatic brain injury via partnership with countries throughout South America, Asia, and Africa.23

Study Limitations

This analysis represents a review of trainee research requirements across the globe via internet query of guidelines produced by certifying and/or accrediting bodies, as well as regional research productivity via advanced search of the PubMed database. We recognize that our study is limited in scope because of its third-person analysis of published requirements, rather than direct survey of individuals from the various nations. While we can comment on the presence or absence of documented guidelines or requirements, we cannot determine the way in which these requirements are enforced, nor how they are perceived by trainees and faculty. Additionally, our study is inherently biased toward English-language literature based on the restriction of our literature search to the PubMed database. Publication within the major peer-reviewed journals of the field is considered a gold standard for the dissemination of research. However, barriers to publication do exist, such as language differences and financial limitations. Various initiatives have been undertaken by neurosurgical publishers to promote access to neurosurgical literature by stakeholders across the world. As an example, the Neurosurgery Speaks program, undertaken by Neurosurgery, provides written and oral abstracts for dozens of publications translated into 10 different languages by native speakers.8 We also cannot fail to acknowledge the importance of international scholarly contributions outside of the peer-reviewed literature, including social media posts and digital teaching. The website Neurosurgical.TV (https://www.neurosurgical.tv/) provides a forum for hosting video conferences by neurosurgeons across the globe and is broadly shared across neurosurgery pages on social media platforms such as Facebook and Twitter. While these are not a substitute for the peer-review process, they are important modalities for improving international dissemination of neurosurgical research and knowledge. We anticipate that as social media continues to rise in prominence within neurosurgery and the field of medicine as a whole, tools for the assessment of scholarly productivity will adapt to account for such contributions.

Recommendations and Future Directions

Clinical experience must remain the focus of neurosurgical training to maintain the most appropriate care for patients. However, the importance of research and scholarship in establishing training programs and evolving care cannot be understated. Protected research time is common in training programs throughout developed countries, but is often reliant on an established research infrastructure. Thus, partnerships permitting integration of local trainees into the scholarly activities of an outside institution may circumvent a lack of resources in less-developed programs.28 Institutions in developed countries seeking to aid in global surgical efforts can effect some of the greatest changes by assisting in the development of local training programs, as has been accomplished via Duke University and Mulago Hospital in Uganda.13 Such efforts should include training in research methodologies and collaborative projects to characterize aspects of neurosurgical care in developing countries and assess the impact of any interventions that are instituted. Finally, we believe instituting a requirement can help establish research involvement in the culture of an institution and/or nation. Future prospective research in the form of surveys administered to trainees and faculty across the globe would provide a more direct assessment of the requirements and understanding of individuals’ personal experiences. We believe it is critical for such perspectives to be collected to inform efforts targeted at augmenting research productivity.

Conclusions

Overall, we found that research requirements during training or prior to board certification are common in neurosurgical programs across the globe as an incentive to contribute novel knowledge to the field while maintaining research productivity and academic standing. These requirements vary in intensity and timing during training, ranging from exposure to research methodology or critical literature evaluation to completion of a thesis and publication in a peer-reviewed journal. While our analysis is quite limited, we failed to demonstrate a correspondence between the presence of requirements and research output. We hope that this study will provide a set of novel preliminary data through which the global neurosurgery community can begin to systematically assess the importance of research participation throughout the spectrum of neurosurgical training.

Acknowledgments

We would like to acknowledge the incredible work of all neurosurgical educators who are working tirelessly to ensure the continued growth of our specialty and the delivery of optimal care to our patients across the globe.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Nanda, Rallo, Ashraf. Acquisition of data: Rallo, Ashraf, Jumah. Analysis and interpretation of data: Rallo, Ashraf, Gupta. Drafting the article: Rallo, Ashraf, Jumah, Gupta. Critically revising the article: Nanda, Rallo, Jumah, Gupta. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Nanda. Statistical analysis: Rallo. Administrative/technical/material support: Nanda. Study supervision: Nanda, Gupta.

References

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    Clancy AAPosner G: Attitudes toward research during residency: a survey of Canadian residents in obstetrics and gynecology. J Surg Educ 72:8368432015

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    Elkbuli ANarvel RIZajd SHai SMcKenney MBoneva D: Factors affecting research productivity of burn surgeons: results from a survey of American Burn Association members. J Burn Care Res [epub ahead of print] 2019

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    Elsevier: World Neurosurgery. Elsevier.com (https://www.journals.elsevier.com/world-neurosurgery) [Accessed January 20 2020]

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    European Union of Medical Specialists Section of Neurosurgery: European Training Requirements for the Specialty of Neurosurgery. (https://www.uems.eu/__data/assets/pdf_file/0007/44449/uems-2015.34-european-training-requirements-in-neurosurgery.pdf) [Accessed January 20 2020]

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    Fuller ATran TMuhumuza MHaglund MM: Building neurosurgical capacity in low and middle income countries. eNeurologicalSci 3:162015

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    Gasco JBarber SMMcCutcheon IEBlack PM: Neurosurgery certification in member societies of the WFNS: Africa and the Middle East. World Neurosurg 76:182754–56 2011

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    Gasco JBarber SMMcCutcheon IEBlack PM: Neurosurgery certification in member societies of the WFNS: global overview. World Neurosurg 76:2312382011

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    Japan Neurosurgical Society: Regulations for the Board Certification System. (http://jns.umin.ac.jp/english/board-regulations) [Accessed January 20 2020]

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    Joint Committee on Surgical Training: Certification guidelines for neurosurgery. (https://www.jcst.org/-/media/files/jcst/certification-guidelines-and-checklists/certification-guidelines--ns-2017-final.pdf) [Accessed January 20 2020]

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    Kashkoush APrabhu AVTonetti DAgarwal N: The Neurosurgery Match: a bibliometric analysis of 206 first-year residents. World Neurosurg 105:3413472017

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    • Export Citation
  • 19

    Khan NRSaad HOravec CSNorrdahl SPFraser BWallace D: An analysis of publication productivity during residency for 1506 neurosurgical residents and 117 residency departments in North America. Neurosurgery 84:8578672019

    • Search Google Scholar
    • Export Citation
  • 20

    Kuwait Ministry of Health: Kuwait Institute for Medical Specialization Neurosurgery Residency Program. (http://kims.org.kw/pge/uploads/pdf/pdf-1252469562.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 21

    Mansi AKaram WNChaaban MR: Attitudes of residents and program directors towards research in otolaryngology residency. Ann Otol Rhinol Laryngol 128:28352019

    • Search Google Scholar
    • Export Citation
  • 22

    Nair SCIbrahim HAlmarzoqi FAlkhemeiri ASreedharan J: Addressing research barriers and facilitators in medical residency. J Family Med Prim Care 8:114511502019

    • Search Google Scholar
    • Export Citation
  • 23

    National Institute for Health Research: Global Health Research Group on Neurotrauma. Neurotrauma.world (http://neurotrauma.world/about) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 24

    National Resident Matching Program: Charting Outcomes in the Match: U.S. Allopathic Seniors. (https://www.nrmp.org/wp-content/uploads/2018/06/charting-outcomes-in-the-match-2018-seniors.pdf) [Accessed October 17 2019]

    • Search Google Scholar
    • Export Citation
  • 25

    Neurosurgical Society of Australasia: About us. NSA.org.au (https://nsa.org.au/nsa/about_us/nsa/) [Accessed January 20 2020)

  • 26

    Neurosurgical Society of Australasia: Regulations for the Surgical Education and Training Program in Neurosurgery. (https://www.nsa.org.au/documents/neurosurgial%20training/regulations%20training%20program.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 27

    Omerhodzic ITonge MMatos BMusabeliu ERaspanti CFerdinandov D: Neurosurgical training programme in selected European countries: from the young neurosurgeons’ point of view. Turk Neurosurg 22:2862932012

    • Search Google Scholar
    • Export Citation
  • 28

    Servadei FRossini ZNicolosi FMorselli CPark KB: The role of neurosurgery in countries with limited facilities: facts and challenges. World Neurosurg 112:3153212018

    • Search Google Scholar
    • Export Citation
  • 29

    Singapore Ministry of Health: Specialists Accreditation Board Neurosurgery Residency Training Requirements. (https://www.healthprofessionals.gov.sg/docs/librariesprovider9/downloads/neurosurgery-residency-training-requirements-(as-@-14-sept-18).pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 30

    University of Zambia School of Medicine: Proposal for Neurosurgery Training Programme. (http://neurotrauma.world/wp-content/uploads/2018/07/proposal-for-neurosurgery-training-programme_v2.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 31

    World Federation of Neurosurgical Societies: Criteria of The C-CNS-ECSAR WFNS Reference Center. WFNS.org (https://www.wfns.org/training-centers/37/) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 32

    Xu TEvins AILin NChang JHu GHou L: Neurosurgical postgraduate training in China: moving toward a national training standard. World Neurosurg 96:4104162016

    • Search Google Scholar
    • Export Citation

If the inline PDF is not rendering correctly, you can download the PDF file here.

Article Information

Contributor Notes

Correspondence Anil Nanda: Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ. an651@rwjms.rutgers.edu.INCLUDE WHEN CITING DOI: 10.3171/2019.12.FOCUS19856.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
Headings
Figures
  • View in gallery

    Quantification of publications in World Neurosurgery, Neurosurgery, and Journal of Neurosurgery among countries detailing no research requirements, partial research requirements, or specific research requirements.

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    Quantification of publications in World Neurosurgery, Neurosurgery, and Journal of Neurosurgery across continents.

References
  • 1

    Accreditation Council for Graduate Medical Education: Program Requirements for Graduate Medical Education in Neurological Surgery. (https://www.acgme.org/portals/0/pfassets/programrequirements/160_neurologicalsurgery_2019.pdf?ver=2019-06-20-114304-737) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 2

    Almeida JPVelásquez CKarekezi CMarigil MHodaie MRutka JT: Global neurosurgery: models for international surgical education and collaboration at one university. Neurosurg Focus 45(4):E52018

    • Search Google Scholar
    • Export Citation
  • 3

    American Board of Neurological Surgery: ABNS Training Requirements. (https://www.abns.org/wp-content/uploads/2019/08/abns-training-requirements.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 4

    Arab Board of Health Specializations: Neurosurgery Logbook SummaryFebuary 2018. (http://arab-board.org/sites/default/files/neurosurgery%20logbook%202018.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 5

    Clancy AAPosner G: Attitudes toward research during residency: a survey of Canadian residents in obstetrics and gynecology. J Surg Educ 72:8368432015

    • Search Google Scholar
    • Export Citation
  • 6

    College of Surgeons of East Central and South Africa: Training Curriculum: Fellowship in General Surgery 2019. (http://www.cosecsa.org/sites/default/files/fcs%20gs%20curriculum%20final.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 7

    College of Surgeons of East Central and South Africa: What is COSECSA? COSECSA.org (http://www.cosecsa.org/about/what-cosecsa) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 8

    Congress of Neurological Surgeons: Neurosurgery Speaks! Neurosurgery. (https://academic.oup.com/neurosurgery/pages/neurosurgeryspeaks) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 9

    Elkbuli ANarvel RIZajd SHai SMcKenney MBoneva D: Factors affecting research productivity of burn surgeons: results from a survey of American Burn Association members. J Burn Care Res [epub ahead of print] 2019

    • Search Google Scholar
    • Export Citation
  • 10

    Elsevier: World Neurosurgery. Elsevier.com (https://www.journals.elsevier.com/world-neurosurgery) [Accessed January 20 2020]

  • 11

    European Association of Neurosurgical Societies: JRAAC accredited units. EANS.org (https://www.eans.org/page/jraac-units) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 12

    European Union of Medical Specialists Section of Neurosurgery: European Training Requirements for the Specialty of Neurosurgery. (https://www.uems.eu/__data/assets/pdf_file/0007/44449/uems-2015.34-european-training-requirements-in-neurosurgery.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 13

    Fuller ATran TMuhumuza MHaglund MM: Building neurosurgical capacity in low and middle income countries. eNeurologicalSci 3:162015

    • Search Google Scholar
    • Export Citation
  • 14

    Gasco JBarber SMMcCutcheon IEBlack PM: Neurosurgery certification in member societies of the WFNS: Africa and the Middle East. World Neurosurg 76:182754–56 2011

    • Search Google Scholar
    • Export Citation
  • 15

    Gasco JBarber SMMcCutcheon IEBlack PM: Neurosurgery certification in member societies of the WFNS: global overview. World Neurosurg 76:2312382011

    • Search Google Scholar
    • Export Citation
  • 16

    Japan Neurosurgical Society: Regulations for the Board Certification System. (http://jns.umin.ac.jp/english/board-regulations) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 17

    Joint Committee on Surgical Training: Certification guidelines for neurosurgery. (https://www.jcst.org/-/media/files/jcst/certification-guidelines-and-checklists/certification-guidelines--ns-2017-final.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 18

    Kashkoush APrabhu AVTonetti DAgarwal N: The Neurosurgery Match: a bibliometric analysis of 206 first-year residents. World Neurosurg 105:3413472017

    • Search Google Scholar
    • Export Citation
  • 19

    Khan NRSaad HOravec CSNorrdahl SPFraser BWallace D: An analysis of publication productivity during residency for 1506 neurosurgical residents and 117 residency departments in North America. Neurosurgery 84:8578672019

    • Search Google Scholar
    • Export Citation
  • 20

    Kuwait Ministry of Health: Kuwait Institute for Medical Specialization Neurosurgery Residency Program. (http://kims.org.kw/pge/uploads/pdf/pdf-1252469562.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 21

    Mansi AKaram WNChaaban MR: Attitudes of residents and program directors towards research in otolaryngology residency. Ann Otol Rhinol Laryngol 128:28352019

    • Search Google Scholar
    • Export Citation
  • 22

    Nair SCIbrahim HAlmarzoqi FAlkhemeiri ASreedharan J: Addressing research barriers and facilitators in medical residency. J Family Med Prim Care 8:114511502019

    • Search Google Scholar
    • Export Citation
  • 23

    National Institute for Health Research: Global Health Research Group on Neurotrauma. Neurotrauma.world (http://neurotrauma.world/about) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 24

    National Resident Matching Program: Charting Outcomes in the Match: U.S. Allopathic Seniors. (https://www.nrmp.org/wp-content/uploads/2018/06/charting-outcomes-in-the-match-2018-seniors.pdf) [Accessed October 17 2019]

    • Search Google Scholar
    • Export Citation
  • 25

    Neurosurgical Society of Australasia: About us. NSA.org.au (https://nsa.org.au/nsa/about_us/nsa/) [Accessed January 20 2020)

  • 26

    Neurosurgical Society of Australasia: Regulations for the Surgical Education and Training Program in Neurosurgery. (https://www.nsa.org.au/documents/neurosurgial%20training/regulations%20training%20program.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 27

    Omerhodzic ITonge MMatos BMusabeliu ERaspanti CFerdinandov D: Neurosurgical training programme in selected European countries: from the young neurosurgeons’ point of view. Turk Neurosurg 22:2862932012

    • Search Google Scholar
    • Export Citation
  • 28

    Servadei FRossini ZNicolosi FMorselli CPark KB: The role of neurosurgery in countries with limited facilities: facts and challenges. World Neurosurg 112:3153212018

    • Search Google Scholar
    • Export Citation
  • 29

    Singapore Ministry of Health: Specialists Accreditation Board Neurosurgery Residency Training Requirements. (https://www.healthprofessionals.gov.sg/docs/librariesprovider9/downloads/neurosurgery-residency-training-requirements-(as-@-14-sept-18).pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 30

    University of Zambia School of Medicine: Proposal for Neurosurgery Training Programme. (http://neurotrauma.world/wp-content/uploads/2018/07/proposal-for-neurosurgery-training-programme_v2.pdf) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 31

    World Federation of Neurosurgical Societies: Criteria of The C-CNS-ECSAR WFNS Reference Center. WFNS.org (https://www.wfns.org/training-centers/37/) [Accessed January 20 2020]

    • Search Google Scholar
    • Export Citation
  • 32

    Xu TEvins AILin NChang JHu GHou L: Neurosurgical postgraduate training in China: moving toward a national training standard. World Neurosurg 96:4104162016

    • Search Google Scholar
    • Export Citation
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