The demands on human resources have been rapidly growing worldwide for a number of demographic and epidemiological conditions 1. A major consequence has been an accelerated international migration of health workers, mainly from developing countries to more developed countries, a phenomenon known as "brain drain" 23. Indeed, 23 to 28% of physicians practicing in the four major recipient countries (i.e., the United States, the United Kingdom, Canada, and Australia) are international medical graduates. The source countries for 40 to 75% of these international graduates are lower income countries and the source countries for the remainder are either middle income countries or high income countries 2.

Most of the research on the international migration of physicians has focused on low income countries, and rightly so. Indeed low income countries, affected by physician migration, unlike middle income countries, are suffering from chronic understaffing of healthcare facilities, and shrinking of available services 4. In many low income countries, particularly in the Sub-Saharan Africa, physician migration is also a major impediment to disease-reduction initiatives sponsored by international organizations 5. However, middle income countries affected by physician migration still lose intellectual capital and educational investment. Moreover, the dynamics of physicians' migration in middle income countries apparently differ from those in low income countries as migration has been shown to be positively related to better health systems and development in source countries. 6.

Lebanon provides an illustrative example of the flight of physicians from MICs. Lebanon has the highest emigration factor in the Middle East and North Africa and the 7th highest in the World 2; the emigration factor is an approximate percentage of medical school graduates from a source country working in one of four major recipient countries 2. In 2004, about 40% of those who had graduated from Lebanese medical schools over the prior 25 years were in the US 7. Lebanon ranked 2^nd after adjusting for country population size among the countries from where international physicians practicing in the US graduated 7 indicating a high migration density 8.

We were interested in further exploring the dynamics of physician migration from Lebanon, as a middle income country. As residency training abroad is a critical step in the migration of physicians 9, the objective of this study was to survey students of Lebanese medical schools about their intentions to train abroad and their post training plans.

Of 576 eligible students, 430 responded to the survey. We excluded 5 responses because they were missing data for the outcome variables of interest. The survey response rate was thus 73.8%.

In summary, 406 (96%) of 425 students of Lebanese medical schools in the pre-final and final years responding to our survey intended to travel abroad either for specialty training (330 (77.6%)) or subspecialty training (76 (17.9%)). The top 4 destination countries were the US (301(74.1%)), France (49 (12.1%)), the United Kingdom (31 (7.6%)) and Canada (17 (4.2%)). One hundred and two (25.1%) of those who intended to train abroad intended to return to Lebanon directly after finishing training abroad; 259 (63.8%) intended to return to Lebanon after working abroad temporarily for a varying number or years; and 43 (10.6%) intended to never return to Lebanon.

This study has a number of strengths. The study population is largely representative of students of Lebanese medical schools and the high response rate decreases the likelihood of response bias. Also, this is the first study describing the demographics of students of Lebanese medical schools, an important source country for international physicians in four key recipient countries. In addition, the validity of the study questionnaire is strengthened by its thorough development. Finally, we were not able to identify any other published study that assessed, among medical students planning to train abroad, the post training migration intentions.

In terms of limitations, although the study population is representative of students of all Lebanese medical schools, it does not include students of Lebanese medical schools graduating from foreign medical schools. It is however important, from the perspective of healthcare policy development, to also assess the intentions of this group. Assessing intentions and not actual behavior represents a limitation of this study. We were not able to identify any study assessing how good of a proxy the migration intention is for the migration behavior. However, even if we were to assume a less than strong association, the percentage of those intending to train abroad remains concerning in the context of the information about the actual migration of Lebanese physicians in the recent past 7. Another limitation of this analysis is that for some of the analyses of subgroups the confidence intervals were wide and leave us with some uncertainty about the magnitude of effect.

Recent studies from other countries have revealed high percentages of students intending to train abroad, but not as high as in our study. In a 2004 survey of 166 final year students of Indian medical schools, 59% thought of leaving India for further training abroad. The top two destinations were the US (42%) and the UK (43%). 11. In a recent survey of first-year house officers practicing in New Zealand, 65% of the 157 respondents intended to leave New Zealand within 3 years of graduating 12. In another New Zealand survey of final year medical students as well as to junior doctors in their first to fourth postgraduate year, 69% of respondents stated that they plan to work overseas 13. It is estimated that up to one half of graduates of South African medical schools emigrate 14. One study of Ugandan nursing students found that 70% of participants would like to work outside Uganda, and that within five years they would likely be working in the U.S. (59%) or the U.K. (49%) 15.

Our findings are consistent with those of the study by Arah et al. showing that source countries with better human resources for health, more economic and developmental progress, and better health status lose proportionately more physicians than the more disadvantaged countries 6. Indeed the World Bank classifies Lebanon as a high middle income country. The physician density in Lebanon (325 physician per 100,000) is the second highest in the Middle East and North Africa 16. In addition, and according to the 2006 World Health Report, Lebanon total expenditure on health was the highest in terms of percentage of the total gross domestic product (10.2%) and the second highest per capita (US $730) in the WHO Eastern Mediterranean Region (EMR) 17.

The extremely high percentage of students of Lebanese medical schools that intend to migrate for post graduate training is intriguing. A qualitative study exploring the factors affecting these students' intentions to train abroad found the chief motivation to be the need to gain a competitive advantage, through abroad training, in an oversaturated Lebanese job market 10. In fact, there is abundance of medical schools and an influx of graduates of foreign medical schools leading to the relatively high physician density as noted earlier 18. There is evidence to suggest that an oversaturation of the local physician job market, mainly by graduates of foreign medical schools, is contributing to the international migration of Lebanese medical graduates (unpublished data). Training capacity and quality were also major factors reported by respondents, 98.6% of whom intended to complete residency training. See Additional file 1: Characteristics of Lebanese medical school.

The findings of the multivariate analysis indicate that female sex was inversely associated with the intention to stay abroad temporarily or permanently. This is consistent with, although it does not completely explain, previous findings that only 17% of Lebanese medical graduates in the US are females 7, while 41% of students of Lebanese medical schools (at least in this study) are females. There is a need to explore the factors underlying these intentions and we believe that social and familial considerations are important factors. The associations of the attended medical school with the outcome variables indicate that, being a student of LU or USJ (both schools using French as a, or the, primary language of education) was associated with France being the destination countries. This illustrates the importance of the language of instruction on the destination country. Also, earlier language or cultural preference might affect both the choice of medical school and the destination country. The inverse association between the plan to train in a surgical specialty and the intention to travel abroad might be related to a perceived difficulty of obtaining surgical training spots abroad."

While some might argue that the migration of physicians from Lebanon is not a case of brain drain given the relatively high physician density (325 physician per 100,000 19), we believe that it is an alarming case of brain drain. First, this migration is associated with loss of intellectual capital and of educational investment with uncertain return. Second, there is indirect evidence that those who migrate might be the best among their peers 2021. This possible selection process could negatively affect the quality of health care services in Lebanon. Unfortunately, we were not able to identify studies of the impact of physician migration on the Lebanese healthcare system.

From the perspective of the US physician workforce, the impact is probably less dramatic given the relative size of the US workforce (902,053 physicians in 2006) 22. However, US policymakers should consider the implications of the global migration of health workers for the source countries, LICs in particular. Although these countries benefit financially through remittances, skills transfer, and possible investment upon migrants' return 23, they suffer from a loss of educational investment and intellectual capital, 4 and from worsening of the already depleted healthcare resources in these countries 24. A major consequence is the widening of the gap in health inequities worldwide 24.

The findings of this study are alarming in terms of the future migration of Lebanese physicians and have implications for both policy making and future research. Lebanese policy makers need to devise a comprehensive national health workforce plan using the proposed strategies and frameworks to deal with physician migration 2526. Such a plan should carefully address the oversaturation of the Lebanese job market and other factors contributing to the migration of physicians, such as residency training capacity and quality.

There is a need for research investigating the impact of migration on the effectiveness and efficiency of health care systems in both the source and receiving countries. There is also a need for further methodological work in the field of human resources for health 8. We plan to follow up this cohort of students to compare their current intentions with their future actual behavior in terms of country of residency training and most importantly in terms of migration status.

None

The authors declare that they have no competing interests.

EAA: conception and design, data collection, data analysis, data interpretation, article drafting, final approval of the article. NM: conception and design, data interpretation, critical revision and final approval of the article. SM: data collection, critical revision and final approval of the article. CA: data collection, critical revision and final approval of the article. AA: data collection, critical revision and final approval of the article. JC: data collection, critical revision and final approval of the article. MS: data collection, critical revision and final approval of the article. CKL: data interpretation, critical revision and final approval of the article. BJBG: data interpretation, data analysis, critical revision and final approval of the article. HJS: conception and design, data analysis, data interpretation, critical revision and final approval of the article.