In Reply: Neurosurgical Endovascular Credentialing in Europe and the United Kingdom for the “Complete” Neurovascular Surgeon: The Time has Come

To the Editor: We thank Dr Michael Stuart and co-authors for their letter1 regarding our editorial.2 We acknowledge that issues in hybrid credentialing are not unique to Europe or the United Kingdom and appreciate their detailing the Australian situation as an example. The challenges Australian neurosurgeons face in obtaining a North American fellowship are shared by Europe and United Kingdom, namely inability to travel abroad for an extended period of time, the lack of a "familiar referee," a different curriculum vitae, and regulatory requirement constraints. As they have rightly pointed out, few candidates in the current system may succeed in navigating these barriers. We agree that any new endovascular matching system should include mechanisms by which "exceptionality" can be recognized, in systems that differ from those in North America. The situation across Europe is heterogeneous—flourishing hybrid practices are supported at several institutions, although in some countries legislation can prohibit surgeons from practicing endovascular altogether.2 In the United Kingdom, the hybrid landscape is in a position further behind Australia. Neurosurgeons do not have a pathway by which they can be credentialed in the United Kingdom, and only a handful are dual trained. There is a lack of representation by neurosurgeons in credentialing bodies: Most practitioners of endovascular treatment are interventional radiologists. Other specialties are only now beginning to train in endovascular practice, mainly driven by a need to increase access to mechanical thrombectomy. Many neurosurgeons in Europe and the United Kingdom believe that through an increase in the number of hybrid surgeons, a critical threshold will be reached to allow formal pathways to develop and ultimately enable the training of hybrid surgeons within one's own country. Although Australia is one step ahead of some countries, there appears to be ongoing barriers that prevent in-house training. The audience in Europe and the United Kingdom would benefit from learning about these challenges in Australia. We believe it is just as important to address these barriers as it is crucial to maintain access to North American fellowships. Ultimately, the ability to train, credential, and maintain a practice environment for hybrid surgeons within one's country is what will lead to true independence.