Doctors For The World: Indian Physician Emigration

Fitzhugh Mullan

Health Affairs. 2006;25(2):380-393. 

In This Article

The Lure of Going Abroad

Rate of Return

"Going abroad" for postgraduate work has long been perceived as a prestigious step for young physicians. Most leave with at least an open mind on the subject of return to India, but growing familiarity and acceptance as well as clinical opportunities and income make return less likely. Most respondents volunteered that virtually all physicians going to the United States for training ended up staying permanently; return rates from the United Kingdom were higher. "If you work hard, everything is possible in the U.S.," one U.S.-trained, returned Indian nephrologist told me. Current data indicate that 59,095 Indian-educated physicians are working in the United States, the United Kingdom, Canada, and Australia. They constitute 4.9 percent of the U.S. physician workforce and 10.9 percent of the U.K. physician workforce.[21] Analysis of U.S. residency data indicates that there are about 5,000 graduates of Indian medical schools in U.S. training programs today, meaning that approximately 1,200 enter into the U.S. residency system each year.

Reasons for Emigration

The psychology of emigration is captured in a recent book about medical practice in India titled What's Up, Doc?[22] Author Saranaya Nandakumar summarizes the "ideology of the brain drain" as follows: (1) "The West Is Best Epidemic"—the long-standing belief of young doctors and their parents that training outside of India is superior and a mark of achievement; (2) "The Materialism Bug"—the expectation of bigger incomes and more material acquisition associated with life in the West; (3) "Specialization in Extremis"—the lure of high-tech training and "super" subspecialization perceived as prevalent in the West; (4) "Governmentitis"—reaction to the strictures and barriers of Indian governmental management of the education system and the corruption often associated with it; and (5) "Chaos-phobia"—escaping the chaotic government and commercial systems in India in favor of what are perceived to be the more regularized and merit-based medical systems of the West.

Multiple respondents described rationales similar to these for the continued high interest in going abroad in the current epoch in spite of improvements in the Indian economy. This very growth in private medical education seems likely, in the eyes of many, to result in even higher levels of emigration in the future. The cost of private medical education is high ($75,000-$100,000), and students who make this kind of investment are likely to expect a financially productive career—something predictably found in the West. This expectation, combined with the increasingly crowded ranks of doctors in the Indian fee-for-service sector, will likely result in more graduates intending to emigrate.

Attitudes Toward Emigration

Prasad Rao, then secretary of the Ministry of Health and Family Welfare, addressed emigration without ambivalence. "India is a big country," he told me. "We have a billion people. We graduate 20,000 doctors every year. If 600 leave us, that is not a problem."[23] These comments are important for two reasons beyond the data they convey. First, Rao's estimate of 600 annual physician emigrants is a sizable underestimate: At least 1,200 come to the United States each year, and hundreds more leave for other countries. Likewise, his complacency in regard to the departure of physicians from India is indicative of the level of acceptance that exists among current Indian policymakers.

Although attitudes about the benefits and advisability of emigration vary, most people accept the ongoing reality of physician emigration and the right of human beings to try to better their positions. Nevertheless, the "brain drain" (a term that was frequently used) is an emotional topic, with many people expressing concerns about the departure from India by doctors educated at public expense in publicly financed hospitals. This vexation was not much diminished in regard to graduates of private medical schools, since, many people observed, those schools receive many government benefits, and their students often learn medicine in public hospitals. Many stated with resignation that a major exodus of physicians is inevitable until the Indian economy is greatly improved and should not be opposed by public policies in India or the recipient countries.

Notable comments about emigration included the following: (1) A professor at a private medical college described the college's strategy as being one of training physicians who are "globally competitive but locally responsive." (2) With a mixture of pride and frustration, an academic nephrologist told me that "there were more Indian nephrologists in the U.S. than in India." (3) The director of a department of surgery talked about "the paradox of saturation," where Indian cities had too many doctors, and the countryside, almost none. (4) The dean of a medical college declared that with the spate of new private medical colleges, he was worried about "the growing danger of a large number of new doctors who have no commitment to this country or to ethical standards of practice. At least if they go abroad we are rid of them." (5) A community organizer in a Mumbai slum that has virtually no allopathic physician practitioners commented, "I just cannot believe the government spends all that money [estimated to be about $40,000 per medical student] on a medical education for a doctor who turns around and leaves the country. We could make amazing progress here [in the slum] if we had the tuition of just one medical student."