International electives in neurological surgery training: a survey of program directors from Accreditation Council for Graduate Medical Education–approved neurological surgery programs
Authors: Miller Christopher , Lundy Paige , Woodrow Sarah 
Published: July 2020

OBJECTIVE
The burden of neurosurgical disease in low- and middle-income countries (LMICs) has emerged as a significant factor in global health. Additionally, calls have been growing for first-world neurosurgeons to find ways to help address the international need. Allowing residents to pursue international elective opportunities in LMICs can help alleviate the burden while also providing unique educational opportunities. However, pursuing international work while in residency requires overcoming significant logistical and regulatory barriers. To better understand the general perspectives, perceived barriers, and current availability of international rotations, a survey was sent out to program directors at Accreditation Council for Graduate Medical Education (ACGME)–approved residencies.

METHODS
An anonymous survey was sent to all program directors at ACGME-approved residencies. The survey included branch points designed to separate programs into program directors with an existing international rotation, those interested in starting an international rotation, and those not interested in starting an international rotation. All participants were asked about the perceived value of international training and whether residents should be encouraged to train internationally on a 5-point Likert scale. The survey ended with open-response fields, encouraging thoughts on international rotations and overcoming barriers.

RESULTS
Forty-four percent of recipients (50/113) responded; of the 50 programs, 13 had an established international elective. Of programs without a rotation, 54% (20/37) noted that they were interested in starting an international elective. Key barriers to starting international training included funding, the Residency Review Committee approval process, call conflicts, and the establishment of international partners. Perceived learning opportunities included cultural awareness, unique pathology, ingenuity, physical examination skills, and diagnosis skills. The majority of respondents thought that international rotations were valuable (74%, 37/50) and that residents should be encouraged to pursue international educational opportunities (70%, 35/50). Program directors who maintained an existing international rotation or were interested in starting an international elective were more likely to perceive international rotations as valuable.

CONCLUSIONS
Recent calls from The Lancet Commission on Global Surgery for increased surgical interventions in the developing world have been expanded by neurosurgical leadership to include neurosurgical diseases. Resident involvement in international electives represents an opportunity to increase treatment of neurosurgical disease in LMICs and develop the next generation of international neurosurgeons. To increase opportunities for residents at international sites, attention should be focused on overcoming the practical and regulatory barriers at a local and national level.