CORR® International—Asia-Pacific: Young Physicians Are Fleeing the Asia-Pacific Region

From the Column Editor,

In this month’s CORR® International—Asia-Pacific column, Prashant Meshram MS, DNB, a clinical fellow from Mumbai, India examines why young physicians (residents, trainees, and junior specialists like orthopaedists) in the Asia-Pacific region are emigrating to more stable and economically developed countries. Dr. Meshram has worked as a resident and junior physician at two of the highest volume tertiary care centers in the region, and in this column, he offers his detailed insights into the region’s treatment of young surgeons.

During training, young surgeons in the Asia-Pacific region are expected to work long hours for little pay—a rite of passage, perhaps. But have we gone too far? Countries in the region that pushed for expanded or universal health care did not properly consider the burdens placed on a young workforce that simply cannot handle the high demand for care. As patient workloads become untenable, young physicians—for reasons detailed in the column—have signaled their willingness to work elsewhere, leading to a major physician shortage in the region.

Please read Dr. Meshram’s guest column to find out more about why young orthopaedic surgeons are leaving the Asia-Pacific region.

— Tae Kyun Kim MD, PhD

While it is admirable that the Asia-Pacific region is willing to implement ambitious nationwide healthcare initiatives benefitting its citizens, none bigger than universal health care [34, 39], most of the day-to-day execution of such programs rests on the shoulders of residents, trainees, and junior specialists. Young physicians in the Asia-Pacific region practicing in the clinical specialties like orthopaedics are generally at the bottom of a lengthy food chain, one in which the hours are long, the patient volume is excessive, the working conditions are questionable, and the compensation makes it difficult to retain and motivate a competent workforce [11]. These issues should not be overlooked as simply young physicians paying their dues; they are, in fact, contributing to major physician shortages across the region. Real reforms are needed in workforce planning, development, and funding [11] to address the shortage of young health workers (including orthopaedic surgeons) in the Asia-Pacific region.

This shortage is severe, and its implications are serious. The data from 27 countries of the Asia-Pacific region shows that there are approximately 1.3 physicians per 1000, with the lowest being 0.2 in Cambodia and Nepal—both of which are well below the Organization for Economic Co-operation and Development (OECD) average of 3.3 for 2016 [25]. For perspective, the physician density in the rural United States is 13.1/10,000, or a little more than six times the density in Cambodia and Nepal, which is 0.2/1000 [24]. Because of the aging demographics and increased health coverage, the workload of physicians in the Asia-Pacific region will continue to rise dramatically [17].

Workload

Given those kinds of statistics, it is no surprise that young physicians in the Asia-Pacific are suffering from overwork [16] and burnout [5]. The working hours of young physicians in the region typically exceed 80 hours per week [9, 18, 20] and 130-hour workweeks are common [23]. Even in developed countries like Australia, the proportion of orthopaedic trainees experiencing burnout may be as high as 50% to 60% [2].

Overwork causes not only physical and emotional illness and diminished job satisfaction among doctors, but also leads to decreased quality of medical care and increased medical errors [2]. Furthermore, an excessive workload leaves limited time for research or recreational time with family, further reducing the opportunities for professional advancement and personal quality of life [16]. Perhaps most importantly, if the job is perceived as one that cannot be done safely or well, fewer people in the Asia-Pacific region will choose medicine as a career, or if they do, they will choose to work somewhere else, further exacerbating the shortages of physicians in this already-underserved part of the world [18, 37]. This creates a vicious cycle in which overburdened facilities both in cities and rural areas must be staffed, and that staffing leads to excessive workloads on young physicians in across the region [3, 21].

Responding to the physician shortage, government medical schools in India are making more undergraduate seats in medical schools available to students. India’s health ministry aims to increase undergraduate medical student enrollment by more than 30,000, and postgraduate positions by more than 15,000 by 2020-21 [13]. Healthcare reforms, such as implementing a tier-based referral system at primary and secondary care centers could effectively distribute patients and relieve congestion in tertiary care centers. Furthermore, tertiary care centers should regulate the working hours of junior doctors and provide a healthy working environment to young doctors [5, 7, 26].

Low Compensation

Along with the long working hours, low compensation contributes to the extreme dissatisfaction among young doctors in the region [37]. The annual income of a trainee doctor is much less in China (USD 9360) [36], India (USD 7000) [27], and Pakistan (USD 4000) [28] compared to the average US orthopaedic surgeon resident (44000 USD) [31]. In 2014, Asian countries spent just 4.7% of their gross domestic product on health care, compared to 9.3% in OECD countries [25]. Furthermore, the renumerations of healthcare workers in terms of salaries, wages, and allowances were 35.5% of the general government health expenditure in Southeast Asian countries compared to 49.8% in North and South American countries, resulting in depressed healthcare salaries for young physicians in the region [12].

The governments in Asia-Pacific countries, particularly those in the low- and middle-income countries, should make physician compensation a higher priority in their budget allocations. Raising the compensation level for trainee doctors is a great recruiting tool and could make a major impact on the physician shortages across the region.

Of course, the money to fund this kind of change must come from somewhere. Low-income governments should focus on easily collectable taxes such as those on imports and exports of goods, large corporations, or formal-sector employees [35]. The World Health Organization also recommends governments look for new ways to raise funds for domestic health care such as raising taxes on harmful products like tobacco and alcohol, which could reduce consumption, as well as increase the resources governments can spend on health care [35].

Violence

Although an underreported story in the west, workplace violence against doctors (particularly young doctors [8, 22, 30, 33]) is rampant across many Asia-Pacific countries, and I believe this is a symptom of a system suffering under increasing burdens of the kinds I’ve described here. Indeed, 70% to 80% of doctors in the region have reported suffering either physical or verbal violence at the hands of patients who are frustrated with the lack of basic facilities, long waiting time, poor communication, and expensive out-of-pocket expenditures [15, 30]. The reported deaths of 40 doctors and nurses in China since 2001 and reports of violence from other countries in the region [4, 18] force young physicians to question whether their workplace environment is safe, and may cause motivated, capable young people who have other career options to choose not to study medicine, and in so doing, further worsen the pressures on the overtaxed healthcare systems in this region.

Regional governments must formulate laws against healthcare workplace violence and ensure their strict implementation [6, 14]; reports from China [10], India [8], Pakistan [32], and Nepal [19] suggest this is not yet being done. Hospitals and secondary healthcare centers in the region should implement zero-tolerance policies regarding workplace violence, provide adequate security measures, police reporting, legal action, and reimbursement in cases of violence against the doctors. Unfortunately, it appears these standards are not normative in many parts of the region; more than 95% of Chinese doctors are not compensated after being attacked and injured at work [18]. Healthcare workers should report all violent incidents, attend relevant educational and training programs, and seek guidance from counselors or mentors who have decades of experience handling difficult patient interactions and heavy patient workloads in the region [14].

Relaxing the professor/resident hierarchy could indirectly curb the workplace violence we are seeing in the region. As a young resident in India, my peers and I had only distant relationships with professors and senior colleagues, and this is a missed opportunity. Senior colleagues should take the time to discuss patient communication with their residents, particularly situations involving a patient death or explaining complications to a patient’s family, as these types of communication breakdowns have led to violence towards physicians in the past [16]. Violence towards a physician—even for poor communication—should never be tolerated. But if residents are taught how to empathize with their patients, perhaps patients will show a greater tolerance towards and respect of physicians.

Emigration

The serious, systemic failures listed above have caused many young physicians to relocate to more-developed countries in the region, and even to the west, where they find attractive salaries, better training infrastructure, professional opportunities, and superior living and working conditions [29]. Specifically, the Philippines, India, Indonesia, China, Pakistan, Sri Lanka, Bangladesh, and Nepal all have seen a growth of physician emigration to more-developed countries [38]. For example, about 30% of physicians in the National Health Services, the publicly funded national healthcare system in England, are of Indian descent [1]. In the United States, there is one Indian doctor available for every 1325 Americans. In India, there is one Indian doctor for every 2400 Indians [1].

The emigration of young physicians and junior specialists to developed countries—and their reasons for leaving—should be a major concern for the Asia-Pacific region. Although we are seeing pockets of reform in parts the region, change is not occurring nearly fast enough. Young doctors in the Asia-Pacific should not hesitate to speak out against these issues, as they hold more power than their titles might suggest.