Physician Migration Research Articles

A source and a destination country for migrant healthcare workers: the case of Ireland

Abstract Background Ireland has a long tradition of emigration, particularly to countries such as the United Kingdom and the USA. Since 2000, Ireland has become increasingly reliant upon migrant healthcare workers. At present, 43% of nurses and 45% of physicians registered in Ireland, trained internationally. Methods This study draws on literature and available data (migration and registration data) to illustrate recent patterns of healthcare worker migration into and out of Ireland. Results The data show that Ireland depends heavily on migrant healthcare workers to staff its health system. In 2021-22, internationally trained healthcare workers comprised 71% of new entrants to the medical register and 69% of new entrants to the nursing register. In terms of outward migration, the data also indicate a consistent pattern of outward migration of physicians to countries such as Australia, the United Kingdom, Canada, and New Zealand. Conclusions A heavy (and growing) reliance on migrant healthcare workers to staff the Irish health system implies a failure to train or retain sufficient healthcare workers locally and indicates weak healthcare workforce planning capacity. It also highlights a disconnect between Irish healthcare workforce planning and the WHO global code on the international recruitment of health personnel. This study will consider some of the risks associated with high rates of inward and outward healthcare worker migration in the Irish context.

Physician migration in Romania: a study on the emigration preferences within the Cluj County healthcare system

Introduction. Medical migration represents the movement of healthcare professionals from one country to another. The migration of Romanian doctors has evolved as a captivating and diverse phenomenon in the complex framework of global healthcare. As Romania struggles with its healthcare issues, many of its experienced medical personnel travel to foreign areas, lured by various factors ranging from economic concerns to the desire to gain clinical experience. The aim of this study is to elucidate the dynamics of this migratory phenomenon among physicians from Cluj County, Romania, between 2017 and 2022. Methods. This retrospective study was performed between 2017 to 2022, and it was based on data from Cluj County Romanian College of Physicians, which included 571 specialist and consultant physicians from Cluj County who permanently migrated to other countries. Results. Between 2017 and 2022, a total of 571 physicians permanently migrated from Cluj, Romania, to various other countries. Analysis of the gender distribution among these emigrants reveals a predominant female presence (58.1%) and a trend toward younger emigrating physicians, predominantly those under 30 years. In terms of professional specialties, Anesthesia and Intensive Care, as well as General Medicine/Family Medicine, are the most represented specialties, constituting 11% and 9.1% of the emigrating physicians, respectively. There was a declining trend from 2017 to 2021, followed by an upward trend in 2021. Conclusions. Medical migration significantly impacts Romania’s Cluj County healthcare, intensifying workforce shortages and possibly in the future compromising patient care. Failure to address this may perpetuate systemic vulnerabilities, hindering optimal healthcare provision and necessitating some reforms for resilience and sustainability.

Physician retention and migration in rural clinics designated for areas without physicians in Japan: descriptive epidemiological study using the national physicians’ survey

BackgroundIn Japan, local governments have rural clinics designated for areas without physicians (RCDA) to secure physicians for rural medical care. Moreover, a medical policy of dispatching physicians between the RCDA and core hospitals for rural areas (CHRA) exists. This study aimed to assess the actual situation of physician migration from RCDAs and those who migrated, and examine the factors associated with their migration.MethodsThis retrospective cohort study used biennial national physicians’ survey data from 2012 to 2018. It targeted physicians who worked at RCDAs in 2012 and participated in all four surveys (n = 510). The physicians were divided into two groups. One group consisted of physicians who worked continuously at the RCDA over the four study periods (retained physicians, n = 278), and the other included physicians who migrated to other institutions midway through the study period (migrated physicians, n = 232). We tracked the types of facilities where RCDA physicians worked from 2012 to 2018, also examined the factors associated with their migration.ResultsAmong physicians from RCDAs who migrated to other institutions (n = 151) between 2012 and 2014, many migrated to hospitals (n = 87/151, 57.6%), and some migrated to CHRA (n = 35/87, 40.2%). Physicians in their 40s (Hazard ratio 0.32 [95% CI 0.19–0.55]), 50s (0.20 [0.11–0.35]), and over 60 years (0.33 [0.20–0.56]) were more likely to remain at RCDAs. Changes in their area of practice (1.82 [1.34–2.45]) and an increase in the number of board certifications held by physicians between 2012 and 2018 (1.50 [1.09–2.06]) were associated with migration.ConclusionsMany migrating physicians choose to work at hospitals after migrating from RCDAs. It was seemed that the physician dispatch system between RCDA and CHRA has been a measure to secure physicians in rural areas. Young age, obtaining board certification, and changes in areas of practice were associated with physician migration from RCDAs.

Socio-Cultural and Professional Integration of Foreign-Born and Foreign-Educated Physicians in German Outpatient Care: an Interview-Based Study in Baden-Württemberg and Hessen

Introduction In recent years, it has become increasingly hard to fill outpatient physician vacancies in all parts of Germany. This development is particularly pronounced in general practice. At the same time, the number of doctors trained abroad is increasing, predominantly in the inpatient sector. In the next few years, foreign-born and -trained physicians will presumably be increasingly active also in the field of family medicine. The aim of this study was to explore experiences, support needs and possible improvements from the perspective of such physicians in the outpatient sector with a focus on primary care.Method In this qualitative study, semi-structured interviews were conducted with physicians not raised and trained in Germany and working in the outpatient setting in Germany. The evaluation was carried out by means of qualitative content analysis. Categories were derived in a deductive-inductive manner.Results Thirteen physicians (of which nine were primary care physicians) were interviewed. Next to the deductively derived main categories (departure, des-orientation, adaptation) four subcategories as overarching problems emerged in the interviews: Administrative tasks, communication and professional as well as social adaptation / integration in Germany. Proposed solutions were categorized in structuring measures (official, easily accessible guidelines for physician migration, paid qualification period), specific preparatory courses for the outpatient sector, and personal support such as mentoring and networking of outpatient physicians in training.Conclusions Some of the problem areas mentioned were similar to those known from the inpatient setting. To support sustainable recruitment in the outpatient sector, specific preparatory courses and the promotion of networking among physicians appeared to be additional measures that would benefit physicians applying for positions in the outpatient sector and also easy to implement.

Puerto Rican physician’s recommendations to mitigate medical migration from Puerto Rico to the mainland United States

Puerto Rico (PR) is a United States (US) territory with a history of colonial violence, poverty, and government corruption. Due to these sociopolitical factors and natural disasters (e.g., hurricanes and earthquakes), there has been a sharp increase in PR residents migrating to the mainland US. Local media and professional health organizations focus on the impact of medical migration on the PR health system (e.g., health personnel shortages and long waiting periods for critical care). According to the PR College of Physicians and Surgeons, 365–500 physicians have left annually since 2014, which represents a crisis of access to health services. However, few studies have focused on ways to mitigate medical migration from PR to the US mainland. This article describes the recommendations provided by migrating and non-migrating Puerto Rican Physicians (PRPs) to mitigate medical migration from PR to the US mainland. We focus on qualitative data from a mixed-methods NIH-funded study (1R01MD014188) to explore factors that motivate or mitigate migration among migrating (n = 26) and non-migrating (n = 24) PRPs. Interviews were analyzed following thematic analysis guidelines. Results show the following themes: 1) strategies to retain early-career medical residents living in PR; 2) recommendations for local government on future health policy; and 3) work environment initiatives for health institutions to mitigate physician migration. Findings suggest multilevel efforts are required to mitigate medical migration in PR.

"They think we wear loincloths": Spatial stigma, coloniality, and physician migration in Puerto Rico.

Puerto Rico (PR) is facing an unprecedented healthcare crisis due to accelerating migration of physicians to the mainland United States (US), leaving residents with diminishing healthcare and excessively long provider wait times. While scholars and journalists have identified economic factors driving physician migration, our study analyzes the effects of spatial stigma within the broader context of coloniality as unexamined dimensions of physician loss. Drawing on 50 semi-structured interviews with physicians throughout PR and the US, we identified how stigmatizing meanings are attached to PR, its people, and its biomedical system, often incorporating colonial notions of the island's presumed backwardness, lagging medical technology, and lack of cutting-edge career opportunities. We conclude that in addition to economically motivated policies, efforts to curb physician migration should also address globally circulating ideas about PR, acknowledge their roots in coloniality, and valorize local responses to the crisis that are in danger of being lost to history.

Migration intentions of nurses and nursing students from Slovakia: A study on drivers

Nurses are an essential resource in health systems. However, the shortage of skilled nursing workforce is a global phenomenon with negative consequences – many factors, including individual, occupational, and socio-political aspects, influence nurse migration. Thus, the aim is to explore the migration intentions of nurses and nursing students, forcing them to seek work abroad. An online survey was conducted among nurses and nursing students as part of the APVV and VEGA projects. The questionnaire focused on the essential characteristics of the respondents and staffing approaches in hospitals in Slovakia. Data were obtained from a survey of 752 hospital nurses and 423 university nursing students. The statistical analysis consisted of factor and correspondence analysis. The findings highlight the factors influencing the migratory sentiments of nursing students and working hospital nurses. They are organization of work, staff remuneration, employee benefits, workroom equipment, shortage of nurses, bureaucracy, communication and relations with colleagues, superiors, and patients, training and career development, material and spatial security, instrumentation, digitization of work, the prestige of the medical profession, and current situation in the Slovak Republic. The paper identifies and evaluates groups of push factors of migration intentions – satisfaction/dissatisfaction with hospital working conditions. The results of the factor analysis indicate that such factors as material and spatial security, communication and relations with colleagues, work organization, lack of personnel, bureaucracy, the prestige of the medical profession, and the current situation in Slovakia affect their working conditions and pleasure. AcknowledgmentThis study is elaborated within the framework of the projects APVV č. 19-0579 “Personnel management processes setup in hospitals and its impact on the migration of physicians and nurses to work abroad” and VEGA č. 1/0691/22 “Economic aspects of emigration of university graduates in health care departments in the context of the sustainability of staffing of health care facilities in the Slovak Republic.”

Миграционные намерения студентов медицинских вузов в Кыргызстане: Фактор риска и вызов для здравоохранения Республики

Physician migration challenges healthcare systems in developing countries. The “Irish paradox” phenomenon, where doctor shortages persist despite numerous medical graduates, is emerging in Kyrgyzstan (KR). Limited research on this exists in Central Asia. The study explores medical students' migration intentions, offering insights for regional and global health authorities. A cross-sectional study surveyed 526 final-year medical students in KR. We analyzed demographic characteristics, intentions to work abroad, future professional preferences, and “Pull and Push” factors for migrations that might influence students’ decision to migrate. 86.1 % expressed willingness to emigrate. Intention to migrate was categorized by certainty of migration: 12.5 % “leave KR”, 14.5 % “highly likely to leave KR”, and 59.1 % “might leave KR”. 13.9 % decided to stay in KR. The significant predictors of migration were marriage and rural living; the main migration destinations were Russia (41.5 %), Kazakhstan (18.8 %), and the EU (11.5 %). Pull and push factors significantly differed among groups. The main limitations of the study arose from the nature of the observational study. The study results are alarming, uncovering the potential scale of physican migration in Central Asia. The majority of medical graduates in KR plan to migrate, posing a threat to healthcare sustainability. The presence of the "Irish paradox" amplifies the pressure on these processes in the country and should be considered in the development of migration policy. Monitoring students' intentions provides timely information for adjusting migration programs promptly, and the combined score of Pull and Push factors might serve as an express test to address the challenge more effectively. Migration programs should be developed jointly with the Russian Federation, as the main destination and give priority to professional development in the group with low migration intentions.

Medical students’ migration intentions: Risk factor and challenge for the healthcare system in Kyrgyzstan

Physician migration challenges healthcare systems in developing countries. The “Irish paradox” phenomenon, where doctor shortages persist despite numerous medical graduates, is emerging in Kyrgyzstan (KR). Limited research on this exists in Central Asia. The study explores medical students' migration intentions, offering insights for regional and global health authorities. A cross-sectional study surveyed 526 final-year medical students in KR. We analyzed demographic characteristics, intentions to work abroad, future professional preferences, and “Pull and Push” factors for migrations that might influence students’ decision to migrate. 86.1 % expressed willingness to emigrate. Intention to migrate was categorized by certainty of migration: 12.5 % “leave KR”, 14.5 % “highly likely to leave KR”, and 59.1 % “might leave KR”. 13.9 % decided to stay in KR. The significant predictors of migration were marriage and rural living; the main migration destinations were Russia (41.5 %), Kazakhstan (18.8 %), and the EU (11.5 %). Pull and push factors significantly differed among groups. The main limitations of the study arose from the nature of the observational study. The study results are alarming, uncovering the potential scale of physican migration in Central Asia. The majority of medical graduates in KR plan to migrate, posing a threat to healthcare sustainability. The presence of the "Irish paradox" amplifies the pressure on these processes in the country and should be considered in the development of migration policy. Monitoring students' intentions provides timely information for adjusting migration programs promptly, and the combined score of Pull and Push factors might serve as an express test to address the challenge more effectively. Migration programs should be developed jointly with the Russian Federation, as the main destination and give priority to professional development in the group with low migration intentions.

Adopting WFME Standards, Case Study of Saudi Arabia

The Kingdom of Saudi Arabia has witnessed a full-size boom in the number of scientific colleges over the past a long time, driven by using the growing call for healthcare services. This rapid enlargement has raised concerns approximately the exceptional and consistency of medical schooling throughout the one-of-a-kind establishments. Ensuring amazing medical training is critical, as it immediately impacts the competence and performance of future healthcare carriers. Robust high-quality guarantee mechanisms are important to maintain standards and promote continuous development. The proliferation of medical schools worldwide with questionable education quality, coupled with the increased migration of physicians, has raised international concerns about safeguarding the practice of medicine and, ultimately, the service offered to patients. This study aims to examine the potential adoption and implementation of the World Federation of Medical Education (WFME) standards in medical schools in an emerging country context using the Kingdom of Saudi Arabia as a case study. The study investigated the quality assurance systems in four medical schools using semi-structured interviews developed based on the WFME framework to identify gaps that the WFME global medical standards could address and understand the challenges faced in the implementation of quality assurance, the findings of this research will contribute to the understanding of the implementation of quality assurance frameworks in medical education, with specific insights from the Saudi Arabian context. The outcomes can inform policymakers, medical education institutions, and stakeholders in their efforts to enhance the quality and consistency of medical education in the Kingdom.

Factors related to the resignation and migration of physicians in public health administration agencies using nationwide survey data in Japan

BackgroundPhysicians in public health administration agencies (public health physicians: PHP) play important roles in public health; however, there are not enough such physicians in Japan. This study aimed to elucidate the factors related to the resignation and migration of PHPs using nationwide survey data.MethodsData from the Survey of Physicians, Dentists, and Pharmacists (2010, 2012, 2014, and 2016) were analyzed. The outcome was the resignation of PHPs or migration to public health administration agencies. The explanatory variables in the resignation analysis were age, sex, workplace, and board certification status. The type of work was added as an explanatory variable in the migration analysis, and clinical specialty was added to the clinical doctor-restricted analysis. The odds ratios (ORs) of the explanatory variables were calculated using generalized estimation equations.ResultsIn the resignation analysis among PHPs, women had a significantly lower OR, whereas younger PHPs and those with board certifications had significantly higher ORs. In the migration to public health administration agencies analysis among medical doctors, women and those aged between 35 and 39 years had significantly higher ORs, but those with board certifications had significantly lower ORs. Hospital/clinic founders or directors had significantly lower ORs, but the clinic staff and ‘others/not working’ had significantly higher ORs. In the migration to public health administration agencies analysis among clinical physicians, those aged between 35 and 39 years had significantly higher ORs. Still, those with two or more board certifications had significantly lower ORs. Hospital/clinic founders or directors had significantly lower ORs, but the clinic staff had significantly higher ORs. Clinical doctors specializing in surgery and other specialties had significantly lower ORs, but those specializing in pediatrics and psychiatry/psychosomatic medicine had significantly higher ORs.ConclusionsHaving board certifications were significantly related to the resignation of PHPs and migration to public health administration agencies. Women migrated to public health administration agencies more than men and younger PHPs were more likely to resign. However, medical doctors aged between 35 and 39 years were more likely to migrate to public health administration agencies. Similarly, clinic staff, non-clinical physicians, and those whose specialties were pediatrics and psychiatry/psychosomatic medicine were more likely to migrate to public health administration agencies.

Going Back Home: Understanding Physician Migration to the United States.

In 2021, US foreign-born population reached a high of 14.2% of the total US population. Up to 28% of US working immigrants are physicians. The decision to leave one's home country, though, is rarely an easy one to make and is often riddled with cultural and emotional challenges.

Incentive policies for retention of physicians in the private health sector in Portugal

<p align="justify">The high demand for quality healthcare services in Portugal is generating concerns about meeting the optimum number of healthcare professionals in the private sector such as doctors and clinicians. Critical interventions are currently in progress aiming to provide quality healthcare that will be accessible and sustainable through actionable retention strategies such as investing and developing the human capital, introducing better conditions of service to attract and retain talent in the private healthcare sector, and prioritizing the needs of patients. The objective of this study is to understand which factors promote the migration of physicians from the public to the private sector according to the theoretical assumptions of incentives. In this context, a phenomenological study was carried out, using semi-structured interviews of fifteen physicians working in the private health network. Content analysis was done using NVivo 12. The results indicate that performance evaluation in the private sector exists but has no alignment with incentives. The condition makes the private healthcare sector unattractive, however, other policies of remuneration remain promising. Current proposals that could revive the image of the sector include collective decision-making and strong labour relations advocacy for physicians in the private sector.</p>

International Physician Migration: A Comparative Study of Healthcare in the US, UK, & India

Physician migration patterns are a phenomenon that affects the healthcare system within developing countries, but there is no strong evidence to show why doctors migrate to the West after getting an education from elite Indian medical institutions. This study aims to explain why physicians from India choose to leave given the different push and pull factors. Prior research shows that better opportunities for higher education, socioeconomic status, upward mobility, and equitable healthcare systems contribute to why physicians are attracted to the US and the UK. This leads to the next main question: which country do doctors prefer after moving away from India, the US or the UK? With further investigation through interviews, it becomes evident that there is no actual preference for one country. Each country has unique assets within the types of healthcare and lifestyles offered. Physicians note that social networks, support systems, and recruitment are all reasons for moving to the West. Female and lower caste/class doctors with adequate resources who left India discuss that they were able to feel more valued for their merit outside of the country. Some upper caste/class physicians were privileged enough to have more autonomy when deciding where to go; for them, the West was just another option. Upper-caste narratives also shed light on the politics they fled from, such as the medical education quota system for undergraduate and postgraduate institutions. To summarize: physicians didn’t worry too much about the destination. Rather, they just wanted to leave India.

Depression, anxiety, stress levels and five-factor personality traits as predictors of clinical medical students' migration intention: A cross-sectional study of brain drain.

Physician migration has a profound impact on healthcare systems and can be caused by many reasons. One of the most important healthcare-related problems in Turkey recently is the increasing migration trends of physicians. Although many studies have investigated physician migration's social and political determinants, the psychological factors that may yield this trend have not been adequately studied. It is aimed to examine the relationship between clinical term medical students' intention to migrate and temporary factors such as depression, anxiety, stress, as well as persistent factors such as personality traits in this study. After questioning the migration intentions and possible related determinants of 575 students participating in our study, Depression Anxiety Stress Scale-21 and Five-Factor Personality Inventory were applied. While 46.3% of the participants had the intention to migrate, 53.7% planned to live in Turkey in the long term. Higher depression and stress levels are significantly associated with migratory intention. Identifying oneself as man, having a partner, high-stress levels, high openness, and low agreeableness traits were found to be major predictors of migration intention. Our study shows that besides many sociological studies on this subject, the investigation of psychological factors has an important role to understand the recent physician migration.

Can the medical educator speak? The next frontier of globalisation research in medical education.

Can the medical educator speak? The next frontier of globalisation research in medical education.

On leaving: Coloniality and physician migration in Puerto Rico

Puerto Rico (PR) has a growing physician migration problem. As of 2009, the medical workforce was composed of 14,500 physicians and by 2020 the number had been reduced to 9,000. If this migration pattern continues, the Island will not be able to meet the recommended physicians per capita ratio proposed by the World Health Organization (WHO). Existing research has focused on the personal motivations for movement to, or permanence in, a particular setting, and social variables that encourage physicians to migrate (e.g., economic conditions). Few studies have addressed the role of coloniality in fostering physician migration. In this article we examine the role of coloniality and its impact on PR's physician migration problem. The data presented in this paper stem from an NIH-funded study (1R01MD014188) that aimed to document the factors associated with physician migration from PR to the US mainland and its impact on the Island's healthcare system. The research team used qualitative interviews, surveys, and ethnographic observations. This paper focuses on the data from the qualitative interviews with 26 physicians who had migrated to the USA and ethnographic observations, which were collected and analyzed between September 2020 and December 2022. The results evidence that participants understand physician migration as a consequence of three factors: 1) the historical and multidimensional deterioration of PR, 2) the idea that the current healthcare system is rigged by politicians and insurance companies, and 3) the specific challenges faced by physicians in training on the Island. We discuss the role of coloniality in fostering these factors and how it serves as the backdrop for the problem faced by the Island.

Understanding why oral health professionals migrate: A qualitative investigation of Iranian dentists who have moved to Canada (Oral health professionals’ migration)

ABSTRACT Background The migration of health professionals from Low- and Middle-Income Countries (LMICs) to High-Income countries (HICs) is an ongoing phenomenon that has been accelerating with globalisation. While there has been growing research around the migration of physicians and nurses, there is less understanding of the motives surrounding the migration of dentists, and even less about their migration from specific countries. Objectives This qualitative study explores the migration motivations of Iranian dentists who have moved to Canada. Methods Semi-structured interviews of 18 Iranian-trained dentists in Canada were conducted to obtain information about their motives for migration. Interviews were coded and categorised into themes using qualitative thematic analysis. Results Motivations to migrate were grouped into four analytical areas: socio-political; economic; professional; and personal. An inverse relationship was identified between the strongest motives to migrate and the topics respondents were least comfortable discussing. Socio-political-related motives were predominant with respondents focusing on their dissatisfaction with the social ethos and restrictions on personal freedom within Iran. Conclusion Country-specific context is critical to fully understand health professional migration; in particular, the dynamics and interplay between socio-political, economic, and professional/personal factors within the home country. While Iranian dentists’ motives to migrate have some similarities to other health professionals who migrated from Iran, and dentists from other countries, differences need to be considered to fully understand migration patterns.

What price Romania has to pay for being one of the main providers of physicians in Europe?

PurposeThe migration of physicians is a global interest, causing imbalances between developed and developing countries. Romania is one of Europe's major providers of physicians, not because there is a surplus, but because physicians are drawn to places with better living and working conditions. Medicine in Romania is increasingly highly advanced, and Romanian physicians are well appreciated all over the world. Despite being one of the countries with the most medical graduates in the world, Romania is suffering a doctor exodus. After joining the EU, the problem of physician migration became widespread, resulting in a deficient and inefficient healthcare system. Therefore, the purpose of this study is to estimate the losses registered by Romania because of physicians' decision to migrate.Design/methodology/approachThese losses were calculated in two ways: utilizing the statistical life value and the amount of money invested in training a medical graduate.FindingsAccording to the findings, the losses in 2018 were 104.16 million euros, approximately 0.12% of GDP.Originality/valueThe originality of this paper consists in data, being provided by the College of Physicians from Romania and the method used, this study being the only one that estimates the cost of Romanian physicians' migration. The paper adds to existing knowledge an empirical results regarding quantifying the value reflecting the departure of physicians, using value of statistical life and the amount of money invested in preparing a medical graduate.

Introduction and Critique of the Paper "Medicine of the Safavid Era Relying on Western Travelogues"

The Safavid period is considered one of the most important periods in the history of Iranian medicine. During this period, medical knowledge was developed many works in the field of medicine were written and several hospitals were established. In recent years, several studies have been conducted on the medical history of the Safavid period. The purpose of this study is to introduce and critique the paper "Medicine of the Safavid era relying on Western travelogues" by Saeed Agharezaei and Shiva Rezaei. This research is an analytical-critical study that uses library resources to review and evaluate the paper in terms of structure, content, and method. The paper has coherent writing and indicates the authors' efforts to explain the medical and health situation of the Safavid period from the perspective of Western tourists. In the structure of the paper, sometimes inappropriate references and writing errors are seen. Failure to mention the reasons for the migration of physicians to India, failure to determine the true location of hospitals, failure to mention the position of dental, veterinary and surgical knowledge, failure to mention epidemics and ambiguity of the pharmacology situation in the Safavid period can be enumerated content critiques. The results show that the paper, despite attempts to reveal various aspects of medicine in the Safavid era, has some structural, content, and method problems. Therefore, it is expected that the respected authors, by eliminating the mentioned problems, will be able to publish a more significant work on the history of medicine in future research.