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.  

Locum Tenens As A Physician Career?

By James H. Bledsoe, MD, FACS

Locum Tenens can be a rewarding, if non-traditional career for the right physician.

With all of the  changes that medicine is experiencing, I felt compelled to write about my time spent as a locum tenens general surgeon. My experience is probably similar to many who already are going to places where their services are needed and very much appreciated. Having said that, I must state that there are no two physicians that have the exact same reasons to do locums nor are all of the assignments the same.

After serving two years in the Air Force, assigned to a regional hospital, I started private practice in Arkansas in what was a  small community hospital in 1976. I was there for a year and a half before moving to a larger community hospital. Even though the hospital had only 165 beds, it was a very well run institution with great services. As a general surgeon, I was called on to perform major vascular and thoracic cases. My associates and I were repairing abdominal aortic aneurysms – both elective and ruptured. During that time we performed three distal spleno- renal shunts for bleeding esophageal varices. On two occasions we performed extra-anatomical grafts for infected aortic grafts. Some of the many thoracic procedures included pneumonectomies and esophageal resections. Since I was responsible for the patients’ follow-ups, I can state with certainty that with very few exception these patients did well.

During these years, we had a significant number of major trauma victims and unless they had a bad head injury we took care of them. I will not dwell any more on the types of surgical cases I was involved in, but suffice it to say it was varied and many patients were involved. Early on we had no blood bank or arteriography capabilities. The arteriograms were done in a facility 25 miles away and we obtained blood from the blood bank 75 miles away. No ultrasounds were available much less MRI nor CAT scans which came later. Discussion of the logistics involved under these circumstances is for a later date.

In my own personal practice I was starting to stay more with strictly general surgery which by now included laparoscopy. Vascular and thoracic surgeons were starting to open practices in our area so the decision to limit doing these cases was much easier.

Also, the politics in medicine was becoming a real issue. Physician practices and hospitals were being bought up and this created awkward situations for referring doctors to send patients to a specialist outside their network. Referral lines that had been present for years were disrupted. In short, instead of medicine being in large part a ministry it was becoming business. Physicians were now working for their respective corporations -  not their patients.  I am not necessarily saying that this is altogether a bad thing but it was quite different.

Another factor in my life was that my children were now married. My oldest son is an Emergency Medicine physician working in Alabama, my other son is a surgeon working in Louisiana, and my daughter is on maternity leave as an attorney for a law firm specializing in malpractice defense.

The factors mentioned plus I am trying to slow down all played roles in my decision to look for a change. Locum tenens appeared to be a viable possibility. It certainly seemed better than retirement.

I knew very little about locums so I had a lot of learning to do. Still I was so certain  that I was ready to change courses that I stopped my private practice and began my research. I signed on with two locums companies and within weeks I started assignments with them. My first assignment was in New Hampshire and I was able to start immediately because in this state you can get a temporary license. (Not all states have this provision and in most states it takes as long as six months to receive a license so it is wise to be proactive so that you can keep gaps in your work schedule at a minimum.) Since I am classified as an independent contractor, I must with hold my own taxes. I do this by having a separate bank account and pay my quarterly taxes out of this. Also, I have to have my own personal health insurance. At the onset of my locums career this latter was daunting but it worked out by looking at all of the options.

All of the locums companies I have signed on with have similar pay scales. They all cover your travel expenses and malpractice premiums. Speaking of malpractice coverage, I had to pay for my tail which consisted of one year’s payment coverage that I had with my old company and the locums group covers me while I work for them. I had one lawsuit filed against me in my 29 years of practice before locums and it was dismissed with my insurance company not having to pay anything. However, just the fact that I had a suit filed against me was a red flag in all of my applications. I  had to document everything. What I am saying is that malpractice issues may not preclude a physician from working as a locums provider but it will be a big issue when applying at a hospital.

The other expense is lodging and this is usually provided by the hospital where you are working. In fact, some hospitals allow their on call physicians to eat there with no charge. Basically, your overhead is very low doing locums.

Another aspect I greatly love is that you can decide if you want to work at a particular location and for how long. All of this will be decided before you arrive at a location and I can say that all parties have been very accommodating in this regard.

One thing I must strongly advise physicians in accepting an assignment is to be certain about your skills and what you ask for regarding privileges. For example, one of the small hospitals I was scheduled to work in required general surgeons be able to perform C-sections. Before I agreed to come I made it clear that I would only do C-sections as an absolute emergency. This particular hospital was isolated and in a few instances the only safe thing to do was have the best medical personnel available perform whatever had to be done.

Along the same lines, all operating rooms have some differences. It takes a little while to feel comfortable with the personnel and their capabilities.  Some of the after hours personnel are not as familiar with the laparoscopic equipment, especially the instruments. Some cases have to be converted to an open procedure if for no other reason due to a safety aspect. Also, there is a wide variety in surgical instruments, not just laparoscopic, at each hospital. The larger the hospital where you are assigned, the less chance these issues become a real adventure.

I have doing locums since June 2005 and I am very glad I am doing it. It is not for everyone. If a physician still has children at home, I would not recommend it. My wife accompanies me when she can especially on long assignments. I have worked for as short a period as a weekend and as long a time as two years. I can definitely say that all of my assignments have been good with some better than others. I am licensed in six states and this is all I plan to keep current as there are plenty of opportunities to work.

Regarding the location, time, and frequency of work is pretty much the choice of the individual practitioner once you are established into the system. The more you work, the better will be your compensation. All of the locums companies pay a certain amount on a daily basis guaranteed. After six or eight hours, depending on the company and the work situation, you are paid an amount per hour overtime. Working at a Level II Trauma Hospital will pay more than a less active community hospital and obviously the more overtime accrued the more the compensation. I feel the pay structure is very fair.

In summary, for physicians who are tired of the hassle of private practice but want to stay fairly active, locums should be considered.

James H. Bledsoe,MD,FACS

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