Monday, June 23, 2008

Medical Tourists

The first or second year I was in practice I received a call from Dr Gaspar Anastasi. He had been the head of my plastic surgery residency while I was at Boston University Hospital. He was calling to ask me to do follow up for him on an otoplasty patient who lived in Arkansas. I readily agreed. In fact, I was honored that he would ask.

These days we think of the medical tourist as someone who goes to another country (ie. from the USA to Singapore for an operation), but in some ways the same issues may arise when the patient simply goes out-of-state to have a procedure done. They are not always ready, willing, or able to go back for follow up. This is especially true if a complication arises, be it small (missed stitch) or large (wound infection). They may have used up all their vacation time and not want to take the days off for travel.

I have had patients come to me from Nevada, Arizona, Texas, Louisiana, Tennessee, and Mississippi. Usually because they have family that lives here. They plan on staying with them while they recover. Still, I ask the ones who are more than 3 hours away if they are willing to stay around 10-14 days after surgery before agreeing to do the procedure. I ask them if they are willing to return if the need arises or if they have a local physician who is willing to help out. I try to make them think about what could happen. Even the ones who live closer I try to outline the follow up that will be expected.

There is a nice article in this month's Contemporary Surgery Journal discussing the ethics of caring for/refusing to care for a patient who comes to you with a complication after having their surgery elsewhere. You can read it here (may have to register).

A former patient presents with general malaise and reports having had low-grade fever. The examination is unremarkable, but laboratory tests indicate an infection not isolated to an organ system. Groin and blood cultures are positive for MRSA.

A while ago you diagnosed an abdominal aortic aneurysm in this patient, but she went to India for aortic endograft placement. You are considered an authority on graft infection. What should you do?

A. Tell her to return from whence she cometh.

B. Alert the media to the problem of cheap international medical care.

C. Advise the patient to sue in International Court.

D. Care for her as you would any patient.

E. Tell her that once a patient leaves your care, she leaves permanently.

My answer is D. Though I wish the patient would come to me for the entire "package", I would do what needed to be done. I would prefer to meet them before the initial surgery, but we don't always have that luxury. I would prefer that I could try to get them to do their care (if it is available, though specialized care is not always) closer to home or at least at a distance they are more willing to travel as needed. I would prefer that the surgeon call me and let me know that he would like me involved in the postop care.

Is it possible that this concept of international travel for surgery is here to stay? Most likely. So maybe the patient should find a "local" surgeon who would be willing to do the postoperative care when they return. The patient could then give their "international" surgeon the name, address, phone number, and e-mail address of the "local" surgeon so that information could be communicated and care coordinated.

What would your choice be?

Article:

The Medical Tourist Whose Outcome Went South; Contemporary Surgery, Vol 64, No 6, pp 290-291; James W Jones, MD PhD, MHA (This article was condensed from: Jones JW, McCullough LB. What to do when a patient’s international medical care goes south. J Vasc Surg. 2007;46;1077-1079.)

4 comments:

Ian Furst http://www.waittimes.blogspot.com said...

The national problem is a lot easier to solve because everyone has basically the same standards and practices. How do you manage a patient that has had substandard care? If they present with a complication the choice is simple but if you become part of the health care team do you also become liable? In Ontario my collegues will often see my patients when they go back to school and vice versa but i don't think I'd want to be part of an international team as a cost savings measure.

rlbates said...

Here, if you see the patient you can be sued. I don't think we will be able to stop the patients from doing international med tourism. So I'm just trying to think of a way to help protect them (from themselves?). To protect our own butts from law suits, I think we would have to write well worded notes in our patients charts that we cautioned them against said trip, but if you insist here is my information for the doctor.

DHS said...

there is also the money problem here -- you cop most of the liability, with almost none of the pay. would your answer be different if it was not a former patient of yours?

rlbates said...

I'm not proposing to do the postop care or complication care for free. But if the patient with a complication shows up in the ER, we have no choice but to care for them. Why make them go that route?