Living and working abroad as a neurologist

Summary

More American neurologists may consider the possibility of living and working abroad as the world changes in coming years. This option may be particularly appealing to neurologists who are younger or older (and have fewer family responsibilities) and to some in mid-career. Professional life for a neurologist in America is generally secure and well-reimbursed, and the decision to move across the globe is not trivial. On the other hand, many more locales offer favorable practice opportunities as the world generally becomes wealthier, and health care in some places, like the Middle East and China, is expanding rapidly. Reasons to consider taking a job abroad include the adventure of living in a foreign culture, altruism, unique professional opportunities, a somewhat less rigorous work schedule, vacation travel in areas distant from America, a shared family experience, and occasionally financial benefit. Potential complications include physical safety in some places, cultural incompatibility, language barriers, funding American university education for children, and returning to employment in America.

Will you live and work abroad?

The world is a big place, but it is rapidly getting smaller because of the electronic revolution and population migration. More and more bright individuals from all over the world1 have chosen to study or work as neurologists in the United States2,3 or Canada4 for a variety of reasons related to quality of training, practice, and life. On occasion, American trained neurologists also choose to travel abroad. I am not talking here about a 2-week vacation to Paris but rather about a decision to live outside the United States for a period of years.

Currently, the number of neurologists choosing this career path is relatively small, but the number will grow in the future, at least in part because of easier communication and transportation. Living abroad might suit a variety of life situations, including the following:

• A young individual who performs some training abroad5–7

• A family with very young children who take advantage of less expensive childcare costs abroad

• A family with older children who want to show those children the world

• Academic neurologists in mid-career who choose to do a sabbatical abroad

• American-trained but foreign-born neurologists who want to live and work closer to their families elsewhere in the world3

• Neurologists nearing the end of their careers (like many of us8) who want new experiences, and perhaps more excitement, before retiring

I am a neurologist who has worked abroad. In 1997, my wife and I and our 3 daughters aged 8, 11, and 13 left America for Saudi Arabia. I have lived in Saudi Arabia for 12 of the intervening 15 years, and I must say that these have been among the most fascinating years of my life, both professionally and personally. The experience has given me some insight into the advantages and disadvantages of moving abroad that I will attempt to share here. Some of these factors are obvious (people speak Arabic in Saudi Arabia … and I do not), but some were not in the least obvious to me before our initial departure. The time we have spent abroad has turned out extremely well for me and my family, and living abroad might possibly turn out as well or even better for you. Or it might not.

The setting in the United States

American training9,10 and certification11,12 in neurology is arguably still among the most uniform13–15 and rigorous in the world.16–18 We American neurologists get to practice in world-class medical facilities with relatively easy access to the resources necessary to take care of neurologic patients. We are very well reimbursed to do so by world standards. Perhaps most importantly, while living in America we are enveloped in the stability, personal protections, and rule of law that permit the American dream to flourish. In general, we can purchase something or get something done relatively quickly, efficiently, and safely. Americans, including American neurologists, work hard to make this possible.

So, why would you consider living and working abroad? This is a complex question for each of us, and each of us has a different answer. Some of you read this question and realize that you have absolutely no interest in testing the risk-benefit ratio of living abroad at this point in your life. Others read the question with more interest. Perhaps your days on some humanitarian mission seemed too brief. Or, you realize that you have begun to live your life for your vacations rather than for the neurology you practice on a daily basis. Or, your current work situation has become too repetitive or too time-consuming, or your job contains certain dissatisfactions with partners or an administrative structure or American health care itself that make you consider alternative venues.

America is so large that it offers many venues within itself.19 If you don't like the cold winters of the American Northeast, then you can try the Southwest. If Boston is too judgmental, then consider San Francisco. If schools in Georgia do not seem adequate for your children, then move to Philadelphia. Each part of the United States is a bit different culturally and geographically, although over the last generation America has become relatively homogenous so that the advantages and disadvantages of one place over another for a neurologist have become smaller. Many areas offer excellent opportunities for neurologic practice or neuroscience research, so that you almost certainly are not required to move across the ocean to find a job.

But you might want to. Life is short, and there is a big world out there. There are people with neurologic disease in the world who unequivocally do not have access to the quality of medical care that you could provide. There are populations with types of neurologic diseases that do not appear frequently in an American exam room. Perhaps you were born abroad, trained in America, and are now interested in returning to a place closer to your extended family.20 Even those of us without close family ties outside of continental America know that there are cultures and geographic settings that are astonishingly alluring. Perhaps you are looking for more pleasure and fulfillment from your professional circumstance. Perhaps you want to experience more of the world's diversity; or perhaps you feel that your children should, since they will be living in a more interconnected world in the future.

A number of these factors played a role for us. I had an excellent job as Chair of Neurology at an academic hospital in Philadelphia. I ran a residency program, saw fascinating patients, trained neuro-ophthalmology fellows, wrote articles, and sat on committees for the American Academy of Neurology. In retrospect, however, traveling had always been a major life theme, moving from undergraduate school on the East Coast to medical school on the West Coast to residency training back on the East Coast. I spent a year as a neurochemistry fellow at the Institute of Neurology, Queen Square, London, during neurology residency, and my wife and I briefly surveyed the world for possible job opportunities near the end of my neuro-ophthalmology fellowship before deciding to stay in the Northeast. Fifteen years later, we began to worry that our children, growing up in a classic upper-middle-class American suburb, were experiencing somewhat less of human life’s grand variability than we had. Our children seemed well-adjusted, and everybody in our extended family was healthy. Without realizing it, we were prepared for another move.

The setting abroad

American neurologic training may be the best, but there are excellent neurologists and excellent neurologic opportunities all over the world. This last generation has taken huge steps toward normalizing neurologic health care delivery across the globe21 at the same time that it has homogenized America. Most places in Europe, of course, have superb neurologic training, facilities, laboratories, and practice opportunities. Some of these may be available to individuals who speak the language and can arrange a position in a hospital or laboratory. However, European countries generally train more neurologists than they need,22 making the typical flow of neurologists out of Europe and into America.21 Canada, Australia,13 New Zealand, and the United Kingdom speak English but offer opportunities with roughly similar caveats.

At the risk of a gross overgeneralization, it might be said that many other places in the world23–26 offer good medical facilities, well-trained medical colleagues, a warm cultural environment, and substantially fewer neurologists per capita than the United States.21 There are, of course, many exceptions to this general statement, and every physician thinking of stepping outside of the United States should give careful thought to the specifics of a potential new situation, both for professional (are you confident that you can deliver a quality of care with which you will be comfortable?) and personal (can your children get a good education, and are you and your family going to be safe?) reasons. On the other hand, the current vagaries of health care financing in the United States may mean that a job abroad in some places has comparable security to certain jobs in America.

Other considerations

I would suggest a couple of additional considerations that may not be immediately obvious. There are unequivocally places in the world where an ethnically distinct American individual or family may not be physically safe right now. However, the assessment of a typical inhabitant of mainland America regarding this issue may not be accurate. For example, some friends are concerned about our safety in Saudi Arabia, but our experience over a dozen years is that Riyadh may be safer than many major American cities. Nevertheless, if safety is a concern in a particular locale, then you should try to arrange a locum tenens or a visit before making a final decision.

You will consciously or unconsciously take a large number of other factors into consideration when thinking about something as serious as a move across the globe to practice neurology. Some of these factors relate to your own cultural preferences and family background. Is India too hot? Is Siberia too cold? Are rates of kidnapping and other crimes too high in certain parts of South America? Would intolerance of certain behaviors or ethnicities be a barrier in other locales?

Language is one of the most important issues. Perhaps you speak Swahili or Mandarin, and this will influence your plans. I speak only English and have little facility for learning new languages, so I could not easily practice neurology in Germany. However, I can practice neurology in the Middle East because English is the language of medical education in most of the region, almost all physicians are bilingual in Arabic and English, and I have always had bilingual residents, fellows, or other medical personnel with me when seeing patients. My impression is that similar arrangements permitting an English-speaking American neurologist to practice medicine may not be immediately available in many other parts of the world. Of course, you may consider the option of working in a laboratory on a sabbatical, where it is quite possible that most of the scientists and many of the technicians may be English-speaking.

Finances of a move abroad

You will need to think about the financial aspects of a position abroad. American physicians, including neurologists, are quite well paid by world standards, and many parts of the world do not have the resources to pay you what you could earn at home. This is due to the realities of the world economy rather than to an inappropriate appreciation of the value of an American neurologist. In addition, every American working abroad continues to pay American income tax, in contrast to Europeans and most Canadians working, say, in the Middle East, who pay no income tax at all. That said, there are still situations abroad where health care is expanding rapidly, currently in the Middle East and in the future possibly in China,27 where you may be able to earn as much as or more than at home. A shorter work week and more vacation time than are typical in America may make these situations particularly appealing.

Every individual's financial situation has certain fixed costs. Would you sell your home if you moved abroad in order to avoid paying upkeep and property taxes? If you keep your home, would you rent it out, with the attendant risks and complications? Perhaps the most onerous virtual tax on middle-class America is the cost of university education for our children. Most of us have relatively high academic aspirations for our children, and the cost of an Ivy League (or equivalent) education is now about $60,000 per year, after taxes. Even state universities these days entail substantial expense for tuition, room and board, travel, and books. In contrast, children of our European colleagues go to University in their home country with little or no expense, and university training is typically free in the Middle East. These factors will require careful attention if you are considering traveling abroad in the middle of your career when your financial potential and financial needs are the greatest because it is commonly difficult for governments and hospitals abroad to understand the somewhat more demanding financial realities of a neurologist who pays American taxes and whose children will eventually go to a private university in America.

Why would you consider moving?

You may consider a number of reasons for practicing neurology outside of America. Probably the greatest number of people who do this were born abroad, trained in America, and decided to return to a place close to their original home. This sort of move offers cultural and family harmony and a huge benefit to the local society without major financial dislocation. The other people who may find it easiest to consider working abroad are those young enough or old enough not to have children living at home or requiring financial support. In these circumstances, the financial constraints above are somewhat less onerous, and the excitement of new experiences in foreign settings may be even greater.

Many other American neurologists thinking of moving abroad will consider additional factors. Sometimes this may be a desire to help other people, or wanderlust, or unhappiness with some aspect of the current situation in America, or all of the above. Having made the decision to move abroad twice, it is now clear to us that every individual and every family has a different calculus in these matters. My reasons would almost certainly not be your reasons. The financial considerations above are major constraints for most of us, but people weigh financial constraints differently, and certain factors (such as humanitarian ones) may outweigh other considerations at times. Many of us have been extremely lucky in our lives, and there can be a great joy in the altruism of providing care and teaching abroad.

Family matters

And then there is your family. Children affect this type of decision in different ways at different times in their lives. Infants and young children are more difficult travel companions, but certain parts of the globe (including the Middle East) make care for young children easier because of a family-oriented culture and less expensive live-in childcare. We had very good friends who moved to Saudi Arabia with 4 children under the age of 2 years (don't ask), and they only survived the experience because they could afford a live-in nanny in Riyadh, where they could not have easily afforded live-in childcare in America. Of course, living and working abroad does add its own complications. For this family, just getting 4 small children back to America for summer vacation was a bit of a trial.

Our children figured prominently in our decision to move abroad. They were in grade school at the time, old enough to remember their experiences but young enough that they were not yet completely attached to their peer groups. We all saw the initial move abroad as something of a grand adventure. All 3 attended the American International School in Riyadh, and my wife was on the Board of the school at the time our oldest daughter graduated from high school there. Like children everywhere, our girls offered an avenue through which we became close friends with other families from all over the world, families who have remained friends even though our children are now grown. In the process, our children learned that there are many cultures, each with its own internal consistency and validity. They became particularly entranced with the Middle East, Islam, and the role of women in Arabic culture.

The move abroad also changed our family life. Modern communications made the painful decision to move away from family and friends substantially less difficult than it would have been in the past. I worked fewer hours in the hospital, which gave me more time to spend with family and with academic pursuits in the evenings. Typical of the region, we led a much less hectic family lifestyle. Women cannot drive yet in Saudi Arabia, but automobiles and drivers are inexpensive, and my wife and daughters constantly traversed the city to visit friends. On vacations we learned firsthand that there are many places geographically close to Riyadh (e.g., Istanbul, Cairo, Bahrain, Muscat, Amman, and Tunis, in addition to other regions of Saudi Arabia) that are not at all close to our home in America. We traveled through Europe many times because it is on the way back to the United States from the Middle East.

We spent more time together as a family, traveling and otherwise, than we would have living in Philadelphia, but our lifestyle also meant that our children learned a type of independence that would never have happened if we had stayed in America. As an unexpected benefit, living abroad was a major positive factor in the college application process. Each of our children studied the Middle East in their own way in college (1 at Yale and 2 at Stanford), and each chose to live for a while during college in an Arabic-speaking part of the world (Jeddah, Cairo, and Rabat, Morocco). They each speak Arabic, while I have not yet managed to learn the language.

America redux

Unless you are committed to living the rest of your life abroad, you will need to give some thought to re-entering the American medical marketplace. You will need a “plan B” in case your life situation abroad does not work out or becomes more complicated than is comfortable. Nuclear or extended family members may get sick, or the cultural norms in your adopted home may lead to uneasiness, or world events may be unsettling, or the clinical practice situation may not develop as you had anticipated. Returning to a job in America will involve a somewhat different set of problems for an academic physician than for somebody who needs to rebuild a patient base. These factors need to be considered, but ambiguities surrounding a return from life abroad should not form an inordinate barrier to the initial decision to depart. Neurologists are currently in demand in America, at least in part because of relatively advantageous demographics in neurologic care.8

I returned to America for 3 years while my younger daughters were finishing high school. I again had a challenging and enjoyable job as Chief of Neurology in another academic hospital, but I nevertheless decided to go back to Riyadh because I received an unanticipated offer to combine clinical neuro-ophthalmology with genetics as part of a small research group of my own choosing. This was an extremely difficult decision because I was fond of my American hospital, its doctors, and its patient population. However, I have come to feel strongly that now is the time, given the growing power of our genetic tools, and Saudi Arabia is the place to study human genetics. Our children have all finished college and are living independently, which gives my wife and daughters the freedom to be in America, in Saudi Arabia, or somewhere else based on employment and other variables. Meanwhile, I have a job that has been academically28–34 and personally rewarding in a place that I find endlessly fascinating. Your decision to live and work abroad could well offer a similar outcome.

Correspondence to: tmbosley@bosleynet.net