Ashwini Bapat, MD, a palliative care physician who used to work at Massachusetts General Hospital, realized that her dream of living and working overseas might actually be possible in 2019 when, after another fruitless day of suburban house-hunting, she left the polar vortex in Boston and flew to Spain with her family for a vacation.
"The next day was summery, with warm, beautiful weather. We walked by a Roman aqueduct. That's when we said: 'Okay, why don't we live here?' We decided that we weren't going to buy a house in Boston. Instead, we started looking into how to get a medical license approved in Europe."
Bapat, her husband Emeric Bojarski, MD, a psychiatrist, and their two young children moved to Coimbra, a city of about 100,000 in central Portugal, on August 21, 2020. "That was our Independence Day."
Since moving, she has launched two small businesses. One is a telemedicine start-up called EpioneMD, which provides virtual palliative care consultations as well as advance care planning and serious illness coaching for individuals and their families. She and her husband also founded , an online physician community and resource to help other U.S. physicians explore their own overseas adventures.
With a supposition that a number of other doctors had already made the jump, they started a Facebook group in May of 2020 with the intention of collating their experience. The Facebook group evolved into a business providing information and other services to interested doctors. Its membership has grown to 4,056.
"One of our goals was to make sure it was sustainable for Emeric and me to do the editing, revising, and creation of content for the community while making it accessible and helpful and posting as many job opportunities as possible," Bapat said. Physicians join for free but there is a charge to employers for job listings and sponsored advertisements. It also offers a one-on-one guidance service connecting interested U.S.-trained physicians with those who have already transitioned to a particular country.
There are three main ways American-trained doctors can use their medical training while living abroad, Bapat said. One is to practice medicine in person, after completing whatever exams, licensing, and supervised experience are required locally. There are 14 countries where American physicians can use their credentials to practice medicine abroad with only moderate .
Physicians can also work in non-clinical positions such as in research or the government. A third area is to practice clinically in the U.S. via telemedicine, which is what Bojarski does currently as a psychiatrist .
"One of the main missions of Hippocratic Adventures is to help doctors realize they have a choice. We do that by giving them tools and resources," Bapat said. Other countries want American doctors, who are among the most skilled and best trained in the world.
For Bapat, practicing medicine in Portugal will require gaining enough fluency in Portuguese to pass the medical exam and communicate with patients. "It's hard when your 4-year-old is more fluent in the local language than you are." She took a language immersion course when she first arrived, and continues to pursue private language lessons.
'A Lot of Doctors Are Unhappy'
Bapat, 35, was born in Queens, New York, and grew up spending every summer at her grandparents' home in India. "This was a very familiar experience for me. I learned there wasn't just one way to live, and that complete opposites could exist in one life. I've spent my entire life trying to understand such differences."
During medical training, she did a medical mission to Nicaragua, and she worked in South Africa during residency. "I was scheduled to do another placement in Uganda, but having a child changed my plans." Her husband, who was born in France but grew up in the U.S., shared her desire to experience other ways of living. "We were clear that we wanted to have the experience of living in two worlds and to share that with our children."
Bapat started working as a palliative care attending in Boston in February of 2018, and quickly noticed that her colleagues, who loved palliative care, often looked burned out after several years on the job. "There just were too many asks -- to teach, to publish, to be part of research, to see more patients. When you talked to them, you could see it. I didn't want to be burned out like that in 10 years."
She was also sitting at the bedside of patients who were acutely aware of their mortality and trying to find meaning in their lives and their illnesses. "Yet they showed so much courage even to show up for their appointments, doing their best to live with what they had in the present moment and creating memories for their families."
She remembers one patient in particular who was living with advanced pancreatic cancer. "He brought his son to the medical visit. I asked: What are you most proud of in your life? He answered that it was his son. The son was sitting next to him, crying. I thought that moment will carry them a long way through whatever comes next."
Other patients expressed regrets. "One said he'd soon be going to his funeral, followed by a hearse full of regret," Bapat recalled. "I realized I have regrets, too. I have dreams I haven't fulfilled. It's like he was telling me: Don't make that mistake."
While she figures 60% of her desire to live overseas was fueled by dreams of experiencing other ways of life, the rest reflects concerns about the direction her own country is heading. "I remember walking down the street with my young son in a stroller when a truck drove by waving white nationalist flags. This is in Arlington, Massachusetts!" she said.
She was also concerned about gun violence and the spate of shootings at schools and shopping malls. She worries about the U.S. healthcare system, which feels increasingly unresponsive to patients' needs.
"A lot of doctors are unhappy," she said. "Practicing medicine these days can be incredibly frustrating. They feel exploited, under-appreciated, and then blamed. I've been to a doctor's office myself and had to wait 2 hours for a 5-minute visit with a very harried physician who I'm sure would have wanted to spend more time with me."
Delivering Palliative Care From Anywhere
was inspired by Bapat's interest in the role for telemedicine in palliative care and the ways it might enhance opportunities to connect patients with U.S.-trained and licensed physicians regardless of location -- since a televisit can be done from anywhere there is internet access.
"I thought we could create our own organization to help people access palliative care," she said. "If I had found a telemedicine service that was already doing great palliative care among the more than 50 companies I applied to, I would have joined them, instead."
EpioneMD, which is new and still getting its feet wet, has two distinct service lines. A concierge coaching service helps individuals who are aging or living with illness and their caregivers define what is most important to them, develop a personalized advanced care plan, communicate their wishes with their loved ones and medical team, and learn about palliative and hospice resources.
This virtual coaching empowers patients, caregivers, and families with a framework on how to deal with the ramifications of serious illness in their lives. It is paid out-of-pocket by the consumer, Bapat said, adding that EpioneMD does not take insurance, which reimburses poorly for this kind of comprehensive, personalized counseling.
To attract coaching clients, EpioneMD reaches out to local councils on aging, senior centers, and primary care practices across New England.
The company is still in talks with healthcare organizations in New England about its second service line, providing virtual palliative care consultations within health facilities. Its five palliative care specialists will use a consultation model to see patients virtually and then advise the patient's medical team, but not write prescriptions or medical orders.
"It's not all that different than a palliative care consultation I would have done in a hospital in Boston, although I can't hold the patient's hand," Bapat said. "I miss that."
Palliative care requires trust and rapport between clinician and patient, although she believes that can be achieved remotely. She does many of the firm's coaching sessions from Portugal, working around the 5-hour time difference.
The Right Choice
A little more than a year after moving to Portugal, Bapat is sure she made the right choice.
"Within a month, I no longer had the weight of regret, even though it's the hardest path I've ever chosen. The need for community is huge, because relocating is hard. I don't have a bunch of colleagues on the same path as I am, and that can be very isolating," she said. "But I'm finally in a place where I can say we are living life on our own terms."
Coimbra, with its 13th-century university, is a city on a hill packed with terracotta roofs overlooking the Mondego River, an hour from the ocean. Orange trees grow in abandoned lots, an ancient aqueduct cuts through the city, and the sultry Portuguese sun requires sunscreen even in January.
Her family recently bought their dream house, although a lot of their stuff is still in boxes. There is a local medical office just down the street. "Now I need to get my Portuguese medical license."
Bapat intends eventually to start making connections with local palliative care providers in a country that has a significantly older population than the U.S. "Every time I mention palliative care, I am told they really need the help."