We thank Ms. Parsi for her thoughtful Letter to the Editor and for engaging with our scoping review concerning the barriers and facilitators affecting access to neurosurgical care across diverse Canadian communities. We appreciate her grounding of these access challenges in bedside observations from rural and remote transfer pathways, including pediatric transfers from northern and predominantly Indigenous communities, and in the downstream burdens on patients.

A key contribution of Parsi’s letter is the emphasis on a potentially under-recognized driver of avoidable transfers: educational and structural gaps in how early training and system protocols support referral and transfer decision-making, particularly for non-neurological specialists practicing in resource-limited settings. Her point aligns closely with our review’s finding that barriers often manifest not only through geography and resource concentration but also through communication and coordination challenges that amplify delays and inefficiencies across the care continuum. In our review, the qualitative literature consistently highlighted delays in access driven by transportation constraints, constrained resources and system bottlenecks, with disproportionate impact on rural and remote communities and on Indigenous patients.

At the same time, a recurrent theme was that imperfect information flow and coordination across referring sites, transport systems and receiving tertiary centers can intensify risk-averse decisions and contribute to transfers that are ultimately low yield. This is precisely where Parsi’s proposed “upstream” intervention, to strengthen the shared educational foundation and practical decision supports, can complement broader system-level reforms.

We agree that there is an opportunity to strengthen medical training by moving beyond “black-and-white” presentations of neurological emergencies and instead emphasizing variant presentations, structured red-flag assessment and context-sensitive referral thresholds, including how symptom interpretation and access decisions may differ across diverse population groups. Importantly, these educational efforts should not be framed as placing responsibility on individual clinicians working in constrained contexts; rather, they should be situated as a systems-oriented equity intervention that equips clinicians with shared language, standardized approaches and reliable access to subspecialty backup when needed.

From an implementation standpoint, we see several practical directions consistent with the facilitators identified in our review. First, scalable decision-support resources, for example, concise, stepwise guidance and case-based tools, could be integrated into undergraduate medical education, family medicine training and rural practice onboarding. ^{Reference Bougadis, Rome, Perera and Ebinu1} Ideally, this would be co-developed with rural clinicians, neurology/neurosurgery services and Indigenous partners to ensure cultural safety and local relevance. Second, these educational supports can be paired with the alternative access mechanisms we discussed, such as telehealth and rapid image transfer or e-consult infrastructure, to reduce geographic burden while maintaining timely escalation for true emergencies.

Finally, Parsi’s letter also highlights a clear research gap. While our scoping review synthesized qualitative evidence across four major themes – delays in access, alternative healthcare options, policy barriers and communication and coordination – educational and training-focused interventions were not a dominant focus in the included literature. Future work should focus on evaluating how educational and structural factors shape referral decisions, including transfers of pediatric patients and patients from Indigenous communities. Particularly, these factors, if paired with outcomes that matter to patients and families, such as travel burden, costs, cultural safety and system strain, can ensure timely transfer for urgent cases.

We again thank Ms. Parsi for her constructive contribution. We share her view that strengthening early training and practical referral decision-making supports represents a feasible, collaborative step that can complement policy and infrastructure reforms to advance equity in neurosurgical and neurological access across rural and remote Canada.