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Is it possible for a US academic physician to spend least several months a year working in a developing country?

There are many medical students and residents interested in this question. International training programs are increasingly common within medical school and residency curriculums as are global health projects (e.g. www.shouldertoshoulder.org/History.htm).

It has become a given that a number of young physicians in the US will wish to make a major contribution to international health care on an annual basis. The question is – Can this be done within the medical community, especially within academic medicine?

In general, the academic world will work with faculty physicians who plan to spend time working internationally. If what one wants to do is take a group of colleagues or students abroad once or twice a year for a few weeks to do primary care health and education, it won’t pose a problem for most institutions and they won’t likely ask for salary support to be provided externally. In academics faculty have a lot of control (usually) over their schedule and a few weeks for something like this is relatively easy to arrange. It helps to notify public affairs at the institution and provide them with pictures upon returning to put in the institutional magazine. I’m only half joking about this. It never hurts to work with public affairs to explain to the public the importance of ones work overseas.

However, beyond spending perhaps 4-6 weeks each year abroad, making arrangements in any setting, academic or private practice becomes much more problematic. Lets look at some of these obstacles and how they might be overcome.

Let’s consider:

   1. family
   2. personal finances
   3. legal and licensing issues
   4. research support

First comes family. Now this may not affect any individual’s situation but it does pose an issue for most people. It is a lot easier to be a med student and assume that ones life will work out so that they can spend 3-6 months traveling each year than to be a parent (or spouse!) and try to actually make this happen.

For many people, it will be best to spend 6 months to 2 years working internationally early in a career (see www.bayloraids.org/corps and www.doctorswithoutborders.org/volunteer/field/ as examples) than to make it work throughout a career. With that initial experience faculty are prepared to work within their career goals (e.g. a tenure track) to develop a more usual 4-6 weeks/year international travel schedule once interests and research areas are established.

It is also easier to do frequent travel at a later stage of ones family life and career. Teenagers and older children are often much more amenable to a parent being gone for a few months than small kids. It is still not easy, so for those who have or plan to have a family, this is an important issue. Better to think about it up-front and recognize the challenges than just assume that ones loving spouse and 2 children won’t mind living in a place without many amenities for 6 months at a time each year.

Small girl in remote village of BelizeThe second issue is personal finances. Someone has to provide a salary for each person while they are working abroad. In academics, faculty can find institutions that will work on this but it is not easy and there is no guarantee that faculty will be able to get their institution to provide 100% salary while working only 50-75% of the year. It is possible to work out a system in which one works intensively before traveling each year (clinics, night-call, etc all have to be considered) or have specific funding for the overseas work that will support the salary of those who go.

However getting international agencies to fund a large amount of salary for an American physician is exceptionally hard to arrange (albeit not unheard of). The team from the US may be willing to work for less than full salary, but the university has its needs too such as clinic and night-call coverage and must pay health insurance, malpractice and life insurance and provide office space throughout the whole year. Again, this is doable, but will involve some challenging negotiations.

It sounds easy to say that if a faculty member usually does 5 months each year of hospital work, they can just do them back-back over 6 months and then go off to see the world! This is a lot harder to do in reality and even then doesn’t account for the other tasks that will be left undone during that time such as committee meetings, teaching classes, etc.

Third are technical issues including licenses and working with the foreign government. If an American physician is going overseas for a long-term arrangement, or trying to set up a clinic somewhere, they’ll need to think about these issues.

I’ve never obtained a medical license in another country, but I’m told it isn’t always easy. Malpractice concerns may not really exist in some developing countries, but they exist in a lot more places than one might expect. The faculty will need to consider how the government might feel about an American setting up shop there. In some areas the Americans could be seen as competition for the local doctors and this could pose issues. As in the US, the more urban the practice, the more likely one is to have a problem.

Language issues are likely greater in a rural setting. I have seen physicians in The Gambia who were from Cuba and spoke only Spanish, working in a country where the health care system was almost entirely conducted in English, and the people spoke only Mandinka (en.wikipedia.org/wiki/Mandinka_language). Not much communication going on there! But if truly rural, what about spending several months every year without much electricity, potable water and the like? Remember, the locals mostly don’t want to work there either – same issues as rural health care in the US.

Last is the issue of exactly what one is going to do there academically (teaching and research) and who is going to support the actual work that is being done. If it is a pure clinical practice, the American physician will need to find money to support the building, staff, and medications. I know academic physicians who spend much of their time while in the US fund-raising for their overseas clinic. If it is research-related one will have to go after grants and deal with ethical issues that are considerable. These grants can come from foundations, from companies, or from governments.

If one has a background in public health, this will help. Research-related grants in international health, especially from governments are not easy to obtain. US funding agencies often focus on the needs of the underserved in the US and overseas agencies may not be enthused to fund an American working abroad in this area. They may be more focused on large international groups and projects. One needs to find a niche, a unique research area based on ones training and skills. These exist (tropical medicine, HIV, nutrition, etc), but one needs to have a track record of research or work for someone who does.

American physicians and scientists can consider working on pharmaceutical trials. However this too is challenging. Clinical research has to be done under “Good Clinical Practice” www.fda.gov/oc/gcp guidelines, which isn’t easy to do in many settings.

In summary, we are at a time of tremendous interest in physicians from the US working overseas in clinical care settings and in education and research. Short-term projects can be readily accomplished and contribute substantially to the health-care of some of the world’s poorest people.

However, for an American academic physician to spend a large portion of their time overseas doing medical care and research remains very challenging to arrange. Medical students and physicians-in-training should have a realistic understanding of the obstacles they face in this area and develop realistic personal and professional goals.

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