Thursday, October 27, 2005

The Physician Brain Drain

In the latest New England Journal of Medicine is an article about the "brain drain" of physicians from less to more developed countries. Specifically, about one quarter of all physicians practicing in the US, the UK, Canada, and Australia were trained in other countries. The majority in the US and the UK were from less developed countries. [Mullan F. The metrics of the physician brain drain. N Engl J Med 2005; 353: 1810-1818.]
A NY Times article suggested that some smaller less developed countries have lost a substantial portion of their total physician supply to the more developed countries. For example, Jamaica has lost 41 percent, Haiti, 35%, and Ghana, 30%. The Times article included an interview with Dr. Ageyeman Akosa, director general of the Ghanian health service, who gave some vivid examples of the effect of the brain drain on his country. He challenged the US, in particular,

One of the most important things the United States can do for global health, frankly, is to educate more physicians in the United States to work in the United States.
What is going on here? The US, of course, spends over a trillion dollars on health care, more absolutely an in terms of proportion of GDP than any other country. Then why can't it educate enough physicians?
A previous post on Health Care Renewal noted how the US short-changes the financing of basic medical education. Other posts (see this one and its links) have noted how the US under-finances primary care and other cognitive specialties, so that fewer and fewer trainees want to go into them.
There is something rotten here, but not in Denmark. The brain drain from less developed countries appears to have resulted from the inability of the US and other developed countries to train and retain enough physicians, particularly in primary care. In the US, in turn, this may result from failure to adequately support medical education, and the focus of almost all US efforts to cut costs on primary care and some other cognitive specialties, leaving their practitioners so poorly remunerated relative to their clinical efforts, so loaded down with bureacracy, and left with so little autonomy that hardly any one wants to go into these fields.
There has been little open conversation in the US about how this has come to pass. Based on our ongoing discussion on Health Care Renewal, I submit that the underlying cause is concentration and abuse of power in health care. Our large health care organizations, often lead by people with little real experience in health care, who may be overly self-interested, and sometimes corrupt, will do everything they can to protect their financial interests. But their mismanagement and outright malfeasance contributes, probably substantially, to the rapid rise of health care costs. But then the only remaining targets for cost-cutting are the hard-working but politically vulnerable, such as primary care physicians.
This has to change, or we will soon find ourselves without any primary care, and hence without a functioning health care system.

3 comments:

Dave Schuler said...

All good points, Dr. Poses. Linked in my update.

Dr. Bob said...

And it's still getting worse. Applications are down again this year for Family Medicine. I think we'll start seeing some training programs close down this year, which will make it really hard to reverse the trend once the US wakes up to the problem.

Anonymous said...

In the harder sciences, like physics, it is nearly impossible to find a decent paying job. It is very funny to see companies, say Ratheon, issuing press releases saying that we are not producing enough math and science students and we will have a shortage in the future.

What they are really asking for is that we allow MORE international students/professions to fill the US jobs at lower pay rather than pay fair market value for the position.