“The Metrics of the Physician Brain Drain”


Farrokh Saidi MD*


Author’s affiliation:  Academy of Medical Sciences of I.R. Iran, Tehran, Iran .

•Corresponding author and reprints: Farokh Saidi MD, Academy of Medical Sciences of I.R. Iran, Tehran, Iran.  
Fax: +98-21-22938051


Accepted for Publication: 12 September 2006





hysicians brain drain was a hot topic a few decades ago. It was reopened about a year ago in the New England Journal of Medicine.1 This paper was what it said it was—quantification of the problem. Additionally, host countries, or the four major recipients of the “medical brains,” were identified in that article as being the United States, the United Kingdom, Canada, and Australia. The term “international medical graduates” (IMGs) has also replaced the former “foreign medical graduate” (FMGs), because this newer term also covers the large number of the United States citizens who obtain their medical education outside the United States.

The phenomenon of physician brain drain really reflects the boundless capacity of the American society to absorb health manpower, regardless of source. Even more disconcerting is the fact that all four host countries have officially announced that they intend to expand the total pool of IMGs in their countries over the next few years, further threatening worsening the situation in the future. The harmful impact of such policies upon the donor countries, mostly developing ones in the Third World, has been acknowledged, and medical leaders and statesmen of developed countries do lament the fact that they are draining the medical manpower of developing countries. To soften the blow, reference is sometimes made to the remittance emigrating physicians can make to their native country from their increased income in their new home. A more egregious benefit proclaimed for donor countries is that the prospects of their people receiving a visa to America or Australia is bound to stimulate them to greater investment in education.2

The fact is that physicians brain drain is neither exploitation nor active recruitment, emigrating physicians leaving on their own for greener pastures. And, it is neither illegal nor immoral for developed countries to keep their doors open to the influx of medical graduates. After all, the phenomenon has a 2000-year history behind it, beginning with the Ionian physician Galen emigrating to Rome. It is not even a manifestation of the “tragedy of the Commons,”3 the metaphor used to illustrate the conflict between individual interest and common good. Human nature has always held the upper hand when it comes to self-preservation, and it would be naive to think that physicians would behave any differently than expected.

Only donor countries, themselves, can staunch hemorrhaging their trained health manpower to recipient countries. What have some of them done in this respect? The Chinese produced barefoot doctors for some years, knowing that they could not be exported. Iran, in a perfectly natural revolutionary spirit, educated rapidly a large number of physicians. This was a grave mistake. Not only was there an unavoidable drop in the quality of medical education, but this policy contributed to an oversupply of physicians in the country—a situation worse than not having enough doctors. Those who raise the issue of improper distribution of health manpower pool, fail to grasp the futility of forcing physicians to serve in outlying posts. The results of all these efforts on the part of donor countries to stem the tide of physicians brain drain, as the New England Journal of Medicine article points out, is that none of them works.

It is assumed that Third World countries, development is hampered by emigration of their educated manpower, physicians included. This point has not and cannot be proven. It may, in fact, be an unwarranted assumption. Development is too inclusive and its description elusive. The basic fallacy is that doctors are attracted to development, but by themselves, do not create development. All governments of developing countries suffer under the illusion that health of their citizens is assured by physicians. Their tacit policy is therefore, to train more doctors. A policy actively encouraged by their people who view technical education as the surest way to emigration. The resulting surfeit of physicians is counterproductive resulting in discontent among the educated classes. Emigration of physicians is in reality a social safety valve, a welcome brain flush. In sub-Saharan Africa, with one doctor for quite a few thousand population, is a totally different matter. Here also, the issue has become clouded by sociologists and economists who, sharing government’s perspective, cannot see that what these countries need is better public health, not more practicing doctors.

Very little has been said about or written on the physicians’ perspectives on the subject of brain drain. True, many, if not most, emigrating physicians depart with some pangs of conscience. Economic imperatives, however, overshadow such deliberations. There are other factors, some even more potent than economic ones, which propel physicians to leave their native country. These include having tasted the benefits of higher education, physicians seek better educational opportunities for their children, a powerful attraction of developed industrial countries. It is often not realized how much the practice of medicine rests on team work and prompt backup support in the form of technicians, equipment, associates, and above all, proper administrative practices. For this very reason, while job opportunities for physicians are plentiful in industrialized countries, they are far more limited in developing countries, handicapping physicians in developing countries. Next in line are interpersonal tensions, something universal and not restricted to the field of medicine. Rivalries and misunderstandings among physicians in industrialized countries are resolved by established and accepted rules and guidelines which have evolved over decades. These are weak or non-existent in developing countries. Worse, friction among professionals in developing countries are not settled promptly, but linger on with a negative impact on everybody else in the working environment.

Physicians who are truly dedicated to research are often strapped for financial and technical support. And, those enlightened enough to go into public health—an unglamorous but vitally
 important career in developing countries—are often mired down in slow moving bureaucracies and poor economic support. While modern medical concepts and practices, including those related to medical education which evolved in the West, have been successfully transplanted to the East, administrative and managerial systems necessary for their smooth operation, have not been fully adopted as yet by the latter.

A special group within the brain drain pool are physicians who have had part or all of their medial education and training in western countries.  These physicians upon return home face a cultural shock that sends them right back to where they came from. Invariably, they exonerate themselves by claiming lack of appreciation or support for their skills at home. Rarely do they admit that they themselves reinforce and perpetuate the very circumstances that engender the brain drain phenomenon. This comes about in a number of ways. Most often, these professionals consider themselves academic elites and, accordingly, demand better treatment. All too often they gravitate towards political posts and high administrative appointments. Many delude themselves into thinking, firstly, that their western education has also prepared them for assuming leadership. They set their sight on becoming part of the superstructure instead of improving the existing infrastructure. Rather than offering solutions, they become part of the problem. Their jealousies, back biting, cronyism, politicking, and whatever else is needed for personal advancement becomes second nature to them. One would expect western-educated professionals to join hands and overcome problems that affect them all, rather than embarking on internecine struggle which sends many of them packing.

The whole phenomenon of physicians brain drain is far more complex and multifactorial than can be dissected into its many components to be solved in a Cartesian manner. What is perfectly obvious is that in the process, donor countries lose and host countries gain. The former seemingly cannot do anything about it, and the latter clearly do not wish to do anything about it. 




1         Mullan F. The metrics of the physician brain drain.
N Engl J Med. 2005; 353: 1810 – 1818.

2         The Economist. November 5th, 2005: 86. 

3         Handin G. Tragedy of the Commons. Science. 1968; 162: 1243 – 1248.

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