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.

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 on the heels of Obamacare


Happy Thanksgiving to all of my American readers!  I hope everyone has a wonderful and safe holiday.

I’m home for a while, sort of.

After returning from Mexico this October, I’ll be spending the rest of the Fall/ Winter here in the United States while I replenish my writer’s budget by completing some travel assignments.  (Coming soon – to a hospital near you!)

Now that I am home, I have been catching up on all of the local news – and it looks like Obamacare hasn’t really kicked off to a wonderful start.  Of course, it was naive to think that anything SO large/ SO involved / Affecting some many people could go off without (several) hitches, but as one of the people losing their coverage because of it – I certainly understand all of the anxiety and worry out there.

In the midst of continuing coverage of the current Obamacare fiasco, as millions of Americans lose their existing health care, several new articles on medical tourism have been making headlines across the country.  Here’s a look at some of the latest news and reports from this past month.globe ribbon

In the Bay Area, NBC news‘ Elyce Kirchner, Jeremy Carroll and Kevin Nious published “Medical tourism: the future of healthcare?” along with a televised report. It’s the usual patient narrative along with an overview of medical tourism.

Kevin Gray, at the Men’s Journal talks about the domestic and international options available in his narrative, “Medical Tourism: Overseas and under the knife.”  Gray takes a slightly different approach and discusses how consumers can comparison shop for health care services.

Among these publications, is “Medical tourism: Spanning the globe for health care,” by Kent McDill which includes information from one of my publications and a recent interview published right here at Latin American Surgery.com

The sky’s the limit?

Also, in counterpoint to the numerous press releases and newspaper articles talking about Iran, Bermuda, and various other medical tourism destinations seeking to “cash in” on the phenomena, British researchers (Lunt et al.) have published a report that contradicts the “if you build it, they will come” philosophy which has taken over the industry in many quarters.

Medical News Today published a summary of their findings early this month.  Researchers also point out that much of the credible data required to provide a full and accurate picture regarding medical tourism is absent.

On a related note: While I talked about the limitations in medical tourism, accuracy of reported statistics and public perceptions in-depth during my 90 minute NPR interview, you wouldn’t really know it from my 2 sentence quote.

Pitfalls..

USA Today also published a story on some of the pitfalls for destinations with thriving medical tourism.  Kate Shuttleworth takes a look at the strain that Eastern European medical tourists have placed on some Israeli facilities.

Is medical tourism on the rise?  or is it all a spin of the numbers?  I guess it all depends on who you ask.. But for now – Obamacare is not a viable alternative to medical travel.

CBS news on the cons of medical tourism


CBS published a refreshing take on medical tourism – an article reviewing the pros and cons of traveling for medical care along with an interview with an American orthopedic surgeon,  Dr. Claudette Lajam from New York University Langone Medical Center.

Video interview with Orthopedic Surgeon

While Dr. Lajam pretty much rejects any form of medical tourism – she made some excellent points in her interview.  In the discussion, she stressed the need for facility AND provider verification.  She also talked about the need for people to know specifics – and gives one of my favorite examples, “American trained”.

“American trained

As she points out in the interview, this is a loose term that can be applied (accurately) to a Stanford educated surgeon like Dr. Juan Pablo Umana in Bogotá  or in a more deceptive fashion to one of the many surgeons who have taken a short course, or attended a teaching conference within the United States. A three-day class doesn’t really equate, now does it?

The discussion (and the article) then turned to the need to ‘research’ providers.. Now, if only CBS news had talked to me..   That would have made for a more balanced, detailed and informative show for watchers/ readers.

(Telling people to ‘research’ their medical providers falls a bit short.  Showing people how – or providing them with resources would be more helpful.)

“Off-label medical travel”

In addition, the print article should have gone a bit further in discussing the pros and potential consequences/ harmful effects of traveling for ‘off-label’ treatments instead of merely quoting one patient.  Since the area of harm is actually far greater in this subsegment of the medical tourism population due to the amount of quackery as well as the sometimes fragile state of these potential patients  – a bit more discussion or even a separate segment on “off-label medical travel” would have been an excellent accompaniment.

Speaking of which, several weeks ago, I interviewed with NPR (National Public Radio) as part of a segment on medical tourism.  During that discussion we talked about all of the pluses and minuses mentioned on the CBS segment as well as the “Selling Hope” aspect of ‘off-label medical travel” and the potential harms of this practice, as well as some of the issues involved in transplant tourism.  I am not sure how much of my interview, Andrew Fishman, the producer for the segment, will use – or when it will air, but I’ll keep readers informed.

Start here…


This is a page re-post to help some of my new readers become familiarized with Latin American Surgery.com – who I am, and what the website is about..

As my long-time readers know, the site just keeps growing and growing.  Now that we have merged with one of our sister sites, it’s becoming more and more complicated for first time readers to find what they are looking for..

So, start here, for a brief map of the site.  Think of it as Cliff Notes for Latin American surgery. com

Who am I/ what do I do/ and who pays for it

Let’s get down to brass tacks as they say .. Who am I and why should you bother reading another word..

I believe in full disclosure, so here’s my CV.

I think it’s important that this includes financial disclosure. (I am self-funded).

I’m not famous, and that’s a good thing.

Of course, I also think readers should know why I have embarked on this endeavor, which has taken me to Mexico, Colombia, Chile, Bolivia and continues to fuel much of my life.

Reasons to write about medical tourism: a cautionary tale

I also write a bit about my daily life, so that you can get to know me, and because I love to write about everything I see and experience whether surgery-related or the joys of Bogotá on a Sunday afternoon.

What I do and what I write about

I interview doctors to learn more about them.

Some of this is for patient safety: (Is he/she really a doctor?  What training do they have?)

Much of it is professional curiosity/ interest: (Tell me more about this technique you pioneered? / Tell me more about how you get such fantastic results?  or just tell me more about what you do?)

Then I follow them to the operating room to make sure EVERYTHING is the way it is supposed to be.  Is the facility clean?  Does the equipment work?  Is there appropriate personnel?  Do the follow ‘standard operating procedure’ according to international regulations and standards for operating room safety, prevention of infection and  overall good patient care?

I talk about checklists – a lot..

The surgical apgar score

I look at the quality of anesthesia – and apply standardized measures to evaluate it.

Why quality of anesthesia matters

Are your doctors distracted?

Medical information

I also write about new technologies, and treatments as well as emerging research.  There is some patient education on common health conditions (primarily cardiothoracic and diabetes since that’s my background).  Sometimes I talk about the ethics of medicine as well.  I believe strongly in honesty, integrity and transparency and I think these are important values for anyone in healthcare.  I don’t interview or encourage transplant tourism because I think it is intrinsically morally and ethically wrong.  You don’t have to agree, but you won’t find information about how to find a black market kidney here on my site.

What about hospital scores, you ask.. Just look here – or in the quality measures section.

Cultural Content

I also write about the culture, cuisine and the people in the locations I visit.  These posts tend to be more informal, but I think it’s important for people to get to know these parts of Latin America too.  It’s not just the doctors and the hospitals – but a different city, country and culture than many of my readers are used to.

Why should you read this?  well, that’s up to you.. But mainly, because I want you to know that there is someone out there who is doing their best – little by little to try to look out for you.

How the site is organized

See the sidebar! Check the drop-down box.

Information about surgeons is divided into specialty and by location.  So you can look in plastic surgery, or you can jump to the country of interest.  Some of the listings are very brief – when I am working on a book – I just blog about who I saw and where I was, because the in-depth material is covered in the book.

information about countries can be found under country tabs including cultural posts.

Issues and discussions about the medical tourism industry, medical safety and quality are under quality measures

Topics of particular interest like HIPEC have their own section.

I’ve tried to cross-reference as much as possible to make information easy to find.

If you have suggestions, questions or comments, you are always welcome to contact me at k.eckland@gmail.com or by leaving a comment, but please, please – no hate mail or spam.  (Not sure which is worse.)

and yes – I type fast, and often when I am tired so sometimes you will find grammatical errors, typos and misspelled words (despite spell-check) but bear with me.  The information is still correct..

Thank you for coming.