organising a year abroad – out of programme advice from the gat

france canada australia new zealand usa south africa

1

Organising a Year Abroad

Out-of-programme advice from the GAT Committee

3rd EditionEditor: Dr Adam M. Paul

2

o r g a n i s i n g a y e a r a b roa d

Contents

Foreword ....................................................................................................................................................................................3

Introduction ..............................................................................................................................................................................4

AAGBI & GAT ...........................................................................................................................................................................5

AAGBI affiliates .......................................................................................................................................................................6

Approval for out-of-programme training / research ..................................................................................................7

British Medical Association .................................................................................................................................................9

Some things to consider ................................................................................................................................................... 10

Before you go ........................................................................................................................................................................ 11

Whilst you are away ........................................................................................................................................................... 12

On your return ..................................................................................................................................................................... 12

Money ...................................................................................................................................................................................... 13

Pension .................................................................................................................................................................................... 15

Trainee grants ...................................................................................................................................................................... 16

Where to go ........................................................................................................................................................................... 17

France....................................................................................................................................................................................... 18

Canada ..................................................................................................................................................................................... 20

Australia .................................................................................................................................................................................. 23

New Zealand ........................................................................................................................................................................ 26

USA ........................................................................................................................................................................................... 28

South Africa ........................................................................................................................................................................... 30

Developing World ................................................................................................................................................................ 32

Working on an expedition cruise ship .......................................................................................................................... 37

© Copyright of the Association of Anaesthetists of Great Britain and Ireland. No part of this book may be reproduced without the written permission of the AAGBI


3

Foreword

Organising a year working overseas during the training programme is becoming ever more popular amongst anaesthesia trainees. Oft-cited reasons for doing so include a desire to work in a different culture, for personal academic and social development, to broaden one’s anaesthesia experience and any one of: climbing that mountain / skiing those pistes / riding those waves / biking that trail / diving that wreck*. Whatever the reason, advance preparation and heightened organisational skills are the keys to a successful year.

This third edition of the handbook, edited by Dr Adam Paul, builds on the previous editions by incorporating the recent changes to postgraduate medical training structure and the complexities of gaining approval from the overarching, responsible organisations in the UK. Adam, a GAT Committee member and veteran of out-of-programme training, has contributed a significant amount of hard work to this publication and should be congratulated.

The handbook will, necessarily, evolve and, for this to happen in line with experience, we need your input as members of GAT. Please do contact us via [email protected] or AAGBI headquarters: 21 Portland Place, London W1B 1PY.

Finally, I hope you enjoy reading this booklet and find it useful when planning your trip. Have a great time abroad.

Chris MeadowsChairman, GAT Committee 2007-9

(* delete or include as appropriate)

The AAGBI makes every effort to ensure that information in this publication is up to date and accurate.

However, conditions in different countries and rules can change, and AAGBI cannot accept any

responsibility for members travelling to work overseas. Travel safe and take care.

4


Introduction

Dear Colleagues,

Rather than buying the T-shirt (well, I did that as well), I have been asked to re-write, revise, update and edit this GAT publication about working and training abroad. I should state my conflict of interest here as I spent a year at Middlemore Hospital in Auckland, New Zealand. I had a great year, both professionally and socially. Whilst everyone will have different experiences, different highs and lows and different reasons for going, hopefully you will enjoy and develop as much as I did. I would like to point out that this adventure will take more effort to organise, cost more money and generate more angst than you can ever factor for but, despite this, I still wholeheartedly recommend the effort.

There are a great variety of medical placements that can be taken up abroad. The emphasis of this booklet is on training posts, specifically those worked as a year that will count toward a Certificate of Completion of Training (CCT). I would strongly recommend that you choose a placement abroad that will provide curriculum vitae enhancement and assist you in securing a consultant post when you return to the ever more competitive UK market. If you are going abroad post-CCT or outwith a training programme then you will still find useful information and contact details herein.

I would like to thank the editors and authors of the first and second editions; I have updated much, but the format and some lists remain largely unchanged. Also, big thanks to the AAGBI Council and Executive for their support and suggestions with this publication.

Many colleagues have helped and contributed. Their names are attached to their articles, but I want to say another big thank you here for their time in recounting their own experiences and suggestions.

What follows are some thoughts, suggestions, facts and contacts to start you down the road and help along the way of organising your year away.

Good luck!

Dr Adam M. Paul

GAT Committee Member and previously…Pre-Registration Fellow in General Anaesthesia and Fellow in Simulation, Middlemore Hospital, Auckland, New Zealand.

June 2009


5

The AAGBI was founded in 1932 by Dr Henry W Featherstone (1894-1967) and now has over 10,000 members.

The Association represents the medical and political aspirations of anaesthetists in the UK and Ireland and has close links with many other countries’ societies, which may be very useful in setting up a year abroad. Specific contacts are on the next page and a more exhaustive list can be found at the Association website: www.aagbi.org. There are also a number of AAGBI travel grants available to members from the International Relations Committee (IRC). Further information can be found online at: www.aagbi.org/grants/travel.htm.

GAT was founded in 1967 and its objectives are to promote training, the practice of anaesthesia and communication amongst trainees. GAT has over 3500 members, all of whom have voting rights within the Association. All GAT activities are co-ordinated by the GAT Committee, the only democratically elected body that exists to specifically represent the interests of anaesthetic trainees at a national level. This is by far the largest hospital specialist trainee body in the UK.

Training abroad is often easier to set up and you are more likely to fulfill your expectations if you can speak to people who have been there before. To this end, the GAT Committee has published this booklet to act as a catalyst for its members wishing to go abroad. Membership also comes with the following benefits and can be continued whilst abroad:

• Personal injury and life insurance cover of up to £1 million for patient transfer - for more information see:

www.aagbi.org/aboutaagbi/membership/insurance.htm

• Free subscription to Anaesthesia - the renowned international monthly journal

• Free copies of the Association guidelines

• Free monthly newsletter Anaesthesia News keeping you up to date with new developments in the specialty

• Special rates for scientific meetings including the GAT ASM

• Priority booking and special rates for seminars at 21 Portland Place

• Free advice and information

• Free information handbooks for trainees & SAS grade doctors

• Representation at Westminster and the DoH

• AAGBI website with up-to-date news on the Association and anaesthesia

• Private members’ forum hosted by Doctors.net

• Opportunities for grants and awards

• 20% discount on textbooks from Oxford University Press and Blackwell Publishing

• AAGBI subscription is on the HM Revenue & Customs approved list of professional organisations for tax relief

Association of Anaesthetists of Great Britain and Ireland (AAGBI) & Group of Anaesthetists in Training (GAT)

6


American Society of AnesthesiologistsHeadquarters Office520 N. Northwest HighwayPark Ridge, IL 60068-2573United States of AmericaWeb: www.asahq.org Tel: (847) 825 5586 Fax: (847) 825 1692Email: [email protected]

Australian Society of AnaesthetistsSuite 603 Eastpoint Tower180 Ocean StreetEdgecliff NSW 2027AustraliaMail to: PO Box 600, Edgecliff, NSWWeb: www.asa.org.au Tel: (02) 9327 4022 Fax: (02) 9327 7666Email: [email protected]

(The GASACT (Group of ASA Clinical Trainees) Committee is the Australian equivalent of GAT and a very good place to start for information. They can be contacted via: www.gasact.org.au)

Canadian Anesthesiologists’ Society1 Eglinton Avenue East, Suite 208Toronto, ON, M4P 3A1CanadaWeb: www.cas.ca Tel: (416) 480 0602Fax: (416) 480 0320Email: [email protected]

New Zealand Society of Anaesthetists (not CIG but close ties with AAGBI) 99 The TerraceWellington, New ZealandMail to: PO Box 10-691, WellingtonWeb: www.anaesthesia.org.nzTel: (04) 494 0124 Fax: (04) 494 0125Email: [email protected]

AAGBI affiliates (via the Common Interests Group, CIG)


7

There have been significant changes to the process of gaining approval for a year out since the last edition. Read this section carefully! If your paperwork is not correct you may not get approval for training, which may then mean you end up not going or, if you do, you may have to repeat the training year when you get home and thus delay your CCT. The key changes are:

1) The name. Previously all time out of programme was called ‘out-of-programme experience (OOPE)’. In order to take up overseas posts which are recognised for training, a trainee must now apply for ‘out-of-programme training (OOPT)’ or ‘out-of-programme research (OOPR)’. OOPE now refers specifically to clinical experience posts that are not approved by PMETB and therefore cannot count toward training and CCT. ‘Out-of-programme career breaks (OOPC)’ apply to those wanting to spend time off-programme and out of medicine.

2) Approval. Previously the gift of approval was in the hands of the Royal College of Anaesthetists (RCoA). Now, final approval is in the hands of PMETB although the RCoA is still involved and will recommend approval of a post to PMETB. However there have been cases where the post has been recommended by the RCoA but refused by PMETB – you are not good to go until they say so! This is particularly relevant in the case of relief work in developing countries, e.g. for Médecins Sans Frontières. Applications have been accepted by the RCoA and then rejected by PMETB. Note that it is the post that is approved and not the applicant.

3) Timing. You must be post-FRCA and have completed year 2 SpR or ST4. You must also have at least 6 months training time remaining on your programme in the UK upon your return.

So how do you get a post approved?

Prospective approval must be sought for ALL posts and this will take time – leave at least 6 (or more sensibly 12) months for this. The process is as follows:

• Download the OOPT/R application form and guidance from the RCoA website (www.rcoa.ac.uk/docs/OOPTform.pdf) and take this through the following process:

• Secure provisional approval from your Deanery. This will usually be through your Training Programme Director (TPD).

• Seek approval from your Regional Advisor (RA) in Anaesthesia and/or ICM that the OOPT/R will form part of a balanced training programme and will contribute towards the training needed for a CCT.

• Submit the application form to the RCoA together with sufficient evidence to satisfy PMETB that the training will meet their criteria (see below).

• The RCoA then makes a recommendation and the Deanery makes an application to PMETB.

• PMETB makes its decision and informs the Deanery and the trainee.

Approval for out-of-programme training / research

8


You should note the RCoA advises that ‘applicants should not commit themselves financially or professionally until formal approval has been received from PMETB’.

Appropriate evidence for submission with your application form consists of:

‘a statement from the competent authority in the country concerned, e.g. Training Board, College or Faculty, confirming the hospital (and post) is approved for training and the supervision arrangements are adequate’.

The RCoA can help with a list of whom you should contact. Any aid work, developing world medicine, or other posts not covered by recognised Training Boards should be discussed with your RA. Remember, they won’t be approved until PMETB says so.

On your return, you will need to submit an evaluation, a report and a supervisor’s statement to the RCoA. You will need to complete the RITA F or ARCP 5 form and will almost certainly be required to present a completed logbook at your annual review.

For further information please contact:

Claudia Moran The Royal College of Anaesthetists Training & Examinations Directorate The Royal College of AnaesthetistsChurchill House35 Red Lion SquareLondon WC1R 4SGTel: 020 7092 1554E-mail: [email protected]: www.rcoa.ac.uk

Irish Trainees For further information please contact:

The College of Anaesthetists RCSI22 Merrion Square NorthDublin 2Tel: 0353 16614412 Email: [email protected]: www.anaesthesia.ie


9

Guidance on working abroad produced by the BMA International Department can be found on the BMA website and provides answers to the most frequently asked questions from doctors intending to work overseas. The two relevant booklets are:

‘Opportunities for doctors within the European Economic Area’ www.bma.org.uk/careers/working_abroad/EEA.jsp

and:

‘Guide to Working Abroad’ www.bma.org.uk/careers/working_abroad/index.jsp

The BMA can:• Provide general information on registration (in

the most popular destinations)• Guide members to other useful sources of

information and the relevant regulatory bodies

The BMA cannot:• Find jobs for members • Advise on overseas contracts• Provide lists of employers abroad• Assist with immigration arrangements

Contracts and terms and conditions of service

BMA staff cannot advise on specific terms and conditions of employment overseas. This is due to the variations in overseas employment law which govern contracts, and on which BMA staff are not qualified to comment. However, the BMA have produced a checklist of points that they state should be included in any employment contract. This is called ‘Notes on Contracts for Appointments Overseas’, and can be found at:

www.bma.org.uk/careers/working_abroad/overseascontracts.jsp

It is recommended that an employment contract should be signed by both parties prior to the trainee’s departure from the UK. The equivalent BMA organisation in the country of employment should be the first port of call for detailed industrial relations advice.

For further information:

BMA International DepartmentBMA HouseTavistock SquareLondon WC1H 9JPTel: 020 7383 6133/6793Fax: 020 7383 6644Email: www.bma.org.uk

British Medical Association

10


Why do I want to go away?

To pursue an area of Anaesthesia, Pain Medicine or ICM that is unavailable within your rotation or even in the UK? To experience a different medical and social culture? To spend time on a sunny beach sipping cold lager (or equivalent)? The answers to these questions (and others) will determine whether, and where, you choose to go.

Some of the features that you need to consider about your chosen destination include:• Distance from the UK• Climate• Language• Religion• Communication links• Diet and hygiene• Domestic utilities• Social amenities• Personal health• Personal safety (including transmissible

disease, threat from terrorism/war and crime rates)

The Foreign and Commonwealth Office (FCO) aims to provide information on issues and risks to British travellers and British citizens resident overseas so as to facilitate informed decisions as to whether or not they travel or stay in a particular location. For up to date information from the FCO, including travel advice by country, navigate to:

www.fco.gov.uk/en/travell ing-and-living-overseas/living-overseas

When to go?

Pre-CCT – you are allowed up to one year that can be counted towards your training without extending your training time. It can help you to distinguish your CV from those of your peers. It does not preclude spending another year abroad post-CCT (and you will find it much easier to organise the second time). An advantage of a pre-CCT year is that you have a job to come home to. The main problem is that when you have really enjoyed yourself, you will still need to leave. There is no opportunity to extend. The return home may be a strange experience - consultants will ask if you have been on the other side of town, as they have not seen you for a while!

Post-CCT – you may have a better idea about what you want to do as a ‘grown-up’ and so be able to tailor your year better. It may be used as a stopgap before applying for a UK consultant post if few are available when you finish your training programme. If you love the job and the country, you are not bound to return home. You may be able to take an offered consultant post abroad as you will already have your CCT. You will not be governed by PMETB although you should still keep a logbook and obtain letters of reference when you leave the post.

The decision is yours.

Good reading:

The Medics Guide to Work and Electives around the World. Mark WilsonArnold, 2004, £14.99, pp 496 ISBN 0 340 81051

Some things to consider…


11

Health and Domestic

• You may have to undergo a medical examination with or without investigations prior to travel – be sure to use a registered doctor and investigation service for the country you wish to visit. Your contact overseas will normally provide a list of approved UK doctors, e.g. the list of Australian Immigration-approved doctors in the UK can be found at:

www.immi.gov.au/contacts/overseas/u/united-kingdom/panel-doctors.htm

• Take all the relevant paperwork regarding your occupational health immunisations and investigations (Hep B, MMR, TB etc) with you.

• Find out if you require further immunisations – for travel and professionally.

• Investigate whether you and your family need health insurance - this is a good place to start:

www.dh.gov.uk/en/Healthcare/Healthadvicefortravellers/Stayinghealthy/DH_411485

• Visit the dentist.

• Remember to inform those who need to know your change of address – consider a forwarding service from the post office.

• Take at least one copy of all-important paperwork – get it verified as being authentic (a good idea is to digitally scan all paperwork and email it to yourself so that it can be accessed anywhere – make sure it is password protected if you carry it on a USB stick or equivalent).

• Get documents translated where needed.

• Take evidence of your car and home insurance no-claims bonuses.

• Do you need an international driving licence? At the very least apply for a new-style UK photo licence – no other country’s officials ever understand a licence without a photograph!

• Try to organise somewhere to stay on arrival, e.g. hospital accommodation / hotel / with a friend.

• Take your mobile phone – it will be very useful for the first few days but too expensive to use long term. You may be able to unlock your phone so that all you need is a new SIM card, or alternatively register with a network provider in your destination country and purchase a new phone.

• Professional indemnity – contact your UK defence organisation which may provide cover at your destination or at the very least will be able to tell you who to contact.

• Agree a return date and a return job with your Deanery and TPD. Also remind them approximately 6 months before you intend to return to the UK.

Remember, you will need your work visa, return ticket or funds to show that you intend to (and are financially able to) leave the country after your period of employment, a copy of your contract and evidence of registration with the foreign medical council (or documentation showing intent to do so). Otherwise, it could be a short trip!

Before you go…

12


• Complete and return RITA form F / ARCP 5.

• Collect a reference.

• Keep a logbook.

• Collate demographic and socio-economic data for the hospital and catchment area so that you can compare to your practice at home (useful for conference posters).

• Keep some form of diary or aide-mémoire.

• Collect names and email addresses of friends, colleagues and contacts.

• Take photos – you are bound to be asked to give a presentation on your return and having photographs makes this very easy.

• You require a statement from your supervisor confirming the dates that you worked and that you performed to a satisfactory level as evidence for your Specialist Training Committee (you may be immersed into the local appraisal and assessment scheme and so can return with copies of completed forms along with a supervisor’s report).

• Plan your job on return to the UK – stay in contact with your Training Programme Director via email as post allocations and rotations do change.

• Write up your experiences whilst you can still remember them.

• Submit your report and your training supervisor’s report to the College. The post will have been approved before you left the UK, but these documents prove that you took up the post and performed to the required level.

• Write to thank your contacts.

• Thank any financial body that gave you assistance (and submit a copy of your report to them; you may be surprised by a publication in their journal or newsletter).

• Don’t be disheartened when others do not want to see your 5000 photos!

Whilst you are away… On your return…


13

Everyone who has been abroad has spent more money (usually considerably more!) than they expected, but most trainees say they have no regrets. Just as you should have a contingency fund before you build a house, the same is true before you go away.

Major costs before you leave (some of them!):

• Visa application and document checking.

• Medical clearance by an approved doctor.

• Bank account opening – you can do it before you leave in most countries.

• Letting costs if you want to let your property in the UK during your absence – this can be time-consuming and costly to set up so start looking early. (Rental properties are subject to an ever-expanding list of rules and regulations).

• Storage / removal – if you cannot afford to leave your home unoccupied for a year you will need to store the contents somewhere.

• Shipping – most people decide not to ship sofas and fridges but there may be some items of furniture you wish to take with you, particularly as most antipodean properties will be rented unfurnished.

• Travel Insurance.

• Health Insurance.

• Flights.

• Vaccinations (including those required for stopovers).

• Clothing appropriate to the weather conditions at your destination.

Costs whilst you are away:

Loan repayments / credit card repayments / insurance / mortgage shortfall – all these amounts will seem bigger when trying to pay them in almost any other currency!

The biggest potential cost is your mortgage, especially if you cannot let your house or if the tenants move out whilst you are away. Make sure a trusted friend or family member is ready to chase the letting agent and keep an eye on the property for you. Speak to the bank and consider changing to an interest-only mortgage or, better still, a payment holiday (take financial advice on the implications of these). Remember to let your bank and home insurer know if you are letting for a year.

Some costs can be recouped abroad, e.g. in New Zealand you can claim back medical registration, medical indemnity, and professional body fees, so keep all receipts. On your return to the UK, you may be able to claim tax relief for the period you have been away. Discuss this directly with your Revenue & Customs office.

If you need to let your house:

There are many options here and the following suggestions are not meant to be exhaustive.

• www.sabbaticalhomes.com – this international e-organisation was set up by an American academic to allow fellow academics to travel and take sabbaticals abroad. The website guides you through

Money

14


locating tenants for rental or house exchange. You are responsible for setting up the let – there is no agent so no fees, but on the other hand, there is no-one to fix the leak! An example might be a US professor and a NZ PhD student each offering to rent for 6 months whilst you are away. As a further security, you should telephone their prospective employers (universities or hospitals) for confirmation that they exist! Alternatively, setting up a house exchange can be a great way of organising your accommodation before you leave the UK.

• Hospitals – let your property to colleagues, other medical professionals or, even better, those doing the same as you but in reverse. Ask medical secretaries in other departments as they will know if there are clinical fellows or attachments expected from abroad.

• Letting agents – fees and quality seem to vary hugely so it is best to ask around at work and find people who have used local agents. If you find your own tenants, you can still use an agent to manage your property whilst you are away – try to negotiate a better rate as you have done the hard part.


15

Please read this section very carefully as getting pension payments wrong whilst you are away will cost you a significant amount in the long term.

The NHS superannuation scheme is well recognised as a good pension scheme. Your pension is valuable, so try not to lose your accumulated years of service. If you have completed more than two years NHS service and intend to return after an overseas break, it is possible to preserve it by continuing to pay a monthly contribution whilst you are away. This will prevent you losing the time that you were away. You must organise your continued contributions before you leave. You cannot buy back additional years anymore.

If in doubt about your pension, it is recommended that advice from your Trust Pensions Officer or local BMA representative is sought before departure. If you are not stopping work, but are having a break from the NHS to work elsewhere, such as overseas for an aid organisation, it may be possible to stay in the pension scheme under the ‘direction’ arrangements.

Further advice on the NHS pension scheme can be obtained from the relevant authority responsible for administering the scheme.

NHS Pensions DivisionHesketh House200-220 BroadwayFleetwoodLancashireFY7 8LGTel: 01253 774774Web: www.nhsbsa.nhs.uk/pensions

Scottish Public Pensions Agency7 Tweedside ParkGalashieldsTD1 3TEWeb: www.sppa.gov.uk

Pension

16


There are major changes occurring in the world of research and travel grants in anaesthesia. The following is the latest information at June 2009:

Research Grants

These will be awarded through the National Institute of Academic Anaesthesia. www.niaa.org.uk

There is a plethora of grants available from the AAGBI, RCoA and other organisations. Have a look as something may be relevant to what you are going to do.

Travel Grants

The International Relations Committee (IRC) of the AAGBI considers applications from members who are seeking funding for projects usually, but not exclusively, in the developing world. Further information can be found at: www.aagbi.org/grants/travel.htm. In addition, grants and awards for trainees remain independently funded by the AAGBI Foundation. Reports will be considered for publication in Anaesthesia News. Please contact:

AAGBI Secretariat21 Portland PlaceLondonW1B 1PYTel: 020 7631 8807/12Email: [email protected]

A number of grants are available through the RCoA for a variety of educational or training purposes, including travel and subsistence assistance. Each application will be assessed on its merit. Applicants should send details of their proposal including expected personal benefit, expected benefit to the hospital being visited and expected benefit to their UK anaesthetic department. A pre-condition of any grant is that, on return, a report is submitted to the RCoA (maximum 2000 words), which will be considered for publication in the College Bulletin. Enquiries and proposals should be addressed to:

Mrs Morgan CenanEmail: [email protected]

Alternatively, further details can be found here: www.niaa.org.uk/index.asp?PageID=150

Trainee grants


17

The world is your oyster. Anaesthesia is a particularly portable specialty and your skills will be useful the world over.

What follows are some helpful hints and suggestions from those who have been before you. Please remember that, just as our administrative paperwork is constantly changing, so it is abroad, and therefore check guidelines before you leave and remember that the more time you allocate to organise, the better.

For contacts from almost every Medical Association in the world, go to: www.wma.net/e/members/list.htm

Europe

‘Free movement and the mutual recognition of professional qualifications, this is what the EU stands for’.

Of course, in practice, it is always a little more complicated. The following list covers the countries where ‘free movement’ is permissible. Note that this is not the case for international medical graduates who have completed their primary medical training outside the EU but who are currently working in the UK. The process is different for each country.

EU members:

Austria, Belgium, Bulgaria, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Hungary, Greece, Ireland, Italy, Latvia, Lithuania, Luxembourg, Malta, Netherlands, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, UK.

Current negotiating countries: Croatia and Turkey.

Current applicant country: FYR of Macedonia.

The excellent BMA International handbook is to be recommended – it contains a full list of contacts for each country.

Where to go

18


Dr John Dick

I took a short sabbatical from my consultant job to work in a tertiary hospital in Paris as an anaesthetist in 2008. This was definitely the most challenging and educational period of my career so far.

Finding a position

Individual hospital departments offer jobs and the person to speak to is the Director of the department. How you narrow down your choice of department is likely to be a result of a mixture of factors such as local expertise in a sub-specialty, geographic location, personal recommendations and departmental publishing power.

Registration to practice

The French equivalent of the General Medical Council is the Conseil de l’Ordre des Médecins that covers the Département relevant to your hospital’s location. Your hospital’s personnel department will be able to assist in finding the right Conseil. Contact them directly and they will explain what you need to furnish them with to have both your basic medical diploma and your anaesthesia qualification recognised. They insist on copies of (at least) the following documents in English and in ‘certified-translated French’ (contact the French embassy in the UK for a list of certified translators):

• medical degree• FRCA certificate• identity, e.g. passport• curriculum vitae• a cheque in Euros (in 2008 this was 137.50€)

This is a simplification. Never underestimate French bureaucracy! I was asked for evidence that I had finished my basic medical training (sign-off after house officer posts), which I managed to find, as well as paperwork that I couldn’t produce (e.g. confirmation by the UK ‘Minister of Health’ that I was allowed to work abroad!).

This process, including translations, will take months, so plan ahead. You will have to meet the Director of the local Conseil once you are in France, who may interview you briefly before signing you onto the register.

1. Registering your original documents Once in France you will have to make an

appointment to produce the originals of your degree / paperwork to be certified by a body known as the DDASS (Directeur Departemental des Affaires Sanitaires et Sociales).

2. Get medical insurance Called ‘assurance’, this wasn’t expensive and

buys you peace of mind.

3. Language proficiency I didn’t find there was any formal process

for this beyond the informal interview with the Professor of the department. I was encouraged to find an equally ‘laissez-faire’ attitude towards occupational health! This consisted of a squiggle on a piece of paper by the boss attesting that I was physically and mentally up to the job (luckily he was right!).

France


19

How good does your spoken and written French have to be? This is hard to judge, and the best person to ask is a French person, and ultimately the person who is offering the job. There are medical French courses available, but I didn’t use them and found that looking through the relevant chapters in a medical English / French book and a very attentive ear sufficed. The most demanding area is telephone conversations when all visual clues are lost! Fortunately in our job, there’s not a lot to write!

What are the benefits?

The healthcare system is very good and the standard of medicine high. I found that the French medical fraternity has retained some great traditions that we have largely lost; eating together daily in the doctors’ mess being the most obvious (and most missed!), 24 hour on-calls (European Working Time Regulations? What European Working Time Regulations??) and proper handover.

You will see different approaches to the job that make you question all of your practice at home (working with nurse anaesthetists, for example). And of course you will have the pleasure of immersing yourself in the real French way of life once you are on the workforce. Vive la différence!

Useful contacts:

For medical French courses try either:

Alliance Francais - www.alliancefrancaise.org.uk/bespoke.htm orInstitut Francais - www.institut-francais.org.uk/courses/lc_business.php

France - articles in the College Bulletin about working & living in France as a trainee:

www.rcoa.ac.uk/docs/bulletin19.pdf (page 951)

www.rcoa.ac.uk/docs/bulletin41.pdf (page 2073)

www.rcoa.ac.uk/docs/Bulletin33.pdf (page 1648)

Anglo-French Medical SocietySecretary: Dr Mark CottrillEmail: [email protected] Web: www.anglofrenchmedical.org

Included below are useful contacts for information gathering about the other more popular countries:

Anglo-German Medical SocietyEmail: [email protected]: www.agms.net

Medicine in GermanyWeb: www.medknowledge.de/germany

Italian Medical Society of Great BritainProf Salvatore M. Aloj, Scientific Attaché, Embassy of ItalyEmail: [email protected]: www.ambitalia.org.uk

20


Canada

Dr Jon McCormack

Canada is a huge country with dramatic scenery, wide open vistas, some of the world’s best skiing and well respected fellowship programmes based in the country’s top teaching hospitals. These teaching hospitals are found in Vancouver, Toronto, Montreal, Calgary, Edmonton and London.

The working environment in Canada has many similarities to that in the UK but also some key differences. There is a conspicuous absence of ODPs or Anaesthetic Nurses in theatre and there are no anaesthetic induction rooms. Theatres run on fixed time schedules, and delays must be justified. Flexibility is therefore fast learned, with Fellows being expected to recover one patient, ‘pre-op’ the next patient, prepare airway equipment and drugs and induce anaesthesia, all with minimal assistance, within the allocated 10-minute turnaround time. The hours can be long, with a 7am start usually expected, and the caseload is heavy, although the majority of lists aim to be finished by 4pm.

Fellows will usually be appointed a mentor. Contact with that person should be made prior to departure from the UK to ensure that clinical and research objectives are documented before arrival. A Fellow’s time will be divided between clinical and non-clinical or research work. Your mentor is usually involved in this work allocation.

The posts are for 12 months, typically running from 1st July onwards, which is usually non-negotiable. The salary is C$60,000, which, at current exchange rates, equates to roughly £30,000. Fellows receive no supplement for on-call but this is non-resident, and less frequent that most UK posts (typically around 1 in 10). The monthly take-home pay is C$3,500. The cost of living has increased in Canada over the last 5 years.

How to get there?

Jobs have been advertised in the BMJ but most Registrars who travel appear to choose either a desired location or a desired sub-specialty and make direct enquiries to the teaching hospitals regarding vacancies.

Application forms are sent with your references attached, and your referees will be contacted prior to short listing. If you are successful you will be sent a contract by the teaching hospital. Despite having an approved and signed contract you will be unable to take up the post until you have an approved Human Resources Department of Canada (HRDC) file number. This is only issued to you after verification from your prospective employers that there are no suitably qualified Canadian applicants for the offered position. It is this number that entitles you to a work permit which you obtain from the Canadian High Commission in London, currently costing C$150. To obtain a work permit, you will be required to have a medical examination, chest X-ray and blood tests, costing around £250, and which can only be carried out at a Canadian Commission-approved GP. Once your work permit is approved you will collect it at your port of entry on arrival in Canada.

Canada


21

Be warned this whole process takes a minimum of 6 months. Those travelling with a spouse who has a work permit with an offer of employment can apply for an open work permit and can therefore apply for a post on arrival in Canada. Spouses and children who will not be working need not complete any additional paperwork, effectively entering the country as visitors.

Who else will be after your cash?

Registration needs to be obtained with the appropriate provincial College of Physicians and Surgeons, and the University Postgraduate Dean. The College will seek permission to conduct a criminal record check for which you hand them a banker’s draft for C$20. The College will also employ the International Credentialing Service of the Education Commission for Foreign Medical Graduates (ECFMG, www.ecfmg.org) to seek independent verification of the authenticity of your medical degree. The ECFMG will request from you numerous documents, photographs and dollars (approximately US$150). There will then be a considerable amount of time spent as your documents travel back and forth across the Atlantic, and whilst some of this can be electronic, many requests will be for original certificates or at least authorised copies, another expense. Next, the Canadian Medical Protection Association (CMPA), who can be contacted via www.cmpa-acpm.ca, will be after your money. Registration with the CMPA as a Fellow is presently just over C$1,000 per year.

You will also need a social security number prior to starting work. Healthcare (Medical Service Plan, MSP) is government-funded but only applies after you have been resident for three months, so you will need private health insurance for that

initial period, and you must remember to register for MSP immediately on arrival in Canada.

There appears to be plenty of rental accommodation in Canada, but most is advertised less than a month before becoming available and unfurnished is standard. A premium will be paid for furnished accommodation. A useful resource is www.craigslist.ca.

Fellowship posts in Canada are popular and some have waiting lists for vacancies; for example, at the time of writing, Fellowships in Paediatric Anaesthesia in Vancouver are filled for the next two Fellowship years.

The paperwork does take considerable time, averaging over 6 months. Despite the tedious and often costly bureaucracy, the final message is that early and thorough preparation will result in a fantastic year with unforgettable clinical and social experiences, and a ski tan that is second to none!

Useful contacts:

Canadian High CommissionImmigration Division 38 Grosvenor Square London, W1K 4AAWeb: www.UnitedKingdom.gc.ca/visas/menu-eng.asp Canadian Medical Association 1867 Alta Vista DriveOttawa, OntarioK1G 5W8CanadaWeb: www.cma.ca

22


Provincial Medical Regulatory (Licensing) Authorities

College of Physicians and Surgeons of Albertawww.cpsa.ab.ca

College of Physicians and Surgeons of British Columbia www.cpsbc.ca

College of Physicians and Surgeons of Manitobawww.cpsm.mb.ca

College of Physicians and Surgeons of New Brunswickwww.cpsnb.org

College of Physicians and Surgeons of Newfoundland and Labrador www.nmb.ca

College of Physicians and Surgeons of Nova Scotia www.cpsns.ns.ca

College of Physicians and Surgeons of Ontariowww.cpso.on.ca Collège des médecins du Québecwww.cmq.org Canadian Medical Protective Associationwww.cmpa-acpm.ca

Citizenship and Immigration Canadawww.cic.gc.ca


23

Dr Adam M. Paul

Procedures have recently changed so please read the following carefully to avoid problems and delays with document verification.

Verification of credentials:

In Australia, national policy requires that international medical graduates (including UK medical graduates) have their qualifications assessed by the Educational Commission for Foreign Medical Graduates (ECFMG, www.ecfmg.org) International Credentialing Service via the Australian Medical Council (AMC). After contacting the AMC about the job you wish to apply for, they will arrange for individual UK medical graduates to apply to the International Credentialing Service, which is based in the United States, by sending a witnessed application form with two copies of each credential to be verified, a certified photograph and a fee made payable to the ECFMG. The Service then sends a copy of each credential back to the issuing body in the UK (the GMC, University, RCoA etc.) with a request that it be verified. This takes time.

Finding a Job

You should first find a post, prove that you are eligible for registration at state board level and then apply for a visa.

Read the BMJ classifieds and the locum agencies (the latter are likely to list more rural posts). The

Medical Journal of Australia website, www.mja.com.au, is a good source, as is the following site: www.doctorconnect.gov.au/internet/otd/publishing.nsf/Content/work-Finding-a-job

The Australian and New Zealand College of Anaesthetists (ANZCA) website is the best source of contact details with links to Faculty of Pain Medicine for pain and the Royal Flying Doctor Service (www.flyingdoctor.net) also carries advertisements but, as usual, the best route is word of mouth. Ask colleagues and friends who have worked in Australia before you.

Australia’s public healthcare system is called Medicare. To practice you will need to be registered with the individual state medical board (see contacts overleaf). You can be registered with or without conditions. If you are going for OOPT/R then register with conditions or you will have to sit exams. If English is not your native tongue you will have to pass an English exam. Registration with conditions will allow you to practice supervised training, teaching or research or in areas of need.

Assuming that you are not emigrating permanently then the recommended visa pathway is Temporary Business (long stay) (subclass 457) which has a straightforward application process. Spouses and children are included on this visa and so are entitled to Medicare and schooling. For other options, read:www.immi.gov.au/skilled/medical-practitioners/visa-options-doctors.htm

Luckily most hospitals have a great deal of experience of British trainees and will be able to help with both visa and registration – often an immigration team is available in the hospital

Australia

24


to aid recruitment. You can usually get great help and advice from them regarding housing, banking, hotels, etc. (it’s always worth checking about hospital residences too, at least whilst you find your feet).

You will also need a medical examination with an Australian Immigration-approved doctor. Using a panel doctor in the UK who submits the report online may accelerate this process. See: www.immi.gov.au/contacts/overseas/u/united-kingdom/panel-doctors.htm for details. Speed of application will also vary by geographical territory.

When you do get there it is worth noting that speaking to an accountant early can afford you tax savings. Tax deductable items are very different to the UK and it may be possible for many fixed monthly outgoings such as rent to be ’salary-packaged’ and deducted from your salary prior to income tax.

In the hospital, the anaesthetic secretary submits all hours for on-calls to the payroll so there are no time sheets to complete.

Useful contacts:

Australian High Commission Australia House Strand LondonWC2B 4LA Tel: 020 7379 4334 Fax: 020 7240 5333Web: www.australia.org.uk

Australian Medical Association (AMA) This, like Australia, is run on a federal structure so it is best to try to contact the specific state office if you know where you are going. General enquires go to the main Canberra office. Remember that registration varies slightly from state to state.

National Office Australian Medical Association PO Box 6090, Kingston ACT 2604 Australia Tel: +61 2 6270 5400 Fax: +61 2 6270 5499 Email: [email protected]: www.ama.com.au

State branches New South Wales – www.nswama.com.au Northern Territory – www.amant.com.au Queensland – www.amaq.com.au South Australia – www.amasa.org.au Tasmania – www.amatas.com.au Victoria – www.amavic.com.au Western Australia – www.amawa.com.au

Competent authorities – state/territory medical boards/councils

Medical Board of the Australian Capital Territory www.medicalboard.act.gov.au

New South Wales Medical Board www.nswmb.org.au

Northern Territory Medical Board www.nt.gov.au/health

Medical Board of Queensland www.medicalboard.qld.gov.au


25

Medical Board of South Australia www.medicalboardsa.asn.au

Medical Council of Tasmania www.medicalcounciltas.com.au

Medical Practitioners Board of Victoria www.medicalboardvic.org.au

Medical Board of Western Australia www.wa.medicalboard.com.au

Australian and New Zealand College of AnaesthetistsANZCA House 630 St Kilda Road Melbourne VIC 3004 Australia Tel: +61 3 9510 6299 Fax: +61 3 9510 6786 Email: [email protected]: www.anzca.edu.au

Australian Medical CouncilPO Box 4810 Kingston, ACT 2604 Australia Tel: +612 6 270 9777 Fax: +612 6 270 9799 Email: [email protected]: www.amc.org.au

Department of Immigration and Citizenshipwww.immi.gov.au/index.htm

Medicare Australiawww.medicareaustralia.gov.au

26


New Zealand

Dr Adam M. Paul

Land of the long, white cloud. Currently there is a significant shortage of trainee doctors and, generally, the further out of the cities you get, the greater the shortage. Moreover, they view British-trained doctors with high regard and have a very similar training system. They also like watching the All Blacks thumping the home nations!

For a post lasting less than 3 years you will need a temporary work visa. This application will need to be sponsored by your prospective employer – the hospital will have lots of UK medics coming out so will be able to help you with the details. Generally, the paperwork is much more straightforward than for Australia, and usually will not require a medical examination. Spouses are also entitled to a work visa. In this case, it is worth noting that the primary applicant will have a permit to work for a specific hospital and the spouse will have an open work visa. If one of you is more likely to locum then they should elect to be the ‘spouse’ so that they can work in a variety of institutions.

You will need to pre-register with the New Zealand Medical Council (NZMC) and make sure that you have an appointment arranged with them or their local representative for when you arrive.

I spent a year in Auckland and loved it. Anyone you meet from outside Auckland will hate it! The cost of living in NZ has increased over the past few years but is still significantly below the UK. Having said that, you will be earning in NZ$ and, relatively, NZ is at least as expensive as the UK, so remember to take your earnings into account when looking for a place to rent. Renting accommodation, buying a car and getting a telephone contract will all be much simpler with a NZ bank account. All the major banks allow you to set them up from the UK. It is worth doing this and depositing funds so they are available when you arrive.

I took a Provisional Fellow post. Essentially, most NZ trainees will spend 6-12 months as an SHO, 4-5 years as a Registrar and then a ‘final training year’ or an extra year as a Provisional Fellow. Provisional Fellows tend to work on a level between Registrar and Consultant (i.e. similar to a Senior Registrar) and, as such, will receive great training and usually a slightly better salary than Registrars. If you are intending to travel pre-CCT, I would definitely suggest you enquire about Provisional Fellowship posts.

Finding a job

Look through the BMJ classifieds and the locum agencies. Most district health boards (DHBs) will have a website listing information regarding vacancies.

In addition, the links and search engine at New Zealand Health Online can be used to find District Health Boards (DHB), hospitals and job opportunities: www.everybody.co.nz.


27

Useful contacts:

New Zealand High Commission New Zealand House 80 Haymarket London SW1Y 4TQ Tel: 020 7930 8422 Fax: 020 7839 4580 Email: [email protected]: www.nzembassy.com

New Zealand Medical Association PO Box 156 Wellington New Zealand Tel: + 64 4 472 4741 Fax: + 64 4 471 0838 Email: [email protected]: www.nzma.org.nzWeb: www.nzma.org.nz/about/info-for-foreign-doctors.html

Medical Council of New ZealandPO Box 11649Wellington New Zealand Tel: + 64 4 384 7635 Fax: +64 4 385 8902 Email: [email protected]: www.mcnz.org.nz

Australian and New Zealand College of Anaesthetists PO Box 25506Wellington New Zealand Tel: +64 4 499 1213 Fax: +64 4 499 6013 Email: [email protected]: www.anzca.edu.au

28


Dr Kate Prior

The land of opportunity! America is a vast country and offers a huge range of fellowship opportunities in pretty much any subspecialty you care to choose. Being in the USA also offers fantastic travel opportunities to see the country because internal flights are very reasonably priced and most Americans think nothing of jumping on a plane for a long weekend away.

How to get there?

The federal system means the application systems and rules for overseas trained doctors vary from state to state. International graduates must be registered with the Education Commission for Foreign Medical Graduates (ECFMG, www.ecfmg.org), but this does not mean one has to be in possession of the USMLE. Not every state will require you to have passed the medical licensing exam, so choose where you want to go very carefully. Many overseas fellows choose programmes by word of mouth rather than from job advertisements, so it is often better to approach the hospital and programme director directly. The fellowship programme must be recognised by the Accreditation Council for Medical Education (ACGME) for your time in America to be recognised by PMETB and the RCoA.

Once you have your job offer, the delights of ‘credentialing’ begin. You will be faced with a small mountain of paperwork to enable the hospital to apply for your medical licence. Be prepared to send it all off with references attached or warn

your referees to expect a reference request by email. You need to allow at least 6 months.

The process of getting a US visa is lengthy and can only be started once you have a job offer and confirmation of your licensing. Your employer in America will sponsor the application. The US Embassy website is helpful. You will have to pay a visit to one of the Embassy offices to be interviewed for your visa application.

Most fellowship posts start at the beginning of July, but this is negotiable. The salary ranges from US$50,000-70,000. The cost of living is much cheaper than the UK. Unfurnished accommodation to rent is most common. Your hospital personnel department can help out with advice on good areas to live.

Once in the country you will need to apply for a Social Security Number. It can take Immigration up to 10 days to put your details on to the computer system, so it is worth waiting once you’ve landed before applying rather than going immediately only to be told to come back another day. It is also vitally important to be in possession of medical insurance.

Working Life

George Bernard Shaw said “England and America are two countries separated by a common language” and this is never more true than in theatre. Drugs are prescribed by brand name, emergency surgery is referred to as ‘emergent’, the diathermy is the bovie, the consultant is an ‘attending’ and the theatre is the operating room or OR.

Expect to start work early with many jobs having start times of 7am or earlier and the hours can be long, but the majority of lists finish by 5pm.

USA


29

Paperwork is vitally important and billing is everything in the US. You can expect to be nagged if you have forgotten to fill in any part of it.

Some of the biggest differences are the absence of ODPs, the presence of nurse anaesthetists and not having anaesthetic rooms. An attending anaesthetist can expect to supervise one or two theatres, which can mean moving from one surgical specialty to another several times a day. The ‘anaesthesia provider’ is either a nurse anaesthetist or an anaesthesia resident. The attending has to be present for induction, blocks, invasive monitoring procedures and emergence. The anaesthesia residency programme is 4 years long and residents have recently been limited to an 80-hour working week, so they work hard (and are worked hard) during their time as trainees. They sit professional exams at the end of the residency, so do not seem to have the in-depth knowledge of the basic sciences that many UK-trained anaesthetists have from the Primary and Final FRCA. The salary for a 4th year resident is only $44,000 at the time of writing.

On-calls are resident to maintain the level of supervision required for residents and nurse anaesthetists and can be very busy if working in a hospital that sees a lot of trauma.

So... why do it?

Despite the considerable organisational burden of the paperwork and US visa application, working in America offers some fantastic training opportunities and the chance to work in a very different healthcare system to the NHS. The countryside is so varied from coast to coast and from north to south that there are places and climates to suit everyone whether you are a keen skier, surfer or a shopaholic!

Useful contacts:

US Embassy24 Grosvenor SquareLondonW1A 1 AETel: 020 7499 9000Web: www.usembassy.org.uk

Education Commission for Foreign Medical Graduateswww.ecfmg.org

Accreditation Council for Graduate Medical Educationwww.acgme.org

Federation of State Medical Boards – for contact information for all the state medical boardswww.fsmb.org

30


Dr Rob Hearn

SA is a less obvious choice for a year abroad, but both you and the country will be better off for it. There are many types of experience you can get from a year there: from working in a high quality tertiary referral centre, working in the busiest, largest trauma centre in the Southern Hemisphere, to being the sole doctor working in a rural clinic or hospital dealing with anything that comes through the door.

I chose a hospital in rural KwaZulu-Natal that was described as “where the worst of the third world meets the best of the first”. Wherever you choose, you will have an unforgettable experience in a country with incredible natural beauty and amazing opportunities for adventure and travel.

Organisation

It is often best to approach both the hospital and head of department directly, but you will make the process considerably easier if you get in touch with Africa Health Placements / Rural Health Initiative, as they will guide you through the process (see contacts overleaf). They are also your best bet if you have no job offer as they can place you where you are needed. They will help you prepare the paperwork for the Foreign Workforce Programme for Medical Practitioners (FWMP), South African Department of Health, Educational International Credential Services (EICS), the Health Professional Council of South Africa (HPCSA) and, finally, the South African

High Commission for the Work Permit. They will also ensure that all is in order, and in on time!

Working Life

You may feel still feel a bit like a medical student for the first few days as you get to grips with the routine and the very foreign language. You may also have to come to terms with the fact that you are not the GP of the hospital! As an anaesthetist, you are generally expected to pass gas and not routinely intubate in the Resus Unit, save lives in the ICU and relieve pain on the labour ward. But then you will have plenty to keep you busy in theatres. My experience was that routine emergency work for the general surgeons comprised blunt and penetrating abdominal and chest injuries as well as the slightly more mundane septic abdomen or leg. Orthopods were also plagued with infected joints and bones but also had to deal with the consequences of road traffic accidents and bush knife attacks to various limbs. Obstetric services were on a different site and had no time for epidurals with an average of 10 Caesarean sections a day and as many ERPCs and ectopics.

Positives

The climate you will encounter depends on where you go. Cape Town and the Western Cape have beautiful, reliable, warm weather in the summer but are cold, rainy and windy in the winter, whereas in the north the climate is much more tropical with warm, dry winters and sweltering, wet summers.

The lifestyle best suits an active person. There is available access to watersports, windsports, mountain climbing, walking, safaris and 4x4ing

South Africa


31

all over the country. For those who enjoy the city life, it can be enjoyed in Cape Town, Durban or Johannesburg but, if you restrict yourself to this, you are definitely missing out. The cost of living is low and, with pay as a specialist doctor relatively high, you can live well and afford to get the most out of your time.

Negatives

There are drawbacks to working in this fantastic country and are the reasons that most people, including my mother, cite when dissuading themselves or others from going, and why many native South Africans have emigrated.

These are, in no particular order: HIV rate of up to 50% in some areas along with AIDS/TB; high levels of personal crime – burglary and carjacking; uncertain political future and high levels of corruption; widespread and overt poverty and inequality.

These are not to be ignored and care must be taken to try and avoid the avoidable. I had no negative experiences in this regard, but everyone knows somebody who has a bad South Africa story.

Things I learned

I am happy that I got what I wanted from my year abroad. Specifically, I had a great deal of exposure to trauma anaesthesia and severely septic patients. I also learned to be self-reliant as the anaesthetic nurses were variably present and variably skilled, and you would also be expected to get on with cases which in the UK would attract a consultant. I was exposed to the South African training scheme which, in my view, is in

contrast to the UK, and allows and encourages trainees to experience many different specialties which seems to make more rounded, competent doctors.

In addition to the work, I had a fantastic year in a foreign country and travelled extensively. I visited mountains, beaches, wilderness, desert and cosmopolitan cities. With so much on their doorstep it’s not surprising that not many South Africans have left their continent.

Useful contacts:

Rural Health Initiative / Africa Health Placements

Mr Martin Schroeder 54 Edgeway Rd, Oxford, OX3 0HE (Standard Mail) 40 Pembroke St, Oxford, OX1 1BP (Special Mail) Tel: 07920 520600 Fax: 01865 423324 Email: [email protected]: www.ahp.org.za

Dr Derek BarrettChief AnesthesiologistNgwelezane HospitalEmpangeniTel: +27832317858Email: [email protected]

32


Dr Halia O’Shea (with thanks to Drs Michael Dobson and Andy Longmate)

This will be the best thing you ever do. You will do it for a year or less but will talk about it as if it happened yesterday for the rest of your days. You will have the luxury of being altruistic and unselfish for perhaps the only time in your working life.

Preparation

Talk to anyone and everyone you can who has spent time in the developing world and keep a record of suggested contacts and what they said about their experience. It takes a year minimum to put your trip together – you need to start thinking about it, planning and preparing far in advance.

MAKE ABSOLUTELY SURE that you attend the ‘Anaesthesia in Developing Countries’ course organised by Mike Dobson (www.nda.ox.ac.uk) in Oxford before you go. This fantastic course is also held in Uganda and is absolutely invaluable as a source of contacts and advice from people who have been and done it, as well as providing a taste of what it might be like to take apart, clean, and reassemble a halothane vaporiser, use an OMV on a patient, use an oxygen concentrator, and how to employ a kitchen sieve / gauze blood recycling technique! In addition, get hold of

Mike Dobson’s book ‘Anaesthesia in the District Hospital’ and join the World Anaesthesia Society (www.worldanaesthesia.org). Ideally, go and do the Diploma of Tropical Medicine and Hygiene in Liverpool or London before you go (it runs twice a year for 3 months and is incredibly useful and great fun).

Learning the local language hugely enriches your experience and makes you more useful in your work. My son spoke Tok Pisin before he could speak English!

Motives and Safety

What do you want from the experience? To ‘do good’? (you will get far more out of it than anyone else will get out of having you) or to have an ‘experience’. Be honest with yourself and close family. Tell your boyfriend / girlfriend if you are coming back or not. Tell your mother-in-law where you are taking her grandchildren and what the risk of cerebral malaria and volcanic eruption is. Make sure your partner and children are going to be safe and happy accompanying you. Will your partner have to spend much time on their own in isolation? Who will look after your children if you both work?

Road traffic accidents, infectious disease, natural disasters and violence are things to be aware of. Undertake the trip with a full awareness of where you are going (e.g. Congo vs. South Pacific) and what you are going to be doing (MSF vs. VSO). I had malaria, an armed break-in at night whilst alone with my 1-year-old, volcanic eruptions close by and an 8.2 Richter scale earthquake within 6 weeks of arriving in Papua New Guinea. Thereafter things were relatively quiet.

Developing World


33

What do you have to offer?

Are you going as a consultant (post-CCT) or middle grade trainee? Whatever your level of expertise and training you will benefit yourself and those you will be working with by making some preparations and getting some extra training and kit together.

Experience in paediatrics and obstetrics is really important for the developing world. Take as many paediatric cannulae, paediatric endotracheal tubes, paediatric blades and spare laryngoscopes by asking anaesthesia equipment reps for equipment. Ask those at your destination what you can bring that would be especially helpful. Can you borrow a pulse oximeter, a Hemocue or even an oxygen concentrator?

Pay more attention to the other side of the drapes - watch how your surgical colleagues close a wound and try to acquire some surgical skills before you leave.

Raising money

Make it known that you are going abroad to work and consider doing some fundraising or applying for some of the excellent anaesthesia grants available before you go. I applied for a number of grants and was able to use the money to fund resuscitation education and training, a public health campaign on nutrition, and to send my hard working colleague (Anaesthesia Technical Officer and mother of six!) to a national meeting.

When you get there be a ‘grey’ person

Be a ‘grey’ person for at least a few months. Be quiet and watch - keep your thoughts and criticisms to yourself as you wonder why on earth they do things in a certain way. The politics and patterns may take a while to become apparent so try not to assume before you have an inkling of how things work. Adapt to the pattern of work in place, do not force them all to adapt to you. The infrastructure and money in the NHS are rarely seen in the developing world resulting in work patterns that you may find puzzling for some time.

Humility

Remember that those you work with will almost invariably be anaesthesia technical officers, anaesthesia practitioners and, in some instances, a porter or hospital orderly who was spare at the time. It is unlikely you will be working with other physician anaesthetists. These people are often incredibly good, dedicated, and far more skilled at anaesthetising neonates and sick children, or using ketamine and halothane safely, than you are. Be humble and learn from them. They may have a different attitude to infection control and analgesia – be aware of the context. The Papua New Guinean surgeon and paediatrician with whom I worked closely were wonderful and inspiring doctors. The paediatrician did appendicectomies, Caesarean sections and ectopic pregnancies when he was on-call. The surgeon opened heads, bellies and chests and tried hard to save everyone – there was nothing he would not do.

34


Keep a record

Keep a daily log of the anaesthetics you give, the cerebral malaria cases you attempt to resuscitate, the obstetric epics and tragic paediatric cases you encounter. Your daily journey from elation to despair, frustration and rage can flip back to hilarity and delight again within the hour. None of it may be counted by the college as valid, supervised experience but you will be getting valuable experience in working independently, managing, and teaching as you diagnose and treat leprosy, tuberculosis, malaria, congenital heart disease, Burkitt’s lymphoma and yaws.

Be versatile

You may be an anaesthetist but you are first and foremost a doctor. If they need you to run the paediatric ward for a few months and there is someone else perfectly capable of giving anaesthetics then do it. If they need you to do minor surgery or run clinics, work in the wards or casualty, go out to the islands, take X-rays, drive the ambulance or sort out the generator then just do it. Don’t be surprised when the water or electricity stops.

Support

Identify mentors in a few different areas – who can you ring for help and advice in the UK at 2am? Have a few ‘phone a friend’ options in paeds, obstetrics, medicine, surgery, orthopaedics and infectious diseases.

Be prepared to use technology – it may be possible for you to send an image of a skin lesion,

clinical appearance, radiograph or wound to a friend back home and get on-the-spot advice.

Teach

Leave a positive legacy and set a good example. Do not use sophisticated techniques or kit if they are not available or safe in the hands of those who continue once you disappear back to running water, shops with everything, and electricity. Work to the lowest common denominator and teach what is safe and viable in the setting. Do not use LMAs if you do not have access to propofol.

Try to encourage a shift toward spinal anaesthesia for Caesarean section rather than GA. Try to foster a good approach to infection control, recovery and safety.

Try to do ALS, ATLS, and as many courses of this ilk as possible before you go. Ideally, qualify as an instructor and have some teaching experience so you can run similar courses once you arrive. Take some of the teaching materials with you.

Support your colleagues

Talk about issues that you are able to in settings where others find it difficult. I put up posters about HIV and STIs in a Catholic mission hospital and talked openly about contraception in a place where it was frowned upon for the nuns to do these things. I spoke to the Archbishop about problems with domestic violence and child abuse in the community when it would have been very difficult for my longer serving local colleagues to do so without consequences.


35

Relief and Rest

Be prepared for a culture shock and have some supports in place before you leave. Plan some rest or something to look forward to. Keep in touch with mentors and family / friends. Remember that those you work with may be paid next to nothing and work much harder than you with no or rare holidays. Take the opportunity while you are there to give them a good break to see long unseen family or just have some time off. Try doing their 1 in 1 on-call when they go off for a meeting for a week. It may be that when you go again they will get little relief or support again for some time.

After you return home

DON’T FORGET those you have said goodbye to and thanked. Continue to support and encourage them. Keep in contact and send equipment and money for them to run training days, attend meetings or buy materials.

Upon your return after the most incredible experience you will ever have in your life be prepared for no one to care or be interested in either what you have done or where you have been or those impoverished but delightful people you have been working with and giving anaesthetics to. Just cherish your memories and make sure that, after your children are grown up and off your hands, you go back one day and do it again. In the meantime, remember those you have left behind and support them as best you can. Go out on teaching trips or short ‘surgery tours’ with plastic surgery organisations (Interplast), ocular, cardiac or fistula surgery missions… there are plenty of opportunities.

Spread the word that the anaesthetic diaspora is broad, wide, and deep… and often very poor. Ketamine, suxemethonium, halothane and cinchocaine rather than sugammadex. We should all be aiming to make anaesthesia safer throughout the world. Present to as many people as you can when you return. Show the pictures and tell the story. Hopefully you will inspire someone else to emulate your experience.

Courses on Anaesthesia in the Developing World

UK/UgandaOxford course is in July (run by Mike Dobson), Uganda course in November Tel: 01865 221590Web: www.nda.ox.ac.uk

CanadaHalifax, Nova ScotiaCourse runs in MayEmail: [email protected]

AustraliaEmail: [email protected]

Teaching Resources

Anaesthesia at the District Hospital 2nd Edition, Dobson, WHO 2000

Anaesthesia in Developing Countries (December 2007 Supplement to Anaesthesia): www3.interscience.wiley.com/journal/118530539/issue

36


Primary Trauma Care website: www.primarytraumacare.org Update in Anaesthesia, journal of the World Federation of Societies of Anaesthesiologists

TALC (Teaching aids at low cost). Apart from low price books, TALC can also provide free CDs which incorporate all of Update in Anaesthesia, Anaesthesia Resource 3 and a number of useful books just as a start!

Care of the Critically Ill Patient in the Tropics and Sub-Tropics, Watters et al, MacMillan 2004

www.aagbi.org/publications/anaesthesia_news/2007/april07.pdf (p28)

Médecins Sans FrontièresWeb: www.uk.msf.org

Médécins du Monde UKWeb: www.medecinsdumonde.org.uk MERLINWeb: www.merlin.org.uk

Voluntary Service OverseasWeb: www.vso.org.uk (NB: NHS Scotland sponsors 10-20 staff to do 12 months VSO and retains their job for when they return – this is not yet the case elsewhere!)


37

Dr Mark Hearn

Working for a short time as the Ship’s Doctor on a small ship is an excellent opportunity to visit some remote parts of the world that are otherwise very expensive to get to, and meet interesting people and see wildlife that you previously believed only BBC cameramen got to see. These include, but are not limited to, the Arctic, the Antarctic, the Galapagos Islands, the Indian Ocean islands, and even the North Pole on a Russian nuclear icebreaker.

Some of the operators of these expedition cruise ships believe that anaesthetists make the best Ship’s Doctors as, on board, one’s primary responsibilities are to stabilise medical emergencies and deal with nausea and vomiting - two areas that we are all very familiar with! However, you are extremely unlikely to have to give an anaesthetic so it is difficult to convince the ‘Powers That Be’ that it should count towards training, so doing this other than in a period of annual leave will necessarily delay your CCT. If this doesn’t matter to you and you have an understanding Training Programme Director then this sort of job is relatively easy to organise.

You will be responsible for the health of everyone on board, passengers and crew. Whilst the passengers are usually fairly fit, on many cruises, particularly in the Antarctic, the average age can be in the 70s so you may have to deal with any of the potential problems of this age group. The

crew are usually on 9-month contracts on the ship and have no access to any other healthcare. For this reason, some experience in A&E, General Medicine or General Practice is preferred.

However, most of the time, there is little medicine to do and you can participate in the expedition activities of landings and wildlife watching. Also, if you are interested, you can take advantage of working on a commercial vessel to learn new skills such as powerboat driving, ocean navigation and use of VHF radios, etc.

Because of the popularity of these jobs, most of the operators have found that they still get sufficient applicants even if they do not pay the doctor. The precise details of the contracts vary from company to company, with some being better than others, but you should expect your travel to and from the ship to be organised and paid for and a reasonable daily allowance on board for laundry, email, soft drinks in the bar, etc.

Similarly, because there are people queuing up to do the job, there are only short contracts available, typically between three weeks and three months, with three months being unusual.

The other thing to consider is medical indemnity insurance. Some companies provide it, others don’t. It can be quite expensive so check this early before you commit yourself to a contract.

If this all sounds appealing, first of all you need the ‘in-principle’ approval of your Training Programme Director to take a period of unpaid leave. Then you need to contact the ship’s operator, request a contract, and find out when they have slots available. These things are usually

Working on an expedition cruise ship

38


organised at least a year in advance so don’t leave this bit too late.

Then you need the approval of your Dean and the RCoA. However, as you are not asking to count this job towards training (you are really only asking for a period of unpaid leave), their threshold for approval is much lower. There is also no need to contact PMETB.

Finally, go, have a great time, take lots of pictures, and come back. On your return, assuming you took more time off than just annual leave, you will need to write to the RCoA telling them precisely how long you were away for so that they can adjust your CCT date.

Useful contacts:

www.oceanwide-expeditions.com/ocn.htmwww.quarkexpeditions.com www.auroraexpeditions.com.au/site/home.aspxwww.expeditions.com


39


21 Portland Place, London W1B 1PYTel: 020 7631 1650Fax: 020 7631 4352

Email: [email protected]

organising a year abroad – out of programme advice from the gat

Documents