Original Article
Neurosurgical Residency Training in Latin America: Current Status, Challenges, and
Future Opportunities
Ricardo Murguia-Fuentes1,2, Nuruddin Husein1, Alfonso Vega3, Leonardo Rangel-Castilla4, J. Marcus Rotta5,
Alfredo Quinones-Hinojosa6, Gerardo Guinto7, Yoshua Esquenazi1
- BACKGROUND: This analysis provides an overview of
neurosurgery residency programs in Latin America; it
evaluates strengths, weaknesses, and limitations within
the Latin American Federation for Societies in Neurosur-
gery countries. Considering the shared cultural background
between these neighboring countries and globalization of
neurosurgical education, similarities in training charac-
teristics and equal opportunities are expected. However,
program differences are inevitable and should be investi-
gated to promote collaboration and homogenization of
training.
- METHODS: A 39-item survey was distributed to 970
neurosurgeons and residents in Latin America to assess
aspects including working conditions, teaching, research,
training, educational opportunities, and socioeconomics.
- RESULTS: In total, 276 neurosurgeons (28%) from 16
countries completed the survey. The average participant’s
age was 37
7 years, and the average duration of resi-
dency programs was 5
1 years. Trainees participated in
around 5e10 cases during the typical 80e100 work hour
week. Only 5% of survey respondents had a day off after a
night shift, and 60% worked at least 3 night shifts per
week. Only 34% had a mentorship program, Morbidity and
mortality conferences were reported by 57% and research
activities were compulsory in 45%. Satisfaction with
evaluation methods was reported in 29%, although 96%
reported satisfaction with their training programs overall.
Key words
- FLANC
- Latin America
- Neurosurgery
- Residency
- Training
Abbreviations and Acronyms
FLANC: Latin American Federation of Societies in Neurosurgery (Federación
Latinoamericana de Sociedades en Neurocirugía)
OR: Operating room
From the 1Vivian L. Smith Department of Neurological Surgery, The University of Texas at
Houston, Houston, Texas, USA; 2Universidad Nacional Autónoma de México, Mexico City,
WORLD NEUROSURGERY 120: e1079-e1097, DECEMBER 2018
- CONCLUSIONS: This study is the first of its kind to
review neurosurgical training in Latin America’s. Sug-
gested areas of improvement include regulation of working
hours, implementation of mentorship programs and stan-
dardized examinations, protected research time, increased
support for conferences, and more opportunities for
exchange rotations that will potentially bolster collabora-
tion between programs.
INTRODUCTION
N eurosurgery is a highly competitive residency, with a
multitude of applicants competing for only a few posi-
tions.1 It typically attracts ambitious students who are
committed to undergoing intense and rigorous training.
Neurosurgery residents face particular challenges such as a high
workload and high-stress environments. Total self-immersion as
well as substantial responsibility during training are required to
become a proficient and competent surgeon.2 During this period
of rigorous training, there are still many variables that may have
an impact on the acquisition of skills and overall expertise in
the field. The Latin American Federation for Societies in
Neurosurgery (Federación Latinoamericana de Sociedades de
Neurocirugía [FLANC]) is one of the biggest neurosurgical
organizations in the world, with members from more than 20
different countries across Latin America and Europe. FLANC’s
main goals include the diffusion of medical knowledge, creation
Mexico; 3Department of Neurosurgery, Centro Médico Naval, Secretaria de Marina, Armada
de México, Mexico; 4Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA;
5
Department of Neurosurgery, Hospital do Servidor Publico Estadual, Sao Paulo, Brazil;
6
Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA; and 7Department of
Neurosurgery, Centro Medico Nacional Siglo XXI, Mexico City, Mexico
To whom correspondence should be addressed: Yoshua Esquenazi, M.D.
[E-mail: Yoshua.EsquenaziLevy@uth.tmc.edu]
Citation: World Neurosurg. (2018) 120:e1079-e1097.
https://doi.org/10.1016/j.wneu.2018.08.232
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
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RICARDO MURGUIA-FUENTES ET AL.
of training opportunities, and the analysis and implementation of
educational strategies to keep up with international standards of
neurosurgical training. Although differences between residency
training programs are likely to be found in such a diverse and
multinational organization, equal training opportunities across
countries are to be expected and have become an important
objective for FLANC, to achieve the highest standards in
neurosurgical education. A critical analysis of program
characteristics could produce valuable information that could be
used to identify strengths and weaknesses in programs across,
or within, different countries. The present study shows the
results of an online, 39-item survey distributed to nearly 970
neurosurgeons from Latin America. Training features, educational
curricula, socioeconomic, and demographic aspects are evaluated
in depth. The results of this study will provide an opportunity for
educational, scientific, and interdisciplinary collaboration within a
highly subspecialized and rapidly evolving specialty.
METHODS
Survey Development
An electronic survey using Google Forms (Spanish and Portu-
guese) was designed to address the following 7 areas: de-
mographic background; working conditions; teaching; research
and conferences; economic and social benefits; evaluations; and
medical rotations and training opportunities. Each section in-
cludes a subset of data that pertain to the following aspects of
neurosurgery training:
Section 1 “Demographic Background” included age, sex, country
of training, and the prerequisites required to begin neurosurgery
training.
Section 2 “Working Conditions” included the number of working
hours, frequency of night shifts during residency, and the average
workload.
Section 3 “Teaching” encompassed the availability of mentorship
programs, rotations outside the main institution, teaching time,
quality, and teaching resources. It also incorporated the general
satisfaction of residents and the total number of cases performed
during residency.
Section 4 “Research and Conferences” evaluated both research
involvement and conference attendance, to determine if these
were compulsory or optional in nature, and if the training program
supported them.
Section 5 “Economic and Social Benefits” assessed frequency of
paid versus unpaid residencies, sexual equality, and the availability
of mental health support services for residents.
Section 6 “Examinations/Evaluations” focused on frequency and
type of examinations/evaluations used by various programs to
measure resident performance and experience, including the
prevalence of national certification examinations for accreditation.
Section 7 “Medical Rotations and Training Opportunities” evalu-
ated the components of residency training programs, such as
cranial versus spinal case concentration, specific case types per-
formed, and availability of fellowship and overseas rotations. Data
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were also collected regarding the most desired training locations
both in Latin America and worldwide.
The full questionnaire in English is included in Appendix A. An
online version including the original text in Spanish/Portuguese
can be accessed through this link: https://goo.gl/forms/
rJMMmOineZHwAzvD2.
Data Collection
Most data were collected in collaboration with the FLANC and
their electronic database of neurosurgeons and residents. Each
member was contacted via email. Board members from each
country and representatives of FLANC generously shared their
respective contacts to increase the available database.
The survey was sent via email to 970 FLANC members on 3
separate occasions. In addition, because of a very poor initial
response from the Brazilian community, invitations to participate
in the survey were posted in the weekly bulletin of the Brazilian
Society of Neurosurgery (Sociedad Brasileira de Neurocirurgia).
Data Analysis
Data were analyzed in R, a software for statistical computing and
graphics supported by the R Foundation for Statistical Computing
(Vienna, Austria).3 Data were primary analyzed through the
calculation of means with standard deviations and percentages
according to the results obtained during the survey.
Statistical analysis included the creation of graphs using the
same software. Dynamic tables, created with the data, were used
to make comparisons between countries for each individual
question, allowing the analysts to highlight obvious differences.
RESULTS
Survey Response
In total, 276 individuals from 16 Latin American countries and
more than 50 different programs completed the questionnaire.
From these responses, 269 were included in the analysis. The
remaining 7 survey responses contained incoherent information or
were incomplete and, thus, were not included in the analysis.
Responses from participants who were not trained within Latin
America were also excluded from the analysis.
Demographics of Survey Respondents
Of responders, 87% were male, with an average age of 37
7
years. Of the 16 countries that were selected as training sites, the
largest percentage of residents (48%) were trained in Mexico. The
average duration of neurosurgery residency was 5
1 years, with
training as short as 3 years reported by participants from Chile and
El Salvador. Of residency institutions, 64% required partial
accreditation in general surgery (typically 1 year), with the
exception of Peru, which did not report any requirement for
general surgery training. The distribution of training location of
the participants is provided in Figure 1. Also, a comprenhensive
summary of this information can be found in Table 1 of
Appendix B.

RICARDO MURGUIA-FUENTES ET AL.
Figure 1. Country and distribution of the survey
participants (n ¼ 269 surveys). The x-axis shows the
proportion of individuals from each country as a fraction
of the 100% of our sample (1.0), with the y-axis
showing each specific country in Latin America
included in the survey. The blue scale bar with “m”
Working Conditions
The typical working hours during residency in Latin America
range from 80 to 100 hours over a 7-day week, according to 41% of
the respondents. The highest number of work hours per week
(>100) was reported by Mexico, Colombia, Brazil, and Venezuela.
Participants from Argentina reported programs with <60 weekly
work hours 3 times more often than did the rest of the countries
and had a higher number of survey participants reporting <3
procedures per week. Of the respondents, 48% performed be-
tween 5 and 10 procedures each week. Residents from Mexico and
Venezuela reported the highest number of procedures per week
(>10) and participated in twice as many cases compared with the
rest of the group. The authority figure of a chief resident was
present in most programs (94%). Night shifts are a common
practice, with 46% of participants reporting 3 night shifts per
week; Venezuelan, Argentinian, Cuban, and Peruvian trainees
typically reported <3 night shifts per week, and 95% of the resi-
dents worked a regular day after call. A mosaic plot with the
distribution of the working hours and the number of procedures
per week is provided in Figure 2. Further information about
working conditions is included in Table 2 of Appendix B.
Teaching
Educational activities seem to follow a relatively traditional
scheme (theoretic classes and journal discussions). Less than 40%
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(which stands for male) shows the proportion of men
contributing to the sample in each country, the darker
the blue, the lower the proportion of male participants.
Our data show that even in the countries with fewer
male respondents, they were still barely less than 70%
(0.7) of the population in each country case.
of the responders reported having between 3 and 5 hours of
teaching per week. Mexico, Cuba, Brazil, and Venezuela are the
few countries reporting >10 teaching hours per week. Argentina
and Guatemala indicated the lowest number of teaching hours
each week. Only 34% of respondents reported having a mentor
(mentorship program) during their training. All Cuban re-
spondents reported a mentorship program. Argentina, Cuba, and
Venezuela also used this training modality for >50% of their
residents. Morbidity and mortality conferences were reported by
only 57% of trainees. Availability of away rotations was reported by
88% of the participants, especially from Mexico, Argentina, Cuba,
and Peru. These rotation opportunities were seldom reported by
trainees from Guatemala and El Salvador.
Subspecialty conferences were available to only 57% of re-
spondents. The average year during residency when trainees
started playing an active role in the operating room (OR) was 2.30

1 years. A notable geographic variation exists between countries
that promote early resident inclusion in the OR from the first year,
typically seen in Mexico, Cuba, Argentina, and Venezuela, and late
involvement in the OR (starting after the fourth year), as seen in
Bolivia and Peru.
Members’ overall evaluation of their residency program was
mostly favorable, rated on a scale from “1every deficient” to
“5eexcellent”; the results yielded an average of a 3.84
0.84,
equivalent to a minimum of “3eregular,” and a maximum of
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Figure 2. Distribution of procedures and work hours in
residency. The width of each bar (4 in total) represents
the proportion of respondents, with most (40.89%)
working 80e100 hours a week. The x-axis shows the
total number of working hours and the left y-axis the
numbers of procedures per week and right y-axis the
proportion of individuals in every case. Each color
“5eexcellent.” Programs scoring the highest (>60% of responses
being “4egood” and higher) were most often within Mexico, Cuba,
Argentina, and Brazil. The lowest scores (“2edeficient” or lower)
were reported in Nicaragua and Guatemala in >30% of cases.
In 78% of cases, residents performed 500 procedures during
their training. Programs from Mexico, Guatemala, Brazil, and Peru
reported the highest number of procedures (typically >1000) in at
least 25% of their residents, whereas some programs in Argentina
and Venezuela reported the lowest number of cases during
training (<500) for approximately 40% of their trainees. The
measured parameters in teaching are provided in Table 3 of
Appendix B.
Research and Meetings
Research activities were compulsory for 45% of the participants,
although allotted time for research is provided to only 18%. Of the
participants, 40% reported no publications during their residency,
particularly those from Mexico, Venezuela, and Peru.
A distribution between the number of indexed publications and
the number of (meeting/conferences) attended is seen in Figure 3.
Attendance at 1 meeting/conference per year is allowed for 46% of
residents, but funding provided by the institution was available in
only 32% of these cases, particularly in programs from Mexico,
Argentina, Cuba, and Brazil, which represented 80% of the
countries with such support. A distribution showing the
relationship between research exclusive programs and the
support for meetings is shown in Figure 4 (P ¼ 0.001). A
comprehensive outline of this relationship is included in Table 4
of Appendix B.
Economic and Social Benefits
Almost 10% of the respondents reported having to pay for their
training. Programs from Colombia, Chile, and the Dominican
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represents a different category in the number of
procedures (4 intervals in total). Programs with >100
work hours per week could still perform <3 procedures
per week in every case (red), whereas programs with
<60 work hours per week did not report being able to
perform >10 procedures in a week (bright yellow).
Republic typically charged tuition. Tuition was reported in Mexico
only for non-Mexican citizens. When a salary was available,
members were asked to evaluate their compensation with respect
to its ability to cover their basic needs on a scale of “1every
deficient” to “5eexcellent”. On average, members gave a score of
2.74
1.06. All participants from Chile and Costa Rica perceived
their salary as excellent, whereas Cuba showed the least satisfac-
tion with compensation from most of its participants (67%).
Despite being a predominantly male specialty, 78% of members
still perceive equality in opportunities for both sexes. Inequality
was mostly perceived by programs within Bolivia and the
Dominican Republic, as reported by 67% of its respondents. Both
paternity and maternity leave were offered by only half of the
training programs and were rarely available (25%) in Venezuela,
Guatemala, and Colombia. Mental health programs for the insti-
tutional staff were reported in only 20% of the cases. In Mexico,
Cuba, and Argentina, they were present in 30% of programs. The
surveyed data for Economic and Social Benefits is provided in
Table 5 of Appendix B.
Examinations
Institutions use annual examinations in 65% of cases. Only 55% of
members reported that their examinations were standardized.
Only 29% (mostly from Cuba, Brazil, Chile, and Paraguay) re-
ported satisfaction with the tools/methods used for evaluation.
National and international board certification examinations were
taken by 74% and 3% of members, respectively (mostly in Mexico,
Argentina, and Chile).
Rotations and Training Opportunities
Overall, cranial surgery was the predominant field of training in
most programs (85%), except for Colombia, Panama, and El Sal-
vador, which favored spine surgery, as reported by more than two

RICARDO MURGUIA-FUENTES ET AL.
Figure 3. Relation between the number of indexed
publications and the number of meetings per year
attended. The width of each bar represents the
proportion of respondents. The x-axis shows the total
publications and the left y-axis the numbers of
meetings per year and right y-axis the proportion of
Figure 4. Distribution of programs with protected
research time and support for meetings. The x-axis
shows programs with protected research time, and the
y-axis shows the proportion for the respondents who
replied “yes” or “no”. The color scale differentiates in
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individuals in every case. Each color represents a
different category in the number of meetings (4
intervals in total). Most (40.29%) reported no indexed
publications during residency, and those individuals
with at least 3 publications attended 1 meeting a year
according to our data.
each case who received support for meetings, showing
that programs with a protected time for research were
more likely to allow their trainees to attend meetings,
compared with programs without research protected
time.
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thirds of participants. Only 39% of respondents reported fellow-
ship opportunities in their training institution, most (50%) being
from Mexico, Argentina, Cuba, and Brazil.
Joining an overseas rotation during residency with institutional
support (Mexico, Argentina, and Brazil) was reported in 34%. In
43% of the cases, the rotations were arranged by residents without
the aid of their home institution.
The final 2 data sets were obtained by asking participants, in an
open answer format, “Where in Latin America would you wish to
pursue surgical training to complement their skills?”, then,
“Where in the World would you wish to pursue further training?”
Brazil was, by far, the most requested place to train in Latin
America. Worldwide, the United States was the top choice (17%),
followed by Germany (9%) and Spain (6%). Details from the most
requested countries for rotations are shown in Figure 5.
DISCUSSION
Despite Latin America’s considerable population of neurosur-
geons, and their contributions to neurosurgery, there is a scarcity
of available published data on the various conditions that affect
the development of neurosurgery residents pursuing accreditation
in this part of the world.
This pioneer study serves to assess the aspects of training,
education, working conditions, and research activities across Latin
America and compares them with previously published data
concerning neurosurgical residency conditions in other countries.
It is our hope that this kind of analysis will strengthen training
programs by bringing to light the challenges, desires, and views of
neurosurgery residents, allowing them to homogenize their
approach to training and foster more collaboration on a global
scale.
Working conditions in Latin American residencies proved to be
harsh. Most neurosurgery residents are overworked, with pay that
barely covers their basic needs. Mental health programs are not
available at most of the training institutions, and in 2/3 of cases,
neither is a mentor. These conditions, occurring simultaneously,
can give rise to burnout. Affecting up to 70% of physicians and
residents worldwide, burnout is particularly detrimental in the
practice of neurosurgery, because it is associated with adverse
physical health, increased risk of substance abuse, and medical
errors.
Latin American residents typically work >80 hours a week, and
one third of respondents put in >100 hours a week. Over the course
of a 6-year to 7-year residency, the risk of succumbing to burnout is
significant. In the United States, an attempt is made to reduce these
effects by limiting residency hours to 80 per week. Despite such
efforts, burnout has been reported in 67% of U.S. neurosurgery
residents.4 Data from a survey of 500 European neurosurgery
residents5 proved that <40% of them were satisfied with the 48-
hour work week of the European time directive. Neurosurgery is
certainly a specialty that requires a considerable amount of time
for adequate training, and although implementation of reduced
hours regulations in countries such as the United States resulted
in a positive effect,6 it remains unknown how this would be
received in Latin America. The workload during residency
training in Latin America is most likely related to an excessive
number of patients managed by providers and the limited
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availability of subspecialty care. A short-term or even midterm so-
lution to this issue is complex considering the financial resources of
the health care systems. No study has addressed the correlation of
burnout rate to hours worked by Latin American neurosurgery
residents; thus, further study into this matter should be of great
interest. There is the possibility that the surgeons who did not
respond to this item represent part of this concern. Implementation
of mental health support for institutional staff is also an effective
measure to help curb burnout.7 This survey highlighted the fact that
almost 80% of residents lack such support. Furthermore, programs
with a culture of scheduling residents to work the day after a night
shift are also less likely to have a mental health support program for
staff. Considering the workload, and the psychological effects of
residency, it certainly does not help that residents perceive their
salaries as barely sufficient to cover their basic needs. In some
cases, residents are paying the institution, rather than being
compensated for their work. This wide disparity in pay could be
subject of future study because it may be a consequence of social
and economic health care disparities across countries.
Recent data8 have shown a stark increase in female neurosurgical
residents as well as an increasing number of women joining
organized neurosurgery. Although there were no significant
differences in responses between genders, gender inequality was
perceived by 22% of the participants. Women in neurosurgery
face complex challenges and have been historically isolated from
the field. Working around the challenge of supporting a family as
a female neurosurgeon requires understanding and
encouragement and must become part of the workplace culture.
Several studies have shown how effective mentorship plays a
critical role in the professional growth and performance of resi-
dents.9,10 Latin American programs use mentorship programs in
only 1/3 of the survey population. Implementation of a mentorship
program is easily accomplished and could benefit the develop-
ment of residents.
Evaluation analysis and repeated examinations have a critical role
in training. The use of standardized examinations, for example, and
computer-based testing has shown benefits in both learning and
examination performance.11 More than 70% of the respondents
were unsatisfied with the current methods/tools of evaluation.
These metrics across Latin America (Table 6 in Appendix B)
varied widely, leaving most trainees without feedback about their
performance. One potential solution would be to develop a
standardized examination across members of FLANC, such as the
primary board examination developed by both the American
Board of Neurological Surgery and the European Association of
Neurosurgical Societies, which evaluates knowledge and provides
direction for continued learning. As shown in the present study,
there are various differences in training programs across Latin
America. In addition, the certification process is different,
ranging from rigorous requirements to none at all12 (see
Supplementary Figure 1). Current ongoing efforts from FLANC
representatives include the creation of a common academic
program across all countries allowing future improvement in
training and the certification process, which is currently well
established only in Brazil and Mexico.
The adaptation and identification of specific neurosurgery
training programs according to specific necessities of particular
countries could also enhance learning by allowing residents to

RICARDO MURGUIA-FUENTES ET AL.
Figure 5. Requested training and rotations in Latin
America and worldwide. The x-axis shows each
country that was mentioned by the respondents as
their desired country and the y-axis is the proportion of
the individuals. The graph does not show the
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proportion of individuals who did not reply in the case
of Latin America (42.74%) and worldwide (58.37%),
leaving a total response of 57.26% for Latin American
rotations and 41.63% worldwide.
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RICARDO MURGUIA-FUENTES ET AL.
spend time in both specialty centers that routinely manage complex
conditions (e.g., skull base, vascular, endovascular, functional,
radiosurgery) as well as community programs to allow exposure of
common conditions. Such a task is challenging but can be achieved
via collaboration between programs and countries.
Morbidity and mortality conferences are critical for ongoing
education. It is surprising that just 58% of the respondents indi-
cated the presence of a formal morbidity and mortality conference.
The implementation of these activities has a clear positive impact
on outcomes, safety, and quality of care and should be considered
across all institutions.13,14
Another point of discussion is that 40% of all residents were not
academically productive during training. The results of the survey
showed correlation between indexed publications and conference/
meeting attendance. Furthermore, there is also a correlation be-
tween institutional support for conference attendance and allotted
time for research, proving that institutional support is related to
academic productivity. Programs that have an established fellow-
ship program also supported their residents more in obtaining
their own rotation opportunities. Given that rotations in epilepsy,
pediatrics, spine trauma, radiosurgery, and peripheral nerve sur-
gery were underrepresented, national and international collabo-
ration and exchange rotations could allow residents to gain
experience in these areas (Table 7 in Appendix B). Increasing
resident exposure to simulated training and neuroanatomy
laboratories can provide targeted coaching in areas of weakness
and buffer against the steep learning curve faced in achieving
competency in this highly complex specialty.15,16
There is a clear tendency in Latin American programs to favor
training in cranial procedures, leaving many residents without
adequate proficiency in complex spine procedures. Only half of
survey respondents attended rotations in spinal trauma (54%) and
even fewer respondents attended a peripheral nerve surgery rota-
tion (32%). To allow for development of neurosurgery residents to
become fully competent spine surgeons by the end of training,
Latin American programs should emphasize greater focus on
spine training through either exchange rotations or formal
enfolded fellowship programs.
The most desired training center within Latin America,
according to the study, is Brazil. Since the 1970s Congress in
Brasilia, the Brazilian Society of Neurosurgery (Sociedad Brasileira
de Neurocirurgia) has made profound efforts to regulate the
training and qualifications for specialization in neurosurgery,17
and the current system suggests better performance. Although
the specific reason for such strong popularity is unknown, it
could be Brazil’s reputation for surgical skills, prominent
institutions, or the internationally recognized neurosurgeons
known for accepting international fellows under their tutelage.
On a global level, the most desired training location is the
United States. Neurologic surgery training in the United States is
overseen by the Accreditation Council for Graduate Medical Edu-
cation, granting residents specific supervision policies, work hour
restrictions, and a milestones-based curriculum. Prestige of the
programs, world-renowned institutions, and economic compen-
sation may also contribute to this favorable response.
Although this study highlighted the challenges of neurosurgery
training, most respondents believed that their academic programs
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were more than satisfactory. Of respondents, 43% did not choose
a different desired training location within Latin America, and
59% did not choose a different location worldwide, signifying a
strong endorsement for their respective programs.
Limitations
Although 970 e-mails were sent, only 276 responses (28%) were
received. Some questions required deep thought to provide an
answer, and this could have had an impact on the number of re-
sponses. Even with the diversity of FLANC members, and support
from the SBN’s (Brazilian Society of Neurosurgery) Brazilian com-
munity, most responses came from Mexican neurosurgeons and
residents. There was a concern that the data presented in the study
may not be representative of all countries in Latin America. None-
theless, statistical analysis of the data showed that responses from
Mexican participants did not differ significantly from other coun-
tries. It is remarkable, in demographic terms, that the use of the
database of the World Bank and World Federation of Neurosurgical
Societies Workforce in 201618,19 showcased that we obtained a bigger
than expected representation of countries with apparently fewer
participants, as in the case of Guatemala with 29%, Venezuela with
30%, and Panama with 38%, because of its considerably smaller
population compared with Mexico, in which we reached 27% of the
workforce of neurosurgeons. We also found several disparities,
particularly in programs from Mexico, in terms of work hour regu-
lations, satisfaction, and number of procedures performed, which is
expected considering differences in individual programs.
CONCLUSIONS
This study was the first of its kind to assess the characteristics of
Latin American neurosurgery training, based on the member
countries of FLANC. This population encompasses highly profi-
cient, trained neurosurgeons who are competitive in terms of in-
ternational standards. However, there are still a few issues related
to working conditions, economic and social benefits, teaching
modalities, and the implementation of effective research programs
that need to be addressed. Armed with the data and comparisons
discussed in this study, each country has the ability to improve
specific elements of their respective programs, thereby strength-
ening the quality of training and encouraging collaboration be-
tween nations. It is the duty of each society, and of its leading
educators, to come together and promote collaboration within
their specialties, homogenizing both training and patient care
worldwide. This study allows the Latin American neurosurgical
community to move 1 step closer to that goal.
ACKNOWLEDGMENTS
We would like to extend our gratitude to all survey respondents for
their time, assistance, and generous support in making this study
possible.
In addition, we would also like to thank the following groups/
individuals:
 FLANC, La Sociedad Brasileira de Neurocirurgia, and Priscila
Calvante for their efforts in increasing the circulation of the survey.
 Jose Murguia-Fuentes, for his contribution to the statistical
analysis.

RICARDO MURGUIA-FUENTES ET AL.
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Conflict of interest statement: The authors declare that the
article content was composed in the absence of any
commercial or financial relationships that could be construed
as a potential conflict of interest.
Received 19 July 2018; accepted 31 August 2018
Citation: World Neurosurg. (2018) 120:e1079-e1097.
https://doi.org/10.1016/j.wneu.2018.08.232
Journal homepage: www.WORLDNEUROSURGERY.org
Available online: www.sciencedirect.com
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Appendix A. Survey Sent to the FLANC Country Member Participants

Training in Neurosurgery

Section 1: Demographic background

Questionnaire items Choices
1. What is your gender? B Male
B Female

2. What is your age now (in years)? Numerical

3. In which country did you complete your neurosurgery residency training? B Argentina B Guatemala
B Bolivia B Honduras
B Brazil B Mexico
B Chile B Panama
B Colombia B Peru
B Costa Rica B Dominican Republic
B Cuba B Uruguay
B Ecuador B Venezuela
B El Salvador

4. How long was your residency program (in years)? B 4 years

B 5 years
B 6 years
B 7 years

5. Did your school require a full, or partial, general surgery B Full accreditation
program accreditation to apply for neurosurgery residency? (If answering “Not B Partial accreditation
Required,” skip question 6)
B Not required

6. How much of an accreditation in general surgery did your residency program B 1 year
require to apply? B 2 years
B Full general surgery course

Section 2: Work conditions

Questionnaire items Choices
7. On average, how many hours per week does a neurosurgery resident work in the B Fewer than 60 hours per week
program you attended? B 60e80 hours per week
B 80e100 hours per week
B More than 100 hours per week

8. In an average week, how many procedures did you perform? B Fewer than 3 per week
B 3e5 per week
B 5e10 per week
B More than 10 per week

9. Is there a “Chief Resident” in your program? B Yes

B No

10. On average, how many night shifts per week are mandatory for your program? B 1 per week
B 2 per week
B 3 per week
B More than 3 per week

Continues

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Appendix A. Continued
Training in Neurosurgery

11. Does the hospital allow you to take the day off after a night shift? B Yes
B No

Section 3: Teaching
Questionnaire items Choices
12. Did a tutoring or mentorship program exist at your institution? B Yes
B No

13. Did your residency program allow you to participate in rotations outside the B Yes
principal hospital? B No

14. Which of the following activities were part of the training program in your , Theoretical classes
institution? (You can mark more than one choice) , Medical cases discussion
, Analysis of scientific articles
, Multidisciplinary conferences (neurology, endocrinology, radiology,
and ophthalmology)
, Subspecialty conferences (neuro-oncology, epilepsy surgery vascular
surgery, spine surgery, functional surgery, pediatric surgery)

15. How many hours a week did you spend in the educational activities listed in B Less than 1 hour per week
Question #14 at your institution? B 1e3 hours per week
B 3e5 hours per week
B 5e10 hours per week
B More than 10 hours per week

16. In which year of the residency program did you start taking on an active role in B 1st year B 5th year
the B 2nd year B 6th year
operating room?
B 3rd year B 7th year
B 4th year

17. How would you score your institution’s academic program? B 1 Very deficient
B 2 Deficient
B 3 Satisfactory
B 4 Good
B 5 Excellent

18. Estimate the number of surgical cases in which you participated throughout your B Fewer than 250
residency program. B 250e500
B 500e750
B 750e1000
B More than 1000

Section 4: Research and meetings

Questionnaire items Choices
19. In your residency program, research activities and/or conference attendance was B Obligatory
considered: B Optional
B Not included in my program

20. Was there a specific period allotted to you for research activities in your B Yes
program? B No
*In positive case, specify how long?

Continues

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Appendix A. Continued
Training in Neurosurgery

21. How many articles were you able to publish in medical journals during your B None
residency program? B 1e2
B 3e4
B More than 4

22. How many medical conferences were you allowed to attend in any given year? B None
B 1
B 2
B 3
B More than 3

23. Did your residency program support you in attending conferences? B Yes
B No

Section 5: Economic and social benefits

Questionnaire items Choices
24. Did you receive financial compensation during your residency? B Yes (Go to question 25)
B No financial compensation, but no cost for residency program either
(Go to question 26)
B No compensation, and paid to attend the residency program (Go to
question 26)

25.- On a scale of 1 e 5, how well did your institution’s financial compensation B 1 Poorly
(salary) cover your basic needs? B 2 Barely
B 3 Covers basic needs
B 4 Well
B 5 Very well

26. Do you think residents of both sexes were being granted the same opportunities B Yes
during residency? B No

27. Does your program offer maternity and/or paternity leave? B Maternity
B Paternity
B Both
B None

28. Was there a mental health support program available to the staff at your B Yes
institution? B No

Section 6: Examinations
Questionnaire items Choices
29. Which of the following types of evaluation modalities were used by your , No examinations
institution? (You can mark more than one choice) , Annual examinations
, Biannual examinations
, Self-examination
, “Standardized Knowledge” examination
, Opportunity for students to evaluate their instructors

Continues

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Appendix A. Continued
Training in Neurosurgery

30. Do you consider your program’s current evaluation tools adequate? B Yes
B No

31. What type of examinations were used by your program? (You can mark B Respective coordinator examination of the rotation
more than one choice) B Department examinations
B National certifications
B International certifications

32. Was there a national certification exam that accredits your specialty? B Yes
B No

Section 7: Medical rotations and training opportunities

Questionnaire items Choices
33. Were cranial or spinal neurosurgery cases more predominant within your B Cranial surgery
institution? B Spine surgery

34. From the following options, please select the training areas included within your , Cranial tumors in adults
program. (You can mark more than one choice.) , Cranial trauma in adults
, Epilepsy surgery in adults
, Skull base surgery
, Vascular cranial neurosurgery
, Endovascular neurosurgery
, Radiosurgery
, Spine surgery
, Awake craniotomy and brain mapping
, Pain management neurosurgery
, Sellar and parasellar tumors
, Spine trauma in adults
, Cervical decompression and stabilization techniques
, Lumbar discectomy
, Thoracolumbar fusion
, Pediatric cranial tumors
, Pediatric cranial trauma
, Pediatric spine surgery
, Pediatric epilepsy surgery
, Pediatric ventriculoperitoneal (VP) shunt placement
, Adult VP shunt placement
, External ventricular drain placement
, Intensive care
, Neuroanatomy lab
, Surgical lab
, Electrophysiology
, Simulation rooms
, Overseas rotation
, Other

Continues

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Appendix A. Continued
Training in Neurosurgery

35. Did your residency program offer rotation opportunities overseas? B Yes
B No

36. Did your program support you in arranging an overseas rotation of your choosing? B Yes
B No

37. Did your institution regularly employ trainees for fellowship programs? B Yes
B No

38. Within Latin America, what institution would you consider to be the most ideal Open answer
location for you to receive neurosurgical residency training?
39. Now, on a global scale, what institution would you consider to be the most Open answer
ideal location for you to receive neurosurgical residency training?

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APPENDIX B
Table 2. Working Conditions
Working Hours per Week (%)

Table 1. Demographics of Survey Respondents <60 2.23

60e80 25.27
Overall Survey Response Rate (%)
80e100 40.89
Number of surveys distributed (n) 970
>100 31.59
Number of responses, n (%) 276 (28.45)
Surgical procedures in operating room per week (n)
Number of surveys in analysis, n (%) 269 (27.73)
<3 1.85
Sex
3e5 30.85
Male 87.26
5e10 48.32
Female 12.73
>10 18.95
Age (years) 36.63
7.38
Chief residency coordinator
Medical residency training country
Yes 93.68
Argentina 10.40
No 6.31
Bolivia 1.11
Night shifts per week (n)
Brazil 4.46
1 9.29
Chile 2.23
2 30.85
Colombia 3.34
3 46.46
Costa Rica 0.74
More than 3 13.38
Cuba 6.31
Day off after night shift
Dominican Republic 1.11
Yes 4.46
Ecuador 2.97
No 95.53
El Salvador 1.11
Guatemala 3.34
Mexico 48.32
Panama 0.74
Peru 4.46
Uruguay 0.37
Venezuela 7.43
Residency duration 5.1
0.65 years
Previous general surgery program
Total 4.47
Partial 64.17
Not required 31.34
Time required in general surgery
1 year 85
2 years 10.55
Full specialty 4.44

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Table 3. Teaching Table 4. Research and Meetings

Mentorship Program Research on Residency Program (%)
Yes 33.95 Compulsory 45.14
No 66.04 Optional 42.16
Local rotations outside institution None 12.68
Yes 88.47 Exclusive period for research
No 11.52 Yes 17.91
Teaching tools, n (%) No 82.08
Theoretic classes 235 (87.36) Indexed publications
Morbidity and mortality conference 155 (57.62) 0 40.29
Journal discussion 216 (80.30) 1e2 34.70
Multidisciplinary conferences 188 (69.89) 3e4 19.40
Subspecialty conferences 153 (56.88) >5 5.59
Teaching hours per week Meetings allowed per year
<Fewer than 1 4.08 0 7.43
1e3 27.50 1 45.72
3e5 39.03 2 31.22
5e10 25.27 3 6.69
>10 4.08 >3 8.92
Year of start of active role in operating room 2.30
1 Program support for meetings
Academic program evaluation 3.84
0.84 Yes 32.34
Number of procedures during residency No 67.65
<250 2.60
250e500 18.58
500e750 26.39
750e1000 26.76
>1000 25.65

Values are % except where indicated otherwise.

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Table 5. Economic and Social Benefits Table 6. Examinations/Evaluations

Payment in Residency (%) Tools Used for Evaluation
Income 84.70 No tools 10 (3.71)
No income 5.59 Annual evaluation 175 (65.05)
No income þ fee 9.70 Biannual evaluation 84 (31.23)
Cover of basic needs 2.74
1.06 Self-evaluation 41 (15.24)
Sex equity in program Standardized evaluation 149 (55.39)
Yes 78.35 Evaluation of teachers 44 (16.36)
No 21.64 Satisfaction with current tools (%)
Paternity/maternity leave Yes 28.83
Paternity 3.34 No 71.16
Maternity 27.13 Type of examinations
Both 53.53 Teacher examination 153 (56.88)
None 15.98 Department examination 140 (52.04)
Mental health program National certification 118 (43.87)
Yes 21.93 International certification 7 (2.60)
No 78.06 International board examination (%)
Yes 73.60
No 26.39

Values are number (%) except where indicated otherwise.

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Table 7. Rotations and Training Opportunities Table 7. Continued

Predominant Type of Surgery Program No 60.59

Cranial 84.75 Request training in Latin America

Spine 15.24 Brazil 36.06

Rotations Argentina 9.29

Adult cranial tumors 242 (89.96) Mexico 6.32

Adult cranial trauma 210 (78.10) Colombia 2.97

Adult epilepsy surgery 103 (38.29) Peru 0.37

Skull base surgery 186 (69.14) Uruguay 0.37

Cranial vascular surgery 208 (77.32) No reply 42.74

Endovascular surgery 119 (44.24) Training outside Latin America

Radiosurgery 65 (24.16) United States 17.10

Spine surgery 224 (83.27) Germany 8.92

Awaken craniotomy/mapping 95 (35.32) Spain 5.95

Pain surgery 77 (28.62) France 3.72

Sellar and parasellar tumor 212 (78.81) Canada 2.60

Adult spine trauma 146 (54.28) Japan 1.86

Peripheric nerve surgery 87 (32.34) Finland 0.37

Cervical decompression 168 (62.45) Belgium 0.37

Lumbar discectomy 211 (78.44) Russia 0.37

Thoracolumbar fusion 151 (56.13) Switzerland 0.37

Pediatric cranial tumors 166 (61.71) No reply 58.37

Pediatric cranial trauma 165 (61.33) Values are % or number (%).

Pediatric spine surgery 33 (12.27)

Pediatric epilepsy surgery 64 (23.79)
Pediatric ventriculoperitoneal shunt 189 (70.26)
Adult ventriculoperitoneal shunt 221 (82.16)
External ventricular drainage 95 (35.32)
Intracranial pressure monitor 65 (24.16)
Intensive care 182 (67.66)
Neuroanatomy laboratory 73 (27.14)
Surgical laboratory 61 (22.68)
Electrophysiology 81 (30.11)
Simulation room 9 (3.35)
Overseas rotation by program
Yes 33.82
No 66.17
Independent overseas rotation
Yes 42.91
No 57.08
Fellowship program in institution
Yes 39.40

Continues

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Board Written Oral Procedures

Country Examination Examination Examination log
Argentina ? ✓ ✓ ?
Bolivia ? ? ? ?
Brazil ✓ ✓ ✓ ✓
Chile ✓ ✓ ✓ ?
Colombia ? ? ?
Costa Rica ✓ ?
(Not
compulsory)
Cuba ✓ ? ? ?
Dominican ✓ ? ? ?
Republic
Ecuador ? ? ? ?
El ? ? ? ?
Salvador
Guatemala ? ? ? ?
Mexico ✓ ✓ ✓ ✓
Nicaragua ? ? ?
Panama ? ? ?
Paraguay ✓ ? ? ?
Peru ? ? ? ?
Uruguay ✓ ? ?
Venezuela ? ? ? ✓
Supplementary Figure 1. Certification process in counts with the mentioned feature on their programs,
selected places in Latin America. The countries listed whereas the cross mark (#) indicates the lack of it; the
are those that have confirmed these data in the current question mark indicates that the information was
literature, including the most common procedures for unavailable or is unknown.
certification. The check mark (U) indicates the country

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