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      Medical students’ characteristics as predictors of career practice location: retrospective cohort study tracking graduates of Nepal’s first medical college

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          Abstract

          Objective To determine, in one low income country (Nepal), which characteristics of medical students are associated with graduate doctors staying to practise in the country or in its rural areas.

          Design Observational cohort study.

          Setting Medical college registry, with internet, phone, and personal follow-up of graduates.

          Participants 710 graduate doctors from the first 22 classes (1983-2004) of Nepal’s first medical college, the Institute of Medicine.

          Main outcome measures Career practice location (foreign or in Nepal; in or outside of the capital city Kathmandu) compared with certain pre-graduation characteristics of medical student.

          Results 710 (97.7%) of the 727 graduates were located: 193 (27.2%) were working in Nepal in districts outside the capital city Kathmandu, 261 (36.8%) were working in Kathmandu, and 256 (36.1%) were working in foreign countries. Of 256 working abroad, 188 (73%) were in the United States. Students from later graduating classes were more likely to be working in foreign countries. Those with pre-medical education as paramedics were twice as likely to be working in Nepal and 3.5 times as likely to be in rural Nepal, compared with students with a college science background. Students who were academically in the lower third of their medical school class were twice as likely to be working in rural Nepal as those from the upper third. In a regression analysis adjusting for all variables, paramedical background (odds ratio 4.4, 95% confidence interval 1.7 to 11.6) was independently associated with a doctor remaining in Nepal. Rural birthplace (odds ratio 3.8, 1.3 to 11.5) and older age at matriculation (1.1, 1.0 to 1.2) were each independently associated with a doctor working in rural Nepal.

          Conclusions A cluster of medical students’ characteristics, including paramedical background, rural birthplace, and lower academic rank, was associated with a doctor remaining in Nepal and with working outside the capital city of Kathmandu. Policy makers in medical education who are committed to producing doctors for underserved areas of their country could use this evidence to revise their entrance criteria for medical school.

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          Most cited references16

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          The metrics of the physician brain drain.

          There has been substantial immigration of physicians to developed countries, much of it coming from lower-income countries. Although the recipient nations and the immigrating physicians benefit from this migration, less developed countries lose important health capabilities as a result of the loss of physicians. Data on the countries of origin, based on countries of medical education, of international medical graduates practicing in the United States, the United Kingdom, Canada, and Australia were obtained from sources in the respective countries and analyzed separately and in aggregate. With the use of World Health Organization data, I computed an emigration factor for the countries of origin of the immigrant physicians to provide a relative measure of the number of physicians lost by emigration. International medical graduates constitute between 23 and 28 percent of physicians in the United States, the United Kingdom, Canada, and Australia, and lower-income countries supply between 40 and 75 percent of these international medical graduates. India, the Philippines, and Pakistan are the leading sources of international medical graduates. The United Kingdom, Canada, and Australia draw a substantial number of physicians from South Africa, and the United States draws very heavily from the Philippines. Nine of the 20 countries with the highest emigration factors are in sub-Saharan Africa or the Caribbean. Reliance on international medical graduates in the United States, the United Kingdom, Canada, and Australia is reducing the supply of physicians in many lower-income countries. Copyright 2005 Massachusetts Medical Society.
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            The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain

            Background The objective of this paper is to describe the numbers, characteristics, and trends in the migration to the United States of physicians trained in sub-Saharan Africa. Methods We used the American Medical Association 2002 Masterfile to identify and describe physicians who received their medical training in sub-Saharan Africa and are currently practicing in the USA. Results More than 23% of America's 771 491 physicians received their medical training outside the USA, the majority (64%) in low-income or lower middle-income countries. A total of 5334 physicians from sub-Saharan Africa are in that group, a number that represents more than 6% of the physicians practicing in sub-Saharan Africa now. Nearly 86% of these Africans practicing in the USA originate from only three countries: Nigeria, South Africa and Ghana. Furthermore, 79% were trained at only 10 medical schools. Conclusions Physician migration from poor countries to rich ones contributes to worldwide health workforce imbalances that may be detrimental to the health systems of source countries. The migration of over 5000 doctors from sub-Saharan Africa to the USA has had a significantly negative effect on the doctor-to-population ratio of Africa. The finding that the bulk of migration occurs from only a few countries and medical schools suggests policy interventions in only a few locations could be effective in stemming the brain drain.
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              A critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas.

              The shortage of healthcare professionals in rural communities is a global problem that poses a serious challenge to equitable healthcare delivery. Both developed and developing countries report geographically skewed distributions of healthcare professionals, favouring urban and wealthy areas, despite the fact that people in rural communities experience more health related problems. This review provides a comprehensive overview of the most important studies addressing the recruitment and retention of doctors to rural and remote areas. A comprehensive search of the English literature was conducted using the National Library of Medicine's (PubMed) database and the keywords '(rural OR remote) AND (recruitment OR retention)' on 3 July 2008. In total, 1261 references were identified and screened; all primary studies that reported the outcome of an actual intervention and all relevant review articles were selected. Due to the paucity of prospective primary intervention studies, retrospective observational studies and questionnaire-driven surveys were included as well. The search was extended by scrutinizing the references of selected articles to identify additional studies that may have been missed. In total, 110 articles were included. In order to provide a comprehensive overview in a clear and user-friendly fashion, the available evidence was classified into five intervention categories: Selection, Education, Coercion, Incentives and Support - and the strength of the available evidence was rated as convincing, strong, moderate, weak or absent. The main definitions used to define 'rural and/or remote' in the articles reviewed are summarized, before the evidence in support of each of the five intervention categories is reflected in detail. We argue for the formulation of universal definitions to assist study comparison and future collaborative research. Although coercive strategies address short-term recruitment needs, little evidence supports their long-term positive impact. Current evidence only supports the implementation of well-defined selection and education policies, although incentive and support schemes may have value. There remains an urgent need to evaluate the impact of untested interventions in a scientifically rigorous fashion in order to identify winning strategies for guiding future practice and policy.
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                Author and article information

                Contributors
                Role: executive director
                Role: administrative assistant
                Role: professor, head of research committee
                Role: assistant professor
                Role: professor, assistant dean
                Role: professor, assistant dean
                Role: professor, dean
                Journal
                BMJ
                BMJ
                bmj
                BMJ : British Medical Journal
                BMJ Publishing Group Ltd.
                0959-8138
                1756-1833
                2012
                2012
                14 August 2012
                : 345
                : e4826
                Affiliations
                [1 ]Nick Simons Institute, Box 8975, EPC 1813, Kathmandu, Nepal
                [2 ]Institute of Medicine, Kathmandu, Nepal
                [3 ]Harvard Medical School, Boston, Massachusetts
                Author notes
                Correspondence to: M Zimmerman  markz@ 123456nsi.edu.np
                Article
                zimm000487
                10.1136/bmj.e4826
                3419272
                22893566
                15d68e58-a64a-48a8-9c59-691f9342a6d9
                © Zimmerman et al 2012

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See: http://creativecommons.org/licenses/by-nc/2.0/ and http://creativecommons.org/licenses/by-nc/2.0/legalcode.

                History
                : 06 July 2012
                Categories
                Research
                Epidemiologic Studies
                Undergraduate
                Medical Humanities

                Medicine
                Medicine

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