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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 68-77

Brain drain in academic medicine: Dealing with personnel departures and loss of talent

1 Department of Surgery, St. Luke's University Health Network, Bethlehem, Pennsylvania, USA
2 Temple University School of Medicine - St. Luke's University Campus, Bethlehem, Pennsylvania, USA
3 Department of Surgery, Northeast Ohio Medical University, Akron City Hospital – Summa Health System, Akron, Ohio, USA
4 Department of Anesthesiology, University of Toledo, Toledo, Ohio, USA

Date of Submission07-Apr-2016
Date of Acceptance14-Apr-2016
Date of Web Publication2-Jun-2016

Correspondence Address:
Stanislaw P Stawicki
Department of Research and Innovation, St. Luke's University Health Network, EW2 Research Administration, 801 Ostrum Street, Bethlehem, Pennsylvania 18015
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2455-5568.183332

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The phenomenon of “brain drain,” (BD) or the unanticipated and significant loss of skilled people and the talent they represent via voluntary turnover, continues to be a significant problem across many academic medical centers. This BD is a result of a multifactorial interplay between personal, professional, institutional, peer-driven, and socioeconomic factors and affects mainly academic healthcare organizations characterized by a specific set of leadership, economic, and competitive preconditions. Institutional impact of BD, both financial and nonfinancial, can be profound and is often underappreciated. Financial considerations of BD include loss of clinical and non-clinical income, contraction of institutional expertise, severance and recruitment expenses, as well as costs of onboarding new faculty. This article focuses on how to identify risk factors for BD at both institutional and personnel levels. Proposed steps for prevention and early intervention are outlined.
The following core competencies are addressed in this article: Professionalism, Practice-based learning and improvement, Systems-based practice, Interpersonal skills, and Communication.

Keywords: Academic medicine, brain drain, faculty retention, institutional decline, leadership, talent management

How to cite this article:
Wernick B, Wojda TR, Wallner A, Yanagawa F, Firstenberg MS, Papadimos TJ, Stawicki SP. Brain drain in academic medicine: Dealing with personnel departures and loss of talent. Int J Acad Med 2016;2:68-77

How to cite this URL:
Wernick B, Wojda TR, Wallner A, Yanagawa F, Firstenberg MS, Papadimos TJ, Stawicki SP. Brain drain in academic medicine: Dealing with personnel departures and loss of talent. Int J Acad Med [serial online] 2016 [cited 2022 Nov 29];2:68-77. Available from: https://www.ijam-web.org/text.asp?2016/2/1/68/183332

  Introduction Top

It is not unusual to see high faculty turnover at major academic institutions.[1],[2] The concept of “brain drain” (BD) in healthcare, and especially in academic medicine, is well defined and its importance well established.[3],[4] Because the problem of BD is complex and multi-factorial, objective studies of this phenomenon are inherently difficult to conduct.[5],[6] Moreover, this topic did not reach the “top priority” list among academic medical leaders until relatively recently, when more quantitative approaches to measuring the social, academic, and economic impact of BD revealed the true cost and magnitude of the problem.[7],[8] As academic medical centers grew and evolved into increasingly “corporate-like” entities, workforce issues typical of large corporations became palpable among the traditionally independent and sheltered academic medical faculty.[8]

Although economic and talent migrations have traditionally been described to occur between geographic regions and countries, the type of BD discussed in this article is centered around loss of talented faculty from a specific organization, either via departure of a single faculty member or via larger scale faculty movements between institutions. It is important to recognize that although the more “local” or “micro” phenomenon affecting individuals and institution discussed in this manuscript has some socioeconomic similarities to the more “global” or “macro” phenomenon of BD affecting specific countries, political regimes, or geographic regions of the world, there are also important differences. Issues specific to the individual/institutional BD include faculty's desire for better compensation, promotion, recognition, power, control, and the ability to “externally circumvent” the presence of institutional “glass ceilings”. Another reason for faculty-leadership dissonance that may lead to BD includes the lack of support for personal and/or professional faculty development, particularly for ideas/goals that may not necessarily be consistent with leadership focus or agendas. This manuscript will concentrate on how to identify risk factors for BD at both institutional and personnel levels. The authors will also outline potential steps for prevention and early intervention in cases of probable/suspected BD.

  What Is “brain Drain”? Top

One can broadly define BD as a form of voluntary intellectual migration observed across a variety of institutional, socioeconomic, or geographic settings.[9],[10],[11] It is important to recognize that the term BD is a heterogeneous “catch-all” entity, encompassing numerous socioeconomic, environmental, institutional, political, and individual factors.[12],[13],[14] While this paper focuses on BD among academic medical centers, the concept of BD was originally described at the level of the nation-state. For some, BD may represent flight from wars and persecution.[12],[15] For example, before and during World War II, there was a great exodus of Jewish scientists from Nazi-occupied Europe to the United States and Great Britain.[16] Later in the 20th century, there was a mass migration of healthcare professionals from low-income countries to the developed world, with motivational drivers including the desire for personal and economic freedom, better compensation and quality of life, as well as a number of other socioeconomic factors.[12],[15] Even now in the 21st century, the mass migration from the Middle East to the West has hurt economies and the intellectual underpinnings of many countries.[17] In addition, the recent economic woes of Greece have been compounded by the emigration of over 1% of its population who has almost entirely consisted of teachers, engineers, scientists, and physicians.[18],[19]

Regardless of the underlying cause(s), BD results in severe reallocation of human capital and heavily favors departing individuals and their new destinations.[20],[21] The direction of BD and its magnitude is determined by a dynamic interplay of various “push–pull” forces.[22] Among powerful, “pull” forces are better working conditions and desire for a better lifestyle, educational opportunities, targeted recruitment, as well as various other economic and psychosocial factors. At the same time, poor working conditions, low compensation, few or absent incentives, lack of recognition, lack of (research) funding, limited career advancement options, and threats of violence all “push” talented health care professionals to migrate.[22]

The phenomenon of BD in the context of the current manuscript represents mainly an interplay between institutional factors and individual faculty choices, where the latter often occur as expressions of self-determination and self-development, with multitude of other potential variables that dynamically interact during the process.[23],[24] Among variables that direct individual behavior, the desire to change work environment or lifestyle may play a role as seen frequently in the so-called rural BD where individuals leave comfortable life in the countryside and relocate to larger towns or cities.[25],[26] At yet another level, BD in healthcare can be described as the internal (e.g., within-country) loss of talent to other professional fields due to disappointment, dissatisfaction, perceived loss of decisional control, and lack of advancement opportunities within medicine.[27],[28] This phenomenon was very prominently seen in the former Eastern Bloc countries after the fall of the Iron Curtain. The problem of medical BD has been identified as a global priority that requires coordinated action by key stakeholders because of its effects on local/regional populations and socioeconomic stability. Important parties in the overall discourse include healthcare institutions, governments and global public health organizations.[12],[15],[29],[30]

  Academic Institutions and “brain Drain:” a Balancing Act Top

Despite significant negative effects of BD, some have argued that a certain degree of BD within a closed system (e.g., within a region or a country) actually helps disseminate knowledge and skills across institutions and thus may actually contribute to the advancement of science and education.[31] This, in fact, may be the reason why majority of academic medical institutions do not actively “resist” faculty departures but rather accept this reality and then recruit new faculty, perhaps with better individual-institution “skill set fit”, to newly vacant position(s). This more “healthy” form of BD must be differentiated from a more “pathologic” form where multiple members of faculty depart the institution simultaneously. The latter situation tends to be a symptom of a mismanaged, declining organization.[32]

In the setting of an organization in distress, the phenomenon of “institutional BD” becomes evident when some of the top performers begin to leave the organization. The process is initially subtle, with no palpable changes felt within the organizational or departmental matrix. Some authors have pointed out that multiple job opportunities are almost always available for high performers and that other institutions may be willing to reward “top talent” more handsomely than the current institution.[33] Over time, the level of talent occupying various leadership positions at a declining organization also tends to deteriorate, contributing to further acceleration of the institutional decline.[32] As the process gains momentum, more high-performing individuals depart en masse when an organization begins to face financial problems and is unable provide existing employees with new opportunities for career development. This is usually accompanied by declining morale, slowing or negative business growth, and internal (managerial/structural) conflicts.[34] Again and again, across various disciplines of medicine and surgery, it has been noted that the most marketable, high-value employees will seek better external opportunities when their organization is faced with significant challenges, leadership failure, uncertainty, or decline.[32],[35]

After identifying that BD may be taking place, and facing significant faculty attrition, institutional leadership must act swiftly to stabilize the workforce, incentivize and invest in talent, and then reverse the BD over time (e.g., institutional rebuilding phase usually takes much longer than the decline phase). In this game of brinksmanship, impeccable ethics and top-notch leadership are required for success.[36] Failed attempts at organizational stabilization may result in irreversible changes, up to and including the demise of an institution and/or its department(s).[37],[38] Among factors involved in the ultimate success or failure of an institution are decisions made by individual members, the cumulative influence of other employees, the collective momentum of the group, and finally key leadership decisions. In certain failure modes, the phenomenon known as “bandwagoning” emerges manifesting by both leaders and “activists” defecting in large groups to more rewarding environment(s) or institution(s).[39] As more people leave an institution, the tendency toward “bandwagoning” may intensify, sometimes leading to further acceleration of the BD.

  Why Does Talent Leave Academia? Top

In the absence of institutional and professional stressors, it has been shown that turnover tends to be lower among good performers.[40] However, no guarantees exist when it comes to top talent. High-performing academic faculty may choose to leave their institutions for a variety reasons, including a combination of the following: (a) Workload imbalance, (b) poor employee retention strategies, (c) lack of career advancement opportunities within the organization (e.g., “glass ceilings”), (d) loss of trust between the faculty and leadership, (e) lack of recognition, and (f) insufficient communication of expectations and/or goals.[41],[42],[43] At times, real or perceived threats by new leadership, especially in the setting of building new teams and alliances, may prompt talented individuals to venture outside of the organization. This may be especially relevant in situ ations where there are concerns regarding conflicting agendas, both at personal and professional levels.

Although poor performance is usually not an issue among the “highest performers,” faculty who feel underappreciated may channel their energies “out of sync” with institutional priorities or create a negative working environment for others.[44],[45] Less commonly, such individuals can be disruptive, usually as a response to the forces outlined in the previous paragraph.[46] In cases of workload imbalance or talent underutilization, top performers will seek positions at other institutions where they may be better compensated and feel more challenged (and appreciated). It has been noted that retention practices employed by human resource professionals tend to stress “career opportunities” and “financial rewards” while employee needs may extend beyond the above considerations including factors such as “social atmosphere,” “job content,” and “work-life balance.”[47] It is not uncommon for new leadership to bring in new “trusted” teams. This, in turn, may create the impression among high-performing faculty that they are being neglected or ignored. Along the same lines, leadership transitions may create the perception of the new leader “cleaning house” for a new vision or direction. Whether intentional or unintentional, such a perception may become a significant destabilizing force, especially if new expectations (e.g., new institutional goals and directions) are not clearly communicated or appropriate reassurances not provided.

Although the above-mentioned factors may provide some rationale for why a single or several top performers may choose to leave an organization from time to time, the BD is usually a more pronounced phenomenon and a result of multiple forces coming together.[48],[49],[50] Because of its complexity, only limited understanding of BD is possible by studying actions and decisions of individual faculty members. Studies indicate that employees gauge the stability of their workplace through observing the behavior of others in similar positions, at comparable organizations, and under specific situational conditions.[51],[52] Among “top performers” within any organization, there often exist social networks where information regarding individual success or standing within the organization may be discussed.[53],[54],[55] When members of these social networks are faced with institutional decline, whether perceived or real, they may decide to leave either individually or as a group (e.g., “bandwagon effect” outlined in the previous section).[56],[57],[58]

An important set of influences to consider in this context are institutional “push” and “pull” factors regarding relative attractiveness of the workplace to its employees [Figure 1].[59] Different “push factors” compel employees to abandon their jobs. These include substandard working conditions, lack of educational and advancement opportunities, absent or insufficient recognition, discrimination in wages and promotions, inability to breach the institutional “glass ceiling,” and lack of professional freedom and/or autonomy.[22],[60],[61],[62],[63] The presence of said “push factors” may lead individuals or groups to leave their current organization in hopes of better conditions, or finding an organization with certain “pull factors,” which represent attributes that attract and retain talented individuals – adequate financial compensation, organizational transparency, better working conditions, organizational stability, and opportunity for advancement.[62],[64],[65],[66] Although faculty turnover may be highest among assistant professors,[67] some degree of “postpromotion” migration can be present as well.[68] The presence of faculty development programs and the institution's ability to provide effective mentorship are important factors in the overall faculty “loss-retention equation.”[68] Finally, as outlined elsewhere in this manuscript, faculty perceptions of both institutional and leadership factors are powerful determinants of job satisfaction and retention.[69] Unfortunately, many executives and managers continue unabated in their failure to effectively develop and retain employees, preferring instead to look for talent elsewhere.[63] Such status quo is unacceptable.
Figure 1: Simplified diagram showing different institutional “pull” and “push” factors associated with employee satisfaction-dissatisfaction spectrum. Persistent employee dissatisfaction may lead to the emergence of “brain drain”

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  Brain Drain and Organizational Decline: How and Why Do They Coincide? Top

Workplace is the “home away from home” for academic faculty, many of whom spend more time at work than at home. Employees may lose motivation when their organization declines, becomes less competitive, and the emphasis on competencies diminishes in parallel with the severity of organizational crisis.[70],[71] Talented, top performing employees are critical to the well-being of any successful organization, whether it be retail, fabrication, government, healthcare, or academic institutions.[72],[73] Feedback loops exist within organizations, with both positive and negative implications depending on the general direction of the organization (e.g., growth versus decline).[74],[75] The loss of top talent – commonly seen as part of the phenomenon of organizational BD – is associated with a negative feedback loop, leading to increasing attrition of highly skilled and competent employees from an institution, resulting in a downward spiral of “institutional decline”.[49],[76] Rosenblatt and Sheaffer [32] list a number of proposed risk factors that make organizations particularly prone to BD. These factors can be broadly divided into three categories: individual, organizational, and environmental. It should be stressed that factors from the three domains can dynamically interact, in various proportions, to result in BD and unanticipated (and voluntary) employee turnover [Figure 2].[11],[77]
Figure 2: Interaction between organizational, individual, and environmental factors that may lead to institutional “brain drain”

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Highly skilled employees are instrumental to the optimal performance of an organization.[78],[79] Specific skillsets can encompass any combination of business-specific, industry-specific, or general skills.[80],[81],[82],[83],[84] Employees with industry-specific or general skills – such as leadership or entrepreneurial abilities – tend to be more sought after in the labor market.[81],[82],[85],[86] As a result, they are the individuals who tend to leave organizations first, usually in search of an environment where their skills are more valued, put to better use, and competitively compensated.[87],[88] The exodus of skilled workers tends to accelerate as increasing numbers of employees with valuable skills abandon the declining organization when they sense that their career ambitions (e.g., advancement and compensation) may be curtailed or threatened.[88],[89] This is generally consistent with an old adage, “get out while the getting's good”. Furthermore, ensuring that employee awareness of the value of their skills to the organization is recognized by the institution, plays a very important role in preventing BD.[90] In one example, employees who participated in tuition-reimbursement programs and were subsequently promoted were much less likely to leave than those who were not promoted in similar circumstances.[89] Workers who have excellent entrepreneurial skills also tend to have a low threshold for leaving declining organizations, usually following institutional restructuring or cutbacks that affect resources available for innovative or experimental projects. Finally, relatively new employees and those with a higher educational level may be more prone to leave a declining organization.[91]

Internal factors within the organization can also lead to BD, including the curtailment of internal career opportunities, unbalanced workload, and undifferentiated retention incentives.[32] Declining organizations often respond to crises by cutting costs. As such, they tend to remove positions not deemed “critical” to their core business, particularly within the ranks of middle management.[92],[93] Thus, talented individuals may find themselves “disposable” due to factors they cannot control, and as a result, highly skilled employees previously aspiring to move up in the organization now seek opportunities elsewhere.[93] Another consequence of organizational decline relates to worker layoffs and translates directly into increased workload for the remaining employees,[94] especially the so-called “front line” managers who often are left to deal with the post-layoff impact.[95] This may further exacerbate employee dissatisfaction, again prompting the most talented workers to seek more satisfying employment options.[94],[96],[97] Emotional intelligence training may offer partial solution to this challenging problem.[98] One of the strategies struggling companies use to downsize during periods of decline involves offering incentives for employees to leave voluntarily. However, when these incentives are offered to the entire workforce, the more competent, highly skilled employees may be among the first to take advantage of such opportunities.[99],[100],[101]

It is very important to note that “purely administrative” executives, especially in health care, often fail to accurately measure and appreciate the true organizational and financial impact of high turnover.[102],[103] Moreover, it has been proposed that as institutions begin to face increasing number of challenges, the executives may become “stretched beyond their limits” or “decisional abilities” to control a number of important variables, thus leading to “benign neglect” of further signs, symptoms, and manifestations of BD.[67],[104] In terms of the “real impact” of BD, it has been estimated that average annual cost of faculty turnover may exceed $400,000 for a fairly typical academic medical or surgical department.[67]

Environmental and socioeconomic factors, in particular opportunities in the labor market, also contribute to BD in declining organizations. As discussed earlier in this manuscript, these “pull forces” make it tempting for talented employees to leave their current institution for more attractive employment opportunities.[62],[64],[65],[66] Within this framework, individual, organizational, and environmental factors act synergistically to produce BD as an end-result. For example, a young, highly educated, talented employee may be overworked due to recent layoffs at his or her company, and in a setting of a wide open labor market, would be naive not to seek opportunities elsewhere.[96] Whatever the cause(s), BD results in progressive decline of the organization and tends to disproportionately benefit the departing employees and their new employer or geographic location.[20],[21],[105]

  Brain Drain in Academic Medicine: Focus on Identification and Prevention Top

While the influx of medical professionals into the US is fairly well quantified and tracked, the same cannot be said about “internal” or inter-institutional and regional migrations of healthcare professionals.[12] One could speculate that BD in the medical field is driven largely by a combination of the same “pull–push” factors outlined in the previous sections of this manuscript. In-depth understanding the effects of BD first requires reliable and objective methods of analyzing it. This information can then be employed to develop and validate predictive models that would allow health care leaders identify and predict factors that increase the risk of institutional and/or individual BD.[106],[107],[108],[109],[110] Optimally, such information would become available without processing delays, perhaps in a form of a BD “dashboard”.

One critical factor to consider, especially in the context of the US healthcare market, is the hugely deleterious effect of noncompete agreements on regional BD.[111] For example, a highly trained individual who agrees to a “noncompete clause” in their contract will be effectively barred from seeking employment with a competing institution in the same geographic region, despite of the profound consequences such restriction may have on the local availability of specialty services. For that reason, California and a number of other states do not allow courts to enforce noncompete agreements, certainly with positive effects to their local economies.[112] It is also important to point out that the American Medical Association discourages the use of restrictive covenants as they inherently “…restrict competition, can disrupt continuity of care, and may limit access to care.”[113]

Although each case of institutional BD tends to be fairly individualized and there is significant heterogeneity, it is important to remember that academic faculty departures should be reported to top institutional leaders early and that system-wide reviews at the affected institution are performed proactively. For example, leader-subordinate discordances can be addressed and may help modify final decisions. Further, especially in cases of large number of faculty threatening to leave or leaving simultaneously, institutional leadership must determine whether the issue rests with a specific manager or department director. If that is the case, it is a lot less costly in the long run to replace the leader/manager than to recruit talent for multitude of vacant positions. In general, damage done by leaders who are incompetent, inflexible, or not collaborative, if stopped early, can be hard to perceive. However, if an incompetent or ineffective decision maker is not “stopped” promptly, a “contained situation” may turn into a generation-long crisis and damage may take decades to fully recover from.[114],[115]

Active involvement of academic institutional leadership is required to “stop the bleeding.” We recommend that predefined thresholds should be established for mandatory department/division chief reviews in cases of faculty complaints, threats of departure, or actual departures. For example, if more than two faculty members depart the institution from a particular department or a division within a short period, and the above departures are not due to “performance” issues, then the leader of said group should be scrutinized as a potential source of employee dissatisfaction. Prompt intervention and/or remediation should be pursued.

At the same time, complex organizations must keep track of multiple high-value employees, paying close attention to each top performer's “career trajectories,” with prompt identification of any potential “intersects” or “conflict paths”.[116] Again, proactive approaches will be much more effective than a delayed reaction to an employee who becomes frustrated and loses faith in the organization. It is important to remember that leader-employee interactions are characterized by a combination of objective and subjective (e.g., perceived) factors.[117] Consequently, any misperception may result in disequilibrium and dyssynchrony within the working team and/or the organization.[117],[118],[119]

  Organizational Outcomes of Brain Drain Top

The impact and ultimate outcomes of BD at the national and regional level may inform the impact on academic institutions. In Africa, which has been subject to perhaps the worst-case BD scenario, many countries report 0.2 or fewer doctors per 1000 population compared to 24 per 1000 in the United States.[120] The financial implications are massive. Monetary deficits add up to 2.17 Billion dollars for Sub-Saharan Africa alone.[121] For example, it has been estimated that for every doctor and nurse who leaves, Kenya loses $517,931 and $338,868, respectively.[122] Of interest, these statistics are very similar to the cost of academic faculty replacement in the US (e.g., approximately $400,000).[67]

BD may prove harmful to the long-term functional capacity of an organization. Secondary losses to the institution include significant financial damages, lost opportunity, and the more difficult to measure loss of reputation. Some of the underappreciated costs of BD include money allocated to new staff recruitment and training, stabilization of remaining workforce, as well as reassuring and supporting personnel after the departure of their colleagues (e.g., reversing the potential tendencies toward “bandwagoning” and further staff departures).[104] These costs often go unnoticed until the organizational bottom line becomes affected.[104],[123] As discussed earlier in this review, BD may initiate an institutional “downward spiral”. When a company is actively declining, a multitude of simultaneous processes occur that may lead to additional employee departures, again beginning with the top performers.[124],[125] Furthermore, workers in departing employee's social network usually take notice, which again can lead to further departures and may make recruitment of new employees more challenging.[126],[127] Often, organizations must aggressively innovate to stop the BD. However, cutbacks and loss of talent make this difficult, further fueling the negative feedback loop. After top employees exit, the second tier workers pick up the slack, which may cause further stress and instigate mass employee departures. Effective employee retention policies, and development programs are key to stopping, and subsequently reversing, the BD.[124],[125] Additional consideration needs to be given to generational factors and corresponding employee characteristics.[128]

The link between the access to health care and health outcomes is relatively well understood.[129] Implementation of health interventions is difficult without skilled workers.[130] The remaining staff is over-extended, which compounds logistical and decisional mistakes, and may increase medical errors in the setting of suboptimal staffing.[131],[132] Scarcity of workers may weaken the organization's ability to attract external resources, leading to further deterioration of the institution.[12],[133]

One of the most important aspects of BD is that when left unchecked, the phenomenon leads to deep distrust between organizational leadership and employees. Thus, processes designed to facilitate institutional “healing” are central to restoring the mutual trust between key institutional stakeholders.[134] In times of BD crises, leaders must stop reacting and need to become proactive in their approaches to limit the extent of organizational damage.[134] In some cases, the situation may be reversible and the leader may turn out to be an effective one, given a new equilibrium state and targeted leadership development strategies.[135],[136] In other situations, the so-called “substitutes for leadership” can be implemented, where decentralized team-based governance may help “re-assemble” a better functioning organization out of the viable remaining subcomponents.[137],[138] A comprehensive understanding of various mechanisms that force people to “abandon ship” is imperative to combat an organizational decline.

  Conclusions Top

BD in academic medicine continues to be a major problem. Economic conditions, employee recognition, opportunity for promotion (e.g., ability to transcend “glass ceilings”), and the desire to retain some degree of independence and decision-making power, are among key drivers causing academic physicians to leave their jobs in search of greater career fulfillment. One must keep in mind that the problem is extremely complex, with many unexplored facets. Multiple individual, cultural, and institutional factors combine to influence each case's outcome. Faculty may be less likely to look for external advancement if they achieve greater level of social integration with their local community. Family, previous institutional affiliations, and other local factors also play an important role. Finally, as eloquently stated by Kao and Gao,[139] “Brain goes where brains are, brain goes where money is, brain goes where humanity and justice prevail, brain goes where recognition and healthy competition is assured.”

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