Tuesday, September 22, 2009

The Not-So-Accidental Tourist

Should surgeons treat the complications of medical tourism? Today, that's not purely a hypothetical question, as some patients seek out lower-cost alternatives for elective surgical care (something I wrote about a while back). It is also a question posed at last year's clinical congress of the American College of Surgeons in a "point/counterpoint" debate. The surgeons chosen to address the topic are well respected academicians -- Dr. Karen Deveny from the Oregon Health and Science University, and Dr. Ira Kodner from Washington University in St. Louis. The scenario presented was :

A 53 year old man visits an American orthopedic surgeon 10 weeks ago after undergoing a total knee replacement in Thailand. He's had pain and erythema for 1 week, and a physical exam indicates probable cellulitis. Is it the surgeon's responsibility to treat this patient?
Their responses, the complete text of which are here, are thoughtful. Me? Meh, I'm not always so thoughtful, but I do (as always) have a few opinions of my own.

Dr. Deveney took the "absolutely, treat and ask no questions" approach. Her response can be boiled down to one sentence -- "Of course, it is the orthopedic surgeon's responsibility to provide medical care to the patient, as that is the ethical high ground." Hard to ague with that. This patient has at a minimum a mild infection, and possibly a more severe underlying infected hunk of hardware that may need to be removed, and this is not a simple matter.

Dr. Kodner's response, on the other hand, is one that is in tune with time-honored principles of interactions with patients -- "Treating this patient would corrupt the doctor-patient relationship. That relationship requires trust, which would be hard to achieve in this situation because the patient has already decided that the system in the United States couldn't meet his needs." Plus, this is a very complicated problem, one which may require multiple operations and may lead to an unsatisfactory outcome (here's a good description).

Who is right? In the end, they both are. There is no question in my mind that should a patient with a similar problem ended up in the ED when Dr. Kodner was on call, he would care for that patient. That is what we are supposed to do -- care for patients in need, even when the patient has made what appears to me to be a boneheaded decision. But in my business, I routinely care for folks who make boneheaded decisions --- driving drunk, getting into a brawl in a nightclub, having a smoke while working on a carburetor.

When a patient leaves the US, which has the highest standards of care in the world, and chooses to have an elective operation outside of the country, one presumes he is doing so with a great deal of forethought. I think that is why most surgeons would feel just like Dr. Kodner --- in choosing to go out of the country for care, the medical tourist patient is viewed as specifically rejecting the care and physicians available here. Hey, we're human; this feels like a bit of an insult. Gee, if I am not good enough to care for a patient in the most optimal, elective situation, why am I good enough when things are going downhill faster than Michael Moore riding a greased sled in the Himalayas?

Unfortunately, I have been put into this exact predicament on two occasions. I had absolutely no records available for review, no ability to speak with the original surgeon, and no clear idea of what was done to their innards until I was there trying to sort out their anatomy. It was painful and frustrating, and certainly my "pucker factor" in worrying about being sued was off the charts. My worry is one that is shared by Dr. Kodner, who noted that in the hypothetical situation,
...the foreign hospital and the foreign physician will probably be out of the picture if there is a lawsuit. The orthopedic surgeon will be taking the full risk.
Dr. Deveney references this concern curiously, stating that
...a successful lawsuit is not at all likely as long as the surgeon documents the facts in the case and treats the patients with respect.
Hmm. If I am understand her correctly, I shouldn't worry because though I may be sued, it is unlikely that I will be sued successfully in this situation. Wow! I'm reassured already! Put the Rolaids away!

Perhaps this is simply a situation in which I am hopelessly behind the times. If I am nothing else, I am very old-fashioned in my approach to the way physicians should interact with patients and each other. However, it is hard to go wrong with the premise that a surgeon assumes significant responsibility for a patient once an incision is made. Rather than discussing what we should do when a patient shows up with a complication of a medical tourism excursion, we should focus on educating patients what such a trip may lead to. As Dr. Kodner puts it,
Once you have seen a patient, you have assumed responsibility and have entered into a physician-patient relationship. This includes the responsibility of finding another surgeon if you eventually want out. Once you start, you can't abandon the patient. Don't start!
Medical tourism is a clever business model, but let's be honest --- it is a business model, not a complete patient care model. As the eloquent Sir Robert Hutchison stated,
It is unnecessary - perhaps dangerous - in medicine to be too clever.