Physician Migration and its Implications for Puerto Rico's health care system

项目概要/摘要 波多黎各（PR）正面临着700亿美元外债和最近的一场重大生存危机。 自然灾害导致卫生基础设施恶化。1，2，3，4这些事件加剧了 医生大规模迁移到美国大陆，据估计，公关将失去一半的已经 20我们建议从多层次的角度探索，如何 公共卫生保健系统使用一个概念模型来应对医生移民危机，该模型由以下内容组成： 移民理论，空间耻辱和医疗保健系统的弹性。我们提出以下目标： 目的1：记录推拉因素的作用，以及空间污名的潜在作用， 促进和/或减轻医生从PR移民到美国大陆， 他们当前和以前的工作环境和设置的特征。 目标2：记录从PR迁移到美国的医生的地理迁移模式 由于香港持续的经济危机和 最近的自然灾害。 目标3：确定医生迁移对PR医疗保健系统功能和弹性的影响 通过对受医生迁移影响的地点进行系统的人种学观察。 目标4：为地方/联邦政府制定科学的政策建议， 使用目标1-3的结果和医疗保健系统利益相关者的输入，在PR中进行医生迁移。 我们将实施多阶段混合方法设计。在第一阶段，我们将随机招募一名 医生样本（总N=560）在移民和非移民之间平均分配。他们将完成：a） 深入的定性访谈（n=50），以收集关于决定离开或 stay，B）认知访谈，用于调查细化（n=10），以及c）简短调查（n=500），用于收集信息 关于促进/减少移徙的推拉因素以及那些 离开（目标1和2）。这项调查将使我们能够分析这一现象的地理影响， Arc-GIS技术。在第二阶段，我们将进行机构民族志观察/绘图， PR中受医生迁移影响的设置（目标3）。我们将进行半结构化的定性访谈 理论驱动样本（总N=100）：卫生设施管理人员（n=20），卫生政策制定者 （n=20）、医疗保健专业人员（n=30）和患者（n=30），以了解医生迁移的影响 对医疗系统的恢复力和病人获得医疗服务的影响。在第三阶段，我们将制定政策， 建议减少医生移徙，开展参与性人种学讲习班， 卫生保健系统的利益攸关方，并实施有针对性的传播计划。结果将使我们能够 协助地方/联邦政府制定解决医生移徙问题的战略。

Project Summary/Abstract Puerto Rico (PR) is facing a major existential crisis fostered by a 70 billion dollar external debt and recent natural disasters that have fostered the deterioration of the health infrastructure.1,2,3,4 These events fuelled the mass migration of physicians to the US mainland, and it is estimated that PR will lose half of its already depleted physician workforce in the next decade.20 We propose to explore, from a multi-level perspective, how the PR health care system responds to this physician migration crisis using a conceptual model informed by theories of migration, spatial stigma, and health care system resilience. We propose the following aims: Aim 1: Document the role of push and pull factors, as well as the potential role of spatial stigma, on fostering and/or mitigating physician migration from PR to the mainland US by richly describing the characteristics of their current and previous work contexts and settings. Aim 2: Document the geographical migratory patterns of physicians who have moved from PR to the US mainland in the last decade (2009-2019) as a consequence of the territory's ongoing economic crisis and the recent natural disaster. Aim 3: Determine the impact of physician migration on PR's health care system functioning and resilience through systematic ethnographic observations of sites affected by physician migration. Aim 4: Develop science-based policy recommendations for the local/federal governments to mitigate physician migration in PR using findings from Aims 1-3 and input form stakeholders in the health care system. We will implement a multi-stage mixed methods design. During Stage 1, we will recruit a random sample of physicians (total N=560) equally divided between migrants and non-migrants. They will complete: a) in-depth qualitative interviews (n=50) to gather rich descriptions of the factors behind the decision to leave or stay, b) cognitive interviews for survey refinement (n=10), and c) a brief survey (n=500) to gather information about the push/pull factors that foster/mitigate migration and the geographical migration patterns of those who have left (Aims 1 & 2). The survey will allow us to analyze the geographical impact of this phenomenon using Arc-GIS technology. During Stage 2, we will carry out institutional ethnographic observation/mapping in settings impacted by physician migration in PR (Aim 3). We will carry out semi-structured qualitative interviews with a theoretically-driven sample (total N=100) of: health facility administrators (n=20), health policy makers (n=20), health care professionals (n=30), and patients (n=30) to understand the impact of physician migration on the health care system's resilience and patient's access to care. In Stage 3, we will develop policy recommendations to mitigate physician migration, conduct participatory ethnographic workshops with key stakeholders in the health care system, and implement a targeted dissemination plan. Results will allow us to assist the local/federal governments in developing strategies to address physician migration.