*Ferenc Horváth, András Terebessy, Vince Pongor, Pèter Balázs
Ethical norms of medical school students and the workforce migration
Department of Public Health, Faculty of Medicine, Semmelweis University, Budapest, Hungary
Head of Department: Károly Cseh, MD, PhD
Introduction. In the 21th century, cross-border migration of physicians has a deep impact on health services of central-eastern European nations in terms of human workforce management and public financing of care alike.
Aim. This study is concerning the medical school students’ views about working abroad based on their socioeconomic background and ethical values in the proto-professional period of training and education.
Material and methods. For exploring the future medical doctors’ views and fields of national intervention we performed a self--administered questionnaire based study among the 4th year medical school students (N = 1413) of the Semmelweis University Budapest with response rate of 86.1% in 2009-2012. Completing the usual socioeconomic and cultural background questions, we also endeavoured to clear the proto-professionally perceived ethical values of future medical doctors based on selected items of two internationally standard questionnaires.
Results. As a result, we confirmed that beyond financial interests cross-border migration is also influenced by ethical values and considerations.
Conclusions. Willingness of working abroad is influenced not only by the foreign country’s economic incentives but also by the students’ ethical norms as well. This shows clearly that the students are aware of their social responsibility after they graduate in the tuition free publicly funded higher education.
The international migration of medical workforce, pre-eminently that of physicians, is a worldwide significant phenomenon both for source and receiving countries. Generally the higher education system of low and middle income countries is mostly affected since medical doctors endeavour to seek employment just after graduation in the most developed countries leaving this way behind the financial burden of their training expenses. This problem is clearly indicated by studies of researchers of Nepal (1-3) and Ghana (4, 5) wile analysing the future plans of medical students graduated in these countries. Ethical attitudes of just graduated medical doctors were assessed by Indian researchers (6). In the European Union (EU) the typical migration route leads from central-eastern European region toward Northern and Western member countries. These source countries (except Romania and Bulgaria) joined the EU May 1, 2004 however relevant studies did not indicate any mass migration in the subsequent years (7, 8). The latest deadline (after joining of Bulgaria and Romania January 1, 2007) was May 1, 2012 the end of Germany’s and Austria’s derogatory protection that closed down the labour market of these countries for the new EU-members since 2004. As a result the EU’s internal labour market became totally open also in terms of medical workforce migration. The first Hungarian study about physicians’ migration was published 2003 thus after the fall of Communism in 1989 but prior to Hungary’s EU-joining (9). Recent Hungarian data suggest an increasing nevertheless no massive trend in the cross-border migration (10).
Our present study is concerning the actual situation of medical school students’ views about working abroad based on their socioeconomic background and ethical values in the proto-professional period of training and education.
Material and methods
We performed our data collection by self-administered questionnaires among the Semmelweis University’s fourth year medical students during the winter semesters between 2009 and 2012. By summarizing the yearly data (2009 = 321, 2010 = 272, 2011 = 311, 2012 = 313) we obtained a total of 1217 valid questionnaires. In 31 questions, 14 assessed demographic data (family, place of residence, prior education, and part-time jobs during the training). We measured separately the proportion of students educated in religiously affiliated secondary schools and the activities in religious communities without asking for a specific type of religion. Economic status of families was classified on a four-point scale (very good, acceptable, temporary difficulties, poverty). We measured also the students’ knowledge about the physicians’ actual wages and their future expectations. Mean and deviations from mean by 40 and 60% in negative and positive directions were indicated on a five score scale. The options for activities after graduation were: leaving the medical profession, to be employed abroad or in Hungary in private or public service or becoming self-employed. As informal payment is a widespread revenue source in Hungary, we asked also for participating in or rejecting this business (11). Additionally, we assessed the students’ opinion about the actual sum of informal payment in terms if it depends on the patient’s solvency or the doctor’s professional performance. Five of questions asked for evaluation of elements and features of medical professionalism. Following the recommendations of the American Board of Internal Medicine (ABIM) (12), the weight of characteristics was defined by the students’ own opinion and by their perceived social expectations. The Calman key values used in the United Kingdom were also assessed (13). Data were processed by IBM-SPSS v.22 program. For analytical reasons we used Pearson Chi-square probe at significance level p < 0.05.
Female students dominated the gender distribution (61.5%). Both parents of our students are alive (94.3%), the majority of them live in marriage (79.7%), 18.2% are divorced but cohabitation was not significant (2.1%). Physician is the mothers’ 15.4%, 11.0% are working as other health care professionals. 15.7% of fathers are physicians but only 1.2% are otherwise engaged in the health care. Students do not have any siblings in 12.9% (1 brother or sister = 53.7%, two = 21.9%, three = 5.9% and four or more = 5.7%). The majority of the sample grew up in Budapest (35.3%) and in other metropolitan cities (34.2%), the share of villages and towns was 14.6 and 13.2% respectively. According to 62.2% of students their family’s economic status is acceptable, 17.7% described it as very good, 17.7% said to have temporary financial hardships and 2.1% said they lived in poverty. 8.2% of students are working in part-time jobs earning money for their education, whereas 5.7% are employed outside of health services. 18.7% of students graduated in religiously affiliated secondary schools, 26.4% of students are attending regularly church services and 18.4% admitted to be non-believer.
Concerning the actual net wages of physicians, 18% of students estimated it at 40% of the actual mean value and only 0.6% set it higher than 120% of the mean. As to the expected wages, 72.6% defined it to 120-160% of the actual mean. 62.1% of the students would accept informal payment. The sum of informal payment for a single service depends in 77.1% on the wealth of the patient, in 10.7% on the doctor’s professionalism and on both in 12.2%. Immediately after graduation 2.8% will not enter the service and 34.6% will leave for working abroad.
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