Contemplation and action on leaving homeland: A mixed-methods study among physicians from Turkey

International physician migration, a subtype of high-skilled migration, has become a notable phenomenon in global health due to its potential impact on the widening gaps of disparities in physician distribution and the sustainability of healthcare systems in emerging countries. This migration, like other high-skilled migration types, typically flows from low- and middle-income countries (LMICs) to high-income countries (HICs), with detrimental consequences for the healthcare systems of the origin countries. These consequences include reduced healthcare quality and more burden on systems that are already dealing with a high disease burden and low physician density (Packer et al., 2009). In the last five years, Turkey has witnessed a substantial rise in the migration of physicians. The Turkish Medical Association's (TTB) records of applications for Good Medical Certificates, which are necessary for practicing abroad, demonstrates this rising trend. Since 2021, migration rates have nearly doubled, exceeding 3,000 per year by 2023 (TTB, 2023). Considering that Turkey already has the lowest physician density among OECD countries, this trend presents further risks to maintaining high-quality healthcare (OECD, 2021). The objective of this study is to explore the key factors that contribute to the migration of physicians from Turkey, investigate the behavioural aspects of physicians' contemplation to migrate, and discover possible alternatives to migration. This study is designed as a mixed-method study, it utilizes surveys and semi-structured interviews to comprehensively examine the multifaceted aspects of this issue. The sample size included Turkish physicians who have considered or undertaken migration in the past five years. The theoretical framework incorporates the Push and Pull theory to explain the driving factors of migration and Hirschman's Exit-Voice and Loyalty (EVL) model to understand Turkish physicians' perceptions and behaviours regarding migration. Study findings showed push factors for physicians from Turkey had substantial effect on their migration decision and these factors mainly originate from physicians' dissatisfaction with overwhelming working conditions and broader concepts including economic instability, political and societal climate. This study also revealed that the exit overweighs voice and loyalty for physicians. Although efforts to voice their issues were made, these were seen as futile, prompting physicians to view migration as the only viable option. Both the disbelief in voicing concerns and the perception of push factors are shaped by a significant sense of hopelessness among participants, which appears to stem from physicians' dissatisfaction with the current political and societal atmosphere. The exit driven by this lack of hopelessness for change in Turkey causes migrating physicians to develop a complicated relationship with their migration decision.