Physician demography in Lebanon 2024: identifying gaps and proposing solutions for sustainable healthcare system | BMC Health Services Research

Healthcare staff demographics are a vital indicator for assessing a country’s health status. Following the 2019 economic crisis, Lebanon has experienced a significant ‘brain drain’ that included a significant migration of physicians [3]. Thus, it is important to evaluate the adequacy of the physician population in relation to the population they serve.

In our study we relied on the biographic data of registered physicians in the LOP branches of Beirut and Tripoli. However, it is important to recognize that these data may not truly reflect current actual numbers, as findings from the comprehensive study on plastic surgeons revealed a significant percentage of registered surgeons who are either no longer active or working abroad [4]. LOP-generated data shows that the population density of physicians registered as residency-trained primary care practitioner i.e. family medicine and internal medicine, stands at 7.11 per 100,000. This is sharply below the recommended 41.5 physicians per 100,000 population [9]. In contrast, registered surgeons across all specialties exhibit a density of 70 per 100,000 population, eclipsing the recommended 37.1 per 100,000 population density [9]. This underscores a strong preference of medical school graduates for specialization.

Non-residency trained general practitioners (GP) on the other hand, exhibit a population density of 72.8 per 100,000 – significantly exceeding the recommended 41.5 per 100,000 for primary care physicians. Although GP function in the capacity of primary care physicians, they lack the formal training necessary to address the multitude of health issues that FM and IM physicians face. Moreover, many function solely in institutional or administrative settings such as in prisons or health insurance companies, thus removing them from the availability pool serving the general population [10].

Emergency medicine represents another essential specialty that is in stark shortage in Lebanon – with a physician density of 1.55 per 100,000, as compared to a recommended 12.3 per 100,000. Not surprisingly, many emergency rooms in Lebanon are often covered by a GP who will only perform the most cursory of workups before immediately triaging to the appropriate specialist for further diagnosis and treatment. However, this is not the case in university hospitals, where ER rooms are usually well equipped with medical, surgical, and pediatric units. In a country that is constantly at risk of political unrest and war, the scarcity of residency-trained emergency medicine specialists raises high concern.

Physical medicine and rehabilitation as a specialty has been severely neglected by the Lebanese Ministry of Public Health (MOPH). With only marginal funds contributed to public hospitals, training programs are few. In Lebanon, this specialty also addresses palliative care needs for the general population, and yet there is no palliative care offered through government-subsidized health coverage programs. Fortunately, the Lebanese Society for Palliative Care has been recently created, and serious consideration to allocate needed public and private funds for its recognition is underway [10].

Other specialties exhibiting low physician density ratios may be due to their relatively recent introduction in Lebanon. Allergy and Immunology is a recently recognized specialty by the Lebanese Ministry of Public Health according to the resolution number 1431/1 in 2017 [11]. Prior to that point, issues dealt with by an Allergy and Immunology specialist were treated by physicians practicing Internal Medicine. This highlights another important factor in specialization in Lebanon – that of board certification. In contrast to the United States, where a specialist’s recognition and hospital credentialing are tied to their board certification status, in Lebanon a specialist needs only to provide proof of residency and/or fellowship training to the MOPH. Therefore, many physicians function within a loosely defined scope of practice with little regulatory oversight.

Moreover, in certain specialties the significant deficit manifests in the limited services offered within specialized centers. This includes pathology, where limitation in the availability of Mohs surgery, for optimal treatment of many skin cancers, is evident [12]. Due to the scarcity of pathologists, samples are sent to specific centers for diagnosis, leading to intervention delay and instances where the surgery should be repeated on patients. Even in the Beirut metropolitan area, only 3 Mohs surgeons are available on a part-time basis to provide services in a city of over 2 million people [10]. From this, it can be inferred that an even more severe shortage is expected in underserved rural areas.

Although the physician density for some specialties seems reassuring, it belies an underlying crisis. Anesthesiology exhibits an apparent oversupply (11.2 vs 9.1); however, the numbers are generally skewed in favor of larger hospitals and institutions, leaving hospitals in underserved areas covered by a single anesthesiologist [10]. Dermatology, which offers its practitioners an easy segue into aesthetic medicine and the potential for a lucrative income, represents a specialty that is in oversupply – 5.55 per 100,000 compared to the recommended 3.1. This is consistent with another study that showed an excess of plastic surgeons practicing aesthetic medicine in Lebanon [4]. Nevertheless, like other specialties of a total reassuring ratio, a shortage was noted outside of the Beirut Metropolitan area.

For that reason, observing the distribution of physicians across Lebanon is as crucial to assessing adequate provision of care as looking at overall physician density across an entire region. As Beirut is the cultural and economic center of Lebanon, it houses the largest hospitals and teaching institutions. With the country’s only international airport, it also attracts foreign medical tourists seeking healthcare from across the Arab world. Under-equipped hospitals in rural areas offer less surgical services as evident by the significant referrals to the tertiary centers in Beirut [4]. In a small yet mountainous country, many rural areas are no less than 2 h away from Beirut by ambulance, and thus facilities and services in these areas are woefully inadequate to manage emergent cases.

With many of Lebanon’s medical school graduates pursuing opportunities abroad, and with many of its remaining physicians choosing to practice in the Beirut metropolitan area, the problem may not just be a simple issue of inadequate personnel. Rather, it is a problem of maldistribution – not only in practice scope, but practice geographic location as well. In short, most doctors choose to train in specialties that they deem as lucrative while locating their primary practice locations in or near Beirut. Even if, as in Fig. 2, all recent graduates from residency training programs in specialties that are in shortage remain, there would still be a significant glaring shortage in those specialties. This underscores a deficit in graduate medical education offering training in specialties that are in shortage. It is worth mentioning that community – based residency programs, for example, promote practice in rural areas where shortages in primary care services or other specialties are found. This showed that graduates from these programs tend to pursue a career within these specialties of gaps, and eventually achieve a distribution of physicians that meet community needs [13]. Thus, this reinforces the importance of incorporating community needs in the organization of residency programs at medical schools.

Potential solutions to address these concerns have already been put forth in the form of a law that mandates all graduating medical students not intent on residency training, in other words general practitioners, to pursue at least two years of family medicine practice after their graduation. This is an essential requirement for them to be officially registered as a physician and allowed to practice medicine in any capacity. Another recent law demands a service of two years in a rural area for newly graduated physicians, and doctors working for the first time in Lebanon. These may help to stem not only the shortages in primary care practice, but also to alleviate shortages in rural areas outside of Beirut. Moreover, a legislative proposal is already raised at the parliament to establish a Lebanese Medical Board Certification, which will put physicians under a re-assessment every 5 years for their specialty certification. Enforcing these laws would definitely address the underlying issues. As a suggested measure, the authors believe that the LOP must work collaboratively with the MOPH and schools of medicine in Lebanon, to orient medical students toward specialties that are in shortage and to increase the number of training program positions for said specialties.

Moreover, digital health offers another immediate solution to combating shortages in underserved areas. Some health institutions like the American University of Beirut Medical Center (AUBMC) have already adopted virtual consultation systems into their patient evaluation infrastructure. The LOP is working on developing this aspect more broadly across the whole country. However, this initiative requires a strong infrastructure like a stable internet, and extensive orientation sessions for physicians who are not familiar with technology as no specific retirement age for physicians is mandated in Lebanon. Finally, financial incentives could highly improve rural healthcare and workforce retention. The World Health Organization (WHO) suggests providing housing support and transportation assistance to physicians in this scope [14]. Also, allocating public funds to support the small hospitals in rural areas, and ensuring they have a well – equipped hospital with diagnostic and surgical equipment, will undoubtedly improves patient outcome and creates an ideal environment that attracts and retains physicians.

Limitations of our study include a lack of an accurate census in Lebanon – the last official census having been conducted in 1932 [15]. We were unable to assess the physician density of pediatricians given that we also lack accurate census data on the pediatric population. Moreover, our data are secondary, thus some information about the physicians may be outdated as mentioned previously within the text.