- Email: [email protected]
Global Diversity and Academic Success of Foreign-Trained Academic Neurosurgeons in the United States
Accepted Manuscript Global Diversity and Academic Success of Foreign-Trained Academic Neurosurgeons in the United States Akshitkumar M. Mistry, MD, Nishant Ganesh Kumar, BS, Rebecca A. Reynolds, MD, Andrew T. Hale, MS, John C. Wellons, III, MD, MSPH, Robert P. Naftel, MD PII:
S1878-8750(17)30657-5
DOI:
10.1016/j.wneu.2017.04.149
Reference:
WNEU 5668
To appear in:
World Neurosurgery
Received Date: 20 March 2017 Revised Date:
21 April 2017
Accepted Date: 22 April 2017
Please cite this article as: Mistry AM, Kumar NG, Reynolds RA, Hale AT, Wellons III JC, Naftel RP, Global Diversity and Academic Success of Foreign-Trained Academic Neurosurgeons in the United States, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.04.149. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Global Diversity and Academic Success of Foreign-Trained Academic
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Neurosurgeons in the United States
Akshitkumar M. Mistry, MD,1 Nishant Ganesh Kumar, BS,2 Rebecca A. Reynolds, MD,1 Andrew T. Hale, MS,2 John C. Wellons, III, MD, MSPH,1,3 Robert P. Naftel, MD1,3
Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA;
2
School of Medicine, Vanderbilt University, Nashville, TN, USA;
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1
Division of Pediatric
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3
Neurosurgery, Monroe Carell Jr. Children’s Hospital, Nashville, TN, USA.
Corresponding Author: Akshitkumar M. Mistry, M.D.
Department of Neurological Surgery, Vanderbilt University Medical Center
Nashville, TN 37232-2380
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T-4224 Medical Center North, 1161 21st Avenue South,
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Telephone: 615-322-7417; Fax: (615) 343-5315; E-mail: [email protected]
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Key Words: Neurosurgeon; Neurosurgery; Residency; Academic; International; Global Running Head: Foreign-Trained U.S. Academic Neurosurgeons Abbreviations:
U.S. – United States
NIH – National Institutes of Health, United States NRMP – National Resident Matching Program
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ABSTRACT Objective: To quantify the proportion of academic neurosurgeons in the United States (U.S.) who acquired residency training outside of the U.S. and compare their training backgrounds and
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academic success to those who received their residency training in the U.S.
Methods: We identified 1338 clinically-active academic neurosurgeons from 104 programs that participated in the neurosurgery residency match in the U.S. from January to February 2015.
SC
Their training backgrounds, current academic positions, and history of NIH grant awards from
M AN U
2005-2014 were retrieved from publicly-accessible sources.
Results: Eighty-four U.S. academic neurosurgeons (6.3%) received their residency training in 20 different countries outside of the U.S./Puerto Rico, representing all major regions of the world. The majority had trained in Canada (n=48). No major difference was noted between the foreigntrained and U.S.-trained neurosurgeons in their male to female ratio, year of starting residency,
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proportion with positions in medical schools ranked in the top 15 by the U.S. News and World Report, general distribution of academic positions, proportion with an NIH grant. Compared to U.S.-trained, foreign-trained academic neurosurgeons had significantly more Ph.D. degrees
EP
(32.1% vs. 12.3%; p<0.0001) and held more associate professor positions (34.5% vs. 23.1%;
AC C
p=0.02). The academic practices of the foreign-trained neurosurgeons were distributed throughout many states in the U.S. Conclusions: There is a small group of the U.S. academic neurosurgeons (6.3%) who have acquired residency training outside of the U.S., representing all major regions of the world. Their general demographics and academic successes are comparable to U.S.-trained neurosurgeons. Key Words: Neurosurgeon; Neurosurgery; Residency; Academic; International; Global
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INTRODUCTION The United States (U.S.) has long been a place where many professionals from around the world
RI PT
have found support to start or grow their careers in various fields.1 The medical field, and specifically neurosurgery, is no exception. Foreign-trained physicians have and continue to receive attention in our society,2-4 and especially in the current socioeconomic and political environment, where international exchange of physicians in American medicine and training of
M AN U
SC
foreign physicians is under scrutiny.1,5
Bias against foreign medical graduates still exists in medicine, including neurosurgery. This bias leads to challenges in obtaining further training, finding employment, and interacting with other medical professionals. In order to counter and possibly quench such lingering bias in the field of
TE D
neurosurgery, our aim is to 1) quantify the prevalence of foreign-trained neurosurgeons in academia to demonstrate diversity of their residency training and 2) compare some of their career attributes to U.S.-trained neurosurgeons. To the best of our knowledge, no such prior records of
EP
our academic profession are available.
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METHODS
Neurosurgery Residency Training Programs Program websites of all institutions participating in the Neurological Surgery National Resident Matching Program (NRMP) were accessed between January and February of 2015 to generate a list of academic neurosurgeons in the U.S. and Puerto Rico. The city and state of each program in the U.S. was recorded. Programs with associated medical schools whose average historical
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research ranking was in the top 15 from 1994-2013 on the U.S. News and World Report ranking
Identification of Academic Neurosurgeons
RI PT
were also noted (see Supplementary Table 1 for the list of schools).
Academic neurosurgeons were defined as staff members listed on the programs’ neurosurgery departmental webpages with a medical degree (M.D., D.O., M.B.B.S., or their equivalents) who
SC
were active in clinical neurosurgery at institutions and hospitals participating in the training of neurosurgical residents. While we recognize that there may be academic neurosurgeons who
M AN U
practice in non-academic institutions and are involved in research and teaching activities, we limited the search to only academic institutions with residency training programs to generate a highly-specific and reproducible list of academic neurosurgeons with a concrete methodology and minimal subjectivity. We excluded staff members who were receiving training as fellows,
TE D
held an emeritus status, or participated exclusively in research without any clinical activity. Staff members designated as visiting, adjunct, or volunteer faculty were only included if the program website noted that residents trained at the hospitals or institutions of their practice, or if the
EP
faculty member was involved in the training of residents.
AC C
Academic Success Metrics and Training Backgrounds of Neurosurgeons Each neurosurgeon’s gender, training background, and current academic position were extracted from reliable, professional, and publicly-accessible websites, which most commonly was the neurosurgeon’s profile webpage on the institutional website. The year of starting neurosurgical residency training as well as the country of the residency training institution were recorded. Current academic positions were categorized as assistant, associate, full professor, or chairman
ACCEPTED MANUSCRIPT
according to the institution. Whether a neurosurgeon was designated as the principal investigator or project leader for one or more U.S. National Institutes of Health (NIH) grants in the last ten years (2005-2014) was also recorded. This information was retrieved by querying the NIH
RI PT
Research Portfolio Online Reporting Tools (RePORT), accessed at the following website: https://projectreporter.nih.gov/reporter.cfm. In addition, if a neurosurgeon had a Doctor of Philosophy degree (Ph.D. or D.Phil.) or a Master's degree in the fields of science or math was
SC
also noted. A Master’s degree in clinical research, investigative methods, epidemiology, or
M AN U
public health was not recorded.
Data Analysis
Primary data collected included mainly categorical variables and were compared between groups using two-tailed Fisher's exact test. Year of starting residency, treated as a continuous variable,
TE D
was compared using two-tailed Mann-Whitney U test, as normality was not met. Statistical analyses were conducted using GraphPad Prism version 7.00 for Windows (GraphPad Software, San Diego, CA, USA). Statistical significance α was set at 0.05 for all statistical analyses. For
EP
geographical visualization of numerical data, map charts were created using mapchart.net ©
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(https://mapchart.net/).
RESULTS
A total of 104 programs actively participating in the neurological surgery residency were identified from the NRMP. Cumulatively, the total number of academic neurosurgeons identified in these programs was 1338. Of these, 84 (6.3%) neurosurgeons had acquired residency training outside of the U.S./Puerto Rico (Table 1). 82 neurosurgeons had obtained residency training in
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20 different countries representing all major regions and continents of the world (Asia, Africa, North America, South America, Europe, and Australia) with the most common being Canada (n=48; Figure 1). The country of residency training for two neurosurgeons was unable to be
RI PT
ascertained.
Comparison of the foreign-trained with U.S./Puerto Rico-trained neurosurgeons revealed no
SC
major difference in their male to female ratio, year of starting residency, proportion with positions in medical schools ranked in the top 15, general distribution of academic positions, or
M AN U
proportions with a history of NIH grant acquisition (Table 1). Of the 84 foreign-trained neurosurgeons, 17 (20.2%) held faculty positions at an top 15 research medical school based on U.S. News and World Report rankings; 14 (16.7%) held positions as full professors; 3 (3.6%) were principle investigators on an NIH grant; and 2 (2.4%) were chairman. However, foreign-
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trained academic neurosurgeons had significantly more Ph.D. degrees (32.1% vs. 12.3%; p<0.0001) and held more associate professor positions (34.5% vs. 23.1%; p=0.02). Although the academic practices of the foreign-trained neurosurgeons were widely distributed throughout the
EP
U.S., majority are located in the northeastern states (Pennsylvania, New York, and Ohio) and
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California (Figure 2).
DISCUSSION
Our results demonstrate that U.S. academic neurosurgeons who have acquired residency training outside the U.S. compose a small group. Although a majority of the foreign-trained neurosurgeons had received residency training in Canada, these neurosurgeons have collectively received training in all major regions of the world. Overall, they have similar general
ACCEPTED MANUSCRIPT
demographics and are comparable in academic successes to U.S.-trained neurosurgeons. A majority of the foreign-trained neurosurgeons practiced in states generally recognized to be multicultural: California, New York, Pennsylvania, and Ohio (see Supplemental Figure 1).
RI PT
However, these are also the states with high number of medical schools and population.
A major difference noted between the two groups was in proportion of neurosurgeons with a
SC
Ph.D. degree. The exact basis for this remains speculative. For example, this may be due to an increased standard for foreign-trained neurosurgeons to enter academic practice in the U.S.
M AN U
Research training may not be a common component in neurosurgical residency training outside the U.S., and a formal Ph.D. research training helps fill this training gap.
In the current U.S. immigration and work visa environment, we hope these results initiate
TE D
meaningful thought. While these results demonstrating global diversity in residency education among a small group of U.S. academic neurosurgeons are encouraging, we recognize that this is only a singular measurement of diversity and that there are other equal, if not better, dimensions
EP
of diversity. Further, these data represent only a snapshot in time and a trend over years may be more meaningful. Although we have ensured the credibility of the sources used as best as
AC C
possible, our data must be interpreted with the limitation that they were retrieved from widelyaccessible, public sources.
CONCLUSIONS
There is a small group of the U.S. academic neurosurgeons (6.3%) who have acquired residency training outside of the U.S., representing 20 different countries from all major regions of the
ACCEPTED MANUSCRIPT
world. They have similar general demographics and are comparable in their academic successes
RI PT
to U.S.-trained neurosurgeons.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosures / Conflict of Interest: The authors report no conflict of interest concerning the
SC
materials or methods used in this study or the findings specified in this paper.
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EP
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Acknowledgments: None
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REFERENCES 1.
Armstrong K, Anderson ME, Carethers JM, et al. International Exchange and American Medicine. N Engl J Med. 2017. Sopher P. Doctors With Borders: How the U.S. Shuts Out Foreign Physicians. The
RI PT
2.
Atlantic. 2014. Accessed December 5, 2016. 3.
Campbell-Page RM, Tepper J, Klei AG, et al. Foreign-trained medical professionals:
4.
SC
Wanted or not?A case study of Canada. J Glob Health. 2013; 3(2): 020304.
Norcini JJ, Boulet JR, Dauphinee WD, Opalek A, Krantz ID, Anderson ST. Evaluating
M AN U
the quality of care provided by graduates of international medical schools. Health Aff (Millwood). 2010; 29(8): 1461-1468.
Masri A, Senussi MH. Trump's Executive Order on Immigration - Detrimental Effects on
EP
TE D
Medical Training and Health Care. N Engl J Med. 2017.
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5.
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FIGURE LEGENDS
Figure 1. Countries where 82 of the 84 foreign-trained U.S. academic neurosurgeons in
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2014 acquired their residency training. Foreign-training is defined as training outside of U.S./Puerto Rico. The country of residency training of two neurosurgeons remained unknown.
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Figure 2. States where 84 foreign-trained U.S. academic neurosurgeons in 2014 practiced
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clinical neurosurgery.
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84 (6.3%) 73 (86.9%)
U.S./Puerto Rico residency training 1254 (93.7%) 1161 (92.5%)
1992.5 [1985-1998.5] 27 (32.1%) 1 (1.2%)
1994 [1984-2001] 154 (12.3%) 13 (1.0%)
0.15† <0.0001 0.60
1994 [1984-2001] 181 (13.5%) 14 (1.0%)
307 (24.5%)
0.43
324 (24.2%)
104 (8.3%) 291 (23.2%) 290 (23.1%) 512 (40.8%) 57 (4.5%)
0.06 0.18 0.02 0.65 0.11
106 (7.9%) 305 (22.8%) 319 (23.8%) 544 (40.7%) 64 (4.8%)
102 (8.1%)
0.20
105 (7.8%)
NIH grant PI§
2 (2.4%) 14 (16.7%) 29 (34.5%) 32 (38.1%) 7 (8.3%)
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17 (20.2%)
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Faculty in a top 15 research medical school‡ Academic position Chair Professor Associate Professor Assistant Professor Unknown position
3 (3.6%)
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Year of starting residency† PhD degree Masters in science/math
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Foreign residency training Total Male gender
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Table 1. Characteristics of U.S. academic neurosurgeons in 2014 with and without residency training in the U.S. P value*
Total
0.09
1338 (100%) 1234 (92.2%)
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* = P values of a two-tailed Fisher's exact test are reported, except in the case designated by †. Values meeting statistical significance are bolded. † = Median values with interquartile range are reported; Mann-Whitney U test is used to compare values. ‡ = The 10-year average (2004-2013) U.S. News and World Report rankings for medical schools in the research category was used. § = Principle investigator of any National Institutes of Health (NIH) grant from 2005-2014
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Highlights We demonstrate that there is a small group of U.S. academic neurosurgeons who have acquired
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residency training in 20 different countries outside of the U.S., representing all major regions of the world. Their general demographics and academic successes are comparable to U.S.-trained
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neurosurgeons.
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SUPPLEMENTARY MATERIAL
Table 1. The average medical school ranking was generated by averaging each year’s ranking on
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the U.S. News and World Report for medical schools in the research category from 2004-2013. The following institutions, listed in alphabetical order, had an average ranking of 15 or less.
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Columbia Duke
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Harvard Johns Hopkins Stanford UCLA
UCSF University of Chicago
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University of Michigan
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UCSD
University of Pennsylvania
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University of Pittsburgh
University of Washington Washington University Yale
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Figure 1
Figure 1. U.S. map by state demonstrating foreign-born population, excluding population born at sea. This map is obtained directly from
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https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_5YR _DP02&src=pt. Data are obtained from the “Selected Social Characteristics in the United States”
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based on the 2011-2015 American Community Survey 5-Year Estimates.
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Disclosure / Conflict of Interest Statement We, all co-authors of this manuscript, transfer the ownership of copyright to the World
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Neurosurgery journal should their work be published in this journal.
We certify that this manuscript is a unique submission and is not being considered for
publication by any other source in any medium. Further, the manuscript has not been published, in part or in full, in any form. We have no conflicts of interest to disclose or any financial
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M AN U
SC
disclosures to report. All authors have read the manuscript.
S1878-8750(17)30657-5
DOI:
10.1016/j.wneu.2017.04.149
Reference:
WNEU 5668
To appear in:
World Neurosurgery
Received Date: 20 March 2017 Revised Date:
21 April 2017
Accepted Date: 22 April 2017
Please cite this article as: Mistry AM, Kumar NG, Reynolds RA, Hale AT, Wellons III JC, Naftel RP, Global Diversity and Academic Success of Foreign-Trained Academic Neurosurgeons in the United States, World Neurosurgery (2017), doi: 10.1016/j.wneu.2017.04.149. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Global Diversity and Academic Success of Foreign-Trained Academic
RI PT
Neurosurgeons in the United States
Akshitkumar M. Mistry, MD,1 Nishant Ganesh Kumar, BS,2 Rebecca A. Reynolds, MD,1 Andrew T. Hale, MS,2 John C. Wellons, III, MD, MSPH,1,3 Robert P. Naftel, MD1,3
Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA;
2
School of Medicine, Vanderbilt University, Nashville, TN, USA;
SC
1
Division of Pediatric
M AN U
3
Neurosurgery, Monroe Carell Jr. Children’s Hospital, Nashville, TN, USA.
Corresponding Author: Akshitkumar M. Mistry, M.D.
Department of Neurological Surgery, Vanderbilt University Medical Center
Nashville, TN 37232-2380
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T-4224 Medical Center North, 1161 21st Avenue South,
EP
Telephone: 615-322-7417; Fax: (615) 343-5315; E-mail: [email protected]
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Key Words: Neurosurgeon; Neurosurgery; Residency; Academic; International; Global Running Head: Foreign-Trained U.S. Academic Neurosurgeons Abbreviations:
U.S. – United States
NIH – National Institutes of Health, United States NRMP – National Resident Matching Program
ACCEPTED MANUSCRIPT
ABSTRACT Objective: To quantify the proportion of academic neurosurgeons in the United States (U.S.) who acquired residency training outside of the U.S. and compare their training backgrounds and
RI PT
academic success to those who received their residency training in the U.S.
Methods: We identified 1338 clinically-active academic neurosurgeons from 104 programs that participated in the neurosurgery residency match in the U.S. from January to February 2015.
SC
Their training backgrounds, current academic positions, and history of NIH grant awards from
M AN U
2005-2014 were retrieved from publicly-accessible sources.
Results: Eighty-four U.S. academic neurosurgeons (6.3%) received their residency training in 20 different countries outside of the U.S./Puerto Rico, representing all major regions of the world. The majority had trained in Canada (n=48). No major difference was noted between the foreigntrained and U.S.-trained neurosurgeons in their male to female ratio, year of starting residency,
TE D
proportion with positions in medical schools ranked in the top 15 by the U.S. News and World Report, general distribution of academic positions, proportion with an NIH grant. Compared to U.S.-trained, foreign-trained academic neurosurgeons had significantly more Ph.D. degrees
EP
(32.1% vs. 12.3%; p<0.0001) and held more associate professor positions (34.5% vs. 23.1%;
AC C
p=0.02). The academic practices of the foreign-trained neurosurgeons were distributed throughout many states in the U.S. Conclusions: There is a small group of the U.S. academic neurosurgeons (6.3%) who have acquired residency training outside of the U.S., representing all major regions of the world. Their general demographics and academic successes are comparable to U.S.-trained neurosurgeons. Key Words: Neurosurgeon; Neurosurgery; Residency; Academic; International; Global
ACCEPTED MANUSCRIPT
INTRODUCTION The United States (U.S.) has long been a place where many professionals from around the world
RI PT
have found support to start or grow their careers in various fields.1 The medical field, and specifically neurosurgery, is no exception. Foreign-trained physicians have and continue to receive attention in our society,2-4 and especially in the current socioeconomic and political environment, where international exchange of physicians in American medicine and training of
M AN U
SC
foreign physicians is under scrutiny.1,5
Bias against foreign medical graduates still exists in medicine, including neurosurgery. This bias leads to challenges in obtaining further training, finding employment, and interacting with other medical professionals. In order to counter and possibly quench such lingering bias in the field of
TE D
neurosurgery, our aim is to 1) quantify the prevalence of foreign-trained neurosurgeons in academia to demonstrate diversity of their residency training and 2) compare some of their career attributes to U.S.-trained neurosurgeons. To the best of our knowledge, no such prior records of
EP
our academic profession are available.
AC C
METHODS
Neurosurgery Residency Training Programs Program websites of all institutions participating in the Neurological Surgery National Resident Matching Program (NRMP) were accessed between January and February of 2015 to generate a list of academic neurosurgeons in the U.S. and Puerto Rico. The city and state of each program in the U.S. was recorded. Programs with associated medical schools whose average historical
ACCEPTED MANUSCRIPT
research ranking was in the top 15 from 1994-2013 on the U.S. News and World Report ranking
Identification of Academic Neurosurgeons
RI PT
were also noted (see Supplementary Table 1 for the list of schools).
Academic neurosurgeons were defined as staff members listed on the programs’ neurosurgery departmental webpages with a medical degree (M.D., D.O., M.B.B.S., or their equivalents) who
SC
were active in clinical neurosurgery at institutions and hospitals participating in the training of neurosurgical residents. While we recognize that there may be academic neurosurgeons who
M AN U
practice in non-academic institutions and are involved in research and teaching activities, we limited the search to only academic institutions with residency training programs to generate a highly-specific and reproducible list of academic neurosurgeons with a concrete methodology and minimal subjectivity. We excluded staff members who were receiving training as fellows,
TE D
held an emeritus status, or participated exclusively in research without any clinical activity. Staff members designated as visiting, adjunct, or volunteer faculty were only included if the program website noted that residents trained at the hospitals or institutions of their practice, or if the
EP
faculty member was involved in the training of residents.
AC C
Academic Success Metrics and Training Backgrounds of Neurosurgeons Each neurosurgeon’s gender, training background, and current academic position were extracted from reliable, professional, and publicly-accessible websites, which most commonly was the neurosurgeon’s profile webpage on the institutional website. The year of starting neurosurgical residency training as well as the country of the residency training institution were recorded. Current academic positions were categorized as assistant, associate, full professor, or chairman
ACCEPTED MANUSCRIPT
according to the institution. Whether a neurosurgeon was designated as the principal investigator or project leader for one or more U.S. National Institutes of Health (NIH) grants in the last ten years (2005-2014) was also recorded. This information was retrieved by querying the NIH
RI PT
Research Portfolio Online Reporting Tools (RePORT), accessed at the following website: https://projectreporter.nih.gov/reporter.cfm. In addition, if a neurosurgeon had a Doctor of Philosophy degree (Ph.D. or D.Phil.) or a Master's degree in the fields of science or math was
SC
also noted. A Master’s degree in clinical research, investigative methods, epidemiology, or
M AN U
public health was not recorded.
Data Analysis
Primary data collected included mainly categorical variables and were compared between groups using two-tailed Fisher's exact test. Year of starting residency, treated as a continuous variable,
TE D
was compared using two-tailed Mann-Whitney U test, as normality was not met. Statistical analyses were conducted using GraphPad Prism version 7.00 for Windows (GraphPad Software, San Diego, CA, USA). Statistical significance α was set at 0.05 for all statistical analyses. For
EP
geographical visualization of numerical data, map charts were created using mapchart.net ©
AC C
(https://mapchart.net/).
RESULTS
A total of 104 programs actively participating in the neurological surgery residency were identified from the NRMP. Cumulatively, the total number of academic neurosurgeons identified in these programs was 1338. Of these, 84 (6.3%) neurosurgeons had acquired residency training outside of the U.S./Puerto Rico (Table 1). 82 neurosurgeons had obtained residency training in
ACCEPTED MANUSCRIPT
20 different countries representing all major regions and continents of the world (Asia, Africa, North America, South America, Europe, and Australia) with the most common being Canada (n=48; Figure 1). The country of residency training for two neurosurgeons was unable to be
RI PT
ascertained.
Comparison of the foreign-trained with U.S./Puerto Rico-trained neurosurgeons revealed no
SC
major difference in their male to female ratio, year of starting residency, proportion with positions in medical schools ranked in the top 15, general distribution of academic positions, or
M AN U
proportions with a history of NIH grant acquisition (Table 1). Of the 84 foreign-trained neurosurgeons, 17 (20.2%) held faculty positions at an top 15 research medical school based on U.S. News and World Report rankings; 14 (16.7%) held positions as full professors; 3 (3.6%) were principle investigators on an NIH grant; and 2 (2.4%) were chairman. However, foreign-
TE D
trained academic neurosurgeons had significantly more Ph.D. degrees (32.1% vs. 12.3%; p<0.0001) and held more associate professor positions (34.5% vs. 23.1%; p=0.02). Although the academic practices of the foreign-trained neurosurgeons were widely distributed throughout the
EP
U.S., majority are located in the northeastern states (Pennsylvania, New York, and Ohio) and
AC C
California (Figure 2).
DISCUSSION
Our results demonstrate that U.S. academic neurosurgeons who have acquired residency training outside the U.S. compose a small group. Although a majority of the foreign-trained neurosurgeons had received residency training in Canada, these neurosurgeons have collectively received training in all major regions of the world. Overall, they have similar general
ACCEPTED MANUSCRIPT
demographics and are comparable in academic successes to U.S.-trained neurosurgeons. A majority of the foreign-trained neurosurgeons practiced in states generally recognized to be multicultural: California, New York, Pennsylvania, and Ohio (see Supplemental Figure 1).
RI PT
However, these are also the states with high number of medical schools and population.
A major difference noted between the two groups was in proportion of neurosurgeons with a
SC
Ph.D. degree. The exact basis for this remains speculative. For example, this may be due to an increased standard for foreign-trained neurosurgeons to enter academic practice in the U.S.
M AN U
Research training may not be a common component in neurosurgical residency training outside the U.S., and a formal Ph.D. research training helps fill this training gap.
In the current U.S. immigration and work visa environment, we hope these results initiate
TE D
meaningful thought. While these results demonstrating global diversity in residency education among a small group of U.S. academic neurosurgeons are encouraging, we recognize that this is only a singular measurement of diversity and that there are other equal, if not better, dimensions
EP
of diversity. Further, these data represent only a snapshot in time and a trend over years may be more meaningful. Although we have ensured the credibility of the sources used as best as
AC C
possible, our data must be interpreted with the limitation that they were retrieved from widelyaccessible, public sources.
CONCLUSIONS
There is a small group of the U.S. academic neurosurgeons (6.3%) who have acquired residency training outside of the U.S., representing 20 different countries from all major regions of the
ACCEPTED MANUSCRIPT
world. They have similar general demographics and are comparable in their academic successes
RI PT
to U.S.-trained neurosurgeons.
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosures / Conflict of Interest: The authors report no conflict of interest concerning the
SC
materials or methods used in this study or the findings specified in this paper.
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EP
TE D
M AN U
Acknowledgments: None
ACCEPTED MANUSCRIPT
REFERENCES 1.
Armstrong K, Anderson ME, Carethers JM, et al. International Exchange and American Medicine. N Engl J Med. 2017. Sopher P. Doctors With Borders: How the U.S. Shuts Out Foreign Physicians. The
RI PT
2.
Atlantic. 2014. Accessed December 5, 2016. 3.
Campbell-Page RM, Tepper J, Klei AG, et al. Foreign-trained medical professionals:
4.
SC
Wanted or not?A case study of Canada. J Glob Health. 2013; 3(2): 020304.
Norcini JJ, Boulet JR, Dauphinee WD, Opalek A, Krantz ID, Anderson ST. Evaluating
M AN U
the quality of care provided by graduates of international medical schools. Health Aff (Millwood). 2010; 29(8): 1461-1468.
Masri A, Senussi MH. Trump's Executive Order on Immigration - Detrimental Effects on
EP
TE D
Medical Training and Health Care. N Engl J Med. 2017.
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5.
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FIGURE LEGENDS
Figure 1. Countries where 82 of the 84 foreign-trained U.S. academic neurosurgeons in
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2014 acquired their residency training. Foreign-training is defined as training outside of U.S./Puerto Rico. The country of residency training of two neurosurgeons remained unknown.
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Figure 2. States where 84 foreign-trained U.S. academic neurosurgeons in 2014 practiced
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clinical neurosurgery.
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84 (6.3%) 73 (86.9%)
U.S./Puerto Rico residency training 1254 (93.7%) 1161 (92.5%)
1992.5 [1985-1998.5] 27 (32.1%) 1 (1.2%)
1994 [1984-2001] 154 (12.3%) 13 (1.0%)
0.15† <0.0001 0.60
1994 [1984-2001] 181 (13.5%) 14 (1.0%)
307 (24.5%)
0.43
324 (24.2%)
104 (8.3%) 291 (23.2%) 290 (23.1%) 512 (40.8%) 57 (4.5%)
0.06 0.18 0.02 0.65 0.11
106 (7.9%) 305 (22.8%) 319 (23.8%) 544 (40.7%) 64 (4.8%)
102 (8.1%)
0.20
105 (7.8%)
NIH grant PI§
2 (2.4%) 14 (16.7%) 29 (34.5%) 32 (38.1%) 7 (8.3%)
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17 (20.2%)
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Faculty in a top 15 research medical school‡ Academic position Chair Professor Associate Professor Assistant Professor Unknown position
3 (3.6%)
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Year of starting residency† PhD degree Masters in science/math
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Foreign residency training Total Male gender
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Table 1. Characteristics of U.S. academic neurosurgeons in 2014 with and without residency training in the U.S. P value*
Total
0.09
1338 (100%) 1234 (92.2%)
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* = P values of a two-tailed Fisher's exact test are reported, except in the case designated by †. Values meeting statistical significance are bolded. † = Median values with interquartile range are reported; Mann-Whitney U test is used to compare values. ‡ = The 10-year average (2004-2013) U.S. News and World Report rankings for medical schools in the research category was used. § = Principle investigator of any National Institutes of Health (NIH) grant from 2005-2014
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Highlights We demonstrate that there is a small group of U.S. academic neurosurgeons who have acquired
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residency training in 20 different countries outside of the U.S., representing all major regions of the world. Their general demographics and academic successes are comparable to U.S.-trained
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neurosurgeons.
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SUPPLEMENTARY MATERIAL
Table 1. The average medical school ranking was generated by averaging each year’s ranking on
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the U.S. News and World Report for medical schools in the research category from 2004-2013. The following institutions, listed in alphabetical order, had an average ranking of 15 or less.
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Columbia Duke
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Harvard Johns Hopkins Stanford UCLA
UCSF University of Chicago
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University of Michigan
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UCSD
University of Pennsylvania
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University of Pittsburgh
University of Washington Washington University Yale
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Figure 1
Figure 1. U.S. map by state demonstrating foreign-born population, excluding population born at sea. This map is obtained directly from
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https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=ACS_15_5YR _DP02&src=pt. Data are obtained from the “Selected Social Characteristics in the United States”
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based on the 2011-2015 American Community Survey 5-Year Estimates.
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Disclosure / Conflict of Interest Statement We, all co-authors of this manuscript, transfer the ownership of copyright to the World
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Neurosurgery journal should their work be published in this journal.
We certify that this manuscript is a unique submission and is not being considered for
publication by any other source in any medium. Further, the manuscript has not been published, in part or in full, in any form. We have no conflicts of interest to disclose or any financial
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disclosures to report. All authors have read the manuscript.