Intended for healthcare professionals

Education And Debate

An international work exchange: better than a midlife crisis

BMJ 1998; 317 doi: (Published 19 December 1998) Cite this as: BMJ 1998;317:1709
  1. Douglas T Bridge, palliative care physiciana,
  2. James Gilbert, consultant in palliative medicineb
  1. Royal Perth Hospital, Box X2213, GPO Perth, Western Australia 6001
  2. Exeter and District Hospice, Exeter EX2 5JJ

    The Australian initiative

    Several years ago my wife and I began to reflect on the delightful possibility of an extended period in another country. The concept of a sabbatical year is well recognised,13 and has been recommended in the BMJ as a means of promoting personal development for general practitioners whose professional lives are stagnating.4 We decided to attempt a variation: a job swap in which we also exchanged houses and cars with a compatible colleague. But how do you find a compatible colleague in a distant land? I started by writing to the (British) Association for Palliative Medicine, who published my proposal in their twice-yearly newsletter. One of the respondents was Jim Gilbert, from Exeter, who seemed quite keen to explore my wild proposal. He was, like me, a consultant in palliative medicine, his curriculum vitae was impressive, and his work sounded interesting. He had an appealing sense of humour: “We would, of course, extract signed agreements from Wilf (aged 4) and Tilly (18 months) not to destroy your house!”

    During a 1 hour telephone call we worked through all the significant issues we could think of, and began the long process of establishing a curiously intimate friendship, considering it began with an advertisement!

    We agreed to a 4 month working segment, but which months? The Bridge family wanted to enjoy a British summer and escape before the thermometer plunged below zero. The Gilberts wanted to experience an Australian spring, and escape before temperatures reached the range where small children can easily get sunburnt. July to November satisfied all parties.

    Administrative arrangements were rather slow, but proceeded smoothly. Our employers decided to continue to pay us our normal salaries. We obtained appropriate medical registration, immigration permits, malpractice indemnity, and health clearances.

    Professional enrichment

    The modern hospice and palliative care movement began in London, and the practice of palliative medicine is very advanced in the United Kingdom. Australian clinicians have kept up to date with international developments, however, and the most noticeable thing was how similar we are in philosophy and practice. The hospice in Exeter was built in 1992 in the grounds of the Royal Devon and Exeter Hospital. This is clearly the best model, symbolising the reintegration of hospice care into mainstream health care.

    Being removed from the usual pressure of administration I revelled in the abundance of hands on clinical work. There was also the luxury of easy access (compared to the vast distances in Australia) to other hospices and conferences, notably the fourth congress of the European Association for Palliative Care.

    There were minor differences in the availability of drugs. Diamorphine was the standard injectable opioid (unavailable in Australia) but I found it no better than morphine. Fentanyl transdermal patches, then restricted in Australia, were more widely used.

    If I could introduce one new drug to Australia it would be methotrimeprazine. It has definite efficacy in alleviating nausea, using remarkably small doses (as low as 6.25 mg twice a day).

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    Other benefits

    Although the professional stimulation was valuable, the greatest benefits were non-medical. We can echo the words of a British nephrologist describing his sabbatical in the United States: “… the chance to talk to one's wife, spend time with one's children, discover the lost art of reading novels. The chance for a few months to live in, not merely visit a different culture.”6

    The proximity of Europe was irresistible. We seized the opportunity and rented a mobile home in Germany before the exchange began. Trying to satisfy simultaneously three sons aged 18, 12,and 5 was a challenge. Parental delights in cathedrals and art galleries were balanced by visits to toy factories and the frequent use of McDonald's hamburgers as bribes.

    The English response

    Australians in general enjoy a reputation for plain speaking more than for meticulous planning. In swapping jobs with Doug Bridge I found someone with an abundance of both qualities, and as a result quite complicated professional and domestic arrangements were made with remarkable ease. The job at Royal Perth Hospital lacked some of the complexities and challenges associated with inpatient hospice and community based palliative care teams, but involved more “general medicine for those with advanced disease.” The range of easily available drugs for patients needing palliative care in Australia was significantly narrower than in the United Kingdom.

    Hints for overcoming “red tape” associated with an international exchange

    1. Ensure that your medical qualifications are adequate for the post you wish to occupy

    2. Obtain written approval for the exchange from your host institution. This will require defining your service contract and salary arrangements. Each party continuing to be paid by their home institution may simplify tax and pension implications

    3. Obtain a certificate of good standing from your home medical registration council or board. Apply for recognition by the host medical registration council or board. This may be restricted to the institution where you will work and require evidence of approval

    4. Satisfy the health requirements of your host employer, such as your immunisation status and a statement of your good health

    5. Clarify whether or not you need medical malpractice indemnity

    6. Apply for the relevant category of immigration visa and work permit for you and any accompanying dependants. The personnel department of your host employer can do a lot to facilitate this

    7. Satisfy any financial criteria, such as proof of your ability to support yourself

    8. Ascertain your status in the event of illness or accident, and obtain appropriate insurance (usually part of a travel insurance package)

    9. Obtain an international driving licence

    10. Be patient and keep meticulous records. The process may take 6-12 months

    There was great benefit merely from working in a new environment for a few months, and the bonuses offered by Western Australia in particular included assorted marsupials (are they specifically designed to amuse toddlers?), dolphins, whales, 80 metre trees that you're allowed to climb, and some unbeatable coffee shops. There was also much to be gained from leaving some things at home. Most importantly, many apparently crucial consultation papers and meetings passed me by with no heartache. On returning 5 months later the complete absence of resultant catastrophe provided an invaluable perspective! The final unanticipated benefit to our exchange came from the assessments of the strengths and weaknesses of one's department as judged by a sympathetic and positive consultant colleague with no personal axe to grind.


    An international work exchange is a particular form of sabbatical leave. It has the great advantage of providing instant accommodation and transport at virtually no cost. For those interested in pursuing such an exchange we offer the following advice.

    • It is not for the anxious.

    • It requires a spirit of adventure and a willingness to entrust your house and cars to your exchange family.

    • Plan ahead. It may take 2 years to identify a suitable colleague and then complete the necessary paperwork.

    • Be explicit in your negotiations. Describe clearly the duties and hours of work required. State how long and which months you wish to exchange. A telephone call is worth 10letters.

    • Exchanges are unsuitable to those in private practice.

    • Meeting each other for 2 to 3 days at the beginning and end of the exchange is invaluable: at the beginning to explain the idiosyncrasies of your car, dishwasher, and central heating; at the end to report on breakages, settle finances, and review insights about each other's professional experiences.

    • A formal, written evaluation is a useful discipline and helpful for one's employer and colleagues.5

    • In calculating the cost of living you could construct a table listing the price of various goods and services. A simpler overall guide is the cost of a McDonald's standard hamburger! On this basis, Exeter was 1.6 times as expensive as Perth.


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