Part-time international health work while in private practice
Saturday, November 16th, 2002 9:00 a.m.
Moderator – Vinita Goyal
Note taker – Erika Schroeder
Dr. George Brannen, Professor, Department of Urology, University of Washington
School of Medicine
Congratulations to the International Health Group for putting on this conference.
I had most of my overseas experiences after I was in private practice. After leaving
private practice I earned my MPH from Berkeley. Upon my return to Seattle I worked
part-time for the University and also for the state. My work for the state involved caring
for delinquent teens. My superintendent was the person that made my trips abroad
possible. It was my responsibility to find people to take my place. Most of the time
practitioners from a clinic in Snoqualmie filled in for me as they “wanted to do what I
was doing but couldn’t so wanted to make it possible for me to go.” At times I was gone
as long as a year.
Slides: Approximately 25 million people are displaced by war and famine.
Organizations that I have worked with and may be helpful to you include:
Doctors of the World
World Vision (faith based)
Refugee camp in Thailand: Refugees were referred to as illegal aliens, for part of the time
there was no school and the children were very hopeless. They could not cross the fence
or they would be shot and that happened while I was there. Each person received a liter
of water a day for drinking and washing. Injured Cambodians were brought in rice
trucks. The camp was run by the Red Cross and was overseen by the U.N. It was
important to keep newborns with their mothers as the babies were often abandoned if
they were taken away for treatment. Malaria was common; the local healer would come
in to “coin” patients. The refuges felt much better about our service because we
incorporated traditional healers into their care. Prior to modernizing when you go into a
camp you need to ask yourself if they will still be able to do what they are doing after you
are gone. You are there as a learner and a teacher, but first you must learn about the
culture to be able to teach. These are some of the drawings that the children in the camp
drew; this one was of people being slaughtered.
Beruit: International Committee of the Red Cross was the only organization recognized
by all of the combatants.
Ethiopia: In the camp 45 of 50 caretakers were Ethiopian. It was very inspirational to see
these people take care of their fellow Ethiopians.
Somalia: There were five of us to take care of 80,000 people. We were totally
overwhelmed and so we decided to teach some of the refugees how to be care takers.
Many of the women died in childbirth as there was no sanitation and very little
knowledge of what was happening. Measles and Polio vaccines greatly reduced
Iran: Kurdish refugees shortly after the gulf war. A fourteen year-old who spoke four
languages was my translator.
Russia: There was a ward for premature infants with sixty infants but only one incubator.
Kosovo: I lived with an Albanian family while I was there. I made rounds twice a week
with the Serbian staff. Although we always think of Serbs as horrible people, these
people were wonderful people who really cared about their patients. As the Albanian
children in the villages were not eligible to receive vaccinations, we went to the villages
to explain the importance of vaccinations and administer vaccinations.
Dr. Jim Owens, Emeritus Clinical Professor, Department of Pediatrics, University of
Washington School of Medicine
It is a pleasure to be here. I am here to make you comfortable with living two lives; one
to practice in the U.S. and to provide care in a third world country.
When I was 47, I was director of transplants at Virginia Mason. I had accomplished
more than I thought I would when I was sitting in your seat. I had paid off my loans and
my three sons were pre-college aged. I was comfortable and had a little bit of retirement
but was by no means rich. I felt that I was giving very little here in the U.S. where
performance is based on how quickly you can get the report to medical records.
I then moved with my family to Camaroon, West Africa. There I met more fundamental
Three things that I have learned from my experience:
1) There is never a good time to go, this is very important to remember. Of 30 inquires to
me about working abroad only one person actually goes, I want to change that today.
There is ALWAYS something happening.
2) A physician will return to their previous standard of living fairly quickly and
3) Experience far exceeds the sacrifice and the experience lasts indefinitely, I have been
back for seven years and I am still benefiting from the experience.
Slides - Images of the hospital in Camarron: rewashing and sterilizing the gloves,
washing and rolling the gauze
This was a family experience. My sons missed junior high here in the U.S. but I did not
feel that it was a great loss. My hobby while I was there was to try to understand
traditional healing. I wanted to understand the biomedical model. Ex: the long bones of
a powerful animal used to splint a broken arm. Community explanation for illness is
extremely important. For example, a person may become sick due to a misunderstanding
with a fellow community member. This person must make amends in order to get better.
You have a cycle of reactions when you enter into a new culture -
There a few months – you see how grossly difference they are
Few months to a year – you feel that their thought processes are extremely different
1-3 years – realize that they are identical, there are just phonotypical differences
After returning I have stayed in contact with the people that I lived with. This experience
has changed my life – it keeps my head on the horizon rather than on my toes.
One thing to remember: I love the United States. Our health system is the best in the
world for the patients. We need to keep our eyes on the global community to make more
of an impact.
Dr. Matt Thompson, Assistant Professor, Department of Family Medicine, University of
Washington School of Medicine
I am at a much more junior level in my career.
Ways that I have tried to do this:
- Yearlong clinical position overseas
- Short-term medical missions
- Research position
TOMA – Tribal Outreach Medical Assistance focuses on Yonomami indigenous people
of Venezuela, population of approximately 15,000
Health challenges are mostly infectious diseases, especially malaria. The people have
surprisingly few possessions. Medical care is very limited, some provided by the
government but mostly limited to missions. The area is incredibly remote. One of the
things that we were trying to promote was the use of bed nets. I am no longer involved
with this organization because I found someone who could do it better. I think that short
term medical missions are not always effective.
Kwazulu, South Africa
I lived there for a year several years after graduating from medical school. I had been
there on a third year medical rotation. Most of my learning was related to doing
something such as a cesarean section that I had learned how to do but that had to be done
differently due to different equipment. There was a lot of TB, HIV, pellagra,
hypertension, alcohol, stroke, trauma. It was both a learning and a teaching experience.
Pacific Islands, Continuing Education Program (PICCEP)
The project is on six islands including Guam, Yap and American Somalia. Funded by
HERSA to update clinical skills of the primary care docs, updating medical references
(people cannot afford to get on line). It is very difficult to keep up with current medical
practices if you are disconnected from the medical world.
- Oncome/housing - Medicine can be a wonderful thing
- Continuity of clinical care - Attitudes
- Clinical productivity -Public health, cross-cultural health
- Primary care vs. specialty care, underserved
- Health -Costs/quality of care
- Family -Primary health care
- Utility of short term work -“altruism”
- Finding opportunities - Service
Ways to do it:
During Med school:
-Residency programs with IH tracks
-Tropical medicine training courses
-Disease based research vs. public health
- Urgent care
- Clinics where there is a rotating sabbatical
- Take breaks between clinical positions
Clinical/teaching positions overseas
Underserved communities in the U.S.
Q and A
Q: How do you deal with medical licensing requirements while abroad?
A: Not too difficult or stringent. B: I begin discussion 6 months before leaving and the
visa is the main requirement. Liability issues are almost nonexistent. O: I agree T: I had
some insurance while in South Africa
Q: Could you please talk about the experience for your families.
A:O: we had two sons, 12 and 13 while we were in Cambodia. They were the right age,
they enjoyed the experience and now feel that it changed their outlook on life. My wife
is a teacher and thus she taught while we were in the camp. T: I have a very young son
and have not figured it out although I would be somewhat worried about infectious
diseases. It can be difficult it you have a significant other who is not in the medical
profession. B: My wife is non medical and she was concerned that the experience would
be mine. However, she had a great experience and is as much or more enthusiastic than I
am about our experience. She found that you just have to open your eyes and you will
find plenty to teach. Our third son elected not to go as he was 18. For those of you who
are first-year medical students and are wondering if you can contribute, yes you can. Go!
Q: Dr. Brannen, how did you select the site in Cameroon and how much urology did you
A: It took me 18 months of intense communication to set up the experience. Most of
what I did was urology.
Q: What kinds of technical equipment or training were important to leave behind when
A: Knowledge was the most important thing to leave. You must be very cautious about
leaving equipment as these countries are full of broken equipment. O: We found the
centers for disease control people that were present in the camps to be very helpful. T:
Most equipment sits around rusting mainly because they require a lot of upkeep. You
can leave some of your clinical work ethic and the impression that some things should be
available such as penicillin. Even the simplest things require ongoing supply and
Q: How do you keep up on tropical medicine skills.
A: Work in travel medicine, or immigrant clinics. There are also training sessions on
Q: Are you aware of any loan replacement programs through international health?
A: No. Possibly through Fogherty or other research grants. O: All of the organizations I
went with paid my expenses and some provided a stipend.
Q: Did you ever run into situations where the traditional and conventional ideology
directly opposed one another?
A: O: I never saw things that I thought put the patient’s life at risk. Self medication can
be a bit of a problem. In Ethiopia, it was often thought that you would not be healed
without a shot. There is a lot of education and “selling” involved in treatment. B: The
healers were very sound, they have hundreds of years of experience which may be just as
good as a double blinded study. Most everything that they did was beneficial. You just
have to listen and respect. I did not see anything harmful and the spiritual care was
tremendous. T: You tend to see the failures in the hospitals but not all of the people who
got better. There are also lots of problems with Western medicine, ex. Hepatitis C
epidemic in Egypt caused by vaccine needles. Mental health is also an issue in
Q: Could you elaborate more on the challenges of reentry?
A: O: Upon our return from Somalia, we went to the Food Giant and upon entering my
wife started crying. It was difficult to see some of the excesses in the U.S. after living
among such poverty. B: Reentry was by far the most difficult. The excesses and the
choices are overwhelming when you return. Changes occur here in the U.S. while you
are away. Little things such as changes in drug names froze me. I felt that I had lost my
memory for details such as meeting dates/times. It took me six months before I really
felt comfortable. T: People often don’t understand and it sometimes seems like the past
year has not happened. The internet is amazing and makes communication much easier
than it was in the past.
Q: What were the most effective ways of dealing with the language barrier?
A: O: We tried to learn a few phrases in each country. People love to see that you are
trying to learn the language. We had good interpreters everywhere I worked. There are
also cultural differences; I found that it was hard for patients to respond to choice
questions. B: We were trying to understand pigeon English which we found very
difficult. It took me about a year and a half to manage in pigeon. T: It is very important
to learn at least a few words. Clinically you can learn to take a history fairly easily.
Spanish can be a huge advantage, I would recommend learning it.
Q: Are there different issues for women?
A: T: Safety can be somewhat more challenging. Also, women often have to take
starting a family into consideration. B: Male and females were pretty much equal when I
was overseas. I didn’t really see any difference re: comfort.
Q: Could you please comment on your work with nurse practitioners?
A: O: I think that nurse practitioners are essential. T: Physicians often seem to be
overpaid and have huge egos. In most of the communities that I was in the NP were
managing the clinics. Skills that NP have are very useful in the international setting. B:
Credentials can sometimes be unfamiliar to the culture but otherwise I would encourage.
Q: What has working abroad with vulnerable populations contributed to your practice
A: O: You see a lot of the same issues in the clinics where I work. The kids I worked
with wanted to be part of what I was doing abroad. T: You bring back clinical skills
because you see more advanced pathologies. You also bring back an appreciation for
resources. There are a lot of things that we do here without proof of efficacy. Just do it!
There is never a perfect time! There are always things that will make it difficult. B:
There can be difficulty in translating your mindset and giving people the compassion that
they deserve (upon return). I found that touch can make a huge difference. Illness is
different than disease…the biomedical model is a small part of it. You mature as a
physician in America – eye contact is very important.