Many residents and medical students are engaging in international medical activities. Before departing many do (or should) undergo pre-departure training but how prepared are medical learners to return on the other end? Many struggle with “reverse culture shock”.  This month’s ALiEM MEdIC series case considers how we might help a learner returning from an international elective. Please join us in discussing the case this month, we would love your thoughts and advice.


P.S. Teresa Chan, Brent Thoma, Sarah Luckett-Gatopoulos, and I would also like to invite you all to register for the ALiEM MEdIC pre-conference workshop at SMACC.  Come out and be part of a LIVE version of the ALiEM MEdIC case development and release for a special SMACC version of the case series!

MEdIC Series: The Concept

Inspired by the Harvard Business Review Cases and initially led by Dr. Teresa Chan (@TChanMD) and Dr. Brent Thoma (@Brent_Thoma), the Medical Education In Cases (MEdIC) series puts difficult medical education cases under a microscope. On the fourth Friday of the month, we pose a challenging hypothetical dilemma, moderate a discussion on potential approaches, and recruit medical education experts to provide “Gold Standard” responses. Cases and responses are be made available for download in PDF format – feel free to use them! If you’re a medical educator with a pedagogical problem, we want to get you a MEdIC. Send us your most difficult dilemmas (guidelines) and help the rest of us bring our teaching to the next level.

The Case of The Returning Traveller

by Amy Walsh (@docamyewalsh)

Olivia hadn’t seen her friend Miguel in a few weeks as he had been away on an international elective. He was really interested in global health and this was his second trip to Africa in the last year. She saw him leaving the locker room and hoped to catch him before they started their shift. She quickly walked down the hall of the emergency department and called out, “Hey Miguel, welcome back!”

He turned around with a big smile. Olivia was excited to hear about his trip and asked, “Do you have time to grab a beer after work and tell me about Ghana?”

“Sure, I’d love to! It was such a great experience. The people are incredible and I felt like we really made a difference. I’ll even bring my computer so I can show you some photos!”

They made plans to meet up after their shift at a local pub. As they walked into the department, Miguel noticed that the waiting room was unusually empty. It was typically quite busy on a Friday evening. He figured that although it was slow and he may not get to see much, this would actually be a great shift to transition back to western emergency medicine.


Olivia was in the staff lounge getting ready to leave for the evening. As she packed her bag Miguel quietly walked into the lounge and sat down, looking quite upset, almost angry. This was odd, she thought. He seemed so happy earlier.

“What’s wrong? What happened?” she asked, genuinely concerned.

“It’s just so hard to come back and see how wasteful we can be with our resources. And how incredibly entitled some of our patients are. There just seems to be a general lack of respect towards the system and towards physicians. You wouldn’t believe what just happened, Olivia! The father of my last patient got incredibly upset with me because he had to wait 20 minutes to be seen by a doctor. His daughter had a very minor bump on the head with one episode of vomiting. Perfectly fine now with a normal neuro exam and negative CT head criteria. Yet he is demanding we obtain imaging and get some bloodwork done… and my attending just signed off for all that unnecessary testing! It makes me so angry!”

“It’s just wild how quickly I forgot how different things are back home. People in Ghana wait for hours in the heat to see a physician and when they do, they’re incredibly grateful that you took the time to see them. And at the end of the day there were usually still lines of people waiting to be seen that we simply didn’t have the time or resources to evaluate. No one received unnecessary testing. No one argued with our treatment plan. It’s just so hard to gain perspective again. How do we not realize how lucky we are to be living in a country where we have clean water to drink and 24/7 access to world-class healthcare? It’s sobering really.”

Olivia was overwhelmed by how upset Miguel was. She had never had the experience of working abroad and didn’t have much knowledge of other healthcare systems or cultural practices. She didn’t know how she could help Miguel get through this.

Key Questions

  1. How do you cope with culture shock after your international experiences?
  2. What advice would you give Miguel as he transitions back to his normal residency work
  3. What strategies do you use in working with demanding and entitled patients?

Weekly Wrap Up

As always, we posted the expert responses and a curated commentary derived from the community responses one week after the case was published. This time the two experts are:

  • Dr. Jennifer Thompson RN, MD, Senior Resident, McMaster University EM Residency Program
  • Ashley Lucas (@AshleyFayeLucas) RN, Masters Candidate (UCSF) International Health

On March 6, 2015 we will post the Expert Responses and Curated Community Commentary for the Case of The Returning Traveller. After that date, you may continue to comment below, but your commentary will no longer be integrated into the curated commentary.  That said, we’d love to hear from you, so please comment below!

All characters in this case are fictitious. Any resemblance to real persons, living or dead, is purely coincidental. Also, as always, we will generate a curated community commentary based on your participation below and on Twitter. We will try to attribute names, but if you choose to comment anonymously, you will be referred to as your pseudonym in our writing.

Eve Purdy, BHSc MD

Eve Purdy, BHSc MD

Queen's University in Kingston, Ontario, Canada
Student editor at
Founder of