The Primary Care Physician Workforce: Ethical and Policy Implications

Barbara Starfield; George E. Fryer

doi:10.1370/afm.720

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Table 1.

Characteristics of Countries Exporting a Higher and a Lower Percentage of Primary Care Physicians Than the Overall Percentage of Primary Care Physicians in the US Practicing Physician Pool, 2004

	Percentage of PCPs Compared With US Percentage*	Mean	Standard Error Mean	t	P Value
Note: Except for gross national income (2003).
GNI = gross national income; PC = primary care; IMG = international medical graduate; DPT3 = 3 doses of diphtheria-pertussus-tetanus toxoid vaccine; polio3 = 3 doses of polio vaccine.
* Percentage of IMGs in primary care compared with the US percentage of physicians practicing primary care (31%). There were 38 countries contributing a higher percentage than the US average and 35 contributing a lower percentage.
GNI per capita, 2003, US$	Higher	2,994.7	703.8	−5.01	<.001
	Lower	14,946.9	2,279.8
Population per physician, 2004, No.	Higher	2,924.8	959.8	2.19	.034
	Lower	782.6	188.3
Host country physicians per PC IMG, No.	Higher	69.2	11.6	−4.39	<.001
	Lower	497.5	96.8
Host country physicians per IMG, No.	Higher	28.3	4.8	−3.66	.001
	Lower	129.7	27.2
Under-5, 2003, mortality rate	Higher	49.6	8.3	3.62	.001
	Lower	17.7	2.9
Life expectancy at birth, 2003, y	Higher	66.8	1.7	−3.75	<.001
	Lower	74.3	1.1
1-year-old children–DPT3, 2003, % immunized	Higher	83.7	2.8	−2.28	.026
	Lower	90.9	1.4
1-year-old children–polio3, 2003, % immunized	Higher	83.9	2.7	−2.61	.012
	Lower	91.6	1.2
1-year-old children–measles, 2003, % immunized	Higher	84.7	2.7	−1.46	.148
	Lower	89.1	1.4

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Table 2.

Characteristics of Countries (by World Region) Expatriating a Higher and Lower Percentage of Primary Care Physicians Than the US Average (31%)*

Region	Percentage of PCPs Compared With US Percentage*	No. of Countries	Ratio of IMGs to 100 Host Country Physicians, 2004	Per Capita GNI, 2003, US$	Physicians per 100K Population, 2004	Physicians (Including IMGs in US) per 100K Population, 2004
GNI = gross national income; IMG = international medical graduate; PCP = primary care physician.
*All data weighted by the 2004 population of each country in the region and in the total figures.
Africa	Higher	5	8.9	267	16.4	17.9
	Lower	2	4.1	2,438	75.1	78.2
	Total	7	7.8	774	30.1	32.5
The Americas	Higher	16	14.0	4,073	146.4	166.9
	Lower	7	1.4	2,825	198.8	201.6
	Total	23	6.3	3,311	178.4	189.6
Southeast Asia	Higher	3	6.4	520	47.4	50.4
	Lower	2	2.2	1,113	19.1	19.5
	Total	5	5.6	635	41.9	44.3
Europe	Higher	8	1.6	8,167	392.3	398.6
	Lower	15	1.4	20,185	297.0	301.2
	Total	23	1.5	13,883	347.0	352.2
Eastern Mediterranean	Higher	4	7.3	563	68.1	73.1
	Lower	3	4.3	1,750	164.0	171.1
	Total	7	6.1	1,043	106.9	113.4
Western Pacific	Higher	2	10.9	778	84.3	93.5
	Lower	6	0.2	4,396	166.9	167.2
	Total	8	1.2	4,044	158.9	160.8
Total	Higher	38	7.0	1,941	107.6	115.1
	Lower	35	1.0	5,516	167.4	169.1
	Total	73	3.6	3,837	139.3	144.3

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Table 3.

Correlations With Percentage of Primary Care IMGs Who Attended Medical School in Countries Expatriating Physicians to the United States

Need Heading	r	P
DPT3 = 3 doses of diphtheria-pertussis-tetanus toxoid vaccine; IMGs = international medical graduates; polio3 = 3 doses of polio vaccine.
Under-5 mortality rate, 2003	.44	<.001
Life expectancy at birth (y), 2003	−.44	<.001
% Immunized, 2003, 1-year-old children, DPT3	−.33	.004
% Immunized, 2003, 1-year old children, polio3	−.34	.012
% Immunized, 2003, 1-year old children, measles	−.28	.018

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The Article in Brief

The Primary Care Physician Workforce: Ethical and Policy Implications

Barbara Starfield, MD, MPH , and colleagues

Background Professionals from other countries make up more than a quarter of the medical and nursing workforces in Australia, Canada, the United Kingdom, and the United States. This study examines the characteristics of countries that export doctors to the United States.

What This Study Found Poor countries with high physician shortages, high infant mortality rates, lower life expectancies, and lower immunization rates disproportionately help the United States to maintain its primary care workforce. The most impoverished, underdeveloped African nations are a major source of primary care doctors to the United States, further reducing their own abilities to meet the needs of their citizens.

Implications

The United States disproportionately uses graduates of foreign medical schools from the poorest and most deprived countries to maintain its supply of primary care doctors.
The ethical aspects of depending on foreign medical graduates is an important issue, but it is particularly troubling when it deprives disadvantaged countries of their graduates.
US policy makers need to create more opportunities and incentives for primary care training and practice to make it an appealing career choice for US graduates.