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Wednesday
Jun132012

A Surgeon’s Nightmare- The Other Side Of Medical Tourism

Medical TourismGuest post by Samuel Bledsoe MD

There is an element of a gamble inherent in the medical tourism industry as it currently exists.

An interesting thing happened to me at work the other day.  It was Friday afternoon, and I received a call from a primary care doctor. The phone call began with, “I’m really sorry about this, but I have a surgeon’s nightmare in my office.”

This is not a good way to begin a conversation.

He began to tell me about the patient. This particular woman had a Lap Band placed several years ago. For one reason or another, she decided that she would like this converted to a different procedure. She drove by my hospital to get to the airport, hopped on a plane and flew over hundreds of other well-qualified bariatric surgeons in order to reach a surgeon in Mexico where she had her Lap Band removed. She then returned 6 months later and had a sleeve gastrectomy. This is where things go bad.

The patient developed a leak from the staple line on her stomach after the procedure. She was taken back to the operating room for her third procedure where she was washed-out and large drains were placed. Amazingly, four days after the procedure, she was released from the hospital with the large drains still draining gastric secretions, a feeding tube in her nose, a prescription for oral antibiotics, and instructions to find a bariatric surgeon where she lived to finish taking care of her. At this point, she was stable and doing well. As one of two bariatric surgeons in the community, I was asked to consider taking care of this woman.

My answer, after much thought, was a refusal. I did review this woman’s extensive medical record and even spoke with her personally on the phone to try to give her some advice. One thing she said still rings in my ears, “I thought if I had any problems I could just come back here and someone else could take care of me.” I recommended that she return to Mexico until she was well. This, I was told, was impossible. I did ask my office to attempt to find help for this woman.  After my nurse spent most of the day on the phone, talking with almost a dozen different doctor’s offices around the state, there wasn’t a single bariatric or specialty surgeon in the entire state willing to accept her as a patient. Ultimately, the best advice we could give her was to go to the local county hospital emergency room for care.

Lest I be thought of as heartless, if this woman or any other patient were sick or in dire straights or needed quick intervention, I would have treated her to the best of my ability regardless of where her surgery was performed. All doctors would do the same. But a patient who is currently stable and safe, presents a unique dilemma.  Don’t I have the right to choose them just like they had the right to not choose me in the first place?  Am I required to treat every surgical disease that presents itself to me?  Shouldn’t I be allowed to help them find a higher level of care?

On the one hand, I do feel for this woman. She will never find a surgeon who will willingly take her on as a patient.  Before she is finished, she could rack up a serious hospital bill.  Although she was doing fine at the time of our conversation, I was extremely concerned about her health. She seemed genuinely sorry about her decision to leave the country and was certainly very nice. On the other hand, this places the accepting surgeon in an impossible position. Who is better able to take care of this woman’s complications than the original surgeon? Who do you think she will sue if she decides she can’t pay her hospital bill or she becomes disabled or she loses her job, and she discovers that the surgeon in Mexico is legally untouchable?

I admit to being a little frustrated towards the presumptuousness of this woman. Did she call and ask me or another surgeon if we would help in the event of complications? Who did she expect would manage her lifetime needs of follow-up after this procedure? If I’m not good enough to do your relatively straightforward original surgery, then why would you think that I would be good enough to manage the highly complicated post-operative care that is required?

However, my biggest complaint is with the current system of medical tourism. A foreign hospital system profits from American patients, and when there’s a complication, they ship them back quickly and dump them out at the local American ER. The foreign physician is immune from lawsuits by virtue of the fact that they are out of the country. The medical tourism company that linked the patient and doctor bears no responsibility since they are simply a mediator. The foreign hospital simply washes their hands of the mess that they’ve created. It’s the local doctor, the local hospital, the local medical establishment, and the local economy that pays the high price.  And most unforgivable, the patient may pay the highest price of all. Excuse me for saying, but there has to be a better solution.

Medical tourism is a newly coined term for a very old practice.  In 430 B.C, the Temple of Asclepius was built in Epidaurus, Greece. This temple was a healing shrine where the sick and infirm would travel from all over the world to spend the night in this temple. During their sleep, the cure for their ailment would be revealed in dreams. The following day the dream would be interpreted by priests who would then implement the cure. The original Hippocratic Oath contained this invocation, “I swear by Apollo the Physician and by Asclepius… .”

The Greeks weren’t the only ancient people catering to medical tourists.  For thousands of years, pilgrims would travel to Jerusalem to the Pool of Siloam for its healing powers. The Bible notes in John 9 that Jesus used this pool as part of the healing of a man blind from birth.

Even today, there are spas, resorts, and retreats the world over that cater to the sick. In my home state of Arkansas, the city of Hot Springs has been attracting the sick and injured for centuries. Native Americans and frontiersmen would travel there for the medicinal properties found in the superheated baths. Today, thousands of people travel there every year to seek the same healing.

Many nations around the world cater to the American medical tourist. It is estimated that medical tourism siphoned around $15-20 billion dollars from the US economy in 2011 alone. Hundreds of thousands of patients will leave America in order to have their care provided to them. This trend is expected to grow between 15-20% in the foreseeable future. There are a hundreds hospitals scattered at locations ranging from Brazil to Mexico to Thailand to India that have tried to establish themselves as the “go-to” location for medical tourists.

Currently, there is an impressive list of procedures from a wide array of specialties that are offered at institutions that cater to the medical tourist. One such facility, advertises care in the fields of dentistry, orthopedics, ENT, cosmetic surgery, bariatric surgery, cardiac surgery, spine surgery, ophthalmology, oncology and fertility. This only represents a partial list of what is available.  If it’s an elective procedure and profitable, it is probably offered somewhere.

In response to a growing trend in medical tourism in bariatric surgery, the American Society for Metabolic & Bariatric Surgery (ASMBS) published a position statement on global bariatric healthcare. One of their primary concerns is a concern that is shared by many- appropriate continuity of care. This concern is highlighted by the following statement: “extensive travel to undergo bariatric surgery should be discouraged unless appropriate follow-up and continuity of care are arranged and transfer of medical information is adequate.”

Certain procedures, such as bariatric surgery, are unique in the fact that they require long-term follow-up. Also, the likelihood of short-term and long-term complications are significantly diminished with appropriate follow-up. Because of this, the ethics of medical tourism for bariatric surgery has been called into question. (http://www.ncbi.nlm.nih.gov/pubmed/20346442)  

To say it differently, having a colonoscopy or your teeth filled in India is one thing,  To have your hip replaced or your heart bypassed is a different thing altogether.

I would propose three simple solutions to this to improve the current system. First, protect the innocent.  By that I mean, the American physicians and hospital systems who get involved in complications resulting from medical tourism should have immunity from lawsuits. If you CHOOSE to leave the country for elective medical care, you should forfeit your right to unlimited medical compensation from an American physician who is simply trying to fix what someone else broke. This choice involved in medical tourism is in stark contrast to someone who becomes ill or injured overseas and has to have emergency medical care. This would be similar to Good Samaritan Laws found in many states. Second, a system accrediting hospitals and facilities overseas should be further developed. Joint Commission International http://www.jointcommissioninternational.org/About-JCI/ is one such system that has standardized and defined what constitutes adequate medical care and monitors facilities for compliance with these standards. It is the oldest such commission with 450 facilities in over 50 countries. Patients should insist that the hospital where the procedure is going to be performed be accredited by JCI or an equivalent.  Third, patients should be extremely proactive.  They should obtain or confirm insurance coverage in case of complications. They should thoroughly vet both the hospital and the surgeon. They should also ensure that there is a plan in place for adequate follow-up prior to the procedure being performed. They should also obtain copies of all medical records for their physician in their home town.

Don’t get me wrong, I am an Adam Smith capitalist to my core. If a patient believes that they can get better care or cheaper equivalent care in a foreign country, I certainly believe that they have the right to do so. But the patient, the foreign physician, and the foreign hospital system should accept the responsibility for their collective exercise of freedom and enterprise. Complications should be treated to a logical endpoint, and they should be truly stable for transfer back to their local community.  There is an element of a gamble inherent in the medical tourism industry as it currently exists. I do not believe that when the gamble doesn’t pay off, my colleagues, my hospital, my community, and I should be the only ones forced to face the repercussions of someone else’s decisions.

About: Dr. Samuel Bledsoe is a General & Bariatric Surgeon in Alexandria, LA.  He is founder of Bariatric Fuel, a company that manufactures vitamins for patients who have had a surgical weight loss procedure. You can follow his blog at www.bariatricfreedom.com.

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Tuesday
Jun122012

Healthcare: The Desirable Duopoly Of Doctor & Patient

Healthcare Reform Doctor - PatientGuest post by Daniel Kaufman MD

Ask any corporate tycoon what the toughest business structure to beat is, and surely they'll tell you it's a duopoly - two co-dominant institutions presiding over a market, essentially cutting out all other competitors or outside influences.

Are the two big players friends or foes? One can make a case for both. Republicans and Democrats, Ford and GM, and even Magic and Bird - all dominant duopolies that symbiotically blasted and outlasted their competition. That is, of course, until the third party showed up - the new kid on the block. Traditionally, the third party, or its potential to arise from obscurity into the limelight, has been a great offsetting entity to the status quo of the omnipotent duopoly. Just ask the Tea Party, Chrysler, or Michael Jordan. These entities, the consummate "start-ups", all served to destabilize the ruling double-team, and thus helped democratize whatever industry they were involved in. As it turns out, this destabilization, a requisite force of the free market, serves to wipe up the cobwebs of industry stagnation, and create new avenues and vectors for ingenuity and prosperity. But not all third parties share in this benevolent intention. Some third parties have done the exact opposite. 

It might sound like blasphemy coming from a libertarian, whose inherent belief system is governed by the ultimate aspiration for democratization and equalization of opportunity; but, we need to reinstate the desired duopoly in medicine: the Doctor and Patient. Since the dawn of humanity medicine has always been a two-person dance. An elegant, professional, distinctly intimate interaction guided by altruism and professionalism on the doctor's part and self-preservation on the patient's part. This exchange of privileged professional services, the provision of healthcare from doctor to patient, does involve, however, an economic exchange as well. This is where the vultures and hyenas of society smell the blood. They’ve noticed something: an opportunity for profit and control. Insidiously, the third party of medicine, be it commercial healthcare insurance companies or government-run programs, has been let into the doctor's office, and predictably, has done nothing to improve quality or cost of healthcare. Third party payers have so entrenched themselves into the healthcare system, that they no longer serve as a typical “insurance” entities, but now serve as all-powerful administrators and “approvers” of medical care. The healthcare insurance industry is no longer used only for coverage of catastrophic events, but is now “approving” CT scans, X-rays, mammograms, and blood work, to name just a few. They’ve also been deemed authoritative enough to decide whether a procedure is “medically necessary”, all without ever meeting the patient. Now, how does this make any sense?

Patients need to realize that their healthcare insurance carrier is not in the business of caring – they are in the business for profit. Corporate medicine, that is healthcare controlled and administered by centralized, detached, omnipotent bureaucrats, ultimately leads to a frustrated and powerless workforce – the doctors themselves. Ultimately, the very people delivering healthcare are driven out of the business, both materially and spiritually. Now don’t get me wrong, one mustn’t blame the corporation for being a corporation. It is, after all, acting in its own best interest and well within its moral imperative. Profit drives it, and that is good. But the ballooning administrative control that third party payers have achieved has hardly contributed to an improvement in the quality or diminution of the cost of healthcare. In fact, this burdensome control only siphons money out of the system, away from doctors and nurses and towards middlemen and pencil-pushing bureaucrats. The federal government’s solution to the problem, the Center for Medicare and Medicaid Services (CMS), has an even worse track record than private entities. Medicaid and Medicare reimbursement fees are so abysmal (perpetually controlled by the flawed Sustainable Growth Rate (SGR) formula) that many doctors can't afford to take care of those patients, ultimately decreasing access to quality healthcare. Insolvency is all but an inevitability, and sooner or later, the system is headed for complete collapse. Dr. Milton Friedman once reiterated: “there's no free lunch” - to mean that nothing in this world is for free. Not any product and not any service. Sadly, medicine, as we know it in 21st century America, has become the last bastion of serfdom. A virtual expectation that, at times, the doctor work for free. It is, after all, a profession born of altruism and compassion….

So, how do we fix the problem? Let us reestablish basic principles. Let us return medicine back to its free market roots. But let’s not ask narcissistic, corrupt, temporary politicians to do this by legislative fiat or decree. Let’s just do it on our own. Let us not accept the status quo of the insurance healthcare fraud. Let us unshackle ourselves from their administrative hegemony and price point controls. Let us be sovereign, willing agents of the free market. Let us rise and fall by the merits of our professional actions and demeanor. Let us educate and empower our patients to act as their own advocates and take the fight to their insurance carriers. Let us get all the pretenders and imposters out of the doctor’s office. Let’s restore the fiduciary relationship between doctor and patient, and get back to the desirable duopoly.

About: Dr. Daniel Kaufman is a Board-certified plastic and reconstructive surgeon and a Surgical Facility Inspector for American Association for the Accreditation of Ambulatory Surgery Facilities. He is the founder and medical director of Discreet Plastic Surgery, PC, with offices in Manhattan and Brooklyn. He blogs at Medical Spa MD.

Sunday
Jun102012

US Health Care vs. The World

This cart presented without editorial comment.

source: National Geographic

Tuesday
Jun052012

Hello Doctor. I Wouldn't Hesitate To Sue You

nonclinical medical malpracticeGuest post by Dr. Mandy Huggins

How many times during your day does the specter of a malpractice law suite rear its ugly head?

“I wouldn’t hesitate to sue you.”

"I’m sorry, what?"

That is what I heard from the mother of one of my patients. At the time, I was only 2-3 months into practice, and I was evaluating a high school athlete who had recurrent stingers and a possible episode of transient quadriparesis . I wasn’t on the sidelines for these injuries, so I had to go on the reports given to me by the athlete and the school’s athletic trainer. However, with that information, I did not want to clear this player to return to football until I could be certain he didn’t have cervical stenosis or any other abnormality that might put him at risk for permanent damage if he suffered another neck injury. I told the athlete and his mother that I needed to get an MRI of his cervical spine in order to determine this. The athlete was understandably upset with my decision, but his mother supported my decision to proceed with caution. She explained to me that if her son played again, sustained another injury, and something “bad” happened, she would be more than happy to take legal action against me.

Fantastic.

First of all, I can’t say that I would blame her for being angry (at the very least) if I screwed up. But to tell me in my office, to my face, that she’s already thinking about suing me? I found that ridiculous. I must be in the minority, however. If you Google “how to sue a doctor,” an abundance of information follows. There’s an “ehow” on the subject, and even CNN offers an opinion.

I’m sure many can offer some anecdote about how a physician did this or that wrong, and I agree that there are some bad apples out there. That’s not the point of this post. The point is, way too many people are looking, just waiting, for something to happen to they can “get theirs.” It’s disappointing, and quite frankly, very scary. I didn’t go through a lifetime of education and training to doubt everything I do for fear of a law suit. I’m lucky; my specialty is non-surgical and rarely deals with critical health issues. But I’m hardly in the clear. A 2011 study in the New England Journal of Medicine estimated that by the age of 65, “75% of physicians in low-risk specialties had faced a malpractice claim, as compared with 99% of physicians in high-risk specialties.” So I have a 75% chance, give or take, that I’ll be named in at least one claim during my career. Of course, not all of these claims go to court and/or end up with the plaintiff being awarded, but you can see how frequently patients are quick to take action if they think they’ve been wronged.

I’ll continue to do what I’ve been trained to do – practice good, evidence-based medicine, communicate well with my patients, and document the you-know-what out of everything. But at the end of the day, the fear of a malpractice claim, valid or not, will always be in the back of my mind.

About: Dr. Mandy Huggins, MD is a sports medicine physician who practices in south Florida. She is board certified by the ABPMR and holds an added certificate of qualification (CAQ) in Sports Medicine. Learn more about Dr. Huggins at http://www.drmandyhuggins.com/

Submit a guest post and get the word out. 

Monday
May282012

Hospital Administrators Are Not Always Honest

Guest post by John Di Saia, MD

Hospital administrators have an agenda that's not always aligned with yours.

I used to do emergency work at a hospital in a large chain. It was hardy profitable and became less so over time. When I moved an hour away I sought to limit my emergency exposure for obvious reasons. The hospital administration cited sections of the Bylaws and Rules and Regulations that mandated that surgical specialists take call. This was specified for Plastic Surgery and Orthopedics.

Later and entirely by accident, I found out that the Orthopedists were being paid to take this emergency call by the same administration that was citing those hospital documents. Essentially they were being paid to take call from 15 minutes away whereas I was required to take call for free from four times the distance. Needless to say I dropped that hospital after briefly entertaining legal action. So soon after my divorce I hardly wanted to enrich another attorney. They are much smarter about getting paid than physicians are. I did inform a contact at the local newspaper who passed on the story stating that the public doesn't really care if a doctor gets screwed over. I found that a bit amusing.

As the story evolved I extended my practice up the street not so far away and something similar almost happened again. This time the administration in my new acute care hospital sought to get into an arrangement with me to take call. They were very quick to stipulate that this arrangement was to be secret. It was to involve some kind of payment from the hospital. The thought left a bad taste in my mouth. Emergency call is a loser. I just stopped taking it.

The moral of this story is that you should not expect hospital administrators to be honorable people. Entering into any kind of business arrangement with them especially a secret one is liable to be unfair, unjust or just plain illegal. You might want to avoid that.

About: John DiSaia MD is a plastic surgeon and blogger who also writes at Medical Spa MD.

Friday
May252012

Physicians In Transition: Learning To Bounce Back

Overcoming setbacks to succeed in your career and in life

If we’ve learned anything from history, it’s that nobody goes through life unscathed—no matter how rich, how smart, how talented, or how fortunate they may be.  One way or another, we can all relate to the raw emotion that strikes people when they are knocked down. 

Perhaps you’ve been fired.  Or you’ve been side-stepped for the promotion you wanted.  Maybe you reached for a golden opportunity—and did not get the nod.  Perhaps you’ve finally made it to the top—don’t like what you see—and you want out.    

These sorts of things may be setbacks—but they are only permanent if you allow them to be.  We can let the negative overcome us—and those around us—or we can plot a course to “bounce back” to make a life transition.  

First, know that you are not the first, worst, or only.  Others have been where you are, and they’re doing just fine now.  But it took some time and effort.

Tips and Action Steps

Evaluate, come to grips with what has happened
Acknowledge the event, but don’t be limited by it.  Learn from experience.  Let your emotions run their course, and then focus on starting to bounce back with a positive attitude.  Take stock of what has happened, and be prepared to attack your transition

Click to read more ...

Wednesday
May232012

Non Clinical Revenue Generation

Guest post by Jordan Grumet MD

Although I mostly expound on the trials and tribulations of practicing medicine, for a guest post, I decided to write about being a small businessman. 

Running a successful private practice can be both difficult and time consuming.  With the recent passage of health care reform, many physicians fear the security of their current income streams.  As primary care doctors, we face the ultimate catch twenty two.  The better job we do, the less outpatient visits and hospitalizations are necessary, the less money that flows through our doors.  Talk about perverse incentives!  Many have thrown their hands up in the air and joined the local hospital or medical group.  For some of us though, the loss of personal freedom is a major concern.  

So what is the burgeoning physician/entrepreneur to do?  How do we continue to be captain of a ship that faces a tsunami of change?  For me, the simple answer lies in maximizing non clinical revenue generation.  

Over the years, I have established myself as a medical expert, nursing home director, and writer.  Each of these activities provides consulting fees that are more lucrative than patient visits, require little or no overhead, and develop new personal goals and interests.By diversifying my skill set, I have created a more stable and enjoyable practice environment.  Furthermore, my time spent in the clinic is more concentrated and busier than ever.  I no longer need to try to actively recruit new patients.

There are many different nonclinical revenue streams available to physicians.  Besides those mentioned above, there are opportunities with pharma, chart review, and biotech to name a few.  Either way, I no longer worry about the traffic through my exam room door.  Most importantly, I am able to practice parsimonious, appropriate care and still bring home a salary that I'm proud of.  

And I learn something new each day.

About: Jordan is an Internal Medicine physician practicing in Highland Park, Illinois. He blogs at In My Humble Opinion.

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