There are plenty of reasons physicians pack their bags and head overseas to practice medicine. Some have charity at heart, rushing to aid the earthquake victims of Haiti, for example, or to Third World countries where doctors and modern medicine are desperately needed. Others are seeking thrills or experience on a locum tenens basis, an opportunity to travel and work in other locations or with people from other cultures.
Many physicians looking for a chance to practice in an international environment generally head for one of two locations: Australia or New Zealand. Both countries welcome American-trained physicians, and both offer a rich, culturally diverse environment with a common language and a familiar healthcare system.
That’s not to say other practice opportunities don’t exist, however. Amy Griffin, director of the international division of recruiting firm VISTA Staffing Solutions, currently places physicians in Bermuda, Canada, New Zealand and Australia, with plans for expansion.
Recently, the United Arab Emirates - especially Dubai and Abu Dhabi - also has opened its doors to American physicians. There, new hospitals are being built at a rapid pace, says Steve Frank, a senior search consultant for the Missouri-based recruiting firm Enterprise Medical Services. "Some adventurous American physicians decide to go there, looking for a challenge," he says. For the most part, though, physicians immigrating to the Middle East are originally from that part of the world and are heading back to be close to family.
In New Zealand, however, International Medical Graduates (IMGs for short) are increasingly becoming the norm. Ian Powell, executive director of the Association of Salaried Medical Specialists, recently told a reporter on New Zealand’s TV One that more than 40 percent of New Zealand’s specialist physicians are IMGs.
A 2008 article in the Medical Journal of Australia reports that the IMG population there is steadily increasing, comprising at least 25 percent of that nation’s general practice work force.
There’s no doubt physicians are needed in both countries, says Saralynn White of the Utah-based recruiting firm Global Medical Staffing. "But there is a worldwide doctor shortage, especially in underserved areas," she adds.
That’s as true for the United States as for foreign locales, however, so what prompts a physician to look abroad for work?
For David Rideout, M.D., a thoracic surgeon from Maine, his decision to practice abroad for a year came from a combination of factors - but burnout figured high on the list.
"I was working in the hospital 110 hours a week; I was on call every other day," he says. And pay was decreasing. "The year before I left, my business had increased by 25 percent, but I was making 10 percent less." At that point, he says, he was ready to leave medicine. Instead, he sold most of what he owned and signed up for a year-long locum tenens position in New Zealand.
Kathy Starkey, M.D., a New York obstetrician-gynecologist, says she wasn’t "burned out" from her private practice. "I still enjoy what I’m doing," she says, but the long days were taking a toll on her personal life. "I was ready for a change of pace to get my life back on track." Starkey loves to travel and began working abroad in 2007. So far, she has worked in the Cayman Islands, Australia and New Zealand.
Like Starkey, Jennifer Rozum, M.D., a California emergency medicine physician, enjoys travel. And like Rideout, she had become increasingly dissatisfied with the U.S. health system - on a number of levels. "I still love medicine, but not the practice of medicine," she explains. She’s currently working in New Zealand.
Still others, like Jennifer Scott, M.D., a Massachusetts obstetrician-gynecologist, go overseas to both practice medicine and conduct research, with a long-term goal of improving health care in the area. She has practiced in Haiti, Ethiopia, Kenya and the Congo.
Whatever the reason for change, making the decision to practice as a locum tenens - internationally or domestically - is just the first step.
The next step is to talk with a recruiting firm that makes international placements. Some agencies, like VISTA Staffing Solutions and Enterprise, have a roster of clients looking for physicians, and the recruiter serves to facilitate the doctor’s direct employment. Global Medical Staffing places physicians primarily on a locum tenens basis.
It’s the recruiting agency’s job to find the best qualified candidates for its clients, so physicians looking for locum tenens jobs at home or abroad will undergo intensive screening processes and background checks.
Once a client hires a physician, recruiters are eager to help them with all necessary documentation and other relocation requirements.
"The relocation packages vary, based on length of stay and seniority of physician, and some include living expenses such as housing and return airfare," says VISTA’s Griffin. The employer also will pay agency fees and often for professional liability insurance, which in New Zealand amounts to about $2,300 a year.
If a physician chooses to go to Dubai, the employer may also provide a car and education allowances for families that want their children to attend private schools, says Frank. "But every facility is different in what they offer," he says. (Physicians considering a position in the Middle East should be aware that the UAE requires passing a licensing exam before practicing there.)
Still, the lack of taxes in the UAE may make that destination especially appealing for doctors who relocate there permanently, which is what most openings in this area of the world require, according to Frank.
"Permanently" is the operative word. In locum tenens positions, no matter where you practice, doctors who are considered independent contractors pay U.S. taxes on what they earn overseas. Complicated? "We offer a tremendous amount of help with taxes and planning," assures White.
Cost-of-living expenses and other perks offered by host countries are recognition, in part, that the foreign country’s pay may not be up to U.S. standards, depending on specialty and country.
"Base salaries in New Zealand range between $93,000 and $195,000 with total remuneration ranging between $125,000 and $285,000 once the various add-ins are included," says Griffin. "These quotes are for public sectors; private often pays more. For Australia, our experience is that total remuneration is 30 percent higher than those available in New Zealand. One factor contributing to the shortage of doctors in New Zealand is they often ’jump the pond’ for better wages in Australia."
Rozum says her New Zealand pay is about $180,000. "The (U.S.) government taxes that at 38 percent, and the exchange rate is about 0.7 percent. I worked this out to making about $6,000 per month take-home in U.S. money." Rozum’s take-home pay in California was more than $250,000. "U.S. pay and benefits are obviously much better," she says.
But because cost-of-living expenses are paid for by employers, says White, "whatever you earn is largely discretionary."
Those physicians who decide to move ahead with an overseas job or other locum tenens position should notify colleagues and patients as soon as possible - just as if they were to take a leave of absence or close a practice. If you plan to return and are currently in a group practice, you can refer patients to other physicians in the group. If you are in private practice, however, ask a colleague if he would be willing to accept patients on a temporary basis.
"A lot of doctors hire a locum tenens doctor to fill the void while they travel," says White. If you plan a permanent move, be sure to notify patients and make arrangements to transfer or store records before you leave - and don’t forget to notify insurance carriers. The American Medical Association or your state medical board can provide tips on how to legally close a practice.
Once physicians land at their new practice location, they need to make some adjustments, say those who have worked abroad.
In Ethiopia and Haiti, for example, Scott says the healthcare infrastructure is limited both in terms of staffing and resources. And the culture is radically different. "There is such inequality for women in many parts of the world," she says. "Sexual violence is common. The women are strong, yet often dispirited.
It’s important to be culturally sensitive while you’re there, especially in the area of women’s health."
American physicians may be surprised to learn that resources are also limited in Australia and New Zealand - though to a lesser extent.
In Rozum’s experience, X-rays were available only from 8 a.m. to 9 p.m., and the lab’s hours were midnight to 8 a.m.
"We do bedside blood glucose, and there is a machine in the department that will give a hemoglobin. If absolutely necessary, the lab tech can be called in after hours," she says. "And while medicine in the United States depends heavily on scans, to get a CT scan or ultrasound here, I have to talk to the radiologist and justify it."
That’s part of the reason Rideout says he needs to shed his Type-A personality when working abroad. "It’s a different culture, and there are different expectations," he says. When you’re accustomed to having the resources and doing what it takes to improve a patient’s prognosis, it can be hard to deal with a system that rations care. "I had an 80-year old patient who needed an operation to survive," says Rideout. "But he knew, at his age, he wasn’t going to get it."
Rozum cites a similar case. "I had an active 75-year-old man who previously had a positive stress test and was referred for an angiogram. It was denied by the public health system. He came in with an acute inferior MI. In the United States, he would have been transferred for rescue angioplasty. Here, he just completed his infarct and lost that part of his heart muscle," she says.
Immerse yourself in the culture.
In order to fit into any country, think like those who live there, suggests David Rideout, M.D. Immerse yourself in their culture. Travel the country.
It’s an experience that may not come again.
Recognize you’re not in the United States anymore. Don’t walk into the job thinking you have all the answers, says Rideout. Nothing will turn off new employers, co-workers and patients like arrogance. "A locums doctor must expect and look forward to something different, or this type of work will not be a good match," says Kathy Starkey, M.D.
Talk to a doctor who has worked in the country. A conversation with a colleague may help prepare you for what you can expect abroad, whether at work or on personal time. "It is different," says Jennifer Rozum, M.D. Just be patient and nice to everyone, she suggests. "Remember, you’re in their country."
Think twice before bringing pets. Physicians who like to travel with pets may want to think twice before bringing them to another country. Rozum says her husband waited behind in the United States because their dogs had six months of testing before they, too, could come. Once the two Akitas landed in New Zealand, they were in quarantine for a month in Auckland before finally joining their owners. "By the time we actually got them, we figured it had cost $10,000," she says.
Rideout, too, might have thought twice about bringing his dogs. He learned only later that dog food in New Zealand is expensive. "That’s where a lot of my income went," he says.
Kathy Fedack, M.D., a Colorado anesthesiologist who worked in Guam and blogged on the VISTA site, says she sees a wide variety of cases with many high-acuity patients. That’s why in international settings, says Fedack, "flexibility and the willingness to improvise" are important attributes to possess. There are pluses to international assignments as well.
"A national health system is easier to work under," says Gregg Shivers, M.D., an internist/hospitalist from the Tidewater area of Virginia who spent a year in New Zealand. "I didn’t have to worry about getting paid or dealing with insurance companies or coding." And there was definitely more free time. "I worked from 8 in the morning until 6 at night," he says. He was on call one in six weekends, and had six weeks of vacation time.
"Patients are respectful and appreciative," says Rozum, who adds that’s not always the case in the United States. "But everyone in New Zealand is kind, friendly and open," she says.
As far as the workplace is concerned, Fedack has found surgery personnel to be "hard-working, knowledgeable, cheerful and eager to assist."
And in New Zealand, Rozum says hospitals are much less hierarchical. "Doctors have to fill out their own forms for X-ray. They draw their own blood gases, set up and clean their own suture trays, and go to the lobby and bring their patients back to a bed," she says.
But even those tasks seem inconsequential in the Congo, where Scott says healthcare providers are too often overwhelmed by the number of patients and lack of resources to split duties. Conditions were even worse in Haiti, where Scott practiced in a field tent. "You learn to be humble," says Scott. "And to work with what you have."
Just as physicians learn to adjust to their environments, so, too, do physician families. For the most part, say those physicians who traveled with family, their loved ones had little problem fitting in.
Shivers brought along his wife and three children, ages 15, 12 and 8. The young Shivers were excited - and nervous, too - about life abroad, says their father.
"They saw it as an important opportunity to learn about life in a different culture. They wanted to go," he says.
Part of the reason Rideout chose to practice in New Zealand was his wife’s profession. "New Zealand is a popular destination for geologists," he says. He regrets, though, not taking the overseas assignment when his children were younger. Instead, they moved as teenagers, and although everyone wanted to make the trip, the children found it difficult to fit in at school. "I wouldn’t take teens again," Rideout advises. "I’d take them while they were between 5 and 12 years, or I’d wait until they were grown."
U.S.-born physicians headed to the Middle East typically live near other Americans and Canadians, says Frank. "Western women are becoming more and more accepted because tourism is huge in places like Dubai and Abu Dhabi," he says. But even then, physician wives are likely to find the Middle East a more challenging location than their husbands, he reports.
Whether physicians travel abroad with family or without, all are appreciative of the extra free time in their schedules. Rideout and his family traveled nearly every weekend, enjoying activities like bungee jumping and fishing. Shivers liked to bike and ski on his days off, and says he came to enjoy "tramping" - the New Zealand word for hiking.
Whether Starkey was practicing in the Cayman Islands, Australia or New Zealand, her partner enjoyed swimming at each location. Starkey herself loves to spend time at local libraries. And Rozum is looking forward to exploring her temporary home. "I have six to eight (tour) books about New Zealand that will take us well beyond our currently scheduled time here," she says.
Locum tenens could still be in your future.
If the idea of practicing short term in a new location appeals to you - but you don’t want to travel overseas, there are plenty of locum tenens opportunities here in the U.S.
"You hear a lot about practicing in underserved areas," says Saralynn White with Global Medical Staffing, "but the fact is, there’s a physician shortage in this country, especially in family practice, so anywhere can be considered underserved." The typical contract for a U.S. locum position varies according to the client hiring the physician. The length could be as short as one weekend a month or as long as a year. Recruiters work with you to find the length of service that works best for you.
Physicians have different reasons for considering a U.S. locum position, says White. "We get a lot of physicians straight out of their residencies. They may not have the money to go into a practice, but they want to start paying their bills."
Although money is probably the biggest motivator, it isn’t the only one.
Some physicians just want to experience a new location, says White. Others want to come out of retirement for a while, and still others take locum positions because they want to practice medicine but no longer want to deal with the business side of medicine. Under a locum contract, whether domestic or international, the client who hires the physician takes care of paying the bills, managing the staff and providing liability insurance as well.
To learn where current locum positions are, contact a physician recruiting firm, or log on to a Web site such as PracticeLink.com. "Some physicians try to find locum positions on their own, but we tell them it’s a more complicated procedure than it looks," says White. That’s why recruiting firms are there.
"We’re always happy to help," she says.
Once the six-month or one-year international locum tenens commitment is met, most U.S. physicians return to their former practices. Still, some will extend their stay, while others decide to practice in their new location permanently, says White. Frank says most of the physicians he places in the Middle East are permanent.
Rozum currently has a one-year contract to work in New Zealand, and it’s fairly easy to get a one-year extension on a one-year work visa, she says. "But to stay beyond two years becomes more problematic, especially since I will be 55 by then and the government places increased restrictions on those over 55," she explains.
That doesn’t mean that physicians nearing retirement age will not be good candidates to work abroad, however. Both Griffin and White say the age of doctors they place runs the gamut - from residents who want an international experience before family ties and a full-time practice, to retired physicians who decide to spend a few years working abroad.
Most physicians, however, choose international posts when they’re mid-career and looking for something different.
Although Starkey enjoys returning to the United States between assignments, she says she has never looked for employment back home. Yet she has no plans to seek a permanent position abroad, either - she enjoys her six-month assignments and plans to keep those for the foreseeable future.
Families have kept both Shivers and Rideout in the United States recently. Both have adjusted to American-style medicine again, yet both are contemplating returning to a practice abroad.
"I’d like to go back to New Zealand," says Shivers. And Rideout says you’ll definitely find him on the road again. "We plan to go for a six-month position in a couple of years," he says. "This time, we’ll go to Australia."
Karen Edwards is a regular contributor to PracticeLink Magazine.