Letter: Costs of Academic Engagement in Organized Neurosurgery in the United States

To the Editor: We read with great interest the recent article published by Covell et al,1 “Costs of Academic Engagement in Organized Neurosurgery in the United States” that highlights a critical and growing challenge for the global neurosurgical community. Specifically, the authors offer a timely and eye-opening analysis of the significant financial burdens associated with participation in organized neurosurgical societies, meetings, and journals. As trainees pursuing academic neurosurgery in the United States, we find the implications of this study not only relevant but also deeply personal. In the study, the authors quantify a reality that many trainees and early-career neurosurgeons intuitively experience—academic engagement, often viewed as a marker of professional dedication and advancement, is increasingly becoming a privilege reserved for those with sufficient financial resources. The calculated baseline cost of $11 588 for standard engagement (2 society memberships, 2 meeting registrations, and board certification) far exceeds similar benchmarks in other surgical specialties such as plastic surgery ($8105), orthopedic surgery ($7013), and general surgery ($5570). These represent barriers to entry that disproportionately affect medical students, residents, junior faculty, and international trainees and physicians. While organized neurosurgery offers invaluable opportunities for continuing medical education (CME), mentorship, leadership, and networking, its cost and accessibility warrant closer examination. One of the most striking findings from the study is the stark contrast in cost-efficiency between traditional in-person and virtual CME formats. For example, the cost per CME credit for the Annual SNS Meeting reaches $124.10, compared with just $0.79 per credit for the CNS Online Education Subscription—a difference of more than 150-fold. As we look toward the future of medical education in a postpandemic landscape, this disparity raises important questions. In a cross-sectional survey on physicians attending in-person conferences conducted by Mueller et al,2 reported advantages included the opportunity to travel and network broadly. However, these same factors were reflected inversely in the preferences of live-stream attendees, who cited convenience and reduced travel costs as primary reasons for favoring virtual formats. A scoping review by Cheng et al3 highlighted some of the secondary downsides of virtual CME. Although cost reduction is a recognized benefit—as noted by Covell et al—it can also create financial strain in offering low-cost or free CME, especially when expenses for platform support and speaker remuneration remain. In addition, concerns have been raised about the credibility of information delivered virtually. Virtual CME may also exacerbate gender disparities, as female physicians often take on a greater share of household responsibilities, resulting in less dedicated time for CME compared with their male counterparts.4 Similar challenges are faced in regions with limited technological infrastructure.5 This study's observation of stagnant CME funding and declining reimbursement points to a growing gap between rising costs and the level of institutional support available. As academic institutions increasingly emphasize diversity, equity, and inclusion, it is important to consider how current systems may present additional challenges for those with limited financial resources. This is especially relevant for international medical graduates, many of whom arrive in the United States without access to departmental funds, are often ineligible for travel grants, may not have had previous opportunities for hands-on rotations, and can be affected by unfavorable currency exchange rates.6-8 For some, the cost of attending a national meeting or subscribing to a key journal can represent a significant financial commitment. To address these inequities, we offer 3 potential solutions below: Virtual Engagement as a Standard: The expansion of virtual opportunities such as virtual attendance at major conferences and remote participation in committees should be viewed not as a temporary solution prompted by the pandemic but as a permanent and essential component of inclusive professional development. Tiered and Transparent Pricing Models: All major neurosurgical organizations should adopt transparent, tiered pricing structures that take into account career stage, training status, and international status, to make participation more equitable and accessible. Equity-Focused Scholarships: The development of scholarships aimed at promoting equitable access—specifically targeting not only underrepresented minorities but also international medical graduates and low-income trainees. This would help to directly address the financial barriers identified in this discussion. If organized neurosurgery is to fulfill its mission of advancing patient care, research, and education on a global scale, it must prioritize greater accessibility and affordability. The current model risks becoming insular, with leadership, innovation, and standards shaped largely by those with the financial means to participate. This is not merely a matter of fairness; it presents a real barrier to progress in a field that depends on global collaboration and diverse perspectives. Covell et al.‘s work has helped open an important conversation within the field. As we work to cultivate the next generation of neurosurgical leaders, it is essential that opportunities for engagement are determined by merit rather than financial means. To ensure neurosurgery remains a forward-thinking, inclusive, and globally relevant specialty, we must critically examine the financial structures we have inherited and be willing to reform them. By fostering a more equitable framework for professional development, neurosurgery can ensure that its future is shaped by talent, innovation, and collaboration—regardless of financial background.