1. CORRESPONDENCE
Letter: Predictors of Academic Neurosurgical
Career Trajectory Among International
Medical Graduates Training Within the United
States
To the Editor:
Khalafallah et al1
compared academic careers of United States
MD/DO graduates and international medical graduate (IMG)
neurosurgeons trained in the United States and identified factors
predictive of academic success. They found that IMGs are more
likely to complete preresidency postdoctoral research fellowships
(PPRFs) (odds ratio [OR] = 9.19; P < .0001) and pursue
academic neurosurgery careers compared to American medical
graduates (AMGs) (59.7% vs 51.1%; P = .011).1
In this corre-
spondence, we discuss their findings and suggest steps that can
help IMGs integrate into United States neurosurgery.
PRERESIDENCY RESEARCH FELLOWSHIPS AS A
GATEWAY INTO UNITED STATES
NEUROSURGERY RESIDENCY AND A
PREDICTOR OF ACADEMIC SUCCESS
Neurosurgery has historically been one of the most competitive
specialties for IMGs. In 2020, less than 30% of IMG applicants
matched, compared to 78% of AMGs.2
There are several paths
to United States neurosurgery residency for IMGs, including
PPRFs, preresidency clinical fellowships, and neuroscience-
related postgraduate programs. Nearly 37% of IMGs matching
into neurosurgery have completed PPRFs.3
Considering that most academic programs offer PPRFs,
that only a fraction of PPRF applicants match into neuro-
surgery, and that United States-trained IMG neurosurgeons who
completed PPRFs are more likely to pursue academic neuro-
surgical careers,1,3
questions may be raised of what attributes
of good PPRFs are and how can IMGs get selected for them.
Answers to these questions can help IMG applicants in selecting
PPRFs as well as program directors in sorting through IMG
residency applications. The predictors of a successful match
and academic career appear similar—on completion of PPRFs,
successful IMG applicants have at least 5 publications and an
H-index of 3.1,3
Although Khalafallah et al1,2
reported IMGs
having lower H-indices than AMGs before residency, the total
number of abstracts, publications, and presentations of matched
IMG applicants in neurosurgery has been higher than those of
AMGs in recent years (60.8 vs 23.4). This discordance may be
due to recent IMG applicants facing a much more competitive
application field compared to the historical cohort studied by
Khalafallah and colleagues.1
Prospective applicants should view these numbers as a
threshold and not a goal. Those interested in academic
neurosurgery should target PPRFs offering them the possibility
of not only meeting but exceeding these targets. Exceeding these
targets should help compensate for the United States Medical
Licensing Examination (USMLE) Step 1 becoming pass/fail and
the increased academic productivity among residency applicants.4
CHALLENGES FACED BY INTERNATIONAL
MEDICAL GRADUATES
Challenges faced by IMGs include lack of mentorship, finding
the right PPRF, lack of funding, and difficulties securing a visa,
amongst others.5
The lack of mentorship may be explained by
the diversity of medical schools and countries with matched IMG
neurosurgeons. For example, only 4 international medical schools
have graduated more than or equal to 5 IMG neurosurgeons.1
Lack of IMG diversity can lead to a lack of mentorship for
IMG applicants. Creating a neurosurgery interest group for IMGs
interested in United States neurosurgery can enhance mentorship
and increase diversity.
Few PPRFs offer funding off the bat, unlike preresidency
clinical fellowships, and most PPRFs do not qualify for inter-
national scholarships like the Fulbright given their nondegree
granting nature. Financing impacts IMGs’ visa status, quality of
life, and scholarly output indirectly.5
J-1 visa holders must show
proof of ≥$1200 per month for themselves, ≥$500 per month
for the first dependent, and ≥$300 per month per additional
dependent.6
Preresidency research fellows need a J-1 visa if they lack United
States citizenship or permanent residency. The J-1 visa requires
renewal but cannot be renewed indefinitely.6
The latter is a cause
of concern because IMGs would have spent some time in PPRFs,
7 yr in residency, and 1 to 2 yr in fellowship.7
Additionally,
holders of J-1 visas issued for clinical training must spend 2 yr
in their home country post-training.6
All these challenges have
made access to PPRFs cumbersome. Fortunately, some solutions
exist, and we recommend that IMGs consult immigration lawyers
early on.
RECOGNIZING ACCOMPLISHED
INTERNATIONAL MEDICAL GRADUATES
Currently, the American Association of Neurological Surgeons
(AANS) and the Congress of Neurological Surgeons (CNS) both
lack a membership category for international medical students or
IMGs in PPRFs. However, the North American Spine Society,
Society of Neuro-Interventional Surgery, and Society for Neuro-
Oncology do allow international students and IMGs to join. The
creation of a special membership category in AANS and CNS will
help facilitate IMG integration through permitting access to their
educational resources.8-10
Additionally, the American Board of Neurological Surgery
may also consider implementing alternate pathways for board
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2. CORRESPONDENCE
certification for fully qualified international neurosurgeons.
Lessons may be taken from the pathways offered by the American
Board of Surgery, the American Board of Radiology, and the
American Board of Anesthesia.11-13
CONCLUSION
In summary, we commend Khalafallah et al1
for their insightful
work. Through the steps recommended above, IMG candidates
can better integrate into the fabric of United States neurosurgery,
thereby increasing their contribution to scholarship and the global
leadership status of United States neurosurgery.
Funding
This study did not receive any funding or financial support.
Disclosures
The authors have no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
Ahmad Ozair, MBBS ∗
Ahmed Negida, MBBCh ‡§
Abdul Karim Ghaith, MD ¶
Ulrick Sidney Kanmounye, MD §
∗
Faculty of Medicine
King George’s Medical University
Lucknow, India
‡
Global Neurosurgery Initiative
Program in Global Surgery and Social Change
Harvard Medical School
Boston, Massachusetts, USA
§
Research Department
Association of Future African Neurosurgeons
Yaounde, Cameroon
¶
Department of Neurological Surgery
Mayo Clinic
Rochester, Minnesota, USA
REFERENCES
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main-residency-match-data. Accessed July 4, 2021.
3. Chandra A, Brandel MG, Wadhwa H, et al. The path to U.S. neurosurgical
residency for foreign medical graduates: trends from a decade 2007-2017. World
Neurosurg. 2020;137:e584-e596.
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race”: analysis of medical student publication in the Neurosurgery Residency
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doi:10.3171/2019.8.JNS191256.
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“Strategies to address projected challenges facing foreign applicants in the U.S.
Neurosurgery Match”. World Neurosurg. 2020;144:301-302.
6. US Department of State. Exchange visitor visa. US Department of State.
https://travel.state.gov/content/travel/en/us-visas/study/exchange.html. Accessed
July 4, 2021.
7. Tomei KL. Commentary: predictors of academic neurosurgical career trajectory
among international medical graduates training within the United States
[published online ahead of print: June 10, 2021]. Neurosurgery. 2021.
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8. Society of Neuro-Interventional Surgery. Membership. Society of Neuro-
Interventional Surgery. https://www.snisonline.org/joinSNIS. Accessed July 4,
2021.
9. Society for Neuro-Oncology. Membership categories. Society for Neuro-
Oncology. https://www.soc-neuro-onc.org/WEB/WEB/Membership_Content/
Membership_Categories.aspx. Accessed July 4, 2021.
10. North American Spine Society. Membership types and eligibility. North American
Spine Society. https://www.spine.org/Membership/Apply-For-Membership/
Become-a-Member. Accessed July 4, 2021.
11. American Board of Anesthesiology. Alternate entry pathway. American Board of
Anesthesiology. https://theaba.org/alternate%20entry%20pathway.html. Accessed
July 4, 2021.
12. American Board of Surgery. Academic pathway to ABS certification for interna-
tional medical graduates. American Board of Surgery. https://www.absurgery.org/
default.jsp?academicpathway. Accessed July 4, 2021.
13. American Board of Radiology. International medical graduates alternate
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radiology/initial-certification/alternate-pathways/international-medical-graduates.
Accessed July 4, 2021.
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