Building a career in global health and expedition medicine
…the good, the bad, and the stuff no one tells you!
AUTHOR: DR LUCY OBOLENSKY
Can I be a neurosurgeon and travel the world with my work?
I’d like to do paediatrics but with some humanitarian work- is that possible?
Will I still be able to get a job if I don’t go straight into core training?
These are the questions I get asked all the time by junior doctors stepping through the minefield of medical careers.
And the answer to all of these is YES … and no!
As a trusted friend once said to me, “You can have your cake and eat it… but just not all at the same time!”
Hopefully, what I mean by this will become clear by the end of this article, so please do read on.
Times are changing:
Remember I started my career in global health and expedition medicine twenty years ago, when pretty much no-one had heard of either! As a trainee in 2010 I asked for study leave to ‘deliver a lecture for Global Health’. It was declined with a note saying ‘What is Global Health? Is this a private company you work for?’
This is not the case anymore in nearly all postgraduate specialties, and any trainee is entitled to go to 80% FTE without specifying a reason (pregnancy and mental health were pretty much the only valid causes in my training!)
I would argue it is now simpler to gain time away with equally many more opportunities to do so. That said, there is still a game to play, strategies to choose and naysayers who convince you that you will never get a job again should you so much as look up and glance at pastures new, away from the treadmill of conventional medical training.
I have stepped off the treadmill, not because the grass was greener, but because I led my own journey, and that is something I would implore you all to do. I will share with you some lessons I have learnt along the way, but please remember these are my lessons from my story which in turn I hope will help you to build your own story, and a highly successful one too.
I started leading expeditions whilst at medical school and as a junior doctor. It was not a requirement then to have tickets such as mountain leader, so I just gained experience on the job: initially as assistant leader for companies like World Challenge, British Exploring, Fulcrum, etc. and then gained skills as a leader which would stand me in good stead to apply for medical jobs in future.
Learning point: If you’re young, free and single, then now is a prime time to bank your days in the mountain, deep in the ocean, or under sail. Acquire some tickets if you can, as these are much more of a requirement now.
Concurrently I had spent most of medical school supporting the building of a clinic and its lab development in north Kenya. I met the most wonderful Kenyan nurse who gave me more insight into humility, empathy and compassion than I had ever learnt at medical school.
Here I found my home, my passion and what makes me tick. I spent hours (probably of those I should have been studying!) organising fundraising events, writing grant proposals, and writing my first ever business plans to the conservation organisation who owned the clinic – convincing them why they should offer their services to all surrounding communities, not just those on their land. Looking back now, I’m embarrassed by the quality of my work, but you have start somewhere. After house jobs and nine months in Australia, I was asked if I could return to support the health services there through developing another clinic in the village of Leparua. My other option was to return home and apply for one of the highly sought-after surgical training jobs.
The result? I spent five months in Kenya doing my DTM&H and gaining experience both in clinical and managerial roles. It was tough trying to study whilst living in the sticks: this was in 2005 in a remote setting with no internet and only a head torch and a lot of books, but we didn’t know any different then and the qualification really helped me in later years.
Learning point: Doing something you love is never a waste of time or energy, even if you’re not getting paid. Say YES to every opportunity you have. Try to gain a qualification in something you’re passionate about. (I’m not trying to be righteous here, and being Poo Lady in a lab staring at slides was definitely not all that glamorous and loveable at the time. But take the rough with the smooth!)
Leparua clinic with the nurse and women Maasai elders
Now came decision time for me. I returned to the UK to follow my medical career dream of being an orthopaedic surgeon with special interest in sports medicine. I’d already spent time in Australia working at a well regarded sports centre, working with the Waratahs, the Australian rugby team and numerous UK teams. This is what I’d always wanted to do. I applied for a Basic Surgical Training rotation (BST = CT) in the South West and was successful.
The interview consisted of many questions, but mostly intrigue about my time away and what I was doing in Africa. It went well but at the end one of the consultants said, “How do I know if I give this job to you, you’re not just going to leave and head off gallivanting all over the world?”
I replied, “You don’t! But I’ve learnt so much being away that has made me a better doctor and person that this is surely a good thing?”
They gave me the job and with two months to go until D-day of starting training, what better time to get married? Our honeymoon was spent delivering an ultrasound machine to one of the Kenyan hospitals and maternity equipment for the clinic. On return to Heathrow airport, I left my new husband to go and unpack into our marital home whilst I switched terminals and went on expedition to South America with a company I’d worked with for years who took disadvantaged kids away. If my husband hadn’t worked out my values already, this was a clear declaration of who I am and what I believe in.
Learning point: Make the most of all the time you have. Global health and remote medicine needs an understanding partner. Either someone who shares this passion with you or supports you in it. For me, it’s the latter. Have this conversation early on in your relationship. My husband has always been incredibly supportive of what I do, and also now taking my kids with me on these trips. But clearly there must be compromise, and only you on your own personal journey can find what that is and what works for you – both of you.
So here I was in the sunny South West in 2008, orthopaedic run-through training ticket in hand. Working hard to hit my ARCP requirements, operate, audit, management, and sustain my work in the clinics. Life was a juggle but I felt like I was thriving – for now…
I’d use annual leave to go back to the clinics, develop services and deliver projects. Nearly always whilst I was there, someone would need to go to the local hospital in Nanyuki, so I became the local ambulance. In Nanyuki I met the local surgeon, Dr Samuel Ndanya, who would become a close friend, life and career mentor to me. He would always invite me to stay and operate with him, letting me close whilst continually reminding me never to leave long ends on the sutures, or waste an extra syringe unnecessarily. “Let’s not add to the patient’s burden Lucy, this will cause financial hardships for their family.”
I know our NHS is in crisis now, but right then, in the operating theatre of a developing country, I was truly humbled by the service we had, and what the true cost of illness and injury was to these patients and their families. Each day, on a ward round with Ndanya, we saw an entire ward filled with young, fit men, three to a bed, all with lower limb fractures from farm work, building or boda boda (motorbike) accidents. All these men, the breadwinners for their families, will wait in hospital until either they can afford all the material they need for their operations (from surgeon and anaesthetic fees and femoral nails, right down to the last venflon), or they wait until the fracture has healed – in some form of position – whichever comes first. What is certain is that they stand a high chance of being disabled for life and never returning to be earning members of society again – with all the knock-on effects that has.
Dr Ndanya asked if next time I come I could bring a trauma team with me to help clear the trauma ward. As an ST2/3 In orthopaedics I merely laughed this off…How on earth would I achieve that!!?
Operating theatre with the Trauma Team and Dr Ndanya
Me with Dr Ndanya
Another 6 months passed by and I was out supporting HIV projects and turning one of the clinics into a VCT Centre, so that we were eligible for Gates funding (again – all about playing the game). I was in Nanyuki taking a patient down and catching up with Ndanya. It was then that I saw Alice, one of the amazing members of the women’s group in Leparua village and a champion of alternative rites of passage for girls (instead of FGM).
She had been knocked down by an elephant (human-wildlife conflict is a real risk in the areas in which we work) whilst trying to protect her two young children. I learnt that one child had been killed, the other was in the paeds ward, badly injured. After seeing her x-ray, my orthopaedic knowledge was good enough to know that the definition of both her knees was ‘Cornflakes’. She would never walk again…and she would not be able to look after her child. My heart sank. How could this be happening to Alice?
Without really thinking it though, I turned to Ndanya and said, “How does February suit you for an orthopaedic project?” He smiled and nodded.
Back in the UK, in sunny Torbay hospital, I put a notice up in theatre coffee room. ‘Volunteers for a trauma trip to Kenya, meet Tuesday 1pm here, entire team needed’. Expecting no-one to turn up, I couldn’t believe how many people came. To this day I’m grateful to every single scrub nurse, physio, radiographer, surgeon, anaesthetist and OPD who put their faith in me. Several rather stressful months later, the first orthopaedic project took place. Ndanya and another close friend, Mary Nduta, organised everything from the Kenyan side, and despite every single one of the UK team before the trip modestly panicking about ‘what they had to offer’, we spent a week working side by side with the Kenyan team, training them in equipment, leaving behind all the instruments and surgical sets needed, an supply of implants and…an image intensifier! More importantly, we worked with hospital managers to use a ‘pay it forward’ system and operate on people the day they came in to get them out and functioning as quickly as possible. Fourteen years later, the Future Health Africa Trauma Team is going from strength to strength…. Without me!
Learning point: There are many reasons that you may become involved in overseas hospital projects and partnerships: professional interest, opportunities arising, or personal and emotional reasons. For me, it was Alice. I had done no needs assessment or QIP (they didn’t really exist then!) and wasn’t sure how it would ever actually happen, but in the words of Arthur Ashe: “Start where you are, use what you have, do what you can.”
Women’s group family planning discussions
Projects in Kenya took over for a while here and although I managed a few expeditions, either with my husband or school groups, they became less adventurous and time consuming for a while. I still taught on expedition courses both for medics and advanced first aid and used my personal expeditions to keep my field time up. .. You don’t always have to do fun trips as ‘The Medic™’. Take some time for you too!
Orthopaedics was also getting more challenging as a registrar, exams were looming, pressure was on to publish papers, complete audits and research and be competent in an increasing number of operations. I worked hard, passed exams, published more than any of my fellow registrars and had more operating logged – mostly through coming in on days off. The ARCP date came and I arrived with an enormous folder filled with evidence (still paper in those days! Yikes, I’m old!!). I was bullet proof in this one….or so I thought…
I walked into the room to see a panel of three men in suits sitting behind the desk, the training programme director in the middle. I put my folder down on the table and sat. He looked at me across the table, pushed my folder away to one side and said “So what’s all this S**T you do in Africa then?” The rest of the review continued in a similar vein, asking why I’d been up Kilimanjaro or climbing volcanoes in my annual leave (implying I should be at home reading ortho textbooks) and culminating the ARCP with him saying, “The problem with you, Lucy, is that you’re not a Mr Grey, and I mean both parts of that”.
I returned to training disillusioned and demoralised, not sure what to do next. I carried on for another six months, until one of the consultants, who is now a very good friend and who had also been on one of the trauma projects with us, said to me one day ‘Lucy, why are you really doing this? I mean really doing this? Having seen you out in Kenya I see how much you love it. I’ll be here doing this for at least another 17 years; doing the same three operations on a Tuesday and with the same nurse in the same clinic room every Thursday. I’m sure you can be an ortho consultant if you want to, but I just don’t see you doing that, I see you up a mountain or out in Africa somewhere”.
A week later I handed in my notice, and gave back the golden ticket route to being a consultant orthopaedic surgeon.
I’m sure that simply wouldn’t happen now in an ARCP, or at least not in the same way, but there’s three main learning points from this:
- Choose your specialty wisely. Are you driven by a specialty or by a region? How open minded is the region and the specialty you choose? Speak to colleagues in the area and ask what the culture is there.
- What really motivates you? And how much of your career do you want to dedicate to expedition medicine or global health? It took a good friend to really question my motives and to make me realise what a long term consultant job looks like. Look at senior colleagues and ask yourself- Do I really want to be where you are in 5, 10, 15 or 20 years time? It’s a long time at the top of the tree. Is your specialty really compatible with taking 4 or 6 weeks off here and there? Being a surgeon or an -ologist is probably less so, GP; ED or anaesthetics possibly more so. Yes, it’s very possible to do some overseas work in the former, but it’s all about balance.
- And here is probably the most important: BE THE BEST YOU CAN BE. Expedition medicine and humanitarian work are still the exception, not the norm. Most of your colleagues, and perhaps your seniors will see this as you going off on a jolly and deserting the NHS in a time of need. You need to show how good you are at your job and how having an alternative career is not at the detriment of being a fantastic NHS doctor
Pass your exams, nail those QIPs and go over and above in ARCPs, and do it all with a smile!
So there a new chapter begins. I did a year as an EM reg, took my exams but then realised I really didn’t want to be an EM consultant and felt guilty asking my colleagues for time off over Christmas whilst I went gallivanting etc. I considered sports medicine, and then settled on General Practice: a nice bunch, plenty of options to specialise in niche areas, and highly flexible.
Here my expedition career started to take off: I was working more closely with the British Exploring Society where I was subsequently appointed their Senior Medical Advisor and had done a few trips with the BBC. The charity work in Kenya was also escalating – in a good way, as we were developing new projects in Emergency Medicine and the girls empowerment programme, Team Talk. I became the queen of OOPEs taking time out for expeditions, global health jobs and a sports medicine role at the London Olympics. Everyone was super supportive and so encouraging.
Learning point: Getting the YES! When taking time out, give your educational supervisor no reason to say no, in fact make them think it’s positively a good idea. Demonstrate all the amazing skills you will bring back to your NHS role, most importantly all the non-technical skills. Describe how you will return more enthused for your job, more resilient and innovative for your NHS career.
I finally finished my general practice training and shortly after taking up a salaried job in GP and part time staff grade in ED, I then landed the BBC Planet Earth II job covering many of their shoots. A fantastic experience, but not compatible with a regular job juggling GP and ED rotas. So I hand in my notice and start down the career path of eternal locum. I work mostly in the same places so people know me: however I’m not, and likely never will be, part of the core team.
Learning point: Flying solo. Locuming is great for flexibility and having control, the pay is also pretty good too. The downside is your vulnerability; you’re not part of a team, not covered for annual leave, sick leave, professional leave or maternity leave, and you’re also more exposed clinically. You never quite feel part of the team, and that’s because you’re not. This aspect is really hard for me, but it comes back to cake and eating it.. Not all at the same time!
A career highlight, in the hot air balloon for the opening scene of Planet Earth II with lovely Sir David Attenborough
So, just a final couple of anecdotes to finish with:
My life then changed quite dramatically as kids came on the scene. I used my first materna-holiday to travel through Kenya, Tanzania, Botswana and Cape Town with my 5-month-old, doing a mixture of community, EM and trauma work. It was tough yet also amazing doing what I loved, but now with my son in tow what previously would have been considered a simple trip now became a whole expedition in itself. Then along came the amazing roles in Blue Planet II…but to complicate matters I was juggling work vs expeditions vs family time with two small children. It was here my husband really stepped in, supporting me to take these jobs and what a difference it made knowing that I had encouragement from home, yet being so far away.
It was shortly after this period that I was in the Himalayas with a different expedition. I had a really challenging clinical case of HACE that although it ended well, really taxed me in my clinical skills. I realised I’d been away from the coal face for too long with these back to back expedition jobs. I probably still had the competence, but the muscle memory and knowledge at my fingertips was fading: I needed to up my clinical game. So on my return, I took a senior registrar job in EM with 40% PHEM at a major trauma centre forcing me back onto a rota of weekends and nights and, more importantly, being the senior on the shop floor when the trauma ATMISTs came in. This was a tough time for me and for the family, as although I wasn’t on expedition and only working in the next county, working 12 hour weekend shifts, lates and nights in an unsafe, overflowing department and sleeping in my van, I saw the family less than I ever had before, and was more exhausted when I did. BUT this boosted my clinical confidence no end and meant I had knowledge and skills at my fingertips for the next time I was a lone practitioner, in the dark and cold with no one to ask for advice or support.
- Adventures don’t stop when you have kids, the challenges you face are just different. Taking your kids to the places you love is one of the most special things you can do.
- Clinical superhero! How much coal face work have you done in the last two years? You can spend ages building up your field and expedition-experience, but remember- you’re the medic! Can you draw up those drugs with freezing wet hands in 50mph winds? Can you do those simple tasks of getting IV access … but in the dark with a fading head torch? Do you feel both competent and confident to deal with a worst case scenario on the trip you are about to undertake? If not then sign up for the next three ED weekend late shifts.. That should help you become the clinical super hero!
Taking kids on adventures.
Over the next few years, I felt like I was cruising. Life was pretty good; regular locum work in the same ED and as an acute GP, balanced with developing our overseas projects where the kids always came too, and going on a few select expeditions.
Then, by turn of fate, my next immense challenge arrived : Endeavour Medical.
Brexit had led to my husband’s work moving to Europe and we moved to France in August 2020. COVID had destroyed all funds for LMICs, with high income countries turning to look only inwards and guard themselves. Poverty, hunger and teenage pregnancies were rising exponentially during this time.
With some spare time on my hands due to reduced clinical work with the move to France, I approached some of the bigger expedition companies I’d taught for throughout my career and asked if we could deliver some not-for-profit courses, with funds going directly into projects in LMICs. They were not forthcoming with this idea, so, with the encouragement from close friends and family, I set up Endeavour Medical. Setting up and running your own business in the middle of COVID and a financial crisis many would say is financial suicide…it is certainly stressful to say the least. What has astounded and inspired me through all of this is the number of truly wonderful individuals who have supported Endeavour from its inception.
Endeavour was set up to bring a community of like-minded health professionals together across the globe to provide equitable access to quality education. At the end of its first year, Endeavour is achieving what it set out to do. We are not a not-for-profit organisation, in fact we believe in paying our faculty well, but we give time, donations and volunteers to global health programmes. Most rewardingly, we have a global network of inspiring individuals who support one another with opportunities, advice and education.
Where will 2023 take us? Who knows, but I’m enjoying the journey with all the challenges and delights it brings along the way.
First Endeavour Medical Altitude Medicine course
My final learning point: LEAP AND THE NET SHALL APPEAR
I hope that my journey has inspired you and sparked your interest in delving into the world of global health. If you’d like to learn a bit more about it, why not take a look at our global health and conservation course ?