Intended for healthcare professionals


Working in other countries

BMJ 2000; 320 doi: (Published 03 June 2000) Cite this as: BMJ 2000;320:1543

Work opportunities in developing countries broaden the mind

  1. Kirsteen J Thompson, specialist registrar. (kirsteenjt{at}
  1. Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow G12 0YN
  2. Department of Child Health, University of Wales College of Medicine, Cardiff CF4 4XN

    EDITOR—Working in other countries can enhance knowledge and skills and broaden one's perspective considerably, as Smith emphasises in her personal view about working for Voluntary Service Overseas.1 Having begun life in India, I qualified in medicine in the United Kingdom and then spent several years preparing to return to rural India as an ophthalmologist. Most people regarded this choice as quaint, but there were colleagues who showed genuine interest.

    I worked for five years as an ophthalmologist in a leprosy hospital (also providing eye services for the general population) in eastern India. These were the most challenging, interesting, and exhausting years of my career. There were times when I felt ill equipped, ill informed, and totally inadequate for my responsibilities. I quickly had to learn how to budget, to buy equipment, to write project proposals, to train and manage staff, and to organise and teach on training courses and workshops. My training in the United Kingdom had not afforded me these skills.

    Clinically, I did my best to put into practice what I had learnt in the United Kingdom and to give equivalent standards of care. This was despite caring for more patients, having less equipment, and there being no senior colleagues on hand to give advice.

    I am now working in Glasgow, and enjoying it. I have plenty of colleagues with whom to discuss topics of interest, plentiful equipment for every procedure, and a wide range of treatments available to prescribe. When I am on call it is for ophthalmology alone. I don't have to set up drips on dehydrated infants, perform lumbar punctures, manage pancreatitis, or deliver babies.

    Is such experience in India and elsewhere valued appropriately? I have worked with scores of dedicated Indian colleagues who practise as I did, with access to a tiny fraction of the budget we have in the United Kingdom. Few have had European or American postgraduate training, but most have a wide range of skills and abilities and a comprehensive “world view” rarely found in developed countries.

    My experience has shown me that my training in the United Kingdom (albeit something I appreciate) has given me a fraction of the knowledge and skills that I regard as valuable, wherever I am working. Work opportunities in developing countries broaden the mind and make us realise how much we can learn from each other.


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    People may make choices at odds with their cultural norms

    1. Elspeth Webb, senior lecturer. (john.clark{at}
    1. Tennent Institute of Ophthalmology, Gartnavel General Hospital, Glasgow G12 0YN
    2. Department of Child Health, University of Wales College of Medicine, Cardiff CF4 4XN

      EDITOR—Like Smith,1 I have worked in Africa. Like her, I am the coauthor of a training pack in race and cultural awareness.2 But my interest was triggered not by Africa but by being a patient in a European country with an excellent and well resourced health service whose staff knew a great deal about the British way of life. I still, however, found myself a square peg squeezing into round Swedish holes, cared for by kind, highly competent staff who made some very incorrect assumptions about me.

      I do not agree that information booklets about “the different needs of Muslims, Sikhs, and Hindus” are what's needed. There are already far too many resource packs, textbooks, and training packs with this cookery book approach, with menus of cultural norms—what A eats, how B does her hair, how C dies. Such an approach, in which the special features of “the Asian family” or “the Afro-Caribbean child” are explored, with rigid and static notions of culture, can worsen the care that black people receive as it leads to pigeon holing, victim blaming, and stereotyping. In reality, people make choices that may be totally at odds with their cultural norms. Indeed, the whole notion of cultural norms in a multicultural society is questionable.

      The idea of cultural norms arises from a simplistic and unidimensional view of people's lives which “ignores the effects of host cultures on minority ethnic communities, both collectively and at the level of the individual. Members of minority ethnic communities live at the intersection of two or even more cultures. At these intersections reactions take place that no textbook can predict.” 3

      Of course professionals need access to information about, for example, Sikh naming systems and Hindu dietary norms. But to put such information in context and to apply it intelligently to their everyday practice, professionals need a structured opportunity to explore their own attitudes; recognise that they are not culturally neutral but a product of their own cultural conditioning; and understand how their own and others' attitudes towards race, colour, and religion interact with those towards class, age, sex, and disability.

      Cultural competence is not about generalising on the contraceptive needs of Roman Catholics or about learning what Somali refugees eat for breakfast on Thursdays. Becoming culturally competent requires first learning a great deal about oneself.


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