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TRENDS IN PHYSICIAN MIGRATION
Change and challenge is in the wind as 2008 comes to an end. The same is true when examining this month's ReachMD XM 160 special series Focus on Global Medicine. We take a look at both the changes and the challenges impacting global medicine.
International medical graduates are a valuable resource to American medicine. What percentage of American physicians was trained elsewhere? You may be surprised with the answer.
Welcome to the Clinician's Roundtable. I am Dr. Leslie Lundt from Foothills Psychiatry in Boise, your host, and with me today is Dr. Elie Akl. Dr. Akl is an internist in Buffalo, New York, where he conducts research in the areas of medical education, development of clinical practice guidelines, and migration of physicians.
DR. LESLIE LUNDT:
Welcome to ReachMD, Dr. Akl.
DR. ELIE AKL:
Thank you Leslie, happy to be here.
DR. LESLIE LUNDT:
You are in a unique position to study international medical graduates. As a graduate of St. Joseph University Medical School in Beirut and you are an epidemiologist.
DR. ELIE AKL:
Yes, indeed, I graduated from St. Joseph's University in Beirut, and came to the US for residency training and I ended up doing a specialty in epidemiology, and as you said, as a migrate myself, I got interested in this huge international migration of physician phenomenon and I am currently studying it.
DR. LESLIE LUNDT:
Now, how common or how prevalent are international medical graduates in the United States?
DR. ELIE AKL:
So currently in the United States there are about 900,000 physicians overall, about 230,000 of these are international graduates. So this is a percentage of 25%, so a quarter of them.
DR. LESLIE LUNDT:
One quarter of all American physicians are international graduates?
DR. ELIE AKL:
I wouldn’t say of all American physicians, I would say of physicians practicing in the US because there is a small nuance in the definition. So, a US physician who goes and does a medical school outside the US is classified as international graduate. A non-US citizen who goes into the US medical school is technically classified as a US graduate. However, these percentages are low.
DR. LESLIE LUNDT:
So, okay roughly a quarter. Now, is this trying to increasing or decreasing?
DR. ELIE AKL:
The trend is definitely increasing. For example, of the last quarter century the number of IMGs in the US grew by about 2.4 times, so it's more than doubled.
DR. LESLIE LUNDT:
Wow! Now, are there certain countries that are more common in terms of IMGs where they come from?
DR. ELIE AKL:
The top country where IMGs come from are India with 20% of IMGs in the US coming from India and the top 5 list include India, the Philippines, Mexico, Pakistan, and the Dominican Republic.
DR. LESLIE LUNDT:
Any ideas why that is, why these countries?
DR. ELIE AKL:
The reason for international migration of physician has been explored in many number of studies. The classic theory of migration of physicians is called the push-pull theory. The push-pull theory says that there are push factor in the source country that kind of push physicians to go out and typically these are poverty, lack of opportunity or civil instability and there are pull factors of the recipient countries, most of the time who are high income countries and examples could be job opportunities, high income, and social security.
DR. LESLIE LUNDT:
Okay, so the trend then is moving from lower income, high poverty area to higher income low poverty area.
DR. ELIE AKL:
Yes and this is the main concern currently because of the widening of the gap in health equities or health inequities worldwide.
DR. LESLIE LUNDT:
Now, how are the IMGs different from the United States medical graduates?
DR. ELIE AKL:
There have been a number of studies that have been conducted in the field and most of the results are consistent and they show that compared with US graduates, international graduates tend to be older and less likely to be board certified. They are also less likely to work in group practice and less likely to work in academic settings. On the other hand, they are more likely to have internal medicine as their practice specialty.
DR. LESLIE LUNDT:
Okay, so that might be one reason why the trend is increasing, that we are getting our primary care docs from abroad?
DR. ELIE AKL:
Yes, definitely the number of internal medicine international graduates is increasing, but I am not sure about the other specialties. I don’t have this information, of course.
DR. LESLIE LUNDT:
Any guess as to why the IMGs are less likely to work in group practice, I find that finding interesting?
DR. ELIE AKL:
This finding has been a consistent finding across a number of studies. However, none of these studies that I know of has explored or determined the reason for this difference.
DR. LESLIE LUNDT:
Now, do the IMGs tend to practice in rural versus urban settings, is there any pattern there?
DR. ELIE AKL:
This is a very interesting question that relatesto policy making. In fact, as you might know, the visa system for physicians coming to practice in the US, especially the J1 visa, allows physicians, these international graduates to stay in the US if they go and serve in underserved areas. Unfortunately, you know, the end result is that there is not much difference between international graduates and US graduates in terms of location. In one of our study, we categorized the zip code of the location of practice of physician into four categories, which are urban, large rural, small rural, and isolated small rural and there was no difference between international and US graduates. You know, I said unfortunately initially is because these policies were intended to drive physicians into these underserved area and improve the provision of health services, but it doesn’t seem that this policy is having any effect.
DR. LESLIE LUNDT:
So, it's not working.
DR. ELIE AKL:
No, doesn’t seem so.
DR. LESLIE LUNDT:
If you are new to our channel, you are listening to ReachMD, The Channel for Medical Professionals. I am Dr. Leslie Lundt, your host, and I am speaking today with Dr. Elie Akl. Dr. Akl is not only an internist, but has advanced degrees in public health and epidemiology as well. We are discussing migration of physicians.
Now, Dr. Akl, you mentioned that primary care, internal medicine, that tends to be a popular specialty amongst IMGs, any other specialties that kind of separate.
DR. ELIE AKL:
Yes, I have a list of top four or five specialty that have the highest percentage of IMGs. The top one is, in fact, psychiatry. Yes, 31% of psychiatrists are international graduates
DR. LESLIE LUNDT:
31% wow!
DR. ELIE AKL:
And this is the highest percentage among the different specialties and the top 5 list includes first psychiatry, second anesthesiology, third pediatrics, fourth radiology, and five general surgery.
DR. LESLIE LUNDT:
Wow, now that's an interesting list. We've got the lowest income specialties with psychiatry and pediatrics and the highest income specialties with surgery, radiology, and anesthesiology.
DR. ELIE AKL:
Yeah, I guess you have to keep in mind that the trend in terms of which specialties have the higher income has recently changed and the percentage of international graduates reflect years of entry into a certain specialty, so expect to see these numbers and percentages change over a time, but in a slower fashion.
DR. LESLIE LUNDT:
So do we have data on incomes?
DR. ELIE AKL:
Nothing in these studies about income. I know of one study that was conducted among family physicians or family practice physicians and it showed that there is no difference between international graduates and US graduates in terms of income.
DR. LESLIE LUNDT:
Now, what are the implications for, as you call the source countries; it seems to me that they are in real danger of kind of brain drain.
DR. ELIE AKL:
Yes, Leslie, brain drain is the exact term that is being used on the international level to describe this migration of physicians and the reason for this is because especially for low income countries in the sub-Saharan Africa, there is loss of intellectual capital and there is evidence now that the better quality physicians are those who are leaving. On the other hand, there is loss of educational investment. You know, lots of money is invested to get someone to go through the medical training and become a doctor. It is estimated that India has lost billions in educational money because of the migration of its physicians. Other implications that are as important are the chronic understaffing of healthcare facilities, going back again to sub-Saharan Africa with the epidemics of AIDS and TB, there are not enough physicians to treat these patients. Another shocking, I think, implication and outcome that many in sub-Saharan Africa do not have enough physicians to produce the next generation of physicians, so there are in a very rough position.
DR. LESLIE LUNDT:
Dr. Akl, you've written about the brain drain in Lebanon, in particular, why did so many Lebanese docs please?
DR. ELIE AKL:
You know I was particularly interested in Lebanon because this is where I come from and we conducted a number of both qualitative and quantitative studies. The reason #1 of the migration of physician is interestingly the over-saturation of the market, as opposed to what's happening in low-income countries. What has happened for a different number of reasons, that since 1990s, the number of physicians in Lebanon has increased dramatically and we could discuss the reasons why? As an outcome, the newly graduating physicians are finding it tough to compete in the market, so they travel abroad mainly to the US to gain better training and have some competitive advantage when they go back to enter the market.
DR. LESLIE LUNDT:
So why is this over-saturated market in Lebanon, for physicians anyway?
DR. ELIE AKL:
As you probably know there was s civil war in Lebanon from 1975 until the late 1980s. During this period, lots of people left and got their education outside. In the early 1990s after the war stopped, most of these went back at the same time which increased the number of physicians. Concomitantly what happened is that after the fall of the Soviet Union, the Eastern European countries opened their universities to foreign students and many of the Lebanese students who couldn’t get into Lebanese medical school went there to get their education and there was no limit on the number so they came back and again it was a big addition in terms of numbers. A third cause which is unfortunately a bad policy making in Lebanon is that during the same period the number of medical schools doubled which increased the number of local graduates.
DR. LESLIE LUNDT:
Do we have any numbers on the reverse migration of US medical graduates leaving the United States and practicing elsewhere?
DR. ELIE AKL:
You know, I am sure that some numbers outside, I am personally not aware of these numbers, but my guess these numbers are relatively low because of the opportunities in the US and compared with other systems, the system in the US is more attractive.
DR. LESLIE LUNDT:
Well, thank you so much for being on the show today.
DR. ELIE AKL:
Thank you, Leslie.
DR. LESLIE LUNDT:
We've been discussing trends in physician migration with our guest today, Buffalo internist Dr. Elie Akl.
I am Dr. Leslie Lundt you've been listening to the Clinician's Roundtable, on ReachMD, The Channel for Medical Professionals. We welcome your questions and comments. So please visit us at www.reachmd.com. Our new on-demand and pod cast features will allow you to access our entire program library. Thank you for listening.
Thank you for listening to our special series Focus on Global Medicine as we celebrate this annual holiday season. Everyone at ReachMD wishes you and your family a happy holiday and a successful new year.
You are listening to ReachMD, XM 160, The Channel for Medical Professionals.
I am Dr. Lee Friedman inviting you to tune in this week to Medical Breakthroughs from the University of Pennsylvania Health Systems as I will be talking with Dr. Joseph Gorman about the biomechanical approach to various heart conditions.
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International medical graduates are a valuable resource to American medicine. What percentage of American physicians was trained elsewhere? Why do they leave their home countries? Internist and epidemiologist Dr. Elie Akl explores the migration of physicians with host Dr. Leslie Lundt.
International medical graduates are a valuable resource to American medicine. What percentage of American physicians was trained elsewhere? Why do they leave their home countries? Internist and epidemiologist Dr. Elie Akl explores the migration of physicians with host Dr. Leslie Lundt.
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