This study demonstrated that a high proportion of medical residents in Iran were inclined to migrate. Furthermore, the majority of medical residents stated that if they had the current insight into the educational and professional conditions of the residency program, they would tend to migrate instead of entering the residency programs. However, only a minority of participants had practically planned to migrate.
Despite the fact that more than half of the medical residents showed tendencies to migrate, the planning for migration was relatively low in our studied population. In line with our findings, a recent study among psychiatrists in Iran has demonstrated that 83.7% of participants had desire to emigrate, which confirms the high inclination of the medical community to migrate. On the other hand, as observed in the present study, only a few had taken practical measures toward migration (15). Older studies in Iran, such as a study by Alaeddini et al., showed that the average level of tendency to migrate among Iranian physicians was 53.3%, most of whom had not yet planned for it (18). These studies reflect an increasing tendency for migration in Iranian physicians over the years. However, it seems that planning for migration is low due to the high costs of migration, low currency value in Iran, the uncertainty of migration outcome, and the policies of the government which restrict the outflow of trained healthcare forces. Accordingly, medical doctors in Iran are obliged to spend a compulsory service before they can obtain their M.D degree. Moreover, recent policies have also mandated the physicians to pay remarkably high money to obtain their M.D degree, even after they have spent their compulsory service. These restraining policies have made the emigration process an almost unachievable pathway for recently graduated doctors with no solid financial background. Meanwhile, studies from other countries have reported various results. Consistent with our findings, a study by Da Costa et al. in Portugal indicates that nearly 75% of medical trainees had ever considered leaving the country, while the majority (70%), had not taken any practical steps toward migration (24). On the other hand, a survey of Romanian medical students revealed that 84.4% of the students had planned to work outside Romania (25). In another study in Nigeria, 70% of the medical residents and medical students who intended to migrate abroad, had started planning for migration (22). While the mobility of physicians and their inclination to migrate, particularly among young physicians, is a global phenomenon, the situation seems to be better in several HICs. For instance, in a study in Lithuania, only one-fifth of medical residents had intentions to migrate (26). Similarly, another study in Austria demonstrated that less than half of the young physicians had the intention to migrate to other HICs (27).
More than half of the medical residents participating in our study stated that if they had had the current insight into the conditions of the residency program before enrolling, they would highly prefer to migrate instead of entering the residency training program as the future career path. This finding highlights the fact that the current condition of medical residency in Iran significantly impacts the migration of young physicians. The remarkable reduction of participants in the entrance exam for the residency program, the dissatisfaction of physicians with the conditions of residency training, along with their concerns about the future of their career, as shown in a study by Lankarani et al. (21), support these findings. Reports from other countries indicate that the conditions of the residency program seem to impact physicians' migration, as well. For example, in a study by Imran et al. (28) in Pakistan, 60.4% of medical students intended to continue training abroad either for a specialty or subspecialty training, and the most common reasons cited for training abroad were the impact of residency training on their future career, the poor salary of the postgraduate trainees, in addition to the working and financial conditions of medical residents. Moreover, findings from a study in Egypt demonstrated that 97.4% of medical residents who wished to emigrate, declared that they would consider changing their decision if the condition of the health sector improved (13). Overall, these observations are indicative that the poor conditions in medical residency programs, particularly in LMICs, play a pivotal role in the migration of young physicians. Therefore, postgraduate medical training could be a crucial target for policymakers of LMICs to retain their healthcare workforce. Optimizing the shift hours of medical residents, decreasing the burden of workload, increasing salaries, providing financial aids, and enhancing the quality of education could be advantageous measures to decrease the outflow of graduate doctors, and thereby increase the rate of enrollment in residency programs.
When investigating the demographic correlates of inclination/planning to migrate among medical residents, our study did not show any association with gender or marital status. Findings of a study almost two decades ago in Iran, indicates that male were more inclined to migrate (18). Traditionally, women have been more involved in social obligations and were more dependent on the family in most LMICs, making them less geographically mobile. However, the findings of our study suggest that the gap between Iranian men and women to pursue their careers far from their families has been narrowed over the years, as we observed no difference between men and women in their inclination and planning to migrate. While several studies have demonstrated that demographic factors might affect the intention to migrate in healthcare factors (29, 30), there have been no significant associations between age, gender, and other characteristics with the inclination and planning to migrate in some other studies (15, 31). Therefore, as de Silva et al. suggest, these differences indicate that the tendency and planning to migrate may be a highly individualized decision, and the affecting factors are unique, diverse, and vary from person to person (31).
On the other hand, the results of our study further showed a significant association between age and the inclination to migrate. This finding indicates that younger physicians have more desire to migrate. Similarly, other studies among Iranian health workers (32) and Icelandic physicians (33) have shown that younger age was positively associated with considering migration. Our findings reflect that junior residents and recently graduated doctors are less adapted to the conditions of the residency programs and have more courage to alter their decision toward migration. In a similar vein, Nigerian junior residents had a higher probability of intention to migrate abroad compared with seniors (22). Supporting our findings, a high number of medical residents in Iran opt out of the residency program within a few months after their enrollment each year. Previously, these applicants had been banned from participating in the entrance exam for the following year. However, due to a very low participation rate in the residency exam, recent policies in Iran have made it possible for these applicants to participate again, even if they had withdrawn the previous year. This has been among the many policies to encourage physicians to enter residency programs in Iran.
There are generally several reasons why young physicians tend to migrate from their home country. Reports from Nigeria, Iraq, Romania, and Germany indicate that job dissatisfaction is a decisive factor in the tendency toward migration among medical doctors (22, 25, 29, 34). In our study, 85.5% of the medical residents indicated that economic and occupational factors are the most important causes of migration among physicians. Other factors, including sociocultural, educational, academic, and personal causes were followed. Financial and occupational factors have been highlighted as the main reasons for healthcare workers' migration in several other studies as well (24, 33–35). However, in another study on Iranian psychiatric trainees and early-career psychiatrists, political conditions and then work-related factors were considered as the most critical factors affecting the migration of physicians (15). Similarly, reports from other countries have suggested the same core of reasons for migration, as the main reasons for migration in Turkey were academic, work, and financial factors, whereas in the Baltics, these reasons were more centered on personal and financial factors (36, 37) and in Egypt, it has been stated that doctors migrate in search of better work and financial incentives (13).
This study had several strengths. First, this was a multi-centric national study in Iran, where a reasonable number of medical residents from top-ranked medical schools and across several disciplines participated. Furthermore, in this study, we developed a structured questionnaire with appropriate validity and reliability to measure the inclination and causes of migration among medical residents, which has the potential to be used in other institutions for comparison across various countries. Finally, considering the current political and financial changes in Iran, and the increasing number of physicians' emigration from the country, the present study was among the few pieces of research to document the inclination to migrate and its underlying reasons, which could be addressed by the health policymakers to reduce the burden of medical brain drain.
In terms of limitations, we investigated the potential causes of migration according to the perspective of the medical residents who are currently practicing in Iran. Instead, a survey from physicians who have already migrated might result in more accurate data on why the physicians emigrate from Iran. Moreover, the nature of the self-report data collection might introduce reporting and social-desirability biases. This was tried to be minimized by assuring the respondents of absolute confidentiality of the data provided, and the questionnaire did not include individual personal identities.