The Primary Care Physician Workforce: Ethical and Policy Implications

Our study was designed to explore the extent to which foreign medical graduates helped the US to maintain its supply of primary care physicians and specialists. We found strong and statistically significant evidence that physicians from countries that were the poorest, had the poorest health levels, and had low physician to population ratios contributed disproportionately to the US primary care physician supply (but not the specialist supply). It seems likely that this is a result both of ‘push and pull’ factors, but we believe that an appropriate ethical response would be for the US to compensate these countries in a commensurate way to help the build health systems that are attractive enough to retain their own medical graduates. Instead of supporting a myriad of competing disease-oriented programs, assistance in building comprehensive and well funded primary health care systems could go a long way to reducing the ‘push’ factors. There is now enough evidence that a strong primary care infrastructure in health systems reduces costs, improves outcomes, and reduces social disparities in health. The US health system would be greatly improved by a stronger orientation towards primary care; giving more support to building such an infrastructure would benefit both our own country as well as others from which we currently derive benefit.

Reference: Starfield, B, Shi L, Macinko J. Contribution of Primary Care th Health Systems and Health. Milbank Q 2005; 83: 457-502

Competing interests:   None declared

This manuscript provides content for thought. There are considerable worldwide tribulations awaiting health care recipients and health care providers in the future requiring a skilled approach. Drs. Starfield and Fryer start with the stated purpose to examine the characteristics of countries exporting physicians to the United States and their contribution to the primary care supply of the United States. Unfortunately, in my opinion, their conclusion misses and inserts a flawed political and ethical opinion into a very complex and multifaceted issue.

These conclusions can only be considered after deeper inspection into the socio-economic and political intentions on both sides of the ocean. The etiologies of this migration phenomenon are not explored. Expatriates are attracted by work, needy American rural communities, economic opportunities, technology and remuneration, living style available in the United States as well as many other origins.1

The statistics offered are confounding, variable and hypothetical in some instances.2 Are tetanus rates an indication of significance to these issues? It appears Canada and other countries were excluded. In my opinion, research into the dynamics of these countries’ health-care migrants would add much greater dimension to this manuscript. Also, information is needed on the retention and return rate. How many returns take back valued educational experiences and help improve political, socioeconomic and health care in their countries of origin? Called for here is a discussion of the impact (positive and negative) of these mobile health care providers on medical practices and patient care in the United States.1

I find this document puzzling. It might be interesting to look at other fields, their trends and conclusions. It is also interesting that many in the technology-related fields who have migrated to the United States are now returning to their country of birth.

Although an interesting read, I fail to see how the stated purpose of this article leads to the conclusions. When discussing a malady process it is essential to investigate the etiology and differential diagnosis. Unfortunately, I feel this is lacking with this text. An in-depth discussion of solutions (in view of causes) would add a tour de force to this study. I found this unclear and byzantine manuscript unfortunately provides no significant insight into this highly intricate and multifaceted issue. I almost get the impression that the authors are criticizing the American system for the shortcomings of the nations they've identified in their study.

This paper takes on a highly significant issue but left me questioning its significance in primary care. This political and psychosocial issue certainly needs to be addressed but the conclusions reached here do very little to affect the practice of family medicine.

References:

1. Jenna Johnson. Born in India, Transforming Rural Md. Washington Post. Friday, December 7, 2007; A01. http://www.washingtonpost.com/wp- dyn/content/article/2007/12/06/AR2007120602851.html

2. CONCEPTUALISATION, MEASUREMENT AND VALUATION OF HEALTH STATES. http://www.who.int/healthinfo/nationalburdenofdiseasemanual.pdf

The Global Burden of Disease Study 1990 asked participants in weighting exercises to make a composite judgment on the severity distribution of the condition and the preference for time spent in each severity level. This was to a large extent necessitated by the lack of population information on the severity distribution of most conditions at the global and regional level. Following the GBD terminology, and consistent with the WHO International Classification of Functioning, Disability and Health (ICF), the term disability is used broadly in burden of disease analysis to refer to departures from optimal health in any of the important domains of health. These include mobility, self-care, participation in usual activities, pain and discomfort, anxiety and depression, and cognition and social participation. In some contexts, the word ‘healthy’ is understood to mean ‘absence of illness’. In the context of summary measures of population health, health is given a broader meaning. As well as implying absence of illness there are also no impairments or functional limitations due to previous illness or injury. We thus refer to disability weights and years lost due to disability (YLD) as shorthand terms for health state preferences and years of healthy life lost due to time lived in states other than the reference state of optimal health, respectively. A year of healthy life refers to a year lived in the reference state of optimal health. Note that disability (i.e. states other than ideal health) may be short-term or long-term. A day with a common cold is a day with disability.

Competing interests:   None declared

Thanks to Joses Muthori Kirigia for providing more detail and more specificity to our recommendations. We would only add that the wealthy international donors need to re-direct their important contributions to building health systems instead of supporting diseases-oriented priorities that compete for scarce country health personnel. Some countries, especially in Latin America, have shown how primary care in poor countries can be made exciting enough not only to retain their workforce but also to provide an exciting challenge to their medical graduates.

Competing interests:   None declared

Starfield and Fryer[1] found that “..the contribution of the [poor] countries to the US primary care physician workforce is highly correlated with measures of health deprivation in those countries: the greater the contribution, the poorer the health measures”. Approximately 18556 physicians trained in Angola (0.9%), Cameroon (0.6%), Ethiopia (1.8%), Ghana (5.0%), Mozambique (0.1), Nigeria (23.0%), South Africa (65.4%), Uganda (1.7%), Tanzania (0.2%) and Zimbabwe (1.3%) work in Australia, Canada, Finland, France, Germany, Portugal, United Kingdom, and United States of America.[2] The neonatal, infant, under-five, maternal and adult mortality rates in the ten African countries are very high.[2] Those high mortality rates are partially attributable to scarcity of skilled human resources for health (HRH) in the countries concerned. There is growing evidence that international migration of HRH has enormous health[1,2] and economic[3,4] negative effects on populations of middle-income (MI) and low- income (LI) source countries.

The OECD countries that recruit scarce HRH from MI and LI countries are denying millions of poor people of their human rights to medical care and to life as stipulated in Articles 25 and 3 of the Universal Declaration of Human Rights.[5] The OECD countries should acknowledge that they have fundamental ethical obligation not only to stop “poaching” HRH from MI and LI countries but also to systematically cooperate with those countries to both counter the push and pull factors.

The OECD countries that are recipients of HRH trained in middle- and low-income countries can take a number of ameliorative actions: (a) Compensate the source countries for the opportunity cost incurred as a result of loss of their skilled HRH, for use in addressing the push factors; (b) Allocate a percentage of overseas development aid (especially grants) for production and retention of HRH in source countries; (c) Insist that a percentage of debt relief funds and global health funds (e.g. GFATM and the GAVI) be allocated towards production and retention of HRH that provide primary health care; (d) Legislate against unethical recruitment of skilled HRH from MI and LI countries; and (e) Accelerate north-south collaboration between the institutions that produce HRH.

References

1. Starfield B, Fryer GE: The primary care physician workforce: ethical and policy implications. Annals of family medicine. 2007; 5(6): 486-491.

2. World Health Organization. The world health report 2006: Working together for health. Geneva; 2006.

3. Kirigia JM, Gbary AR, Muthuri LK, Nyoni J, Seddoh A. The cost of health professionals’ brain drain in Kenya. BMC Health Services Research. 2006; 6:89.

4. Kirigia JM, Gbary AR, Nyoni J, Seddoh A, Muthuri LK: The cost of health -related brain drain to the WHO African Region. African Journal of Health Sciences. 2006; 13(3-4): 1-12.

5. United Nations: Universal Declaration of Human Rights. New York; 1948.

Competing interests:   None declared

In the 1980's when I was in medical school, the rural state that sponsored me in another states' medical school(WAMI) threatened to increase the cost passed on to the medical students to bear the full burden, ie, what the state of Idaho paid to the state of Washington, at that time $29K. In an attempt to dissuade the legislature, I tried to find evidence that indebtedness increased higher-paying specialty choice, driving students away from Family Medicine. At the time there were NO articles to support this theory. There are a few now. Why, as physicians do we believe physicians will behave (or think) differently than any other human being? I cite the title of a best selling book to support this. And, if we really expect those of us in the Guild to behave (or Think) differently, why don't we hold ourselves to this expectation? I understand the third world doctors who want to practice in this country, just like I understand fewer and fewer medical students chosing Family medicine. Last year I made $90k. Our hospital recruited a young radiologist at $350K. Until "the system"(could some one please give me the address of "the system"?) acknowledges that income disparity, above a certain level, is unhealthy we will continue to promote excess, and foster unhealthy practices. It is time for Family Physicians to take up this banner and proclaim the need for a more rational health care system. If we were to acknowledge that WE make enough money, and any physician making over twice what we made was, what, "greedy?", then maybe the forces that influence physician payment would change. Then, maybe the world might not want to come here for our offer of wealth, but for our atmosphere of peace. www.poemd.blogspot.com

Competing interests:   None declared

Dr. Mullan supports our position that concerted efforst must be made to train more primary care physicians to stem the drain of US physicians into specialties and the drain in primary care physicians from countries that cannot afford to lose their own physicians. Making primary care practice more attractive is also an imperative. Students who start medical school with ambitions to serve communities with good primary care practice aften lose that interest ini going through medical school, with its exposures to highly paid specialists who become the role model. Foreign trained physicians entering medical school have the same aspirations, only to be faced on graduation with the absence of primary care practice opportunities in their own countries. Experts in 'global health' are increasingly recognizing' the importance of helping to build primary care- oriented health systems rather than continuing the competing (and therefore inefficient) disese-oriented programs that characterize current aid. Philanthropic donors who have led the way in supporting these disease programs must realize that long term success will come only when they re-direct their attention to helping to build strong health systems that can deal at once and in a coordinated way with health needs of poor countries.

Competing interests:   None declared