Cheryl Martin (Host): What are the dangers of traveling outside the United States to get surgery?

In this insightful episode, we dive deep into the controversial world of medical tourism. We learn all about it with Dr. Mustafa Aman, Chief of the Guthrie Comprehensive Weight Loss Center and Director of the Bariatric Surgery Program. This is Medical Minds, Conversation with Guthrie Experts, a podcast from the Guthrie Clinic.

I'm Cheryl Martin. Dr. Aman, thanks for being on to discuss this topic that at times makes the news headlines.

Mustafa Aman, M.D., F.A.C.S: Thank you so much for having me, Cheryl.

Host: So first, what are the potential risks of getting surgery abroad that patients should be aware of?

Mustafa Aman, M.D., F.A.C.S: Well, that's a great question. You know, it's really a timely one as well, as in this day and age, we're seeing an increasing number of folks traveling outside the United States for surgery. And really this is something we're talking about in terms of a large variety of surgeries, whether it's abdominal procedures, cosmetic procedures, reconstructive procedures.

And it's important that we are aware of some of the dangers of traveling outside the United States for surgery. The first and most obvious one is that being that far away from whomever your surgeon is, does present a concern about what happens after surgery if there are any problems or issues that arise; who will be the person responsible for monitoring, evaluating, diagnosing, and treating a patient during the postoperative period? So regardless of the type of surgery, that does present a challenge with regards to who is going to be taking care of these patients. What often ends up happening is the patient travels back home, they're in their home community where they live, and they go into their primary care physician or their urgent care or the to initiate a workup.

And oftentimes, there's no records of what was performed, who the surgeon was, which hospital, and so that can present a real challenge. The second thing that I would say is that, although there are certainly many, highly qualified surgeons all over the world, one of the benefits of surgical practice in the United States is that it is highly regulated.

And that's to the benefit of our patients. So, government bodies, regulatory agencies, state medical boards, third party payer, insurance panels. There's a whole host of layers of protection, if you will, to ensure that folks who are practicing surgery in this day and age in the United States meet very high safety and quality standards, that their outcomes are being monitored and reported, and that patients have clear and consistent standards, medical evidence based guidelines that are followed as part of their care, and that there is monitoring and follow up.

So, when a patient travels beyond the borders of the United States for this care, all of that kind of falls into a question mark of who's really monitoring, who's really assessing. And so, you know, we've seen patients who have had poor outcomes who have traveled elsewhere for surgery. And the level of quality and safety, and monitoring that's offered for the patients is not the same as it is in the United States.

Host: I'm glad you brought this up because it segues into my question, if you can delve a little bit more on how does the standard of care in other countries compare to that here in the U.S.?

Mustafa Aman, M.D., F.A.C.S: It really varies by surgical specialty as well. For example, abdominal surgery versus plastic surgery, cosmetic surgery, reconstructive surgery, orthopedic surgery, urology, procedures. So in the United States, regulatory agencies, and state medical boards and surgical specialty societies are really responsible for ensuring that doctors, health care systems, surgeons, you know, are providing the highest level of care. Whereas in other health systems outside of the United States, oftentimes there's really no close monitoring, or if there is, it's, it may not be as well organized as it is in the United States.

And the evidence based guidelines that are followed may not be the same as what it is in the United States. I think for a patient who lives in the United States and you're traveling abroad for surgical care, there really is a potential danger that you're kind of going into uncharted waters.

It's not to say that other doctors, surgeons, outside the United States are not qualified or that they don't offer good care. But there is an inherent unknown there. I think it's important to recognize that within the United States, being that surgery is a highly regulated surgical specialty, that really is to the benefit of our patients.

Whereas the standards of care and the practice patterns and the recommendations offered by physicians and surgeons outside the United States may be very different from what is offered in the United States.

Host: Do you want to talk about specific countries where the risk of surgical complications is particularly high, more so than other places? And if so, why?

Mustafa Aman, M.D., F.A.C.S: So I wouldn't say as a specific country where the risk is high, but I would say that where the standards of care are very different. So, for example, being you know, a highly developed country in the United States, the availability of technology, the availability of the cutting edge research, the availability of the best medications, all of these things combined; really offer our patients tremendous advantages to be able to have really good outcomes with surgery. You know, whereas in other parts of the world, those things are not available. So, for example, I have colleagues who have traveled on medical mission trips to countries in Africa or countries in Asia.

Even things that are considered very routine standard surgery in the United States such as having your gallbladder removed laparoscopically or having a hysterectomy performed laparoscopically; those things, oftentimes, in many parts of the world, there are no, facilities that can perform those procedures because they don't have the equipment.

Or if they do have the equipment, they don't have the training. I know, for example, of surgeons who have come from Africa to the United States to learn laparoscopic surgery and then take that skill set home and work with organizations that provide, you know, equipment so that they can perform those procedures.

So, patients often take for granted, the availability of the highest quality care as well as, the technology, medication, infrastructure, staff, health systems to deliver that care here in the United States. And that's often not available outside of the United States.

Another example is robotic surgery. So, for example, robotic surgery has really accelerated in growth over the last several years. There are many parts of the world where robotic surgery is not offered at all. Because it's not available. Advanced endoscopic procedures, the latest techniques, you know, in surgery are often pioneered at cutting edge research hospitals, academic medical centers in the United States.

I want to reiterate here, Cheryl, that there are highly qualified surgeons all over the world. You know, I don't aim to disparage or speak ill of any particular surgeon or health system or institution, but I do think it's worth making sure that our listeners are aware that you really are going into uncharted waters there, and I think, patients need to be aware of that environment that they're going into, because it may be very, very different than what they're accustomed to in the United States.

Host: Have you found that the number one reason patients consider going abroad is economics, the cost there versus here? And if so, what do you say to them?

Mustafa Aman, M.D., F.A.C.S: Oh, absolutely. That's by far the most common reason, and you know, I can't tell you how many patients that I have seen over the years who have traveled abroad to save in cost for the surgery, and regrettably, I've seen far too many cases, far too many cases where, you know, the patients have come to regret that if things did not go as planned, or if there was a problem after surgery, oftentimes patients were kind of left on their own to figure out what to do. And, when coming back home, it's often very difficult for physicians involved in their care to try to piece together what happened.

Oftentimes, records may not be available, or the documentation is not consistent with the standards in the United States. And oftentimes the patients really pay a price for it and wish that they hadn't done so. It's not to say that there are not plenty of patients who've had great outcomes as well, but, I think if more people were aware of the inherent danger with that, most of the time, they find that it wasn't worth the cost saving.

Host: You talked about some who come with their records and they come for help. So what are the challenges and continuity of care for patients who choose to get surgery abroad? Let's say they come with the paperwork.

Mustafa Aman, M.D., F.A.C.S: There's certainly a challenge in continuity care because they're no longer connected to the facility or the practice of the surgeon who performed their procedure. So, in many cases what happens in establishments that perform these medical tourism types of surgeries is that the patient will travel, they'll have their surgery date in advance, they might have had a virtual consultation with the surgeon ahead of time, or, perhaps when they arrive there, and then they'll have the surgery and then they'll typically stay in town for two or three nights, you know, maybe in a hotel, short stay, something like that, and then come back home, fly back home.

The problem with that is, as any surgeon will tell you, the period of monitoring after surgery for any potential problems or complications, extends far beyond those first few days after surgery. And what happens oftentimes with these patients in that period of time is if they run into any trouble, and now they're back stateside, they have to figure out on their own what they're going to do. So they usually end up going to the closest emergency department and have a difficult time articulating what exactly was performed. There's no medical records that are available to see what was performed.

No records available of their medication, things like that. It's actually very rare in my experience I share that a patient would actually have all their records with them or have part of their records with them. Most of the time they have an idea what, they know what surgery they had, but they don't have their records with them.

And so taking that, the time to try to get the records from an international facility, in a different country is very difficult and time consuming and oftentimes, the patients will then have additional testing performed at home, to try to quickly get to the diagnosis and treatment.

And in some cases, you know, unfortunately I've seen patients who've suffered for a long time afterwards trying to recuperate, uh, from, you know, a problem or a complication they've had after surgery. And I've also seen, in some cases where patients actually had a life threatening problem that required emergency surgery to address or take care of.

So, certainly the challenges with regards to not having all of the records in a timely fashion upon presentation to their local physician or emergency department significant.

Host: How does medical malpractice law differ internationally and how can this impact patients who undergo surgery abroad?

Mustafa Aman, M.D., F.A.C.S: That's a great question. In the United States, there are a number of laws, you know, in every state, in every jurisdiction, with regards to medical malpractice and standards of medical malpractice. In many parts of the world, there are no medical malpractice laws.

In fact, in many parts of the world, it's very uncommon for any kind of medical malpractice cases to be carried forward, in events where unfortunate incidents have occurred. In some countries where there are such laws, there may not be adequate resources for the patient, in terms of seeking legal counsel or other types of recourse.

I think from a professionalism standpoint with regards to standards of practice for physicians who are practicing; the regulatory bodies that oversee medical practice often don't have the same level of oversight as we do in the United States. So those are certainly, concerning findings.

Host: Now, when it comes to receiving surgery at Guthrie, what sets it apart from these other places outside the United States?

Mustafa Aman, M.D., F.A.C.S: Guthrie has a long standing history of devotion to patients and serving our community. We are an institution that has been present over a hundred years. We are a large multidisciplinary health network, with several hospitals, regional clinics, regional sites. We try to offer our patients the highest quality care.

We really feel passionate about ensuring that patients who come to our facilities receive care in a timely fashion, in a compassionate manner, and that we offer them the latest technology, highest quality standards of medical practice. When I think about our institution, and my colleagues and the physicians that I know who practice here; I think everybody really tries to put the patient front and center of every decision that we make. Whether it's a decision we're making in the office, or in the emergency department or in the hospital ward, in any clinical care setting; we try to really put the patient front and center and try to do what's best for the patient.

Host: That's great. Anything else you'd like to add on this topic, Doctor?

Mustafa Aman, M.D., F.A.C.S: Well you know, I would just add for any listeners who are considering medical tourism, it's worthwhile having a conversation with your local physician about risks and benefits of surgery, and making sure that you're fully informed and prepared. We certainly caution folks from traveling overseas for especially surgical procedures and then returning back home.

I think, as we've discussed, there's some dangers with that, and just making sure that you're well informed and you're prepared and you do a lot of research, if you really choose to go that route.

Host: Well said. Dr. Mustafa Aman, thanks so much for this very frank dialogue on the risks and benefits of traveling outside the U.S. to get surgery.

Mustafa Aman, M.D., F.A.C.S: Thank you so much for having me, Cheryl.

Host: To learn more, just go online to guthrieweightlosscenter.org. That's guthrieweightlosscenter.org. If you found this podcast helpful, please share it on your social media. This is Medical Minds, Conversation with Guthrie Experts, a podcast from the Guthrie Clinic. Thanks for listening.