I read with great interest the recent article by Bougadis et al., “Factors Affecting Access to Neurosurgical Care in Diverse Communities in Canada: A Qualitative Scoping Review.” ^{Reference Bougadis, Rome, Perera and Ebinu1} The authors highlight how geographic, cultural and systemic barriers continue to limit timely neurosurgical care for patients living in rural and remote communities, including Indigenous populations. The themes identified, including delays in access, the burden of travel and gaps in coordination, resonate strongly with patterns observed regularly in clinical settings.

As a final-year medical student who completed medical electives in adult neurology, pediatric neurology, adult neurosurgery and pediatric neurosurgery in Edmonton, Alberta, I acknowledge that my perspective is necessarily limited, but I am deeply grateful to have had the opportunity to learn from these contexts. During my rotations, I observed the heavy demand on tertiary-center physicians from RAAPID calls, a system allowing rural and remote clinicians to consult about potential patient transfers. I also repeatedly saw pediatric patients and their families from northern and predominantly Indigenous communities transferred long distances for neurological assessment. Many of these children were ultimately found to have no urgent neurological or neurosurgical issues, yet their families incurred substantial financial, emotional and logistical burdens to travel long distances to a tertiary center, echoing the inequities described by Bougadis et al. In many cases, local clinicians had referred these patients out of an understandable desire not to miss serious pathology in settings with limited on-site neurology or neurosurgery support, while tertiary-center doctors accepted transfers due to incomplete information and concern about missing a serious condition.

My experience suggests that one under-recognized contributor to these patterns is educational and structural rather than individual. Current training and system structures may not consistently support non-neurological specialists with clear, practical guidance on which neurological presentations truly represent emergencies or “red flags” and which can be safely observed or managed closer to home. While medical school teaching often presents neurological and neurosurgical emergencies as black-and-white, real patients present in varied ways. With better education on symptom variants and clear protocols to determine emergencies compared to benign causes, there could be a reduced system strain as well as lower thresholds for concern on both sides. Without a strong shared foundation in primary care assessments and ready access to subspecialty backup, clinicians in resource-limited northern settings often choose the safest option by transferring children for symptoms that appear alarming but are typically benign neurologically.

Bougadis et al. rightly emphasize the need for system-level reforms, which I believe could begin as early as medical school to improve coordination and equity in clinical care. There is an opportunity to strengthen medical school education by incorporating teaching on neurological and neurosurgical emergencies that highlights the differences in red flags, referral thresholds and presentations among diverse population groups. From my experience, while we receive substantial teaching on core emergencies, clearer guidance on integration with diverse populations and more detailed referral decision-making would be valuable. Framing these initiatives through case-based teaching, clear graphics with stepwise guidelines and accessible information regarding neurotechnological resources can help trainees and future clinicians in rural communities feel more confident managing benign presentations locally when safe to do so. At the same time, this can also ensure rapid transfer for truly urgent cases. Such measures could modestly reduce avoidable transfers, alleviate burdens on families and tertiary centers and support more culturally and geographically appropriate care for Indigenous and northern communities.

In summary, the work of Bougadis et al. provides an important framework for understanding inequitable neurosurgical access in Canada and reflects patterns that learners, like myself, have consistently observed at the bedside. Enhancing our shared educational foundation in neurology and neurosurgery, particularly with attention to diverse health contexts, represents a practical, collaborative step that complements the system-level changes the authors advocate. Future research examining how current educational and structural factors shape referral and transfer decisions could further inform efforts to improve both equity and efficiency in neurosurgical and neurological care.