. Available from: https://link.springer.com/article/10.1186/s12960-019-0407-z#citeas. Last updated Aug 03, 2023; cited Aug 03, 2023.
Faithful Miebaka Daniel1, Emmanuel Aniekan Essien2, Monica Anurika Gbuchie3, Bonaventure Michael Ukoaka1, Victoria Ezinne Emeruwa4
doi: http://dx.doi.org/10.5195/ijms.2023.2255
Volume 11, Number 4: 343-346
Received 03 09 2023; Rev-request 18 10 2023; Rev-recd 31 10 2023; Accepted 20 11 2023
Access to healthcare is a fundamental human right. However, Nigeria, among other under-resourced countries, continues to grapple with healthcare infrastructure and personnel challenges, making it difficult to achieve the Sustainable Development Goal (SDG) of universal health for all by 2030.1 The low doctor-to-patient ratio in Nigeria is one of the factors contributing to inadequate access to healthcare, which affects 63% of Nigerians.1 This situation is worsened by the decreased interest in specialist training among interns, leading to healthcare worker shortages.2 Additionally, many interns choose not to pursue medicine after completing their internships and show a growing preference to emigrate to developed countries.2,3
Nigerian doctors have various career options, including clinical practice, academia, research, medical advisory, medical entrepreneurship, and nonclinical pursuits.4 During the compulsory one-year internship after graduation, they serve as first-contact physicians under supervision and decide on their career trajectories.2,4 Several studies have explored the factors influencing interns' specialty preferences to foster equitable distribution across clinical expertise.2
International studies have highlighted the impact of internship experiences on career aspirations and emigration decisions.3 They highlight why addressing the brain drain requires a critical focus on internships, a period where future specialists are nurtured and pivotal career decisions are made.2,3 A recent study by Akinwunmi et al. revealed that 79.5% of interns intended to pursue medical practice in foreign nations, and over 41% planned to migrate within two years.5 This coincides with the duration required to conclude their internship training and Nigeria's one-year compulsory National Youth Service Scheme.5 The Nigerian Medical Association reported that 727 medical doctors trained in Nigeria relocated to the UK within six months between December 2021 and May 2022, while 5600 doctors migrated over eight years. Unfortunately, this trend is projected to intensify in the coming years, as medical stakeholders and the Nigerian Medical Students Association (NiMSA) opposed a bill that would mandate Nigerian-trained medical and dental practitioners to practice in Nigeria for a minimum of five years before being granted a full license to migrate abroad.6 The Students' body has advised lawmakers to create a conducive environment and improve remuneration rather than enforcing laws that infringe on fundamental human rights and discourage prospective medical students.6
Adverse experiences during internships can profoundly impact doctors' personal and professional lives, making emigration more attractive.2,3 The negative experiences that favor emigration are classified as push factors and summarized in Table 1. Interns often experience excessive workload and burnout due to long hours, understaffing, limited resources, and being delegated to perform non-core duties.3 These experiences can lead to physical and mental exhaustion, decreased quality of life, loss of empathy, and depersonalization.3 Nigeria's economic challenges have also led to increased financial constraints for doctors, making basic needs and support unaffordable.1,2
Table 1Push and Pull Factors Influencing Physician Emigration and Recommendations from Selected Studies.
| Paper | Push Factors | Pull Factors | Negative experiences during the internship | Recommendations |
|---|---|---|---|---|
| Ikhide E.1 |
|
|
---------- |
|
| Ezeike C.et al.2 |
|
|
------------- |
|
| Cronin et al.3 |
|
|
|
|
Early career doctors in Nigeria cite a lack of professional development and growth opportunities, a challenging work environment, and limited access to necessary equipment and support systems as reasons for migrating.2 This trend contributes to brain drain and negatively impacts Nigeria's healthcare system.2 The mistreatment of younger doctors has been reported as having severe consequences on their emotional well-being, job satisfaction, and professional development.7 These can include verbal abuse, humiliation, intimidation, and excessive criticism, impacting their self-esteem and confidence.7 The influence might be more pronounced in interns due to their early career stage and lack of experience, leading to powerlessness and frustration. Mistreatment and bullying also increase the risk of workplace violence against doctors, as public humiliation devalues the physician before patients, caregivers, and allied health workers.7 Unsurprisingly, such experiences, especially when severe, would naturally drive doctors to seek opportunities that offer a more respectful, supportive, and enabling environment, which is sought after in other countries.1,4,7 These multifarious challenges discourage Nigerian doctors in the diaspora who are willing to return.
The career choices of young interns significantly impact the healthcare system of Nigeria. This factor plays a crucial role in determining the distribution of specialized services and the replacement of retiring healthcare professionals.4 Currently, nearly 50% of Nigerian-trained doctors practice abroad, resulting in a considerable forfeiture in medical education investment and the lost practice years having a multiplier effect.1 Nigeria was among the nine countries that, as a group, lost two billion dollars between 2010 and 2017 due to brain drain.1
Nigerian interns often migrate to Western countries, such as the United Kingdom, the United States of America, and Canada, in search of better job opportunities, remuneration, and working conditions.5,8 Another reason is the promise of better job security and health insurance coverage.9 However, recent studies have shown a growing interest among Nigerian medical doctors seeking job opportunities in Middle Eastern countries, such as Saudi Arabia, Qatar, and Oman.10 Moreover, specialized surgical fields have become increasingly popular among Nigerian medical practitioners in these destination countries.2 The countries where Nigerian medical doctors have shown interest have a defined doctor-to-patient ratio, significantly reducing the likelihood of physician burnout, which is an important reason for medical interns' migration, particularly after the internship year experience.10 Furthermore, these countries share leadership that supports and regulates universal healthcare, backed by efficient government funding and a robust national health insurance scheme.3 These countries also have cutting-edge research institutions, an efficient nationalized health information system, and a preventive medicine approach that has influenced this trend.3 This combination of factors has made these countries an attractive destination for Nigerian medical professionals seeking better opportunities
Given the substantial impact of interns' career choices on the healthcare system of Nigeria, it is justifiable to implement talent retention strategies that focus on interns. This approach maximizes the return on investment in medical education, ensures workforce stability, and secures future healthcare needs.1,3,4 Improving internship conditions would also attract foreign-trained doctors to return for their housemanship, boosting the local workforce and increasing the likelihood of their retention.1 Addressing their concerns and providing mentorships that support their growth would foster their commitment to the country's health system. Younger doctors are more adaptable to changing clinical landscapes, which is advantageous. Therefore, it is essential to address their concerns and provide mentorship that supports their growth to foster their commitment to the country's health system.
The COVID-19 pandemic has had a significant impact on the healthcare system of Nigeria, with essential health workers, particularly doctors, being among the most impacted. In the first week of the pandemic alone, approximately 20 doctors in Nigeria succumbed to COVID-19 complications, highlighting the devastating effect of the pandemic on the country's healthcare workforce.11 The pandemic exacerbated existing fragility in Nigeria's healthcare system. While no specific data links the continuous surge in internal migration to the COVID-19 pandemic, we speculate that the shift could be attributed to the unfavorable experiences many healthcare workers endured, such as shortages of personal protective equipment, limited screening services, and poor hazard allowances.11 The lack of commitment to protecting doctors encouraged intern migration due to inadequate hazard allowances below $14, which is insufficient to cover treatment for potential COVID-19 cases.12 Furthermore, the pandemic led to a shortage of essential healthcare workers, thereby increasing the burden on the few available and contributing to the migration intentions of healthcare professionals within and outside the country.
To retain Nigerian doctors, healthcare systems and policymakers must prioritize creating a work environment that fosters job satisfaction, fair compensation, and professional growth.2,3 Table 1 summarizes recommendations to address this challenge.
To address physician emigration, it is crucial to consider implementing policies and pull factors similar to those of destination countries, as outlined in Table 1. Additionally, it is essential to identify and address any shortcomings in managing the COVID-19 pandemic to improve physician retention in the local healthcare system. To achieve this, the Nigerian Medical Association (NMA), Nigerian Association of Resident Doctors (NARD), Medical and Dental Council of Nigeria (MDCN), Federal Ministry of Health (FMoH), Federal and State Governments, and Postgraduate Medical Colleges must work together.
These stakeholders should prioritize improving remuneration to reflect current economic realities, overhauling the medical curricula, and increasing the number of research institutions and laboratories.4 In addition, stakeholders can explore ways to align the postgraduate academic and fellowship routes to create a more seamless and effective transition for individuals pursuing higher education and professional development and to help increase career options for doctors.4 A balanced rotation through all specialties has been suggested to help with the equitable distribution of specialties.2
Addressing mistreatment and bullying, implementing anti-bullying policies, and fostering a positive work environment can improve doctors' well-being and career satisfaction.7 The MDCN must also enforce the Code of Medical Ethics (COME) to discipline errant medical seniors who abuse their status in the workplace.
It is worth noting that Nigeria has yet to dedicate at least 15% of the annual national budget to healthcare.1 Most systemic challenges bedeviling healthcare can be solved through increased healthcare financing, enhanced healthcare insurance coverage, efficient distribution of resources, and elimination of bureaucratic bottlenecks and corruption. These measures will ensure that healthcare systems remain sustainable, doctors are retained, and patients receive the best care.1,4
To establish sustainable healthcare in Africa's most populous country, increasing the number and distribution of doctors, specialist providers, and clinical researchers is imperative. To achieve this, evaluating career preferences and their determinants, like internship experience, can be a significant step in addressing the issue of brain drain and physician shortages. This assessment would enable stakeholders in the Ministry of Health and healthcare administrators to influence the career choices of interns, which, in turn, would benefit the local population and reduce economic losses from brain drain, thereby contributing towards establishing a robust healthcare system.
In this article titled “Mitigating Physician Emigration in Nigeria by Improving the Internship Experience,” we argue for the significance of positively influencing interns' experiences to address the issue of physician emigration in Nigeria. The negative experiences faced by interns, including excessive workload, burnout, inadequate remuneration, lack of professional development opportunities, mistreatment, and bullying, contribute significantly to their desire to emigrate. Therefore, we propose implementing strategies to create a supportive work environment that offers fair compensation, opportunities for professional growth, and access to necessary resources, along with addressing mistreatment and bullying, improving salaries, overhauling medical curricula, and enforcing the Code of Medical Ethics. By prioritizing the needs of interns, stakeholders can influence their career choices and increase the likelihood of retaining them within the Nigerian healthcare system, reducing the brain drain and addressing physician shortages. Additionally, it is crucial to increase healthcare financing, improve health insurance coverage, and eliminate bureaucratic bottlenecks and corruption to improve the healthcare system and retain doctors in Nigeria.
None.
The Authors have no funding, financial relationships or conflicts of interest to disclose.
Conceptualization; Resources: FMD. Methodology; Investigation; Supervision; Visualization; Formal Analysis: FMD, MAG, EAE. Software: MAG, BMU, EAE. Validation; Data Curation: FMD, MAG, BMU, EAE, VEE. Writing – Original Draft; Writing – Review & Editing; Project Administration: FMD, MAG, BMU, EAE, VEE.
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Faithful Miebaka Daniel, 1 MBBCh. First On-Call Initiative, Portharcourt, Rivers, Nigeria.
Emmanuel Aniekan Essien, 2 MBBCh. FWACP. Federal Neuro-Psychiatry Hospital, Calabar, Cross River, Nigeria.
Monica Anurika Gbuchie, 3 MBBS. First On-Call Initiative, Portharcourt, Rivers, Nigeria.
Bonaventure Michael Ukoaka, 1 MBBCh. First On-Call Initiative, Portharcourt, Rivers, Nigeria.
Victoria Ezinne Emeruwa, 4 MD. First On-Call Initiative, Portharcourt, Rivers, Nigeria.
About the Author: Faithful Daniel is a medical doctor who graduated from the University of Calabar, Cross River, Nigeria, in 2021 with a Distinction in Community Medicine. He holds a primary fellowship in Obstetrics and Gynaecology. In 2022, He was awarded a Finalist and Third Place for the Rhodes West Africa Scholarship for West Africa, awarded by Rhodes Trust..
Correspondence: Faithful Miebaka Daniel. Address: Port Harcourt, Nigeria. Email: dandfaithful@gmail.com
Editor: Francisco J. Bonilla-Escobar; Student Editors:Iqra Nawaz & Jonaviva Thomas; Copyeditor: Leah Komer; Proofreader: Laeeqa Manji; Layout Editor: Ana Maria Morales; Process: Peer-reviewed
Cite as Daniel FM, Essien EA, Gbuchie MA, Ukoaka BM, Emeruwa VE. Mitigating Physician Emigration in Nigeria by Improving the Internship Experience. Int J Med Stud. 2023 Oct-Dec;11(4):343-6.
Copyright © 2023 Faithful Miebaka Daniel, Emmanuel Aniekan Essien, Monica Anurika Gbuchie, Bonaventure Michael Ukoaka, Victoria Ezinne Emeruwa
This work is licensed under a Creative Commons Attribution 4.0 International License.
International Journal of Medical Students, VOLUME 11, NUMBER 4, November 2023