Dr. Expat: American physicians on foreign soil

Kathryn T. Starkey, MD, a gynecologist in a two-physician practice in Auburn, N.Y., was ready for a change.

She liked providing medical care but didn't want to see more patients in less time. She wanted to eat lunch at a table rather than in her car while driving to the hospital, if she ate at all.

"Something had to give. I wanted to try something else, and I was willing to be far away from home."

About 9,000 miles from home, as it turned out -- in New Zealand.

Staffing companies and foreign government agencies are actively recruiting American doctors, with several hundred, like Dr. Starkey, estimated to take these kinds of jobs every year. Some opportunities are permanent, a way for countries to fill their own physician shortages. But many are temporary, with agencies and governments selling the idea that doctors can go somewhere interesting, do a little globe-hopping, yet still practice medicine.

In 2006, Dr. Starkey gave her partner a year's notice and sent letters to patients. She encouraged them to continue with the practice. Because she had been providing only gynecology, she brushed up on obstetrics. And in September 2007, she left for a locum tenens assignment in Gisborne, New Zealand, arranged through a company called Global Medical Staffing in Murray, Utah.

After half a year in the town of 45,000, whose claim to fame is that it is the first city in the world to see the sun each day, Dr. Starkey worked for three months in the Cayman Islands. She then spent six months in Kalgoorlie, a town of 26,000 in western Australia. After some time in the U.S. between assignments, she returned to Gisborne in July. "It's not for everybody, but it is still a nice way to see the world and continue to practice," she said.

The challenge isn't only being in a strange place for an extended time. Experts say you also must figure out how patients will be covered while you're gone (assuming you're coming back), how to handle a more complicated tax situation and how to adjust to the local health system, including going from a private-based payer system to a public one.

Almost all positions provide round-trip airfare, and many come with other benefits. Some agencies, such as Vista Staffing Solutions with corporate headquarters in Salt Lake City, facilitate a doctor's direct employment by a client. Others, such as Global, are primarily locum tenens agencies and employ the physicians. And instead of hiring directly, agencies run by Canadian provinces tend to focus on promoting their regions as good places to work and linking physicians to employers.

Urban placements are possible, but the majority tend to be in rural areas because, much like in the U.S., these areas have the biggest need. Salaries vary, depending on the country and the specialty. Family physicians working through Global typically earn between $275 and $650 per day plus housing, airfare and liability insurance. Specialists are paid $350 to $950 per day. Physicians placed by Vista generally earn between $92,000 to $145,000 annually in Australia and between $61,000 and $97,000 in New Zealand, with short-term housing usually provided before support is given to find their own. Salaries are quoted in U.S. dollars.

But physicians who go on this type of journey say money is not the main motivation. Some are attracted by the idea of working and traveling while seeing more of a county than is possible in a brief visit.

"It's different than just traveling to a country for a week or two. You really change the way you live," said Bruce M. Lovelace IV, MD, a psychiatrist in Portsmouth, Va. "There's a lot of things you need to get used to, but it's a lot of fun." He just returned from a one-year position in Wellington, New Zealand, arranged with Global.

Those who are parents may be looking to show their offspring other cultures without the challenges of living in a less-developed country. "My children now speak Mandarin," said Steven Tucker, MD, medical director of the Pacific Cancer Centre in Singapore. "Growing up in Asia in an international environment makes a very positive impact on them."

Others leave the country for the opportunities. Dr. Tucker had been working in Los Angeles until 2005. He wanted to do more cancer research, and the opportunity presented itself not only to do so in Asia but also to build an oncology center from the ground up. California has many such places. Asia is in dire need of them.

"My immediate answer was, 'Sure, no problem,' even though I had a full practice and no complaints," he said. "The idea of something new and building a Western- or American-style cancer center appealed to me."

Learning a new system

Those who go learn the reality of practicing medicine in a different system, which can be part of the attraction. Those in countries with socialized medicine say they have less paperwork and don't have to deal with insurance companies -- a common complaint in the United States. In Singapore, Dr. Tucker said 60% of his patients are from outside the country, mostly from Indonesia and Vietnam, and pay cash.

Liability insurance also is less expensive. For instance, Dr. Tucker spent an average of $25,000 annually on liability insurance when he was working in the U.S. He now pays $1,200.

But no health system is perfect. "There are limitations on how soon a patient can have an elective operation," Dr. Starkey said, describing New Zealand health services. "You have to stand in line and wait. ... I can only select the medicines that they have. But for the most part, it works quite well."

Problems in these systems are some of the causes of physician shortages. Many New Zealand doctors work in neighboring Australia in part because education is more available and salaries are higher. Canada has lost quite a few physicians to the U.S. According to a study in the April 10, 2007, Canadian Medical Assn. Journal, approximately one in nine physicians educated in that country were practicing in the U.S., although the Canadian government has taken steps to increase retention, including upping salaries.

And expat life is not without challenges. Taxes can be more complicated. The U.S. is the only country that taxes its citizens on global income. This means filing in both the country worked in as well as the U.S., although this rarely translates to a significant tax bill because of various deductions allowed for those living outside the country.

Those with student loans also might have trouble making payments on less than a U.S. salary. Fluctuating exchange rates also make this more difficult.

Visas and medical licensing require a lot of paperwork, although going through a staffing agency can make this easier. Agency fees are paid by the employer.

Links to home may be difficult. Technology has improved this situation dramatically, but time zone differences remain a barrier. Also, the language may be the same, but cultural differences can still cause hiccups.

"Instruments are called by different names. They may not be the same, but they do the job," Dr. Starkey said. "And we all speak with different accents. You have to train your ear."

In addition, re-entry to the U.S. may be as culturally challenging as the first move to another country, although working internationally may make job-hunting easier once home. Dr. Lovelace has just signed a contract to work for the Naval Medical Center in Portsmouth, Va., and said the experience outside the U.S. made him a more attractive candidate.

"It was certainly intriguing to everybody. It was a talking point," he said.

Some doctors end up staying much longer than planned. Gretchen Neumann Stone, MD, a family physician who previously worked in California and Ohio, arrived in Scottsdale, Australia, with her husband and three children in February 2005 with a job through Vista. They planned to stay only a year with the Scottsdale Doctors' Surgery in the town of 2,000 on the island of Tasmania.

"We did this as a one-year family adventure and wanted to spend six months to work our way home," she said. "That has not happened."

Four years later, she's still there. She is a partner in the practice and is eligible for Australian citizenship.