Work Outside the Box

Brett Segal, MD, is living in paradise. For the past three years, he has served as a physician aboard Carnival Cruise lines. His backyard stretches from New Orleans to Martinique and Antigua, with Jamaica, Bermuda, and Aruba in between. It's not a bad gig if you can get it, but the life of a solo physician catering to 1,000 crew members and as many as 3,400 guests is not always as luxurious as it seems.

"It can be very daunting to work on a ship," says Segal. "This is a serious job on the cutting edge of modern medicine. One of the main challenges is being isolated in the middle of the sea with the potential for anything to happen, sometimes a life-threatening situation which we are not prepared to treat on board."

Although Segal is supported by a medical staff of three nurses and a nurse practitioner, a comprehensive on-board medical library, access to the U.S. Coast Guard during medical emergencies, and a fully equipped, high-tech infirmary that would put any clinic to shame, he is basically on call 24/7 for four to six months at a time. "You are not called every night to attend to an emergency, but the potential exists," he says. "It can be very tiring working every day without a break. That doesn't leave much personal time."

Still, for Segal, like many physicians who practice in nontraditional settings, it's worthwhile to give up certain consistencies of a regular practice in exchange for something a little bit different. Whether they're treating the injuries of major league athletes, volunteering in developing countries, or mingling with Mickey Mouse and Donald Duck, these physicians agree that variety spices up their practices.

Floating physicians

Segal, who is trained in emergency medicine, not only treats ailing guests, but also coordinates emergency patient evacuations, negotiates with insurance companies, serves as a primary and occupational physician for a multicultural crew, pacifies family members of sick passengers, and is an expert in guest relations.

For Segal, life as a shipboard physician has been a great financial opportunity -- he's got free living expenses and a good salary (although a cruise line physician generally earns less than a physician in a traditional setting, and has the same responsibilities).

And, not unlike physicians working in a regular medical office, "You really need a sense of humor and a thick skin; otherwise, you will never make it on this job," Segal says. "Guests can be very demanding and rude but you have to understand that they are guests first and not patients. They are on vacation and do not expect to get sick, so they often have unreasonable demands."

Ben Shore, DO, a fleet physician for Norwegian Cruise Line (NCL) and Orient Lines, has been on the other end of the phone during on-board medical emergencies and evacuations, giving shore-side advice to ships' physicians about stabilizing sick guests and instructing them how and where to transport them if additional care is warranted. With a background in emergency medicine, he is well suited to providing immediate feedback to NCL physicians facing a life-threatening medical episode.

Like Segal, Shore is basically on call 24/7, during which time he performs legal, medical, policy-making, purchasing, and human relations duties in an office in Miami. He enjoys the freedom of setting his own schedule, serving as a consultant, and working in a state-of-the-art communication and technology environment. The only thing missing is hands-on patient care, from which he retired in 2002.

His advice for physicians looking for a change? Use your medical degree to expand your opportunities, not limit them.

Helping the poor and remote

James Yu, MD, a staff anesthesiologist with Southern California Permanente Medical Group, takes his medical expertise to remote parts of the world through a nearly two-decade association with Operation Smile, a private, not-for-profit volunteer medical services organization providing reconstructive surgery and related healthcare to indigent children and young adults in developing countries and the United States. Yu recently visited Foraleaza, Brazil, where a team of reconstructive plastic surgeons, anesthesiologists, and nurses performed 155 surgeries in five days, including correcting cleft lips, cleft palates, and other facial deformities.

As a visiting physician, Yu shares modern medical techniques and adds a jolt of confidence to the native physicians and the rest of the local healthcare team, allowing them to eventually assume responsibility for patients. In turn, Yu has benefited from the ingenuity of his Brazilian peers, who create operating rooms with primitive equipment and minimal supplies.

"Volunteering for an organization such as Operation Smile is a very humbling experience," Yu says. "You have to be able to size up what you can offer by doing a little homework, corresponding with the local staff abroad, and doing everything you can to achieve it. There is no room for a superior attitude or for focusing on one's own goals. You can't successfully collaborate with others unless you have a keen interest in helping and a big heart."

He also finds satisfaction in bringing his patients out from under the stigma associated with facial deformities. "Many of these people are outcast by their communities and cover their faces with sheets when in public," he says. "It is a mighty cross to bear. You should see what happens after we perform surgery: mothers become nearly hysterical with appreciation at the physical change in their children."

For four years, Ted Palen, MD, an internist with the Colorado Permanente Medical Group, has been affiliated with Medical Ambassadors International (MAI), a missionary group that combines spirituality and physical healthcare. His recent destination was Quezaltenango, a town in the northwest highlands of Guatemala, occupied by native Mayans. It is not unusual for Palen and his co-workers over a two-day period to treat 150
residents in a cinderblock schoolhouse with a dirt floor. Many of his patients suffer from diarrhea and musculoskeletal aches -- not unusual for women who balance heavy loads on their heads while carrying their children.

He says that helping the less fortunate has changed his priorities.
"This kind of volunteering takes the willingness to step out and do something that may be a bit uncomfortable at first but becomes easier once you forget yourself," Palen says. "In the United States, we are very time-oriented and focused on completing tasks. In many third-world countries, time is a very relative thing and people and relationships are more important than tasks. These cultural differences are important to understand and account for before and during a trip. [You need to] be prepared for rudimentary conditions, often with a lack of supplies, and be able to rely on clinical skills rather than diagnostic equipment."

For physicians who are looking for this kind of practice experience, Palen suggests first volunteering, for example, at a clinic for the uninsured.

The happiest place on earth

If Disney World is indeed the happiest place on earth, then Gary Clonts, MD, may just be the happiest physician. He is medical director for the Orlando, Fla., entertainment complex housing four theme parks and two water parks. A two-week occupational medical residency rotation at Disney World gave him the in, and he has been there since 1988, with no immediate plans to move on.

His responsibilities include overseeing nurses who provide first aid to Disney World guests, treating routine illnesses and injuries and offering preventive care to 51,000 employees, monitoring OSHA requirements, processing family medical leaves, and confirming return-to-work requests. Clonts, along with four full-time physicians and nurses, staffs the 15,000-square-foot medical clinic serving all six Disney World park sites. It's open 14 hours a day, seven days a week.

Clonts' biggest challenge is merging the worlds of business and medicine, which he says is a continual learning process. "When you transition to occupational medicine," he says, "you have to adopt a global perspective -- decisions affect more than one person -- enhance and develop your leadership skills and financial competencies, and accept more ownership in the public health model. All of this requires a shorter learning curve than in a regular healthcare environment."

Clonts admits that occupational medicine is not the route to go for physicians who have high financial goals. You do it because you want to, he says, and because you crave flexibility, want to continue learning, and have a desire to develop leadership and communication skills. He suggests physicians explore their local communities for these kinds of opportunities.

On the sidelines

Although Jay LaCour, MD, is an ophthalmologist in private practice, he or his partner Scott Lanoux, MD, can be found on the sidelines of every New Orleans Saints and Hornets game -- a role they inherited from their late partner. The two physicians are paid a stipend by the teams to treat eye injuries that may occur during football and basketball games. Recently, LaCour treated four Saints when contact with a newly laid surface at the Super Dome sprayed an irritant into players' eyes.

Working with both teams is a bonus for the two physicians, who are avid sports fans. "The affiliation adds a different flavor to our practice," LaCour says. The partners also offer surgical services to the indigent population in New Orleans, who LaCour says are treated with the same amount of respect and care as the physicians' better-known clients.

"The athletes are not asking for any special treatment except to get back on the field as soon as possible. They are appreciative of the time and care," he says.

Mari Edlin can be reached via
editor@physicianspractice.com.

This article originally appeared in the March 2004 issue of Physicians Practice.