Can You Go Home Again?

The next step, they realized, was to become involved in preventive strategies.

But a continuing source of frustration is the lack of available resources compared to what he experienced in the United States. For example, in the United States, ultrasonic surgical scalpels cost $200 or $250 each. In Brazil, each single-use scalpel costs $1500. We are torn, deciding whether to pay so much more for the same thing, he said.

Manufacturers claim that the source of the disparity lies in importation taxation. We see these things being used when we are doing our fellowships, Dr. Carvalho said, and know we will not be able to use them when we go home.

Cultural and language difficulties sometimes blocked a positive experience. Most American trainees could easily make new relationships, but for trainees coming from other countries, especially those whose native language was other than English, it was more of a challenge.

Sometimes we would stay aside, asking few questions at the beginning, Dr. Carvalho said. Although in time they would feel more acclimated and would open up, the barriers still existed. For instance, trainees sometimes come without the advantage of grants and scholarships, forcing them to pay for necessary supplies out of their own pockets. Grant opportunities in Brazil and other developing countries are not easy to obtain. If medical educators had better recognized this, they might have been able to suggest a way to overcome these obstacles.

Certainly, Dr. Carvalho’s training outside Brazil has enhanced his academic career; last year he was promoted to associate professor at the University of São Paulo.

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The Netherlands

Michiel van den Brekel, MD, PhD, is now working at the Netherlands Cancer Institute in Amsterdam and has an affiliation with the University of Amsterdam. In 1996, Dr. van den Brekel completed a one-year fellowship in Toronto, including both clinical training at Mount Sinai Hospital and research at the Hospital for Sick Children. He then returned to the Netherlands.

In principle, Dr. van den Brekel said, the training is more emphasized and intense in North America than it is in Europe, and educators are more motivated in their teaching?there are teaching awards, for example?whereas in Europe, recognition comes only from the scientific and clinical achievements.

With extremely busy clinicians as teachers, the vast majority of teaching revolved around patient care, but Dr. van den Brekel thinks that providing more structured, topic-based training would also have been helpful. He also appreciated the literature discussion clubs in which he participated. In Toronto, at the institutions in which he trained, he was particularly impressed by the extent of multidisciplinary communication. Foremost, the large number of head and neck cases coming from around Ontario allowed probably double what he might have seen in the Netherlands. That volume of patients also made it interesting for neurosurgeons to attend our meetings, which contributed to our education.