Personal Views: Why is it so hard to work abroad?
Authors: Tiago Villanueva
Journal: BMJ (2006)

Iwas recently visited by a Czech friend who had been a law student on exchange in my city, Lisbon, a few years ago, when I was at medical school. He had since graduated, was working in Dublin, and had a new girlfriend, a Slovak, who had finished her management studies in the Czech Republic.

Over a late coffee, it didn't take long before we drifted to a common and popular topic among young people today: professional mobility and working abroad. It was then that I realised both of them had chosen their university degrees to maximise their chances of clinching work opportunities overseas.


Most clinicians' area of influence is confined to their hospital, city, region, or country


My friend's girlfriend told me that she had deliberately opted not to study medicine because she felt that it would restrict her mobility and confine her chiefly to a localised career. I was startled. How could she possibly think that? What had happened to the authoritative words of Mark Wilson (author of The Medic's Guide to Work and Electives Around the World. Hodder Arnold, 2004), “Medicine, as a doctor, nurse, physio or student, is your passport to the world.” But I think she has a point, if you look just at clinical medicine.

One of my friends from Portugal who works in information technology consulting has been sent on regular work assignments to Brazil, Spain, France, Thailand, and the United Kingdom, often with little notice, spending weeks to months in each country. How many doctors will be able to say that they have worked in so many different countries?

My friend is able to move to another country and start working on the day he arrives. He uses English, French, or Spanish, and is also able to communicate in the shared language of information technology.

In clinical medicine, no matter how well intentioned and motivated one might be, and even with the goodwill of a potential employer overseas, there is no way it is possible to start working in a foreign country overnight. Firstly, one needs to be highly proficient in the language of the host country to communicate efficiently and empathetically with patients. Unless you have studied in the country before, or are already an able speaker of the language, you won't stand a chance in taking patients' histories and getting down to hands-on work, regardless of your clinical competence, communication skills, or professional integrity.

In many international jobs in the industry or service sectors, and even in research, some degree of proficiency in key languages may be helpful, but you can often get by without getting to grips with the relevant native tongue.

There are also regulatory barriers in medicine, such as recognition of professional qualifications and exams and associated red tape. In the United States, the whole process costs several thousands of dollars, without a guarantee of a job at the end of it.

Even in the European Union, where there is, in theory, automatic recognition of degrees—so that a doctor who qualified in one of the EU's 25 member states can work in another without being subject to linguistic or professional assessment—things are not as simple as they sound. A German friend, a junior doctor working in Portugal, who moved here to live with her Portuguese boyfriend, took several months to get her paperwork cleared, and had to do to unpaid work for two years before getting her full registration.

If I harboured a burning desire, which I don't, to work in neighbouring Spain, I would have to sit a national exam, in Spanish, testing all the subjects since the first year in medical school. The competition is fierce, with far more applicants than posts.

I believe in the potential of medicine to breed budding international careers, and for all sorts of reasons (war, poor wages, etc), it is often a wise thing to move. I have many friends who have built medical careers overseas, from Australia to Sweden. And there is no shortage of opportunities to work in developing countries, which would be grateful if more of us bothered to spend time there. In areas of medicine other than clinical medicine, such as research or working in the pharmaceutical industry, professional mobility is probably easier.

However, I believe clinical medicine generally still caters mainly to the needs of populations at local and national levels. For most clinicians, their area of influence is confined to their hospital, city, region, or country at best. In contrast, geographical boundaries are expanding in the business world, facilitating a dynamic pattern of professional mobility.

2006 is the European Year of Worker's mobility. This, alongside the increasing popularity of various exchange schemes, will make it easier for students to study in other countries. This makes me hopeful for increased international mobility for future generations of doctors, but probably not for my own.