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DOI: 10.1055/a-2603-9438
Adjunct Training for Neurosurgeons from Low- and Middle-income Countries: A Scoping Review and Survey
Abstract
Essential surgical care for individuals in low- and middle-income countries (LMICs) is lacking, particularly in neurosurgery. Despite global demand, neurosurgical trainees in LMICs face obstacles that include lack of funding, resources, educational opportunities, and clinical exposure. Supplemental education in the form of international fellowships, observerships, exchange programs, mission trips, and online courses can mitigate the gaps in neurosurgical training in LMICs. This scoping review explored existing global opportunities for supplemental neurosurgery training. Structured observership programs, international fellowships, international rotations, and online training modalities available to neurosurgical trainees in LMICs were compiled through a database and literature search. Additionally, international observers at Barrow Neurological Institute were surveyed to assess the effect of observership experiences on their clinical training. A comprehensive list of global opportunities was created, and seven categories of adjunct neurosurgical training for neurosurgeons from LMIC countries were identified: mission trips (n = 9), bidirectional exchange programs (n = 3), fellowships/in-person training (n = 26), observerships (n = 27), virtual training (n = 8), scholarships (n = 4), and international opportunities for US-based neurosurgery residents (n = 10). Survey results from the Barrow Neurological Institute observership program showed that 58 of 89 (65%) respondents found the experience “added a lot of value” to their clinical training, whereas 28 (31%) deemed the experience “indispensable.” Additionally, 67 of 94 (71%) reported increased comfort with complex cases. Participants cited increased clinical experience, mentorship, leadership, networking, and research as among the skills and opportunities gained. Supplemental neurosurgical training for LMICs offers substantial benefits by mitigating gaps in clinical training and improving skills and confidence.
Introduction
Substantial progress has been made in addressing many facets of the global health agenda. However, global access to safe and affordable surgical care remains problematic. Approximately 18.6 million people die each year due to a lack of essential surgical care.[1] This deficit in care is especially prominent in the field of neurosurgery. Each year, 5 million essential neurosurgical cases in low- and middle-income countries (LMICs) go unperformed.[1] To address this deficit, it is estimated an additional 23,000 neurosurgeons are needed globally.[2] The growing need for global neurosurgical care underscores the importance of improving training opportunities for neurosurgeons in LMICs.
Despite the urgent demand, there are significant obstacles in current education and training models for neurosurgeons in LMICs. The number of neurosurgical trainees is disproportionately low in LMICs compared with high-income countries (HICs), and neurosurgical trainees in LMICs often lack access to essential resources and training opportunities.[3] This deficit is attributed to a lack of funding, poor access to resources, few supplemental educational opportunities, limited subspecialty training, and disorganized training structures.[4] [5] [6] On average, trainees in low-income countries (LICs) have less access to training in neurotrauma, neurocritical care, tumor, open vascular, endovascular, functional, pediatric, spine, and peripheral nerve surgery than those in upper-middle-income countries and lower-middle-income countries.[3] Additionally, many LMICs lack the clinical resources (e.g., ventriculoperitoneal shunts, microscopes, angiography, neuronavigation) necessary to treat common neurosurgical pathologies.[7] [8] Furthermore, neurosurgical training years, work hours, case volume, and training structure vary greatly globally.[9] [10] The deficits in training in low-resource settings manifest as decreased confidence in medical decision-making, understanding of surgical indications, and preparedness for handling future cases.[6] [11]
To address the challenges of neurosurgical training in low-resource settings, adjuncts to neurosurgical education exist in the form of collaborative medical missions, bidirectional exchange programs, international fellowships, observerships, and online courses. In the past, medical missions have been the most common form of global surgical collaboration, but in recent years, they have been scrutinized for their short-term effect, inconsistent postoperative follow-up, and limited ability to expand local capacity for future care.[12] [13] For these reasons, efforts have shifted to long-term collaborations that can increase local capacity to address neurosurgical disease through adjunct neurosurgical training for LMICs.[14]
Three main approaches are used to improve long-term capacity for neurosurgical care: annual international rotations for US-based neurosurgery residents, fellowships or observerships, and online courses. International rotations for US residents have been shown to provide mutual benefit for both the visiting surgeons and host countries.[15] [16] [17] [18] International fellowships offer visiting neurosurgeons from LMICs the opportunity to train in high-volume, resource-rich settings to conduct research, use cadaver laboratories, and enroll in courses to develop microsurgical, research, and clinical expertise that can be applied in their home country upon return.[12] [19] Structured observership programs effectively allow participants to observe the treatment of complex pathologies to improve their understanding of neuroanatomy and microsurgical approaches, while witnessing how research can be integrated into clinical practice.[20] [21] [22] Finally, online training modalities can be used as stand-alone programs or in tandem with in-person experiences to build and maintain long-term relationships for continued mentorship and education.[12] [23] [24] Online training programs are well received by participants and have demonstrated the potential to improve situational awareness and procedural knowledge while being inexpensive and accessible.[6] [19] [25]
The objective of this study is to explore the currently available global opportunities for supplemental clinical training. Additionally, we surveyed international observers at Barrow Neurological Institute (BNI) St. Joseph’s Hospital and Medical Center, Phoenix, AZ, United States to assess the effect of an observership experience on their clinical training.
Methods
This study employs a five-stage framework for scoping reviews as originally outlined by Arksey and O'Malley.[26] In addition, we conducted a survey targeting participants from the visiting scholar and neuroscience observer program at BNI to assess the effect of their experience. Institutional review board approval was not obtained due to the retrospective nature of the study.
Stage 1: Identifying the Research Question
The central research question for our scoping review was what opportunities are available to neurosurgeons in LMICs to supplement deficits in their training and career development. We identified various forms of supplemental training opportunities, including mission trips, bidirectional exchange programs, observerships, online and in-person courses, fellowships, and international rotations for US-based residents that function to improve training.
Stage 2: Identifying Relevant Studies
Relevant studies were identified using four electronic databases: PubMed, Embase, Web of Science, and Scopus. The search criteria related to “neurosurgery,” “rotations,” “observerships,” “international rotations,” and “global health.” All database searches were conducted on August 6, 2024. Detailed search terms and filters used for each database are provided in Appendix A.
Next, we conducted a gray literature search using Google to identify supplemental training opportunities described outside traditional academic literature, using the same keywords described above.
Finally, we used the Web sites of the 115 US neurological surgery residency programs to determine the presence of global neurosurgery mission trips and international rotations available at each program.
Stage 3: Study Selection
Only English-language articles were included. Inclusion criteria encompassed any mention of adjunct training opportunities for LMIC neurosurgeons. Articles were reviewed, and those with any mention of adjunct neurosurgical training for neurosurgeons from LMICs were included. Web sites with information relevant to adjunct neurosurgical training for neurosurgeons from LMICs were also included. Exclusion criteria were any Web site or article that did not mention adjunct training specifically for LMIC neurosurgeons or was not available in the English language.
A master list of opportunities was created, logging the organization providing the program, the recipient program or country, a description of the program offered, and a link to the article or Web site where the program was identified. This list was reviewed by two authors (B.W.P., C.E.) to determine its eligibility according to the inclusion and exclusion criteria outlined above.
Stage 4: Charting the Data
Seven categories of adjunct neurosurgical training emerged from the master list: observerships, fellowships, mission trips, bidirectional exchange programs, online and in-person courses, international rotations for US-based residents, and scholarships. Each opportunity from the master list was categorized as belonging to one of these seven categories. Programs offering more than one type of training opportunity (e.g., observership and fellowship) were counted in more than one category. This categorization scheme was designed to facilitate ease of reference for specific types of training opportunities.
Stage 5: Collating, Summarizing, and Reporting the Results
We employed a qualitative approach to collate and summarize our data to effectively address our research question. The focus was on opportunities for LMIC neurosurgeons, and the data were organized to serve as a practical reference for this population. A map was created to visualize the global distribution of adjunct training programs, and the available supplemental training opportunities for LMIC neurosurgeons were organized in tables.
Survey Distribution
The visiting scholar and neuroscience observer program at BNI hosts dozens of international neurosurgeons annually. The program allows for a short-term (weeks to months) site visit during which observers attend daily teaching rounds, have video conferences, observe in the operating room, and interact with faculty and residents. Formally, this program allows only observerships, rather than traditional fellowships. In 2023, a survey was distributed using email contacts on file dating back to 2006. After the survey was initially sent out, three follow-up reminders were sent, once every 2 weeks. Additionally, individualized emails were sent to observers who had not yet responded to improve the response rate and reduce potential bias. Their responses to questions regarding the effect of the observership on their clinical practice were included in this study. The full methods and results of the survey are reported by Rafka et al.[27]
Results
A total of 129 publications were initially retrieved following the database search. Of these, 28 were duplicates and were removed, leaving 101 articles. An additional 81 articles were excluded following title and abstract screening. Full-text screening was done in 20 publications.
In this scoping review, we identified seven categories of adjunct neurosurgical training for neurosurgeons from LMIC countries: mission trips, bidirectional exchange programs, fellowships or in-person training, observerships, virtual training, scholarships, and international opportunities for US-based neurosurgery residents.
[Fig. 1] displays the global distribution of supplemental training opportunities for LMIC neurosurgeons. Programs with more than one location per country for an individual type of training (e.g., mission trip, fellowship) are represented with a single pin. Programs with highly variable locations were excluded from the figure.
We then compiled a list of available adjunct neurosurgical training categorized by opportunity type ([Table 1]). We found 14 programs conducting neurosurgical mission trips, 5 programs conducting bidirectional exchange programs, 26 fellowships or in-person training opportunities, 28 programs offering international neurosurgical observership programs, 11 organizations offering virtual training opportunities, and 5 scholarships for LMIC neurosurgeons.
Abbreviations: AANS, American Association of Neurological Surgeons; EANS, European Association of Neurosurgical Societies; LMIC, low- and middle-income country; NA, not available.
[Table 2] lists 11 international neurosurgical experiences available for US-based residents. The experiences include both HIC and LMIC locations. The experiences range from 1 week to 20 months.
Abbreviations: LMIC, low- and middle-income country; NA, not available; PGY, postgraduate year.
Survey Results
A survey was conducted of former participants in the BNI observership program to evaluate the perceived value, effect on practice, and skills acquired from the observership experience. The survey was emailed to 686 former observers, and responses were received from 94 (13.7%) ([Table 3]).
Note: Data are presented as no. (%) of respondents.
Value of Observership
Most respondents reported significant benefit from the observership experience. Regarding the value of the observership, 28 of 89 (31%) respondents endorsed the experiences as “indispensable,” 58 (65%) endorsed “added a lot of value,” 2 (2%) endorsed “added a little value,” and 1 (1%) endorsed “did not add any value.”
Effect on Practice
In regard to the impact the observership had on respondents' clinical neurosurgical practice, 67 of 94 (71%) respondents endorsed “increased comfort with complex cases,” 36 (38%) endorsed “able to treat new pathologies,” 30 (32%) endorsed “higher case volume,” 33 (35%) endorsed improved outcomes, 12 (14%) endorsed “decreased referrals to outside institutions,” and 26 (28%) endorsed “reduced complications.”
Skills and Opportunities Gained
Respondents reported acquiring new skills and opportunities following their observership experience, including 77 of 94 (82%) respondents endorsing increased clinical experience, 36 (38%) endorsing increased mentorship, 30 (32%) endorsing increased leadership, 44 (47%) endorsing increased networking, and 39 (41%) endorsing increased research. Furthermore, an additional 3 (3%) respondents indicated gaining other skills, including teamwork, operative techniques, and new perspectives.
Discussion
This scoping review is, to our knowledge, the first effort to collate supplemental training opportunities for neurosurgeons from LMICs. We aimed to address the void in the literature regarding adjunct neurosurgical training for surgeons from LMICs. We identified seven categories for supplemental LMIC neurosurgical training: observerships, fellowships, mission trips, bidirectional exchange programs, online and in-person courses, international rotations for US-based residents, and scholarships. These opportunities can be grouped as in-person training in HICs for LMIC neurosurgeons, HIC neurosurgeons visiting LMIC neurosurgery programs, and virtual online training courses.
In-person training for LMIC neurosurgeons in HICs is most available in the form of international observerships and fellowships. Despite not permitting direct patient contact, observerships offer significant benefit to visiting neurosurgeons. International surgical observerships are associated with a perceived expansion of knowledge, improved clinical decision-making, and improved operative skill.[28] [29] [30] In our survey of former participants in the BNI observership program, respondents endorsed increased comfort with complex cases, improved ability to treat complex pathologies, and reduced complications upon return to their home institution ([Table 3]). Additionally, more than one-third of former BNI observers who responded to the survey reported increased mentorship following their experience ([Table 3]). The mentorship relationships formed during an observership experience are critical for long-term collaboration and may be maintained through virtual and online platforms. Several barriers restrict access to observership experiences, including financial constraints, challenges with transportation and housing, cultural differences, and limited institutional funding and support.[28] [29] Additionally, obtaining a US visa can be difficult, and US licensure regulations further limit observers' ability to directly interact with patients.[30] Similarly, fellowships offer the benefit of direct patient care within a high-resource, academic setting. Fellowships provide increased exposure to the treatment of complex pathologies, access to cadaver laboratories, and access to research.[4] [5] [6] [7] [8] Following a fellowship experience, trainees can apply their additional training to address the burden of neurosurgical disease in their country of origin.[12] [19] One potential drawback of training opportunities for LMIC neurosurgeons in HICs is known as the “brain drain.” The “brain drain” describes the danger of LMIC physicians being drawn away from their country of origin after training in a HIC due to greater political stability, better quality of life, and other external factors.[31] However, it is believed that this effect is more closely related to residency training programs in HICs and less prevalent for international physicians seeking fellowships in HICs.[12] Furthermore, the “brain drain” effect may be mitigated by increasing training opportunities for physicians in LMICs.[32] [33]
Clinical collaborations between HIC and LMIC neurosurgeons have a positive effect on both the visiting and host neurosurgeons. These supplemental training opportunities can take the form of mission trips, bidirectional exchange programs, and international rotations for US-based residents. International rotations for US residents provide the opportunity to lead a neurosurgery service and function as a chief resident with the appropriate supervision from local senior physicians.[34] [35] Functioning as a chief resident, US residents may see an increased case volume, experience increased exposure to less common pathologies, and gain proficiency with the fundamentals of surgery without reliance on advanced operative technology.[34] [35] Conversely, host neurosurgeons benefit from the transfer of knowledge and resources between visiting neurosurgeons. A collaborative relationship focused on education can ensure long-term improvements in the care provided by host neurosurgeons following the mission, exchange, or international rotation.[12] For example, the Duke Global Neurosurgery and Neurology division partnered with Mulago and Mbarrara Hospitals in Uganda to implement a local residency program and expand capacity. In the 2 years following the implementation of Duke's structure, the New Mulago Hospital doubled the annual case volume of its neurosurgeons without the assistance of visiting neurosurgeons.[16] Duke has demonstrated what is possible with long-term collaboration between HIC neurosurgeons in LMICs by focusing on building lasting infrastructure and the transfer of knowledge.
The infrastructure for long-term collaboration, time constraints, expenses, and accessibility are limiting factors in international educational opportunities for LMIC neurosurgeons in training. One of the most promising solutions to these barriers is the implementation of online resources.[12] [23] Organizations like the Seattle Science Foundation offer free supplemental educational courses that can buttress neurosurgical training in low-resource settings.[36] With a global increase in internet access, virtual training courses offer an attractive value proposition for training in low-resource settings. Virtual neurosurgical training is cost effective, is accessible, and has been shown to improve surgeons' situational awareness and procedural knowledge.[6] [19] [24] [25] Furthermore, the COVID-19 pandemic has promoted further use of virtual platforms for international collaboration to help facilitate mentorship in an unprecedented manner. InterSurgeon is one example of an online platform being used by many global neurosurgery partners to connect surgeons internationally.[37] [38] Online opportunities can be leveraged by surgeons globally to seek additional training and get connected with surgeons internationally. The long-term benefits of virtual training opportunities compared with in-person programs remain unclear; however, virtual education is generally recommended as a complement to periodic in-person training. It is thought that periodic in-person training can strengthen trainee–educator relationships, reduce attrition, and ensure consistent content delivery and progress tracking.[6] [12] Additionally, the sustainability of virtual training may be challenged by the ongoing time commitment, long-term funding requirements, and the need for strong institutional support from coordinating training centers.[6] [12] However, the recent rise of dedicated neurosurgery training paths in HICs may help address these challenges by providing more structured time and funding.[6]
Limitations
The opportunities available to LMIC neurosurgeons were found through a systematic literature search and gray literature search. There is no unified reference for the opportunities available. For this reason, more adjunct training for LMIC neurosurgeons may be available that is not directly advertised through Web sites or academic literature. We contacted leaders in global neurosurgery to minimize any omissions. Our survey captures subjective outcomes of the BNI observership experience. We did not have access to pre- and postperformance metrics of observers at the BNI. The survey may be subject to response bias because only 94 of 686 former observers responded.
Conclusion
Opportunities for supplemental training for neurosurgeons from LMICs are available in multiple forms, each with distinct benefits and limitations. This article is aimed to assist LMIC neurosurgeons searching for additional training opportunities. Further research may be done to determine the effectiveness of supplemental training opportunities for LMIC neurosurgeons. One area of interest may be conducting outcome analysis for LMIC neurosurgeons before and after supplemental neurosurgery training to determine the relationship between the type of additional training and operative outcomes.
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PubMed (August 6, 2024):
-
((“neurosurgery”[All Fields] OR “neurological surgery”[All Fields]) AND (“international rotations”[All Fields] OR “observerships”[All Fields] OR “clinical observerships”[All Fields] OR “international training”[All Fields] OR “global health rotations”[All Fields] OR “exchange programs”[All Fields])) AND ((ffrft[Filter]) AND (english[Filter]))
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Embase (August 6, 2024):
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(“neurosurgery training” OR “neurological surgery”/exp OR “neurological surgery”) AND (“international rotation” OR “observership” OR “clinical observership” OR “international training” OR “global health rotation” OR “exchange program”)
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Web of Science (August 6, 2024):
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TS = (“neurosurgery” OR “neurological surgery”) AND TS = (“international rotations” OR “observerships” OR “clinical observerships” OR “international training” OR “global health rotations” OR “exchange programs”)
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Scopus (August 6, 2024):
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(TITLE-ABS-KEY (“neurosurgery” OR “neurological surgery”)) AND (TITLE-ABS-KEY (“international rotations” OR “observerships” OR “clinical observerships” OR “international training” OR “global health rotations” OR “exchange programs”))
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Total articles from four databases: 129 articles
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Duplicates removed: 28 articles
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No. of articles for title and abstract screening: 101 articles
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No. of articles excluded: 81 articles
No. of articles for full text screening: 20 articles
Conflict of Interest
None declared.
Acknowledgment
We thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.
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References
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Publication History
Article published online:
19 July 2025
© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
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References
- 1 Park KB, Johnson WD, Dempsey RJ. Global neurosurgery: the unmet need. World Neurosurg 2016; 88: 32-35
- 2 Dewan MC, Rattani A, Fieggen G. et al; Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. Global neurosurgery: the current capacity and deficit in the provision of essential neurosurgical care. J Neurosurg 2018; 130 (04) 1055-1064
- 3 Gupta S, Gal ZT, Athni TS. et al; WFNS Global Neurosurgery Committee, EANS Global and Humanitarian Neurosurgery Committee, CAANS Executive Leadership Committee. Mapping the global neurosurgery workforce. Part 2: Trainee density. J Neurosurg 2024; 141 (01) 10-16
- 4 Cadotte DW, Blankstein M, Bekele A. et al. Establishing a surgical partnership between Addis Ababa, Ethiopia, and Toronto, Canada. Can J Surg 2013; 56 (03) E19-E23
- 5 Kanmounye US, Robertson FC, Thango NS. et al; CAANS Young Neurosurgeons Committee and WFNS Young Neurosurgeons Committee. Needs of young African neurosurgeons and residents: a cross-sectional study. Front Surg 2021; 8: 647279
- 6 Sader E, Yee P, Hodaie M. Barriers to neurosurgical training in Sub-Saharan Africa: the need for a phased approach to global surgery efforts to improve neurosurgical care. World Neurosurg 2017; 98: 397-402
- 7 El Khamlichi A. African neurosurgery: current situation, priorities, and needs. Neurosurgery 2001; 48 (06) 1344-1347
- 8 Gupta S, Gal ZT, Athni TS. et al; WFNS Global Neurosurgery Committee, EANS Global and Humanitarian Neurosurgery Committee, CAANS Executive Leadership Committee. Mapping the global neurosurgery workforce. Part 1: Consultant neurosurgeon density. J Neurosurg 2024; 141 (01) 1-9
- 9 Neurosurgery Across the Globe. . SpringerLink. Accessed June 25, 2024 at: https://link.springer.com/chapter/10.1007/978-3-030-86917-5_36
- 10 Shamim MS, Tahir MZ, Godil SS, Kumar R, Siddiqui AA. A critical analysis of the current state of neurosurgery training in Pakistan. Surg Neurol Int 2011; 2: 183
- 11 Leidinger A, Extremera P, Kim EE, Qureshi MM, Young PH, Piquer J. The challenges and opportunities of global neurosurgery in East Africa: the Neurosurgery Education and Development model. Neurosurg Focus 2018; 45 (04) E8
- 12 Almeida JP, Velásquez C, Karekezi C. et al. Global neurosurgery: models for international surgical education and collaboration at one university. Neurosurg Focus 2018; 45 (04) E5
- 13 Davis MC, Rocque BG, Singhal A, Ridder T, Pattisapu JV, Johnston Jr JM. State of global pediatric neurosurgery outreach: survey by the International Education Subcommittee. J Neurosurg Pediatr 2017; 20 (02) 204-210
- 14 Education-based Solutions to the Global Burden of Neurosurgical Disease. ClinicalKey. Accessed June 24, 2024 at: https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1878875020300656
- 15 Gandy K, Castillo H, Rocque BG, Bradko V, Whitehead W, Castillo J. Neurosurgical training and global health education: systematic review of challenges and benefits of in-country programs in the care of neural tube defects. Neurosurg Focus 2020; 48 (03) E14
- 16 Haglund MM, Kiryabwire J, Parker S. et al. Surgical capacity building in Uganda through twinning, technology, and training camps. World J Surg 2011; 35 (06) 1175-1182
- 17 Miller C, Lundy P, Woodrow S. International electives in neurological surgery training: a survey of program directors from Accreditation Council for Graduate Medical Education-approved neurological surgery programs. J Neurosurg 2020; 134 (06) 1967-1973
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