Willingness of Lebanese physicians in the United States to relocate to Lebanon.

BACKGROUND: We recently proposed that Lebanon could become a regional 'academic hub' through the repatriation of emigrated Lebanese physicians who would then provide clinical services in the Arab Gulf region on a locum tenens basis. The objectives of this study were to assess the willingness of Lebanese medical graduates practicing in the United States of America to relocate to Lebanon and the Arab Gulf region and to explore the factors associated with this willingness. METHODS: In 2009 we surveyed Lebanese medical graduates practicing medicine in the United States. The questionnaire included questions about their willingness to relocate to Lebanon and to the Arab Gulf region and the associated timeframes. The questionnaire also included questions about family factors. We linked responders' answers to their personal, educational, and practice characteristics provided by the American Medical Association Physicians' Dataset. We conducted both descriptive and regression analyses. RESULTS: A total of 286 physicians participated in the survey (57% response rate). A majority (61%) was willing to relocate to Lebanon (51% possibly, 10% definitely). A third (33%) were willing to relocate to the Arab Gulf region (31% possibly, 2% definitely). About half (54%) were willing to relocate to Lebanon as a base for clinical missions to the Arab Gulf region (49% possibly, 5% definitely). Willingness to relocate to Lebanon was independently associated with Lebanese citizenship and the birthplace of the spouse being Lebanon, and inversely associated with US citizenship. Willingness to relocate to the Arab Gulf region was independently associated with being board certified, and inversely associated with being married, the age of the oldest child, and practicing in direct patient care. Willingness to relocate to Lebanon as a base was not independently associated with any factor. CONCLUSIONS: The findings of this study support the feasibility of the proposal of Lebanon becoming a regional 'academic hub'. Future research should explore other factors important for the feasibility of the proposal as well as actual relocation.

An emigration versus a globalization perspective of the Lebanese physician workforce: a qualitative study.

BACKGROUND: Lebanon is witnessing an increased emigration of physicians. The objective of this study was to understand the perceptions of Lebanese policymakers of this emigration, and elicit their proposals for future policies and strategies to deal with this emigration. METHODS: We conducted semi-structured individual interviews with the deans of Lebanon's seven medical schools, the presidents of the two physicians professional associations, and governmental officials. We analyzed the results qualitatively. RESULTS: Participants differed in the assessment of the extent and gravity of emigration. Lebanon has a surplus of physicians, driven largely by the over-production of graduates by a growing number of medical schools. Participants cited advantages and disadvantages of the emigration on the personal, financial, medical education system, healthcare system, and national levels. Proposed strategies included limiting the number of students entering medical schools, creating job opportunities for graduating students, and implementing quality standards. Most participants acknowledged the globalization of the Lebanese physician workforce, including exchanges with the Gulf region, exchanges with developed countries, and the involvement of North American medical education institutions in the region. CONCLUSION: Many Lebanese policy makers, particularly deans of medical schools, perceive the emigration of the physician workforce as an opportunity in the context of the globalization of the profession.

Financial characteristics and satisfaction of physicians practicing in Lebanon: a survey study.

OBJECTIVE: The objective of this study was to evaluate the financial characteristics and level of satisfaction of physicians practicing in Lebanon. METHODS: We conducted an anonymous, interviewer-administered phone survey of physicians practicing medicine in Lebanon. We conducted both descriptive and regression analyses. RESULTS: Of 778 invited physicians, 546 participated in the survey (70% response rate). Their mean age was 47.4 and they were predominantly male (85.9%) and married (87.0%). Reported monthly income varied widely with 47.2% earning less than US$ 2,000, 46.3% earning between $ 2,000 and $ 6,000 and 6.3% earning more than $ 6,000. Only 14.2%, 4.1%, and 3.1% respectively reported having life insurance, disability insurance and a retirement plan. A quarter of participants reported being either somewhat unsatisfied (17.6%) or very unsatisfied (8.1%) with their medical career. A lower degree of satisfaction in professional career was independently associated with female physicians, graduation from a Western European medical school and a lower monthly income. As for the perception of own career's future, 36.7% thought there was no possibility of improvement. CONCLUSION: About half of physicians practicing in Lebanon report earning less than US$ 2,000 per month and about a quarter are not satisfied with their professional career.

Post-graduation migration intentions of students of Lebanese medical schools: a survey study.

BACKGROUND: The international migration of physicians is a global public health problem. Lebanon is a source country with the highest emigration factor in the Middle East and North Africa and the 7th highest in the World. Given that residency training abroad is a critical step in the migration of physicians, the objective of this study was to survey students of Lebanese medical schools about their intentions to train abroad and their post training plans. METHODS: Our target population consisted of all students of Lebanese medical schools in the pre-final and final years of medical school. We developed the survey questionnaire based on the results of a qualitative study assessing the intentions and motives for students of Lebanese medical schools to train abroad. The questionnaire inquired about student's demographic and educational characteristics, intention to train abroad, the chosen country of abroad training, and post-training intention of returning to Lebanon. RESULTS: Of 576 eligible students, 425 participated (73.8% response rate). 406 (95.5%) respondents intended to travel abroad either for specialty training (330 (77.6%)) or subspecialty training (76 (17.9%)). Intention to train abroad was associated with being single compared with being married. The top 4 destination countries were the US (301(74.1%)), France (49 (12.1%)), the United Kingdom (31 (7.6%)) and Canada (17 (4.2%)). One hundred and two (25.1%) respondents intended to return to Lebanon directly after finishing training abroad; 259 (63.8%) intended to return to Lebanon after working abroad temporarily for a varying number or years; 43 (10.6%) intended to never return to Lebanon. The intention to stay indefinitely abroad was associated male sex and having a 2nd citizenship. It was inversely associated with being a student of one of the French affiliated medical schools and a plan to train in a surgical specialty. CONCLUSION: An alarming percentage of students of Lebanese medical schools intend to migrate for post graduate training, mainly to the US. A minority intends to return directly to Lebanon after finishing training abroad.

Did the post war repatriation of Lebanese physicians drive recent Lebanese medical graduates to emigrate? An observational study.

BACKGROUND: A significant number of Lebanese medical graduates have emigrated from Lebanon. The objective of this study was to evaluate the hypothesis that the repatriation of Lebanese physicians educated abroad has contributed to the international emigration of recent Lebanese medical graduates. METHODS: We analyzed the demographic and educational characteristics and the year of registration of physicians registered with the two physician associations in Lebanon as of 2007. We then analyzed the number of new and total registrants and the physician density for the years 1977-2006. Finally we calculated the percentage of Lebanese graduates of the years 1977-2006 registered as of 2007. RESULTS: As of 2007, 10,918 physicians were registered in Lebanon. Most were male (80.4%) and graduated from either Lebanese (36.4%) or Eastern European (30.6%) medical schools. The top three regions of specialty training were Western Europe (31.8%), Eastern Europe (28.4%) and Lebanon (25.7%). About half the physicians registered with the Lebanese Order of Physicians as of 2007 joined during the 1990 s decade; only 26.2% of these graduated from Lebanese medical schools during that decade. The number of new registrants increased dramatically in the early 1990 s and started decreasing in the early 2000s. About 60% of Lebanese medical graduates of the years 1977-2006 were registered in Lebanon as of 2007. Categorizing Lebanese medical graduates by their year of graduation, the percentage registered in Lebanon as of 2007 showed a "dip" for those who graduated in the early 1990 s. CONCLUSION: The high number of physicians educated abroad returning to Lebanon after the end of the civil war may have driven recent Lebanese medical graduates to emigrate.

Symbols were superior to numbers for presenting strength of recommendations to health care consumers: a randomized trial.

OBJECTIVE: To compare health care consumers' understanding, evaluations, and preferences for symbols vs. numbers and letters for the representation of strength of recommendations (SOR) and quality of evidence (QOE). STUDY DESIGN AND SETTING: Questionnaire study in a randomized controlled design in the setting of a community health education program. RESULTS: Eighty-four participants completed the questionnaire. For the presentation of the SOR, participants had better objective understanding of symbols than numbers (74% vs. 14%, P<0.001). They also scored symbols positively, and numbers negatively for ease of understanding (mean difference [md]=1.5, P=0.001), clearness and conciseness (md=1.5, P<0.001), and conveyance of the degree of uncertainty (md=0.7, P=0.092). About half (48%) preferred symbols over numbers. For the presentation of the QOE, objective understanding of symbols and letters was similar (91% vs. 95%, P=0.509). Participants scored both symbols and letters positively; the scores for symbols were however lower for ease of understanding (md=-0.7, P=0.019), clearness and conciseness (md=-0.6, P=0.051), and conveyance of the QOE (md=-0.4, P=0.24). CONCLUSION: Symbols were superior to numbers for the presentation of the SOR. Objective understanding was high for both symbols and letters for the presentation of the QOE, but letters conveyed the QOE better than symbols.

Why are you draining your brain? Factors underlying decisions of graduating Lebanese medical students to migrate.

In the context of a worldwide physician brain drain phenomenon, Lebanon has the highest emigration factor in the Middle East and North Africa. In this manuscript we aim to identify and develop a conceptual framework for the factors underlying the decisions of graduating Lebanese medical students to train abroad. We conducted two focus groups and seven semi-structured individual interviews with 23 students. In the deductive analysis (based on the push-pull theory), students reported push factors in Lebanon and pull factors abroad related to five dimensions. They focused predominantly on how training abroad provides them with a competitive advantage in an oversaturated Lebanese job market. An inductive analysis revealed the following emerging concepts: repel factors abroad and retain factors locally; societal expectations that students should train abroad; marketing of abroad training; and an established culture of migration. The marketing of abroad training and the culture of migration are prevalent in the academic institutions.

Graduates of Lebanese medical schools in the United States: an observational study of international migration of physicians.

BACKGROUND: As healthcare systems around the world are facing increasing physician shortages, more physicians are migrating from low to high income countries. As an illustrative case of international migration of physicians, we evaluated the current number and historical trends of Lebanese medical graduates (LMG) in the US, and compared their characteristics to those of US medical graduates (USMG) and other international medical graduates (IMG). METHODS: We evaluated the number of LMG using the 2004 the American Medical Association Physicians' Professional Data (AMA-PPD) and then compared it to the number of graduates of other countries. We evaluated the historical trends using the 1978-2004 historical files of the AMA-PPD. We analyzed the characteristics of all LMG and compared them to a random sample of 1000 USMG and a random sample of 1000 IMG using the 2004 AMA-PPD. RESULTS: In 2004, there were 2,796 LMG in the US, constituting 1.3% of all IMG. Compared to other foreign countries contributing to the US physician workforce, Lebanon ranked 2nd after adjusting for country population size (about 4 million) and 21st overall. About 40% of those who graduated from Lebanese medical schools in the last 25 years are currently active physicians in the US. Since 1978, the number of LMG in the US showed a consistent upward trend at a rate of approximately 71 additional graduates per year. Compared with USMG and IMG, LMG were more likely to work in medical research (OR = 2.31; 95% Confidence Interval (CI) = 1.21; 4.43 and OR = 2.63; 95% CI = 1.34; 5.01, respectively) and to be board certified (OR = 1.43; 95% CI = 1.14; 1.78 and OR = 2.04; 95% CI = 1.65;2.53, respectively) and less likely to be in family practice (OR = 0.14; 95% CI = 0.10; 0.19 and OR = 0.18; 95% CI = 0.12; 0.26, respectively). CONCLUSION: Given the magnitude and historical trends of migration of LMG to the US, further exploration of its causes and impact is warranted. High income countries should consider the consequences of their human resources policies on both low income countries' and their own healthcare systems.

EBM user and practitioner models for graduate medical education: what do residents prefer?

The objective of the study reported in this article was to assess and explain medical residents' preferences for the evidence based medicine (EBM) practitioner versus the EBM user models. A self-administered survey and focus group of residents attending a core curriculum EBM master session were undertaken. Most residents, particularly those earlier in their training, preferred the practitioner model. Residents perceived that model as an opportunity to gain advanced EBM skills during residency, as providing the ability to choose practicing under both models, and as offering the gain of independent thinking and greater self-confidence in their critical appraisal skills. The user model had the advantage of reduced time requirements. In sum, the majority of residents preferred a curriculum that focuses on the practitioner over the user model.

Electronic mail was not better than postal mail for surveying residents and faculty.

OBJECTIVE: To compare response rate, time to response, and data quality of electronic and postal surveys in the setting of postgraduate medical education. STUDY DESIGN AND SETTING: A randomized controlled trial in a university-based internal medicine residency program. We randomized 119 residents and 83 faculty to an electronic versus a postal survey with up to two reminders and measured response rate, time to response, and data quality. RESULTS: For residents, the e-survey resulted in a lower response rate than the postal survey (63.3% versus 79.7%; difference -16.3%, 95% confidence interval (95% CI) -32.3% to -0.4%%; P=.049), but a shorter mean response time, by 3.8 days (95% CI 0.2-7.4; P=.042). For faculty, the e-survey did not result in a significantly lower response rate than the postal survey (85.4% vs. 81.0%; difference 4.4%, 95% CI -11.7 to 20.5%; P=.591), but resulted in a shorter average response time, by 8.4 days (95% CI 4.4 to 12.4; P < 0.001). There were no differences in the quality of data or responses to the survey between the two methods. CONCLUSION: E-surveys were not superior to postal surveys in terms of response rate, but resulted in shorter time to response and equivalent data quality.

A survey of internal medicine residents and faculty about the duration of attendings' inpatient rotations.

OBJECTIVE: Some training programs are shortening the duration of attendings' rotations from 4 weeks to 2 weeks. Our objective was to determine the effect of 2-week inpatient rotation on self-reported impact on medical education, patient care practices, and faculty performance by internal medicine residents and teaching faculty. DESIGN: Cross-sectional study using an anonymous mailed and emailed survey. SETTING: University-based internal medicine residency program in Buffalo, New York that recently introduced 2-week rotations. PARTICIPANTS: One hundred nineteen residents (99 responded, 83%) and 83 teaching faculty (76 responded, 92%). MEASUREMENTS: Perceived impact on medical education, patient care, and attending performance on 7-point Likert scales ranging from negative (-3) across neutral (0) to positive (+3) ratings. RESULTS: In general, residents and attendings felt that the short rotation negatively affects the attending's ability to evaluate residents and some aspects of patient care, but that it has no negative impact on residents' or medical students' learning. Attendings thought the 2-week rotation positively affects their private life and overall productivity. Subgroup analysis indicated that residents who graduated from U.S. medical schools were more pessimistic about the 2-week rotation compared to their international counterparts. Attendings who had completed at least one short rotation had consistently higher ratings of the 2-week rotation. CONCLUSION: Residents and attendings' perceptions suggest that the shorter attending inpatient rotation might have negative impact on medical education and patient care but positive effects on the attending's work productivity and private life. This tradeoff requires further evaluation including objective medical education and patient care outcomes.