Explore this issue:June 2008
International Head and Neck Surgeons Who Train in North America Find Benefits and Limitations When Returning Home
Over the years, articles in the scientific literature have documented the trials and rewards of foreign doctors who come to North America for their residencies and fellowships.1-3 The psychosocial and professional stresses of leaving one’s native country, and then returning after training, can run the range from negligible to substantial. ENT Today spoke to four graduates of North American fellowships in otolaryngology-head and neck surgery at their offices in Brazil, the Netherlands, Germany, and Puerto Rico. All said their training was superb, but they also thought some aspects of their experiences could be modified to better prepare them for practicing when they returned home.
André Lopes Carvalho, MD, PhD, is a head and neck surgeon practicing in Barretos, Brazil, a small city with a major cancer hospital. He has been there just six months. He went to the United States three different times for training, spending the bulk of his time here as a researcher. In 1999, Dr. Carvalho completed a four-month fellowship at Memorial Sloan-Kettering Cancer Center (MSKCC) in New York, researching clinical outcomes; he received his PhD based on research partially carried out there. In a second training program on cancer epidemiology and prevention, he spent four months at McGill University in Montreal in 2000, and another two months at the National Cancer Institute in Washington, DC in 2002. In his third training program he stayed 18 months at Johns Hopkins Medical Center in Baltimore in 2004, where he completed a postdoctoral fellowship in basic research in head and neck oncology working in the laboratory with Joseph A. Califano III, MD.
Dr. Carvalho cited his greatest gain from these programs as the opportunity to think outside the box and to see many different people working in this field. I could bring back something new every time, not only to change my practice but to teach others, he said.
Dr. Carvalho and a colleague of his, who was also his supervisor and had done extensive clinical training himself in the United States, identified a formidable problem: patients with head and neck cancer arriving at their hospital in Brazil had much more advanced disease than the admitted patients at MSKCC. However, when they compared outcomes in patients from both centers who were at the same clinical stage, they observed that they could provide similar treatment and get similar outcomes. That was very satisfying for us, Dr. Carvalho said.
The next step, they realized, was to become involved in preventive strategies.
But a continuing source of frustration is the lack of available resources compared to what he experienced in the United States. For example, in the United States, ultrasonic surgical scalpels cost $200 or $250 each. In Brazil, each single-use scalpel costs $1500. We are torn, deciding whether to pay so much more for the same thing, he said.
Manufacturers claim that the source of the disparity lies in importation taxation. We see these things being used when we are doing our fellowships, Dr. Carvalho said, and know we will not be able to use them when we go home.
Cultural and language difficulties sometimes blocked a positive experience. Most American trainees could easily make new relationships, but for trainees coming from other countries, especially those whose native language was other than English, it was more of a challenge.
Sometimes we would stay aside, asking few questions at the beginning, Dr. Carvalho said. Although in time they would feel more acclimated and would open up, the barriers still existed. For instance, trainees sometimes come without the advantage of grants and scholarships, forcing them to pay for necessary supplies out of their own pockets. Grant opportunities in Brazil and other developing countries are not easy to obtain. If medical educators had better recognized this, they might have been able to suggest a way to overcome these obstacles.
Certainly, Dr. Carvalho’s training outside Brazil has enhanced his academic career; last year he was promoted to associate professor at the University of São Paulo.
Michiel van den Brekel, MD, PhD, is now working at the Netherlands Cancer Institute in Amsterdam and has an affiliation with the University of Amsterdam. In 1996, Dr. van den Brekel completed a one-year fellowship in Toronto, including both clinical training at Mount Sinai Hospital and research at the Hospital for Sick Children. He then returned to the Netherlands.
In principle, Dr. van den Brekel said, the training is more emphasized and intense in North America than it is in Europe, and educators are more motivated in their teaching?there are teaching awards, for example?whereas in Europe, recognition comes only from the scientific and clinical achievements.
With extremely busy clinicians as teachers, the vast majority of teaching revolved around patient care, but Dr. van den Brekel thinks that providing more structured, topic-based training would also have been helpful. He also appreciated the literature discussion clubs in which he participated. In Toronto, at the institutions in which he trained, he was particularly impressed by the extent of multidisciplinary communication. Foremost, the large number of head and neck cases coming from around Ontario allowed probably double what he might have seen in the Netherlands. That volume of patients also made it interesting for neurosurgeons to attend our meetings, which contributed to our education.
In the Netherlands, competition exists between otolaryngologists and plastic reconstructive surgeons regarding who will perform the reconstructive surgeries. In the institutions where he trained, Dr. van den Brekel said, he was impressed that both specialist groups performed these surgeries together.
One of the problems I encountered when I returned home, he said, was that thyroid surgery is done by otolaryngologists in the US and Canada, but is done by general surgeons here. While in general otolaryngologists have more experience with this anatomy than general surgeons and I gradually have been doing more and more of these, it has been hard to change the system because of the surgical referral pattern here in the Netherlands.
Christian Simon, MD, PhD, completed a fellowship in head and neck surgery at the University of Texas M. D. Anderson Cancer Center in Houston in 2002-03, under Jeffrey N. Myers, MD, PhD, Erich M. Sturgis, MD, MPH, and Helmuth Goepfert, MD, and a second fellowship in plastic and reconstructive surgery of the head and neck at Washington University in St. Louis in 2003-04, with Bruce Haughey, MD, and Brian Nussenbaum, MD. Dr. Simon then returned to Germany, working for a year in Tübingen before coming in 2005 to the University of Heidelberg, where he is an assistant professor in the Department of Otolaryngology-Head and Neck Surgery.
Medical educators make sure you are very well trained and are perfectly ready to perform surgery when you leave, Dr. Simon said. Because of the excellent training he received in the United States, he was well recognized when he returned to Germany, and his surgical career took off. I was immediately put in charge of otolaryngology cancer cases and all the reconstructions, he said. They also named him to the National Cancer Center Board. That was a huge advantage, since I was only 34 years old when I returned, he said. I also came back with a wonderful understanding of multidisciplinary head and neck cancer care, which is something you don’t receive in Germany.
Because the resources in Germany, particularly in the large medical centers, are as accessible as they are in the United States, Dr. Simon found that the approaches and procedures he learned translated well to his settings in Germany. I could apply everything I learned, he said.
Héctor M. Santini, MD, encountered a very different experience after his training. After completing a fellowship in head and neck oncologic surgery in 1984-85 at M. D. Anderson under the former chair, Dr. Goepfert, Dr. Santini returned home to Puerto Rico. He is now an associate professor of otolaryngology-head and neck surgery in the medical training program for the Damas Hospital in Ponce, Puerto Rico, and also has a private practice.
It’s a nice feeling to be so well trained in the States, but it’s difficult to do what you are trained to do when you return to a situation lacking resources, said Dr. Santini. For example, although he was trained with a great deal of teamwork in how to choose and perform the appropriate surgery, the lack of trained nurses and speech pathologists in Puerto Rico was problematic; he had to cover all the bases himself. That limits your time and, of course, in the end limits your ability to apply your training, he said.
Dr. Santini would like to see more training for nurses, speech pathologists, and radiologists-in other words, the whole team on which multidisciplinary care depends.
But the greatest difficulty he has now is the lack of other resources, specifically equipment and technology. It takes a protracted amount of time for the health insurance companies to pay for lasers and CT/MRI scanners, for instance, which makes it impossible to offer his patients cutting-edge care.
The struggle can be somewhat lonely and disappointing. You have the expertise and, as years pass, your feeling of disappointment grows as you continue fighting with the system to get what is best for your patients, he said. Referring patients to the States just begins the same kind of struggles with insurance companies that they face down here.
Another problem is the medical-legal aspect of care. In Puerto Rico we are expected to treat patients and obtain outcomes as they do in the US, he said. No grassroots organizations or nongovernmental organizations serve as advocates in this way. Many physicians are flying to the States for better training but also flying away from the problems here, he said.
Dr. Santini would welcome counsel from someone in the United States, perhaps a program director or someone well placed in a specialty society. He feels that many international physicians and surgeons facing similar challenges would also appreciate such counsel, and he encourages US otolaryngologists to be open to such communications to help with similar feelings of isolation and frustration.
The specialty societies have international members also. It would be easy and so helpful for someone to call and ask, ‘What do you need in your country?’ If you are interested in contacting him, write to Dr. Santini at email@example.com.
- Gaviria M, Wintrob R. Foreign medical graduates who return home after U.S. residency training: the Peruvian case. J Med Educ 1975;50:167-75.
- Adebonojo SA, Mabogunje OA, Pezzella AT. Residency training in the United States: what foreign medical graduates should know. West Afr J Med 2003;22:79-87.
- Srivastava R. A bridge to nowhere?the troubled trek of foreign medical graduates. N Engl J Med 2008;358:216?9.
©2008 The Triological Society