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. 

Someone Needs To Run The Asylum: Why Physician Leadership Is The Answer

We physicians are understandably worried that the push to save money in health care will compromise the care of our patients.

We have witnessed botched attempts to balance the health care budget on the backs of providers and patients: arbitrary reductions in length of stays, denial of payments for "unnecessary" procedures, capitation, etc.

Physician leaders have an opportunity today to lead the way forward to improve care and save money. The solution is quality, measured by patient centric metrics. Physician leaders need to set the bar high and demand consistent patient centric quality care from all of their colleagues.

A true story (the names have been changed to protect the guilty) serves as an example of an opportunity to increase quality and reduce health care costs.

I received a call last week from my cousin Cheryl, who lives in a suburb of Philadelphia. Cheryl has a neurological disorder that is exacerbated by stress. By the tone in her voice it was clear her health was at risk.

Her 50 year old husband, Ron, was admitted at 0200 on a Saturday to a local hospital after awakening with severe sub sternal chest pain described as "someone sitting of my chest". Ron has a well documented history of GI reflux, but also has multiple risk factors for coronary disease.

Ron's ECG was normal and his initial set of cardiac enzymes were normal. He was admitted to the hospital service of a cardiologist. Cheryl was calling at 1100. The cardiologist had not yet seen Ron. When Cheryl questioned the nurses about the expected time of his arrival, she was told that Dr. Jones had made his rounds already and would not be back until the next day.

Cheryl had, understandably, some important questions that she would have loved to ask the cardiologist. Did Ron have a heart attack? Did Ron have something else wrong with his heart? How serious was the present scenario? Should her 20 year old daughter take the train from her University in Maryland and miss her classes next week? Should Cheryl inform her chronically ill elderly mother of the situation? How long will Ron be incapacitated? Who would help her in his absence?

Dr. Jones showed up early Sunday morning. He was covering for several other cardiologists and had limited time to answer Cheryl's questions. He did inform her that Ron did not have heart attack. He might have cardiac disease, however, and therefore could not go home until a stress test was performed. Since it was Sunday, the treadmill could not be performed until Monday morning.

Ron did have the treadmill performed on Monday (late in the afternoon; there were others waiting as well). The treadmill was normal and a GI consult was ordered. Ron had the sense to check himself out of the hospital rather that wait another day for the gastroenterologist.

I don't claim to know the culture of cardiology throughout the country. I do know, however, that there is no hospital in the Seattle metropolitan area where this scenario would have occurred.

Because of effective physician leadership the cardiologists and ER physicians in our area have instituted chest pain observation units for just this sort of problem. If Ron was visiting me when this unfortunate incident occurred, he would have been admitted to a chest pain unit and, when the third set of enzymes came back negative, he would have had a diagnostic test and discharged within 24 hours. The family would have received appropriate answers and short term outpatient follow up.

The family would be happy to have their loved one home quickly, to have their anxieties addressed and resolved. His care in a chest pain observatory unit would not only have provided patient centric quality, but would have saved two days of unnecessary hospitalization costs. Multiply the thousand of dollars saved here by the number of times this kind of scenario occurs and fat, not muscle, disappears from the health care budget.

Physician leaders should be examining the way health care is delivered from a patient centered perspective. Influencing their colleagues to rethink outmoded physician centric behavior will require the mastery of leadership skills. The alternative is to let the lunatics continue to run the asylum.

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.

Swept Up In Sweeps

Sweeps is a four week period that occurs four times a year to closely track ratings, in general and among certain demographic groups, for the purpose of setting advertising rates.

So, how do health and medical stories get picked for sweeps?

Let's look at a few examples.

• Previous proven performance. Just in the first two weeks of February (a sweeps month), I've had only one planned report. It was about an at-home obstructive sleep apnea screening device. I was appointed this assignment because pieces about sleep apnea tend to get good ratings in this market.
• Apparently allergies, particularly pollen allergies, also test well in this market.  As a variation on a theme, I was gievn a piece on food allergies, too.
• Sheer numbers. Another piece worth mentioning was about the higher risk of stroke and heart attack associated with diet soft drinks. This came from a study being presented at the American Stroke Association meeting. Of note, this broke on the same day as the study from JAMA about leaving lymph nodes intact for women with early stage breast cancer.  Because more people drink diet soda than have breast cancer, the former topic wins.
• Some challenges arose. Because the data was not yet published, not all of the figures I was interested in were available to me -- absolute risk, for instance, as well as the risk for the group that only drank regular soda.  Also, all of the stroke neurologists in my city were at the conference.  I ended up interviewing an internist who specializes in diet, nutrition, and weight loss for his perspective.  Because of the preliminary nature of the data and the study design that cannot prove cause and effect, I simply stated the attention-grabbing finding, tried not to vilify diet soda, and made it a point to say the information was being presented at a meeting.
• The buzz.  It's unfortunate a reporter had what appears to be a transient ischemic attack during a live shot at the Grammys, and some say it's unfortunate this unintentionally public medical event became news.  But if you looked at social media sites, or dropped by the water cooler, it was topic of much discussion.  I did not disagree with my bosses on this one -- this was newsworthy.  As a retired neurologist, I saw it as a valuable teachable moment: a TIA is a medical emergency.  I also included a short differential diagnosis in my report, something many of my colleagues did not do in their reporting, so as not to definitely declare this was indeed a TIA.

These aren't the only factors, of course, and we can look at some others the next time sweeps comes around. But it gives you some idea of how news organizations think, and how you and your patients get their local TV news. 

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Trust Between Physicians - Part 2

Is it possible to develop trust where there is none?

In my last post on whether trust between physicians is possible, or necessary, I talked about how having trust or lacking trust (both within interpersonal relationships and teams/organizations) changes everything.  It is indeed one of those "must haves" for anyone who desires to move up, be successful, or simply be fulfilled in their personal and professional lives.

After exhaustive research and experience with individuals and organizations, here are the "truths" about trust (from Stephen M.R. Covey's excellent book "The Speed of Trust") ... see what you think:

Truth #1:  Trust is Possible

Many people believe that trust is just one of those things - either you have it or you don't.  But this has been shown to be simply not true.  Trust is something that can be developed over time, and that has an element of contagion that will positively impact those around you.  Trust can be effectively taught and learned, and it can become your leverageable, strategic advantage.

Truth #2:  Trust Begins With You

Trust is not a "soft" nice-to-have.  It is hard, measurable and concrete.  It is one of the most powerful forms of motivation.  We know that people want to be trusted and that they respond to trust.  In your professional life as a physician, if you desire to enhance your interpersonal, communication, or leadership skills, it is your job to get good at the thing that underlies (and can potentially de-rail) all of those things:  being able to establish, extend and restore trust.  You do not do this as a manipulative technique to get what you want, but as the most effective way of relating to and working with others, and the most effective way of getting results.

Truth #3:  Trust = Character + Competence

The most important thing to remember when thinking about building your "trust quotient", is that trust is a function of two things:

• Your character - which includes your integrity, your  motive, and your "intent" with people
• Your competence - which includes your capabilities, your skills, your results and your track record 

Think of a physician colleague who has a good character - he is a likable guy, has the best of integrity, and authentic motives ... but if he doesn't have the clinical competence or track record of capability, will you trust him with your patients?  Or the converse - you have a colleague that is the most clinically competent physician around, but has always lacked personal integrity, doesn't seem on the "up and up" with certain elements of her cases, or has unclear motives and seems to try and undermine you at every turn... would you trust her?

Both character and competence are vital.  You cannot have trust without either one.  Think about how you may be perceived in either of those areas ... do others see you as "trustworthy"?

Case in point:  when one of my past physician clients ("Dr. A") moved to a new facility, he had trouble with a particular colleague (a fellow cardiothoracic surgeon - "Dr. B") who he saw as aggressive, territorial, and "not supportive of his success".  All of Dr. B's motives and actions were suspect, communication between the two of them was terrible, and it affected Dr. A's wellbeing on a daily basis.  Competence of this fellow physician was never a question - he was a fine clinician.  However, his character was the issue - Dr. A didn't trust that Dr. B was there in support, but instead felt that he was being watched by Dr. B, and "walking on eggshells" around this person who was just looking for a reason to validate his own question of Dr. A's character or competence.  Things quickly deteriorated between the two of them, and Dr. A wasn't sure whether he could stay in this new position.

Once Dr. A began to embrace the idea that this situation could be improved by analyzing his own responsibility in the situation, and began working to develop a trust partnership with Dr. B, things began to change.  He realized that some of his own actions had created suspicion around his motives (even though they were good), and that some of his ways of communicating with Dr. B (talking, not listening, not maintaining eye contact) made it appear that he himself was the aggressive one.  Slowly they found some common ground, and communication became more open.  Dr. A worked hard to bring up issues to Dr. B directly, versus going to his superior with whom he had a much better relationship.  He began to not only speak better of Dr. B with other staff members, but also began to go out of his way to interact with him more positively.  Intent started to feel more transparent and small successes were had.  Patient cases and handoffs went more smoothly.  Trust began to develop - albeit very slowly - which improved their ability to work together for the good of their patients and the clinical staff.  Recognizing the importance and outcome of enhanced trust became the "tipping point" for Dr. A to look at and change his own behavior.  He began to enjoy going to work again.

Truth #4:  Trust is a Process

Changing trust - even within physician groups or organizations that have terrible track records in this area - starts from the inside out.  It is important to recognize that trust is part of a continuum, a ripple effect that comes from what Covey calls the "5 Waves of Trust".  Let's focus on the first two - the key for physicians who want to build their trust competency is to understand and know how to navigate these:

The First Wave - Self Trust:  This is where we learn to have confidence in ourselves;  in our ability to set and achieve goals, keep commitments, to "walk our talk", and to inspire trust in others.  The key principle underlying this wave is credibility, which is made up of integrity (how congruent am I?), intent (what's my agenda?), capabilities (am I relevant?), and results (what's my track record?).  

The Second Wave - Relationship Trust:  This is about establishing and increasing the "trust accounts" we have with others in our lives.  The key principle underlying this wave is consistent behavior, reflected in things such as our ability to talk straight, demonstrate respect, create transparency, show loyalty, deliver results, and keep commitments.  The net result for physicians who build this wave is a significantly increased ability to generate trust and enhance relationships, build better teams, enhance true collegiality, and achieve better outcomes.  As the saying goes, "together we are stronger".

If you pick up Covey's book you can go on to read about the other three waves of trust - organizational, market, and societal, which all cumulatively build on each other.  Depending on your role/responsibilities as a physician or healthcare leader, you may more or less influence over these last three waves.

But we all  have extraordinary influence on the first two waves ... which is where the work begins for anyone who wants to increase this critical competency for themselves.

Bottom-line:  Trust is achievable.  It is a win-win-win-win-win (you, your colleagues, your patients, your hospitals, your community).

How can you make it happen in your life?

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.