Brain drain in Emergency Medicine in Lebanon, building locally and exporting globally

Abstract

Objective

Despite the growth of Emergency Medicine (EM) globally, shortages of EM-trained physicians persist in many countries, disproportionately affecting lower middle/low-income countries (LMIC/LIC). This study examines the career paths of graduates of an Emergency Medicine residency-training program established in Lebanon with the aim of building local capacity in EM.

Design and patients

This descriptive study utilizes secondary data sourced from an alumni database that includes nine cohorts of graduates from an Emergency Medicine residency program at the American University of Beirut Medical Center in Lebanon.

Measurements and main results

Within 12 years since the EM residency program establishment a total of 9 cohorts, including 44 physicians had completed their residency training in EM, with 40.9% being female and 95.5% Lebanese citizens. After graduation, almost half of our graduates (47.7%) enrolled in fellowship training programs and 40.9% joined the workforce. Fellowships in Trauma (19%) and Oncologic Emergencies (19%) were the most commonly pursued. Initial employment destinations predominantly included Lebanon, the United Arab Emirates and the Kingdom of Saudi Arabia, (61.1, 33.3 and 5.6% respectively). However, retention within the local market declined with time, with a median time spent in Lebanon of 1 year and a mean of 3.3 years of practice in Lebanon prior to emigration. Presently, graduates are mostly dispersed across the Gulf Cooperation Council region (38.6%), the USA (25%), and Lebanon (20.5%).

Conclusion

Building Emergency Medicine expertise to match the growing population needs for specialized acute care remains a challenge globally, especially in low-middle income and low-income countries. Our study highlights the challenge of retaining specialized medical graduates in LMIC. Understanding and addressing the root-causes of out-migration of highly specialized medical workforce is an essential component of addressing local workforce challenges that needs to be coupled with capacity building initiatives for meaningful impact.

Introduction

Emergency Medicine (EM) is one of the youngest specialties around the world, gaining official recognition in Europe and North America in the late 1960 after increased recognition of EM specialist’ role in reducing overall morbidity and mortality in acute care [1, 2]. Multiple forces were behind the rise of the specialty. As armed conflict, urbanization and mechanization increased trauma related injuries; the role of secondary prevention for injuries became more salient. Aging population with increased disease complexity coupled with the emergence of high-resource diagnostic and therapeutic interventions for cardiac, vascular and pulmonary diseases pushed more of acute care into the hospital setting and increased Emergency Department (ED) utilization globally [3, 4].These drivers highlighted the need for a unique set of expertise with the cognitive, technical and administrative skills needed to manage the diversity of acute conditions and ages that present to EDs. Sixty years after the establishment of the specialty, EM has blossomed across the globe with over 70 EM national organizations represented in the International Federation of Emergency Medicine [5]. The speciality, however, remains under-developed in many middle and low income countries [6].

To this day, EM workforce supply has not matched the demands of its communities. Many EDs continue to rely on non-EM physicians or residents/interns to cover workforce gaps [2, 8]. While the mismatch continues to be prevalent even in high-resource countries, where inadequate planning and underinvestment of health worker education have resulted in insufficient health workers to meet the escalating demands [7], it is particularly problematic in low and middle-income countries where no EM training programs exists or the specialty remains in its early phases of development [8]. It is in these settings that the need is often greatest because of poor access to primary services, delayed critical presentations and under-developed emergency medical services in general, including under-developed pre-hospital care systems [8]. The inequities in access to emergency health services around the world have led to multiple World Health Assembly resolutions aimed at closing the access gap to emergency medical expertise and systems globally [9].

Building local capacity and creating a pipeline for Emergency Physician specialists requires establishing local EM residency training programs. However, for lower middle and low-income countries, the obstacles are more daunting as resource constraints stand as high barriers to establishing and sustaining local residency training programs. In fact, only 43 countries have EM residency programs with many middle and low-income countries reporting only one training program in their country [2, 8]. Establishing a training program requires funding, expertise, sustainability and a job market that offers opportunities post-graduation. A systematic review of emergency medicine training programs established in low and middle-resource countries found that many of these program depended on partnerships with high-income countries especially during the start of phases [5]. While these variable partnerships and initiatives have succeeded in building EM residency programs in lower middle and low-income countries, what remains unclear is the impact of these programs on the local EM workforce and the retention of graduates in the local market.

Lebanon, initially classified as an upper-middle income country, was downgraded to a lower-middle income country (LMIC) by the World Bank in 2022 following the collapse of its banking sector and a 36.5% drop in GDP per capita [10]. EM was first recognized as speciality in Lebanon in 2005. The first academic Emergency Medicine department was subsequently established in 2007 at the main private academic medical center in Lebanon. In 2012, this department established the first Emergency Medicine training program in Lebanon. The aim of this study is to describe the career paths of graduates of the main EM residency training program in Lebanon twelve years post-establishment, shedding light on the broader issue of local retention of graduates from residency training programs in LMIC/LIC.

Design and setting

Design

This study is a descriptive study using secondary data from an alumni database of EM resident graduates of the American University of Beirut Medical Center (AUBMC) EM residency-training program to explore career paths of residents post-graduation including: initial appointment post-residency, initial country of employment, work setting of initial appointment, destination over time, current location and work setting, and years spent in Lebanon post-graduation. Institutional Review Board (IRB) approval was obtained under protocol number SBS-2024-0146. In accordance with IRB approval protocol, we received and analyzed aggregate de-identified data.

Setting

AUBMC is the largest academic medical center in Lebanon offering tertiary care to adult and pediatric patients. As part of the American University of Beirut, it is also the main training site for the AUB Faculty of Medicine medical school students and the medical center’s 20 residency-training programs. 70% of the faculty are American Board certified in their area of expertise. The ED at AUBMC is one of the busiest Emergency Departments in Lebanon, seeing an annual volume of 54,000 patients [11]. The ED is staffed by a mix of EM physicians and non-EM physicians with extensive experience in emergency care working within a limited set of privileges.

The EM Residency Program is one of the youngest residencies and was established in June 2012 as a four-year training program. All founding EM core faculty were US residency trained and American Board Certified in EM. By the fall of 2016, AUBMC achieved site accreditation from the Accreditation Council of Graduate Medical Education International (ACGME-I) and the EM training program became one of the first to achieve accreditation by the ACGME-I [12]. This was followed by Arab Board accreditation in the same year [13].

The EM residency curriculum includes a two-year cycle of core content, rotations in critical care units, research and quality [14]. Formal education support is provided through a four-hour weekly conference comprising core lectures, electrocardiogram (EKG) sessions, simulation sessions, and case-based discussions. Additionally, residents benefit from lectures delivered by EM faculty and guest speakers. Furthermore, residents are mandated to participate in research projects, where they learn to formulate research ideas and navigate through the literature review process, proposal write-up, IRB approval, data collection, analysis, and manuscript writing. During ED shifts, the attending physician supervise all resident clinical activities, including patient encounters and procedures. Residents rotate outside of the ED, primarily in critical care units (medical and surgical critical care unit, coronary care unit, and pediatric care unit) as well as the operating room (anesthesia, procedure sedation rotations, and obstetrics). Emergency residents also rotate in neurology, ophthalmology, otolaryngology, and radiology as part of their curriculum.

In 2018, the department of EM at AUBMC established two non-clinical fellowships: the administrative fellowship and the educational fellowship in EM [15]. The administrative fellowship aimed at developing fellows for executive healthcare roles by providing experiential post-graduate training in operations, finance, strategic planning, risk management, emergency preparedness, quality improvement and other areas of emergency medicine administration. The education fellowship was designed for graduates with strong interest in education and provided training in education methods, curricular development, education research skills, simulation, and administration.

Method of measurement

The Department of EM residency-training program keeps record of its graduates for alumni communication. This database is updated annually by the departmental education coordinator and includes gender, age at matriculation, medical school (name, sector and country), year of graduation, post residency training, title, current position, hospital name, country of employment and residence. The database includes the first cohort of residents who matriculated in 2012 when the program was established, up to the most recent graduating cohort in June 2024.

Statistical analysis

Graduate demographics were analyzed using descriptive statistics. Continuous variables were reported with means and standard deviations, while categorical variables were expressed as percentages. Graduate distribution per year (Lebanon vs. abroad) was analyzed. Pie charts depicted regional work settings and fellowship details. A Kaplan-Meier survival analysis estimated the duration graduates remained in Lebanon, considering emigration as events. Analyses were performed using Excel and SPSS.

Results

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Table 1 provides a summary of the demographics and educational characteristics of the EM graduates in our program. Since its inception, the Department of EM in Lebanon has graduated 44 individuals, with 40.9% being female. The majority of graduates (95.5%) were Lebanese citizens, 23.8% of whom hold dual citizenships. 90.9% received their medical education from Lebanese medical schools and 81.8% went to private institutions. The average age at matriculation was 26.9 years, with a standard deviation of 2.3 years.

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Table 2 describes the initial career path of EM graduates post residency. A substantial proportion of our alumni cohort, 40.9%, entered the EM workforce immediately post-graduation, while 59.1% pursued advanced education through fellowships (47.7%) or others, such as repeat residency or masters (11.4%). The predominant employment destinations immediately post-graduation was centered in Lebanon (61.1%), the UAE (33.3%) and Kingdom of Saudi Arabia (5.6%). Notably, half of graduates were engaged in academic centers, while the other half opted for practice in private hospitals.

This graph (Fig. 1) depicts the destinations of all graduates to date over time from their year of graduation. In the initial years, the majority of graduates chose to practice locally, initially reaching 100%. Two years after the program’s establishment, a significant proportion of graduates opted for opportunities abroad, resulting in only 55% of all graduates to date practicing in Lebanon. However, there was a noticeable shift between 2017 and 2019, during which 70% of our total graduates chose to practice within Lebanon. Since 2019, there has been a gradual decline, with approximately 20.4% of graduates currently practicing in Lebanon.

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Figure 2 illustrates the current geographic distribution and work setting of our graduates.

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Figure 3 presents the fellowship locations and specialty categories pursued by our graduates. The pursuit of advanced education among our graduates exhibits a diverse landscape, with a predominant inclination towards fellowships outside of Lebanon, constituting 90.5%. The most common destinations for were the USA (57.1%) and the UK (19.1%), followed by Canada, France and Japan, which together accounted for 14.3% of the graduates. Among the various fellowship specializations, Trauma and Oncological emergencies emerged as the most common, each accounting for 19% of the graduates, followed by specialties such as toxicology, ultrasound, pediatrics and Emergency Medical Services (EMS) Fig. 4.

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This Kaplan-Meier survival analysis (Fig. 4) estimates the duration graduates remained in Lebanon prior to emigration, considering emigration as events. The total number of subjects included in this graph is 44, with 26 (59%) leaving immediately after graduation. By the 6th year, 75% had left Lebanon. The median time spent in Lebanon is 1 year. The mean time spent in Lebanon is around 3.3 years prior to emigration. Censored data reflect individuals who remained in Lebanon during the study period and did not emigrate by its conclusion.

Discussion

This study represents the first descriptive exploration of career paths of EM graduates of a training program established in a Middle Eastern LMIC. A notable number of graduates were women, and most were Lebanese citizens. Following graduation, approximately some entered the EM workforce directly, while the majority pursued advanced sub-specialization. Initially, employment trends predominantly favored Lebanon with a shift towards emigration overtime, primarily to opportunities in the GCC region and the USA. Most common fellowship pursued were Trauma and Oncological emergencies.

Few studies have examined talent retention post-residency training in LMICs/LICs. The majority of studies looking at EM capacity building in LMIC/LIC have focused on building training programs through partnerships with HIC programs, while others focus on exploring push/pull factors for brain drain towards HIC [16]. This study is unique as it describes the career paths of graduates of a local capacity building program in a lower middle-income country with a fragile healthcare system and prone to instability [17]. While existing studies have identified challenges faced by EM specialist, they did not examine long-term retention trends of EM graduates within the country [18]. Other studies have highlighted barriers to retention using representative groups but lack analyses of retention rates or trends post-training [19]. In contrast, our methodology diverges by conducting a longitudinal analysis of our graduates’ career paths. Specifically, we monitored the professional paths of individuals up to eight years’ post-graduation from a residency-training program in Lebanon, allowing for a comprehensive description of the professional trajectories of our graduates and addressing a significant gap in the existing literature related to retention of expertise post-establishment of local capacity building programs.

Since its inception in 2012, the Department of EM in Lebanon has graduated 44 individuals, with 40.9% being women. The gender distribution is similar with USA data, where males make up 62.8% of the overall resident body [20]. In Lebanon, the gender gap at medical school training has closed with time, with women now comprising 47% of medical students [21]. Gender distribution across different specialties, however, remains variable with particularly low representation in surgical specialties [22]. In terms of age of trainees, our graduates were relatively young with an average age at matriculation in our study of 26.9 years, as compared to those in high-income countries where the mean age of graduates is in the early thirties in some programs [23, 24]. This could be explained by the more traditional path medical trainees in Lebanon follow, with few gap years between undergrad, medical school, and residency, unlike the North American system where gap years are more common [25].

Our data suggests that while some graduates entered the EM workforce immediately post-residency, the majority chose to pursue advanced education through fellowships. This contrasts with Emergency Medicine graduates in high-income countries, such as the USA, where only 13.4% of graduates over the course of ten years chose to pursue a fellowship [26]. In Lebanon, of those who enter the workforce directly, approximately half of the graduates chose academic settings. This too represents a relatively high proportion compared to graduates from high-income countries, where 63% are employed in community settings [27]. We hypothesize that the difference between Lebanon and the U.S. may stem from the limited job opportunities in Lebanon, which are predominantly academic and require specialized niches [28, 29], unlike the U.S., where numerous and well-paid community-based positions exist [27]. In Lebanon, most Emergency units in hospitals continue to be staffed by residents-in training or general practitioners, through reimbursement models that do not support competitive career paths for EM specialists, leaving a few academic medical centers as viable opportunities to support sustainable career growth [28, 30]. This may be the main driver for pursuit of fellowship training in preparation for careers in academic medicine and could also explain the higher rates of working in academic medical centers within our cohort than in high-income countries where community setting opportunities are competitive and in abundance [29, 31].

Among the various fellowship specializations, Trauma and Oncological Emergencies emerged as the predominant paths pursued by our graduates. This trend may be due to the more facilitated pathways available for International Medical Graduates (IMGs) in these fields as compared to other fellowship programs [32, 33]. In the US the most commonly pursued fellowship trainings are clinical ultrasound followed by EMS [26]. Furthermore, the majority of those who pursued fellowship training in our cohort did so through international programs, primarily in the US (57.14%) followed by the UK (19.1%), with only 9.5% completing fellowship training in Lebanon. This trend may be related to the limited availability of fellowship programs in our setting, which currently only offers three options: EM administration and EM Education, with a recent launch of a Pediatric Emergency Medicine fellowship-training program.

Initially, our ED saw nearly all of its Emergency Medicine graduates who chose to join the workforce immediately post-graduation, practicing locally. However, this number dropped to 55% after two years, despite a brief increase to 70% between 2017 and 2019, after which local retention took a precipitous drop to 20.4% by 2024. This could be explained by the rapidly deteriorating security and economic situation in Lebanon at the end of 2019, when the country saw a collapse of the banking system that was followed by civil unrest and political instability. Out-migration of the medical workforce was further accelerated in 2020 after the security concerns following the Beirut Port Blast that killed 220, injured 6500 and displaced 300 000 [34, 35]. The mean time spent in Lebanon is around 3.3 years prior to emigration. Our findings indicate that the most frequent locations of employment outside Lebanon were GCC countries, followed by the USA. Overall, our study reflects outmigration from lower middle income to high-income countries in 100% of graduates who decided to leave the country. This finding is consistent with other studies that have explored transitions from lower middle-income to high-income countries [5, 36]. Studies on physician workforce capacity in LMICs reveal that “push” factors like conflicts and “pull” factors like better opportunities in HICs drive emigration, particularly in emergency medicine, where recognition and remuneration are often lacking in LMIC and LICs [37].

Our study highlights a significant trend of graduates migrating from LMIC/LICs to high-income countries, a phenomenon known as brain drain. In fact, in the USA as well as the UK, migrant physicians account for 20–30% of the physician workforce [38, 39]. This presents a paradox where LMICs and LICs invest substantial resources into training healthcare professionals [40], only to see these skilled individuals move to regions offering better opportunities. Training in EM is particularly resource-intensive, involving many years of undergraduate education, medical school, followed by residency training, all of which require considerable financial investment [40]. Interestingly, 27.7% of the female graduates chose to remain in Lebanon as compared to 12% of the male graduates. This trend also aligns with observations in several lower middle and low-income countries, where females often constitute the majority of the remaining workforce during conflicts [41, 42]. While the factors driving the out-migration of men versus women remain unclear and require further exploration, understanding these dynamics could be crucial for workforce planning and addressing the reasons behind this gender disparity in out-migration. Furthermore, introducing new fellowship programs within the ED could substantially aid in retaining talent within Lebanon by offering local options for more specialized post-graduate training.

This descriptive study of the career paths of graduates of a local Emergency Medicine capacity-building program in a LMIC highlights the urgent need to couple such development plans with retention plans. Without a clear understanding of drivers of out-migration and, equally important, the reasons why some physicians choose to remain in the local practice context, capacity building programs alone will not be able to address the workforce needs of communities in LMIC/LIC. Exploring reasons physicians stay is an area that needs further research to inform policy-makers and workforce planning. Furthermore, to effectively address this critical issue, policymakers must focus on strategies that encourage graduates to remain in their country of origin, enabling them to contribute to and strengthen their local healthcare systems. Implementing policies that provide incentives, improve conditions, and create professional growth opportunities within lower middle and low-income countries is essential to mitigate brain drain and foster sustainable healthcare development. Additionally, understanding outmigration patterns can help simulate workforce needs, guiding recruitment policies to increase training numbers while factoring in expected attrition rates.

Limitation

While our study provides valuable insights, it is essential to recognize some limitations. The retrospective design inherently limits the completeness and accuracy of data available within our administrative database. Additionally, due to the descriptive nature of our study, we were unable to explore causality or investigate the specific reasons behind graduates’ decisions to leave or remain in the country. This also restricted our ability to evaluate strategies for talent retention. Our analysis focuses on the geographic distribution and tenure of EM graduates in Lebanon from a single academic center. Despite these limitations, our research includes the largest cohort of EM graduates in a lower middle-income country setting, offering a substantial foundation for future investigations.

Conclusion

Building EM expertise to match the growing population needs for specialized acute care remains a challenge globally, especially in LMIC/LIC countries. Our study highlights the challenge of retaining specialized medical graduates in LMIC where significant resources are invested in training locally only to be later exported globally. Understanding and addressing the root-causes of out-migration of highly specialized medical workforce is an essential component of addressing local workforce challenges that needs to be coupled with capacity building initiatives for meaningful impact.

Data availability

Data are available on reasonable request.

References

Razzak J, Usmani MF, Bhutta ZA. Global, regional and national burden of emergency medical diseases using specific emergency disease indicators: analysis of the 2015 global burden of disease study. BMJ Global Health. 2019;4(2):e000733.

Patiño AM, Chen J, DeVos EL, Lee JA, Anderson K, Banks M, et al. Emergency medicine around the world: analysis of the 2019 American College of emergency physicians international Ambassador country reports. J Am Coll Emerg Physicians Open. 2022;3(2):e12681.

Losonczy LI, Papali A, Kivlehan S, Hynes EJC, Calderon G, Laytin A et al. White paper on early critical care services in low resource settings. Annals Global Health. 2021;87(1).

Cydulka RK, Fitch MT, Joing SA, Wang VJ, Cline DM, Ma OJ. Tintinalli’s emergency medicine manual. McGraw-Hill Education; 2018.

Rybarczyk MM, Ludmer N, Broccoli MC, Kivlehan SM, Niescierenko M, Bisanzo M et al. Emergency medicine training programs in low-and middle-income countries: a systematic review. Annals Global Health. 2020;86(1).

Alagappan K, Holliman CJ. History of the development of international emergency medicine. Emerg Med Clin. 2005;23(1):1–10.

Serour GI. Healthcare workers and the brain drain. Int J Gynecol Obstet. 2009;106(2):175–8.

Nowacki AK, Landes M, Azazh A, Ritchie LMP. A review of published literature on emergency medicine training programs in low-and middle-income countries. Int J Emerg Med. 2013;6(1):1–10.

Integrated emergency. critical and operative care [Available from: https://www.who.int/teams/integrated-health-services/clinical-services-and-systems/emergency--critical-and-operative-care

Abdel Samad M. Understanding The 2019–2020 Banking and Financial Crisis in Lebanon. 2021.

Hitti E, Geha M, Hadid D, Bachir R. The disease spectrum of adult patients at a tertiary care center emergency department in Lebanon. PLoS ONE. 2019;14(5):e0216740.

ACGME-i accreditation. [Available from: https://www.aub.edu.lb/fm/gme/Pages/Accreditation.aspx

Cortas N. Innovations in creating incentives for academic achievement and growth: developing a compensation model at the Faculty of Medicine of the American University of Beirut (AUBFM) 1999–2009. Higher education in the Arab World: building a culture of Innovation and Entrepreneurship. Springer; 2020. pp. 279–326.

Emergency Medicine Residency Program. [Available from: https://www.aub.edu.lb/fm/gme/Pages/ResidencyProgram.aspx

Fellowship programs [Available from. https://www.aub.edu.lb/fm/gme/Pages/FellowshipProgram-.aspx

Darbyshire D, Brewster L, Isba R, Body R, Basit U, Goodwin D. Retention of doctors in emergency medicine: a scoping review of the academic literature. Emerg Med J. 2021;38(9):663–72.

Kronfol NM, Sibai AM, Rafeh N. The impact of civil disturbances on the migration of physicians: the case of Lebanon. Med Care. 1992;30(3):208–15.

Farahmand S, Karimialavijeh E, Vahedi HSM, Jahanshir A. Emergency medicine as a growing career in Iran: an internet-based survey. World J Emerg Med. 2016;7(3):196.

Kuipers M, Eapen A, Lockwood J, Berman S, Vaillancourt S, Maskalyk J, et al. Examining critical factors affecting graduate retention from an emergency training program in Addis Ababa, Ethiopia: a qualitative study of stakeholder perspectives. Can Med Educ J. 2017;8(2):e61.

Hayek S, Lane S, Fluck M, Hunsinger M, Blansfield J, Shabahang M. Ten year projections for US residency positions: will there be enough positions to accommodate the growing number of US medical school graduates? J Surg Educ. 2018;75(3):546–51.

Hitti E, Hadid D, Khoury SJ, Tamim H, Makki M, Karam CM. Domestic tethers: gender differences in career paths and domestic responsibilities of top-research medical school graduates. PLoS ONE. 2022;17(4):e0267288.

El Hage S, Wakim E, Sayde G, Akiki D, Salameh P. Assessment of gender gap in surgical specialties among Lebanese medical personnel: the need for involvement of women in surgery. East Mediterr Health J. 2022;28(10):743–50.

Nikolla DA, Zocchi MS, Pines JM, Kaji AH, Venkat A, Beeson MS, et al. Four-and three-year emergency medicine residency graduates perform similarly in their first year of practice compared to experienced physicians. Am J Emerg Med. 2023;69:100–7.

Hayden SR, Hayden M, Gamst A. What characteristics of applicants to emergency medicine residency programs predict future success as an emergency medicine resident? Acad Emerg Med. 2005;12(3):206–10.

Guidi C. Experiencing a gap year: perceptions from students in the United States. Northeastern University; 2018.

Gaeta TJ, Ankel FK, Calderon Y, Holden L, Knapp BJ, Marshall JP, et al. American Board of Emergency Medicine Report on Residency and Fellowship Training Information (2023–2024). Ann Emerg Med. 2024;84(1):65–81.

Singhapricha T, Minkhorst O, Moran T, Swanson J, Shayne P. Predictors of an initial academic position in emergency medicine. Western J Emerg Med. 2019;20(1):127.

Akl EA, Maroun N, Major S, Afif C, Chahoud B, Choucair J, et al. Why are you draining your brain? Factors underlying decisions of graduating Lebanese medical students to migrate. Soc Sci Med. 2007;64(6):1278–84.

Jordan J, Hwang M, Kaji AH, Coates WC. Scholarly tracks in emergency medicine residency programs are associated with increased choice of academic career. Western J Emerg Med. 2018;19(3):593.

Akl EA, El-Asmar K, Maroun N, Adib SM, Khater-Menassa B. Did the post war repatriation of Lebanese physicians drive recent Lebanese medical graduates to emigrate? An observational study. BMC Health Serv Res. 2008;8:1–9.

Lubavin BV, Langdorf MI, Blasko BJ. The effect of emergency medicine residency format on pursuit of fellowship training and an academic career. Acad Emerg Med. 2004;11(9):938–43.

Quinn P, Walton B, Lockey D. An observational study evaluating the demand of major trauma on different surgical specialities in a UK Major Trauma Centre. Eur J Trauma Emerg Surg. 2020;46:1137–42.

Purcell MG, El Majzoub I. The oncologic Emergency Medicine Fellowship. Emerg Med Clin North Am. 2018;36(3):637–43.

El Zahran T, Geha M, Sakr F, Bachir R, El Sayed M. The Beirut Port Blast: spectrum of injuries and clinical outcomes at a large tertiary care center in Beirut, Lebanon. Eur J Trauma Emerg Surg. 2022;48(6):4919–26.

Cheaito MA, Al-Hajj S. A brief report on the Beirut port explosion. Mediterranean J Emerg Med Acute Care. 2020;1(4).

Lin TK, Werner K, Kak M, Herbst CH. Health-care worker retention in post-conflict settings: a systematic literature review. Health Policy Plann. 2023;38(1):109–21.

Naal H, El Koussa M, El Hamouch M, Hneiny L, Saleh S. A systematic review of global health capacity building initiatives in low-to middle-income countries in the Middle East and North Africa region. Globalization Health. 2020;16:1–16.

Aluttis C, Bishaw T, Frank MW. The workforce for health in a globalized context–global shortages and international migration. Global Health Action. 2014;7(1):23611.

Chen PG-c, Nunez-Smith M, Berg D, Gozu A, Rulisa S, Curry LA. International medical graduates in the USA: a qualitative study on perceptions of physician migration. BMJ open. 2011;1(2):e000138.

Mills EJ, Kanters S, Hagopian A, Bansback N, Nachega J, Alberton M et al. The financial cost of doctors emigrating from Sub-saharan Africa: human capital analysis. BMJ. 2011;343.

Witter S, Namakula J, Wurie H, Chirwa Y, So S, Vong S, et al. The gendered health workforce: mixed methods analysis from four fragile and post-conflict contexts. Health Policy Plann. 2017;32(suppl5):v52–62.

Habib RR, Halwani DA, Mikati D, Hneiny L. Sex and gender in research on healthcare workers in conflict settings: a scoping review. Int J Environ Res Public Health. 2020;17(12):4331.