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June 2008, Volume 58, Issue 6

Opinion and Debate

Migration of Doctors: Should we apply the Index of Happiness?

Amin A. Muhammad Gadit  ( Discipline of Psychiatry, Memorial University of Newfoundland, St. John's, NL A1B 3V6 Canada )

Migration of doctors revolves around the reasons of: better structure of medical education, desire for better income, general security and improved prospects for family.1 Study conducted by Talati and Pappas2 revealed that about 1150 doctors emigrate while the Bureau of Emigration and Overseas Employment estimates that annually about 1000 to 1500 physicians leave the country, of whom 10-15% return for a net migration of 900 to 1275 physicians.3 According to the Pakistan Medical and Dental Council (PMDC) currently registered doctors in the country are 137790.4 However, looking at the future, Pakistan will face physician shortages in the range between 57,900 and 451, 102 in 2020 depending on assumptions about future need.2 A study5 found that Pakistan had contributed about 13,000 medical graduates to the United States, the United Kingdom, Canada and Australia. With the rising law and order situation in Pakistan, many doctors are eager to leave the country for a better life structure. Excluding those that return back, a large number of doctors prefer to settle down in the countries abroad. Those in Middle East work there for a number of years but attempt foreign exams and migrate to western countries. Those in United Kingdom seek the path of permanent residency through either Highly Skilled Migration Programme or by virtue of getting married to a British Citizen. Doctors in Canada, Australia and United States also follow the permanent residence and eventual citizenship path. The life structure and other incentives are highly attractive in comparison to Pakistan but whether this confers happiness and satisfaction to these doctors is an important question. There are a number of issues related to migration. The foremost matter is how much stress-free and mentally healthy a doctor was before emigrating. This issue has far reaching repercussions and consequences as any mental health issue which was unattended, can lead to further deterioration. Stresses before leaving the country like the paper work, travel documentations, expenses, anxiety about moving into a new place with associated cultural challenges may pose significant mental stress. During the initial period of settling down in a new environment there are other stresses like the new work environment and expectations, living conditions, nostalgia, discrimination and subtle hostilities are bound to take the toll. The family members like spouse and children of the doctor concerned are the worst affected in the initial period. Most of the spouses who are either non-doctors or non-practicing physicians had to remain house-bound for lack of the desired social milieu as was in the parent country. The children with new school environment and colleagues undergo a transition period of emotional chaos but depending on their personality resilience settle down and get adjusted in the new life circumstances. It is generally said that a person remains happy in the environment of upbringing and birth and develops emotional attachment and identification. What are then the factors which compel migration apart from a short to medium term pursuit of postgraduate education and returning back? The plight of doctors in Pakistan has remained problematic since a long time. The life of a doctor in Pakistan is full of struggles, which begin from early medical years. Most of the private sector medical colleges are devoid of a full-fledged hospital that could meet the minimum standards set by Pakistan Medical and Dental Council (PMDC). The public sector has large hospitals with a galaxy of patients but the teachers are not motivated and individual attention to medical students is a dream. The undergraduate years are thus full of academic stresses with no definite prospects for the future. Ironically, there is no structured career pathway for young graduating doctors unlike the one efficiently placed in our neighbouring country India. After graduation and acquiring a legitimate title of 'Doctor Sahib', a young graduate is faced with a number of problems: internship, residency, post graduation, marriage, and earnings are some of the vital issues. After successfully completing the internship, the huge problem of finding a postgraduate placement becomes important. There are few training slots for a large number of interested medicos. Getting into a desirable training programme becomes a nightmare at times and if one is lucky enough, then the remuneration is quite below the expectation and need. The mill of post graduation especially the local fellowship- FCPS is a tedious process which involves expenditure in terms of fees and courses. Success rate at the first attempt is very low and sometimes it takes years before a doctor gets his certification. Settling down in practice is also a big challenge as placement in an institution is, at times, difficult and the remuneration is not always attractive. The general practice is also full of risk with a view of law and order situation in the country. Political disturbances, break down of civic life, insecurity, looting, kidnapping for ransom and the current trend of 'suicide bombing' has added much misery to the daily life of people.  At a consultant level, doctors mostly remain dissatisfied for a number of reasons and they look for better prospects. The doctors opting for places like Middle East face some discrimination. They get much better salaries and living than in Pakistan but are not treated at par with western doctors who get a much higher salary and incentives. Despite tall claims that the local FCPS is treated at par with MRCP or American Board, the fact is contrary. The foreign passport is a great advantage over the Pakistani one. United Kingdom opened its door for senior doctors earlier but with revamping of their system and new immigration laws, the situation has become somewhat difficult. United States has the problems in acceptance of our doctors since the incident of 9/11. Despite this a number of doctors are still successful in finding their way into USA. The three liberal countries in this regard for especially senior doctors are: Canada, Australia and New Zealand. These countries need trained and certified family practitioners and specialists. Their immigration rules are flexible for these highly skilled migrating doctors and prospective candidates can find a better life style and incentive in these three highly developed regions of the world. There is an attractive package though with a high tax table and modern life style. Immigration and eventual citizenship follows with these incentives. Personal communication and anecdotal evidence suggests that the bond with Pakistan remains intact in one way or other and there is a life time urge to go back and settle in own ambience. With the type of life, education for children and eventual adaptation to the new cultural environment, it becomes extremely difficult for children to re-settle back in Pakistan and that becomes an impeding factor for parents. So, should we assume that migration of doctors deprive them off from the inner happiness for the rest of their life?  Before, we jump to any conclusion, let's have a look at an instrument developed by a British organization, City and Guilds by the name of "Happiness Index".6
By definition, happiness is " an agreeable feeling of the soul arising from good fortune or propitious happening of any kind; the possession of those circumstances or that state of being which is attended with enjoyment; the state of being happy; contentment; joyful satisfaction; felicity; blessedness."7 Happiness is more of a subjective feeling. Hence, association of this feeling with migration can be complex. It can simply be measured by asking people "How satisfied or dissatisfied are you with your life as a whole these days?" and assessing this on a 1 to 10 scale.8  Alternate way of such measurement is in the form of a broader 'Gross National Happiness' (GNH)9 which is an attempt of defining quality of life in more holistic and psychological term. The pillars are: socio-economic development, preservation and promotion of cultural values, conservation of natural environment and establishment of good governance. It is important to note that for many doctors, it is not the social ladder alone but embeddedness in social network is also important. Literature10-12 also reports that a number of mental disorders especially depression are quite high among doctors. With high vulnerability of doctors in view of a number of conditions, the issue of migration can pose significant stress. In the context of migration, this would be an intriguing observation in view of paucity or unavailability of data on pre-migration mental status. Under the circumstances, there remains a dilemma whether migration is associated with relative loss of happiness and is it so simple to apply the 'Happiness Index' and measure the feeling. If we agree to this index and the result obtained by its application, then, what are we supposed to do? Should we discourage migration? If yes, are the current circumstances at the base conducive for the mental well-being and happiness of medicos? Are the doctors opting for lesser evil by long term or permanent migration? Let's ponder over this matter.

References

1. Astor A, Akhtar T, Matallana MA, Muthuswami V,Oluwu FA, Tallo V, Lie RK. Physician migration: views from professionals in Columbia, Nigeria, India, Pakistan and the Philippines; Soc Sci Med; 2005; 61: 2492-500.
2. G Pappas, Talati JJ. Migration, medical education, and health care: a view from Pakistan; Acad Med; 2006; 81: 55-62.
3. Bureau of Emigration and Overseas Employment, Government of Pakistan; Migration of Physicians; available at: http:// www. beoe.gov.pk  date accessed: 31st March, 2008.
4. Pakistan Medical and dental Council (PMDC); Number of doctors: Statistics; available at www.pmdc.org.pk date accessed: 7/3/2008.
5. Mullan F. The metrics of the physician brain drain. N Engl J Med; 2005; 353:1810-18.
6. City and Guilds, UK. "Happiness is being hands on" in 'Happiness Index' available at: www.cityandguilds.com date accessed: 31st March, 2008.
7. Answers.com. "Happiness" available at: http://www.answers.com/topic/ happiness date accessed: 25th March, 2008.
8. Happiness Foundation. "What is happiness?" available at: http://www.happiness.org/Resources/Happiness_Studies/What_is_Happiness.aspx date accessed: 25th March, 2008.
9. Wikipedia. 'Gross National Happiness' available at   http://en.wikipedia.org/ wiki/Gross_national_happiness Date accessed: 31st March, 2008.
10. Gavin BE, Kelly BD, Lane A, O’Callaghan E. The mental health of migrants; Irish Medical Journal; 2001, 94, p: 229-30.
11. Holmes J. Mental Health of doctors-Editorial. Advances in Psychiatric Treatment; 1997, 3: 251-3.
12. New York Times. 'Doctors' toughest diagnosis: own mental health' available at http:// query.nytimes.com/gst/full page.html  date accessed: 27th February, 2008.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: