Original Article
The Path to U.S. Neurosurgical Residency for Foreign Medical Graduates: Trends from a
Decade 2007e2017
Ankush Chandra1, Michael G. Brandel2, Harsh Wadhwa1, Neil D. Almeida1, John K. Yue1, Mohammed O. Nuru1,
Justin Cheng1, Shannon Lu1, Akshar Patel1, Walid Ibn Essayed3, Michael W. McDermott1, Mitchel S. Berger1,
Manish K. Aghi1
- OBJECTIVE: The increasing competitiveness of the
neurosurgical residency match has made it progressively
difficult for foreign medical graduates (FMGs) to match in
neurosurgery. We compared FMG to U.S. medical graduate
(USMG) match rates in neurosurgery and identified factors
associated with match outcomes for FMGs in neurosurgery.
- METHODS: Retrospective review of American Associa-
tion of Neurological Surgeons membership data and As-
sociation of American Medical Colleges Charting the
Outcomes match reports (2007e2017).
- RESULTS: Across 1857 neurosurgical residents (USMG:
91.1%, FMG: 8.9%), average FMG match rates were 24%
(range, 15%e35%) versus 83% (range, 75%e94%; P < 0.001)
for USMG. FMGs were more male (89.5% vs. 82.0%, P [
0.016), older (33.9 vs. 31.8 years, P [ 0.008), and more likely
to take research year(s) before matching (95.8% vs. 78.5%,
P < 0.001). FMGs had greater publications (5 vs. 2, P < 0.001)
and H-indices (3 vs. 1, P < 0.001). The number of matched
USMGs increased by 3.3 annually, whereas that of matched
FMGs remained unchanged (b [ 0.07). Compared with
USMGs, FMGs were less likely to match to National In-
stitutes of Health (NIH) Top 40 (32.7% vs. 47.5%, P < 0.001)
and Doximity Top 20 (20.0% vs. 29.0%, P [ 0.014) programs.
FMGs with prior U.S. neurosurgery program affiliation were
Key words
- FMG
- Foreign medical graduates
- IMG
- International
- International medical graduates
- Match
- Neurosurgery
- National Residency Match Program
- Residency
Abbreviations and Acronyms
AANS: American Association of Neurological Surgeons
BRIMR: Blue Ridge Institute for Medical Research
FMGs: Foreign medical graduates
NIH: National Institutes of Health
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more likely to match at NIH and Doximity Top 20 programs
(P < 0.05). For NIH programs, FMGs were older (35.3 vs. 32.0,
P [ 0.011), had higher H-indices (5 vs. 2, P < 0.001), pub-
lications (7 vs. 2, P < 0.001), and were more likely to take
research year(s) (94.4% vs. 76.0%, P [ 0.002) than USMGs.
FMGs had similar patterns for matching into Doximity Top
20 programs.
- CONCLUSIONS: Although FMGs have lower match rates
into U.S. neurosurgery residencies than USMGs, several
demographic, professional, and academic factors could in-
crease the chances of successful FMG neurosurgical match.
INTRODUCTION
F oreign medical graduates (FMGs) comprise a large pro-
portion of U.S. practicing physicians and can help narrow
the gap of the U.S. physician workforce, particularly in
geographically underserved areas.1,2 Indeed, nearly 1 in 4
physicians currently practicing in the United States trained at a
foreign medical school.3 Many FMGs enter the U.S. workforce
during residency, with over 22% of active medical residents in
the U.S. as FMGs. In contrast, only 8% of active neurosurgery
residents are FMGs, although 12% of practicing U.S.
neurosurgeons are FMGs.4 While there is a growing need for
USMGs: U.S. medical graduates
USMLE: U.S. Medical Licensing Examination
From the 1Department of Neurological Surgery, University of California San Francisco, San
Francisco, California; 2Department of Neurosurgery, University of California San Diego, La
Jolla, California; and 3Department of Neurosurgery, Brigham and Women’s Hospital, Harvard
Medical School, Boston, Massachusetts, USA
To whom correspondence should be addressed: Manish K. Aghi, M.D., Ph.D.
[E-mail: manish.aghi@ucsf.edu]
Ankush Chandra and Michael G. Brandel contributed equally.
Citation: World Neurosurg. (2020).
https://doi.org/10.1016/j.wneu.2020.02.069
Journal homepage: www.journals.elsevier.com/world-neurosurgery
Available online: www.sciencedirect.com
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ANKUSH CHANDRA ET AL.
neurosurgeons in the United States,5,6 the limited number of U.S.
residency spots and the fact that nearly 15% of U.S. medical
graduates (USMGs) do not match in neurosurgery creates
understandably high barriers to successful matriculation of
FMGs into U.S. neurosurgery training programs.7 The
neurosurgery match rate for first-time USMGs in 2018 was
86.4%, compared with 23.3% for FMGs.8 Historically, FMG
acceptance into surgical residency programs has been
difficult.9,10 FMGs that matched into a surgical residency held
more advanced degrees, produced more research works, and
had a higher average U.S. Medical Licensing Examination
(USMLE) step 1 score than U.S. graduates.11,12
Interestingly, FMGs who match into surgical specialties
perform similarly to USMGs on skills assessments and have
comparable clinical outcomes.13,14 Some studies have shown
that FMGs out-performed their American counterparts on in-
training examinations.15 After completing residency, academic
neurosurgeons who trained in foreign medical schools have
comparable academic career success to that of U.S.-trained
neurosurgeons.16 Despite the abundance of literature on
FMGs in other medical specialties, there is a paucity of
information on the outcomes for foreign-trained neurosurgery
residency applicants. Therefore, we analyzed temporal trends in
the FMG neurosurgical match and compared them to USMGs.
We characterized and compared FMG neurosurgery residents to
their USMG counterparts over the past decade and identified
factors among FMG applicants that may lead to greater success
in the neurosurgery residency match. To our knowledge, this
study is the first of its kind to analyze trends in the FMG
neurosurgery match and identify factors associated with match
outcomes and, as such, it can provide guidelines to current
FMG applicants, their advisors, and programs evaluating them
for training spots about metrics that successful FMGs have
exhibited in the past.
METHODS
Cohort Selection of Neurosurgical Residents
Retrospective analysis of membership data collected from
the American Association of Neurological Surgeons (AANS) was
performed, which included all neurosurgical residents during the
study period, as AANS provides complimentary memberships to all
North American neurosurgical residents. Neurosurgical residents
who graduated between 2007e2017 were assessed for age, sex, ac-
ademic degrees, medical school, medical school graduation date,
research year(s) during or after medical school and before residency,
residency program, residency start and graduation dates, and cur-
rent location/affiliation. Country and continent of medical school,
prior residency training, and prior affiliation to U.S. neurosurgery
programs were manually collected from the resident homepages on
neurosurgery residency program websites. Prior affiliation to U.S.
neurosurgery programs included basic science research, clinical
research, clinical fellowships, preresidency fellowships, and faculty
position in a neurosurgery department.
H-Index and Publication Records
Scopus was used to determine the number of publications and
H-index for each individual prior to residency matriculation.17
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ORIGINAL ARTICLE
FMGS IN NEUROSURGERY
Defining Top Neurosurgery Residency Programs
To define top residency programs, 3 different categories were
used: 1) Top 40 National Institutes of Health (NIH)-funded
institutions,18 2) Blue Ridge Institute for Medical Research
(BRIMR) ranking of neurosurgery departments based on total
annual NIH funding,19 and 3) Doximity ranking, all for the year
2018.20 Definition of top neurosurgery residency programs for
the purpose of our multivariate analysis is any resident that
matched into either of the 3 categories of a top program.
Temporal Trends in Neurosurgery Match
Numbers of applicants and matches in neurosurgery for both
USMGs and FMGs were collected from the National Residency
Matching Program Charting the Outcomes reports (2009e2017), and
San Francisco Residency and Fellowship Match data (2007e2008).
Using univariate linear regression, trends over time were analyzed
for USMGs and FMGs matching into neurosurgery.
Inclusion and Exclusion Criteria
For the primary analysis of AANS data, we included all individuals
who matriculated into a neurosurgical residency program in the
United States from 2007e2017. Residents were classified as
USMGs if they attended medical school in the United States, and
FMGs if they attended medical school outside of the United States.
Due to limited availability of data for Canadian neurosurgical
residents, our study did not include that cohort. For secondary
analysis of Association of American Medical Colleges data, we
included all individuals matching to a U.S. neurosurgical resi-
dency between 2008 and 2017.
Statistical Analyses
Statistical analysis was completed using Stata MP version 14.1
(Stata Corp LP, College Station, TX, USA) and R version 3.5.0
(The R Foundation, Vienna, Austria). Characteristics of USMGs
and FMGs were compared using independent samples t-tests, 1-
way analysis of variance, or the Wilcoxon rank-sum tests for
continuous variables, and the Pearson c2 test for categorical
variables. Means or medians were reported for continuous vari-
ables, and proportions were reported for categorical variables.
Unstandardized coefficients (b) were reported for linear regres-
sion. Multivariate stepwise linear regression analysis was
performed to determine factors predictive of successful FMG
neurosurgery match at a top neurosurgery program. All tests
were 2-sided, with statistical significance defined as P
0.05.
The rworldmap package in R was used to generate a geographic
density map of FMG medical school countries. Missing values
for categorical variables in Table 1 were omitted from univariate
statistical comparisons.
RESULTS
Full Cohort Characteristics
In total, 2009 neurosurgical residents were examined for eligi-
bility, and 1857 met inclusion criteria (Table 1). Exclusions
occurred for the following reasons: outside of study period dates
(n ¼ 13), duplicate entries due to multiple residency institutions
(n ¼ 62), and unknown FMG status (n ¼ 77). Residents were
82.7% (n ¼ 1512) male, and 17.3% (n ¼ 317) female. The mean
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.02.069
 ORIGINAL ARTICLE
ANKUSH CHANDRA ET AL. FMGS IN NEUROSURGERY

Table 1. Resident Demographic and Preresidency Information

Factor All USMG FMG P Value

Number 1857 1692 165

Sex 0.016
Female 317 (17.3%) 300 (18.0%) 17 (10.5%)
Male 1512 (82.7%) 1367 (82.0%) 145 (89.5%)
Age, mean (SD) 32.06 (7.80) 31.82 (7.81) 33.94 (7.03) 0.008
H-index, median (IQR) 1 (0, 4) 1 (0, 3) 3 (0, 7) <0.001
Number publications, median (IQR) 2 (0, 5) 2 (0, 4) 5 (1, 15) <0.001
Gap year <0.001
None 370 (19.9%) 363 (21.5%) 7 (4.2%)
HHMI/Doris Duke/NIH/Sarnoff 66 (3.6%) 64 (3.8%) 2 (1.2%)
Degree 151 (8.1%) 132 (7.8%) 19 (11.5%)
Preresidency fellowship/preliminary year 56 (3.0%) 26 (1.5%) 29 (17.6%)
Nonfunded research 46 (2.5%) 14 (0.8%) 32 (19.4%)
Unknown 1168 (62.9%) 1093 (64.6%) 76 (46.1%)
Gap year 1487 (80.1%) 1329 (78.5%) 158 (95.8%) <0.001
Primary degree <0.001
M.D. 1777 (95.7%) 1668 (98.6%) 109 (66.1%)
D.O. 24 (1.3%) 24 (1.4%) 0 (0.0%)
M.B.B.S./M.B.B.Ch. 56 (3.0%) 0 (0.0%) 56 (33.9%)
Master's degree (misc) 56 (3.0%) 52 (3.1%) 4 (2.4%) 0.64
M.P.H./M.H.S./M.S.P.H. 27 (1.5%) 23 (1.4%) 4 (2.4%) 0.28
Ph.D. 159 (8.6%) 142 (8.4%) 17 (10.3%) 0.40

USMG, U.S. medical graduate; FMG, foreign medical graduate; SD, standard deviation; IQR, interquartile range; HHMI, Howard Hughes Medical Institute; NIH, National Institutes of Health.

age at the beginning of residency was 32.1  7.8 years. The median
H-index was 1 (interquartile range [IQR] 0e4), and the median
number of publications was 2 (IQR 0e5). Residents took
research year(s) prior to starting residency 80.1% of the time,
with 3.6% (n ¼ 66) having a research fellowship sponsored by
Howard Hughes Medical Institute, NIH, Doris Duke Foundation,
or the Sarnoff Foundation; 8.1% (n ¼ 150) acquiring an
advanced degree; 3% (n ¼ 55) doing a preresidency fellowship
or a surgical preliminary year; 2.5% (n ¼ 46) doing unfunded
research, and 63% (n ¼ 1170) having a gap year with unavailable
detail. Primary clinical degrees were 95.7% (n ¼ 1777) M.D.,
1.3% (n ¼ 24) D.O., and 3.0% (n ¼ 56) M.B.B.S./M.B.B.Ch.
Additional graduate degrees included a research master's degree
(n ¼ 56; 3.0%), M.P.H./M.H.S./M.S.P.H. (n ¼ 27; 1.5%), or
Ph.D. (n ¼ 159; 8.6%).
Residents were 91.1% USMGs (n ¼ 1692), and 8.9% FMGs (n ¼
165). The proportion of female residents was lower among FMGs
than USMGs (10.5% vs. 18.0%, P ¼ 0.016). FMGs were older than
USMGs (33.9 vs. 31.8 years, P ¼ 0.008) and were more likely to
take research year(s) (95.8% vs. 78.5%, P < 0.001). FMGs had
more published articles (5 vs. 2, P < 0.001) and higher H-index (3
vs. 1, P < 0.001) at the start of residency. There was no statistical
difference in the proportion of residents with master's degrees/
Ph.D.s between FMGs and USMGs.
FMG Cohort Characteristics
The continental distribution of medical schools for FMGs
matching into U.S. neurosurgical residency was 45.5% (n ¼ 75)
Asia, 24.8% (n ¼ 41) Europe, 15.2% (n ¼ 25) North America,
7.3% (n ¼ 12) South America, 4.2% (n ¼ 7) Africa, and 1.2% (n ¼
2) Australia (Table 2; Figure 1). Data were unavailable for 3 FMGs
(1.8%). Interestingly, 13 FMGs (7.8%) got their medical
education at one of the Caribbean medical schools. Of all
FMGs, 28.5% (n ¼ 47) had residency training prior to U.S.
neurosurgical training, with 23 FMGs (13.9%) undergoing
neurosurgical training in their home countries. A little under
half of the FMG cohort had an affiliation with a U.S.
neurosurgery department prior to matching in the United
States (n ¼ 74; 44.8%), with 17% (n ¼ 13) of these FMGs
matching to their affiliated U.S. neurosurgical program. Gap
year activities for FMGs were 39.0% (n ¼ 32) unfunded
research experiences, 35.4% (n ¼ 29) preresidency fellowships
or preliminary years, 23.2% (n ¼ 19) academic degree

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ANKUSH CHANDRA ET AL. FMGS IN NEUROSURGERY

programs, and 2.4% (n ¼ 2) funded research fellowships

Table 2. Characteristics of Foreign Medical Graduates (Table 2).
Matching into Neurosurgery Residency
Factor Number (%) FMG Match Rates and Temporal Trends
During the study period, the match rates for FMGs ranged from
Number 165 15%e25% with an average of 24%, compared with 75%e94% with
Continent of medical training an average of 83% for USMGs (P < 0.001). However, the match rate
did not significantly change over time for USMGs (b ¼ e0.002, P ¼
Asia 75 (45.5%)
0.8) or FMGs (B ¼ e0.006, P ¼ 0.5) (Figure 2A). This stable USMG
Europe 41 (24.8%) match rate reflected comparable parallel increases in the number of
North America 25 (15.2%) USMG applicants by an average of 4.7 applicants per year (P ¼
South America 12 (7.3%)
0.064), the number of programs applied to by an average of 2.7
applications per year (P ¼ 0.022) (Figure 2B), and the total
Africa 7 (4.2%) number of matched USMGs by an average of 3.3 candidates per
Australia 2 (1.2%) year (P < 0.001) (Figure 2C). In contrast, although there was a
Missing 3 (1.8%) significant increase in the number of FMG applicants (b ¼ 1.5,
P ¼ 0.003), there was no change in the FMG applications per
Prior residency training applicant (b ¼ 1.3, P ¼ 0.306) (Figure 2B), or matched FMGs
No 82 (49.7%) (b ¼ 0.07, P ¼ 0.891) over time (Figure 2C).
Yes 47 (28.5%)
FMG Match Programs
Missing 36 (21.8%)
Neurosurgery residency programs matching the most FMGs dur-
Prior neurosurgery training ing our 10-year study period were 1) Cleveland Clinic, University of
No 100 (60.6%) Louisville, and University of Pittsburgh (UPMC) (n ¼ 5 FMGs
each); 2) Baylor University, University of Miami, Johns Hopkins
Yes 23 (13.9%)
University (JHU), SUNY Syracuse, SUNY Buffalo, University of
Missing 42 (25.5%) Minnesota, University of Virginia (UVA), and University of
Prior U.S. neurosurgery affiliation Mississippi (n ¼ 4 FMGs each); and 3) Thomas Jefferson Uni-
versity, University of Arizona, University of Colorado, University of
No 68 (41.2%)
Iowa, University of Kentucky, University of Missouri/Columbia,
Yes 75 (45.5%) University of Texas Southwestern (UTSW), and Vanderbilt Uni-
Missing 22 (13.3%) versity (n ¼ 3 FMGs each) (Table 3).
Matched at affiliated program
FMG Match Top Programs
No 29 (39%)
Overall, matriculated FMGs matched at NIH Top 40, BRIMR Top
Yes 13 (17%) 20, and Doximity Top 20 programs at rates of 32.7%, 20%, and
Missing 33 (44%) 20%, respectively. USMGs had higher match rates at those
programs: 47.5% (P < 0.001), 26.1% (P ¼ 0.088), and 29%
Took gap year(s)
(P ¼ 0.014), respectively. Residency programs among the NIH
No 7 (4.2%) Top 40 institutes that matriculated the most FMGs were 1)
Yes 158 (95.8%) UPMC (n ¼ 5; 9%); 2) Baylor University, JHU, University of
Minnesota, and University of Wisconsin (n ¼ 4; 7%); and 3)
Gap year
University of Colorado, University of Iowa, UTSW, and Van-
HHMI/Doris Duke/NIH/Sarnoff 2 (2%) derbilt University (n ¼ 3; 6%) (Table 3). BRIMR Top 20 programs
Degree 18 (22%) that matriculated the most FMGs were 1) UPMC and University
of Texas at Houston (n ¼ 5; 15%); 2) Baylor University,
Preresidency fellowship/preliminary year 30 (37%)
University of Miami and JHU (n ¼ 4; 12%); and 3) Duke
Unfunded research 32 (39%) University, Columbia University, University of Rochester, and
Matched to top-ranked neurosurgery program Washington University at St. Louis (n ¼ 2; 6%). Doximity Top
20 programs that matriculated the most FMGs were 1)
NIH Top 40 Program 54 (32.7%)
Cleveland Clinic and UPMC (n ¼ 5; 15%); 2) UVA and JHU
BRIMR Top 20 Program (2017) 33 (20.0%) (n ¼ 4; 12%); and 3) UTSW (n ¼ 3; 9%).
Doximity Top 20 Program (2019) 33 (20.0%) Characteristics of USMGs and FMGs who matched at top programs
are displayed in Table 4. For residents matching at Top NIH
HHMI, Howard Hughes Medical Institute; NIH, National Institutes of Health; BRIMR, Blue
programs, FMGs were older (35.3 vs. 32.0 years, P ¼ 0.011), had
Ridge Institute for Medical Research.
higher H-indices (5 vs. 2, P < 0.001) and publication counts (7 vs.

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ANKUSH CHANDRA ET AL. FMGS IN NEUROSURGERY

Figure 1. Map of the countries in which foreign medical graduates attended medical school. Colors correspond to frequency (see legend).

2, P < 0.001), and were more likely to take research year(s) (94.4% vs.
76.0%, P ¼ 0.002). For residents matching at BRIMR programs,
FMGs were older (34.2 vs. 30.6, P ¼ 0.013), had more publications
(7 vs. 3, P ¼ 0.009), and were more likely to take research year(s)
(97.0% vs. 77.3%, P ¼ 0.008). For residents matching at Doximity
programs, FMGs were older (36.9 vs. 32.5, P ¼ 0.014), had higher
H-indices (7 vs. 3, P ¼ 0.002) and publication counts (11 vs. 3, P <
0.001), and were more likely to take research year(s) (97.0% vs.
76.6%, P ¼ 0.006) and be male (97.0% vs. 82.8%, P ¼ 0.033).
FMGs who matched at top residency programs were compared
with FMGs who matched at other programs (Table 5). Median H-
index and number of publications were significantly higher for
FMGs who matched to Top NIH programs and Doximity
programs (H-index: 5 vs. 2, P ¼ 0.009 and 7 vs. 2, P ¼ 0.005,
respectively; publications: 7 vs. 3 publications, P ¼ 0.015 and
11 vs. 3, P ¼ 0.003, respectively). Those matching at Doximity
programs were significantly older than the rest of the FMG
cohort (37.0 vs. 33.2 years, P ¼ 0.026). Matched FMGs with
prior affiliations to U.S. neurosurgery programs were more likely
to match at Top NIH (41.3% vs. 17.7%, P ¼ 0.002), BRIMR
(28.0% vs. 11.8%, P ¼ 0.016), and Top Doximity (32.0% vs.
4.4%, P < 0.001) residency programs. Multivariate analysis
revealed greater number of publications (F-ratio ¼ 3.81,
P < 0.001), taking a gap year (F-ratio ¼ 3.14, P < 0.001) and a
greater H-index (F-ratio ¼ 2.77, P ¼ 0.008) to be independent
factors predictive of FMG match into a top program (Table 6).
DISCUSSION
FMG Match Rates and Trends
Despite an increased demand in the physician workforce,
significant barriers remain for FMGs to match to residency

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Figure 2. Univariate analysis of temporal trends of matching into R2 ¼ 0.00); (B) match rate per year (USMG: b ¼ e0.002% per year,
neurosurgery residency programs (2007e2017) for U.S. medical graduates R2 ¼ 0.01; FMG: B ¼ e0.006% per year, R2 ¼ 0.06); (C) # of applications
(USMGs) and foreign medical graduates (FMGs): (A) # matched per year per applicant for USMGs and FMG candidates for neurosurgery.
(USMG: b ¼ 3.27 residents/year, R2 ¼ 0.83; FMG: b ¼ 0.07 residents/year,

programs in the United States, especially for neurosurgery.5-7 In
this study, we investigated temporal trends and factors affecting
the FMG match rate in neurosurgery. Match rates did not
change over time for FMGs or USMG applicants, although the
total number of matched USMGs increased gradually, whereas
FMG numbers remained stable. One explanation for this
finding is the addition of new residency programs and increase
in residency positions at existing programs. Notably, there has
been a lack of growth in the FMG applicant pool overall and
annually. FMGs applied to nearly 20 fewer neurosurgery pro-
grams than USMGs between 2014 and 2018.21 Factors predictive
of a successful neurosurgical match include USMLE step 1
scores, strong mentorship, and number of interviews.22 Thus
FMGs with higher step 1 scores and those with the
appropriate guidance and mentorship may be the ones
applying to neurosurgery and judiciously choosing programs
based on their competitiveness.22-25 Moreover, the U.S. resi-
dency application process is expensive and FMGs with limited
finances may apply to fewer residency programs and may
choose to apply to fields that require fewer applications, as well
as those fields that have shorter training durations. Another
important confounding factor limiting the number of applica-
tions for FMGs is visa sponsorship.26,27 Although FMGs can be
U.S. citizens and U.S. permanent residents with a foreign
citizenship that does not require any visa sponsorship, FMGs
that are non-U.S. citizens and non-U.S. permanent residents
would require visa sponsorship, thereby significantly decreasing
the number of programs they apply to based on sponsorship.
Over the past decade, 78 programs matched at least 1 FMG and
23 programs matched 3 or more FMGs, representing 62.4% and
18.4% of Accreditation Council for Graduate Medical Education
accredited neurosurgery programs. Of those, 18 were a top 20

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ANKUSH CHANDRA ET AL. FMGS IN NEUROSURGERY

Table 3. Top 3 Neurosurgery Residency Programs that Match Table 3. Continued

Foreign Medical Graduates
Top 20 BRIMR # of FMGs (n, %)
Neurosurgical Residency Program
Baylor University College of Medicine 4 (12%)
Matching the Greatest Number of FMGs # of FMGs (n, %)
University of Miami 4 (12%)
Cleveland Clinic 5 (3.0%)
Johns Hopkins University* 4 (12%)
University of Louisville 5 (3.0%)
Duke University 2 (6%)
University of Pittsburgh* 5 (3.0%)
Columbia University 2 (6%)
University of Texas at Houston 5 (3.0%)
University of Rochester 2 (6%)
Baylor University College of Medicine 4 (2.4%)
Washington University at St. Louis 2 (6%)
University of Miami 4 (2.4%)
Johns Hopkins University* 4 (2.4%)
Top 20 Doximity # of FMGs (n, %)
SUNY Syracuse 4 (2.4%)
SUNY Buffalo 4 (2.4%) Cleveland Clinic 5 (15%)
University of Minnesota 4 (2.4%) University of Pittsburgh* 5 (15%)
University of Mississippi 4 (2.4%) Johns Hopkins University* 4 (12%)
University of Virginia 4 (2.4%) University of Virginia 4 (12%)
University of Wisconsin/Madison 4 (2.4%) University of Texas Southwestern 3 (9%)
Virginia Commonwealth University 4 (2.4%) FMGs, foreign medical graduates; NIH, National Institutes of Health; BRIMR, Blue Ridge
Wayne State University 4 (2.4%) Institute for Medical Research.
*These institutions are common across all categories.
Thomas Jefferson University 3 (1.8%)
University of Arizona 3 (1.8%)
University of Colorado 3 (1.8%)
ranked program either by funding or by reputation. Our study
University of Iowa 3 (1.8%)
shows that it has been more difficult for FMGs to match into
University of Kentucky 3 (1.8%) top programs by both funding and reputation. FMGs who
University of Missouri/Columbia 3 (1.8%) matched at Top NIH 40, BRIMR 20, and Top Doximity 20
programs were older, had higher H-indices, research publica-
University of Texas Southwestern 3 (1.8%)
tions, and in general took more research years than USMGs, as
Vanderbilt University 3 (1.8%) well as FMGs who matched at non-top programs. Prior affilia-
tions to U.S. neurosurgery programs were beneficial for
Top 40 in NIH funding # of FMGs (n, %)
matching into top programs, even if not the same place as the
University of Pittsburgh* 5 (9%) affiliation. Therefore, demonstrating commitment to neurosur-
gery in terms of academic productivity, research years, and
Baylor University 4 (7%)
bibliometrics likely constitute metrics of success to enable
Johns Hopkins University* 4 (7%) FMGs to match at top neurosurgery programs.
University of Minnesota 4 (7%) Neurosurgery remains a highly competitive specialty, with an
unmatched USMG rate of 23% over our 10-year study period, the
University of Wisconsin at Madison 4 (7%)
highest of any medical or surgical specialty,28 despite evidence
University of Colorado 3 (6%) suggesting the need for expanding the U.S. neurosurgical
University of Iowa 3 (6%) workforce. A study by Friedlich et al.5 revealed an increase in
the demand of the neurosurgical workforce over 13 years.
University of Texas Southwestern 3 (6%)
Similarly, a recent report by Gottfried et al.6 showed that the
Vanderbilt University 3 (6%) demand for neurosurgeons nearly doubled both for academic
and private practice jobs. Expanding the number of training
spots in neurosurgery could address this workforce shortage,
Top 20 BRIMR # of FMGs (n, %) and might enable improvements in the USMG neurosurgery
match rate and the low FMG neurosurgery match rate found in
University of Pittsburgh* 5 (15%)
our study. However, doing so would require understanding that
University of Texas at Houston 5 (15%) this workforce is needed in geographically underserved areas of
Continues
the United States, and programs expanding in these regions will
require resources well-equipped to address resident education,

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 e8

ANKUSH CHANDRA ET AL.

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www.SCIENCEDIRECT.com

Table 4. Characteristics of U.S. Medical Graduates and Foreign Medical Graduates Matching into Top U.S. Neurosurgical Residency Programs Among National Institutes of
Health, Blue Ridge Institute for Medical Research, and Doximity Rankings
NIH Top 40 BRIMR Top 40 Doximity Top 40

Factor USMG FMG P Value USMG FMG P Value USMG FMG P Value
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Number 804 54 <0.001 441 33 0.088 491 33 0.014

Sex 0.34 0.096 0.033
Female 146 (18.4%) 7 (13.2%) 75 (17.2%) 2 (6.1%) 84 (17.2%) 1 (3.0%)
Male 648 (81.6%) 46 (86.8%) 361 (82.8%) 31 (93.9%) 404 (82.8%) 32 (97.0%)
Age, mean (SD) 31.96 (7.75) 35.31 (7.84) 0.011 30.64 (6.84) 34.19 (7.18) 0.013 32.50 (8.09) 37.02 (7.46) 0.013
H-index, median (IQR) 2.00 (0.00, 5.00) 5.00 (1.00, 9.00) <0.001 2.00 4.00 0.090 3.00 (1.00, 5.00) 7.00 0.002
(1.00, 5.00) (1.00, 8.00) (2.00, 9.00)
Number of publications, 2.00 (1.00, 6.00) 7.00 <0.001 3.00 (1.00, 7.00) 7.00 0.009 3.00 (1.00, 7.00) 11.00 (2.00, 19.00) <0.001
median (IQR) (2.00, 18.00) (2.00, 16.00)
WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.02.069

Gap year <0.001 <0.001 <0.001

None 193 (24.0%) 3 (5.6%) 100 (22.7%) 1 (3.0%) 115 (23.4%) 1 (3.0%)
HHMI/Doris Duke/NIH/ 52 (6.5%) 0 (0.0%) 35 (7.9%) 0 (0.0%) 37 (7.5%) 0 (0.0%)
Sarnoff
Degree 84 (10.4%) 8 (14.8%) 41 (9.3%) 3 (9.1%) 40 (8.1%) 2 (6.1%)
Preresidency fellowship/ 10 (1.2%) 9 (16.7%) 6 (1.4%) 5 (15.2%) 5 (1.0%) 9 (27.3%)
preliminary year
Unfunded research 8 (1.0%) 14 (25.9%) 6 (1.4%) 11 (33.3%) 7 (1.4%) 12 (36.4%)
Unknown 457 (56.8%) 20 (37.0%) 253 (57.4%) 13 (39.4%) 287 (58.5%) 9 (27.3%)
Took gap year(s) 611 (76.0%) 51 (94.4%) 0.002 341 (77.3%) 32 (97.0%) 0.008 376 (76.6%) 32 (97.0%) 0.006
Primary degree <0.001 <0.001 <0.001
M.D. 803 (99.9%) 36 (66.7%) 440 (99.8%) 25 (75.8%) 491 (100.0%) 26 (78.8%)
D.O. 1 (0.1%) 0 (0.0%) 1 (0.2%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

FMGS IN NEUROSURGERY
M.B.B.S./M.B.B.Ch. 0 (0.0%) 18 (33.3%) 0 (0.0%) 8 (24.2%) 0 (0.0%) 7 (21.2%)
Master's degree (misc) 35 (4.4%) 2 (3.7%) 0.82 14 (3.2%) 1 (3.0%) 0.96 21 (4.3%) 1 (3.0%) 0.73
M.M.P.H./M.H.S./M.S.P.H. 18 (2.2%) 2 (3.7%) 0.49 9 (2.0%) 1 (3.0%) 0.70 7 (1.4%) 0 (0.0%) 0.49

ORIGINAL ARTICLE
Ph.D. 105 (13.1%) 8 (14.8%) 0.71 59 (13.4%) 3 (9.1%) 0.48 65 (13.2%) 2 (6.1%) 0.23

NIH, National Institutes of Health; BRIMR, Blue Ridge Institute for Medical Research; USMG, U.S. medical graduate; FMG, foreign medical graduate; SD, standard deviation; IQR, interquartile range; HHMI, Howard Hughes Medical Institute.
 WORLD NEUROSURGERY -: e1-e13, - 2020

ANKUSH CHANDRA ET AL.

Table 5. Characteristics of Foreign Medical Graduates Matching to Top Neurosurgical Residency Programs Among National Institutes of Health, Blue Ridge Institute for
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Medical Research, and Doximity Rankings

NIH Top 40 BRIMR Top 40 Doximity Top 40

Factor Non-Top 40 Top 40 P Value Non-Top 20 Top 20 P Value Non-Top 20 Top 20 P Value

Number 111 54 132 33 132 33

Sex 0.43 0.35 0.12
For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.

Female 10 (9.2%) 7 (13.2%) 15 (11.6%) 2 (6.1%) 16 (12.4%) 1 (3.0%)

Male 99 (90.8%) 46 (86.8%) 114 (88.4%) 31 (93.9%) 113 (87.6%) 32 (97.0%)
Age, mean (SD) 33.23 (6.53) 35.31 (7.84) 0.15 33.90 (7.06) 34.19 (7.18) 0.86 33.19 (6.78) 37.02 (7.46) 0.026
H-index, median (IQR) 2.00 (0.00, 6.00) 5.00 (1.00, 9.00) 0.009 3.00 (0.00, 7.00) 4.00 (1.00, 8.00) 0.33 2.00 (0.00, 6.00) 7.00 (2.00, 9.00) 0.005
Number of publications, median (IQR) 3.00 (0.00, 12.50) 7.00 (2.00, 18.00) 0.015 4.00 (1.00, 14.00) 7.00 (2.00, 16.00) 0.23 3.00 (0.00, 12.00) 11.00 (2.00, 19.00) 0.003
Gap year 0.42 0.26 0.19
HHMI/Doris Duke/NIH/Sarnoff 2 (4%) 0 (0%) 2 (3%) 0 (0%) 2 (3%) 0 (0%)
Degree 10 (20%) 8 (26%) 15 (24%) 3 (16%) 16 (27%) 2 (9%)
Preresidency fellowship/preliminary year 21 (41%) 9 (29%) 25 (40%) 5 (26%) 21 (36%) 9 (39%)
Unfunded research 18 (35%) 14 (45%) 21 (33%) 11 (58%) 20 (34%) 12 (52%)
Took gap year(s) 107 (96.4%) 51 (94.4%) 0.56 126 (95.5%) 32 (97.0%) 0.70 126 (95.5%) 32 (97.0%) 0.70
Primary degree 0.72 0.26 0.26
M.D. 108 (97.3%) 52 (96.3%) 127 (96.2%) 33 (100.0%) 127 (96.2%) 33 (100.0%)
www.journals.elsevier.com/world-neurosurgery

M.B.B.S./M.B.B.Ch. 3 (2.7%) 2 (3.7%) 5 (3.8%) 0 (0.0%) 5 (3.8%) 0 (0.0%)

Master's degree (misc) 2 (1.8%) 2 (3.7%) 0.46 3 (2.3%) 1 (3.0%) 0.80 3 (2.3%) 1 (3.0%) 0.80
M.P.H./M.H.S./M.S.P.H. 2 (1.8%) 2 (3.7%) 0.46 3 (2.3%) 1 (3.0%) 0.80 4 (3.0%) 0 (0.0%) 0.31
Ph.D. 9 (8.1%) 8 (14.8%) 0.18 14 (10.6%) 3 (9.1%) 0.80 15 (11.4%) 2 (6.1%) 0.37
Continent of medical training 0.34 0.96 0.16
Asia 46 (42.6%) 29 (53.7%) 59 (45.7%) 16 (48.5%) 61 (47.3%) 14 (42.4%)
Europe 27 (25.0%) 14 (25.9%) 33 (25.6%) 8 (24.2%) 35 (27.1%) 6 (18.2%)
North America 21 (19.4%) 4 (7.4%) 19 (14.7%) 6 (18.2%) 21 (16.3%) 4 (12.1%)

FMGS IN NEUROSURGERY
South America 8 (7.4%) 4 (7.4%) 10 (7.8%) 2 (6.1%) 7 (5.4%) 5 (15.2%)
Africa 4 (3.7%) 3 (5.6%) 6 (4.7%) 1 (3.0%) 4 (3.1%) 3 (9.1%)
Australia 2 (1.9%) 0 (0.0%) 2 (1.6%) 0 (0.0%) 1 (0.8%) 1 (3.0%)

ORIGINAL ARTICLE
Prior residency training 0.37 0.20 0.80
No 53 (61%) 29 (69%) 60 (61%) 22 (73%) 63 (63.0%) 19 (65.5%)

NIH, National Institutes of Health; BRIMR, Blue Ridge Institute for Medical Research; SD, standard deviation; IQR, interquartile range; HHMI, Howard Hughes Medical Institute.
e9

Continues
 ORIGINAL ARTICLE
ANKUSH CHANDRA ET AL. FMGS IN NEUROSURGERY

case volume, and quality of life. If such expansion were to occur, it

P Value

<0.001
remains unclear whether the current unmatched USMG or FMG

0.65
0.39
pools would demonstrate greater qualifications and/or interest in
such positions.

FMG Versus USMG Residents

10 (34.5%)

24 (88.9%)
3 (11.1%)
Doximity Top 40

22 (76%)
7 (24%)

7 (64%)
4 (36%)
Top 20

When comparing neurosurgical FMG residents to USMGs, FMGs

were older on starting residency. This is likely driven by research
years undertaken by nearly all FMGs before neurosurgical resi-
dency and/or previous residency training for nearly a third of
FMGs. The proportion of women, who are underrepresented in
Non-Top 20

neurosurgery,29 was lower among FMGs compared with USMGs.

51 (44.0%)
37 (37.0%)

65 (56.0%)
78 (83%)
16 (17%)

22 (71%)
9 (29%)
Several barriers to women considering neurosurgery have been
reported,29 and these barriers may be heightened for FMGs,
consequently widening the sex disparity. FMGs had higher H-

NIH, National Institutes of Health; BRIMR, Blue Ridge Institute for Medical Research; SD, standard deviation; IQR, interquartile range; HHMI, Howard Hughes Medical Institute.
indices and more publications, proxies for academic productivity
P Value

and impact on the field, compared with USMGs. Given the

0.042
0.016
0.74

importance of academic productivity for advancement in

neurosurgery, greater H-indices may reflect not only greater and
higher-quality academic productivity, but also deeper commit-
ment to the field. This may also be reflected in the fact that almost
21 (72.4%)
8 (27.6%)
25 (83%)
8 (27%)

5 (17%)

4 (44%)
5 (56%)
Top 20
BRIMR Top 40

half of FMG residents had prior affiliation to a U.S neurosurgery

department for scholarly activities. Spending meaningful time at a
neurosurgery department provides FMGs an opportunity to
familiarize themselves with faculty, staff, and residents, as well as
demonstrate commitment and productivity in neurosurgery, op-
Non-Top 20

54 (47.4%)
60 (52.6%)
39 (39%)

75 (81%)
18 (19%)

25 (76%)

portunities that USMGs typically have with their home

8 (24%)

institutions.

Potential Factors Limiting FMG Applicants

FMG applicants to neurosurgery comprise a heterogenous group
P Value

0.002

coming from a whole host of countries. Some of the greatest

0.24
0.94

challenges to U.S. neurosurgery faculty and residency program

directors is ascertaining the quality of medical education of the
FMG applicant, as well as the veracity of their letter of recom-
31 (72.1%)
12 (27.9%)

mendations and supplemental information as compared with the

13 (31%)

34 (81%)

10 (59%)
8 (19%)

7 (41%)
Top 40
NIH Top 40

standardized and more familiar U.S. medical education. Because

of the lack of familiarity of these factors, program directors are
often in a dilemma in how to evaluate FMGs and may tend to
raise the bar and hold a higher standard for FMGs with the hopes
of interviewing and matching the best candidates from this
Non-Top 40

56 (56.0%)
44 (44.0%)
34 (39%)

66 (81%)
15 (19%)

19 (76%)
6 (24%)

applicant pool. Indeed, this serves as a significant barrier to

FMGs, with many applicants possibly getting screened out of the
interview pool subsequently. However, this dilemma is not
completely unwarranted. There is evidence that FMGs tend to
have lower performance compared with USMGs on licensing
examinations and specialty board certification examinations, and
receive lower performance ratings by their program directors,30
Prior U.S. neurosurgery affiliation

raising the question on how to best and fairly evaluate FMGs

Matched at affiliated program

for residency.
Prior neurosurgery training

Thus as discussed earlier, involvement with a neurosurgery

Table 5. Continued

department for a significant time period may aid FMGs in 1)

making themselves a “known entity” with residents, staff, and
faculty; 2) scholarly productivity in terms of research, publica-
tions, teaching, and other academic contributions reflecting
commitment to neurosurgery and academics; and 3) avail
Factor
Yes

Yes

Yes

Yes
No

No

No

clinical and academic opportunities that USMGs typically have

with their home institutions. Such opportunities may help

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ANKUSH CHANDRA ET AL.
Table 6. Stepwise Multivariate Analysis of Factors Predictive of
Successful Foreign Medical Graduate Match into a Top
Neurosurgery Residency
Factors F ratio
Number of publications 3.81
Gap year 3.14
H-index 2.77
FMGs in fostering relationships with neurosurgeons who may
vouch for their candidacy and may write a letter of recom-
mendation that weighs more than a letter from a foreign
physician or surgeon. Several U.S. medical schools offer
clerkships to foreign medical students, and thus in addition to
prolonged involvement with a neurosurgery department, FMGs
should consider doing clerkships or subinternships during their
last year of medical school, similar to U.S. medical students. 31
Additionally, attendance at national neurosurgery conferences,
such as the AANS Annual Scientific Meeting and the
Congress of Neurological Surgeons Annual Meetings, may
serve as a platform for networking with faculty, residents, and
programs directors from neurosurgical training programs
across the country. Although not completely supported by our
data, FMGs interested in academic neurosurgery should
consider advanced degrees to demonstrate their commitment
to academia.11,12 In a recent study, 84 U.S. academic
neurosurgeons (6.3%) completed their neurosurgical residency
outside of the United States, in addition to their
undergraduate medical education.16 When compared with
U.S.-trained academic neurosurgeons with appointments in
the United States, no differences emerged in the strengths of
their academic profiles, which included NIH grants, program/
school ranking, and advanced degrees. Foreign-trained neuro-
surgeons were much more likely to have a Ph.D., reflecting
patterns of prolonged academic training for FMGs and more
stringent admission and hiring standards.16 However, this study
cohort is a very small group, and excludes nonacademic
foreign-trained neurosurgeons. Following these tips may allow
program directors to overcome their dilemma regarding FMGs
and motivate them to look beyond the objective metrics and
evaluate FMGs thoroughly for neurosurgical residencies.
Over three fourths of FMGs that matched into U.S. neuro-
surgery programs attended medical school in Asia and Europe.
In contrast, FMGs from Caribbean medical schools, an alterna-
tive to U.S. medical schools for many U.S. premedical students,
represented a very small proportion of FMG residents (7.8%).
Expectedly, these students face similar barriers to non-
Caribbean FMGs due to variability in the standard of education
across the offshore medical schools.32 Studies have found that
Caribbean FMGs tend to have lower performance on USMLE
licensing examinations and specialty board examinations
compared with their USMG and non-Caribbean FMG counter-
parts, necessitating greater perusal into candidate qualifications
by residency program directors.30,33-36 Our data suggest that
these factors, rather than citizenship of the candidate, drive
matching disparities for FMGs.
WORLD NEUROSURGERY -: e1-e13, - 2020
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ORIGINAL ARTICLE
FMGS IN NEUROSURGERY
Factors Predictive of Successful FMG Match at a Top
Neurosurgery Residency Program
Given the competitiveness of the neurosurgical residency match, it
has become even more important to find modifiable factors for
P Value successful neurosurgery match for FMGs. Our multivariate anal-
ysis revealed number of publications, gap year(s), and H-index to
<0.001 be predictive of successful match for FMGs at a top neurosurgery
<0.001 residency program. We have discussed extensively the significance
of greater number of publications and a higher H-index earlier. In
0.008
terms of gaps years, we found that FMGs had a higher rate of
taking a gap year as compared with USMGs, as well as FMGs who
matched to top neurosurgery programs compared with those
USMGs. We found that majority of the FMGs taking a gap year
used their time conducting research, enrolling in preliminary
residency program or a preresidency fellowships, and acquired an
advanced degree. Applicants benefit from gap year(s) not only due
to portfolio enhancement in terms of clinical experience and
publication record, which we have discussed earlier, but also
owing to development of a mentor-mentee relationship. The
mentor-mentee relationship developed during the gap year(s) is
uniquely very personal given the fact there is almost a daily
interaction between the mentee and mentor allowing the mentor
to identify the strengths and weakness of their mentees and
providing personalized advise to maximally benefit the mentee.
Several studies have highlighted the importance of the mentor-
mentee relationship in the match in different specialties,37,38
including in neurosurgery.39 Thus gap year(s) may benefit FMGs
by enhancing objective metrics and developing strong mentor-
mentee relationships.
Limitations
Our study is subjected to the common limitations of a retrospective
review. Causative relationships between factors and outcomes
cannot be proved because of the nature of this study. We used AANS
membership data and Association of American Medical Colleges
Charting the Outcomes data, which did not include individual USMLE
step scores, thus we could not assess the impact of board scores on
match outcomes. However, with the recent change in the USMLE
Step 1 scoring system to a pass-or-fail system, the variables identi-
fied in our study may hold even more weight in evaluation of FMG
neurosurgery applicants by residency programs. Because we
collected academic data for residents using residency webpages,
some of the academic variables were missing. However, we have
reported that data as “unknown” or “missing” and have excluded
those data from our analyses. We used Scopus to collect H-indices
and numbers of publications for our study cohort. Given that Scopus
does not include every publication in its database, such as publi-
cations “ahead of print” and publications not indexed in PubMed,
bibliometrics may be underreported. Another limitation is that we
did not account the number of FMGs that entered into neurosurgery
from outside the match process.
CONCLUSIONS
Although FMGs have an understandably lower match rate into
U.S. neurosurgery residencies than USMGs, we identified de-
mographic, professional, and academic factors that increase the
chances of successful FMG neurosurgical match. Compared with
www.journals.elsevier.com/world-neurosurgery e11
 ORIGINAL ARTICLE
ANKUSH CHANDRA ET AL. FMGS IN NEUROSURGERY

USMGs, FMGs benefit from higher bibliometrics and prior
affiliations with a top-ranked program to match at top-ranked
U.S. neurosurgical programs, factors that FMGs may look to
develop in their portfolios when seeking U.S. neurosurgical
training spots.
CRediT AUTHORSHIP CONTRIBUTION STATEMENT
Ankush Chandra: Conceptualization, Methodology, Validation,
Formal analysis, Data curation, Investigation, Software, Re-
sources, Writing - original draft, Writing - review & editing,
Visualization, Supervision, Project administration, Funding
acquisition. Michael G. Brandel: Conceptualization, Methodology,
Validation, Software, Formal analysis, Data curation, Investiga-
tion, Writing - original draft, Writing - review & editing. Harsh
Wadhwa: Investigation, Writing - original draft, Writing - review
& editing. Neil D. Almeida: Investigation, Writing - original draft,
Writing - review & editing. John K. Yue: Conceptualization,
Investigation, Writing - original draft, Writing - review & editing.
Mohammed O. Nuru: Investigation, Writing - review & editing.
Justin Cheng: Investigation, Writing - review & editing. Shannon
Lu: Investigation, Writing - review & editing. Akshar Patel:
Investigation, Writing - review & editing. Walid Ibn Essayed:
Writing - original draft, Writing - review & editing, Investigation.
Michael W. McDermott: Visualization, Supervision, Writing - re-
view & editing. Mitchel S. Berger: Visualization, Supervision,
Writing - review & editing. Manish K. Aghi: Conceptualization,
Methodology, Validation, Formal analysis, Software, Investigation,
Resources, Writing - original draft, Writing - review & editing,
Visualization, Supervision, Project administration, Funding
acquisition.

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