Practicing Medicine Overseas in the Age of Letters and Fax

The year is 1991. Two medical students arrive by plane to Khon Kaen, Thailand. A flood has washed away the local road, disrupting their transportation plans. They know the name of their contact at the Khon Kaen University Faculty of Medical Sciences but have no idea how to get there. This is pre-internet, and as such, pre-Google Maps, pre-Uber, and pre-Google translate; without these resources or transportation there’s nothing else to do but to start walking.

Khon Kaen, Thailand

These two adventurers had penned several dozen letters and faxes searching for an opportunity to experience medicine outside of the United States between their second and third year of medical school. 

“Someone who knew someone who knew two American researchers working as visiting professors in Thailand.”

They finally connected with “someone who knew someone who knew two American researchers working as visiting professors in Thailand.” These visiting professors offered them an opportunity to work on two projects: one related to Opisthorchis viverrini – a parasite endemic to the area – and the other to understand HIV transmission in women in rural villages.

Dr. Gillian Schweitzer, now a psychiatrist, and Dr. Robert Stern, now an Internist, had taken their first steps towards a life of adventure.

Nyeri, Kenya

Having just completed residency and two years into her residency, Dr. Robert Stern and Dr. Gillian Schweitzer volunteered with the Catholic Medical Mission Board, who sent them to Consolata Hospital, a small hospital in the provincial town of Nyeri, Kenya. The hospital consisted of a men’s ward, a women’s ward, and an isolation ward for patients with TB and HIV. Each ward contained about 30 beds, with patients an arm’s length away from each other. The patients suffered from malaria, typhoid, meningitis, and other febrile illnesses, as well as the usual heart disease and chronic lung diseases. Resources were limited to a small pharmacy, an x-ray machine, 2 oxygen tanks for the entire hospital, and basic lab capabilities.

Doctoring in Kenya required adapting to significant cultural differences. Dr. Stern still recalls a man with metastatic prostate cancer suffering from bony metastasis. He was planning on treating the pain with morphine when the head doctor advised him:  “Do not tell the patient you are giving him morphine- morphine is for serious illness, and he’ll gather that his prognosis is poor. Give him the medicine and don’t tell him anything.” If the prognosis were poor, the patient was not to know.

“It’s amazing how much you could do with just these few medications…Even if we couldn’t check Depakote levels.” 

On her first day at the hospital, Dr. Gilllian Schweitzer was quickly informed that there was no psychiatric illness in Kenya. In response, Dr. Stern rounded on all of the patients in the hospital and prepared a list of patients that may have psychiatric illness. There were over 50. The medication formulary was limited to Amitriptyline, Haldol, Valium, and Depakote. “It’s amazing how much you could do with just these few medications”, Dr. Schweitzer reflects, “Even if we couldn’t check Depakote levels.” 

She still recalls a patient afflicted with diffuse bodily discomfort who had undergone several exploratory surgeries, all of which were unrevealing. With careful history, Dr. Schweitzer elucidated that the patient suffered from severe anxiety and panic attacks, and improved with treatment. Dr. Schweitzer also noticed that many patients had conversations with dead relatives under conditions of intense stress; she soon learned that this was a culturally appropriate response to stress.

Cleveland and Laos

Upon returning to the US, Dr. Schweitzer finished her psychiatry residency and Dr. Stern worked as an internist at Bellevue Hospital. With the birth of their son, they moved to Cleveland where Dr. Schweitzer worked at Cleveland State University in the counseling center and Dr. Stern joined Case Western Reserve University at a time when they were partnering with the National University of Laos in Vientiane. Through this collaboration, Dr Stern – along with Dr. Schweitzer and their 2 young children – spent 4-6 weeks a year supervising local Laotian medical residents in clinic and on the wards.

Cairo, Egypt

As their two children grew older, the couple explored opportunities to move with the family and live overseas. Dr. Stern took a position with the State Department as a Regional Medical Officer. He provided primary care to diplomats and their families located in Egypt, Morocco, Tunisia, Algeria, and Malta. His responsibilities included caring for more than 500 patients, supervising 5 American NP’s, and developing a referral network with reputable local physicians. Typically, his patients weren’t very sick. “It was more the worried well with well controlled diabetes, hypertension,” he recalls.

The entire family received diplomatic visas which allowed Dr. Schweitzer to work locally, though the diplomatic visa did not grant her an Egyptian Medical license. Through the connections with the State Department, Dr. Schweitzer joined the local private psychiatry practice of the Minister of Mental Health and worked under his Egyptian medical license. It was a classic outpatient private practice job and her patients were locals and expats. She also volunteered with a school for refugees, taught psychopharmacology at the local Egyptian residency program, and supervised psychiatry residents. She soon learned that residents rotated on both psychiatric wards and in villas in gated communities, where the mentally ill members of wealthy families were sequestered. 

Their children attended an American private school. The State Department provided furnished housing, and it was easy to connect with American Expats.

New Delhi, India

Dr. Stern continued to work with the State Department and moved to India to become the Regional Medical Officer for India and Sri Lanka. He cared for diplomats, and government employees such as visiting congressmen and senators. He remarks that “though tropical diseases like dengue and malaria were common, most Americans did not get them. Instead, Americans worried more about air pollution.”

Dr. Schweitzer developed a psychotherapy private practice at the American Embassy School in New Delhi where she saw students, teachers, and their family members.

(Check out our post on Practicing Medicine in India for more information)

Repatriation back to the US

The family of four returned to the US in time for their children to attend high school and college. Dr. Stern now works at Johns Hopkins and Dr. Schweitzer has a psychiatry private practice that, since the beginning of the COVID-19 pandemic, has transitioned to a tele-psychiatry private practice.

Inspired?

If these two intrepid physicians were able to find opportunities in the age of letters and fax, you can too. The State Department continues to hire psychiatrists and primary care physicians trained in either family medicine, internal medicine, or emergency medicine to work overseas. And of course, search our Job Board for many in-person and remote opportunities across specialties, all over the world.

Dr. Ashwini Bapat is a palliative care physician who attended medical school at Tufts University and completed residency and fellowship training at Yale-New Haven Hospital. She now resides in Portugal and provides clinical care through telemedicine.

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