The Eckland Effect


It’s been a while since I’ve written – but sometimes between maintaining two blogs, a series on health for Examiner.com, answering emails from potential medical tourists, traveling and working long hours on assignment – I sometimes feel a bit like a candle burning at both ends.

But I am happy to report – that I recently completed my latest assignment and am back home in my native Virginia (for a few days) before heading back to Colombia.

I’ll spend the next couple days getting ready; contacting potential interviewees, researching articles,

Colombia flag

The downside of frequent extended travel is the piling up of all the inevitable errands and hassles.  Sometimes its just stuff like sorting through a couple of months of mail, but other times it’s paying property taxes (in person because I live in a small town) or renewing my driver’s license (now good until 2022!)

But now that we’re all caught up – we can get back to work (and writing!)

The Profiteer Model

Several interesting articles and posts have been written about medical tourism lately. We will talk about some of the other issues in future posts but today, I wanted to share this article by Stacy Hsu from the Tampai Times.  This article takes issue with the “Profiteer’ model of many so-called “Medical Tourism” hospitals and clinics.

VIP Medicine

As we’ve mentioned in previous posts, the idea of exclusive hospitals designed solely for the wealthy foreigner is both a noxious and popular one.  To many people, the idea of a resort-like or decadent atmosphere that caters to the every whim of the monied tourist or “Club Medicine” is a charmed one. VIP/ Executive health programs thrive around the world – from the hallowed halls of academic medicine like  John Hopkins, the Cleveland Clinic to the Planet Hospital branded facilities around the world.

Much of the medical tourism industry has been based on this context.  Programs are advertised on the basis of desirable location, gourmet cuisine menus, luxurious accommodations and nightly turn down service; not surgical skill or publishable clinical outcomes.  No one hypes a short-length of stay or low re-admission rate when catered meals, high-speed internet and cable television are part of the selling points.

money pills

VIP versus Concierge: Not entirely the same

Don’t want to travel?  But want your health care needs catered to?  There are whole branches of primary care practices (ie. the “Royal Pains” practices) that are now based on this principle.  On the surface, it doesn’t sound like much – patients pay extra money to have their doctor actually give them the time and attention they deserve* (during visits, phone calls and emails) but in reality, it can very quickly turn into something else as this ‘bonus’ pay approach changes the patient – provider relationship.

But “concierge medicine” as it is called in primary care medicine is a far cry from the VIP and Executive programs offered as part of medical tourism programs.  In concierge medicine, patients still have a long-term and established relationship with their physician – and it is this relationship that can actually improve health care outcomes along with patient satisfaction.  That’s because having more time with your family doctor means that s/he will spend more time answering questions and explaining care to patients. In turn, the patient is more likely to fill their prescriptions, take their medications and otherwise follow this doctor’s instructions.

*Instead of delegating more personalized care to people like me; the nurse practitioner (NP) or physician assistant (PA) which is more commonly done in standard medical offices.

But is ego-tickling medicine good for your health? 

According to the scant amount of existing research, the answer is often no, when we are talking about short-term patient-provider relationships like the one-day executive physical or the spa style surgery service.  In fact, patients often receive unnecessary and even potentially harmful, expensive tests and procedures (like the famed “Full body CT”).

I liken it to “The emperor’s new clothes” syndrome, where the patient is seen more as a consumer / purchaser of goods than a person seeking health services.  In this scenario, the healthcare provider is more concerned with keeping the customer satisfied than explaining why many of these tests and procedures are not necessary or may even be harmful.

Remember: First do no harm!

The customer is always right!

These contradictory objectives may become a conflict when the needed health advice isn’t what the patient wants to hear*.

Not even the humble fools dare tell the emperor the truth.

Not even the humble fools dare tell the emperor the truth.

The ‘Eckland Effect’

But it looks like this may be changing.  Several new research projects as well as recent articles are showing a move towards data collection and measurement of objective outcomes in regards to medical tourism.  Instead of patient satisfaction surveys, researchers are asking about the incidence of complications.

Other organizations are talking about implementing more accountability, transparency and formal accreditation for medical tourism programs and facilities.  Of course, accreditation is only as valuable as the organization offering it.

*Certainly this dynamic was at play in the care and death of pop star Michael Jackson under the care of Dr. Conrad Murray.

Additional articles for interested readers:

Al-Lamki, L. (2011).  Medical Tourism: Beneficence or maleficence? SQU Med J Nov 2011, 11(4): 444-447.  This is an excellent editorial that offers a concise overview of many of the ethical issues we have discussed here at Latin American Surgery including brain drain, transplant tourism, quality assurance, continuity-of-care and the overall impact of medical tourism on local communities.

In a related article, ” A European perspective on medical tourism: the need for a knowledge base” Carrera & Lunt (2010) argued for the urgent need for record-keeping  and statistical data collection in the medical tourism industry.  While this article is not available for free on-line, a related presentation by the authors is available here.

For readers interested in learning more about the correlation between patient satisfaction and clinical outcomes, I encourage you to read the works of JJ Fenton.

Fenton JJ, Jerant AF, Bertakis KD, Franks P. (2012).  The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality.  Arch Intern Med. 2012 Mar 12;172(5):405-11. doi: 10.1001/archinternmed.2011.1662. Epub 2012 Feb 13.  This study in particular is a must read:  in this study, Fenton et al. followed a group of more than 36,000 patients and found that high patient satisfaction was correlated with increased health costs, greater rates of inpatient admissions to the hospital and a higher overall mortality.  Fenton et al have also conducted several additional studies examining the relationship between patient satisfaction and quality of care.  The findings of these study question the utility of new programs linking patient satisfaction with provider compensation (ie. pay-for-performance) and question the commonly held beliefs that patient satisfaction = high quality care.  It may be that the best care comes at a price:  unhappy patients.  But then again, isn’t not a popularity contest – or at least, it shouldn’t be.

Medscape subscribers can also view a series of articles on this topic including an inteview with Dr. Fenton on his body of work.  Medscape has a series of articles examining both sides of the argument linking patient satisfaction with provider compensation.

Patient satisfaction is overrated – an excellent editorial about the cost to patients (in health and money) related to demands for ‘patient satisfaction”.

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.

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.

the ethical, moral and health hazards of transplant tourism


Re-visiting one of our classic posts on the ethics of transplant tourism – or ‘organs for sale/ steal’

Colombian Culture & Cuisine

Now that’s a mighty long title – for a very small section of medical tourism, which alternates in generating world-wide headlines and being swept quietly under the rug.

Bathtub full of ice

Everyone has heard ‘urban folklore’ regarding the unwary/ drunken/ duped young man who goes looking for sex, and wakes up in a bathtub full of ice.. Conventional wisdom is that these tales serve as a modern-day fairy tale with an underlying moral message.  In this case – cautioning young people against the vices of alcohol/ drugs and anonymous/ promiscuous sex..  If only the truth were really just such a cautionary tale. But, as readers know, the truth is considerably darker – involving the exploitation and even outright murder of citizens around the world to feed the organ trade.

(For the first-person account from a Chinese doctor involved in organ harvesting, click here. )

“Transplant Tourism”

This…

View original post 433 more words

Dr. Ivan Santos

Just another reason for Latinamericansurgery.com


Dr. Ivan Santos

Colombian plastic surgeons operating

because you need someone who is objective (and informed) that is looking out for you, the patient..

In this article, at International Journal of Medical Travel, Kevin Pollard talks about the need for regulation of medical tourism in cosmetic surgery.  I wholeheartedly agree – in fact, Mr. Pollard and I conversed about this very topic in a series of emails last week.

After all – it is why I do what I do, and publish it here for my readers.  The industry does need to be regulated – medical tourism companies shouldn’t pick providers by “lowest bidder” and patients need to be protected (from unsanitary conditions, bad surgeons, and poor care).  But what form will this regulation take?

Will it be Joint Commission certification – which covers facilities and not the physicians (and their surgical practices themselves)?

Will it require facilities to pay a lot of money for a shiny badge?

Or will it be someone like me, low-key and independent, going into facilities at the behest of patients; interviewing surgeons and actually observing the process and talking to patients?

and who pays for this?  The beauty of what I do – is that I am independently (read: self) funded.  True, it hurts my wallet but I have no divided loyalties or outside interests in doing anything but reporting the unvarnished truth.

and ultimately – will this be done in a fair, open and honest way?  Or it is really a witch hunt led by disgruntled American and British plastic surgeons?  Will they bother to discriminate between excellent surgeons and incompetent ones who will it be by geography alone?

I guess we will just have to wait and see.

Sanabria, breast implant

Colombian plastic surgeons answer back


Chairman of International Society of Aesthetic Plastic Surgery questions the ethics of medical tourism, Colombia responds.

Colombia is now 11th in the world for plastic surgeries by volume according to the International Society of Aesthetic Plastic Surgery (ISAPS) but that may change if Dr. Igor Niechajev, Chair of the Government Relations Committee of that same organization gets his way.  ISAPS, who ranked Colombia among the top 25 countries for plastic surgery also printed an article by Niechajev in the spring edition of its newsletter condemning medical tourism.

Chairman discourages medical tourism, stating that medical tourists are victims of inferior care

The strongly-voiced piece accused surgeons outside of European and North America of providing inferior medical care, inadequate pre-operative evaluations and operating in substandard facilities.

States bad outcomes wouldn’t happen at home

In his editorial, Dr. Niechajev provides anecdotal evidence of a botched procedure that occurred in Asia, and stated that “such a tragic outcome” of [procedure cited] “is highly unlikely had the patient not been a medical tourist.”  Dr. Niechajev cites these concerns, not as a surgeon losing business to his competitors but states that he is concerned about the costs of caring for patients with possible complications once they return home.

Not limited to national borders

His concerns don’t stop at national borders, Dr. Niechajev also suggests that surgeons limit themselves to their immediate local vicinity.  What this may mean for a rural patient requiring extensive reconstructive surgeon is not addressed by Dr. Niechajev.

 Statements based on limited data

He bases the majority of his opinions on the shoulders of Dr. Ritz, the Australian National Secretary for Health, who cites one specific incident as the trigger for changing Australian legislature to prohibit this practice.  Additional evidentiary support of gross episodes or a mass epidemic of malpractice by international surgeons appears to be limited to 11 cases in the United Kingdom.  No other data was cited.

International Society debating the issue; Niechajev recommends financial sanctions against patients

These concerns have the officers of ISAPS considering changing the code of ethics of the organization to discourage the practice of medical tourism by its member surgeons.  However, Dr. Niechavej does not seem content to stop there, instead he advocates for governmental announcements advising the public about “increased risks associated with medical tourism” and that “surgery overseas practically means that they [patients] are giving up all their rights.”  He also advocates for financial penalties for patients who experience post-operative complications after surgery overseas, stating, “No preventative measure is as effective as hitting someone’s purse.”

 Colombian plastic surgeons respond

In an exclusive interview with the President of the Colombian Society of Plastic Surgery, he answered many of the allegations by Dr. Niechajev.

Regarding Dr. Igor Niechevaj’s statements on the lack of regulations and substandard facilities in countries that are popular medical tourism destinations, the President of the Colombian Society of Plastic, Esthetic and Reconstructive Surgery, Dr. Carlos Enrique Hoyos Salazar replied that, “All facilities, and hospitals in Colombia are regulated by the Ministry of Health. There are minimum standards that must be met.  Any facilities that are interested in participating in the medical tourism business have additional standards and qualifications for certification by national agencies.  Anesthesiologists, and medical doctors are required to have additional training to perform pre-operative evaluations for International plastic surgery patients”.

 Reports safety and patient protections for medical tourists

He refutes claims that patients receive minimal post-operative care before returning home. In addition to medical advice from Colombian physicians, he cites agreements with Colombian and international airlines to encourage international patients to stay a minimum of 15 days after their surgical procedures to ensure optimal recovery.

Additionally, several plastic surgeons specializing in medical tourism and medical tourism companies offer ‘complication policies’ to pay for any expenses a medical tourist may incur in both the destination and home country should they develop complications post-operatively.  In fact, an advertisement for one of these policies shares space with Dr. Niechevaj’s article.  These policies effectively negate one of Dr. Niechevaj’s (and Dr. Ritz’s) strongest arguments, that medical tourism incurs costs in the home country when patients develop post-operative infections or other problems after returning home.

ISAPS Chairman defending his own wallet?

When asked about Dr. Niechevaj’s position on medical tourism and possible changes to the ISAPS code of ethics, Dr. Hoyos stated, “This is not right.  This has nothing to do with the quality of surgery in Colombia and other countries.  This is about the expensive costs of surgery in Europe and the United States.  If a surgery costs $6,000 (USD) over there and only $3,000 – $3,500 in Colombia, then those doctors are losing money due to medical tourism.”

Good and Bad is a global phenomenon

As we’ve pointed out here on our site (and related work) – good and bad surgical outcomes are certainly not limited by geography, and Dr. Niechajev certainly seems to paint the rest of the world with a wide brush with his call to action.

A more reasonable, and fair response would be continue to encourage work such as mine – using outside, independent and unbiased observers to evaluate surgeons wishing to participate in medical tourism.

In an ideal world, companies such as Blue Cross/ Blue Shield who wish to broaden their international physician base would hire independent medical professionals to review surgeons who wished to be included under their health plan.  This way both consumers and third-party payers would have more information before patients went ‘under the knife’ so to speak.

Patients wouldn’t be shuttled to surgeons who submit the lowest bid (to insurance companies, and private parties) but to surgeons whose qualifications had been authenticated.  All parties would know about the quality of hospital facilities, anesthesia, pre-operative evaluation and post-operative care.

Doing my part

Readers know that I do what I can, in a very small way, to add to the body of knowledge about the quality and care of patients who receive treatment from the surgeons who consent to let me observe, evaluate and report my findings.

Now we just need this on a large-scale, multi-national level.

The cardiac OR


If you’ve never been to the cardiac operating room – it’s a completely different world, and not what most people expect.  For starters, unlike many areas of health care (particularly in the USA), the cardiac operating room is usually very well staffed.

 OR

Just a few of the people working in the OR. (photo edited to preserve patient privacy)

For example, there were eight people working in the operating room today:

Dr. Luis Fernando Meza, cardiac surgeon

Dr. Bernando Leon Urequi O., cardiac surgeon

Dra. Elaine Suarez Gomez, cardiac anesthesiologist

Dr. Suarez observes her patient during surgery. (photo edited to preserve patient's privacy)

Dr. Suarez observes her patient during surgery. (photo edited to preserve patient’s privacy)

Ms. Catherine Cardona, “Jefe”/ Nurse who supervises the operating room

Ms. Diana Isobel Lopez,  Perfusionist (In Colombia, all perfusionists have an undergraduate degree in nursing, before obtaining a postgraduate degree in Perfusion).  The perfusionist is the person who ‘runs’ the cardiac bypass machine.

Ms. Laura Garcia, Instrumentadora (First Assist)

Angel, circulating nurse

Olga, another instrumentadora, who is training to work in the cardiac OR.

This is fairly typical for most institutions.

Secondly – it’s always a regimented, and checklist kind of place.  (I wish I could say that about every operating room – but it just wouldn’t be true.)  But cardiac ORs (without exception) always follow a very strict set of accounting procedures..

For starters – there are labels.. For the patient (arm bands), for the equipment (medications, blood products etc..)  even the room is labeled.

Sign on operating room door (edited for patient privacy)

Sign on operating room door (edited for patient privacy)

Then come the checklists..

Perfusionist Diana Lopez gathers information to begin her pre-operative checklist.

Perfusionist Diana Lopez gathers information to begin her pre-operative checklist.

The general (WHO) operating room checklist.  The perfusionist’s checklist.. The anesthesiologist’s checklist.. and the big white cardiac checklist.

by then end of the case, this board will be full..

by the end of the case, this board will be full..

The staff attempts to anticipate every possible need and have it on hand ahead of time.  Whether it’s nitric oxide, blood, defibrillation equipment, or special medications – it’s already stocked and ready before the patient is ever wheeled in.

Most of these things are universal:

such as the principles of asepsis (preventing infection), patient safety and preventing intra-operative errors – no matter what hospital or country you are visiting (and when it comes to surgery – that’s the way it should be.)

Today was no exception..

In health care, we talk about “OR people” and “ER people”.. ER people are the MacGyvers of the world – people who thrive on adrenaline, excitement and the unexpected.  They are at their best when a tractor-trailer skids into a gas station, ignites and sets of a five-alarm fire that decimates a kindergarden, sending screaming children racing into the streets.. And God love them for having that talent..

But the OR.. that’s my personal area of tranquility.

This orderly, prepared environments is one of the reasons I love what I do.. (I am not a screaming, “by the seat-of-your-pants”/ ‘skin of your teeth’ kind of gal).  I don’t want to encounter surprises when it comes to my patient’s health – and I never ever want to be caught unprepared.   That’s not to say that I can’t handle an emergent cardiac patient crashing in the cath lab – it just means I’ve considered the scenarios before, (and have a couple of tricks up my sleeve) to make sure my patient is well taken care of (and expedite the process).

That logical, critical-thinking component of my personality is one of the reasons I am able to provide valuable and objective information when visiting hospitals and surgeons like Dr.  Urequi’s and Dr. Meza’s operating room at Hospital General de Medellin.

In OR #1 – cardiothoracic suite

As I mentioned in a previous post on Hospital General de Medellin, operating room suite #1 has been designated for cardiac and thoracic surgeries.  This works out well since the operating room itself, is modern and spacious (which is important because of the area needed when adding specialized cardiac surgery equipment like the CPB pump (aka heart-lung machine).  There are muliple monitors, which is important for the video-assisted thoracoscopy (VATS) thoracic cases but also helpful for the cardiac cases.  The surgeon is able to project the case as he’s performing it on a spare monitor, which allows everyone involved to see what’s going on during the case (and anticipate what he will need next) without shouting or crowding the operating room table.

Coordinating care by watching surgery

For instance, if the circulator looks up at the monitor and sees he is finishing (the bypasses for example), she can make sure both the instrumentadora and the anesthesiologist have the paddles and cables ready to gently defibrillate the heart if it needs a little ‘jump start’ back into normal rhythm..or collect lab samples, or double check medications, blood products or whatever else is needed at specific points during the surgery.

More on today’s case in our next post.

Why quality of anesthesia matters: who is administering your anesthesia?


I know some readers find some of my reporting dry and uninspired, particularly when talking about methodology, measurements and scales such as Surgical Apgar Scoring.  But the use of appropriate protocols, safety procedures and specialized personnel is crucial for continued patient safety.

There is a saying among medical professionals about our patients.. We want them all to be boring and routine.   That is what I strive for, for each and every one of my readers – safe, boring and routine.

Excitement and drama are only enjoyable when watching Grey’s Anatomy or other fictionalized medical dramas.  In real life, it means something has drastically and horribly gone awry.  Unlike many of its fictional counterparts – outcomes are not usually good.

this patient is in trouble.. But at least someone is watching the monitor.. (and there is a monitor)..

this patient is in trouble.. But at least someone is watching the monitor.. (and there is a monitor)..

In a not-so-sleepy hollow of upstate New York, a medical tragedy serves to illustrate this point, while also bringing up questions regarding the procedure.  While we don’t know the circumstances behind this case – (and don’t really want to speculate on this specific case), it does open the discussion on the quality of anesthesia and anesthesia-monitoring for non-general anesthesia procedures.  This includes procedures using sedative-hypnotics, epidurals and anesthetic combinations.  This is often referred to as “twilight” or “conscious sedation” procedures.

People tend to think of these procedures as being entirely safe – whether it is so-called “sleep dentistry’ or any variety of scope procedures (endoscopy, colonscopy, bronchoscopy).  In fact, many of these procedures are often done in out-patient settings; dentists’ and doctors’ offices without the services of an anesthesiologist or CRNA (nurse anesthetist) and/or appropriate monitoring.

This is extremely  troubling – especially since a slew of research papers over the years have clearly demonstrated that this is not safe.  In an eye-opening paper published several years ago, over 70% of non-anesthesia trained physicians underestimated the patient’s level of sedation during gastroenterology procedures.  (While I can not find a copy of this article online – its publication led to changes in the recommendations related to administration of anesthesia by non-anesthesia providers).

In an notable survey published on dental anesthesia, 35% of respondents providing anesthesia during dental procedures had no formal training in anesthesia.

Too often, the medical professionals (non-anesthesia specialty) underestimate the level of anesthesia achieved and critical safeguards to prevent potential patient injury are not taken.  One weekend course, or online continuing education course is not sufficient training.

In the case cited above, a young woman underwent an endoscopy procedure.  During this procedure – the patient became hypotensive (low blood pressure) and hypoxic (oxygen-starved) resulting in severe brain damage and disability.  The patient is now unable to see, or speak.  This devastating outcome is a clear example of the risks during these types of procedures due to anesthesia.

While the  details of the case above differ (patient was in a hospital) the family is now suing claiming that the patient did not receive prompt medical attention when these events occurred.

Unconscious, overmedicated and unmonitored in the office: Recipe for disaster

More concerning in my view, is for all of those patients undergoing these very procedures outside of hospital facilities – away from trained experts.  In many cases, the office patients are given medications without any continuous monitoring devices such as continuous telemetry and oxymetry (which detect low blood pressure and hypoxia immediately) versus ‘spot-check’ methods that office staff may employ.

For example; several years ago, one of my good friends worked as a nurse in a gastroenterologists office.  While she was a well-trained and excellent nurse – she was not a trained anesthesia provider – nor was she provided with the adequate equipment to monitor or treat anesthesia complications.

What equipment, you ask?  The office had no cardiac monitoring – (hemodynamic monitoring).  There were no reversal agents available in case of oversedation, no supplemental oxygen for respiratory depression/ hypoxia – and most critically – no crash cart in case of cardiac or respiratory arrest. (While the law requires this in some states, that doesn’t  guarantee that the provider has the appropriate equipment.)

In the office where my friend worked, the nurse administered a set amount of sedation under the guidance of the gastroenterologist.  During the procedure, vital signs were checked every 15 minutes (giving the patient 14 minute intervals to develop serious procedures unnoticed by anyone).

Was this the right or safe way to care for patients?  No, absolutely not – but it remains a common practice in doctors’ offices around the country.

The death of Michael Jackson

Another more extreme but famous example of the dangers of ‘unmonitored anesthesia’ is the death of Michael Jackson during the administration of propofol by a Dr. Conrad Murray in Mr. Jackson’s home.  During the investigation, it was noted that not only was the patient (Michael Jackson) without continuous hemodynamic monitoring (and oxymetry) – he was left unattended for significant periods while Dr. Murray conducted business and placed numerous telephone calls.  While this is an extreme example – it also demonstrates the dangers of anesthesia administration without qualified personnel, appropriate monitoring or rescue equipment.

In 2009 Metzer et. al. reviewed all liability claims and summarized this along with their previous research regarding related anesthesia injury and concluded, “Data from the American Society of Anesthesiologists, Closed Claims database suggest that anesthesia at remote locations poses a significant risk for the patient, particularly related to oversedation and inadequate oxygenation/ventilation during monitored anesthesia care.”

If you are planning to have any sort of procedure requiring any sedation or anesthesia (other than local anesthesia like lidocaine), ask the following questions:

– Who will be administering my anesthesia/ sedation?  What are their credentials and training in anesthesia?

– How will I be monitored during this procedure?  Who will be monitoring me?  What type of safety protocols are in place for peri-procedural monitoring?

– What if there is a problem?  Do you have the equipment necessary to reverse sedation?  perform urgent intubation?  resuscitation?

If this procedure is being performed in a doctor’s office or outpatient surgery center: – What happens if a complication develops during this procedure?  Is there a hospital nearby for emergencies?

References / Resources

Boynes SG, Moore PA, Tan PM Jr, Zovko J. (2010).  Practice characteristics among dental anesthesia providers in the United States.  Anesth Prog. 2010 Summer;57(2):52-8. doi: 10.2344/0003-3006-57.2.52.  (free full text – linked in article above).

Cheney FW, Posner KL, Lee LA, Caplan RA, Domino KB. (2006).  Trends in anesthesia-related death and brain damage: A closed claims analysis.  Anesthesiology. 2006 Dec;105(6):1081-6.   (full text available).  This study clearly showed the benefit of continuous pulse oxymetry and other hemodynamic monitoring to prevent catastrophic complications.

Cohen, L. & Aisenburg, J. (2008).  Endoscopic sedation: Preparing for the future.  Gastrointestinal endoscopy clinics of north America; 18(4).

Hangsheng Liu, PhD;  Daniel A. Waxman, MD;  Regan Main,                                  Soeren Mattke, MD, DSc (2012).  Endoscopies and Colonoscopies and Associated Spending in 2003-2009.  JAMA. 2012;307(11):1178-1184. doi:10.1001/jama.2012.270   The authors attempt to estimate the frequency in which qualified anesthesia providers are used during gastroendoscopy procedures.

Metzner J, Posner KL, Domino KB (2009). The risk and safety of anesthesia at remote locations: the US closed claims analysis.  Curr Opin Anaesthesiol. 2009 Aug;22(4):502-8. doi: 10.1097/ACO.0b013e32832dba50.

Paspatis GA, Tribonias G, Paraskeva K.  (2010).  Level of intended sedation.  Digestion. 2010;82(2):84-6. doi: 10.1159/000285504. Epub 2010 Apr 21.  Article discussing the issues regarding sedation during endoscopy procedures.

Robbertze R, Posner KL, Domino KB. (2006). Closed claims review of anesthesia for procedures outside the operating room.  Curr Opin Anaesthesiol. 2006 Aug;19(4):436-42. Review.

Catastrophic surgical mistakes – and bold red headlines…


Many of you may have seen the bold red headlines for the weekend edition of USA Today, which screams, “What surgeons leave behind.”   If you haven’t read it, this article by Mr. Eisler makes for riveting reading on one of surgery’s most catastrophic mistakes.

(The other catastrophic surgical mistake is a topic we’ve covered before, Wrong-site surgery (wrong side, etc.)  Readers will remember the previous stories about an American neurosurgeon who was found to have performed wrong-sided surgery, on not just one – but several patients.  Readers will also recall that said surgeon has a habit of moving from state to state as each medical board catches up to her*.

The How and Why of Retained Surgical Items is our own contribution to the topic – over at Examiner.com, where we review much of the information regarding retained surgical items or forgotten foreign bodies including risk factors for this phenomenon, and how current practices may actually inhibit efforts to prevent this from occurring.

surgeon clip art

* This surgeon was previously mentioned by name in both my posts, and several news stories about her numerous medical/ surgical errors.. Of course – disclosing her name on this site led to multiple threats of legal action – quite the  long story, for new readers.

the ethical, moral and health hazards of transplant tourism


Now that’s a mighty long title – for a very small section of medical tourism, which alternates in generating world-wide headlines and being swept quietly under the rug.

Bathtub full of ice

Everyone has heard ‘urban folklore’ regarding the unwary/ drunken/ duped young man who goes looking for sex, and wakes up in a bathtub full of ice.. Conventional wisdom is that these tales serve as a modern-day fairy tale with an underlying moral message.  In this case – cautioning young people against the vices of alcohol/ drugs and anonymous/ promiscuous sex..  If only the truth were really just such a cautionary tale. But, as readers know, the truth is considerably darker – involving the exploitation and even outright murder of citizens around the world to feed the organ trade.

(For the first-person account from a Chinese doctor involved in organ harvesting, click here. )

“Transplant Tourism”

This division of medical tourism, “Transplant tourism“,  is the sanitized term for organ selling, or diversion of transplantable organs to wealthy consumers (outside of the formal donor networks like UNOS).

Transplant tourism/ murder for organs is making headlines again this week as Taiwanese legislators try to ban the practice among their citizens and residents.  The Taiwanese lawmakers are trying to prevent the practice of wealthy patients (and companies making money from the sale of organs/ transplantation) using China as a ‘spare parts’ playground.

As widely reported over the last several years – China has become notorious for widespread ethical violations, including the murder (execution) of political prisoners for organ sales and transplantation to wealthy buyers.  Many of these political prisoners are people accused of such crimes as the practice of the religion, Falun Gong, or for expressing ideas that challenge the traditional Chinese culture or current government practices.

Not illegal in the United States

Unfortunately, despite multiple scientific, medical, governmental papers and sporadic media coverage of this issue – it is not illegal for Americans to engage in this practice, nor for American companies to offer transplantation services based on these practices.  (It is illegal for organs to be sold in the USA, but not for people to travel to engage in these practices.) While the United Nations, New Zealand, Australia and now, Taiwan have begun addressing this practice – the US government remains silent.

Protecting citizens from the wealthy foreigner

Other nations, like Pakistan have acted to try to prevent their citizens from becoming donor sources for wealthy foreigners.  Just today, a new law was passed to prevent organs obtained in Pakistan from being given to non-Pakistani residents. While these laws will not eliminate the practice outright, these countries and their citizens have taken a moral and legal stance against the practices. Now, it’s our turn.

Resources/ More information on this topic

More about the people “criminals” the Chinese government is executing – and taking organs from – Washington Post, November 2012

List of famous Chinese dissidents – Wikipedia

More about the murder and torture of practitioners of Falun Gong

The Ugly Side of Medical Tourism – a related post with links to scholarly articles and media reports regarding transplant tourism in China and Latin America.

A look at why transplant tourism is not safe for recipients, either.

Patients with passports – another post on law, ethics and medical tourism discussion focused on the publication of a book by the same title.  Includes links to several articles by Dr. Delmonico – the foremost  expert on illegal organ transplantation.

Medical Tourist death under inquest


Was it a medical mistake/ an accident of fate /  or…. was it the Cocaine?  An inquest is held on the intra-operative death of an Irish medical tourist..

In a recent inquest, the wife of  an Irish tourist who died while undergoing liposuction with a well-known Colombian plastic surgeon talked about her husband and his decision to pursue plastic surgery with Dr. Ricardo Lancheros Pedraza.

liposuction

In a published story by Gareth Naughton of the Irish Independent, the wife of Pierre Christian Lawlor detailed her husband’s decision to undergo cosmetic surgery with the Bogotá surgeon due to unhappiness with his physique.

During her testimony, she also conceded that her husband had taken cocaine in the days and hours immediately prior to surgery – despite being advised specifically to refrain from smoking, alcohol or taking medications.

In a story published in Irish Central – Ms. Andrea Galeano, the Venezuelan-borne wife of Mr. Farrell reported that her husband had taken cocaine on several occasions after arriving in Bogotá for his surgical procedure.

Mr. Farrell is believed to have died from intra-operative myocardial infarction (heart attack during surgery).

Additional Information

This Daily Mail article from 2012 describes how the use of cocaine can cause heart attacks, and sudden cardiac death.

Medical News Today article

Scholarly articles:

Finkel JB, Marhefka GD. (2011).  Rethinking cocaine-associated chest pain and acute coronary syndromes.    Mayo Clin Proc. 2011 Dec;86(12):1198-207. doi: 10.4065/mcp.2011.0338.

Schwartz BG, Rezkalla S, Kloner RA. (2010).  Cardiovascular effects of cocaine.

Circulation. 2010 Dec 14;122(24):2558-69. doi: 10.1161/CIRCULATIONAHA.110.940569. Review.

Dear Edward


In the middle of all the news about Lance Armstrong and his upcoming interview with Oprah Winfrey – where he has reportedly expressed his apologies for his years of lies and cover-ups over blood doping and steroid use, came this interesting piece by Lance Pugmire at The Los Angeles Times.    In the article, several of Armstrong’s teammates and their families talk about what they consider to be the worst aspect of this entire scandal – the years of intimidation, threats and forced silence.  Armstrong committed these abuses of the system, and flagrant cheating for years, and got away with it for over a decade.  Not only that – but he had a team comprised to maintain this conspiracy of silence, of lawyers and such to protect Armstrong  – while his unwilling colleagues paid the price for their honesty and integrity..

In a similar, but much smaller scale – I am publishing an open letter here at Bogota Surgery.  As my regular readers know – we have had our own legal encounters (with threats and intimidation) over several of our previous posts about patient safety.

This all started due to a blog post on patient safety – based on an article from another website, verified by the original news agency and the original investigative reporter.

These fact-based, well-researched posts with supporting documents told the story of a surgeon who had committed multiple surgical errors including several different ‘wrong-sided’ surgeries.  This surgeon, after being reported to the medical board in her state answered this action by moving to another state (where malpractice charges are now pending) and ultimately moved to a third state to practice.

However, one of the limitations of having state-based medical regulatory boards (versus a nationalized system) was that these complaints did not follow the doctor.. Meaning that when current patients / hospitals/ potential employers investigate or look up her licensure or credentials – they will have no idea of the previous charges against her.  However, by publishing a blog post about this individual and re-posting links to original news articles and court documents, her lawyers threatened me with legal action to enact my silence.

So this is my response – in an open letter to her lawyer:

Dear Edward;

First, I would like to extend my sincerest sympathies to you.  I am guessing that you are a nice person, and are working hard to perform your occupation to the best of your abilities.  But by taking on this client, you are doing yourself and American patients a great disservice.

Your client has been found to be medically negligent in multiple cases in the state of Colorado.  She acknowledged that through her own actions, and she now stands accused of the same in Illinois.  Not only that, her brazen disregard for the health and safety of the unfortunate people who came under her care led to changes in the laws and regulations of the Colorado Medical Board.  She may claim that she did not ‘lose’ her license in that state, but it was her actions that demonstrated to the medical board that there were significant loopholes in their processes that allowed physicians who admitted guilt, like your client, to move on to another state without penalty.

However, all of this is fact, and it is public record, so you and your client have no cause or claim against me for writing about these published facts.  In my previous writing, I included supporting articles and documents to demonstrate that what I reported, was indeed, fact.

One of those facts in particular, is that – yes, you are targeting and bullying me.  It is bullying and an intimidation tactic to threaten to sue someone for writing an established truth.  It is bullying and a targeted attack, when it has been confirmed that you have not approached or sent similar letters to major news outlets such as the news agency that wrote and produced the original story, or another large agency that republished the story.  But then again, large agencies have legal departments.  So, yes, it is a targeted intimidation when you threaten me.

You may be just doing your job today, but what about tomorrow or ten years from now?    Unfortunately, you are just part of a bigger problem in regards physicians and medical malpractice, which is what the heart of this discussion is really about; a surgeon who makes repeated surgical mistakes and then denies they ever occurred.  That may not affect you, personally today but what about when one of your loved ones needs care for heart surgery, cancer or maybe even a brain tumor?  How much confidence can you have in a system that allows surgeons such as this one to continue to practice?  How much confidence will you have, knowing how easy it is to threaten others into silence?

My heart goes out to you, but my only advice is – give the money back to your client.  Take no part in her actions and let people like myself continue our efforts; of trying to promote patient safety, education and protect this public, and people like you.

 

Know before you go: Medical tourism and patient safety


The file download for the latest radio program, “Know before you go” with Ilene Little is available.  It’s from the Christmas broadcast with Dr. Freddy Sanabria.

Image courtesy of Ilene Little

Image courtesy of Ilene Little

(I am on the periphery of the show – introducing Dr. Sanabria and talking about safety guidelines and intra-operative safety protocols.  (Same stuff I talk about here – just a different medium.)

Sanabria, breast implant

Dr. Sanabria, plastic surgeon

Dr. Sanabria joined us to talk about his experiences, and his clinic in Bogotá, as well as his ongoing projects and  patient safety protocols.  It was nice to be able to share some of my observations from my visits to his operating room.

safety checklist

Click here to connect to the Radio show archives

Dr. Alejandro Jadad and Jose Vergara


Much thanks to Jose Vergara  for sending me a link to an article on Dr. Alejandro Jadad.  Jose Vergara, aka Frankie Jazz, as some readers may remember, is a Cartagena native and talented artist in his own right.

Frankie Jazz/ Jose Vergara

Frankie Jazz/ Jose Vergara

We try to keep up with each other – so he knows all about my interest in Colombian medicine and surgery, and I love his new album (so I try not to gush and be too much of a groupie when I hear from him) but he recently sent me a link to one of his more recent projects.   The Voxxi article by Silvia Casablanca is pretty interesting, so I wanted to share it with readers.

For starters – Jose Vergara is the photographer for the article..

Dr. Alejandro Jadad, MD, PhD

But it’s the life of Dr. Alejandro Jadad that is so inspiring..  Dr. Jadad is a Colombian anesthesiologist, textbook author and founder of the Centre for Global eHealth Innovation in Toronto, Canada (among other things).  He has been credited with being one of the major innovators in the fields of clinical research, medicine and information technology.

While at Oxford, as a research fellow in Anesthesiology, he developed a validation tool (the Jadad scale) to critically evaluate and analyze clinical research studies.  This is an important tool to distinguish the quality (and value) of individual research studies – or how much weight a study (and its findings) should have.   We talk about the importance of objective scales and measures quite a bit here at Bogotá Surgery, and the Jadad scale is one of the best known and most widely used scales for clinical research.

Clinical research is how surgeons know whether a patient has a better chance for survival with surgery or chemotherapy/ radiation, for example.

So as you can imagine – having a tool like this is particularly vital when talking about clinical medicine / or health research where the findings of research studies are used to guide and determine medical decisions – aka the medical treatments for people like in our example above.

As the Casablanca article points out – Dr. Jadad didn’t stop with writing textbooks and creating the Jadad scale.  After completing his fellowship in the United Kingdom, he moved to Ontario, Canada to continue his research at McMaster University.   Since then, he has continued to innovate and create tools to help both clinicians and the public.  One of the ways he helps clinicians is by further creating and refining tools to evaluate medical research.

He has also been a major creator and contributor to the development of internet and computer based applications to connect doctors and their patients.  His efforts are based on more that the patient – provider dyad, and are part of a larger, global framework for reforming and transforming healthcare.

More about Dr. Alejandro Jadad, MD, PhD

Casablanca, Silvia (2013, January).  Dr. Alejandro Jadad: Redefining health and  making it global.  Voxxi [on-line article].

(Canadian) Pioneers for Change

Making Longer Life Worth Living“, lecture by Dr. Jedad at Singularity webblog as part of the ‘Singularity University lecture’ series.

More about Jose Vergara / Frankie Jazz

Frankie Jazz – wikipedia page

Vimeo page

Let Me Take My Way – which is one of my personal favorites…

Follow up on wrong-sided surgery


We recently mentioned Dr. Denise Crute, an American neurosurgeon in a November blog post, Wrong-sided surgery.  We quoted News of the Weird as our source, with the original source being ABC channel 7 news.  We mentioned her story to illustrate the importance of safety checklists in the operating room.  It would have stopped there, but now we’ve received a threatening letter from a lawyer in Phoenix, Arizona representing Dr. Crute.  (Since we last heard that she was practicing in New York – the Arizona lawyer must be for my benefit.  I wonder if she would have hired a Colombian lawyer if she realized that’s where I spend the majority of my time.)

Harming her reputation?

Her lawyer claimed that by republishing this information that I am liable for damages  caused by the harm to her reputation.

In my opinion, she’s blemished her reputation all on her own (but I’ll let you read the letter for yourself).

To make it easy on everyone – I’ve also linked to my original post, which was a quote from Mr. Shepherd, who stands by his story.

In my defense – Truth is the truth

I think my statements are fair, accurate criticism, particularly given the known facts of the case.  Now, the last thing I want to do is report something erroneously.  After all, I stake my reputation on my honesty and integrity, so if I have made a mistake – I will freely admit it – and will happy display it in ALL CAPS here on the blog.    Not only that, but I will happily travel out to see Dr. Crute and interview her for the blog, so she can set the record straight – if it needs correcting.  But I can’t be cowed by an angry surgeon looking for an easy target.

Litigious behavior doesn’t change the facts

Notably, the lawyer’s letter doesn’t even address the accuracy of the claims against her. But I did see her own personal blog, where she has a one page statement addressing the charges, so I will link to it here.  In it she claims to have been the victim of a one-person driven witch hunt.

Yes, that could happen – but the breadth and width of the charges (hundreds) and the collaborating witnesses in the statements argues against it in this case.

Now, the initial report to the medical board may very well have been the result of professional jealousies, or whatever, as Crute and her legal team claim.  But there are so many charges – with multiple supporting witnesses that it seems highly unlikely.

Her main argument is against the neurosurgeon that helped the medical board evaluate the claims.  She chalks up his decisions and statements against her behavior to competition, since she is the superior surgeon, apparently.  Fine, but that doesn’t account for the majority of charges which have nothing to do with actual surgery – but with the ethics of her practice.  (You don’t have to be a neurosurgeon to know that altering a patient chart and falsifying data is wrong.)

Another point to consider:

But it also may have also taken another neurosurgeon who was finally bold enough to speak up against repeated, repeated and repeated episodes of unprofessional, dangerous and injurous behaviors.

In fact, a recent poll of 24,000 physicians demonstrates the reluctance of doctors to criticize their colleagues.  The Medscape 2012 Ethical Dilemma Survey results showed that just 47% of physicians would caution a patient about a colleague they felt was practicing ‘substandard’ medicine.

While her statement makes it sound like these sort of complaints against providers and surgeons are common – they really aren’t.

While it may seem so for Dr. Crute (and neurosurgeons do have a high rate of malpractice), for another colleague, several nurses and the surgeon’s own PA to make these statements about Dr. Crute to a medical board means that it was more that a personality conflict.

Not having her license stripped away is not proof of innocence.  In most states, medical boards offer disgraced physicians the opportunity to inactivate their licenses.  It’s similar to hospitals (and other organizations) allowing  doctors, CEOs and such, to resign instead of being fired outright.  This practice has been clearly established and well-documented in several notable cases.

Doctor’s story led to changes in the Colorado Board of Medicine

In fact, many say that the recent stories about Dr. Crute (by Denver reporter, Ferrugia) have prompted changes in the licensure and disciplinary processes at the Colorado Medical Board.

But it’s more than that – attacking my blog for using well-publicized and reprinted information (available at multiple sources) to illustrate a discussion here on patient safety, just seems to me like bullying, especially when there are twenty other articles about Dr. Crute on much larger websites with a lot more viewers.  So I also contacted Mr. Ferrugia and Mr. Shepherd (of News of the Weird) to see if they, too, had been contacted by Dr. Crute and her legal team.  No, they haven’t.. Just me.

This makes me suspect that this entire letter/ episode is just an attempt to bully someone smaller and less powerful, and that’s what makes me angry.  This would have been a good opportunity for Dr. Crute to rectify the record, if that’s truly the case (especially since legal action and media coverage appears to have ramped up in the last few days with more and more articles over the last week)  but she doesn’t appear interested in that.  (If she had, we would be seeing retractions from the other writers involved).

But – check out her site, read her defense, and let me know what you think.  It is also worth noting that despite all the ‘glowing’ quotes she has on her website, she doesn’t appear to be operating on patients in her new position.

I’m not sure that the fact that she volunteers or donates supplies to Central America holds any relevance to the discussion – but she put it out there, so I’m reporting it.

 Dr. Crute settlement agreement

documents related to medical practice

In the meantime, I stand by my statements in reference to safety checklists, etc. that a ‘time-out’ for patient safety can prevent many of these errors that are documented in the original papers, such as in 2004 when she performed wrong-sided brain surgery – which she is accused of, along with   then attempting to cover-up in her documentation (and actually had the gall to say that the patient “marked” the wrong-side.) The patient had a right subdural hematoma (and according to the notes on page 7 of attached document) – was in no condition to consent/mark or otherwise make any medical decisions.

Read the original documents – and see if it paints a portrait of someone who did whatever she wanted, when she wanted and thought that she could get away with it – like when she failed to come see an emergency surgical consult at night*.  She gave a telephone order for intubation, and still didn’t bother to come see this critically injured patient.   Then, after it was too late – came by at 7 am in the morning, and back-dated her notes.  (Yes, patient died).  Unfortunately, there is no checklist to address such an ethical lapse.

But in the spirit of honesty and integrity, and in pursuit of the truth, I have contacted the reporter of the original story, John Ferrugia to see if there have been any story updates, retractions or corrections. (Mr. Ferrugia also provided the supporting documents.)  I also offer Dr. Crute the opportunity to give a statement here.  She knows how to contact me, and apparently she’s reading the blog.

But – this isn’t what my blog is really about – so we will get back to our regular topics, like surgical checklists and surgical apgar scoring – on our next post..

Supporting documents – Mr. Ferrugia:

Dr. Crute 1

Dr. Denise Crute 2

Additional articles

Dr.Crute article by Melissa Westphal

* Just one of many incidents documented in the original documents.

Smartphones and Facebook in the operating room


I hope everyone enjoyed posts about Colombian life and culture, but now that I am back in the United States – we will get back to our more serious discussions about patient safety and issues in health care.  One of the things we have talked a lot about in the past – and cover extensively in the Hidden Gem book series is operating room quality and safety measures.  This includes using objective measurement tools such as the Surgical Apgar score (created by physician and author, Dr. Atul Gawande) and the safety checklist.

Surgeon as pilot 

These checklists were designed to be similar to the mandatory checklists used by pilots.    They were originally designed in the 1930’s to prevent pilot errors and accidents as planes become more and more complex.

Tools to measure and improve practice

These tools do more than just rate (or grade) operating room safety procedures – they encourage a ‘culture of safety’ and adherence to practices and procedures designed to prevent errors or mistakes.  This means that the more people use (and become familiar with) these practices – the better they get at detecting and preventing errors.

The importance of these checklists has been recognized for years, but is just now gaining in traction. It wasn’t until 2009, that the World Health Organization recommended use of the checklist in hospitals internationally.

Checklists and hospital reimbursement

American hospitals now use the checklist religiously because ‘core measures’  – and reimbursement are tied to its use.  These ‘core measures’ were established a decade ago as part of quality assurance procedures for Medicare and Medicaid.  American hospitals that do not participate (or score poorly) on core measures such as surgical safety procedures – risk not getting paid for their services.  (There are core measures for other patient care items as well, such as the care of patients having a heart attack, or pneumonia).

Surgical Apgar Score

The surgical apgar score, (and similar scales) have been slower to catch on.  This is unfortunate in my opinion, because this tool has the greatest chance of really improving patient care and preventing patient harm.  The surgical apgar score works by basically rating and grading the actual care of the patient in the operating room.

When consumers think about patient care in the operating room – we tend to focus on the surgeon.  But surgery and surgical skill are only a part of the picture.  The anesthesiologist/ nurse anesthestist and anesthesia care team are critical to the safety and health of the patient – and their inattention / or distraction can be disasterous for patients.  But even when disaster is averted – frequent distractions can lead to increased complications.  Sometimes the effects are subtle; such as twenty or thirty minutes of ‘borderline’ low blood pressure and post-operative organ dysfunction from intra-operative ischemia.

But is anyone paying attention?

But is anyone paying attention?

We all know it happens, but too many anesthesiologists are busy playing on Facebook to address the realities of the situation.

Unfortunately, this is a common problem in operating rooms worldwide

Unfortunately, this is a common problem in operating rooms worldwide

None of this is news to long-time readers, but several new articles confirm the utility of safety checklists and operating room safety practices.  (One of the articles somewhat ironically reports that injuries to patients were not as reduced as anticipated by previous studies – because the checklist was not always used / or used correctly.  The authors note that the checklists reduced patient injuries and complications – when they were actually used.

 

Additional posts on this and similar topics:

Reputation, Ranking and Objective measures – talking about the ‘core measures’.

More about the surgical apgar score – from our sister site.

The original Surgical Apgar score

Additional references

I will be updating this section frequently over the next few days.

Medscape summary articles:

Hilt, Emma, (2012). Surgical checklist from WHO improves safety and outcomes.  Medscape, November 2012.

Source articles:

Fudickar, A., Horle, K., Wiltfang, J. & Bein, B. (2012). The effect of the WHO surgical checklist on complication rate and communication.  Dtsch. Artztebl Int 2012, 109(42): 695-701.  The authors of this German paper examined / analyzed 20 different studies looking at the use of surgical checklists.

Jorm CM, O’Sullivan G. (2012). Laptops and smartphones in the operating theatre – how does our knowledge of vigilance, multi-tasking and anaesthetist performance help us in our approach to this new distraction?  Anaesth Intensive Care. 2012 Jan;40(1):71-8.

Patterson P. (2012). Smartphones, tablets in the OR: with benefits come distractions.  OR Manager. 2012 Apr;28(4):1, 6-8, 10.  [no free full text available].

Pereira, Bruno Monteiro Tavares et al. Interruptions and distractions in the trauma operating room: understanding the threat of human error. Rev. Col. Bras. Cir. [online]. 2011, vol.38, n.5 [cited  2012-12-18], pp. 292-298 .

From news of the weird: Wrong-sided surgery


Admittedly, this is not where I usually look for information on medical quality and safety measures – but this case, as presented in News of the Weird for this week deserves mention:

Neurosurgeon Denise Crute left Colorado in 2005 after admitting to four serious mistakes (including wrong-side surgeries on patients’ brain and spine) and left Illinois several years after that, when the state medical board concluded that she made three more serious mistakes (including another wrong-side spine surgery).

Nonetheless, she was not formally “disciplined” by either state in that she was permitted merely to “surrender” her licenses, which the profession does not regard as “discipline.” In November, Denver’s KMGH-TV reported that Dr. Crute had landed a job at the prestigious Mount Sinai Medical Center in New York, where she treats post-surgery patients (and she informed Illinois officials recently that she is fully licensed in New York to resume performing neurosurgery). [KMGH-TV, 11-4-2012]”

This is an excellent example of the importance of the ‘Time-out” which includes ‘surgical site verification’ among all members of the surgical team.  This also shows some of the limitations in relying on the health care professions to police themselves.  Does this mean that I can absolutely guarantee that this won’t happen in any of the operating rooms I’ve observed?  No – but it does mean that I can observe and report any irregularities witnessed (or deviations from accepted protocols) – such as ‘correct side verification’ or failure of the operating surgeon to review medical records/ radiographs prior to surgery.

It also goes to show that despite lengthy credentialing processes and the reputations of some of the United States finest institutions are still no guarantee of quality or even competence.

What about Leapfrog?

This comes at the same time as the highly controversial Leapfrog grades are released – in which medical giants like UCLA and the Cleveland Clinic received failing marks.  (UCLA received an ‘F” for avoidable patient harm, and the Cleveland Clinic received a “D”.)

Notably, the accuracy of the Leapfrog scoring system has been under fire since it’s inception – particularly since the organization charges hospitals for the right to promote their score.

But then – as the linked article points out – so do most of the organizations ‘touting’ to have the goods on the facilities such as U.S. News and Reports and their famed hospital edition.

Guess there aren’t very many people like me – that feel like that’s a bit of a conflict of interest..

New venture with Colombia Reports


While I have written several books about surgery and surgeons in Colombia, much of this information I’ve obtained from my research has been consigned to sitting on the shelves of various bookstores.

But, now with the help of Colombia Reports, I am hoping to change that.  As I mentioned in a previous post, Colombia Reports.com and it’s founder, Adriaan Alsema have been amazingly supportive of my work, ever since they printed my first article on Cartagena in 2010.

Since returning to Colombia, I have kept in touch with Colombia Reports while we discussed ways to bring more of my research and work to the public.  Colombia Reports is a perfect platform – because it serves a community of English-speaking (reading) individuals who are interested in/ and living in Colombia.   With this in mind, Colombia Reports has created a new Health & Beauty section which will carry some of my interviews and evaluations.

It is an ideal partnership for me; it allows me to bring my information to the people who need it – and continue to do my work as an objective, and unbiased reviewer.  We haven’t figured out all of the details yet – but I want to encourage all of my faithful readers to show Colombia Reports the same dedication that you’ve shown my tiny little blog, so that our ‘experiment’ in medical tourism reporting becomes a viable and continued part of Colombia Reports.

This is more important to me that ever – just yesterday as I was revisiting a surgeon I interviewed in the past (for a new updated article), I heard a tragic story that just broke my heart about a patient that was recently harmed by Dr. Alfredo Hoyos.  While I was unable to obtain documents regarding this incident – this is not the first time that this has happened.

Previous accusations of medical malpractice against this surgeon have been published in Colombian news outlets including this story from back in 2002.

The accusations are from Marbelle, a Colombian artist regarding the intra-operative death of her mother, Maria Isabeth Cardona Restrepo (aka Yolanda) during liposuction.  These accusations were published in Bocas – which is part of El Tiempo, a popular Colombian newspaper, in which the singer alleges that Dr. Hoyos was unprepared, and did not have the proper equipment on hand to treat her mother when she went into cardiac arrest during the surgery.

story about the death of one of Dr. Alfredo Hoyos' patients.

story about the death of one of Dr. Alfredo Hoyos’ patients.

Kristin 002 Kristin 003 Kristin 004

Now – as many of you remember, I interviewed Dr. Alfredo Hoyos back in 2011, and followed him to the operating room, giving me first hand knowledge of his surgical practices.

Readers of the book know he received harsh criticism for both failure to adhere to standard practices of sterility and patient intra-operative safety (among other things.)  I also called him out for claiming false credentials from several plastic surgery associations – and notified those agencies of those claims..   In the book, readers were strongly advised not to see Dr. Hoyos or his associates for care.

But – as I mentioned, my book is sitting lonely on a shelf, here in Bogotá – and in the warehouses of Amazon.com and other retailers.. So, people like that patient – didn’t have the critical information that they needed..

This is where Colombia Reports – and I hope to change all that.   So in the coming weeks, I am re-visiting some of surgeons we talked to in 2011, and interviewing  more (new) surgeons, more operating room visits..

Fundacion Santa Fe de Bogota ranks among the best in Latin America


Santa Fe de Bogotá ranked second in Latin America

In the most recent American Economics (AmericaEconomica), Fundacion Santa Fe de Bogotá ranked second in the category of “Capital Humano” coming in just behind Clinica Alemana, in Santiago, Chile.  Fundacion Santa Fe ranked #4 overall.

Capital Humano

This category ranks and measures the education, training and research among the staff of each facility, as well as on-going improvement projects and educational offerings.

Of course, it’s no surprise to readers of Hidden Gem that the surgeons over at Santa Fe de Bogotá excel at academic excellence.

Now – while we give Kudos to Santa Fe de Bogotá, as well as Hospital Israelita Albert Einstein (Brazil) and Clinica Alemana for their outstanding rankings – we remind readers that rankings aren’t always what they are cracked up to be.

AmericaEconomica, “The best hospitals and clinics in Latin America.”

Patients with Passports: Medical Tourism, Law, and Ethics


A new book on medical tourism – this one by an associate professor at Harvard Law School ( I. Glenn Cohen), which follows the lines of the work done by Dr. Delmonico and several others in addressing the legal and ethical issues in medical tourism – particularly the grey areas (and downright black, in my opinion) such as transplant tourism and surrogacy tourism.  I haven’t had the opportunity to read his book yet  – but I hope he takes aim at the unethical practices of some of the giants like Planet Hospital.

He’s a much bigger voice than an unknown nurse / writer like me – so maybe he will get the attention that this issue deserves.

Maybe at the same time, it will spark interest in efforts like mine – to establish objective and unbiased evaluations of health care services so that people who are looking or relying on medical tourism for their healthcare aren’t just taking a blind stab based on slick marketing tools, and fancy websites?

I sure hope so – even if stories like this one aren’t front-page news like black market kidney sales, it is still a vital and important reason to do what I do.

Final draft.

Objective and unbiased reviews

Author to author – congratulations, Mr. Cohen and best of luck!

Reasons to write about medical tourism: #146, a cautionary tale


As  I mentioned in several previous posts, there are numerous reasons why I write about medical tourism, and protection of the consumer is first and foremost.

Several months ago, I was told an exceedingly disturbing tale of patient abuse at the hands of a plastic surgeon here in Mexicali, MX where I am writing my latest book.  I’ve internally debated publishing information about it – not because I think the patient isn’t credible (the patient is exceedingly credible) but due to the lack of verifiable documentation and evidence related to this story.  Then again, this is exactly the reason that this American patient was so hesitant to come forward.  Ultimately, I feel that by failing to publish this account, I would be further victimizing this patient, and failing to warn consumers of the potential dangers.  It is of the utmost regret that I do not have conclusive proof to bring to the authorities (and readers) to prevent this surgeon from ever operating again.  This patient isn’t being vindictive, or seeking a payout – it’s the furthest thing from her mind.  Her only motivation is the pain, disfigurement and indignities that she has suffered, and a hope of preventing this from happening to another medical tourist.

“I wanted to go to the police, to the medical board, to someone, but how can I prove it?” the patient asks, agonizing over the episode which occurred more than a year ago.

Yet, she is still haunted by it – and the story itself is a harrowing account of  abuse of patient trust – and so it should be presented here.  Given the lack of verifiable documentation, I have omitted the name of the surgeon involved, but suffice to say, he is a popular surgeon in Mexicali, and one that I have intentionally omitted from my latest book.

The patient, who happens to be a bilingual health care provider came to Mexicali for liposuction and rhinoplasty.  While telling the story, she is embarrassed by this – as if her supposed vanity is to blame for what occurred.  It is another reason she was reluctant to report it to the police – for fear that she would be told that she deserved it.

Her surgery was botched from the beginning and almost cost her life.   A simple cosmetic procedure has profoundly damaged her physically and psychologically.   She has scars; both physical and emotional that testify to much of the trauma that occurred.

She presented for surgery that fateful morning with no sense that anything was amiss; the surgeon has an excellent reputation and she had investigated his credentials; he is in fact, a licensed plastic surgeon.  Previous patient testimonials were glowing with no hint of any problems.

The first indication there was a problem came with the initiation of the procedure.  After being given a mild paralytic, she remained conscious and aware during the procedure.  She remembers vividly being intubated by the anesthesiologist who appeared not to notice her distress.  “I could hear the heart monitor going crazy but they all ignored it.”

There were several flashes, and that’s when I realized that the surgeon was taking pictures of me, naked, intubated and helpless.” 

She continued, “I know that many plastic surgeons take pictures for before and after photos, but no one ever asked me about it.  Also, in most clinics – they take the pictures while the patient is still awake before going into the operating room.”

I finally lost consciousness and woke up in the recovery room.  I sensed right away that something was wrong – I had horrible pain on the left side of my abdomen and chest, and bandages on the left side of my abdomen but nothing on the right, or my face.”  [the patient had been scheduled for bilateral liposuction of the abdomen and rhinoplasty.]

Then the PACU nurse delivered devastating news; the procedure had been abandoned mid-way – with the liposuction performed on the left only, because she had gone into respiratory arrest during the procedure.  The nurse also whispered confidentially, that she was “lucky” because the surgeon and one of his staff members had been noticeably intoxicated on their arrival to the operating room, and had left immediately before the procedure [presumably] to “do some more cocaine.”

Later, when the anesthesiologist arrived, the patient questioned him gently; about her intubation experience, the abrupt discontinuation of her surgery – and as to what had happened.  “Nothing happened”, she was told repeatedly.  “Everything went absolutely fine.”  When she insisted, asking why her surgery did not match what was initially planned – the anesthesiologist left.

When the surgeon finally arrived, he was equally uncommunicative.   In answer to her questions; “Did anything happen during my surgery?” he gave repeated denials and assurances that ‘everything was fine.’   He also denied taking any photographs.

When she asked why, then, did she only have half the procedure completed, he answered, angrily, “because I changed my mind,” before stalking out.

When her family came to help her dress and leave the surgical center, there were even more surprises, a series of rounded, purplish marks on her chest.  “My mom asked if they were hickeys, and when I looked in the mirror – that’s exactly what they looked like.”  Being familiar with surgery, and medicine, I interrupted to ask if they could be from the electrodes, CPR or anything else.  “I don’t know” she answered, “but they sure don’t look like any of the marks I’ve seen on other patients before.”

These marks along with a fateful encounter as she was leaving the clinic are what haunt her to this day.  As she was leaving with her family, a young man was chuckling and staring at her as she walked past.  She looked over at him, and he started laughing, saying, “I recognize your face, [and your body] from the photos passed around the hospital.”  The photos that no one will admit to taking.

Even now – she has evidence of the botched procedure – one side of her abdomen has is lumpy and uneven with furrowed tunnels (an attempt at liposculturing, she thinks).  When comparing it to the side that was untreated – she begins to lament the folly of her procedure – and yet again, to blame herself.

“I wish I had never done it.  Now I have to see this everyday.  I am afraid to ever have surgery again (to fix it).”

At the end of the interview, she is in tears, and she leans over and whispers in my ear: the surgeon’s name.

I wish I could prove it,” she says.  “This should never happen to anyone else.”  She states that when she went back to talk to the original nurse (from the recovery room), the nurse was no longer there – so her only collaborating witness is gone.  While her family saw the results – they were told the same story she was, that the surgery preceded normally, and that the surgeon ‘changed his mind’ in the middle of surgery.  Repeated calls to the surgeon for more information have gone unanswered.

I wish she could prove it too – the ensure that everyone knew the name of this heartless surgeon – to prevent anyone else from becoming a victim.  But even without the name, it’s a strong reason for me to continue doing what I do now.

[Readers should note that while this occurred in Mexico – unfortunately events such as this have occurred around the world.  In the 1990’s there was a widespread scandal as a notable plastic surgeon attempted to sell photos to a tabloid of Michael Jackson, Liz Taylor (among others) that were taken without their knowledge during plastic surgery procedures.]

Update:  There is a new scandal at John Hopkins in the wake of the February suicide of one of their popular OB/GYNs who is believed to have taken pictures of his patients secretly, using a mini – camera hidden in a pen.

Likely Suicide of Johns Hopkins Ob/Gyn Tied to Secret Photos” article by Robert Lowes, Medscape, February 2013.

Why read Bogota and other hidden gem titles?


 

As readers of my sister site, Cartagena Surgery know, I am currently hard at work on my third title in the ‘Hidden Gem’ series – with the latest offering on Mexicali, Mexico.  But I continue to get comments from readers, friends, and everyone else asking, “Why bother?”

Why bother reading Hidden Gem?

People should read these titles because we can’t assume that all medical providers have been vetted, or that all medical facilities meet acceptable criteria for safe care.  It is a dangerous assumption to expect that ‘someone’ else has already done the research. [lest you think this could only happen in Sri Lanka, be forewarned.  With new legislation, the critical doctor shortage in the USA will only worsen.]

Medical tourism has the potential to connect consumers with excellent providers around the world.  It may be part of a solution to the long waits that many patients are experiencing when seeking (sometimes urgent) surgical care.  It also offers an opportunity to fight the runaway health care costs in the United States.

But..

But it also has the potential, if unchecked, unvetted, unverified and left unregulated to cause great harm.

Another reason to read Hidden Gem is to find out more about the surgeons themselves, their training, and many of the new, and innovative practices in the realm of surgery. Often the best doctors don’t advertise or ‘toot’ their own horn, so you won’t find them advertised in the pages of your in-flight magazine as “One of the best doctors in XXX” even if they are.  (Many people don’t realize those segments are paid advertisements, either.)

Why bother writing Hidden Gem?

Because ‘someone’ needs to.

I am that ‘someone’ who does the fieldwork to find out the answers for you.  I can never assume that it’s been done before, by someone else.  I have to start from ‘scratch’ for every book, for every provider and every hospital.

I also believe that the public should know, and want to know more about the people we entrust to take care of us during serious illness or surgery.  We should know who isn’t practicing according to accepted or current standards and evidence – and we should know who has/ and is offering the latest cutting edge (but safe and proven) therapies.

 

Read more about the doctor shortages:

NYT article on worsening doctor shortage  (and one of the proposed solutions is a loosening of rules governing the training and credentials of doctors from overseas – coming to practice in the USA).

Honesty and Transparency in Medicine


This week, Glaxo Smith Kline was fined three BILLION dollars for health care related fraud in falsely marketing several of their drugs.  Criminal charges would have been more effective, since the company had already put over 8 billion dollars away (in a rainy day legal fund) for just such an eventuality, (and they can always just pass any fees along to consumers in price hikes..)

The company had been falsely advertising the uses of several of their medications in direct-marketing campaigns to consumers as well as materials (bribes and gifts) to health care professionals.

This harkens back to the days of patent medicines and cocaine laced cough syrups were advertised as ‘cure all’ but it’s actually not the most disturbing part of the story.

This is.

Glaxo Smith Kline (GSK) was also caught paying celebrity physicians to endorse these medications for off-label or unapproved uses – including noted personality, Dr. Drew.  Now, this is nothing new, as we’ve stated.  In fact, several of Oprah’s personal gurus have been caught with their hands in the cookie jar, so to speak – but it is part of a disturbing larger trend of betraying public trust for personal gain.

Unfortunately, in this post-modern world of “Greed is good” and almost daily reports of corporate misdeeds – the fact that a huge company such as GSK would do this – is to most people, unsurprising.  A shrug, and a yawn – change the channel to ESPN.

Odious, I know that corporate responsibility has become such a joke, but even more disturbing is the lack of personal and professional responsiblity on the part of the health care providers that helped endorse these products.  

I don’t just mean Dr. Drew, and his equally contemptible counterpart, Dr. Phil – I include every single one of us – in our white lab jackets.  If we are in a position of public / patient trust – then we must take that very, very seriously and know that our integrity, our reputation and our ethics ARE NOT FOR SALE.

I write about medical tourism every day because my absolute conviction that someone needs to provide transparency , honesty, and objective information in this unregulated industry – but at the same time, I strive to ensure that my readers know EXACTLY where I am coming from.. All of these celebrity endorsers, and even our own family doctors need to so the same.

There was a recent bill passed that requires physicians to do exactly that; and the doctors I know back in the USA have been lamenting about disclosing the number of free lunches, and speakers fees that they receive every year because they think ‘it makes me look bad.’  If it makes you look bad – then maybe you should reconsider doing it.

Sometimes it really isn’t greed – its convenience.  Often drug companies provide dinners with speakers who have conducted research or written academic articles on hypertension, or cancer, or other various topics of interest.  [the new restrictions mean that drug companies aren’t supposed to just have speakers say – “hey, prescribe drug X to all your patients.” ]

So – you’ve worked 12 hours taking care of patients all day, and you are tired, but you read a bit about the study in the New England Journal of Medicine – and now you want to know more.. Having a bite to eat at the same time just makes sense, right?  But it’s about transparency.

So – if you really want to hear a presentation about a recent study in cardiology, go to the ‘dinner’ but pay your own way. 

This is why, in recent years – researchers and presenters have to disclose – whether or not they received money, gifts or other services to do their research study, or give the presentation..

In a larger sense – it means that celebrity endorsers and even people like me, (who are writing for a presumably larger audience who doesn’t always know these rules) that we have duties and obligations to the public: we have a duty to be transparent.

It’s not just that we shouldn’t take money to tout a product, or a service.  It’s also that we need to be willing to disclose our financial information, if needed, to demonstrate that.

It’s something I am fully willing to do – and have done, several times.  Embarrassing, yes – to admit to people:

a. I don’t make much – because I don’t receive, and have never received money from medical tourism companies, doctors, etc.. (and my book sales are less than stellar).

b. sometimes my parents have actually helped me – because as embarrassing as it may be as a thirty-something adult – I would rather take money from parents then sell my integrity.  Their money comes with less strings – they give it because they believe in what I am doing.  (Now before you get the idea that I am some sort of “trust-fund baby” – let’s clarify that right now).. if you saw my pathetic financial statements it wouldn’t be an issue, but transparency, right..

you’d see that I make the majority of my living as a nurse, working in short term positions.

my husband, a computer technican, contributes through his own short term work.  (Sometimes he repairs our neighbors’ computers too for a fee).

you’d also see that writing does not pay – or it pays a pathetic amount.. All the articles, books, etc. combined equal less than one paycheck as a nurse. (and Yes – it is humiliating to admit that I’m no best-seller, but readers deserve no less than the truth.)

(You’d also see a pile of student loan debts, that I am slowly, and steadily attempting to pay off, but that’s another issue.)

No huge sums.  No big payouts.  And no sneaky, sideways, or under the table dealings.

Now, Dr. Drew, Dr. Oz and every other ‘expert’ touting themselves on television to the public, under the guise of their medical credentials, or white coat and stethoscope needs to do the same.

Hospital ranks and measures: Medical Tourism edition?


It looks like Consumer Reports is the newest group to add their two cent’s worth about hospital safety, and hospital safety ratings.  The magazine has compiled their own listing and ratings for over 1,100 American hospitals.  Surprisingly, just 158 received sixty or greater points (out of a 100 possible.)  This comes on the heels of the most recent release of the LeapFrog results.  (Leapfrog is controversial within American healthcare due to the unequal weight it gives to many of its criterion.  For example, it is heavily weighed in favor of very large institutions versus small facilities with similar outcomes.)

Consumer Reports has a history providing consumers with independent evaluations and critiques of market products from cars to toasters since it’s inception in the 1930’s.  It’s advent into healthcare is welcome, as the USA embraces new challenges with ObamaCare, mandated EMRs, and pay-for-performance.

While there is no perfect system, it remains critical to measure outcomes and performances on both an individual (physician) and facility wide scale.  That’s why I say; the more scales, scoring systems and measures used to evaluate these issues – the better chance we have to accurately capture this information.

But – with all of the increased scrutiny of American hospitals, can more further investigation into the practices and safety at facilities promoting medical tourism overseas be far behind?

Now it looks like James Goldberg, a bioengineer that we talked about before, is going to be doing just that.  Mr. Goldberg, who is also an author of the topic of medical tourism safety recently announced that his firm will begin offering consulting services to consumers interested in knowing more about medical tourism – and making educated decisions to find the most qualified doctors and hospitals when traveling for care.  He may be one of the first to address this in the medical tourism industry, but you can bet that he won’t be the last..

If so, the winners in the international edition will be the providers and facilities that embrace transparency and accountability from the very beginning.

Radio Interview with Ilene Little


Interview with Ilene Little, “Know Before You Go”

Last month I completed a radio interview with Ilene Little, talking about Colombia, thoracic surgery, and issues in medical tourism.  I’ve been waiting for the archives to be published so I could provide a link here for interested readers.

Hope you enjoy. (You might recognize some of the names.)  For more print information on the interview – take a look at the article on my sister site.

The dangers of Medical Tourism


A new press release from a law office in the United States – highlights the importance of what I do – and why I think it is a necessary and essential endeavor.  The author, James Goldberg has also written a book about the potential dangers of medical tourism due to a lack of regulation among brokers who are just looking for the cheapest providers (for higher profit margins).  As we all know – that’s not the right way to chose a surgeon (and it’s not fair to consumers who trust brokers to deliver high quality care.)

I just ordered it – so I’ll give a full ‘book report’ once it arrives.

Unfortunately, the more I continue on in my efforts to provide unbiased and object reviews, the more I become disheartened by the lack of interest on the part of the medical tourism industry itself.  For the most part, these travel agencies are just that – and hold themselves to no higher ethical or moral standards that the travel agencies of old – except now we are talking about more than missed flights or less than stellar hotel rooms.

The response from the surgeons themselves has been (for the most part) enthusiastic about being reviewed, but until consumers hold the vendors of these services to a higher standard – it will never happen on any sort of global scale.

For the time being – it looks like it’s just me – and my dwindling retirement fund.

Guia Cirugia


I am glad to see that many of the ideals I’ve promoted in the past – objective and unbiased medical review for medical tourists and consumers are starting to take flight.

I talked with John Coffey, in Cali, Colombia about his project , Guia Cirugia earlier this year, so I am pleased to see he was able to bring it to fruition.  (Some people would see it as competition – I see it as a necessary and needed service for consumers – so I am completely thrilled!!  I just wish there were more people interested in trying to ensure that patients (where ever they come from) receive high quality care.

JCI and the big regulatory agencies don’t count in my mind – there is just too much bureaucratic BS that gets in the way of actually getting down to the nitty-gritty;

Is the place clean?

Is the doctor licensed (at all – or in the specialty where s/he is practicing)?

Do they follow the generally accepted standards and practices for prevention of patient harm?

Do they have the technology and machinery to handle emergencies that may reasonably arise from procedures performed at that facility?  (Let me tell you – if they are operating at a Motel 6, (as we have documented before) – the answer is most assuredly NO.)

So Kudos to John and everyone else at Guia Cirugia.com

Canadians use medical tourism to skip lines, long waits


More and more Canadians are becoming frustrated with the wait times for surgical procedures in their native country – as wait times for procedures such as joint replacement routinely take years.. instead they are turning to medical tourism to satisfy their immediate medical needs, and to get back to a normal, functional life faster..

This is big news in a country that prides itself of its ‘universal’ health care system – which fails to acknowledge the tolls their lengthy waits take on their patients.  So – it may be free, but many residents are opting out.

In this story – documenting several patients who traveled abroad in the last several years – patients express their satisfaction with overseas services (which they rated as ‘excellent’ and ‘superior to care received at home’ despite having to pay-out-of-pocket.)

Interestingly enough – one of the main brokers (or travel agents) for these services – Shaz Pendharkar is a retired school teacher who readily admits he has no medical training. Despite that – he feels confident enough to recommend the services of medical providers overseas.  He states that despite this obstacle, he “knows the doctors.”

While I am in favor of medical tourism to improve the quality of life for patients in North America (and other locations), I am still uneasy about the ready assurances Mr. Pendharker offers his clients, and his easy dismissal of the unhappiness of one of his former clients.  “It was a butt-lift” he says, as if this in itself is enough to dismiss the patient’s claims of dissatisfaction.

I don’t know the facts of the case – so maybe his claim has merit – maybe it doesn’t.  While patients should continue to seek medical care where they can find it – and overseas options are an excellent choice – I’d rather that someone better informed perform the brokering.  How about you?

Do you want a high school principal chosing your surgeon, and your medical facility?  Or would you rather someone with experience in evaluating medical standards do the job for you? I think it’s time people start applying objective criteria to the entire industry – and leave medical travel to the health care professionals.

The reason for the time out

Ranks & Measures

Why Colombia (versus India and Thailand)

The ethics of Indian Medical Tourism

New medical tourism report


There’s a new medical tourism report written by an economist which takes issue with many of the ‘reported facts and figures’ which are bandied about by the medical tourism industry.  As we’ve discussed on previous posts – many of these numbers are fairly nebulous and impossible to verify.  (Afterall, there is no exit surveyor at airports to ask, “During your stay in Mexico, did you undergo any surgical procedures?”)

The report sounds interesting – but at a cost of 800 pounds – it’s out of reach for people like myself.  By the same token, I’d like to know by what methods Ian Youngman was able to quantify his results – since the problems of obtaining accurate numbers is fairly universal.

However, it’s an interesting glimpse into an industry that promotes a lot, but often proves little.

Update :

Another new report – this one by TreatmentAbroad which states that in a survey of their customers – 9 out of ten would do it again.  The press release describes their survey methodology and the company offers readers more information, and invites questions about the project.

Patient testimonials and on-line physician reviews


The New York Times just published a new article that echos my concerns with the validity of anonymous on-line physician reviews (fakery/ fraudulent reviews, skewed perceptions and biased evaluations.)

Don’t get me wrong – the internet is an incredibly powerful tool (after all  – that’s how you found about this blog, and my independent review project.)  But it needs to be upfront and above-board.  Anonymous postings have little value in a competitive market like healthcare and often amount to little more than propaganda (if positive) or even spam or harassment (if negative).   Also multiple studies have shown that unhappy clientele (for any service, not exclusively healthcare) are 20 TIMES more likely to mention their experience to others and mention it to 5 times as many people as people who are content/ happy or satisfied with their encounter.

That being said – I admit that I often sneak over to Healthgrades.com myself to see what former patients have posted about me.

American plastic surgeons lash out against medical tourism


As I’ve mentioned in a few of our older posts – medical tourism makes many American plastic surgeons very, very unhappy.   While many of their complaints are legitimate (patients could get inferior care, infections etc..) all of these complaints or comments apply to their American peers as well.  (On my sister site, we tackle many of the dubious practices in the USA (eye doctors performing liposuction, ‘fake’ doctors injecting people with fix-a-flat, and all those dentists, and hair salons injecting Botox.)

But today I take issue with Dr. Michael A. Bogdan, a plastic surgeon currently practicing in Southlake, Texas.  (Hope everyone is impressed in his degree in Zoology.) But back to the serious issues..

Dr. Bogdan recently authored an article published on Medscape questioning medical tourism in light of the PIP implant scare.  (The full article is re-posted below.)  While he makes some legitimate points in the article, (points that we have discussed here) about the lack of scrutiny on the medical travel agencies themselves, and the lack of data about complications from medical tourism surgeries – he grossly oversteps when he attempts to place the blame for the PIP implants on the feet of the medical tourism industry.

When you consider the THOUSANDS of medical devices (including different versions of breast implants) that have been recalled in the United States in the past 25 years – it undermines his whole premise.  I also find it somewhat offensive that he a.) dismisses all foreign surgeons as using faulty/ inferior equipment – that’s a wide, wide brush to use, Dr. Bogman.. 

and more importantly, b.) that in a small way – he almost sounds to me like he thinks that people who travel abroad for their surgical care – deserve to have these kinds of problems and complications.  Very uncool, and shame on you, Dr. Bogman.

In reality, Dr, Bogman and many other plastic surgeons here in the USA are lashing out at the bad economy which has dampened the public’s enthusiasm for surgical self-improvement.  (Though this article indicates the economy is recovering.)  It’s likely that as a plastic surgeon in Texas (a border state) that Dr. Bogman, seller of such procedural combinations as the ‘mommy makeover’ is feeling the loss of patients more than, let’s say a surgeon in Virginia..

More tellingly, and surprisingly, he doesn’t suggest that patients should research their surgeon wherever and whoever they are.

But read the article from Medscape.com yourself and decide:

The Cost of Medical Tourism by Michael A. Bogdan, MD

Complications From International Surgery Tourism Melendez MM, Alizadeh K Aesthet Surg J. 2011;31:694-697

Summary Medical tourism (ie, traveling outside the home country to undergo medical treatment) is a rising trend. An estimated 2.5 million Americans traveled abroad in 2011 to undergo healthcare procedures. This results in a significant direct opportunity cost to the US healthcare system. Complications from these procedures also affect the US healthcare system because patients often require treatment and have no compensation recourse from insurance. For cosmetic or other procedures that are not covered by insurance, economic motivators are driving medical tourism because some international clinics offer procedures at significantly lower costs, possibly by compromising the quality of care.

Very little data have been available to assess the outcomes, follow-up, and complication rates for patients undergoing cosmetic procedures abroad. The authors of this study distributed a 15-question survey to 2000 active members of the American Society of Plastic Surgeons about experiences treating patients with complications from procedures that they underwent during medical tourism. The response rate was acknowledged to be low, at 18%. Of the respondents, 80% had treated patients with complications arising from surgical tourism. Complications included infection (31%), dehiscence (19%), contour abnormalities (9%), and hematoma (4%). The majority of respondents reported not receiving any compensation for the care delivered to these patients.

Viewpoint Some patients travel to other states or countries seeking specialized care from surgeons who are experts in their field. In these cases, the patients understand that they will be paying a premium for the expertise, as well as the added expenses incurred for travel and lodging. These patients would be paying significantly more than they would have by undergoing the same procedure locally, but they consider the additional cost worthwhile due to the expected higher level of care.

The majority of patients who are attracted to medical tourism have a different motivation — they are trying to attain an equivalent level of care for a lower cost. Consumers are traditionally driven by price rather than quality and generally do not consider issues regarding follow-up and potential complications. Although reputable international clinics that offer high-quality care do exist, the greater majority that are trying to attract medical tourism patients are doing so by offering low prices. Overhead costs may be lower in other countries, but the level of regulation is also lower. Thus, the accepted standards of care tend to be lower as well.

A recent example of this issue is the current crisis involving breast implants manufactured by Poly Implant Prothèse (PIP).[1] Instead of using medical-grade silicone to manufacture these implants, PIP used substandard industrial-grade silicone as a cost-saving measure. Probably because of this, the implants have a markedly higher rate of rupture than other available breast implants. The International Society of Aesthetic Plastic Surgery recommends removal or exchange of these implants to avoid further health risks.[2]

PIP implants have not been used in the US since 2000, owing to the Food and Drug Administration’s (FDA) decision that the premarket approval application was inadequate.[3] In addition to blocking the use of these implants in the United States, the FDA sent a warning letter to the manufacturer discussing inadequacies in the manufacturing process.[4]

PIP implants have a significantly lower price point than implants approved for use in the United States and are therefore competitive in countries with less stringent regulation. International surgeons trying to entice patients with lower costs could easily justify using PIP implants. In my own practice, I have met patients who were lured overseas for less expensive surgery and ended up with PIP implants. These patients are now faced with additional expenditures for surgery to address complications.

If you have influence over a patient’s decision on where to undergo surgery, advise them of the adage: Buyer beware; you get what you pay for.

The best thing about being an unknown writer


While the underperformance of my writing, is often daunting and disappointing – it does offer several real advantages (to both myself, and my modest audience.)

1.  The unvarnished truth –as an unknown writer, I get access to, and write about the ‘unvarnished’ truth.   Since I’m not a household name, or a bestseller – most of the people I interviewed didn’t bother to hide anything (including unsafe practices in several instances.)

Also, since I’m not Dr. Oz, or Oprah – I could go ahead and write exactly what I saw.. (Good/ bad/ ugly/ whatever.)

Afterall – there was no big publishing house to protect from legal action, and very little incentive for people to sue.

    Sure, I saw some appalling practices, and sure,  I wrote about them in full and devastating detail – giving full names, dates, locations etc but none of the affected facilities or physicians will sue..)    Why would they?  For starters – everything I wrote was the truth – and secondly (more importantly to these individuals)  – few people are buying/ reading these books – so why bring attention to it??

Of course, for the most part – I saw excellent physicians, in outstanding facilities providing patient’s with outstanding and high-quality care – but not always.  And it’s the ‘not always’ that people should be read about..  But – if I became Dr. Oz or some other big name writer – that would be the first thing that would get lost..

I wouldn’t be some nameless, faceless nurse watching from the sidelines.  People wouldn’t let me observe at will – things would be staged, and artificial – and the authenticity of my writing would be lost.. (Just like the authenticity of Joint Commission inspections that are announced a year in advance.)

So in many ways – while my lack of commercial success can be frustrating (since I rely on my own funds to travel and perform research) – it’s this very lack of success that gives me the opportunity to give readers the real information they need and want.

So thank you, for not buying my book.

A new medical center for Bogota?


There’s a new article over at IMTJ about a new medical facility being built in Bogotá – but it’s not the facility itself that is interesting (sounds like a new private cosmetic surgery mega-clinic).

It’s the statistics within the article that caught my eye.  I’m not sure how accurate these statistics are, but if true – it confirms much of what we’ve been saying here at Bogotá Surgery.  I’ve placed a direct quote from the article below:

According to Colombia’s Ministry of Commerce, Industry and Tourism the most popular treatments sought by visitors are heart surgery (41%), general surgery (13%), gastric band surgery (10%), cosmetic surgery (10%), cancer treatment (6%), orthopedic treatment (4%, dental care (2%) and eyecare (1%).”

If this information is even remotely accurate – it confirms what many of within the medical tourism have been saying – and contradicts much of the popular media reports.

People aren’t just going overseas for breast implants and face-lifts – people are going overseas for essential lifesaving treatments, and procedures to improve their quality of life.

This is an important distinction to  make, but many people tend to see cosmetic procedures as frivolous, and consider the issues around medical tourism, and travel health to be equally unconcerning*.  So when they see flashy news stories (good or bad) about patients having overseas surgery (which the media usually portrays as plastic surgery) they shrug and change the channel.

Hmmm.. patient died of liposuction in Mexico (or Phoenix or India..)  Or Heidi whatshername had 26 procedures at a clinic overseas..

But as these statistics show – that’s not the reality of medical tourism – and that’s what makes all of the issues around it even more important.

People may not get fired up about insurance coverage for medical tourism for cosmetic surgery – but what about tumor resection?  or mobility restoring orthopedic procedures? Or as cited above, life-saving heart surgery?

When put into this context – the government (President Obama’s) stance against medical tourism looks a little less democratic – particularly given the state of American healthcare.

* This is not the opinion of the author – but an accurate reflection of statements made in multiple articles and news stories

 

In other news:  Joint Commission take note:  The Indian Health Commission plans to perform surprise health inspections of Indian facilities to ensure quality standards.  (Joint Commission announces their impending visits months ahead of time.)  Joint Commission is the organization that accredits most American hospitals.

Medical Tourism Forecast for 2012


Where is Medical Tourism & Travel headed for 2012?   Predictions vary according to sources, but all sources expect the medical travel phenomenon to continue, unabated.

Maria Lenhart at the Medical Travel Report (a private travel company blog) estimates 35% growth over the next year, based on Deloitte statistics.

Where are they going?  According to Depak Datta of the Medical Tourism Corporation – for the most part, people are staying fairly close to home..  Meaning that people from the United States and Canada favor locations in the Western Hemisphere over Thailand, India and other destinations popular with Europeans, Africans and Asians..

Domestic medical tourism remains a popular option with American corporations who are sending their employees to large, well-known facilities within the United States.

In fact, large American healthcare institutions often have the most to gain from medical tourism via international affiliations with institutions in South America, India,  and Asia.  John Hopkins, Cleveland Clinic, Duke, Harvard and several other well-known top-tier American medical giants have branding agreements and other lesser affiliations with hospitals and clinics across the globe.

In the midst of this growth, concerns over patient safety and quality of care should remain at the forefront (in all facilities – domestic and international.) But until more potential customers demand (or even display any interest) in quality, and safety issues – the industry is not going to go out of its way to provide this information.

Colombian government steps up..


In a surprising but admirable move, the Colombian government has announced that it will pay for the removal of PIP implants.    As we discussed at our sister site, Cartagena Surgery, recent disclosures that the French company knew their breast implants were defective as far back as 2005 has sent shock waves of outrage through the medical community.  Further disclosures that the implants contained substandard construction grade materials (not medical grade) and fuel additives which contributed to the exceedingly high rupture rate (7% versus an average rate of 1% for all other implants) has important health implications for women world-wide.

In the wake of this scandal, hundreds of thousands of women across the globe, particularly women in Latin America where the implants were heavily marketed, have been panicking and storming physicians’ offices for answers.

(In a related post at our sister site – we reassured readers who received implants in 2011 by some if the surgeons profiled here..

With the French government advising over 30,000 french recipients of these implants to have them removed promptly, this goodwill gesture by the Colombian government should go far to reassure and calm Colombian women.

Update: 14 Jan 2012

Medpage Today just published a nice comprehensive article on the Poly-Implant Prostheses (PIP) implant controversy.  It’s a good story for people playing catch up on this story – and wondering if they may be affected by this news.

Heart Surgery Abroad – coming to the big screen?


Too bad, the independent filmmaker from Tennessee elected to travel to India rather than closer to home (like Latin America.)  Still – it places a lot of what we talk about into context – the affordability (or lack of) life-saving treatments in the United States versus numerous countries abroad..

Interestingly enough – despite making the choice to travel thousands of miles for a huge operation – it doesn’t sound like he throughly researched his surgeons, facilities  etc.  That is certainly troubling as medical tourism has not yet reached the Kayak, or Expedia level for interested travellers.  While I am very happy, relieved, pleased that everything worked out well – this could have easily been a cautionary tale (and loss for medical tourism) as a well-publicized win.

But, I will continue to hope that stories like his will help promote safe medical tourism, through the establishment of standards and regulations for medical tourism promoters.

Dental care overseas


As reported in numerous stories, many Americans are travelling to Mexico and other countries for dental care. Ex-pats or Americans living abroad are also seeking dental services.

However, as highlighted in this article – determining the quality of your provider overseas is not easy.  (Of course, it’s not easy to find a good dentist for many of us at home – but that’s a separate issue.)

Evaluating dentists and dental services is different that evaluating other health care providers – due to the nature of the service.  Unlike most surgical procedures – most dental procedures do not require anesthesia, (which means that they can be evaluated on a first-person basis).  Of course – for my colleagues who assisted me in writing Bogotá! – it meant quite a bit of time in the dentist’s chair..