Sun, sea and scalpels: Sinead Lay, Case Manager at Medical Protection, unpicks the complex issue of medical tourism, an area of medicine that has surged in popularity.

Over recent years, Ireland has seen a seismic growth in the popularity of medical tourism. Anxiety and fears that once surrounded patients about travelling abroad for surgery appear to have been overshadowed by the affordability, accessibility and broader treatment options available. The availability of inexpensive flights and increased online marketing for cosmetic surgery procedures including social media “before and after” reveals have made travelling abroad for treatment very alluring.

Originally, the term medical tourism referred to the travel of patients from less-developed countries to developed nations in pursuit of the treatments not available in their homeland. However, today we are experiencing shifts in patient mobility, as people travel from richer to less-developed countries in order to access health services. What really puts the word "tourism" into medical tourism concept is that people often stay in the foreign country after their medical procedure. Travellers can thus take advantage of their visit by sightseeing, taking day trips or participating in any other traditional tourism activities.

Treatment abroad scheme

Another attractive option for patients seeking surgery abroad is Ireland’s participation in the “treatment abroad scheme” (TAS) under the European Union Cross Border Directive. This scheme facilitates access to safe and high-quality cross border healthcare within Europe. The TAS covers the cost of planned treatment in another country in the European Union European Economic Area, United Kingdom or Switzerland. Patients must be referred for surgery abroad by a public hospital consultant. The TAS does not accept referrals from GPs or self-referrals. Additionally, the TAS does not cover a patient to have surgical or dental procedures carried out in Turkey.

Risks

All medical and surgical procedures carry some risk, and complications can occur regardless of where treatment is received. If a patient has informed you of their decision to travel abroad for surgery, they should be made aware of the additional risks associated with travelling while being treated for a medical condition or during recovery after surgery or other procedures. Patients should be made aware that air travel and surgery independently increase the risk of blood clots, including deep vein thrombosis and pulmonary emboli; travel and surgery together further increase the risks. Commercial aircraft cabin pressures are roughly equivalent to an outside air pressure at 6,000–8,000 ft. above sea level and it is advisable that patients should not fly for ten days after certain types of surgery, for example chest, abdominal or intraocular surgery, to avoid risks associated with changes in atmospheric pressure. You may wish to familiarise yourself with the Civil Aviation Authority’s guidance for health professionals, as this provides helpful information about the impacts of air travel on the human body and the potential risks for patients with comorbidity and after surgical procedures.

Possible infectious complications associated with medical procedures performed abroad include wound infections, bloodstream infections, donor-derived infections and acquisition of bloodborne pathogens, including hepatitis B, hepatitis C and HIV. The risk of acquiring antibiotic-resistant infections may be increased in certain countries or regions. Several outbreaks of infectious disease among medical tourists have been documented worldwide.

Non-infectious complications among medical tourists are similar to those seen in patients who receive medical care in Ireland and include surgical incision dehiscence, blood clots or contour abnormalities after cosmetic surgery.

What to do if your patient has told you they are seeking surgery abroad

• Ultimately it is a patient’s decision where they choose to have their surgery. However, it is advisable (especially from an aftercare perspective) that a discussion is had with your patient regarding the facility/ hospital they intend to have their surgery in. It is important to discuss any potential risks with the patient, as far as you are able within your area of competence. You should carefully document this conversation and be satisfied that the patient has performed adequate research. The RSCI has released a very helpful information leaflet for patients intending to travel abroad, which may be helpful to refer to during the conversation.
  
• Does the patient intend to use the TAS? And if so, do you need to make a referral to an appropriate specialist for assessment?
  
• Some medical or surgical procedures may require follow up care such as wound management and/or suture removal etc. You should encourage you patient to request a detailed written record of the procedure and an aftercare plan (in appropriate language) for any follow-up care that may be required.
  
• Complications following procedures may require specialist or emergency intervention and therefore you should refer patients accordingly.

Adverse events after surgery

Where there is an adverse event following surgery abroad, generally a doctor would not be criticised in circumstances where they had no involvement in the procedure and were not included in the decision-making process regarding the patient. However, doctors should be aware that they could be liable for any adverse event that arises as a result of aftercare they have provided to the patient. A doctor should not feel pressure to provide specific care to a patient where they consider that the issues at hand would be out of their area of competence. However, in such circumstances GPs should ensure that they refer the patient to a colleague, most likely in secondary care, who has the necessary skillset to see and assess the patient safely.  

In circumstances where there is, for example, a claim for compensation in respect of alleged clinical negligence, doctors will be better placed to defend their position in circumstances where they have carefully documented any justification for the decisions that they have taken in relation to the patient and clearly documented issues of consent, history, examination including evidence of a clear management plan including decisions regarding follow up care and their role regarding same. They will also be able to better defend their position if they can clearly demonstrate (generally by way of the records) that they have communicated clearly with their colleagues and have acted in line with their ethical obligations in relation to referral and handover. 

With more and more people willing to travel abroad for surgery, it is important that GPs understand that they do indeed play a significant role in the care of these patients. Maintaining an open line of communication with your patient and being informed as to the type of procedure your patient is receiving and any necessary aftercare required will ensure that your patients’ best interests are being met and that any potential events that may arise will be appropriately managed, thus aiding to mitigate any complaints or future potential litigations.