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Points of View

MEDICAL BRAIN DRAIN PERSPECTIVES*

KENNETH R. HILLM.D. Lond.

PROFESSOR OF PATHOLOGY,ROYAL FREE HOSPITAL SCHOOL OF MEDICINE, LONDON W.C. 1

THE popular concept of the medical brain drain is anexodus of academic egg-heads, the seed-corn of ourintellectual life, who are leaving the country in largenumbers bound for the United States. In fact the braindrain includes many non-academics, such as generalpractitioners who are the ordinary corn of workaday life.For example, 400 of the 1600 doctors practising inAlberta are British, and of these 80% are in generalpractice or in non-teaching hospitals.How Many ?Government assessments of the brain drain range from

320 to 900 doctors per year 1 2; unofficial observers havesuggested that it is of the order of 500. Certainly 355 doc-tors from Britain emigrated to Canada in 1966, so it is fairto assume that the number is not less than 500. I have theexact figures for Alberta for 1966, and out of 156 newregistrants, 72 came from Britain and only 60 from Canada.Thus, more than half the new doctors in this provincecame from Britain, and together they represent the averageoutput of one of our 27 medical schools. From the pointof view of numbers, one London teaching hospital is justfunctioning to provide Alberta with doctors.

All over the world there is a tremendous movement ofdoctors and paramedical staff. 8750 foreign doctors 3 arepractising in Great Britain, and most of them have comefrom underdeveloped countries, such as India andPakistan. In 1966 about 8000 foreign doctors entered theUnited States, of whom some 3000 intend to stay per-manently, while American schools themselves graduateonly 7500. Overall it is estimated that there are 46,000foreign doctors permanently registered in the UnitedStates of whom 2000 are from the United Kingdom andabout 10,000 from developing countries.How Much? ?

I estimate that the cost of training a medical student isof the order of E14,000. The emigration of 500 doctorsper annum is, therefore, equivalent to the export ofE7 million of capital investment with little or no return.To be more specific, over the past 16 years 747 Britishdoctors have settled in Alberta, and our long-term gift hasbeen of the order of E10 million to a province which is byno stretch of imagination an underdeveloped country.We do not often take into consideration the potential

value of this capital investment in education. The Ameri-cans assess the potential of one of their postgraduates asjust under E80.000 on graduation. If we assess a doctor

similarly, then the 2000 British doctors now in the UnitedStates are equivalent to El 60 million. Furthermore, whendoctors emigrate their new country benefits from theincome-tax they pay. Thus if the 72 new British doctorsin Alberta each have an average income of$20,000 perannum, they pay income-tax to the tune of E43,000, or* Based on an address to the Salisbury Medical Society, Dec. 12, 1967.1. Ministry of Health. On the State of the Public Health for 1966. H.M.

Stationery Office, 1967.2. Overseas Migration Board. Statistics for 1964. H.M. Stationery Office,

1965.3. Hansard (House of Commons) Oct. 27, 1967; see Br. med. J. 1967, iv, 368.4. Report of the Working Group on Migration. Cmnd. 3417. H.M.

Stationery Office, 1967.

4-3% return on capital investment, but they pay it not tothe United Kingdom Government, but to their newCanadian Government. If they had stayed in the UnitedKingdom, they would return through income tax about2-5% of the investment made in their training.Why They Go

Dissatisfaction with the state of society may be onereason for emigrating. The young doctor sees Britain asan island of entrenched privilege, where the old-boynetwork is used as a process of selection and promotion.He assumes that the academics have cornered the distinc-tion awards and the pick of the jobs for their boys.Many students take the American qualifying examina-

tion even before qualification, and in surveys at two schoolshalf the students were interested in going overseas at leastfor a limited period. However, one school found that whenthe survey was continued to cover young doctors, interestshifted from service in developing countries to developedcountries, perhaps because of the sobering effect of

marriage.Comments I collected in a survey of over 30 emigrant

doctors in America include:" I felt I was stuck."" I was offered accelerated promotion."" I couldn’t manage on my salary."" Lack of recognition and no chance to develop a clinical

academic department."" The promised new hospital-a source of disillusionment."" General practice was killing me."" In this country the second-division boys get a chance to do

the things they want to do."Promotion within the hospital service is held up because

there are not enough senior posts for all to reach the top.About 10,000 junior hospital-officers are competing forabout 8500 consultant posts. It takes seven years to trainto be a consultant and the consultant expects at least thirtyyears of working life in that position-i.e., he spends 4-5times as long in his post as on his training-so it isobvious that there is not enough room at the top. It isnot without significance that few consultants emigrate.At one time the drop-out moved from hospital to generalpractice, but nowadays because of the therapeutic revolu-tion and the scientific intensity and complexity of hospitalpractice a medical officer after 5-6 years of hospital serviceseems unfitted, both technically and psychologically, tomake the change. As a result many emigrate.The clinical academics are even worse off. About 500

lecturers and 500 readers and senior lecturers compete forabout 300 professorships. This hierarchical system,pyramidal in form and archaic in design, causes muchfrustration and is a great incentive to emigration to coun-tries where recognition and promotion are believed to bemore liberal and swift.

Furthermore, though the professors are paid on a similarscale to the N.H.S. consultants, other academic staff arepaid less-indeed with the new pay awards, even less thantheir colleagues in other university disciplines. Thesenior lecturer carrying honorary consultant status is per-haps the worst hit of all. He may get less than the non-medical senior lecturer in the same department; he alsogets less, and at slower incremental rate, than his N.H.S.colleagues. Not unnaturally some move over to the N.H.S.where initial and incremental salaries are higher, and it canbe argued that this internal brain drain from university toN.H.S. is a good thing.

In the United States professional incomes are higherthan in the United Kingdom, and though I believe that

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this is not the only reason for emigration, I believe that itis the main motive; but lack of professional satisfaction isanother. Working conditions in the United Kingdom areoften second-rate compared with those in other Westerncountries. Inflation and indecision delay minor depart-mental expansions or indeed reasonable running repairs,so that many doctors have to make do in scientific slums.But in my view the chief responsibility lies with theuniversities and their system of training and to the divisionof the profession into two distinct camps-the hospitalversus general practice.Special Difficulties of General PracticeDuring his training the student learns little of general

practice, and he is brainwashed into believing that thestudy of disease per se is the be-all and end-all ofmedicine and that it can only be done with complex para-phernalia in hospitals. On qualification he tends to beexcluded from hospital and to have few facilities to

practise modern medicine. He is even more frustrated indeveloping countries which have adopted Western methodsof training. In India or Africa, where under Britishadministration medical assistants were given a shorter,practical training yet practised successfully in the field.Today everybody must have a 5-6 years universitytraining. As a result, there is a scarcity of doctors in therural areas (where the majority of the populace is) becausea university-trained doctor stays in the towns. After allhe has been trained only to work in modern hospitals, andhe goes where his training can be used. No wonder somany Indians emigrate, and in this country, it is hard torecruit doctors in the North-East and North-West of

England.SUGGESTIONS TO MODIFY THE BRAIN DRAIN

1. Explain to Students Cost of TrainingDuring training many students complain of their

financial straits and compare themselves with friends

earning E20 a week in industry. They acquire an aggres-sive attitude to society to the detriment of their loyalty andfeeling of indebtedness. If a student realised that his

training was costing El 4,000 and that each year he wasreceiving a subsidy of just under E3000, he might feel anincreased sense of duty to his own country.2. Put Professional House in OrderThe profession must work out its place within society in

terms of new technological methods, and sociologicalchanges and patterns. It must decide to keep alive thedoctor/patient relation and the demarcation between

hospital and general practice must be eliminated. Theprofession might consider whether to institute a secondtier of doctor as of old-a medical assistant or apothecary-for as a rule such people do not emigrate. The doctormust use auxiliary staff more freely.3. Reassessment of the Aims of Medical TrainingThe academic must realise that the ethos of medical

education is to train doctors for service to the communityrather than to concentrate on intellectual excellence per se.The apex of the pyramidal system of administration andpromotion should be flattened to allow young men toreach the top plateau more quickly. There should be

interchangeability with the N.H.S. in both directions andthe distinction awards should be scrapped.4. Increased Deciseveness of Government PolicyThe Government should be more decisive and take the

advice of the profession at the grass-roots rather than onlythat of the Establishment. Thus we might have crashprogrammes-e.g., prefabricated hospital buildings with

a calculated limited life rather than the ponderousplanning and buildings of a past era. Recent expansion inhealth centres may do much to make general practicemore attractive.

In authoritarian countries emigration can be restricted,but in the democratic world it is difficult to prevent.Newly qualified doctors have been directed to a form ofnational service, but this means that rural communitiesare doctored by the newly qualified. Another methodwhich has been tried is to make medical students signa bond that they will not emigrate until after a lapse oftime. This has seldom worked, for-the bond commits thestudent to repay a derisory amount and generally he paysand goes, gleefully. However, the Jamaican Governmentproposes 5 to introduce fairly stringent conditions:

" All Jamaican doctors who are trained locally will be

required to spend one year in the government service aftercompleting their internship. At present the government paysC2000 per annum towards the education of each medicalstudent, who himself pays only E80 per annum; before embark-ing on a course in medicine, each student will be contracted towork for one year in the government service and pay E80 peryear; or will be required to pay E1000 per year for his educationand will be free of obligation to the government. Medicalstudents on full government scholarships will continue to bebonded for a period of five years to work in the governmentservice."

In the United States a student often works his way throughcollege, and this has some advantages. Student loans havealso been mooted and this is worthy of further study.Any country committed to the idea of a Welfare State

which includes a health service should be prepared to paya reasonable market price for talent. It will take a longtime to achieve this on a world basis, but in time this wouldreduce the numbers of the brain drain internationally.Even on a national basis to increase salaries of junior

staff well above those of porters, and salaries of establisheddoctors to scales comparable with higher executives inindustry would go far to ameliorate the situation,particularly if our medical manpower were backed by moreancillary help.5. Encourage Service in Developing CountriesMany medical students and newly qualified doctors

would like to serve overseas provided they could beassured of a place on their return. The - Governmentshould make a special effort to encourage this by buildingsecondment into the career-structure at home. Secondeddoctors do come back and they are the richer, and Britishmedicine is the richer, for the experience. At least the

country gets its capital investment back. At present weallow at least E7 million to drain away every year, never tobe reimbursed. If we spent (say) E3000 per annum each insending these 500 overseas, the annual cost would be £ 11/zmillion which is surely reasonable, a 10% deposit for thefuture.

6. International PolicySomewhere, sometime, the United Nations must sit

down and work out a plan based on the moral values ofthe brain drain. The outside world provides a fifth of theAmerican medical profession, and in terms of dollars thisis more than the United States have contributed in medicalaid to foreign countries. In the United Kingdom theN.H.S. is dependent on 8750 doctors from overseas andthe developing countries.

Collective action should be taken to stop the richercountries from creaming away the manpower of the

5. Jamaican Weekly Gleaner, Jan. 3, 1968, p.2.

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poorer countries. Rich countries should not raise immigra-tion barriers, but they should satisfy their consciencesthat they are spending less on consumer goods and moreon training their own people and spending more on publicservices.Last year the United States rescinded the favourable

quota allowed for British immigrants and in future doctorsfrom this country will supposedly have to take their turnin the queue with 17,000 scientists of all types andnationalities. But the United States are still advertisingfor staff in British medical journals. Places in the waiting-list for graduate immigrants will no doubt be allottedaccording to a grading of importance, and second on thislist come " professions in short supply "-and medicinefalls into this category.To suggest that the income-tax collected from immi-

grant doctors should be returned to their country of originduring their professional life would not be practical, butcountries might be asked on an international basis to refuseto accept immigrant doctors who were in debt to theirown Government, either on bond or for repayment of fees.

Finally, the richer countries of the world must try to getpoorer countries to invest in their own people, and todevelop their countries’ resources in a gradual evolu-tionary way and with more attractive opportunities fortheir own people rather than to try to become a moderntechnological society overnight so as to keep up with theWestern Joneses.

It is time that the British began to think of the braindrain in cash terms and to realise that trained brains areone of the most exportable items in today’s world, andthat countries with selective immigration policies can openthe door widely to the special types of trained immigrantssuch as the doctor. If the truth of this is not grasped, thenthe gap between the richer and the poorer countries willbecome greater and the brain drain will continue to in-crease in democratic societies. The choice between sensible

planning on a moral basis and the present situation is

ours, and woebetide us if we continue to ignore it.

Round the World

JamaicaWhat takes us abroad, nous autres anglais, poised here in the

Caribbean betwixt home and America; an adventurous trait ora strong streak of non-conformity ? This is a beautiful islandwith its mountains, flowers, and sunshine, plenty to appeal toboth the frontiersman and the lotus-eater. Clinical interestabounds and the hospital has a friendly atmosphere andcongenial colleagues. The students are pleasant to teach andthe rapport with junior staff is excellent-no gulf here betweenthe consultant and the non-consultant. There are irritationsof course, such as that thorn in the flesh, the medical recordsdepartment, or supply delays, such as the 21-month wait fornew-format outpatient cards.Time passes and the expatriate finds he is identifying less

closely with Britain, yet he may not be needed permanentlyin the West Indies. Whither should he go ? The hominginstinct may have been further eroded by one or more un-successful 8000-mile round-trips to attend for interview. Hemay take comfort in spreading enlightenment, explaining to aninquiring interviewer that not only can haemoglobin-estimationsbe carried out in Kingston, but radioactive chromium studies,too, where indicated. Invitations to appear before such

appointment committees do not always give the expatriateadequate notice, and indeed our professor regularly receivesfrom Britain requests for references after the interview date.

Consequently, meeting friendly Canadian clinicians who

take a close interest in this medical school inevitably makesone think of becoming the 25th member of one’s year to settlein Canada-any more for Toronto ?

Special Articles

VALUE FOR MONEY IN HOSPITALS

A. BARRM.Sc. (Econ.) Belf., Ph.D. Reading

CHIEF RECORDS OFFICER AND STATISTICIAN,OXFORD REGIONAL HOSPITAL BOARD

Summary Hospital work loads (new outpatients,outpatient attendances, discharges and

deaths, and casualty) increase by 1-3% per annum.

Hospital revenue expenditure grows by 5-10% each

year, or 2% per annum in real-money terms. These

figures suggest that over the period studied (1951-66)the efficiency of the Hospital Service has not improvedsignificantly.

INTRODUCTION

HEALTH Service costs in general and hospital costs inparticular have increased considerably over the pasttwenty years. In the financial year 1949-50, the netrevenue expenditure of hospital authorities in Englandand Wales amounted to El 89 million which has increasedto an estimated E677 million in 1966-67. How has this

money been distributed and what effect has it had onthe number of patients treated ? Questions like these areoften easier to ask than answer. None the less, an under-standing of the relationship between the input of revenueand the output of treated patients is imperative for theproper planning and development of an efficient service.

COSTS AND WORK LOAD

A general picture of the costs and work load of the hospital

Fig. 1-Revenue expenditure in hospitals 1951-52 to 1965-66 andwork load 1951-66.