Around the globe

Have stethoscope, will travel: Despite hassles, DOs embrace life abroad

From the rolling hills of rural New Zealand to the mountains of southern Ethiopia, these DOs found a whole new world of health care.


In the mountains of southern Ethiopia, patients sometimes travel for days to visit Soddo Christian Hospital, where Mark T. Karnes, DO, is an obstetrician-gynecologist. Dr. Karnes says the desperate need of his new patient population is striking.

In Michigan, where Dr. Karnes practiced for 25 years, he had never had a patient die in front of him. But in Ethiopia, where so many lack access to reliable care, his team sometimes loses patients, an aspect of his new environment that still troubles him two years into his stay.

Gregory C. Nacopoulos, DO, lamented the comparatively lax medical standards in his native Greece when he moved back. Recordkeeping is haphazard, and physicians are held far less accountable than they are in the U.S., he says.

“The patients are pretty much on their own,” Dr. Nacopoulos says. “The main hospitals keep records, but there’s no actual system where you can get them if you want to.”

In Bahrain, a country of many expatriates, Nader S. Tadros, DO, found his colleagues from other lands had many different ideas about sound medical practices. “Some of them were good,” he says. “Some of them were kind of iffy.”

While these U.S.-trained physicians have found trouble, disappointment and even violence in their new lands, none of them have plans to return to the U.S. any time soon. The countries and their people have won them over. Thousands of miles away from the United States, these osteopathic physicians have found a practice environment that suits them.

Dr. Nacopoulos, Dr. Tadros, Dr. Karnes and Charlene James, DO, who works in New Zealand, each have different reasons for wanting to stay overseas. Dr. Karnes says his love for humanitarian work and his patients keep him there.

“Africa can get into your bloodstream, and it’s infectious,” he says. “The people here are wonderful. They’re very grateful for the help they receive.”


Dr. Karnes left a world of comfort at retirement age for one where hardship is commonplace. He says he loves caring for patients when the need is so great.

Dr. Karnes recalls helping one patient who had previously experienced 13 miscarriages finally deliver a healthy baby. Another patient was in her 40s and had never been able to conceive. Dr. Karnes removed a noncancerous tumor from her uterus and asked her to return for a follow-up.

Nearly a year later, she showed up again—nine months pregnant, he says. “We did a cesarean section, and she had a little boy. She was just so, so thrilled.”

However, as an OB-GYN, Dr. Karnes also sees evidence of Ethiopia’s grim birth statistics.

“Ethiopia has a very high maternal fatality rate,” he says. “And according to the WHO [World Health Organization], 90% of all women here deliver at home without a health care professional. That means only 10% deliver in a health center or hospital. We’re hoping that will change. There’s definitely a need for physicians here.”

Because of this need, Dr. Karnes trains physicians at his hospital in addition to treating patients. He instructs African physicians who are enrolled in a five-year program to develop surgical skills. When they finish, they practice in remote areas. One of the most recent graduates is the only surgeon for 1 million people, Dr. Karnes says.

“It’s exciting working with these young physicians,” Dr. Karnes says. “It’s one thing to perform a Caesarean section to save the life of the mother and baby, but to teach someone to do that is so much more rewarding.”

Buoyed by his work in Ethiopia, Dr. Karnes says he and his wife plan to stay in the country for another five to 10 years.

“We’d love to stay here. We don’t have any set date to go back to the states to live,” he says.

Bahrain and Egypt

Dr. Tadros was the first osteopathic physician to practice in Bahrain, one of 67 countries outside the United States where U.S.-trained DOs have full practice rights, according to the AOA. Recruited by an American mission hospital to develop its family medicine department, Dr. Tadros spent 1 1/2 years in the country beginning in 2009, helping pave the way for other DOs who may wish to practice there. While certain aspects of practicing in Bahrain—such as working with physicians with different medical standards—frustrated Dr. Tadros, he enjoyed introducing osteopathic principles and practice to a whole new population. It allowed him to help some patients avoid unneeded treatment, he says.

“In Bahrain, competitive clinics sometimes come up that are completely driven by profit and sometimes do unnecessary surgeries,” he says. “Osteopathic medicine gave me an edge in helping diagnose and treat patients appropriately.”

After returning to the U.S. in 2011, Dr. Tadros went abroad again the following year to his home country, Egypt. Driven to improve the country’s faltering health care system, he is developing physician training and mentorship programs at a Cairo-area hospital to improve physicians’ continuing education and create more accountability. He also consults with a number of other area hospitals seeking to do the same, and he hopes to introduce electronic health records in hospitals and perhaps develop patient-centered medical homes.

Dr. Tadros hopes these changes will encourage Egyptian patients to become more involved in their own care. They tend not to be as engaged as they could be, he says.

“There’s a sense of fatalism sometimes: ‘What will be, will be,’ ” he says. “Certainly preventive medicine is very distant from people’s minds. Few people here will look into that, but it’s something that needs to be practiced here big time because so many of the illnesses here are preventable.”

Egypt’s recent unrest means helping reform the medical system will be even more difficult, but also more necessary, Dr. Tadros says.

“We have had some violence near our home,” he wrote in an email. “The hospital where I work has also witnessed violence from people storming it, bringing the wounded and demanding care. People were shooting in the hospital and drawing knives at the staff. Fortunately, no one was hurt and the hospital was OK.

“Our family will continue to stay and work here as long as we can, and we hope that things will become better for the country and the people, not harder.”


About 700 miles across the Mediterranean Sea, Dr. Nacopoulos practices neurosurgery in Athens, where he says he has found a respite from the long hours and defensive mindset of his former practice in Chicago. Lawsuits against physicians are less common in Greece, and the punishments are often less severe, he says. Practicing in Athens has been refreshing without the looming specter of litigation, he says.

Professional liability insurance isn’t even required for physicians in Greece, Dr. Nacopoulos says. When he purchased his, it was 800 euros, or about $1,000, for one year—a stark contrast to the $130,000 per year he paid in Illinois.

“Part of the reason I disliked practicing in the states was that it had gotten to be so bad with lawsuits that all you practice is defensive medicine,” he says. “You need to do what’s good for the patient, but you also need to do what’s good for you.”

One thing that’s good for Dr. Nacopoulos is more time with his wife and young children, which he says working in Greece allows him.

“I was in private practice in the U.S., and there was definitely no way I could have spent as much time with my family there as I do here,” he says.

New Zealand

Unlike Dr. Nacopoulos, Charlene James, DO, was not frustrated with practicing in the U.S. when she signed on for a six-month stint as a locum tenens physician in New Zealand. But she loved practicing there so much that six months quickly stretched to five years. As a locum tenens physician, Dr. James works in various clinics in New Zealand’s rural areas and treats mainly beef, dairy and sheep farmers. She also doesn’t have to worry about getting sued—the New Zealand government foots the bills for any accidents its citizens or visitors may have. And she says the setup of New Zealand’s clinics allows for more comprehensive care.

“I actually go out to the waiting room to get the patient, and there’s definitely an advantage of doing that,” she says. “Of course, I don’t have a chart because it’s all in the computer, so I just go out and call the patient back. Then I can see the patient walking back, which tells me a lot of things about him or her.”

Dr. James doesn’t see herself practicing in the U.S. again on a long-term basis. She says she wishes she could—but being a physician is just easier in New Zealand. The country is years ahead of the U.S. when it comes to electronic health records, and patients are highly compliant thanks to the government-subsidized health care system, she says.

“When people can get medicine, there’s no reason their blood pressure should be out of control,” she says. “In the U.S., you always wonder, ‘Is this person really going to take this medicine? Is he or she going to be compliant?’ Here, I say, ‘Come back in two weeks and let’s recheck your blood pressure.’ Well, the patient comes back in two weeks. I wasn’t so used to people listening to what I said.”


  1. Neil R. Nickelsen, D.O.

    Great article. I have contact in DRC(Congo) president of Katanga Methodist University wanting to start a medical school and has legal issues cleared for site and beginnings. Can you give me any information on D.O.’s practice rights in DRC. He is interested in an Osteopathic Medical school which I am helping him with if this is a possibility. Thank you for your encouraging article about D.O.’s abroad!!
    Neil R. Nickelsen,D.O., FACOP, FAAP ret

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