Thursday, February 24, 2011

Where are the Doctors?

by Leana S. Wen, M.D.

Of the 29 graduates of the emergency medicine training program that I’m interviewing here in Cape Town, South Africa, 5 are living and working abroad, in the U.K. and Australia. That may not seem like a lot, but these are already from the select pool of individuals who chose to stay in South Africa for their post-graduate medical training. Many more South Africans leave after medical school to seek higher-paying positions in developed countries.

Why do they do choose to leave? It’s for the same reason that qualified professionals from throughout the developing world leave their home country: to seek better opportunity and better pay. On the individual level, this pursuit it completely understandable. I’m the child of immigrants who came from China to seek a better life; I am only where I am today, a resident physician in the U.S., because of choices my parents made.

On the systems level, the exodus has created health systems that are deficient in doctors, nurses, and other health professionals. When I was in the Congo a few years ago, the going joke was that there were more Congolese doctors in Washington D.C. than there were serving the entire 68-million population of the Democratic Republic of the Congo. The motivations of individual doctors to leave the Congo was very much understandable—the country was in the midst of civil war! But their departure left the country without a functional healthcare system.

The problem of the global brain drain is described in some excellent papers, and Professor Fitzhugh Mullan among others are working on solutions that take into account individual preferences while also building systems solutions. There are two main issues that need to be addressed. Capacity within the developing country needs to be built. We’re talking the basics like security, but also salary needs to be sufficient, and the type of practice needs to be adequately attractive to retain doctors. In South Africa, for example, there need to be enough consultant posts for these EM graduates—otherwise they will go elsewhere to practice the skills that they were trained to do.

There also needs to be policies in place for developed countries to prevent dependence from doctors trained in the developing world. Currently, the U.S. relies on foreign medical graduates to supply its workforce, with 1/3 of all residency spots filled by graduates of non-U.S. medical schools. Foreign graduates have much to offer our country, and yes, the U.S. is also experiencing a workforce shortage. And yes, we do want to provide opportunity for foreign graduates to train and, if they choose, to establish a better life in our country. But we should take care to not have a policy that effectively poaches the few qualified doctors of a developing country whose services are needed far more there. The U.S. (and our partners in the U.K., Australia, Canada, etc) need to develop more training programs to ensure that we adequately provide for our own workforce.

In South Africa, there are two other workforce issues that should resonate with those of us from developed countries as well. The first is that the private sector continues to offer far more lucrative options than the public sector. What can be done to retain the best and brightest to serve the more than 80% of people who rely on public provision of care? The second is the training of other healthcare providers. The vast majority of care in the country takes place in rural settings that are staffed by nurses and mid-level providers. What kind of training can be done to improve the quality of care in these rural areas, and not just in the cities? Other than compulsory service, what can entice qualified doctors to work in these settings?

My final reflection is that almost every single doctor I’ve talked—including the ones who immigrated—genuinely want to be in South Africa. South Africa is home; they want to improve care for their home, their people. Those who left express a lot of regret, and say that they wish the posts were available for them to come back and fill them so that they can continue to improve health care in their country.

My time in South Africa has been invaluable, and I thank the Partners COE for making my trip and this research possible. I look forward to returning. Please send your thoughts and comments on my posts. Thanks for reading.

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