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.

Evaluating Your International Contract & Employment Opportunity: Questions For Your Potential Employer

Evaluating contracts and employment positions overseas is much like evaluating these things in the States, with a few unique issues that should be discussed prior to signing. 

Here are a few of the questions you should ask any international employer prior to agreeing to a contract.

1. Transportation

If you take a position in another country, by definition you’ll be traveling to another place for your work.  A good question to ask your employer is who will be paying your relocation expenses. 

Some companies will employ you once you arrive at their facility overseas but require you to foot the bill for airplane flights and shipment of your personal items.  Other companies will cover your plane tickets and help cover the costs of shipping your personal items, but will require you to cover anyone in your family who is traveling with you.  The best arrangement for you, of course, is if the company agrees to cover the airfare for you and your family plus the shipment and/or storage of your personal belongings.  It’s important that you ask about this issue up front since you want to be sure to budget for any necessary expenses.

Once on the ground in your new “home,” be sure to ask how you’ll be traveling from home to work and around town.  Can you take public transportation?  Does the company provide a vehicle or do you need to provide your own?  If you are responsible for your own transportation, are there options to rent a vehicle or do most employees buy? 

If you will be driving yourself, be sure to ask about driving laws and restrictions.  Driving regulations can differ significantly from country to country and in some nations, driving may not be allowed.  For instance, in Bermuda, visitors are not allowed to rents cars (only scooters) while in Saudi Arabia, women are not allowed to drive.  Always remember that when you are in a foreign country, you are under the laws of that country.  As strange or unfair as some of the regulations might appear to you, the “that’s not how we do it back home” defense rarely flies when stopped by local authorities.

2.  Housing

An important aspect of your new employment will be discussing where you will live.  Good questions to ask your future employer are whether housing will be provided and if so, will you be given a certain house to use or a housing allowance? 

The house versus housing allowance issue is more than simply semantics.  A housing allowance gives you more flexibility, but a house protects you from rising house rental prices and other possible uncertainties.  For instance, if you are given a housing allowance you can shop around for accommodations that fit you better—a larger home for a family with children or maybe a flat in the city if you’re single.  However, if you are given a house, you are protected somewhat from the rising cost of rent or the uncertainty of where you will live once you arrive.  Regardless, this is a good conversation to have with your employer from the outset.

Another housing question to be considered is how far the housing is from your work site.  A home across the street from work is a big difference than one located out of town.  I have friends, for example, who actually live in the country of Bahrain and commute into the country of Saudi Arabia each day for work.  Yet another question is whether you have veto power over where you live.  If you arrive and the home you are given seems unsafe or unclean, can you move to another location or are you stuck with what’s been given?  Last, an often overlooked aspect of housing is who pays the utilities.  In a country with temperature extremes, this could make a significant difference with your monthly bills.  Find out in advance who is responsible for the utilities as well as who to call in case of maintenance issues (and who pays for any repair bills). 

3. Salary and Cost of Living Issues

Obviously, when you are negotiating a contract with any employer, salary needs to be discussed.  However, when working in a foreign country it is important to ask in what currency you will be paid.  It makes a big difference whether you are paid 80,000 US dollars or 80,000 pesos, for example.  Also, remember that since you are living in a foreign country, international exchange rates now affect your monthly income and purchasing power in obvious ways.  With the falling US dollar, many expatriates I know who are paid in USD’s have seen their relative income drop every year.  The flip side of this equation is that if you are paid in a foreign currency that is rising against the US dollar, you are in affect getting a raise each year relative to your income back in the States.

Be sure to accurately estimate your living expenses each month.  We’ve already discussed transportation and housing costs, but be sure to look into such monthly expenses as food and the cost of standard household items like toothpaste, soap, cleaning supplies, etc…  In some countries these things will be extremely cheap, but in others they could be very high.  Just make sure you know what you’re getting into.

4.  Other Issues to Consider

There are always lots of little loose ends to consider when making a move to work overseas.  There’s no way to cover everything, but a few more things to keep in mind and ask about prior to departure:

• What about education for children?  Are there educational opportunities for your kids and if so, who pays.  I know certain Oil executives who have their children’s school tuitions written into their contract as part of their benefits package.  In some countries, the price of an English-speaking school is very high.  In other countries, it simply isn’t available.
• Have a plan to deal with any chronic medical issues you or your family may have.  Try to pack a few months worth of any necessary meds and be sure to ask about healthcare in the region.  If you’re the only medical professional within 100 miles, you need to know this going in and plan accordingly.
• Who actually is your employer?  This sounds like a silly question except sometimes it’s a difficult one to answer.  Depending on how your contract is structured, you might be an employee of the hospital, or a placement company, or some other entity.  If you sign a contract with an American company that then places you overseas, you in theory have more protections (due to American labor laws) than if you sign directly with a foreign company or government.  Foreign contracts are subject to foreign law, which may differ significantly from American law. For instance, in some countries, an employer can fire an employee for any reason without any notice whatsoever, without appeal.  If your contract is with an American employer, however, you should be given due process during any contract issues and at least have the security of knowing that you are protected under US state and federal labor laws.
• Be sure to ask about health insurance and whether you have American health insurance, health insurance applicable to your employment country, or both (or neither).  I know many expats who have had difficulty with this issue.  In some cases, the expat gets sick in the foreign country only to find out their health insurance only applies to American healthcare.  In other cases, an expat back home on leave gets sick and finds out their health insurance does not cover American healthcare, only healthcare in their country of employment.  Be sure to look into this issue prior to signing your contract and plan accordingly.
• The issue of pets is another one that can be very difficult.  Are pets allowed where you will be living?  Are your pets even allowed in the country in which you’ll be working?  In the Middle East, for instance, many breeds of dogs (specifically certain bulldog breeds) are not allowed into the country.  Exotic pets such as snakes and other unique animals are often difficult to bring into another country for any reason.  If you cannot bear the thought of leaving FiFi behind with friends or family while you’re away, make sure this issue is discussed before you sign a contract.

Working overseas can be a very rewarding experience.  Use these tips to avoid some common pitfalls and you’ll make your overseas experience a lot more enjoyable.

Motor Vehicle Travel: The Real "Death Zone" of International Travel

How do most physicians die in international medicine?

Here’s a pop quiz:  The most dangerous thing you and your companions will do while on your next expedition is:

(A) Trek to 14,000 feet while trying to avoid altitude sickness

(B) Push through that jungle trail hoping not to pick up a malaria parasite along the way

(C) Dive deep in the ocean while dodging Great Whites and the Bends

(D) Drive from the local airport to your hotel

If you answered “D” then give yourself a prize.

When most people think about international travel risks, they think about terrorists, wild animal attacks, exotic infectious diseases, or some other uniquely international threats such as lava flows or voodoo hexes.  However, many people are surprised to learn that statistically, the most dangerous thing they’ll do during their international trip is drive in an motorized vehicle.  Mountaineers talk about the “death zone” on a high-altitude peak, above which life is very sketchy.  For most international travelers, their “death zone” is a busy road in an unfamiliar international location.

According to an article published in the Public Health Reports , the most common way American civilians die abroad (excluding chronic "natural" causes such as heart disease or cancer that roughly correlate with typical US death rates for age and gender) is in traffic accidents.  The only recent exception to this rule is humanitarian workers in areas of conflict—in these cases intentional violence is the most common cause of death .

With so many people dying on the roads while traveling abroad, what are some basic travel-safety tips for medical officers to consider?  Below is an excerpt from the Travel Safety chapter of our Expedition & Wilderness Medicine textbook that was written by Dr. Michael VanRooyen, Director of the Harvard Humanitarian Initiative:

Consider a few practical tips for traveling via automobile when traveling abroad. This includes avoiding the temptation to drive yourself.  If you can hire a local driver, you might get a better sense of the region you are traveling, and if there is a traffic mishap, you are not held directly (and financially) accountable.  If you have to drive, take your time, know where you are going, and seek major routes.  It is also wise to avoid driving at night. Navigating the poorly lit roads in Nairobi in an unfamiliar vehicle, with many pedestrians walking along the road (as there are very few sidewalks) is a recipe for disaster, both for the person or persons you may hit, and for you. 

Helpful hints while driving abroad ( http://danger.mongabay.com/ )

• Become familiar with your vehicle in less crowded conditions
• Don’t drive at night
• Drive slowly and in control
• Avoid large gatherings or busy markets
• Wear a seat belt, always
• Avoid driving when you are suffering from jet lag

If you need to rent a car, look for a common type vehicle from a reputable dealer, and make sure the car is in good working order, making note of any preexisting body damage.  Consider getting a car with air conditioning so you can have the windows rolled up and the car locked when you are in it.  If you encounter what appears to be an informal road block or rocks across the road creating a makeshift barrier, there is a good likelihood that these are ploys to get you to stop. Turn around and drive away. Carjackers and thieves work in very organized groups around service stations, parking lots, markets and along major highways.  Be suspicious of anyone who flags you down, or points to your car to indicate a flat or an oil leak, hails you or tries to get your attention when you are in or near your car.

Also, it is generally unwise to rent a motorcycle or motor scooter.  While locals may be whirring conveniently around, nimbly navigating through traffic, as an outsider you have a reasonable chance of becoming a hood ornament, and being forced to be content with the local health care system. Many organizations who deploy field staff, the US Peace Corps included, have long since discouraged the use of motorcycles or scooters for their staff. 

When my wife and I first moved to Doha, Qatar, a very busy urban area well-known for its aggressive drivers, we opted to drive a very solid Toyota Land Cruiser and practiced our driving during times when traffic was less.   Within a short while, my wife and I could easily negotiate the local roundabouts without difficulty and had no problem following the rules of the road.  However, had we not taken our time to get acclimated to the new driving scene, we most likely would have had some problems.

Motor vehicle accidents are a serious problem and a leading cause of death for international travelers.  However, by following some common-sense tips for motor vehicle safety when traveling, you’ll do much to ensure the safety of yourself and your traveling companions.  Be aware of the risks while traveling in your international “death zone” and you’ll up your chances for a safe and enjoyable time while overseas.

Expedition Medicine National Conference

I wanted to make sure that the Freelance MD community knew that our 2011 Expedition Medicine National Conference will be this September 16th-18th at the Omni Shoreham Hotel in Washington, DC.

This is the five-year anniversary of our event in Washington, DC and it's been gratifying to receive all the positive feedback about the event from the hundreds of physicians, nurses, paramedics, and other medial professionals who have attended past conferences.  Here's a sampling of quotes we've received on our evaluation forms:

“Great conference…first class…the first CME event I have ever attended where I felt I got my money’s worth."  -Richard Knight, MD, Emergency Medicine, Ft. Worth, Texas

“Great experience…incredible speakers who have traveled all over the world and are speaking and educating from firsthand experience…lessons learned are priceless! Thank you." -Sapna Parikh, MD, Fox News Medical Correspondent, New York, New York

“Sorry, all 5s on the evaluation doesn’t help much, but it was that awesome!” -Mark Schwab MD, San Diego, CA

“This was the first conference I’ve attended where I’ve gone to ALL the lectures and looked forward to the next day! The speakers were great – knowledgeable, passionate about what they do, entertaining. I also like the historical info on the infectious diseases and the personal adventure stories.” -Alexia Gordon MD, Virginia

“This conference is truly one of the best I have attended in 50+ years of actively practicing medicine. All of your speakers were outstanding. The material was very interesting and useful to my activities.” -Joseph English MD, Pennsylvania

This year, we have an incredible line up of expert faculty and topics for participants.  For those who have never attended one of our events, we take pride in advertising our faculty as the "best in the business" for medical education.  Our experts our selected based on their demonstrated expertise in their content areas, their significant field experience, and their teaching ability.

Since this conference is about medicine in wilderness areas and on expeditions, it does you, the participant, no good to hear canned lectures from speakers who have never been "in the field." At the Expedition Medicine National Conference all our faculty have significant field experience and are teaching what they actually do when they work in austere environments (not just what they've heard works in these locations). 

Each of our faculty also are excellent communicators and many have received national teaching awards for their demonstrated excellence as educators.  Our course participants remark each year how amazingly talented our faculty are at communicating their material, and how delighted they were to hear the presentations.

For 2011, the following faculty will be teaching at our Expedition Medicine National Conference:

Dr. David Shlim, co-editor of the CDC "Yellow Book" and Travel Medicine expert from Jackson Hole, Wyoming

Dr. Michael Callahan, Infectious Disease specialist from Harvard and Darpa

Dr. David Townes, Associate Professor at the University of Washington and co-editor of Expedition & Wilderness Medicine 

Dr. Eric Johnson, past president of the Wilderness Medical Society and international expedition physician

Dr. Alan Magill, president of the International Society of Travel Medicine and co-editor of the CDC "Yellow Book"

Dr. Peter Hotez, Professor and Chair of the Department of Microbiology, Immunology, and Tropical Medicine at George Washington University 

Dr. Christina Catlett, Associate Director of the Johns Hopkins Office of Critical Event Preparedness and Response (CEPAR)

Dr. Tim Erickson, Director of Clinical Toxicology and Vice Chairman of the Department of Emergency Medicine at the University of Illinois-Chicago

Topics scheduled for our 2011 course include malaria, travel immunizations, hypothermia, high altitude medicine, dive medicine, lightning injuries, reptile envenomations, expedition toxicology, rabies, and disaster medicine among others.

All participants will receive 20 Category I CME credits and a free copy of our textbook Expedition & Wilderness Medicine (sells for $150).

Anyone interested in a possible career change into international health or simply wanting to learn more about some very cool topics (and meet some very cool faculty) is encouraged to attend this event.  I'll be there and I hope we have a good turnout of people from the Freelance MD community.

ExpedMed's CME Polar Bear Adventure: Why You Should Go

Hopefully, you've seen the advertisement here on Freelance MD about our 2011 ExpedMed CME Polar Bear Adventure (during October 20-25, 2011). However, I wanted to take a moment and explain why I think this is such an incredible opportunity for our Freelance MD readers.

In a recent Freelance MD post, Dr. Barry Silbaugh, president of the Americal College of Physician Executives, mentioned that it sometimes takes getting away from it all to have one of those "epiphany" moments that end up being life-changing.  

Here at Freelance MD we're committed to providing opportunities for our readers. We provide these opportunities in multiple ways-- by recruiting excellent authors for our site, by recommending products and services that we believe can be beneficial to today's modern physician, and by creating events in which our readers can participate that can lead to significiant life-change. The ExpedMed CME Polar Bear Adventure is one of those potentially life-changing events.

In late October I will be leading a team of adventurous medical professionals to Churchill, Canada to see the famed polar bears of this region. Churchill is located right on the Hudson Bay, one of the first portions of the Arctic ocean that freezes every winter. In September and October, polar bears come from miles around to await the freeze so they can move onto the ice to hunt seals.  During these months, there is no better place to see polar bears in the wild than Churchill, Canada.

You can read more about the specifics of the trip on our here.  I'll summarize the page simply by saying that the trip will be a lot of fun, you'll earn 25 hours of CME credits for your participation, and you'll get two nights in the famous Tundra Buggy Lodge during your five day adventure. 

However, this trip is more than polar bears and earning a chunk of CME credit.

When I speak with physicians around the US-- and I speak to a lot of them each year-- many seem overwhelmed, despondent, trapped. They're not sure what their next step should be and they're afraid of making a mistake. They're in need of more than simply a job tweak, they're really in need of some life inspiration.

Yes, there are those who have been inspired in their daily work environments, but there's just something about leaving the comforts of your home, going some place truly wild, and taking your mind off your practice and your daily woes that helps refocus your energies and plant the seeds of something new and exciting in your life. It's difficult to be distracted by the problems with your medical billing company when a 1,500 lb creature is staring at you from a few feet away. It's much easier to dream big dreams when your cell phone and pager aren't constantly buzzing and the only "static" you're taking in is the snowfall on the Canadian tundra.

Life is busy. Medical life is especially busy.  This CME adventure is designed to slow everything down and take you away...far, far away.

Ultimately, our hope with this CME adventure is to take you out of your comfort zone, expose you to a magnificent wilderness and some incredibly majestic wild creatures, and help you get your priorities in order (and give your problems a little perspective). You can't do this at home and you can't do this online.  You have to untether yourself from your busy world and make a break for it.  

If you've been looking for an excuse to take a break, this is your opportunity.  This trip will enable you to create memories with other like-minded individuals in a remote wilderness setting that you'll never forget.  

Come with us to Churchill in October and meet other members of the ExpedMed and Freelance MD communities. Earn some CME credits and return home recharged and refocused. Stop making excuses and quit the whining. Take charge of your career and remember this quote from Helen Keller: "Life is either a daring adventure, or nothing."  

The ExpedMed Textbook: Expedition & Wilderness Medicine

For those of you who are interested in learning more about Expedition Medicine or Wilderness Medicine, I'd like to mention our textbook, Expedition & Wilderness Medicine, that was recently published by Cambridge University Press.

This textbook is used as the syllabus for our Expedition Medicine National Conference and also as a teaching tool for many other courses and organizations around the globe.

The textbook is a hardcover text over 700 pages in length, with full-color photos and diagrams.  We recruited more than sixty experts from around the world who contributed content for this project.  Contributors include many notable individuals such as 

Richard Carmona, MD, MPH, FACS: 17th Surgeon General of the United States

Luanne Freer, MD, FACEP, FAWM: past president of the Wilderness Medical Society and founder and director of Everest ER

Ken Kamler, MD: Vice President of The Explorers Club and author of Doctor on Everest

Richard Williams, MD, FACS: Chief Health and Medical Officer for NASA

Peter Hackett, MD: Director, Institute of Altitude Medicine

We have been pleased to read many favorable reviews of our book in multiple journals including the New England Journal of Medicine and JAMA. Here's an excerpt from the JAMA review:

Expedition&Wilderness Medicine, edited by Bledsoe, Manyak, and Townes, is a comprehensive guide to the multitude of issues facing the expedition physician. The book is organized into 3 sections covering expedition planning, specific and unique environments, and specific wilderness illnesses and injuries. The comprehensive and often humorous chapters have been edited in a style that allows for easy reading, and they include numerous excellent illustrations.

Several of the chapters are written by some of the world’s authorities on the topic. Not only have many of the authors published widely on their areas of expertise, they have spent considerable time in the field. The authors have diverse experience ranging from serving as the expedition physician on a climb of an 8000-m peak in the Himalayas to providing medical care to a patient injured thousands of feet underground in a Mexican cave. This experience—and the willingness of many of the authors to illustrate ways to avoid future problems by describing their own misadventures in the field—contribute to the strength of this text.

Expedition & Wilderness Medicine is a must-read before any expedition. It carefully details what an expedition medical kit should contain, along with details on what to consider taking along for toxicological and dental emergencies. Although this book is aimed at the expedition and wilderness medicine physician, many of the chapters are superb summaries of core emergency medicine knowledge that are better distilled and presented than chapters in some more traditional textbooks of emergency medicine. We recommend this text to all who practice acute care medicine and all physicians who hike, climb, or vacation outside the city or who might encounter anyone else who does.

Jones ID, and CM Slovis. JAMA. 2009;302(4):442-44

We'll be writing more about opportunities in Wilderness Medicine and Expedition Medicine here on Freelance MD, but for those of you who need something to begin your journey, pick up a copy of our textbook online or attend our Expedition Medicine National Conference and receive the book for free.

Begin a Career in Wilderness Medicine: Dr. Eric Johnson

I sat down with Dr. Eric Johnson at our Expedition Medicine National Conference to ask him about his career in Wilderness Medicine.  

Dr. Johnson is a past president of the Wilderness Medical Society and has twice served as a physician at the Everest Base Camp Clinic.  In this interview, Dr. Johnson discusses his involvement in Wilderness Medicine, how individuals can get involved in Wilderness Medicine, and then gives his thoughts on our Medical Fusion Conference.