Introduction

The migration of doctors to developed countries from developing countries has been a steady flow from the early post Second World War days, peaking in the 1970’s and 80’s. The historical aspects of doctor migration from developing to developed nations have been described by Wright et al (1). Physicians continue to migrate from developing countries, including India, to the United States, the United Kingdom, Canada, Australia and New Zealand, in search of higher education, better working conditions, better pay, higher standards of living and self realisation (2). Scholars have discussed the factors in physician migration, the impact of such migration and the ethical issues involved. Most work in this field has been at the level of government and international policy. There is a need to learn more about perceptions at the individual level on the issue of physician migration. This study was conducted to assess the attitudes of students in a medical college in Vellore city, Tamil Nadu, South India.

Methods

50 first-year medical students and 52 interns in a private medical college in Vellore city gave their verbal consent to participate in the study. The study, which was done as an interns’ project, received expedited clearance from the institutional review board and administrative approvals as per institutional protocols. Information was collected using a self administered multiple response closed ended questionnaire. Data were entered using SPSS for windows 12.0 software and simple frequencies of responses to each question were analysed for both groups of students.

Questionnaire

The questionnaire consisted of demographic details followed by questions related to the students’ knowledge and attitudes to doctors’ migration. These were: 1. The various reasons why doctors migrate; 2. how doctors who migrate usually contribute to healthcare in India; 3. to what extent the contribution of migrant doctors could contribute to the health system in India; 4. whether doctor migration is a matter of ethical significance, and 5. their responses to the statement “Individual altruism is not a solution for public problems.” Finally, students were asked to comment on two case scenarios: one about a doctor who went abroad for studies and now chooses to apply for a waiver to visa requirements so that she can further pursue her academic interests abroad; the other about a medical student who chooses to join the public health system in India, but is troubled by poor working conditions and a subsistence salary.

Results

There were a total of 120 eligible students (60 students per batch) in the first and internship years in the college. A total of 102 students including 83 students (50 from the first year and 33 from the internship year) from the college, and 19 students who were doing their internship in the college but had studied elsewhere, participated in the study. 63 were women and 39 were men. 50 had doctors in their families and 57 knew doctors who were living abroad.

The common reasons for doctors’ migration, as expressed by the participants, are shown in Figure 1. The top reasons for doctor migration, identified by students, were a good quality of life (53 responses) and higher education (42 responses). The students’ views on how doctors living abroad contribute to the health system in India are shown in Figure 2. The most cited contributions are: collaboration with Indian universities (34 responses), sending revenue home (28 responses) and sharing knowledge and expertise (28 responses). Volunteering to teach in medical colleges was the least mentioned (8 responses).

The Likert scale responses of the three statements are depicted in Table 1. 89 students were of the view that contributions from migrant doctors were of little or no help to the health system in India. Regarding whether doctor migration was an ethical issue, 43 felt it was a very significant issue, 42 felt it was significant to a small extent, and 17 felt it was not an issue at all. In response to the statement “Individual altruism is not a solution for public problems”, 40 agreed, 42 disagreed and 20 had a neutral opinion.

Table 1: Likert scale responses to three statements regarding ethics of doctor migration

Figure 1: Reasons why doctors migrate to other countries

Figure 2: How migrant doctors abroad contribute to health care in India

Figure 3: Dr K is a fresh graduate from a premier medical institute in India. She wrote her foreign medical licensing examination and got certified. She enrolled in a radiology residency programme in a reputed foreign university. Her visa stipulated that she had to return to the country of origin to serve for two years after she completed her training before she could re-apply for a visa. She finished her training and wanted to specialise in nuclear imaging studies. She obtained a waiver of her visa statute and enrolled for a super specialty fellowship

Figure 4: MS is a bright young student from a poor background. He passed the 12th standard exam with a high rank and entered medical college. He completed his MBBS training on a government scholarship, winning several gold medals. He used to dream that after he became a doctor, he would provide his parents with a comfortable life free of discomfort. However, immediately upon graduating, he decided to join the government public health service and was posted in a village without facilities. His salary was just enough to sustain himself, and he wondered how he would solve his family problems.

The responses to the scenarios on the ethics of doctor migration are given in Figures 3 and 4. Regarding the doctor working abroad who seeks a waiver of the visa requirement, 42% of first- year students felt her action was unethical but 44.2% of interns felt her action was appropriate. Regarding the doctor who joined the public health system and faced difficult working conditions, 44% of first-year students felt he was obliged to stay; 28% of first-year students felt he should fight for improved working conditions. 63.5% of interns felt that the doctor had the right to refuse to work in such conditions; 36.5% of interns supported his right to migrate. One intern wrote: “He has to provide for his parents before he provides for the society. If everyone provides for their family, the society at large would benefit.” Another intern wrote: “Take care of yourself before you think of others.”

Discussion

The important findings of the study are: 89/102 students felt that migrant doctors do not contribute much to the healthcare system in India; 17/102 thought that doctor migration is not an important ethical issue; while 40/102 thought that individual altruism has no role in solving public problems.

Further, in response to the scenarios, first-year students gave responses which stressed the commitment of the doctor to the community while interns laid emphasis on individual liberties. The former largely felt that it was unethical of a doctor to seek a waiver in order to study further, and the doctor working in difficult circumstances in the public health system should stay and fight. The views of interns were directly contrary, justifying both waiving visa requirements for better education, and migrating to get away from poor working conditions.

Most published literature on doctor migration describes it as a ‘brain drain’ from developing to developed countries; it aggravates shortages in the healthcare workforce in those countries who have invested on training these doctors. The literature also discusses the ethics of developed countries not investing in training health workers, drawing them from developing countries instead (3). There is little literature on doctors’ attitudes and their influence on doctor migration. Our study findings suggest that the views of medical students may change in the course of their education, from a social perspective to one that focuses on the individual’s rights and benefits. This would imply that it is not only the “pull” factor from developed countries in the form of good working conditions, good remuneration and a high quality of life and the “push” factor in developing countries, such as poor work conditions, but also an overall shift in priorities that has been forced on young learners of the art (4).