Obamacare, American medicine, medical tourism and what it means for me


I haven’t written in a while because I have been looking for a way to describe what’s been going on in healthcare.

the American healthcare system

the American healthcare system

As a provider

There has been a weird unhappy vibe in the  American hospitals these days.. It’s like nothing I’ve ever felt before in the last 15 years.  There has always been a collective feeling of frustration among providers; but it’s usually sat somewhat untended, like a slow cooker slowly simmering away..  These frustrations were related to our inability to provide the best for all of our patients, our frustration with the broken-ness of a health care system so rife with waste, yet with so little help for our vulnerable populations, and those in dire need.

It was manifested by occasion individual grumbling; during case management meetings, during conversations with faceless insurance companies as we explained yet again, why our patient:

a. really needed XYX treatment and

b. how it was actually more cost-effective in the long run..

But it was isolated for the most part, and the majority of providers still felt like they were helping people – and enjoyed the job satisfaction that went along with that..

It seems like a lot of that has changed over the past year.. I don’t know if it’s fear of coming changes, and the uncertainty that goes along with that..  But most providers are actually in favor of the Affordable Care Act – or the concept, anyway.  It’s something else, maybe the forced implementation of governmental changes like clunky and poorly functioning EMRs, the continual threats of “pay-for-performance” or a cummulative effect of all of the above, but many providers seem to have reached the breaking point in frustration.

For the first time that I can recall, a lot of really excellent physicians and other providers I know are just burned out to the point of complete mental and physical exhaustion.  People I’ve know for a long time, people I consider my mentors, my inspiration are talking about retiring early or leaving the field to do something else entirely.

It’s also the first time that I’ve ever seen doctors, nurses, and others as a collective to seem so broken in spirit.

Patients are people, not check box diagnoses

I am feeling a bit of it myself – a kernel of hopelessness that sparks in my heart.. a sinking feeling when I order a standard medication (but individualized for a specific patient/ condition) and enter in the computer – and receive a message telling me that dosage is not permitted.  A follow-up phone call with the pharmacist continues the charade.. Since it doesn’t fall into a specific category between two mandatory dosing schedules (for diagnoses that differ from what my patient has) then – they don’t know how to categorize it on the computer – and thus my patient can’t have it..  This makes no sense to me, I am following best practices, the current literature and evidence-based practice, but somehow my patient’s condition hasn’t been coded somewhere down in the pharmacy, so they won’t release the medication.  Too scared of the consequences I guess – or too apathetic to care that the medicine is for a real, living, breathing person and not a statistical table somewhere.

– and I argue the realities of this individual scenario but the bureaucratic mentality on the other end of the phone doesn’t care..  How am I supposed to do my job; to care and protect my patient in a system like this?  It’s only going to get worse as the government gets more and more involved in patient care.

What?  My patient isn’t a peg, it’s a person – and if this person doesn’t fit the pre-specified check box doesn’t matter to me  (in this specific instance)- what matters is that my patient keeps his leg (which he may not, if he doesn’t get this medication at the dosage I ordered in consultation with his surgeon).

As the consumer – losing my current plan

At the same time that this brokenness is affecting providers nationwide – I have fallen into the dilemma of many of my readers. As a locum tenems provider, I am self-insured.  My current plan, which was flexible, affordable and provided coverage which suited our needs (low monthly fee, low deductible, reasonable co-pay, and two free wellness checks a year) is being discontinued.  It was also a flexible plan that allowed my family and I to see providers nationally.  So if I was working in Texas for six months, I could see a doctor in Dallas. Or Massachusetts, or California, even back in my home state of Virginia.

Now, I am spending most of my days off on the phone and the internet – looking for a policy that doesn’t limit my coverage by location.  Most of the time, I can’t even find the correct phone numbers to talk to the right people.  The numbers listed online at the marketplace are incorrect, or out of service.  The representatives that I do speak to after being on hold for thirty minutes and routed through a computer automated system are sometimes nice, (often completely indifferent) but can’t answer my questions.

I do know that at a minimum my monthly expenditure for even the bronze “no frills” plans will double, and may even triple.  My deductible will also double or even triple, so in January, I will be literally paying two or three times what I paid last month (December) for a fraction of the services.

Paying a lot, and getting almost nothing in return

All of the new government approved plans are based on my home state – and some even limit coverage to my county only.  Since my county is rural – and the nearest major medical center is actually in a neighboring state, having one of these local plans is like being uninsured.  (Some representatives said they would cover out-of-area “life-threatening emergencies*”, but others weren’t sure).

this should be a significant concern for anyone in rural or limited medical access areas**.  For someone with my geographical needs, it’s become a major nightmare.   Even with the increased costs – I may still not have coverage for the majority of my time (for 2013 for example, I was home for a total of 1 month. In 2014, I was home for four months).  Since I can’t predict where I will be sent – I can’t pick a plan for another state.  Not only that – but even if I knew I was going to be posted to Indiana or somewhere like that – I am not allowed to buy a plan outside of my registered address.

No one knows the answers – and what they do know doesn’t sound good:

After another full day on the phone with representatives for the Healthcare Marketplace and different insurance providers, it looks like the answers are pretty ugly when they even know them.  Most of the representatives had no answers.  One of them even asked me, “Well, do you vote?”  They won’t even give a call back number or extension so that when they “accidentally” disconnect you during another of the “let me transfer you to another representative” spiel, you have to go thru the whole rigmarole all over again.

1.  If you have a plan that does not have out-of-network coverage – consider yourself uninsured if you become injured or have a medical emergency outside of your area (which may be as small as your county.)  The cheapest plan for two people on Blue Cross/Anthem/Blue Shield (my existing company) that offers out of network coverage is 594.00 a month (we paid 213.00 a month before).

2.  None of the plans cover medical tourism – even from companies that previously provided these options.  So, if you live in a county like mine (with no trauma center, and a tiny rural hospital) – you aren’t covered for the neighboring hospital in another area in an emergency.

Not only that – you can’t receive coverage for a non-urgent (elective) procedure for something like a knee replacement at another facility.  My town has one orthopedic surgeon (and he isn’t someone I’d ever chose to go to.)  Now I can’t go to Duke, UVA or another nearby facility – and they won’t pay for me to have the same treatment (at a fraction of the cost somewhere else like Bogotá.)

Here’s a typical example of what I’ve learned after several days/ weeks of reading & talking to representatives –

I’ll pay $5,112 in premiums with a $13,200 deductible with NO coverage of any conditions (except an annual physical and a flu shot) until I’ve put out a total of $18,300 (every year – not a one time deal).   Then the insurance will start to pick up the tab.. This is supposed to be affordable?  For whom?

And while some people will pay less in premiums based on their income level – they still have to come up with the $13,200 deductible.  How the heck is that supposed to work for someone making $30,000 a year?

So now we are calling all the other companies and reading, reading, reading all the fine print.  For now – it looks like I will paying an exorbitant amount for minimal coverage, and will need to rely on medical tourism for any non-urgent but essential treatment that either falls below my high deductible or isn’t even available in my home area.  Luckily, I am pretty healthy (but I am currently working in a trauma unit so I know how quick that can change) – but isn’t the whole point of insurance to prepare for the unexpected?

So what does that mean?

I don’t have the answers for everyon1e.. In fact, I don’t even have them for myself. But it may mean that I am better served by paying my premium and using medical tourism for all of my other (non-emergency) health care needs.  After all, $13,199.99 buys a lot of care in Colombia, Mexico and many of the other places I’ve researched and written about.

*And, if you survive – you may have to argue with some bureaucrat whether your illness was actually life-threatening or not.. I mean, it can always be argued that “how serious was it, really, if you made it home alive?”

** Limited access areas may include major cities.  For example, the city of Las Vegas has a very limited number of specialists.

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Ebola and medical tourism


 

biohazard

There’s a new editorial over at the IMJT on Ebola, medical tourists and the medical travel industry.  In the article, “Ebola: a hot topic for the next medical tourism event?” by Ian Youngman, he explores the potential pitfalls from medical tourists who are seeking treatment overseas.  As an insurance expert, who makes his living by preparing for “What if?” scenarios, the author offers valuable insight on a topic that has provoked wide speculation and fear-mongering among the general media.

Mr. Youngman explores current medical screening at airports, the impact on current medical tourists as well as the potential impact of a global pandemic/panic on the medical tourism industry.  Mr. Youngman urges for a clear, reasoned and cohesive discussion and response from leaders in the medical tourism industry.

passport w money

Death of young patient raises questions of safety

IN other news, the BBC is reporting on the recent death of a 24 year old British medical tourist.  While the BBC article offers few details on the patient who died during a liposuction procedure in Thailand, a more in-depth report from the UK Mail reports that the woman stopped breathing after receiving anesthesia at the private medical clinic.  The article reports that this was a repeat visit for the patient, who had previously undergone another plastic surgery procedure at the clinic.

Now questions are being raised about the doctor’s qualifications to perform the procedure, as well as the lack of availability of life-saving medical equipment at the medical clinic.  The doctor at the clinic, Dr. Sombob Saensiri has been arrested while this case is being investigated.

Note: There are conflicting reports regarding the exact circumstances of this patient’s death.  An Asian story reports that the patient had returned after a recent surgery with complaints of a developing infection.

Related posts:  Plastic surgery safety archives

Plastic surgery safety: Know before you go radio interview

Is your cosmetic surgeon really even a surgeon?

Liposuction in a Myrtle Beach apartment

 

Is it safe to fly after surgery?


Long haul flights are a health risk for everyone

While the risks of prolonged immobility and pulmonary embolism with long distance travel are well-known, many potential patients are unaware of the increased risks of thromboembolism after surgery.

Increased risks in specialized populations

People with a personal or family history of previous blood clots (PE or DVT), women on oral contraceptives, and patients who have undergone orthopedic surgery are some of the people at greatest risk.

Increased risk after surgery + Long trips

The heightened risk of thromboembolism or blood clots may persist for weeks after surgery.  When combined with long-haul flights, the risk increases exponentially.

In fact, these risks are one of the reasons I began investigating medical tourism options in the Americas – as an alternative to 18 hour flights to Asia and India.

Want to reduce your risk – Follow the instructions in your in-flight magazine

Guidelines and airline in-flight magazines promote the practice of in-flight exercise to reduce this risk – but few have investigated the risks of thromboembolism in post-surgical patients by modes of transportation: car travel versus air travel.

airplane3

But, is it safe to fly after surgery?

This spring, Dr. Stephen Cassivi, a thoracic surgeon at the world-famous Mayo Clinic in Minnesota tried to answer that question with a presentation of data at the  the annual meeting of the American Association for Thoracic Surgery.

This question takes on additional significance when talking about patients who have had lung surgeries.  Some of these patients require oxygen in the post-operative period, and the effects of changes in altitude* (while widely speculated about) with air travel, have never been studied in this population.

Now, Dr. Cassivi and his research team, say yes – it is safe.  Mayo Clinic is home t0 one of the most robust medical travel services in the United States for both domestic and international medical tourists.

After following hundreds of patients post-operatively and comparing their mode of transportation  – Dr. Cassivi concludes that the risks posed by automobile travel and air travel after surgery are about the same.

Additional reading

For more information on deep vein thrombosis, pulmonary embolism and safe travel, read my examiner article here.

AATS poster presentation abstract:

Safety of Air Travel in the Immediate Postoperative Period Following Anatomic Pulmonary Resection
*Stephen D. Cassivi, Karlyn E. Pierson, Bettie J. Lechtenberg, *Mark S. Allen, Dennis A. Wigle, *Francis C. Nichols, III, K. Robert Shen, *Claude Deschamps
Mayo Clinic, Rochester, MN

Schwarz T, Siegert G, Oettler W, et al. Venous Thrombosis After Long-haul Flights.  Arch Intern Med. 2003;163(22):2759-2764. doi:10.1001/archinte.163.22.2759 .  This is some of the definitive work that discussed the risk of long flights with blood clots in the traveling population due to prolonged immobility.

*Most flights are pressurized to an altitude of around 8,000 feet – which is the same level as Bogotá, Colombia.  This is higher than Flagstaff, AZ, Lake Tahoe, Nevada, Denver, Colorado or Mexico City, D.F.  – all of which are locations where some visitors feel physical effects from the altitude (headaches, fatigue, dyspnea, or air hunger.  In extreme (and rare) cases, people can develop cerebral edema or other life-threatening complications at these altitudes**.

** Severe effects like cerebral edema are much more common at extreme altitudes such as the Base Camp of Mt. Everest but have occurred in susceptible individuals at lower levels.

100% sugar-free!


I am currently on assignment in Massachusetts – and we’ve had our share of snow in the last few weeks.  It certainly makes me long for Latin America..

on assignment in the northeast

on assignment in the northeast

But while I may be in the northeast for the next several weeks, it doesn’t mean that I am hiding under a rock – so I continue to talk / read/ and research issues in medical tourism.

One of the newest reports comes out of the United Kingdom.  The UK has embraced medical tourism to a greater degree that Americans have, and UK researchers are some of the forerunners in the field.  (There are multiple reasons for the ready adoption of medical tourism by large numbers of British citizens but that’s a different topic entirely.)

No candy coating!

No candy coating!

The latest news from the Yorkshire Post is a timely and necessary reminder for all potential medical tourists and facilitators out there.  The article discusses the recently published paper, entitled, “The three myths of medical tourism” as well as interviews with medical tourists.

Research into the medical tourism industry

The paper is based on results of a study conducted at York University.  Researchers at  York University have an ongoing medical tourism project looking at multiple aspects of medical tourism including financial/ economic, as well as quality and continuity of care issues.

Much of what the researchers at York are studying are topics we have discussed previously on our site:

Quality Control

– the lack of standardized guidelines for ensuring quality of care (and continuity of care from the moment the patient leaves home until recovery)

– the lack of accountability for facilitators/ tour operators/ medical tourism companies for patient safety and outcomes  (this means that companies can send you to the cheapest surgeon)

– the lack of recourse for patients who experience complications/ serious injury or inadequate care.  (It’s a black hole for medical malpractice at present).

– The potential financial costs of complications:  While some surgeons require their patients to purchase ‘complication insurance’ to cover treatment of complications (if they occur) in the home country, there is no universal requirement.

Papers in-press

Unfortunately, much of this work (by Lunt & Smith) is currently in-press.  I’m anxious to see their reports but I am also wondering what sort of regional differences may exist.  Medical tourism by British residents is often to neighboring areas of Europe, Eastern Europe, India and Israel.  I’d be fascinated to see how that compares with outcomes and experiences for medical travelers to Latin America, and different South American countries in particular.

In any case – it’s a timely report.  Hard scientific information is dearly needed since the majority of data over the last decade has been anecdotal in nature or statistical “projections/ estimates / guesstimates”.

Hard data is particularly important when it comes to allegations regarding poor post-operative care/ and increased incidence of infections (specifically in medical tourists from the UK who traveled to India).  Many of these complaints arise from local plastic surgeons and may have little supporting data.  If there is a problem, we need actual numbers, not case reports (particularly if we are dealing with antibiotic resistant infections).

The industry has also been plagued with numerous biases on both sides..  – Biases towards the perception that all overseas medical care is cheaper (not always the case)

and/or that cheaper = inferior

Quantitative data would also be helpful when discussing patient satisfaction and quality of care.  Most of the time, statistics are bandied about from the Deloitte Institute – but I want to hear what patients think from other sources.  How did patients rate their experiences in Britain?  In California?  Where were the patients going?  What countries?  What clinics were mentioned repeatedly?

Other issues – Patients poorly informed

Researchers also found that medical travelers were poorly informed or ignorant of the risks involved with medical tourism.

In some cases, patients were ‘willfully ignorant‘ and relied on social media and friends for all of their health information.  A subset of these patients also traveled for unproven/ unregulated medical treatments (such as bovine stem cell injections).

Many patients were ignorant of the risks or potential complications of the surgical procedures themselves (lap-band was specifically cited numerous times) as well as the problems that arise when your surgeon is thousands of miles away.

Patients were also unaware/ poorly informed about the financial implications of developing/ treating complications in their home country – (or the costs involved if they needed to return to their surgeon).  Some of the financial issues mentioned in this (and previous data I’ve encountered) is more specific to British residents with their National Health Services and it’s reimbursement structure.

However, it’s not unimaginable to picture similar circumstances for uninsured medical tourists, or tourists seeking aftercare at an “out-of-network” facility once they returned to the USA.

Ignorance of health care information – an ethical/ safety issue

Some of this ignorance may be directly attributed to the way that many medical tourism companies operate – with patients being funnelled overseas thru a “facilitator” versus referring physicians and nurses.  During a recent conference on medical tourism, I was astounded when a prominent American medical facilitator brushed aside my concerns about the lack of medically trained personnel, stating, “I’ve been a paralegal for 22 years in a malpractice office – I know all that anyone needs to know about surgery.”

But what about the ‘caregiver’?

Facilitators and medical tourism companies often tout the use of ‘caregivers’.  This  terminology is misleading in my opinion.

Since “doctor”, “registered nurse”, and other healthcare personnel are professions that require certification and educational degrees – companies often label their assistants ‘caregivers’ since it’s illegal to use the title of nurse.   In reality, the term ‘caregiver’ is more akin to ‘paid companion’.  These individuals have no medical or nursing training and may actually be a source of misinformation (as this paper states.)*

In the usual course of surgery – as part of the pre-operative process, patients receive information, education and instructions during their initial consultation/ and pre-operative visits.  This also gives patients a chance to ask questions, in-person to a medically knowledgeable person.  Skype, and email just can’t replace this critical component.

Many times, critical information is obtained (and given) by the surgical team during the physical examination and history-taking on the initial consultation.    If the referring service is a layperson, and the initial (in-person) consultation  takes place after the patient arrives in the destination country, these crucial education opportunities are lost.

Call for Regulation for patient safety

As readers know, I believe that regulation is both necessary and desirable to improve/ promote and grow the medical tourism industry.  This regulation needs to be undertaken by knowledgeable people/ institutions outside of the industry.

Other research in medical tourism –

Simon Fraser University – British Columbia, Canada

*In a related aside, one of the more popular Canadian medical tourism facilitators uses her unemployed sister in the role of ‘caretaker’.  While the sister has no medical or nursing training, the facilitator bragged that it allows her to put her family on the payroll and bill the client for these services.

Narcotics and Analgesia in Latin America: Issues related to managing acute pain in chronic opioid patients


This article is part of a new series that explores issues in medical tourism.

The geopolitical landscape of drug trafficking?

As a writer who has written on both Colombia and Mexico, the most frequent questions I encounter from friends, colleagues and acquaintances are almost always related to drugs and drug-related violence.  As I’ve mentioned in previous posts, the real risks of crime and violence affecting medical tourists is actually quite small in many of these areas, despite media headlines*.   Questions related to the drug trade are for all intents and purposes outside of my area of expertise..   However, this does bring up some other related issues that are increasingly relevent for our on-going discussions about medical tourism.  But, first some background –

drugs2

The Latin American Drug Problem?

Just ask a Mexican, Colombian or another person from Latin America and they will tell you, the United States is the place with the drug problem.

Not only that, but the majority of Latin American countries hold the USA as responsible for fueling much of the violence that has devastated these countries in recent years.  Erik Vance over at Slate.com recently published an excellent essay on this topic which explores the role and collective responsibility of American citizens for drug related atrocities under the guise of a Friday night high.

This isn’t Colombia Reports, its Latin American Surgery.com

But talking about the politics and trade issues regarding the growth, harvesting, and distribution of illegal drugs isn’t really the focus of my work.   Healthcare is, so my interpretation of issues regarding drugs is very different – almost like another language.  If you could see inside my head, and watch my thought processes, it would look a little like this:

Drugs —> Narcotics —-> medications for pain —–> treating pain —–> international / cultural issues related to pain and treatment of pain —> who is most heavily affected by this?

When I hear “drugs”, I think “medications.”  When I think of medications, or more specifically, narcotics – I don’t think of tiny, little bags littering the street in Medellin, but the somewhat vague medical definitions for narcotics..

drugs

Narcotics, Narcotics, Narcotics…

The definition of narcotics depends on the discussion..

Legally, a narcotic is any medication or drug that is prohibited/ restricted / illegal.  Thus while the government classifies amphetamines, MDMA (ecstasy) or cocaine as narcotics, healthcare providers usually don’t.

Medically, narcotics usually refers to opioid compounds or other medications used to relieve physical pain.  More recently, the term analgesics has replaced narcotics in the everyday vernacular.  When we refer to narcotics, we are usually talking about using medications in a therapeutic fashion specifically to treat pain – like prescribing Percocet or Lortab for pain after surgery..

pills2

A kid in the candy store

Americans are the kings of narcotics. But unlike the common perception of drug abuse being isolated to crack pipes, cocaine and heroin junkies – the majority of drug abuse in the USA is derived from legal prescription medications, readily available at large chain pharmacies.

CVS and Walgreens versus the Colombian drug dealer

It’s usually a Colombian or Mexican drug dealer – at least on the latest episode of modern crime dramas.  I guess that’s because the truth is a lot more mundane.  In actuality, CVS, Walgreens and any number of local pharmacies are the real ‘drug dealers’ for many Americans.

We prescribe, we use, and we abuse at astronomical rates.  No other country comes close to being as heavily medicated as ours. Not only have overdoses and addiction rates skyrocked, but so have the cases of “Chronic non-cancer pain” treated with long-term narcotics.  Some of this use is legitimate, some of it isn’t but anyway you look at it – we have a problem.

The prescription drug problem: Overdoses, addiction and chronic pain

In  a recent Medscape article by one of the foremost experts on chronic pain,  chronic pain management and addiction medicine,  Laxmaiah Manchikanti in “Lessons Learned in the Abuse of Pain-Relief Medication_ A Focus on Health Care Costs” estimates that there are over 100 million chronic pain patients in the United States. 

That’s a lot of pills and prescriptions.

But even if we ignore issues of prescription abuse and misuse, there still remains a large segment of people with chronic pain and chronic opioid use.  These people aren’t abusing their medications, but they are using opioid medications over long periods of time, often in escalating doses.

Chronic pain and Chronic Pain treatment with opioids

The problem chronic pain patients face is one of tolerance.  When patients are treated with opioid medications, including long-term opioid medication regimens for problems like chronic back pain, tolerance to these drugs and their effects occurs.  This means that it takes more of the medication to produce analgesic (and other) effects.

For example, a dosage that would make an opioid naive patient comatose for example, may only serve to reduce pain from a “10 [unbearable agony]” to an “8 [excruciating] ” in a patient with tolerance.

While an isolated prescription for Percocet after major surgery or an injection of morphine in the emergency room for an acute fracture shouldn’t cause any long-term problems, many of people with chronic use have developed a significant tolerance to these medications.

Tolerance makes obtaining adequate analgesia in acute pain difficult

This means that the ‘standard’ doses of pain medications that are usually ordered after procedures may be inadequate to manage their pain.  Huxtable et al describe the problem of maintaining adequate analgesia in opioid tolerant individuals during episodes of acute pain in his 2011 review, which gives a comprehensive overview of the issues involved.

But, if you can imagine the scenario of an opioid tolerant patient awakening from major surgery, only to find out that the prescribed medications aren’t working  – then you have a pretty good idea of how potentially traumatic and devastating this could be.

If you are planning for surgery: 

– Pain management planning (baseline pain score, realistic pain management goals, multi-modal therapies, and thorough review of medication history)

But more critically, people with increased opioid tolerance need to talk – to their providers and their caregivers about realistic expectations of post-operative pain control.  Together, patients and providers should review their pain medication history, as well as baseline pain scores.

Also contributing factors like depression or other emotional distress should be addressed prior to surgery.  (Even if you don’t have a diagnosed depression – antidepressants can often help alleviate pain).

For example:

Patient P is scheduled for a knee replacement.  While P’s knee has been hurting for some time, P’s chronic arthritis pain is mainly centered in P’s low back.  P takes several medications for his back pain, including oxycodone and has done so for several years since a workplace injury landed him in the emergency room with a herniated disk.  Now P is concerned about his pain after surgery.  

What are some of the issues that P faces?

If prior to surgery, patient P reports a chronic (baseline) pain level of 6 in his back (on scheduled, long-term narcotics):

– obtaining pain relief (a score of 3 or less) might be impossible.  It is almost certainly impossible that the same medication regimen used for opioid naïve patients is going to be equally effective for patient P.

 After a frank discussion with his/her surgeon during pre-surgical evaluation, P’s doctor anticipates P’s increased needs for post-operative analgesia.  The doctor also orders a wide range of non-pharmacological interventions and adjuvant medications to help alleviate P’s acute pain needs.

However, neither P nor P’s surgeon anticipate that this regimen will treat or relieve P’s chronic pain.  Following adequate recovery from surgery, P is referred back to his/her pain management specialist for long-term needs.

Sounds good, right?  Well, it should since this is the textbook scenario for patient care that has been taught in universities all over the United States for the last decade.

But this is Latin American Surgery..  so we need to explore the regulations and attitudes regarding pain management and analgesia outside of the USA.

But the very first thing people should know is: 

1.  Pain is culturally defined.

Cultural beliefs affect everyone, not just the patient..  So it isn’t just about whether the patient displays stoicism or tears.  It’s much more complex than that.   Cultural beliefs affect everyone; including doctors and nurses, so this means that culture also plays a role in pain management too…

That’s not to imply that some cultures just tell their patients “to shut up and suffer” but that pain and appropriate pain management may be viewed very, very differently depending on where the person is being treated.

In general, some cultures are more openly expressive of pain – and in these cultures pain may be treated with stronger medications and more frequently.  But that is not always the case – because the cultural beliefs surrounding pain and suffering also reflect that individual society’s belief regarding the value of suffering, as well as beliefs/ fears/ concerns regarding addiction.

Crying

Many of the cultures that are frequently cited as “highly emotive” or as cultures where pain is readily expressed are some of the same cultures where narcotics are not heavily used in in-patient or outpatient settings.

For example, many classic sociology references cite latino culture as being very expressive and emotive (ie. not stoic regarding pain).  At the same time, the use of narcotic pain medications (in my observations) are quite limited in both in-patient or outpatient settings.  Numerous medications (tramadol, ketorolac and other NSAIDS) are used to manage post-operative pain in these patients – including formulations not available in the United States.  Patients certainly weren’t undertreated:  during interviews and visits with patients, the vast majority of these patients reported good to excellent pain relief.

However, in the three years that I have been working closely with physicians in Mexico, and Colombia – I have very rarely seen a doctor order narcotics (ie. morphine, dilaudid or similar medications) on the post-operative orders.  I have never  seen a written prescription for percocet, lortab or similar medications for a patient in the outpatient setting (or as part of discharge medications.)

Obviously that doesn’t mean that these medications aren’t prescribed.  But it does show that what would be considered a routine Rx in the USA (ie. Discharge prescriptions for Percocet after cardiac surgery or lung surgery) is not routine for the doctors in the various practices that I have observed in my numerous travels.

So patients with opioid tolerance or chronic opioid use would certainly want to discuss this with their surgeons prior to surgery.

Of course, “cultural traditions” aren’t the only reason narcotics may be used / dispensed differently in other countries.  Other reasons may include:

Legal constraints / Availability

Globally, pain management practices may also be influenced by that nation’s laws as issues of supply and scarcity.  This is less of an issue in parts of Latin America but may be more problematic in Asia or other countries where narcotics are more tightly controlled.

In Mexico, for instance, many of the legal constraints for the prescribing and use of narcotics mirrors the United States.  There is a centralized governmental agency, COFEPRIS, similar to the DEA which regulates and monitors prescription drugs.  Narcotics like morphine, hydromorphone and fentanyl require a specific type of prescription called “Type 2” (and prescriptive authority for the prescribing physician).  There are dosage limitations and restrictions.  Only certain types of doctors are authorized to write these prescriptions and frequent follow ups are required (monthly) for on-going prescriptions of Type 2 drugs (A. Ballesteros, 2014).

globe ribbon

Happy, safe, successful travels

None of the above is to suggest that medical travel is contraindicated for American patients.  But like any big occasion or event, advanced planning is critical for a successful medical trip.

It is also a reminder to have clear expectations, good lines of communications and thorough discussions with medical providers** prior to having surgery or other procedures, particularly if you have special needs (like chronic pain management) or other health conditions.

*Venezuela is a different story. Travelers are advised to be informed, and take precautions prior to visiting this area.

** Overseas, domestic or just down the street

Additional references and resources

Vital Signs: Overdoses of Prescription Opioid Pain Relievers and Other Drugs Among Women — United States, 1999–2010.  A CDC report.

Cultural aspects of pain management.  Marcia Carteret.

Laxmaiah Manchikanti (2007).  National Drug Control Policy and Prescription Drug Abuse: Facts and Fallacies. Pain Physician, 2007;10;399-424.

Hartrick, Craig (2007).  Long term opioid treatment.  Virtual Mentor (American Medical Association Journal of Ethics).

Huxtable et. al. (2011). Acute pain management in opioid tolerant patients: a growing challenge.  Anesthesia Intensive Care, 2011, 39: 804-823.

Brafman, B (2014). Advance for nurses: Addiction in the surgical patient.

For fellow Medscape subscribers – there is an excellent series of articles as well as video lectures addressing multiple facets of the American prescription (opioid) pill problem.  I’ve included links to just a few of them here.

Managing pain

Safe prescribing

The “lessons learned” article, previously cited above.

The “Pain TV” series.

Medical tourism for pets?


Hello everyone, and season’s greetings from Dallas, Texas!

I am on assignment as a locum tenens for the next several months, so I will be traveling around the United States quite a bit.  In the meantime, this blog post  by Marian Ruiz over at Borderzine caught my eye so I thought I would share.

In the article, Ms. Ruiz interviews Elva Lomas, a California resident who travels to Mexicali for her pet care.  This article drew my attention for a couple of reasons:

1. I know Mexicali, MX.

Mexicali is one of my favorite cities.  I guess it’s an occupational hazard; since Bogotá ranks pretty far up there on my list, as well.

But back to Mexicali –

After spending several months there writing my most recent book, this area of dusty and hard-packed, sun-scorched concrete, asphalt and dry dirt became near and dear to me.

Mexicali sign

2. I have pets.

The other reason this story caught my eye was the part about the animals.  Mexicali was the first time I was able to bring my own pets on one of my writing projects.  Both of our cats, 17 year-old Sid, and 4 year-old Cora came with us for the nine month stay in Mexico.  (We previously transported the cats to the (U.S.)Virgin Islands, and on multiple cross-country car trips, so the cats were veteran travelers, but this was their first international trip.)

Our cats (at our home in Virginia), circa 2010.

Our cats (at our home in Virginia), circa 2010.

Over the course of several months, both of our cats saw veterinarians in Mexicali – including two different ones – on Avenue Maduro and another office, closer to our apartment.  We also went to the veterinary college in Mexicali.

Sid, prior to his final illness

Sid, prior to his final illness

But our experience was a little different from Ms. Lomas and her seven dogs, particularly for our geriatric cat.

In fact, at each clinic, the veterinarian expressed surprise at Sid’s age.    In what turned out to be his final illness, we were forced to go across the border to El Centro, California to get Sid the aggressive, intensive care that he needed.

Sadly, he was too sick and too weak – so we brought him back to Mexicali to our apartment to die.

3. Many Americans have “close” relationships with their pets that maybe considered uncommon in other cultures.

What we found during this experience wasn’t that veterinarians on either side of the border were more or less qualified than the other.  What we found is that the cultural expectations and the role of pets varied significantly by country.  (I am certain that a case could be made that there were several other factors as well – such as our familial and socio-economic status).

For our vet in Mexicali – Sid was our beloved pet, and they were happy to offer compassionate and competent care.   For our vet in El Centro – he understood that like many childless, middle-class couples, Sid was more than a pet – he was family.  [Not everyone feels that way about their pets – but all of us know people who do.. However, not all cultures view this ‘child-pet’ attitude as indulgently as we do.]   This meant that the vet offered more services and treatments (like emergency dialysis, and mechanical ventilation) for our ailing, long-term companion that they did at the vets’ offices in Mexicali.

In the end, it didn’t make a difference, after 17 years, my cat was at the end of his life.  We didn’t put him on dialysis, or advanced life support.  Instead, we made him as comfortable as possible and watched him slip away from us, surrounded by people who loved him (my husband and my dear friend).

The cultural context of care

But the focus of this story isn’t about pets, veterinary care or Mexico at all.  It’s more about the importance of cultural context and cultural values related to health care.  In fact, one of the reasons that I focus on health care / medical tourism in Latin America is due to concerns over differences in cultural expectations related to health care.

Life support despite medical futility as a cultural expectation*

In general, these differences are minimized for people from the United States when they receive care from Latin American providers due to similar cultural backgrounds and cultural expectations.   (A good example that highlights the differences in healthcare related to culture that is often cited in the literature has to do with end-of-life and ‘futile care‘.)  This is care that may be very expensive to provide – and may actually do nothing to prolong life.  It’s one of the hallmarks (or pitfalls) of American healthcare.  But then again, it’s only a pitfall, or ‘wasteful spending’ when it’s not your family member.

Translated this ‘futile care’ means that in most parts of Northern America, metropolitan areas of Latin America, people may receive treatments (like dialysis, prolonged mechanical ventilation/ or other artificial ‘life support’) despite having minimal or a low or no chance of survival.  Ethicists can debate the issues related to the use of limited or scarce resources to keep someone’s elderly grandmother, or extreme ‘preemie” baby alive, but for the most part – doctors (and patients) in Bogotá, Mexico City, Dallas, Texas or Washington, D.C.  all want the same level of care and are willing to provide some level of this care, even when doctors feel it may be futile in nature.  It is part of the culture, and the cultural expectation shared by most patients.

However, if you contrast that with other common medical destinations (by country, not facility), the answer is not always the same.  If the average life expectancy/ infant mortality / or level of available technology is dramatically different, than the cultural expectation of “appropriate care” may be very different.  That isn’t to say that the doctors or families of patients in these countries care about their patients any less.  However, it may translate to a very different level of care in similar circumstances.

For example, I currently work in a surgical program that specializes in providing valve replacement (cardiac) surgery to the extreme elderly (patients in their late 80’s and early 90’s).  In other cultures and societies, expensive and scarce medical resources would not be allotted as freely to this group of patients.  It’s one of the concerns in our own country with the advent of ‘Obamacare’ or a socialized medicine schemata, and it is a legitimate one.

Whether or not we consider it right or appropriate to offer this level of care to high risk groups is often debatable, but as Americans we take it for granted – that we have the right to decide this for ourselves.  We might not be as happy if it’s not offered (or available) to us as medical tourists somewhere else.

*This field of study is a subspecialty of Sociology – while it’s not scientific, the linked description on wikipedia may be helpful for readers who want a basic overview on some of the ways culture affects health beliefs and behaviors.