Although LMG constituted only 1.3% of all IMG active in the US in 2004, Lebanon ranked second among the countries from where physicians in the US graduated after adjusting for country population size. 41.1% of LMG over the last 25 years are currently active physicians in the US. There has been a consistent upward trend in the number of LMG in the US since the late 1970s. Compared with USMG and IMG, LMG were more likely to work in medical research and to be board certified, and were less likely to be in family practice.
This study has a number of strengths. First, it is the first study attempting to build the evidence base for the migration of LMG to the US. Lebanon is arguably- relative to his population size – the foreign country that has contributed the most of its physicians to the US physician workforce (see below). Second, we used a dataset that is compiled using systematic and comprehensive methodology and accounts for all active physicians in the US[9
] Third, we were able to assess the historical trends of this migration over a period of a quarter century reducing the possibility of chance findings that a simple cross-sectional analysis would bear. Fourth it accounts for the majority of LMG outside Lebanon. In fact, in 2004 there were only 17 LMG active in the United Kingdom (7 residents and 10 practicing physicians; personal communication, UK department of health) and 153 active in Canada (3 residents and 150 practicing physicians; personal communication, Canadian Medical Association). We could not obtain the numbers for France, the other country where LMG are known to be practicing medicine.
The study has some limitations. First, the AMA dataset does not include LMG who are in the US but not as licensed physicians (e.g. doing research exclusively). This number however should be very small. Second, in terms of its utility in investigating Lebanese human resources, this study looks at graduates of Lebanese medical schools and not at Lebanese physicians. In fact, it does not account for Lebanese physicians, graduates of non-Lebanese medical schools and active in the US. It also includes non-Lebanese physicians, graduates of Lebanese medical schools.
LMG differed from both USMG and IMG for most of the analyzed characteristics. Similar to our results, Freshnok et al. showed in the early 1980's that physicians in group practice tended to be younger and be US graduates[13
]. Hagopian et al. compared the characteristics of Sub-Saharan African medical graduates to those of USMG[14
]. As in the case of LMG, Sub-Saharan African graduates were younger, and more likely to be residents and work in urban locations [14
One may argue that Lebanon ranks 1st
and not 2nd
among countries from where physicians active in the US graduated after adjustment for country size. In fact, less than 1% of Grenada graduates who are licensed in the US are Grenada citizens, while 82% of LMG in the US are Lebanese citizens [9
]. In either case, the study findings indicate the seriousness of the Lebanese physicians' "brain drain" i.e. the loss of human capital and educational investment.
The historical trend data require a closer look. For example, the bump on the trend curve of residents in the early 1990s, the immediate post war period, is intriguing. Although the historical trend fitted a simple linear regression model one is tempted to relate it to a change in migration patters following the exacerbation of fighting in the late 1980s. Another possible explanation is dissatisfaction with the political, economic or social situation that followed the end of the civil war in 1990.
Many HIC including the US [15
], the United Kingdom [16
], Canada [17
] and Australia [18
] are planning to expand their physician workforce partly by recruiting from LIC. These countries should consider the consequences of such policies on both the sources countries' and their own healthcare systems [19
]. While the source countries benefit from remittances and skills transfer,[20
] they suffer from a brain drain, and losses in educational costs and returns from investment[21
] In addition the healthcare systems of the source countries face reduced range of available services, and understaffing of facilities [22
]. In many LIC, particularly in the Sub-Saharan Africa, the brain drain of physicians is a major impediment to disease-reduction initiatives [23
]. It has even impacted some of these countries' ability to continuously develop academics to provide quality training of new doctors [25
]. There is also indirect evidence that those who migrate might be the best among their peers [26
]. The international recruitment of physicians can have consequences also for the HIC. In fact, with the increased threat of global pandemics, the public health in HIC increasingly depends on the effectiveness of healthcare systems in LIC [27
The actions taken to deal the medical international recuritment of physicians are few and far between. A 2002 review identified eight codes of practice on ethical international recruitment of health professionals [28
]. As an example, the UK Department of Health has published a Code of Practice "to promote high standards of practice in the international recruitment and employment of healthcare professionals" [29
]. There is evidence however that the code has not affected the inflow of these professionals from "proscribed" countries [30
The relative size and historical trends of migration of LMG to the US are remarkable. A qualitative study showed that the chief motivation for Lebanese medical students to train abroad was the need to gain a competitive advantage in an oversaturated Lebanese job market [31
]. In fact, Lebanon suffers from an oversupply of physicians [32
] and has a physician density of 325 physician per 100,000 (2001 data), the second highest in the Middle East and North Africa [33
This study has important implications for research. There is a need to explore the causes of the oversupply of physicians in Lebanon. It is also important to study the impact of this migration on the Lebanese healthcare system. Finally, it would be interesting to explore whether the observed differences in practice characteristics (type, location and primary employer) among the studied groups reflect differences in personal preferences or in training and job opportunities.