Plugging the medical brain drain

Global health and care worker migration requires a global response

The global migration of the health and care workforce (HCWF) has intensified, leading to complex policy scenarios and diverse migration patterns. While the traditional narrative of individual health and care workers (HCWs) migrating from low- and middle-income countries to high-income countries in search of higher income, career prospects and working conditions remains relevant, it now coexists with many other drivers, incentives, and dynamics at individual and policy level. The evolving dynamics of HCW migration have profound implications extending far beyond health labour markets, influencing broader societal and political landscapes. Despite their significance, the qualitative shifts in HCWF migration patterns and the governance challenges they present are poorly understood and under-researched, and policies have thus been limited in their effectiveness. In this policy comment we argue for a global response and an enhanced focus on policy implementation, using selected case studies to illustrate the argument. The cases highlight complexities of HCW migration patterns and opportunities for strengthening implementation of the WHO Global Code of Practice to respond effectively to the diverse needs of health systems and individual HCWs.

The Intentions of Migration Among Graduated and Postgraduate Sudanese Nursing Students 2022

Background: Migration of healthcare workers has become a foremost issue of health systems, generally from developing countries toward countries with higher income, producing destructive effects on health indicators. Aim: This study was proposed to investigate the intentions of migration among graduated and postgraduate Sudanese nursing students and the causes behind their intentions to migrate and determine the proportions and characteristics (e.g., per gender and profession) of Sudanese nursing students, both graduated and postgraduate, who intend to migrate. Materials and Methods: A descriptive cross-sectional survey was carried out in Khartoum State, Sudan, between January and April 2022. The study involved 321 Sudanese nurses, both graduate and postgraduate, who were selected through convenience sampling. Data collection was performed using a semistructured, self-administered questionnaire created by the researchers. The questionnaire, prepared in English, was distributed via Google Forms on social media platforms. The study received approval from the Research and Ethics Committee of Alzaiem Alazhari University. Informed consent was obtained from all participants prior to their involvement. Data analysis was conducted using the Statistical Package for Social Sciences (SPSS) software, Version 25. The results were presented in frequency tables and cross-tabulations. The Chi-square test was used to assess statistical significance, with a p value of < 0.05 considered significant. Results: The current study reflected that half of the nurses (49.5%) were willing to migrate after graduation if provided the opportunity. More than a third (36.8%) of them are interested in migrating to the Gulf countries, while that quarter (24.9%) of them said their main reason for migration is to save money quickly. There was a significant association between five sociodemographic variables (age, sex, education program, marital status, and place of residence) and the reason for migration with a p value of 0.05. Conclusion: The study concluded that there is high intention among graduated and postgraduate nursing students in Sudan to migrate and work outside Sudan.

Medical education needs a new model for global leadership

BACKGROUND

Like other fields in medicine, medical education relies on collaboration and cooperation between countries and regions of the world, although no single institution or position unifies the global medical education community in the way that the WHO does in public health, for example. Recent research in medical education has drawn attention to many injustices that exist in the field, where power and influence is held in relatively few Global North countries, although most practice happens in Global South countries.

METHODS

In this article, we examine three positions that hold global prominence in medical education, including the presidents of the World Federation for Medical Education and the Association for Medical Education in Europe, and winners of the Karolinska Institutet Prize for Research in Medical Education.

FINDINGS

We highlight that these positions have problematic histories and have perpetuated the current power disparities in the field. We argue that an alternative model for global leadership is required that should be determined democratically by those involved in medical education all around the world. Such a model should prioritise diversity and inclusivity, empowering leaders from countries who have previously been peripheral to the decision-making platforms in the field.

CONCLUSION

Given the shortcomings of existing leadership positions and organisations, we suggest that a new institution is required to realise this new vision, and that the principles that govern it should be determined through debate and democracy, with a focus on inviting those voices that have not previously been heard in global medical education circles.

Beyond Borders: A Longitudinal Study of Nepali Nurses' Dreams, Realities, and the Pursuit of a Global Career

The global migration of nurses, particularly from developing nations like Nepal, is a complex tapestry woven with threads of ambition, sacrifice, and resilience. This longitudinal qualitative study followed the journeys of 17 Nepali nursing graduates, some who embarked on international careers and others who chose to remain in their homeland. Their narratives challenge simplistic notions of "brain drain," revealing a dynamic interplay of evolving motivations, unexpected opportunities, and the bittersweet realities of pursuing dreams abroad. The study uncovers a stark contrast between the idealized vision of working in "modern, first-world hospitals" and the lived experiences of migrant nurses, highlighting the emotional toll of cultural adjustment and the often-unmet expectations related to financial gains and professional advancement. Yet, amidst these challenges, nurses demonstrated remarkable adaptability, leveraging language acquisition, mentorship, and community building as strategies for integration and resilience. The study also sheds light on the unexpected paths to fulfillment found by those who remained in Nepal, challenging the prevailing narrative that migration is the sole route to success. These findings underscore the urgent need for comprehensive policies and support systems that address both the structural factors driving migration and the individual needs of nurses, fostering a more equitable and sustainable global healthcare workforce.

Fear of violence and brain drain analysis among healthcare workers in Turkey

BACKGROUND

This study investigates the relationship between healthcare professionals' intention to emigrate and their exposure to violence in Turkey, using a quantile regression model. Through this approach, it aims to reveal how healthcare professionals' attitudes toward brain drain vary across different levels of fear of violence, considering factors such as professional experience and income.

METHODS

A cross-sectional study design was employed, utilizing a quantile regression model to analyze the variation in brain drain attitudes across different percentiles. The model examines how fear of violence affects these attitudes at various levels.

RESULTS

The analysis reveals that the intention to engage in brain drain increases with professional experience. Interestingly, a high fear of violence is associated with a reduced tendency to emigrate. Furthermore, the findings indicate that as income increases, attitude scores toward brain drain decrease, suggesting a complex interplay of factors in this phenomenon.

CONCLUSIONS

The study's findings have significant implications for policymakers. By understanding the role of factors such as fear of violence, income level, and professional experience in healthcare professionals' decisions to stay or leave, policymakers can develop targeted strategies to prevent or manage brain drain. Future research could further investigate these variables, providing valuable insights for policy development.

A generation at risk: the unseen consequences of Nepal's nursing shortage on undergraduate nursing students clinical education

BACKGROUND

The global nursing shortage has particularly severe consequences in resource-constrained countries like Nepal, where a significant outflow of healthcare professionals exacerbates the crisis. While the impact on patient care, workforce dynamics, and organizational challenges within healthcare settings have been extensively researched, the profound implications of this crisis for nursing education remain underexplored. This qualitative study sheds light on the often-unseen consequences of the nursing shortage on undergraduate nursing students' clinical education.

METHODS

Data were collected from three focus group discussions involving eighteen final-year nursing students from two tertiary institutions. The first two discussions took place in June 2024, with the third one in July 2024. Thematic analysis was employed to identify and interpret the key themes.

RESULTS

Four overarching themes emerged: (1) Compromised Learning, highlighting the detrimental impact on skill acquisition and student preparedness; (2) Abandoned in the Field, revealing the emotional toll of isolation, with students describing themselves as "ghosts, silently observing from the sidelines"; (3) Forging Ahead, showcasing the unintended resilience and resourcefulness of students seeking alternative knowledge sources; and (4) Digital Mentors, spotlighting the innovative use of Artificial Intelligence (AI) as a supplementary learning tool in overburdened clinical settings.

CONCLUSION

The nursing shortage in Nepal has created a challenging and often isolating clinical learning environment (CLE) for students. While their resilience and adaptability are commendable, these qualities are not substitutes for nurse staffing shortages and inadequate mentorship. This study underscores the urgent need for systemic change, including increased investment in the nursing workforce, cultivating a supportive learning environment, and integrating technology into nursing education. These findings have implications for Nepal and other resource-constrained settings grappling with the challenges of a nursing shortage.

Building resilient surgical systems that can withstand external shocks

When surgical systems fail, there is the major collateral impact on patients, society and economies. While short-term impact on patient outcomes during periods of high system stress is easy to measure, the long-term repercussions of global crises are harder to quantify and require modelling studies with inherent uncertainty. When external stressors such as high-threat infectious disease, forced migration or climate-change-related events occur, there is a resulting surge in healthcare demand. This, directly and indirectly, affects perioperative pathways, increasing pressure on emergency, critical and operative care areas. While different stressors have different effects on healthcare systems, they share the common feature of exposing the weakest areas, at which point care pathways breakdown. Surgery has been identified as a highly vulnerable area for early failure. Despite efforts by the WHO to improve preparedness in the wake of the SARS-CoV-2 pandemic, measurement of healthcare investment and surgical preparedness metrics suggests that surgical care is not yet being prioritised by policy-makers. Investment in the 'response' phase of health system recovery without investment in the 'readiness' phase will not mitigate long-term health effects for patients as new stressors arise. This analysis aims to explore how surgical preparedness can be measured, identify emerging threats and explore their potential impact on surgical services. Finally, it aims to highlight the role of high-quality research in developing resilient surgical systems.

Consensus statements for the establishment of medical intensive care in low-resource settings: international study using modified Delphi methodology

BACKGROUND

The inadequacy of intensive care medicine in low-resource settings (LRS) has become significantly more visible after the COVID-19 pandemic. Recommendations for establishing medical critical care are scarce and rarely include expert clinicians from LRS.

METHODS

In December 2023, the National Association of Intensivists from Bosnia and Herzegovina organized a hybrid international conference on the topic of organizational structure of medical critical care in LRS. The conference proceedings and literature review informed expert statements across several domains. Following the conference, the statements were distributed via an online survey to conference participants and their wider professional network using a modified Delphi methodology. An agreement of ≥ 80% was required to reach a consensus on a statement.

RESULTS

Out of the 48 invited clinicians, 43 agreed to participate. The study participants came from 20 countries and included clinician representatives from different base specialties and health authorities. After the two rounds, consensus was reached for 13 out of 16 statements across 3 domains: organizational structure, staffing, and education. The participants favored multispecialty medical intensive care units run by a medical team with formal intensive care training. Recognition and support by health care authorities was deemed critical and the panel underscored the important roles of professional organizations, clinician educators trained in high-income countries, and novel technologies such as tele-medicine and tele-education.

CONCLUSION

Delphi process identified a set of consensus-based statements on how to create a sustainable patient-centered medical intensive care in LRS.

Exploring global barriers to optimal ovarian cancer care: thematic analysis

OBJECTIVE

To explore the barriers to ovarian cancer care, as reported in the open ended responses of a global expert opinion survey, highlighting areas for improvement in global ovarian cancer care. Potential solutions to overcome these barriers are proposed.

METHODS

Data from the expert opinion survey, designed to assess the organization of ovarian cancer care worldwide, were analyzed. The survey was distributed across a global network of physicians. We examined free text, open ended responses concerning the barriers to ovarian cancer care. A qualitative thematic analysis was conducted to identify, analyze, and report meaningful patterns within the data.

RESULTS

A total of 1059 physicians from 115 countries completed the survey, with 438 physicians from 93 countries commenting on the barriers to ovarian cancer care. Thematic analysis gave five major themes, regardless of income category or location: societal factors, inadequate resources in hospital, economic barriers, organization of the specialty, and need for early detection. Suggested solutions include accessible resource stratified guidelines, multidisciplinary teamwork, public education, and development of gynecological oncology training pathways internationally.

CONCLUSIONS

This analysis provides an international perspective on the main barriers to optimal ovarian cancer care. The themes derived from our analysis highlight key target areas to focus efforts to reduce inequalities in global care. Future regional analysis involving local representatives will enable country specific recommendations to improve the quality of care and ultimately to work towards closing the care gap.

International Medical Graduates and the Physician Workforce

Importance

Physician shortages and the geographic maldistribution of general and specialist physicians impair health care delivery and worsen health inequity in the US. International medical graduates (IMGs) represent a potential solution given their ready supply.

Observations

Despite extensive clinical experience, evidence of competence, and willingness to practice in underserved communities, IMGs experience multiple barriers to entry in the US, including the immigration process, the pathways available for certification and licensing, and institutional reluctance to consider non-US-trained candidates. International medical graduates applying to postgraduate training programs compare favorably with US-trained candidates in terms of clinical experience, prior formal postgraduate training, and research, but have higher application withdrawal rates and significantly lower residency and fellowship match rates, a disparity that may be exacerbated by the recent elimination of objective performance metrics, such as the US Medical Licensing Examination Step 1 score. Once legally in the US, IMGs encounter additional obstacles to board eligibility, research funding, and career progression.

Conclusions and Relevance

International medical graduates offer a viable and available solution to bridge the domestic physician supply gap, while improving workforce diversity and meaningfully addressing the public health implications of geographic maldistribution of general and specialist physicians, without disrupting existing physician stature and salaries. The US remains unable to integrate IMGs until systematic policy changes at the national level are implemented.

Assessing interventional radiology specialty knowledge and perception amongst Tanzanian medical students before and after exposure to an immersive curriculum

AIMS

This study aims to assess the impact that delivering an introductory interventional radiology (IR) lecture series has on the knowledge and perception of the specialty among medical students in a resource-limited setting with, until recently, no IR presence.

MATERIALS AND METHODS

An introductory four-hour lecture series in IR was delivered to third-year medical students in Tanzania. Prior to and following the lecture series, participants completed a 27-item paper-based survey assessing their knowledge and perception of the specialty.

RESULTS

Out of a class of 213, the pre- and post-lecture survey was returned by 148 (69.5%) and 151 (70.9%) respondents, respectively. 94.5% of respondents indicated that they were aware of IR as a specialty. Among respondents, 97.3% expressed interest in having IR lectures integrated into their curriculum, compared to 29.0% that reported having any prior IR training. 27.3% believed their knowledge in IR compared to other specialties was either "good" or "excellent", which improved to 43.3% (p<0.001). Identification that IR physicians consult patients directly, have outpatient clinics, have inpatient beds, and do rounds improved from 55.4% to 81.1% (p<0.001), 49.7% to 60.3% (p=0.066), 48.3% to 66.7% (p=0.001), and 52.0% to 66.2% (p=0.013), respectively.

CONCLUSION

By introducing short lectures on IR-relevant topics, knowledge and perception of IR improved among Tanzanian medical students. Early education and exposure to IR should be prioritized to promote the continued growth of the specialty in this setting.

How are early-career dementia researchers considered and supported on a national level by dementia plans and organizations? An overview of global policy approaches

INTRODUCTION

Despite representing an essential workforce, it is unclear how global policy efforts target early-career dementia researchers (ECDRs). Thus, this study aimed to provide an overview of policies through which ECDRs are considered and supported by dementia plans and organizations.

METHODS

G20 member states were evaluated for their national dementia plan alongside policies of leading dementia organizations. Data targeting support for ECDRs were extracted and subject to content analysis using inductive coding. Findings were categorized and narratively synthesized.

RESULTS

Only China, Denmark, England, Greece, Northern Ireland, Scotland, Spain, and the United States mentioned ECDRs in their national plan. Additionally, 17 countries formalized ECDR support via dementia organizations. Support efforts included research funding, dissemination and networking, career development, and research advice.

DISCUSSION

Few nations formally recognized ECDRs in dementia plans or through dementia organizations. To facilitate equal prospects for ECDRs, top-down approaches are urged to enhance and align their efforts.

HIGHLIGHTS

Few G20 countries (8/46) had national dementia plans for early-career researchers. Targeted support comes from government and nongovernmental dementia organizations. Support includes funding, training, advice, research dissemination, and networking. Inconsistent definitions and eligibility criteria are barriers to accessing support. Global coordination and top-down policy will aid early-career dementia researchers.

Gaps and priorities in innovation for children's surgery

Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.

Down the brain drain: a rapid review exploring physician emigration from West Africa

BACKGROUND

The emigration of physicians from low- and middle-income countries (LMICs) to high-income countries (HICs), colloquially referred to as the "brain drain", has been a topic of discussion in global health spheres for years. With the call to decolonize global health in mind, and considering that West Africa, as a region, is a main source of physicians emigrating to HICs, this rapid review aims to synthesize the reasons for, and implications of, the brain drain, as well as recommendations to mitigate physician emigration from West African countries to HICs.

METHODS

A literature search was conducted on PubMed, EMBASE and The Cochrane Library. Main inclusion criteria were the inclusion of West African trained physicians' perspectives, the reasons and implications of physician emigration, and recommendations for management. Data on the study design, reasons for the brain drain, implications of brain drain, and proposed solutions to manage physician emigration were extracted using a structured template. The Hawker Tool was used as a risk of bias assessment tool to evaluate the included articles.

RESULTS

A total of 17 articles were included in the final review. Reasons for physician emigration include poor working conditions and remuneration, limited career opportunities, low standards of living, and sociopolitical unrest. Implications of physician emigration include exacerbation of low physician to population ratios, and weakened healthcare systems. Recommendations include development of international policies that limit HICs' recruitment from LMICs, avenues for HICs to compensate LMICs, collaborations investing in mutual medical education, and incorporation of virtual or short-term consultation services for physicians working in HICs to provide care for patients in LMICs.

CONCLUSIONS

The medical brain drain is a global health equity issue requiring the collaboration of LMICs and HICs in implementing possible solutions. Future studies should examine policies and innovative methods to involve both HICs and LMICs to manage the brain drain.