Migration of doctors from their country of training impacts on medical workforce planning [1, 9, 21, 39], represents a major loss of state investment in medical education [3, 40], and may impact negatively on health sector goals. There is clear evidence that once abroad, increasing numbers of early-career doctors who emigrate with intentions of returning to their homeland to work never actually return [21, 25, 28, 29, 41]. The continued emigration of early-career doctors from Ireland is resulting in a loss of investment to the exchequer [13], necessitates high levels of replacement through inward migration of non-EU doctors (in 2017, 42% of doctors in Ireland were non-EU-trained [16, 22], and is contributing to the high number of Ireland’s currently unfilled consultant posts [41]. In addition, doctor emigration deprives the Irish health system of ‘potential leaders who might otherwise demand, initiate and deliver reform’ [20].
Despite implementation since early 2015 of a multi-stakeholder, Department of Health-led national strategy, designed to increase graduate retention in Ireland [42,43,44], this study of interns found that almost two thirds (64%) of our respondents intended to leave after their mandatory year of working within the Irish healthcare system. This should be of huge concern: while most intended (or hoped) to return, an earlier study of Irish-trained doctors abroad showed that many would not act on this intention unless working conditions and career opportunities in Ireland improved [23]. Furthermore, evidence shows that as emigrants’ roots abroad are established, emigration becomes permanent [25, 28].
Our study demonstrated an important and statistically significant predictor of the intention to migrate, which remained when adjusted for age, and which has not previously been reported: well over half (60%) of GEM doctors intended to remain in Ireland following their internship, compared with only one quarter (24%) of DEM doctors. This finding suggests that GEM doctors are more likely to stay working within the Irish health system. However, among the doctors who planned to leave (64%, n = 134), the same proportion of DEM and GEM doctors planned to return (89% DEM, 85% GEM) and to leave permanently (DEM 10%, GEM 15%) (χ2 (1) = 0.46, p = 0.504).
Independent of the study pathway, doctors’ intention to migrate were significantly associated with their negative working experiences, and possible effects of their experiences, during their mandatory year as an intern. This was seen most strongly for those intending to leave permanently. In this study, negative working experiences, as previously reported in research among doctors in postgraduate training programmes in Ireland [18] and reported by Irish-trained doctors abroad in relation to working in Ireland [23, 42], are found to be evident after as little as 1 year of work as a hospital doctor. Our study found that of the interns who responded to our survey, 70% rated as negative both ‘protected training time’ and the ‘staffing levels in their workplace’, while close to 60% rated as negative their experiences of ‘non-core task allocation’. While reported previously in more experienced hospital doctors [24, 45], this study also shows that burnout and callousness were common, experienced at least once a week, in one third of doctors after a single year working in Irish hospitals. These experiences were also presenting as predictors of intention to migrate (with the strongest effect for both factors seen in those intending to leave permanently); however, in the absence of a temporal relationship, no causal link with working conditions has been demonstrated, which may be a subject for future studies.
These findings should be of great concern to Irish health workforce policy makers. The 2014 national strategy was introduced specifically to address unsatisfactory training and working conditions in order to improve graduate retention [42, 43]. The recommendations targeted the enforcement of protected training time and the reduction of non-core task allocation for doctors in training. Our results show that these areas continue to be sources of difficulty for interns in 2018 and are contributing to interns’ migration intentions.
Negative perceptions of training in Ireland were significantly associated with interns’ intention to leave and return, while a positive perception reduced the likelihood of leaving permanently. Intended specialty choice was also a statistically significant factor, with those planning a career in Medicine more likely to leave and return compared with those planning to train in General Practice. Surprisingly, despite being at the point of making training and career choices, many respondents appeared not to have formed an opinion about the training landscape in Ireland (Table 4). This may indicate a necessity for training bodies to not only improve training options in Ireland, but also promote awareness of training options during the 1-year internship [43]. However, considering the global networks among medical graduates [23], it will be necessary for Ireland’s medical training to be viewed as competitive when considered against the training opportunities, staffing levels, and working conditions in destination countries such as Australia [21, 41].
While our findings are limited by the relatively small sample size, low response rates from medical professionals, and doctors in training, are well documented [46], with some published findings reporting response rates as low as 7.8% [47]. And while there is little known about the non-responders (sampling frames were unavailable from medical schools and/or hospitals), of those who did respond, a very high proportion completed the entire survey (96%). Our findings around burnout and callousness require further analysis in order to establish the direction of, and predisposing factors for, these outcomes and also to establish if they are a precursor to, or a subsequent development of, an intention to emigrate.