Two-thirds of Iceland’s specialist doctors had considered moving abroad and 51% had considered moving and were able to do so. Experiencing extensive cost-containment initiatives, being stressed about personal finances, experiencing job dissatisfaction, having worked abroad during vacations, and being young all had significant effects on doctors’ desires to emigrate, even when controlling for job position. These factors were equally important for both male and female doctors; there were no significant gender interactions.
The migration of specialist doctors has never been an issue in Iceland. When young doctors return home after completing their specialist training in other countries, they usually stay. The high proportion of specialists who considered migrating in our study is therefore unusual and surprising. Some authors have reported that intentions data are only imperfectly correlated with future behaviour [22, 23]. On the other hand, studies have confirmed that migration intentions are indeed predictable of subsequent move [24, 25].
Moreover, there is evidence that these considerations were acted upon: unpublished data from the Icelandic Medical Association shows that between 2005 to 2012, there was a significant increase in the emigration of Icelandic doctors. Mullans’ emigration factor was 23 in 2005 (318 emigrants and 1060 doctors working in Iceland) and 39 in 2012 (661 emigrants and 1049 doctors working in Iceland), (p < 0.0001) . This also reflects the concerns in the Icelandic society that young specialists with postgraduate experience from abroad are not returning to Iceland [27, 28]. Since May 2009, the Icelandic Medical Association has kept data on doctors moving to and from Iceland. These are the most accurate data available, since 96% of the Icelandic doctors are registered there. Between May 2009 and February 2013 244 doctors moved from Iceland and only 91 doctors moved back. In a two-year period from May 2009 to April 2011, there were only 30 doctors who returned to Iceland, whereas in the following 22 months 61 doctors returned (personal communication, manager Sólveig Jóhannsdóttir, Icelandic medical association). Actually, this suggests an increase in the number of doctors returning after specialization. Unfortunately, we could not include the doctors abroad in our study. A study of their opinions and intentions to migrate back to Iceland is needed.
We found that specialist doctors who had experienced cost-containment initiatives at work were more likely to consider moving abroad. Seventy-five per cent of the doctors in our study agreed or strongly agreed with the notion that cost-containment initiatives had interfered with their work (see Table 2). As mentioned previously, health expenditure in Iceland decreased following the economic crisis and doctors have had to deal with limits on the affordable number of diagnostic tests, reduced numbers of doctors and nurses on call, etc. . With regard to migration, studies have shown that poor working conditions and a desire for greater access to enhanced technology, equipment, and health facilities can be important [29, 30]. To our knowledge, no studies have shown a connection between cost-containment initiatives at work and migration. This is probably because countries with high emigration rates tend to have stable but depressed economies. In Europe, over recent decades, there has been emigration from less wealthy and more turbulent regions to richer ones [31–35]. In Germany, however, the emigration of German doctors is increasing and this is related to doctors’ dissatisfaction with their salaries, among other things .
Costigliola’s recent review of the mobility of medical doctors in cross-border health care concluded that one of the most-cited factors for physicians’ mobility is financial motivation . This is consistent with our results: doctors who were more stressed about personal finances were more likely to have considered or decided to move abroad. In our study, however, such worries may be a reflection of the general economic recession in the country, which affects all groups in society. In the Nordic countries, which have democratic socio-political systems and relatively high levels of equity, medical professionals do not earn particularly high wages. As already mentioned, doctors’ salaries increased by only 3.7% between 2008 and 2009 , when the CPI increased by 27% . According to Voydanoff, economic stress refers to aspects of economic life that are potential stressors for employees and their families and consists of both objective and subjective components regarding employment and income . The three aspects of economic stress that have been researched thoroughly are unemployment, underemployment, and job insecurity . Although these aspects are not especially relevant to the doctors in our study, the subjective economic stressor (economic strain) is germane. Voydanoff describes economic strain as perceived financial adequacy, financial concerns and worries, and adjustment to change in financial status . Only 37% of the specialist doctors in our study were not worried about personal finances (see Table 2). Well-being and behavioural outcomes are more closely related to subjective economic stress than to objective stressors, and economic stress is known to negatively influence well-being . Our indicator of economic strain, namely doctors’ worries about their private finances, was a significant predictor of whether doctors wanted to migrate, controlling for job satisfaction. Evidence in several studies of an association between doctors’ and nurses’ incomes and their motivation to migrate validates our findings [30, 32, 39–41]. However, our findings are also unique in that they refer to a stable and previously wealthy European country.
Our results indicate that job dissatisfaction among Icelandic doctors may motivate them to emigrate. With the exception of study of Canadian family doctors , to our knowledge, the present study is the first to present evidence of a relationship between migration considerations and job satisfaction in an adjusted model, covering doctors of all specialities. Job satisfaction among Iceland’s doctors requires further study, because it is not only important in relation to migration but is also related to burnout , turnover [15, 43], and health-care service quality . We found no evidence that job position affected emigration considerations. This emphasizes the fact that such considerations are quite widespread and generalized in the medical profession.
The president of the Icelandic Medical Association, Þorbjörn Jónsson, reports that commuting has increased among doctors after the economic crisis . In our study, ten percent of the specialists had worked abroad during vacations. Because of Iceland’s small population, commuting might help doctors to maintain their skills and increase their experience. Nevertheless, according to our study, 90% of the specialists who had worked abroad during vacations had considered moving or were moving abroad and were five times more likely to have considered migration than those who had not worked abroad during vacations. The doctors get much higher pay abroad , which might partly explain these findings.
Even more worrying is the finding in our study that younger specialists are more likely to consider migration than their older colleagues, which confirms a finding among Canadian physicians [14, 45]. Because young doctors represent the potential future health-care services of a country, their perceptions about moving abroad have important implications for maintaining a high-quality health-care service in the years to come .
A review of physicians’ intentions to withdraw from practice by Williams concluded that the combination of job stress and dissatisfaction can be so powerful that some highly trained and committed professionals may quit while others cope by reducing their work hours, changing practice emphasis, or abandoning direct patient care . A shortage of physicians may impose excessive burdens on many, who then quit, and this may spark a downward spiral that exacerbates the initial shortage, which in turn might lead to even more stress and heavier workloads for the remaining doctors . When doctors migrate, they are likely to form networks overseas that may promote further emigration by colleagues with whom they keep in touch and to whom they might advertise migration opportunities and provide assistance. Evidence of the influence of social networks on migration by nurses is apparent in other studies . Our findings call for appropriate strategies on the part of relevant authorities, focusing on the doctors’ working conditions, such as their salaries and how cost containment influence their work.
Strengths and limitations
A major strength of this study is that, because of the size of Iceland’s population, we were able to invite almost all (96%) of the doctors in the country to participate in it; the response rate of 61% is relatively high for doctors. Although this represents only 55% of all specialists in the country, all specialities are well represented. A potential weakness of the study is that all measures are self-reported. Furthermore, because this is a cross-sectional study, we cannot make inferences about the causal effects of the statistically significant predictor variables.