The medical environment in North Africa's more developed nations is radically different from that of the rest of Africa, where private Christian hospitals with reasonably good surgical services that treat the poor have little or no competition from other hospitals. North Africa also has far more trained and licensed surgeons, and as an outside surgical educator I first had to learn how to work in a medical environment that is prescribed by the local medical community. In North Africa the expatriate surgeon must often compete with licensed local surgeons for surgical cases that residents can learn to do. He or she must be very aware of what the local surgical community considers to be the appropriate way to manage surgical disease. When complications occur the medical-legal environment can be a threat to the residents and to their teachers, especially since we are used to managing our own complications "in house." in Egypt complications are not tracked or discussed as we do in developed countries, and patients with serious complications are usually transferred to another hospital to protect the reputation of the surgeon and the hospital. This provides additional challenges to training surgeons. Working cross-culturally as an international medical educator requires humility, patience, and a strong commitment to learn how cultural and religious differences impact medical practice and the way decisions are made