Crossing International Borders As A Physician

If you’ve never had the pleasure of crossing a border into a remote part of a developing country, you’re in for a real treat.  Some of the best travel stories-- both good and bad-- occur at border crossings.

While most crossings involve little more than a little eye contact and a perfunctory paperwork inspection, things can turn bad in a hurry for those who are unprepared.  Stories abound on the international travel circuit of travelers being detained—or worse—when attempting to cross a border in a less-than-appropriate fashion.  If you’re going to be traveling in remote, undeveloped regions, it’s best to have a plan for handling the crossing of national borders.

For many Westeners—especially the inexperienced physician traveler—the idea that someone in a country that they’re “trying to help” might not believe their good intentions seems preposterous.  Regardless of your intentions, however, you can run into problems.

You might be the nicest, most altruistic person in the world but look at it from the perspective of a border guard:  you’re foreign, you probably don’t speak the native language, you might appear rude due to your dress or mannerisms, and if you’re a medical officer you’re probably carrying lots of suspicious-looking pills, tablets, instruments, and other doo-dads. 

In the first chapter of our Expedition & Wilderness Medicine textbook, Dr. Howard Donner has some helpful tips for dealing with border crossings.  I’m quoting Howard here at length: 

Don’t carry white powder in zip lock bags.  As obvious as this may sound, it is amazing how tablets of all sorts tend to break down with humidity and then slowly disintegrate in zip lock bags. A poorly identified zip lock bag, with pulverized white medicine inside, presents a rather suspect impression to a customs official.  Try to be meticulous with your drugs.  Place your medicines in clearly labeled zip lock bags or medicine vials. If you choose to use zip locks, protect them from physical damage inside of a sturdy kit or case.   The more organized the kit looks, the less dubious the custom’s officials seem to look. 

Carry a copy of your medical license.  Showing a customs official a photocopy of your medical license carries a bit more credibility than stating, “but I’m a doctor, really." 

Present a letter of introduction.  Customs officials seem to love embossed stationery or letters embellished with gold seals. These blank forms can be easily purchased through most office supply stores.  Even if you’re not traveling with the National Geographic Society, you can print up your own letter on embossed stationary. Introduce yourself as the expedition doctor for the “2008 blank blank expedition”.  As long as your name is on the letter, along with a signature from the sponsoring foundation, (such as a friend of yours), custom officials seem to relax.

-Dr. Howard Donner, Chapter One: The Expedition Physician in Expedition & Wilderness Medicine

In addition to medical kit issues, another big problem with border crossing revolves around trying to exit a country with interesting items of question.  Remember that really cool “antique” the local hustler sold you outside the tourist area?  Turns out it’s a stolen artifact from the local museum.  Be wary of buying local valuables that are sold in a surreptitious manner.  At a border it will be you, not the local “entrepreneur,” who will be charged with theft and attempts to export a national heirloom. 

Also, remember that many animal products such as furs or trophies (especially of endangered species) cannot be taken home as well as most alcohol, plants, food items, and some forms of tobacco.  If there’s any question, it’s best not to attempt to transport it.  Just leave it alone and tell stories about “the one that got away” to your friends when you’re home safe and sound.

Even with all the proper documentation and appropriate behavior, frustrating things can still happen when attempting to cross a border.  Some seasoned travelers recommend having a few small "give away" items such as cigarettes, t-shirts of your favorite ball club, small candies, or other light-hearted gift items in your luggage to help sooth escalating tempers.  It's amazing what a small gift accompanied by a smile and a calm demeanor can do to improve a difficult situation.  

If things still go from bad to worse, the best advice is always be respectful, keep your eyes open and your mouth shut, and do not attempt to bluff your way through with threats or angry gestures.  Remember, this is not your home turf, you are not in charge, and you are very much at the mercy of the nearest supervisor in the area.  All your impressive credentials and academic publications won't matter at all to your cellmate in the local jail, and in this situation, Miranda rights certainly do not apply.

Border crossings are a normal part of international travel.  By keeping a few principles in mind, these events can become routine and fun rather than frustrating and frightening.

Staying Connected While Working Overseas: How Technology has Shrunk the World

In the not so distant past, a job placement overseas meant extensive time away from family and very little real-time communication with those back home. 

I remember traveling the EurRail the summer after my first year of medical school and buying prepaid phone cards to use on the pay phones in the various European cities we visited.  That was 1996. My how things have changed.

Today if you decide to take a medical post in an international location, you can almost continue relationships with friends and family back home unabated.  There’s a trick to it, of course, and you have to adjust to the time-zone differences, but with the internet and all sorts of new communication tools, the world has never felt so small.

There’s so much material in the area of international communication technology that there’s really no good way to cover it all in a single post.  For those who want a more thorough discussion of some of the unique ways communication tools are being used in medical expeditions, I would recommend the chapter entitled Communications Planning for the Expedition Medical Officer by Dr. Christian Macedonia that’s part of our Expedition & Wilderness Medicine textbook.  For the others of you who are simply interested in hearing a quick overview of how technology has shrunk the world and taken a lot of the hassle out of working overseas, I give you the following anecdotes…

In 2003, as part of my International Emergency Medicine fellowship at Johns Hopkins, I was sent to the desert of Sudan to perform a nutritional study on a people group called the Beja.  The Beja live in the northeast corner of Sudan, a very desolate, arid region where the locals live basically as they have for thousands of years.  Due to the civil war in that country, the Beja had been cut off from their natural trading routes and many were starving.  USAID had provided a grant to help feed these people and I was sent by Johns Hopkins to ensure that the food was getting to the needy and they were responding to it appropriately.

The project itself was very challenging and after three weeks in the desert I was ready to come home, but it was a great experience and one I wouldn’t trade for anything.  One of the main memories I had of the trip was simply how isolated our group was.  After crossing the border from Eritrea into Sudan, it was simply desert sand—no roads, no electricity, nothing but khaki expanses, a few distant camel trains, and an occasional burned out armoured vehicle or unexploded ordinance left behind from the war and half-buried by sediment.

Amazingly, in spite of this isolation, I was still able to talk to my family back home in the States from time to time through the use of a satellite phone, and every night, powered by a battery that had been charged during the day with solar panels, our group listened to satellite radio as if we were all hanging out together on an extended camp out.  I’ll never forget how odd it seemed to be sitting out under the immense sky of that distant desert, listening to the camels while I talked to my girlfriend (now wife) on the phone and tapped my foot to the classic rock music coming in from the stereo.  Surreal.

In another example, a few years later I took a new job and my wife and I moved to the country of Qatar.  Initially, one of our main concerns was  keeping in touch with friends and family back home.  It shouldn’t have been.  Between email, online video chats using either the Apple iChat technology or video Skype, and our Vonage internet phone, staying in touch was a breeze.  Matter of fact, when we ordered our Vonage phone, we chose a local US phone number.  That way when our friends and family from the States called, it would be a local call for them and rang our house in Qatar just like any ordinary phone line.  It was crazy to talk to our loved ones on their cell phones while they were running errands, and so convenient to just walk over and call the States just like on any other household phone.  The cost for this convenience? A whopping $20 per month.  It was a steal.

The Vonage phone system worked so well and was so easy to use, I never felt like I skipped a beat when we moved outside the US.  My writing and other projects continued without difficulty.  Matter of fact, multiple conference calls relating to the planning of our Expediton & Wilderness Medicine textbook were held while I was overseas and our first Expedition Medicine National Conference was organized and planned using the internet, email, and our Vonage phone, entirely while I out of the country.  I flew back to the States the day before the event and went back overseas when it was over.

Another great device we purchased just prior to our expatriat experience was the Vonage V-Phone.   The V-Phone looks and feels like a flash drive and is designed to be stored on a keychain.  When my wife and I would travel to other countries, we could attach this device to our laptop, plug in a headset, and the V-Phone would enable us to make calls just like an ordinary phone.  It was amazing.  Currently these devices cost around $50 US, and they are well worth it.  However, it should be noted that the V-Phone is not compatible with Mac laptops and they are blocked in certain countries.  When we traveled to Dubai, for instance, we were disappointed to learn that not only our V-Phone but also Skype and the other internet phone services were blocked by the local government there. 

One last communication device worth noting…

During our travels, the coolest member in any expat community was the guy who had a device called a Slingbox hooked up to his tv.  Basically, a Slingbox is a device that enables you to control your home television over the internet.  Savvy expats would buy the device and install it on their home TVs back in the States (or give it as a gift to a family member or friend and install it on their TVs).  When overseas, the owner could go to the Slingbox webpage, login, and watch live television while having total control over the channels and DVR.  It was a great way to follow the home ball club (even though the games were usually played at 3am) or simply get a taste of your favorite TV show from time to time.  What’s great is that now the Slingbox has an iPad ap that allows Slingbox owners to watch live TV on their iPads.  I remember being at a lunch not long ago and noticing that golfing great Phil Mickelson, just one table away, was watching a live NFL game on his iPad via Slingbox.  Slingbox is a very cool technology for those who want to say in touch with certain sporting or cultural events while living in a foreign environment.

So there’s a quick anecdotal tour of how modern technology can keep the world small and enable you to stay in touch with colleagues back home, even though you’re miles away.  An international assignment does require some sacrifice at times, but modern communication technology greatly lessens the impact of such a move these days, and allows you to stay connected no matter where you live. 

Getting Started In International Medicine

Alright, so you want a career in international medicine.  Where do you begin?

You’ve finished your specialty training and you’re looking for opportunities to work overseas.  Great.  You know how to run a code and diagnose a pneumonia.  Fantastic.

Now the work begins.

International medicine is such a broad field that whenever I am approached by a physician who wants to work overseas I always ask them to tell me a little about their overall goals.  Do you want to make international medicine a career pursuit?  Is your goal to work short-term in a variety of locations while holding a full-time position back home?   Where do you see yourself in 5-10 years?

It’s true that life has a way of rerouting even our best-laid plans, but it’s always better to have some sort of plan before embarking on a new career pursuit.  For those that don’t really know where to begin, I recommend the following:

1. Just get some experience

You can’t go wrong just getting a few short trips under your belt.  Whether you want to simply dabble in international health as a side career or begin to build a full-time career as an international medicine specialist with hopes of leading  a non-governmental organization (NGO) or academic research group, the place to start is with a few short volunteer trips.  No NGO or credible organization is going to actually pay you to do international health if you’ve never worked “in the field.” If you ask any seasoned person in international medicine, they always say time in the field is one of the biggest criteria they have for important hires.  You might be brilliant. You might have great “people skills.”  You might have incredible letters of recommendation, but if you’ve never packed your bags and lived in a remote place for a time providing medical care, then you’re basically an untested commodity.  No credible organization will take a chance on an untested person and place them in a position of responsibility if they can avoid it.  If you want to make international health a part of your life, you need to get some experience.

Where do you go to get experience?  Well, there are two easy places to begin.

First, visit your local faith centers or nonprofits and see if there are any positions available for volunteer physicians overseas.  In today’s world, you’d be surprised how many local religious organizations and nonprofits are sending people to obscure places and would absolutely love to have a physician come along (especially if the physician is paying their own way—and you need to be prepared to pay your own way in the beginning).  This is a great way to practice preparing for a trip, evaluating the medical gear you will and will not need, working with others (not a physician strong suit typically), and working in an unfamiliar environment.  Many individuals who go on to formal international medicine careers begin as volunteers in positions just like this. 

Second, there are multiple locum tenens companies who are placing more and more physicians in foreign environments.  Obviously, working in a fully staffed hospital in Australia is much different than working in a remote clinic like the Everest Base Camp ER, but you have to start somewhere and using a locums company like Global Medical Staffing to get your initial experience internationally can be a good place to start. 

2. Network

I’m not a fan of joining organizations simply for the sake of joining. However, there is a lot to be said for joining a couple of organizations in the beginning and attending a few medical conferences designed for international medicine, especially if you don’t have a lot of connections in these fields already.

In the United States, the three organizations that seem to most help individuals looking for opportunities in international medicine are (in no particular order) the Wilderness Medical Society (WMS), the International Society of Travel Medicine (ISTM), and The American Society of Tropical Medicine and Hygiene (ASTMH).  All of these organizations offer medical conferences where you can meet potential mentors and network with other event participants.  In addition to these organizations, there are a couple of private conferences that always garner great participant reviews.  The first is our ExpedMed events (yes, I direct these events and I am biased, but we do get great reviews and we draw top talent from the WMS, ISTM, and ASTMH, as well as many academic institutions, as speakers each year).  Information on ExpedMed can be found at www.ExpedMed.org  .  The other private group that always receives great reviews are the folks at  www.Wilderness-Medicine.com  .  Yes, I guess the reality is that these guys are really competitors of ExpedMed, but we use some of the same faculty and we consider them friends, so I don’t have a problem recommending them. 

I’m sure there are plenty of other great organizations and events that I could mention here, but these are the ones I hear about the most and the ones with which I have personal experience.  If you need a good place to start, I’d begin with one of these entities.

3.  Read

It goes without saying that if you’re interested in a career in international medicine you should be reading about the subject.  There are some great journals and textbooks out there, including our Expedition & Wilderness Medicine textbook, but don’t just stop there.  Read blogs about international medicine.  Get some adventure stories that are non-medical but involve international health in some fashion (Shackleton’s adventure for instance or Teddy Roosevelt’s River of Doubt journey).  Use these resources to not only stimulate your desire to travel but also to learn the history of the field you’re entering.  Oh, and when you read the academic work, don’t just read for clinical knowledge, read to see who the authors are and where they’re working. Look through the bibliography and see who is cited and where the research is taking place.  You never know where this sort of “sleuthing” might take you or what connections you might make.

4. Investigate formal training opportunities

I say "investigate" because depending on your career goals you may or may not need/want formal training. However, it's worth looking into since there are some great programs to teach things like tropical medicine or public health in disaster situations.

For Emergency Medicine specialists, formal fellowships in International Emergency Medicine are available around the country.  I completed one of these programs at Johns Hopkins in 2004, and really enjoyed the experience.  I wrote a prior post on the subject of International Emergency Medicine and for EM docs looking to move into the world of international medicine in a formal way, a fellowship is a great way to jump-start the process.

If tropical medicine is your thing, there are some excellent 3-4 month courses around the world that offer intensive tropical medicine education.  The two most famous are the Gorgas Course in Lima, Peru, and the course at the London School of Hygiene & Tropical Medicine.  I have friends who have graduated from and teach at these events and both are widely respected. You can check out a prior post here on Freelance MD that serves as an introduction to these courses.

The Health Emergencies in Large Populations (HELP) course is a great way to get exposure to handling public health issues after disasters (more information on this course can be found here ), and for those who really want to go deep, a Masters degree in Public Health from a university with an international focus like Hopkins or Harvard, will significantly broaden your view while deepening your understanding of international public health issues.

These tips should get you going and when you have some experience under your belt and some colleagues in the field to call, you’ll be surprised at the opportunities that begin presenting themselves.  

International Emergency Medicine

Here's a career focus that has tremendously expanded over the past decade for Emergency Medicine physicians:  International Emergency Medicine.

Not too long ago if you were an Emergency Physician and you wanted to do international work, you simply picked a geographic location and went.  There was no formal training and most practitioners learned by doing. 

While much of the international work done by these hardy individuals was well intentioned, many reported that it was difficult adjusting to a foreign assignment, especially in a remote region.  Few of these physicians had any training in tropical medicine and even fewer had exposure to public health.

In the 1990's a group of Emergency Physicians with extensive experience in international and remote medical care came together to attempt to codify the training needs of physicians who were going to similar locations.  Out of these discussions, a formal curriculum was recommended and fellowship programs in International Emergency Medicine began to spring up around the country.

I was fortunate enough to have been one of these International Emergency Medicine fellows from 2002 to 2004.  Our program included training in public health, clinical shifts at our academic institution, and extensive field work overseas.  It was a great experience and opened the door to a thousand opportunities for me that completely altered the trajectory of my career.

In 2004, towards the end of my fellowship, we published a review article in Prehospital and Disaster Medicine that reported on the International Emergency Medicine fellowships offered around the country to EM trained residents. You can read that article here . When the article was published, there were eight programs available. I find 23 on the website of the Society for Academic Emergency Medicine now.

Of course, there are detractors. When I told people I was going to extend my training for two years to do a fellowship in International Emergency Medicine, a number of my colleagues questioned whether this would be a good investment of time. Why not just sign up with an international organization and go?  Why lose two years being a fellow when you could be overseas gaining experience, or working in an emergency department somewhere paying off school loans?

I wasn't sure how to answer these questions when I decided to do the fellowship.  At the time, I just thought it was the right thing for me and I was really excited about the opportunity.

In retrospect, it has turned out to have been a pivotal moment in my career and an excellent investment of time. The fellowship in International Emergency Medicine  exposed me to leaders in international medicine. It trained me in public health. It offered me incredible opportunities to perform field work in remote locations all over the globe and it taught me how to think like an academic physician-- how to research, how to teach, how to write.

So the question is, if you're an Emergency Medicine doc and you're interested in international work, should you do a fellowship in International Emergency Medicine? 

My answer: it depends. 

It depends on a lot of factors including where you see yourself in five years and what your long-term goals are for your career. Not everyone has to do a fellowship to do international work. I know plenty of physicians who are not fellowship trained who do short-term international work and absolutely love it.

However, if international medicine is something you think you would like to do full-time as a career focus, then a fellowship might be the right move for you. The longer you spend overseas in remote areas the more important training in public health becomes. Also, the connections you make through a fellowship can open up job opportunities that you never would have found otherwise.

For those who are EM trained, fellowships in International Emergency Medicine are a good place to start a career in international health.