Tag Archives: Medical Tourism

Nurse Practitioners and Medscape

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A couple of new articles over at Medscape highlight the role of Nurse Practitioners (and Physician’s Assistants) in patient care.

The Role of Nps and PAs with MDs in today’s care

A study from Loyola showed that surgical NPs reduced emergency room visits  : here’s a link to the article abstract by Robles et al. (2011).

Reducing cardiovascular risk with NPs: the Coach trial

And yet again, Nurse Practitioners trump physicians in patient satisfaction surveys.

This is just a sampling of the articles featured over at Medscape’s NP perspective.

From the free-text files: a selection of articles showing the growing use of Nurse Practitioners around the world

Nurse practitioners improve quality of care in chronic kidney disease: two-year results of a randomised study.  – a study from the Netherlands

A Parallel Thrombolysis Protocol with Nurse Practitioners As Coordinators Minimized Door-to-Needle Time for Acute Ischemic Stroke.  A taiwanese study showing the impact of nurse practitioners in reducing door-to-needle time in acute coronary syndromes.

Helping patients attain and maintain asthma control: reviewing the role of the nurse practitioner.

Type 2 diabetes, cardiovascular disease and the utilisation of primary care in urban and regional settings.  An Austrailian study discussing the impact of NPs in rural care.

Hospital General de Mexicali

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Following surgery at Hospital Alamater, we proceed to the Hospital General de Mexicali.  This is the largest public facility in Mexicali, and is surprisingly small.  After a recent earthquake, only three floors are currently in use, with the two remaining upper floors undergoing demolition for repair after earthquake-related damage.  The facility is old and dated, and it shows.  There are ongoing construction projects and repairs throughout the facility.

On the medical and surgical floors there are dormitory style accommodations with three patients in each room.  Sandwiched across from the nursing station are several rooms designated as ‘Intermediate’ care.  These rooms are full with patients requiring a higher level of care, but not needing the intensive care unit which is located downstairs adjacent to the operating theater.

 

surgical nurses at Hospital General

The intensive care unit itself is small and crowded with patients.  There are currently five patients, all intubated and in critical condition.  Equipment is functional and adequate but not new, with the exception of hemodynamic monitors.  There is no computerized radiology (all films are printed and viewed at bedside.)

We visit several post-operative patients upstairs on the surgical floors, and talk with the patients at length.  All of the patients are doing well, including several patients who were hospitalized after holiday-related trauma (stabbing with chest and abdominal injuries.) The floors are busy with internal medicine residents and medical students on rounds.

Despite it’s unattractive facade, and limited resources – the operating room is similar to operating rooms across the United States.. Some of the equipment is older, or even unavailable (Dr. Ochoa brings his own sterile packages of surgical instruments for cases here.)  However, during a case at the facility – all of the staff demonstrate appropriate knowledge and surgical techniques. The anesthesiologist invites me to look over his shoulder (so to speak) and read through the chart..

Since respiratory therapy and pulmonary toileting is such an important part of post-operative care of patients having lung surgery – we stopped in to check out the Respiratory department.  I met with Jose Luis Barron Oropeza who is the head of Respiratory Therapy.  He graciously explained the therapies available and invited me to the upcoming symposium, which he is chairing.  (The symposium for respiratory therapy in Mexicali is the 18th thru the 20th of this month.  If anyone is interested in attending, send me an email for further details.)

After rounding on patients at the General Hospital – despite the late hour (it is after midnight) we make one more stop, back at the Hospital Alamater for one last look at his patients there.  Dr. Ochoa makes a short stop for some much-needed food at a small taco stand while we make plans to meet the next morning.

Due to the limitedavailable resources, I wouldn’t recommend this facility for medical tourists.  However, the physicians I encountered were well-trained and knowledgeable in their fields.

Fired!!

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As I review the few short film clips I delegated to my ‘cameraman’ (my husband) – all I can say is that he is totally, and completely fired!!  (and I am pretty irritated.)

All I needed was a few background clips of Mexicali for the first new video cast for the iTunes series – I took all the stills, interviewed the surgeons and got all the intra-operative footage..  He just needed to get about two minutes worth – for the introductory segments..

Totally.  Fired.

So, readers, I apologize but my first iTunes video cast won’t be the wonderful, glossy creation I had hoped for.. More like a schizophrenic, slightly generic – art house production.

But we’ll try again on our next journey – (with a new cameraman!)

In the operating room with Dr. Carlos Ochoa, thoracic surgeon

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Mexicali, Baja California (Mexico)

Dr. Carlos Cesar Ochoa Gaxiola, Thoracic Surgeon

We’ve back in the city of Mexicali on the California – Mexico border to interview Dr. Carlos Cesar Ochoa Gaxiola as part of the first of a planned series of video casts.   You may remember Dr. Ochoa from our first encounter back in November 2011.  He’s the personable, friendly thoracic surgeon for this city of approximately 900,000 residents.  At that time, we talked with Dr. Ochoa about his love for thoracic surgery, and what he’s seen in his local practice since moving to Mexicali after finishing his training just over a year & a half ago.

Now we’ve returned to spend more time with Dr. Ochoa; to see his practice and more of his day-to-day life in Mexicali as the sole thoracic surgeon.  We’re also planning to talk to Dr. Ochoa about medical tourism, and what potential patients need to know before coming to Mexicali. He greets me with the standard kiss on the cheek and a smile, before saying “Listo?  Let’s go!”  We’re off and running for the rest of the afternoon and far into the night.  Our first stop is to see several patients at Hospital Alamater, and then the operating room for a VATS procedure.

He is joined in the operating room by Dr. Cuauhtemoc Vasquez, the newest and only full-time cardiac surgeon in Mexicali.  They frequently work together during cases.  In fact, that morning, Dr. Ochoa assisted in two cases with Dr. Vasquez, a combined coronary bypass/ mitral valve replacement case and a an aortic valve replacement.

Of course, I took the opportunity to speak with Dr. Vasquez at length as well, as he was a bit of a captive audience.  At 32, he is just beginning his career as a cardiac surgeon, here in Mexicali.  He is experiencing his first frustrations as well; working in the first full-time cardiac surgery program in the city, which is still in its infancy, and at times there is a shortage of cases[1].  This doesn’t curb his enthusiasm for surgery, however and we spend several minutes discussing several current issues in cardiology and cardiac surgery.  He is well informed and a good conversationalist[2] as we debate recent developments such as TAVI, carotid stenting and other quasi-surgical procedures and long-term outcomes.

We also discuss the costs of health care in Mexicali in comparison to care just a few short kilometers north, in California.   He estimates that the total cost of bypass surgery (including hospital stay) in Mexicali is just $4500 – 5000 (US dollars).  As readers know, the total cost of an uncomplicated bypass surgery in the USA often exceeds $100,000.

Hmm.. Looks like I may have to investigate Dr. Vasquez’s operating room on a subsequent visit – so I can report back to readers here.  But for now, we return to the case at hand, and Dr. Ochoa.

The Hospital Alamater is the most exclusive private hospital in the city, and it shows.   Sparkling marble tile greets visitors, and patients enjoy attractive- appearing (and quiet!) private rooms.  The entire hospital is very clean, and nursing staff wears the formal pressed white scrub uniforms, with the supervisory nurse wearing the nursing cap of yesteryear with special modifications to comply with sanitary requirements of today.

The operating rooms are modern and well-lit.  Anesthesia equipment is new, and fully functional.  The anesthesiologist is in attendance at all times[3].  The hemodynamic monitors are visible to the surgeon at all times, and none of the essential alarms have been silenced or altered.  The anesthesiologist demonstrates ease and skill at using a double lumen ETT for intubation, which in my experience as an observer, is in itself, impressive.  (You would be surprised by how often problems with dual lumen ETT intubation delays surgery.)

Surgical staff complete comprehensive surgical scrubs and surgical sterility is maintained during the case.  The patient is well-scrubbed in preparation for surgery with a betadine solution after being positioned safely and correctly to prevent intra-operative injury or tissue damage.  Then the patient is draped appropriately.

The anesthesiologist places a thoracic epidural prior to the initiation of the case for post-operative pain control[4].  The video equipment for the case is modern with a large viewing screen.  All the ports are complete, and the thoracoscope is new and fully functioning.

Dr. Ochoa demonstrates excellent surgical skill and the case (VATS with wedge resection and pleural biopsy) proceeds easily, without incident.  The patient is hemodynamically stable during the entire case with minimal blood loss.

Following surgery, the patient is transferred to the PACU (previously called the recovery room) for a post-operative chest radiograph.  Dr. Ochoa re-evaluates the patient in the PACU before we leave the hospital and proceed to our next stop.

Recommended.  Surgical Apgar: 8

[1] There is another cardiac surgeon from Tijuana who sees patients in her clinic in Mexicali prior to sending patients to Tijuana, a larger city in the state of Baja California.  As the Mexicali surgery program is just a few months old, many potential patients are unaware of its existence.

[2] ‘Bypass surgery’ is an abbreviation for coronary artery bypass grafting (CABG) aka ‘open-heart surgery.’  A ‘triple’ or ‘quadruple’ bypass refers to the number of bypass grafts placed during the procedure.

[3] If you have read any of my previous publications, you will know that this is NOT always the case, and I have witnessed several cases (at other locations) of unattended anesthesia during surgery, or the use poorly functioning out-dated equipment.

[4] During a later visit with the patient, the patient reported excellent analgesia (pain relief) with the epidural and minimal adjuvant anti-inflammatories.

French implant update

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More scary news for women around the globe – as the manufacturer, PIP discloses frightening information regarding their defective implants.  It has been discovered that the company knew that the implants were defective since 2005 – but continued to sell the implants for use world-wide, particularly in Latin America.

More disturbingly, this manufacturer did not use medical grade materials – instead opting for cheaper, construction grade chemicals including petroleum and fuel additives, components which have never been tested for [internal] human use.  The health effects of exposure to these materials is unknown.  The risks associated with the use of these materials is enhanced due to the high rate of rupture among this brand of implant.  These chemicals certainly have carcinogenic potential and the implications for thousands and thousands of women are terrifying.

French officials have urged women to have their implants surgically removed.

A preliminary search of PubMed and other published research shows mixed results – and primarily discusses the results of exposure to benzene (and other petroleum derivatives) via water contamination, or occupational exposure.   (In fact, only limited information is available regarding the safety of breast implants in general, and the material is fairly dated.)

As we stated in a previous story, while researching Bogota! and interviewing plastic surgeons – I investigated the types of implants used by the surgeons profiled in the book.  (None of the surgeons used this company’s implants at the time of my interviews in Winter/ Spring 2011).

Update:  In fact, the Colombian government has offered to pay for the removal of PIP implants.  More on this story here.

Aortic Valve Replacement & the elderly

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I just read an interesting article in the Annals of Thoracic Surgery.

Unfortunately, the full-text article is not available for free – but I did find a nice article abstract (which I’ve posted below.)  It confirms some of the previous discussions we’ve had here at Cartagena Surgery on the role of surgery in Aortic Stenosis, even in ‘elderly’ patients.  [I put elderly in quotes since the definition can be fairly elastic depending on who is doing the judging.]

The article below is from Medscape.com

Aortic valve replacement in the elderly: the real life.

Ann Thorac Surg. 2012; 93(1):70-8 (ISSN: 1552-6259)

Langanay T; Flécher E; Fouquet O; Ruggieri VG; Tour Bde L; Félix C; Lelong B; Verhoye JP; Corbineau H; Leguerrier A Department of Cardiovascular and Thoracic Surgery, University Hospital, Rennes, France.

BACKGROUND: Aortic stenosis is of concern in the elderly. Although aortic valve replacement provides good long-term survival with functional improvement, many elderly patients are still not referred for surgery because of their age. Percutaneous aortic valve implantation offers an alternative to open-heart surgery. Concerns about the management of aortic valve stenosis in the elderly will be reviewed.

METHODS: We retrospectively analyzed 1,193 consecutive aortic valve replacements, performed in octogenarians since January 2000. A total of 657 patients (55%) had at least one associated comorbidity (eg, respiratory failure) and 381 (32%) associated coronary lesions. Valve replacement was the only procedure in 883 patients (74%), and was associated with coronary revascularization in 262 cases, or with another cardiac procedure in 48 patients.

RESULTS: Overall operative mortality was 6.9% (83 of 1,193 patients); 5.5% for single replacement and 11.5% if associated with coronary artery bypass surgery. Univariate and multivariate analyses identified 11 operative risk factors related to general status, cardiologic condition, and the procedure itself: older age (p< 0.015); respiratory failure (p <0.03); aortic regurgitation (p <0.001); emergency surgery (p <0.0029); New York Heart Association class IV (p < 0.0007); right heart failure (p < 0.03); atrial fibrillation (p < 0.04); impaired ejection fraction (p < 0.001); coronary disease (p < 0.01); redo surgery (p < 0.02); associated coronary revascularization (p < 0.008).

CONCLUSIONS: Today, valve replacement has acceptable low hospital mortality, even in the elderly. Thus, older patients should not be denied surgery due to their advanced age alone. Conventional surgery remains the gold standard treatment for aortic stenosis; the decision should be made on an individual basis. If several risk factors suggest very high-risk surgery, then percutaneous valve implantation should be considered instead.

In more disturbing news:

As predicted, the unproven ‘easy option’ of TAVI is now being pursued by more low-risk patients.  These lower risk patients are people who should have been encouraged to undertake the more durable, safe and proven surgical therapy [Aortic Valve Replacement.]  I guess this just shows how quickly those new recommendations [for patient protection and safety] were thrown out the window.

In this article (posted below) by Kurt Ullman at Medpage Today – German researchers discuss their preliminary findings and discuss the use in low risk patients.

The bar for transcatheter aortic valve implantation (TAVI) is dropping as more lower-risk patients are undergoing the procedure and their outcomes are favorable, a single-center study from Germany found. [Unfortunately – as we’ve seen so many times in the past, and as I am finding out while preparing this presentation on the Syntax trial – studies such as this can be quite deceiving – and LONG term data is needed. – Cartagena Surgery].

When stratified by quartiles based on enrollment date, Q1 patients had higher logistic EuroSCOREs, higher Society of Thoracic Surgeons (STS) scores, and higher median N-terminal pro-B-type natriuretic peptide levels compared with those enrolled later in Q4, noted Nicolo Piazza, MD, PhD, and colleagues from the German Heart Center in Munich.

Although there were significant decreases in 30-day and six-month mortality from Q1 to Q4 in the crude analysis, after adjustments for baseline characteristics, the significant differences disappeared (HR 0.29 for 30-day mortality and HR 0.67 for six-month mortality), according to the study published online in the Journal of the American College of Cardiology.

“These results suggest that underlying comorbidities play an important role in acute and intermediate-term survival after TAVI,” the researchers wrote.

The researchers noted anecdotal information suggesting a shift toward using TAVI in patients who are less sick than those enrolled in premarket trials. Additionally, the next wave of trials involving the CoreValve (Medtronic) and the Sapien XT (Edwards Lifesciences) devices will involve intermediate to high surgical risk patients, providing “yet another indication that TAVI is being directed at the treatment of lower and lower surgical risk patients,” Piazza and colleagues wrote.  [There are significant ethical considerations here which seem to be ignored – similar to criticisms of the Syntax trial – Cartagena Surgery.]

A single-center French study of low-risk TAVI patients found the procedure to be safe in this population. The study was presented at the European Society of Cardiology meeting in Paris.

The impact on this shift in patient selection was uncertain, they said, prompting a retrospective review of 420 patients who underwent TAVI at their institution from June 2007 to June 2010.

The consensus that a patient was suitable for TAVI was derived from a team that comprised cardiologists, cardiac surgeons, and anesthesiologists. This team approach is exemplified by the recent announcement that the American College of Cardiology and the Society of Thoracic Surgeons will jointly sponsor a TAVI registry to monitor the safety and efficacy of the procedure as it rolls out in the U.S.

Patients received either the CoreValve or Sapien device, the latter of which was just approved for use in the U.S. based on the PARTNER trial. PARTNER found that TAVI was as good as surgery in high-risk patients with severe aortic stenosis. [‘as good as’ – ah.. another ‘non-inferiority’ study….. view with skepticism folks..]

Researchers divided patients into four quartiles of 105 patients each. Those in Q1 were seen earlier in the study time frame than those in Q4.

Compared with Q4, Q1 patients had higher EuroSCOREs (25.4% versus 17.8%, P<0.001), STS scores (7.1% versus 4.8%, P<0.001), and NT-proBNP levels (3,495 versus 1,730 ng/dL, P<0.046).

There were significantly less transfemoral access approaches from Q1 to Q4, with a concomitant rise in transapical approaches. There also were significantly less intubations moving from Q1 to Q4, and the use of contrast significantly decreased over time.

Researchers noted that transfemoral complications decreased by 17% from Q1 to Q4 (P=0.008), but found no significant differences in the rate of stroke or transient ischemic attack or the need for a permanent pacemaker.

However, there was a shift in the later quartiles toward the treatment of younger patients with fewer comorbidities and lower surgical risk scores, Piazza and colleagues wrote.

Univariable analysis for 30-day mortality showed it was associated with age, STS score, atrial fibrillation, previous heart surgery, and previous stroke (P<0.10).

The factors associated with six-month mortality were age, logistic EuroSCORE, STS score, left ventricular ejection fraction, atrial fibrillation, previous cardiac surgery, chronic obstructive pulmonary disease, and N-terminal pro-B type natriuretic peptide (P<0.10).

Because only baseline characteristics were included, the authors noted the possibility that procedure-, operator-, or device-related factors might influence both 30-day and six-month mortality. The study is also limited by potential unmeasured confounding.

The investigators cautioned that little is known of the long-term durability of these devices should they be routinely implanted in younger patients with a longer expected life span.  [especially since the lifespan of the patients these valves were designed for was six months to one year..]

Piazza is a consultant and proctor for Medtronic and CardiAQ. Other authors revealed consultant status with Medtronic and Edwards Lifesciences, or instuctors for Medtronic

French Implants recalled

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Hundreds of thousands of french made breast implants have been recalled – sending women all over the globe into a panic.  These implants which are no longer in use in France, have been linked to an increased rate of rupture, and possible increased incidence of cancer.

But good news for readers – as you may recall from my interviews with several of the surgeons (as written in the book) – none of the surgeons I interviewed used french implants.  The majority used FDA approved implants (only one brand currently FDA approved.)  Several others use german made implants*.. But this is an example of the details I’ve ferreted out for my readers..

* Brand information and other details are available in the book, “Bogota: a hidden gem guide to surgical tourism.”

More stories about fake docs including this one about a phony performing liposuction while smoking a cigar on AWAKE patients..

This guy was actually a doctor, but that didn’t stop ten of his patients from dying after bariatric procedures..

Cartagena on CNN

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It looks like our Hidden Gem of a city is finally getting some of the attention it deserves – earlier this month, the city of Cartagena was featured as a ‘secret treasure’ on CNN Travel.    The article talks about the Caribbean flavor of this bright, diverse and colorful city and its rich history.

photo by CNN

Across ‘the pond’ in the UK – the Telegraph was also singing the praises of this tropical, elegant paradise and it’s status as a ‘cultural capital’..

The doctor can’t see you now..

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On the other side of the equation (from the doctor won’t see you now)- is the on-going physician shortage, which will impact millions of Americans just as the aging baby boomer generation places increased demands on our strained health care system..  Rural areas will be the hardest hit (and already have the hardest time attracting physicians and other care providers).

In this article by Beverly Miller, [re-posted below] the author suggests solutions to the blooming crisis.

 I would like to add my own.  In her article, Ms. Miller gives short shift to nurse practitioners and physician assistants filling the gap.  This is unfortunate as multiple studies have shown that NPs and PAs provide an excellent level of care, and patient satisfaction – and have served as the mainstay of primary care in many rural and inner-city communities since the late 1970’s.  Nurse practitioners and physician assistants are currently hampered by several federal and state legislative issues which limit compensation and billing by nonphysician providers.  Several attempts at open and earnest dialogs among legislators, nurse practitioners and physicians have been hampered by physician attitudes.  A new report from the Institute of Medicine on the future of nursing emphasises the need to utilize nurse practitioners in this role (as we discussed here) but without further community and public support – much of the utility of NPs will fail to be realized**.

But as this author (Dr. Richard Cooper) points out – there just aren’t enough NPs, PAs and MDs combined to fill the projected shortfalls.  (So we shouldn’t argue amongst ourselves – there are plenty of patients to go around.)

PBS special on Nurse Practitioners a look at NPs in primary care.

To support your local NPs – take legislative action!  Right now, NPs are lobbying to be able to order home health and hospice for our patients as part of the ‘Medical Home’ bill.

How to handle the physician shortage  – Beverly Miller

The primary goal of health care reform deals with providing health coverage for all Americans. Policymakers tell us that it will pay for itself, but with the influx of an estimated 40 to 50 million people who were previously uninsured and the baby boomer generation now becoming eligible for Medicare (some say at a rate of eight per second), who do these policymakers believe is going to take care of these patients?
The problem is one of basic economics: supply is simply not keeping pace with demand.
Supply
The physician shortage in the U.S. is not a new problem caused solely by health care reform. Twenty-two states and 17 medical specialty societies are already reporting shortages today, long before the 2014 influx under the provisions of the Patient Protection and Affordable Care Act. Aging and population growth have created a greater demand for physicians than ever before.
Family practice, internal medicine, and geriatric specialists will be the gatekeepers under the reformed system. These specialties require more knowledge in a broader spectrum of diseases than other specialty physicians, yet are paid less for these services. For those doctors choosing family practice, internal medicine or geriatrics as a career, it is often a social decision.
A large number of physicians, mirroring the rest of the population, are reaching retirement age. The American Medical Association (AMA) has reported that in 2017, more than 24,000 physicians will turn 63. The number of retiring physicians could be even higher if the economy rebounds and many who delayed retirement for financial reasons decide to retire.
For the fifth year in a row, family practice and internal medicine have topped the Merritt Hawkin’s recruiting and retention survey.
It has been noted that new physicians are:

– opting for higher paying specialties since student loan debt often exceeds $150,000 – opting to practice at hospitals and health care systems where better technologies are available – desiring more flexible scheduling for family time and social activities – desiring to live in high-population areas  leaving vast areas of the U.S. underserved.

Also, the availability of residency slots is not keeping pace with the demand for new physicians and often residency slots for family medicine and internal medicine often go unfilled. A cap on Medicare-funded residency programs by the Balanced Budget Act of 1997 has not kept pace with needs. Also, there has been less availability of graduate medical education (GME) funding through state Medicaid programs
The Patient Protection and Affordable Care Act does include a provision for redistribution of residency positions by the Health and Human Services (HHS) secretary if residency positions have been unfilled for three Medicare cost reporting periods. The slots, which appear to number approximately 600, will be redistributed giving preference to hospitals located in states with a low resident physician to population ratio; or with a large population living in primary care health professional shortage areas, rural hospitals, and urban hospitals with accredited rural training tracks.
Demand
Need is driving the demand for primary care physicians. Groups and hospitals are rushing to form Accountable Care Organizations, patient-centered medical homes and other employment models, all of which are centered around the foundation of primary care.
As we moved to a managed care delivery system, the overriding belief was that good primary care promotes better outcomes and prolongs life. In many respects, it was a success since preventive care was added to coverage and patients began to think in terms of quality rather than quantity of care.
Moving to the next stage, most believe that it must better connect consumers to the health care system and that it must use information technology to better manage costs and patients.
Demand for services will continue to increase as the economy rebounds, resulting in more covered workers, and the baby boomer generation continues to attain Medicare coverage. And if the provisions of the legislation stay on track, there will be even more demand in 2014.
What do we do?
Varying solutions are being discussed.
Nationally, medical school enrollments have been flat over the past 20 years. Policymakers are calling for a significant increase in new physicians, recommending increases in medical school enrollments and increases in GME positions.
Signing bonuses, relocation expense reimbursement and medical education allowances remain standard in most physician recruitment incentive packages. Higher base salaries and productivity bonuses are slowly becoming the norm for family practice and internal medicine.
The 2009 stimulus package and health reform law have designated nearly $300 million for the National Health Service Corps to offer medical loans repayment to new physicians who practice in underserved areas.
Increase in reimbursements for family practice and internal medicine services are necessary to entice physicians to specialize in these areas.
Nurse practitioners and physician assistants can fill some of the void, along with non-U.S. trained physicians becoming eligible to practice in the U.S.
Shorten the training time for primary care physicians from an average of ten years to a more targeted education taking five to eight years by eliminating undergraduate majors and moving straight to medical curriculum and clinical training.
Expand the role of telemedicine as technology becomes more widely adopted by healthcare providers and patients.
There are no certain answers to the problem, but physicians have always been flexible and innovative. In conjunction with other players in the system, physicians themselves will be the ones with the right ideas and solutions. [unfortunately, physicians have also used their strength and influence to prevent alternative solutions in the past – cartagena surgery].


Beverly A. Miller, CPA, CAPPM , is Manager of Physician Services with Hayflich & Steinberg, CPA’s, PLLC and the current president of the National CPA Health Care Advisors Association. She has been heavily involved in practice startups, as well as aiding existing practices with billing issues, accounting issues, staff modeling and selection, project analysis, financial management, compliance issues, and tax planning. Beverly can be reached at (304) 697-5700.
Hayflich & Steinberg, CPA’s, PLLC is also a proud member of the National CPA Health Care Advisors Association (HCAA). HCAA is a nationwide network of CPA firms devoted to serving the health care industry. Members provide proactive solutions to the accounting needs of physicians and physician groups. For more information contact the HCAA at info@hcaa.com.

** As mentioned previously on this site, Nurse Practitioners work in a variety of specialty medicine and surgery practices. As an acute care nurse practitioner in specialty surgery practice – I work directly with a surgeon (versus a NP in primary care practice.)

More about the Mexicali project

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The ‘Mexicali project’ is different from any of the previous surgical tourism projects I’ve undertaken.  For starters – since I am currently working full-time in Northern Arizona – I can’t just drop everything and move to Mexicali for several months, like I’ve done previously.

So I really am a tourist – just like you, while I am here.  (I just plan to be a repeated one.)  That’s a critical difference because one of the most important aspects of my writing is that in many ways, I am just like you.  Or, at least a lot like many of the people reading my articles.  The only difference is that I am a nurse with a lot of experience in surgery and medicine.  But as a stranger in a stranger land? – well, I’m a novice, like many of the people who are considering traveling for health care.

I don’t speak Spanish – or at least not much.  [It’s one of the first things people assume about me, “Oh, you must speak Spanish”, but they are wrong.]   I am kind of learning a bit as I wander my way around different locations, which is fun – but I’ll never be fluent.  That’s crucial when I am roaming around in a strange country – How well can I navigate?  How safe is it for foreigners?  Will I be able to find people to help me (get directions, find a restroom, etc.)

I’m not an adventurous person (actually, I am kind of a chicken.)  – Many of you might be adventurers at heart, but I don’t want people to assume that medical travel is only for the daring or brave-hearted because I can be one of the meekest, mildest, most easily intimidated people you could ever meet.  You might think that some of my recent travels would have made me more confident or brave – but that’s not really the case.  I still get nervous going to unfamiliar places, reading maps, finding the right bus – so I understand how other people might feel (and for much of my travels – I’ve gone alone..)  So I like to think that this is my own kind of litmus test – if “Cartagena Surgery” can manage to find her way around, then most of my readers will be able to also.

But this time, it’s a little different – I’m not traveling alone – I brought my husband this time – and he’s a big gringo too.. (okay, I’m five foot one, so I am a “little” gringo).   He speaks even less ‘Spanglish’ than I do..But since he’s with me – I’ve changed the pace a little bit.. No 16 hour days this time. [During the Bogotá trip, I lost almost thirty pounds, because I was basically working or writing during all of my waking hours, and things like regular meals were pushed to the wayside.]  So, now I am smelling the roses, so to speak – enjoying the local culture instead of breezing past most of it.  Also, having my husband here helps me maintain perspective – of how others may see Mexicali.  Not everyone gets excited by medical facilities and doctors’ offices.

the hotel del Norte

So for now, I am planning to make several short trips to Mexicali – to fact-find and bring you information; about medicine, doctors, and facilities and some of the other things we encounter along the way.

“Exceeded Expectations!”

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is how I would rate my entire trip to Mexicali.  After making several previous trips to different parts of Mexico over the years – I had a lot of preconceived notions about Mexicali.  But despite being a large border city; I encountered few, if any of the tourist stereotypes that I expected (from visits to Ensenada, Cabo San Lucas, La Paz, and other tourist towns).  Instead of being treated like a ‘mark’ or a rich gringo, everyone I encountered went out of their way to be helpful, friendly and polite.  Strangers on the street offered directions – hotel staff gave friendly advice, and all of the medical receptionists I spoke with were exceedingly kind (which is not always the case.)  Much of the time, people on the street, in restaurants, and other locations assisted us in English.  Needless to say, it was a pleasant surprise – that my husband commented on several times.

Of course, some of the stereotypes about border towns were true; such as the occasional whiff of open sewer, poorly maintained sidewalks and pedestrian walkways but there were crosswalks at many corners and drivers did seem to yield to pedestrians.  Traffic was fairly smooth and uncongested in Zona Central.  Stoplights were present and functional, but the streets were not particularly well-lit at night, so I would advise taking the usual ‘big-city’ precautions.

The border crossings were easy (took about fifteen minutes to come back across to Calexico), and it seemed like even the American border patrol were more pleasant than usual.  (Unfortunately, I found in the past that they do look at you a bit sideways in Orlando after several months in Colombia).

I don’t usually recommend hotels and such (since I’m not ‘Trip Advisor’, after all) but in this case – I would like to recommend the Hotel del Norte for several reasons.  It’s a modest but attractive establishment, reasonably priced with friendly staff but more importantly, it’s one of few appropriate hotels in Zona Central, where most of the medical offices and hospitals are located.

There are quite a few gorgeous, and luxurious properties in Mexicali but most of them are located farther across town.  The Hotel del Norte is literally just steps away from the border on Francisco Maduro, which was very convenient for my needs. (I prefer to be in walking distance of the areas I am touring/ interviewing in.)  So – over time – as I move across town in my interviewing process, I get to see and know more parts of the city I am writing about.  I stayed in four different hotels while writing the first Cartagena book, for example.

I’ll bring you more news on my next visit..

Welcome to Mexicali!

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As I mentioned in a previous post – here at Cartagena Surgery, we’ve decided to explore some of the border cities of our neighbor to the south, Mexico.  For many people,  Mexico is the most practical option when it comes to medical tourism.

For our first look at Mexico, we’ve decided to travel to Mexicali, in Baja, California.  It’s just across the border from Calexico, California and is home to around one million people – making it a large metropolitan area.

With the drastic increase in drug-related crime and killings plaguing many of the other cities in Mexico such as Cuidad Juarez “Murder capital of the world,”  Tijuana and even the smaller Nogales, Mexicali is the safer, sweeter option for border cities.

In fact, Mexicali is known as the most affluent of cities in Baja California – and it is certainly apparent during our visit due to the availability of a wide range of medical services.  While the entry from the central border gate leads to a bustling commercial district, the more upscale, attractive residential neighborhoods are only a fifteen minute walk from the border.

At the Mexicali - Calexico border

About Mexicali:

Travel and Tourism links for Mexicali:

Official Mexicali tourism page – has English version. Also has a health section promoting local physicians and hospitals.

Mexico Tourism Information

WikiTravel

Getting Here:

The easiest way to get for (for many people) is to walk.  After driving to Calexico, California – turn down Imperial Boulevard and head towards the border.  Turn right on second street – and cross the railroad tracks.  Immediately on the left – there is a secured parking lot.  It costs about three dollars to park here overnight.

Take your valuables with you – and as you leave, proceed back down second street towards Imperial.  Cross Imperial – and walk about two more blocks.   Turn left on Rockland, and proceed towards the Calexico government building.  On the front of the building – you will see a set of turnstiles (like at an amusement park.)  Walk through the turnstiles – walk another 40 feet to the second set of turnstiles – and you are now in Mexico..

the doorway to Mexico

You will then walk through a short underground causeway – filled with little shops, and money changers/ cambios.  (This is one of the better places to change money – the rates are surprisingly competitive, and beat anything on the American side.)  When you emerge from the short hallway – there are stairs on the left.

These stairs lead to one of the main streets in Mexicali for medical services – Maduro.

Update: March 2012

I will be living in Mexicali for several months – so look for more postings and information about medical tourism/ medical services in Mexicali in the future.

Free trade, Colombia and Medical Tourism

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A new trade agreement between the United States and Colombia may usher in a new era of economic growth and strengthen political ties between the two nations.

As reported in Colombia Reports, Colombia’s biggest English language news source, while some experts caution that parts of this trade agreement may temporarily lower prices of some Colombian goods – other economic forecasters believe that this will bring financial growth and economic stability to both countries. In this webpage from US Government trade officials – the proposed benefits of this alliance our outlines – with job creation as a number one priority. I have contacted Ellie Shay at the Office of the United States Trade Representative for further comment on how this new agreement will impact medical tourism and travel to Colombia, and am awaiting a  response.

What will this new trade agreement mean for medical consumers and medical travel, if anything?  The Huffington Post previously predicted big wins for Colombia (2010, July) but is it too early to tell what impact this will have on the burgeoning medical tourism industry?

We’ll keep this story updated as it develops.

 

 

More mobile applications

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As you know, I am a nurse practitioner and medical writer  – not a programmer, but I am still working on expanding our mobile applications to include Apple, Kindle, Blackberry and other mobile products.

The latest version of “The Bogotá Companion” is a bit more limited than previous Android Market versions.  (The new application doesn’t allow for some of the features such as interactive maps.)  However, it does have video clips, some links to helpful travel information and feeds to our blog.

Here’s a browser app version..

Interview with an Escape Artist

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I had an interesting telephone interview with Jane MacLean Craig from the Escape Artist.com, a website for north American ex-pats, retirees and other people interested in living overseas.  She’s currently writing her fifth (or sixth?) book.  Her latest book is about overseas living, and we talked about the medical tourism and medical care abroad as part of that.

She’s very easy to talk to – and I love talking about the book and my day-to-day life as a nurse practitioner in cardiothoracic surgery, so we had a fine time!  I even talked a bit about my own experiences as a patient last winter, and how it sparked the Bogota book.

Her book is untitled as yet – but will be published by Random House in early 2012, so we’ll keep an eye out for it in the future..

American Presidental candidates in favor of medical tourism as part of health care solution

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In this story at Forbes.com – commentator Avik Roy discusses Rick Perry’s position supporting medical tourism, free-market health care, and health insurance to cover patients internationally.  Mr. Roy also discusses how these ideas would benefit the average American.

While I stay out of politics myself – and many people consider Rick Perry and several of the other potential candidates to be far from center – the Governor of Texas seems to have a good grip on the issues facing many of his constituents such as ballooning unemployment and a lack of health care access and affordable health options.

Medical tourism library

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Recent Articles about Medical Tourism

This page will be frequently updated and contains stories from a variety of sources.  It’s a mix between media articles, patient and industry blogs and ‘scientific’ and medical journals.

Note: ‘Medical’ articles are often heavily weighted against medical tourism (but consider the source – as the majority are written by UK and USA physicians.)  However, many of these articles bring up important points to consider prior to considering medical travel, such as quality control , patient safety and objective measurements (and other issues that we have discussed here before).

For more on patient safety issues – see my sister site, Cartagena Surgery.

I have also omitted patient perspective/ ‘testimonial’ type stories for the most part – as we’ve discussed here and on Cartagena Surgery – first-person narratives are not helpful in that patients themselves often do not have all of the necessary components to provide recommendations.

Medical Tourism: the element of cost – Healthnews.com

Crime, drug wars threatens Mexico’s medical tourism – opinion article

A portable medical health record – for medical tourists and other travelers.  A paper talking about a new free application to assist travelers in maintaining portable health records, and how this may change the face of health care, and consumer expectations/ safety.

An excellent overview of the issues involved in medical tourism – including quality of care, cultural issues and informed consent.  (this is a British article and focuses primarily on medical tourism to Thailand, India).  However, all of the issues raised in this article are addressed in the Bogotá book.

A review of the literature surrounding ‘the patient experience’ of medical tourism’

A nice article talking about the availability and quality of medical tourism information available on the internet (something we’ve talked about many, many times.) Of course the name of the article, “Nip, Tuck and Click” does give a hint of the writers bias against medical tourism.

Medical Tourism backlash

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One of the trends I’ve seen in the last few months is a growing assortment of medical propaganda that can only be termed ‘medical tourism backlash’.  Frighteningly, these writers are often willfully misinformed and published on websites that give the appearance of legitimacy.  I’ve included an example here – published on a website called News Junky Journal.  The junky part is certainly accurate.

This article is a thinly disguised ad for a US based plastic surgeon – Dr. Delgado and persists in spreading misinformation, untruths and some blatant lies.  The author, Charles Hale makes no effort to distinguish between medical tourism destinations, much less the facilities and surgeons themselves but uses a blanket brush to depict all non-US surgeons as poorly trained uncredentialled hacks operating without consideration for patient outcomes due to a lack of fear for repercussions.  He presents his ‘facts’ as absolutes – and as all educated consumers know – there are no absolutes.  Yes, there are bad surgeons (everywhere – and quite a few unlicensed frauds in the USA as well, as we’ve documented over at Cartagena Surgery as part of a series explaining how to evaluate medical and surgical providers.)

But there are also well-educated, kind, caring EXCELLENT surgeons like the ones we’ve identified during this project.  Fear-mongering is not the way to drum up patients or protect people from adverse outcomes.  Objective, and honest research is.

There are several other blatant inaccuracies in the above mentioned article – including statements that insurance companies NEVER pay for medical tourism – as we’ve discussed here, and in the book – several American health care companies such as Blue Cross actually have medical tourism divisions to help patients find providers overseas.  This medical tourism company helps people use their Health Savings Accounts for medical travel.

He also ignores ‘complication insurance’ as offered by many of the providers interviewed in Bogotá – which explicitly covers the treatment of any surgical complications whether at the destination or after patients return home.

As I’ve mentioned numerous times, I do think that the medical tourism industry should be regulated – ‘tour operators’ shouldn’t sell the services of people they’ve never met, but to disregard medical tourism as simply a plaything of indulgent people wanting to have surgery while frolicking on the beach, as implied in his last paragraph is ignorant and insulting to the very people who rely on medical tourism as their only option outside of complete financial devastation.

Sadly, I think scare articles like this are only the beginning; as American surgeons (particularly plastic surgeons who rely on elective procedures for their income) continue to feel the effects of a poor economy.  But slandering an entire industry and hundreds of thousands of hard-working medical professionals, and terrorizing patients is not the answer.

E-formats and other things..

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Still working on creating the e-formats of Bogotá!  Due to my unstoppable love for footnotes, re-formatting the manuscript for electronic formats is a slow, tedious and painstaking process.  After several days of working at it (25 + hours so far – I am only on about page 80) but as annoying as re-formatting is – it’s also necessary so that my e-reader using buyers have a high quality, easy-to-read book.

I’ve hired a translator to start working on creating a Spanish version of the book, for all the native Bogotanos (only seems fair that they should be able to use my book) – as well as my other Spanish readers.  Should be about a month to complete – and then I’ll start formatting that book into electronic formats as well.  So there is still a lot of work ahead of me, but that’s the life of the independently published writer.  I don’t have an army of minions to do these things for me; I am writer, investigator, fact-checker, publicist, graphic artist, typesetter, publisher and the IT department all rolled into one.

It’s definitely been an interesting process this time around, and I don’t regret self-publishing because I like having creative control.  I think that’s essential in a project like this when your integrity, and your honesty is the basis for the product.

More photos from Bogota event

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Back stateside, and bracing for Irene.  We are pretty far inland so probably just a lot of rain and refugees from the storm but the sky is black and still – so you never know.  I missed the recent earthquake – safe in Colombia! and despite being a historic home, it was a small quake (5.8) so we made out just fine.

I have some more pictures – sent over from Author’s Cafe that I thought I’d share.  Readers will recognize most of the players – since it was a ‘thank you’ party to everyone that participated in the book.

with Ximena Reyes, RN

 

 

 

 

 

 

 

Dr. Gamboa looks really stern, but that’s not his nature at all – they just caught him in-between laughs.

with Dr. Gamboa and a friend

with Dr. Francisco Cabal, Orthopedic Surgeon, Medical Director of Clinica del Countrywith Ximena Reyes, RN

Dr. Roosevelt Fajardo (left) and Dr. Francisco Holguin

Book Party!

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Signing a book for Dr. Freddy Sanabria

 

Author’s Cafe,

Bogotá, Colombia

Had a wonderful event to share my book with and thank all of the people who made it possible.  (No surgeons, no book).  It was wonderful to see everyone – and I want to thank all the surgeons – who literally came straight from surgery to give their support of this project.  Some of the great friends I have made from all walks of life (outside the hospital) were also there – which means a great deal – I know that I live and breathe writing and surgery, but I also know that this is not true for most people.

That’s been the theme of all of my visits to Colombia; kindness, caring and support.  So many people; from surgeons, nurses, to taxi cab drivers and even random strangers in passing have been kind to the little (sometimes lost) American.

What’s next?

About 1/3 complete on formatting the e-version.  It’s a tedious job, but once it’s complete – it will give me the freedom to do instant book updates as needed.

Also hoping to translate the book into Spanish versions. It’s been difficult to find someone due to the technical/ medical language.

Now that the Bogotá project is essentially complete – I anticipate that this blog may change in focus – similar to Cartagena Surgery.  There will be more of a focus on medical tourism and medical news, now that interviews will be few and far between.  (Never done entirely.)

 

Interview

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Just had a really nice visit with James Gherardi, and his cameraman from the local TV station, WSET – 13 to talk about the book.  Now if only all my poise hadn’t suddenly fled – leaving me an awkward mess!  Gratefully, all my loyal readers know that despite all outward appearances, I really am a capable, competent individual with full use of my faculties.

Lets hope viewers are as kind.

It is scheduled to air as just a quick segment this evening at 6pm.. and let me warn my devoted readers – yes, I had a hair tragedy, but it’s only temporary (and for a good cause!)..

The Chicago Tribune, Medical Tourism and Patient Safety

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The Chicago Tribune recently published an article about medical tourism  by Alexia Elejalde Ruiz that quotes Joseph Woodman pretty heavily.  He writes about medical tourism and quality but from more of a statistical and policy perspective (no medical background.)

The article was written to give tips to potential medical travelers, and mentions JCI accreditation and standards etc.  I think this shows a growing awareness among the media and consumers that there is a need to regulate this industry to protect patients from harm.

Unfortunately, this article did not go into more detail, and despite mentioning Colombia in the article subtitle, there was nothing further about Colombia in the article.

Too bad – as my long time readers know – my entire purpose and mission in writing and researching this book was to provide consumers with exactly this sort of information  – from first hand observation.

Reputation, Ranking and Objective Measures:

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Reputation,  Rankings and Objective measures

The top-10 heart and heart surgery hospitals (according to US News 2011) were as follows:

  1. Cleveland Clinic
  2. Mayo Clinic
  3. Johns Hopkins
  4. Texas Heart Institute at St Luke’s Episcopal
  5. Massachusetts General
  6. New York Presbyterian University
  7. Duke University Medical Center
  8. Brigham and Women’s Hospital
  9. Ronald Reagan UCLA Medical Center
  10. Hospital of the University of Pennsylvania

(US News, July 19, 2011)

The First shall be First..

Well, the latest US News hospital rankings are out – and as usual, John Hopkins is at the top of the list – as they have been for the last seventeen years.  Or are they on the top of the list because they were ranked #1 for the previous sixteen years?

How much do these or any rankings actually reflect the reality of the health care provided?  What are they really measuring?  These are important questions to consider.  While US News uses these rankings to sell magazines, other people are using these results to plan their medical care.

 So, what do these rankings or studies show[1]?  The answer depends on two things:

1.  Who you ask.  2. The measure(s) used.

Reed Miller, over at Heartwire.com reported the results of a study by Dr. Ashwini Sehgal over at Case Western Reserve examining the US News Rankings back in 2010 (and re-posted below.)  Dr. Sehgal explains that much of what the US News is measuring is not scientific, nor objective data – it’s public opinion, which as we all know, may have little basis in actual facts.  Ask any fifteen-year- old girl who is the most qualified candidate for president – now imagine Justin Bieber in the White House[2].  An extreme example, to be sure – but one that fully illustrates the pitfalls of relying on this sort of subjective data.

News versus Tabloid

This isn’t the first time that the magazine has come under scrutiny for the methodology of their ‘ranking’ practices.  Teasley (1996) exposed similar flaws in their ranking schemes almost fifteen years ago.  Green, Winfield, Krasner & Wells (1997) explained in JAMA that there
were additional limitations to US News approaches due to a lack of availability of standardized data, despite the magazine using what they considered to be a strong conceptual design.  They cite the same concerns with the weight given to reputation as a majority deficiency.

However,  these significant oversights does not prevent the media and hospitals from continuing to present their results as a legitimate measure of  performance. In fact, more people know about these rankings than they do about government data collected for the same purpose.

Core Measures

Compare this well-known ranking, with governmental attempts to quantify and compare American hospitals.  Medicare and Health and Human Services quantifies and ranks hospital  performance using a ‘score card’ scenario known as “Hospital Compare.”

While this government system is far from perfect since it relies heavily on individual physician documentation, it is an evidence-based measurement tool, making it far more objective.  The government rating system uses a series of specific criteria called Core Measures.  These core measures are used to evaluate adherence to accepted treatment strategies for different conditions such as heart failure, heart attack, and pneumonia.  This data is then published on-line for consumers.

The advantages to measurement tools such as Core Measures is that it an easily applied checklist type scoring system.

For example, the core measures used to evaluate the appropriateness of treatment for an acute myocardial infarction (heart attack) are pretty clear cut:

– Amount of time in minutes for patient to receive either cardiac cath or thrombolytic drugs “clot busters”

– How long (minutes) for patient to receive first EKG after presenting with complaints consistent with AMI

– Did patient receive aspirin on arrival?

– Did patient receive ACE/ ARB for LV dysfunction?

– Did patient receive scripts for beta blockers, ACE/ ARB, aspirin at discharge?

As you can see – all of these measurements are clear, easily defined and objective in nature.  The main problem with core measures in many institution is getting doctors to clearly document whether or not they instituted these measures.  (But that too reflects on the institution, so hospitals with multiple staff members not adhering to the national guidelines will have lower scores than other facilities.)  In fact, this is the main criticism of this measurement tool – and this criticism often comes from the very doctors that omit this data.  (In recent years – hospitals have tried to address this shortcoming by making documentation an easier, more streamlined process – and allowing other members of the health care team to participate in this documentation.)

Then this data is compared to other hospitals nationwide, with subsequent percentile ratings, and status.  Ie. a hospital may rank higher or lower than national average for death rate or re-admission for heart attack, pneumonia, post-surgical infection or several other diagnoses/ conditions.  Consumers can also use this database to compare different facilities to each other (such as several hospitals in a local area).

The accessibility and publication of this data for health care consumers is a very real and meaningful public service.  This allows people to make more informed choices about their care, without relying on third-party anecdotes, or reputation alone.

How does this tie in with surgical tourism?  (or what does this have to do with Bogotá Surgery?)

As part of my efforts to provide objective, unbiased information on the institutions, physicians and surgical procedures in Bogotá, Colombia, I applied the Core Measures criteria as part of my evaluation.  I used these measures not on an institutional level, but on an individual provider level – to each and every surgeon that participated in this project.

However, core measures (NSQIP) was not the only tool I used during my assessment.  I also used several other measurements to get a fair/ well-balanced evaluation of the providers listed in my publication.  (Other criteria used  as part of this process will be discussed more fully in a future post.)

Surgical tourism information needs to be clear, objective and meaningful to be of use to potential consumers.  Reputation alone is not sufficient when considering medical treatment either in the United States or abroad – and consumers should seek out this information to help safeguard their health.

Article Re-post from Heartwire.com

Popular best-hospital list tracks subjective reputation, but not quality measures

April 20, 2010 | Reed Miller

Cleveland, OH – US News & World Report‘s list of the top 50 hospitals
in the US reflects the subjective reputations of the institutions and not
objective measures of hospital quality, according to a new analysis [1].

The magazine’s ranking methodology includes results of a survey of 250 board-certified physicians from across the country, plus various objective data such as availability of specific medical technology, whether the hospital is a teaching institution or not, nurse-to-patient ratios, risk-adjusted mortality index based on Medicare claims, and whether the American
Nurses Credentialing Center has designated the center as a nurse magnet.

In his analysis of the US News rankings system, published April 19, 2010 in the Annals of Internal Medicine, Dr Ashwini Sehgal (Case Western Reserve University, Cleveland, OH) points out that previous investigations have compared the US News rankings with external measures and found that highly ranked cardiology hospitals had lower adjusted 30-day mortality among elderly patients with acute MI, but that many of the high-ranked centers scored poorly in providing evidence-based care for patients with MI and heart failure. Also, performance on Medicare’s core measures of MI, congestive heart failure, and community-acquired pneumonia were frequently at odds with US News rankings.

Sehgal sought to examine a broader range of measures internal to the US News system and “found little relationship between rankings and objective quality measures for most
specialties.” He concludes that “users should understand that the relative standings of US News & World Report‘s top 50 hospitals largely indicate national reputation, not objective measures of hospital quality.”

Sehgal performed multiple complementary statistical analyses of the US News & World Report 2009 rankings of the top 50 hospitals in the US, as well as the distribution of reputation scores among 100 randomly selected unranked hospitals.

He examined the association between reputation score and the total score and the connection of objective measures to reputation score. According to Sehgal’s analysis, the statistical association is strong between the total US News score and the reputation score. The association between the total US News score and total objective scores is variable, and there is minimal connection between the reputation score and objective scores.

The majority of rankings based on reputation score alone agreed with US News overall rankings. The top five heart and heart-surgery hospitals based on reputation score alone were the same as those of the US News top five heart hospitals (Cleveland Clinic, Mayo Clinic—Rochester, Johns Hopkins University, Massachusetts General Hospital, and the Texas Heart Institute), and 80% of the 20 heart and heart-surgery hospitals with the best reputation scores were also on the US News top-20 heart and heart-surgery centers.

Objective measures were relatively more influential on cardiology centers’ total scores than in some other categories, but reputation still carried a lot more weight than objective measures. Sehgal used the nonparametric Spearman rank correlation p value to assess the univariate associations among reputation score, total objective-measures score, and total US News score. The p2 value indicates the proportion of variation in ranks of one score that are accounted for by the other score.

Additional Resources and References

1.  Teasley, C. E. III (1996).  Where’s the best medicine? The hospital rating game. Eval Rev. 1996 Oct;20(5):568-79.

2. Green J,  Wintfeld  N., Krasner M.  & Wells C.  (1997).  In search of America’s best
hospitals. The promise and reality of quality assessment. JAMA. 1997 Apr 9;277(14):1152-5.

3. Sehgal, A. R. (2010). The role of reputation in U.S. News & World Report’s rankings of the top 50 American hospitals. Ann  Intern Med. 2010 Apr 20;152(8):521-5.

[1] US News may be the best known, and most widely published source, but there are multiple
studies and reports attempting to rank facilities and services nationwide.

[2] This is probably not a fair analysis given the current state of American politics.

Final drafts.

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Looks like I am getting closer to the finish line; I submitted what is (hopefully) the last and final draft last week.  After one last round of review – it will be off to the publisher.. (This is the most frustrating part of the process – it’s all formatting issues – unrelated to content.)

Otherwise – the book looks pretty darn good!

Proof copies!

Proof copies!!

 

 

Patient Safety & Medical Tourism

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I’ve posted a link to an article talking about patient safety, and facility/ physician oversight in foreign medical facilities for patients seeking medical tourism options.

This is the rationale and purpose behind the both the Cartagena and the upcoming Bogotá books – that as an independent, unbiased reviewer and health care professional; I am able to observe, interview and evaluate facilities, surgeons and procedures for safety issues (and adherence to accepted national and international standards / protocols.)

This eliminates the uncertainty for patients seeking medical tourism; is the facility clean?  Are the physicians licensed?  Are the procedures performed according to accepted practices?

As a reputable, practicing health care provider with no secondary gain (other than book sales), patients can find a trustworthy source for this information.   I don’t work for the surgeons, the medical tourism companies or the governments of the host countries.  I don’t make a dime from these medical procedures – and have no vested interest in where patients ultimately seek care.

But, the development of infections, post-operative complications or other problems with medical tourism is bad for business (for the providers and facilities reviewed) so these facilities had a vested interest in letting me into their hospitals and their operating rooms.  They wanted me to see what they had to offer – particularly the facilities that are doing everything right..

(The facilities that weren’t following accepted practices invited me in, as well.  I think because they assumed that an American nurse wouldn’t know any better.)  That’s their oversight, and to your benefit – because I was able to observe and report my findings to you, my readers.

I think this is going to become a more popular and frequent practice – but hopefully the reviewers are going to be people like me; people familiar with the procedures and practices, and the operating room.  This is another separate issue – that has already reared its head.  There are several medical tourism books out there, including books that have made millions of dollars, written by arm-chair MBAs who looked at published statistics (only) and used this as the basis of their reports.. As everyone knows, published statistics are only part of the story, and can certainly be manipulated.

Physically viewing the facilities, talking to the surgeons and watching the procedures are the real test of how things function on a daily basis, and what care a patient should expect.

Friday, I am heading to Reston, Virginia to interview one of the people involved with the new Colsanitas medical tourism venture that we discussed in a previous post.  I’ve already been to the hospitals in Colombia (Clinica Colombia and Reina Sofia) and I’ve interviewed the surgeons involved, so I know the quality and care provided by the facilities involved.  But do they?  What rigor has this company performed to protect potential patients (and consumers of their services)?  In this case, I know that both the hospitals and the surgeons are excellent, but do they?  And how do they know this?   I’ll try to get answers to all of these questions and post them here for readers.

ProExport Replies to our inquiries..

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First, I would like to give my sincere thanks to Gabriel Amorocho, who sought me out to address my concerns regarding ProExport.  He then made a special effort to follow up with me and to get all of my questions answered.

Since I was unable to meet any of the ProExport representatives during my stay in Colombia – I submitted a list of questions for your information.  I am posting the questions and the official answers from ProExport here.

Questions and Answers with Erick Forero of ProExport:

1.     What do you anticipate for the future of medical tourism in
Colombia?

Thanks to the high quality level of our health services, as well as the efficiency of its administration and management, Colombia has become an international leader in the health services sector, with the United States, the Caribbean islands and Ecuador as its main
clients.  The plan moving forward is to continue strengthening the sector, as well positioning the country even more as a health destination.

In addition, Colombia is now going through an excellent moment on the subject. Colombian health institutions have reached worldwide acknowledgement thanks to its state of the art technology, qualified personnel, customized attention, excellent service-lead times and competitive pricing.

The sector is currently working very strong on accreditation activities. While the country has its own accreditation system, there are some institutions working on their accreditation from the Joint Commission International (JCI).

So far we have two accredited institutions and around 15 in the process to enter the United States’ market.

2. How is the government promoting Colombia as a medical tourism destination?

The Government chose the medical services exports sector as a world-class industry, on the basis of which the Ministry of Trade, Industry and Tourism is conducting its activities around
creating tools to facilitate and overcome certain barriers that have been identified in the health field.

The duty-free regulation arose from the fact that sufficient beds were not available. Thus, the duty-free zones will increase the capacity by over one-thousand.

Furthermore, as part of its exportation promotion activities, Proexport Colombia is working very hard on positioning the country abroad by participating in events and arranging fam-trips where we bring insurers and facilitators to display our technology, infrastructure and the clinics.

3.     What do you see as the advantages of medical tourism in Colombia for North American consumers?

There are several reasons why Colombia is a health-tourism destination: First of all, it stands out at Latin American level thanks to its research on scientific and health topics; it has
established itself as an annual host for prestigious academic events, conventions, seminars and health training sessions; in addition to being pioneers in Latin America on the creation of its own health-accreditation systems (a total of 16 institutions have national accreditation and two have JCI international accreditation).

Colombia ranks first in Latin America in overall health system performance, and 22 in the world, according to the World Health Organization (WHO).

On the other hand, significant advancements have been made in the country as contributions to the medical world, such as the creation of the pacemaker (useful for certain heart
diseases), the Hakim valve (created to treat brain diseases) and the Malaria vaccination (a tropical disease that causes serious health problems in the region), among others.

Because of this, and thanks to the firm commitment to always guarantee the highest quality standards of health services, Colombia is one of the most attractive destinations world-wide for
health tourism.

4. I know Colombia has regulations in place restricting organ transplantation in Colombia to prevent black market sales.  Can you tell me more about that?

This is not a competency of Proexport Colombia. There is a regulation in place to give priority to national patients for transplants. The entity in charge is the National Health Institute. Its web
page is www.ins.gov.co.

5. Is Colombia planning to be represented at the Medical Tourism Association Congress in Chicago this October?

Who will be representing Colombia, and what will they be presenting?

We will be at the Convention in Chicago. The Colombian representation will be led by 10 institutions from the whole country. Proexport Colombia will coordinate the entire participation, thus we will have a stand with information regarding the country and four of
the participating clinics, which are all accredited and will have a stand. The best of the best from the country is going to be present at the event. They will be presenting their services, their export offer and the progress made in matters of infrastructure and technology acquisition.

6.    Is there anything specific you would like to pass along to Americans considering coming to Colombia for surgical procedures?

The offering found in Colombia by the foreign visitors coming to the country seeking these services is varied; however, the main sectors sought after are Cardiology, Cancer treatments,
Ophthalmology, Orthopedics, Dentistry, medical check-ups and plastic surgery.

Amongst the sales channels identified by Proexport, the entity in charge of exports, investment and tourism promotion in Colombia, we have the end user, insurers, facilitators and foreign doctors.

However, the arrival of new visitors into the country seeking these services is due to the various international conferences and conventions which take place, web-page promotions, insurer and
facilitator Fam Trips.

Bogota and Medellin are the main destinations for foreigners, followed by Bucaramanga, Cali, Santa Marta, Barranquilla, Cartagena and the Coffee Triangle.

Colombian Doctors are very experienced, and the majority of them have been educated in universities abroad.

We also have state-of-the-art technology and a one of a kind diversity of climates all year round, which is great for all patients.

In addition, thanks to our economy and exchange rates, we are very favorable in terms of costs, considering that health services are very costly and slow in other countries, while the opposite
occurs in Colombia.

Furthermore, we have good air-traffic connections with the United States.

7.      Can you explain the medical visa to me? Is a medical visa needed?

This is Foreign-Affairs Ministry issue.  But Colombia does not require a medical visa. If the treatment is a very lengthy one, lasting over six months, you must request a visa.

Thanks again, Mr. Amorocho, and Thanks, ProExport Colombia.

Colombia as a medical tourism destination: my experiences & observations

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I submitted an article on Colombia as a medical tourism destination to Yahoo! for publication.  The article discusses several of the factors I’ve mentioned before, and includes my observations from the last several months.  We’ll have to wait and see if they think it’s suitable for publication.. Of course, if they reject it – I’ll be sure to post it here, for all of you and your critiques..

Interview with ProExport

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Update: 14 May 2011: I received a comment on the website from a Mr. Gabriel Amorocho (of ProExport) inviting questions – so I have sent him several.. Thank you for contacting me. I will update readers and let them know if I receive a reply..

Original Post

There’s nothing like a government agency to remind you of your own insignificance.  In this case, it’s Colombia’s ProExport..  ProExport is the government tourism division and one of its specific aims is to promote medical tourism to Colombia..  and here I am, writing a guide to medical tourism in Colombia…hmmm.

So as a writer on medical tourism in Colombia – I thought it would be nice to meet with someone over there, just to hear more about ProExport, what they do, what they are doing to further medical tourism, what they thought the future of medical tourism was in Colombia, etc..  It was a pretty important interview for me – because I thought I would be able to get a lot of questions answered for potential medical travelers, from an official source… yeah – it would have been nice.. But..

Nope, Nada, Never.  Not even after five months!  of calling, emailing and trying to get an appointment with someone, anyone, over at ProExport.  Everyone I’ve met here has tried to intercede, even my downstairs neighbor (who knows someone who knows someone etc..)  to get me just twenty minutes with someone from ProExport..  I’ve emailed several people at ProExport directly, from the information they provided..  I even managed to navigate the operators, with multiple transfers only to be transferred to an endlessly ringing phone.. and called again, and again, and again..  Never even got a form response to my emails..

It was easier – to get a reply from the President himself, (President Juan Manual Santos), and he was exceeding gracious about it..  (I sent him a copy of my first book – silly, but I was excited – my very first book, and just a week or so later, I received a very nice thank you note..)

So it’s the last weekday, of my last week here in Bogota, so I guess this humble writer, has been humbled again – and I will accept defeat.. There will be no ProExport interview for this unknown writer..

In the operating room with Dr. Rafael Beltran, Thoracic Surgeon

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Dr. Rafael Beltran, Thoracic Surgeon

Spent the morning at the National Cancer Institute, which really is a pretty amazing place, with a pretty amazing guy – Dr. Rafael Beltran. He’s one of the many incredible people I’ve met here – that truly make the world a better place through their work. I could have spent all day with him, seeing patients, surgery, discussing his cases and research – (Heck – I’d love to work with him!) but unfortunately, I had to race across town after several hours for another interview..

Dr. Beltran (tall gentleman on the left) and his surgical team

I really like this picture here, I think it highlights one of the important aspects of surgery – the surgical team.. As you can see above, Dr. Beltran (left) certainly doesn’t work in isolation – and that’s his philosophy about cancer care – the surgeons from different specialties work together closely, along with oncologists, radiologists, hematologists, therapists and other specialties to give well-coordinated, and well-rounded care. While I was the operating room, I stood next to a shy young woman.. After I badgered her for a little bit – she told me her story. She’s a respiratory therapist – and she was watching the surgery, so she would better understand how to take care of her lung surgery patients – and to understand exactly what they had been through. Not often do surgeons find room in their ORs for respiratory therapists – but Dr. Beltran understands that by having this young woman here observing – she learned more today than she could ever glean from books.. By doing so – he’s integrated her into the surgical team, and that’s important when often today’s medicine is an exercise in fractured and fragmented care.

In the operating rooms all around us – the same thing was occurring, with orthopedics, plastic surgery, neurosurgery.. As you can tell – on all my visits to the National Cancer Center, I’ve been very impressed with the physician commitment and the level of care.

As I raced off – I received a text that the doctor I was next scheduled to meet had to go to another hospital – he offered to meet me there, but he had an emergency, so I thought it best to reschedule for when he had more time.  I’m really looking forward to talking to him – so I didn’t want him to be too distracted.. I get the best interviews when we can just sit down and talk..

Then – a thoracic surgeon we’ve talked about before – texted me that he had 2 interesting cases – did I want to go? So I spent he remainder of the afternoon talking with Dr. Juan Carlos Garzon, thoracic surgeon. I’m glad I did – because I had lots of questions from our previous interviews, and between cases, he spent the time to answer my lingering questions; about his practice, about thoracic surgery in general, and about Colombian medicine so it was definitely a worthwhile trip..

  Dr. Juan Carlos Garzon, Thoracic Surgeon..

The Future of Thoracic Surgery

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Dr. Juan Carlos Varon in the bronchoscopy suite


Actually, this title sounds way too dire for the pleasant and relaxed day I spent over at Hospital Santa Clara, interviewing Dr. Barrios, Thoracic Surgeon and two Thoracic residents, Dr. Juan Carlos Veron and Dr. Carlos Carvajal.. But it’s essentially true as I talked to the up and coming Dr. Barrios, and the future thoracic surgeons… Dr. Barrios is currently involved in some very interesting treatments for metastatic cancer.

Dr. Juan Carlos Varon, unmasked

Dr. Carlos Carvajal

I also interviewed Dr. Juan Manuel Troncoso and his partner, Dr. Elena Facundo, two general surgeons who are currently involved in some interesting projects..

Last week in Bogota

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well, everyone – my visa is expiring, I’ve spent my retirement, I’m physically exhausted, and I need a job – it’s come time for me to return home to the United States. But not before I cram in as many last-minute interviews as possible before my plane takes off in the early morning hours of May 16th.

My only regret is despite interviewing as many surgeons as I was physically able, it just wasn’t possible to meet and talk to all of the thousands (literally thousands) of surgeons here in Bogota.

For my last week, I have some great interviews lined up – going to meet with several more surgeons at Hospital Santa Clara, going to the operating room with Dr. Beltran from the National Cancer Institute and interviewing with the amazing trauma surgeon, Dr. Borraez, inventor of the ‘Bogota Bag’ aka the ‘Borraez Bag.’  I’ll be seeing Dr. Holguin, as well, from the first edition – to catch up as he now lives in Bogota part-time.

I’m still hopeful I’ll be able to slip in and see a few more surgeons – waiting to hear back now..

But I won’t be away from Colombia for too long!  I plan to be back in August, once I’ve completed the arduous task of editing the hundreds of pages of notes, and thousands of pages of additional materials – to present my book, here in Bogota, first – to all the people who have assisted me, took time out of their busy schedules to talk to an unknown nurse, and budding writer.

Even if I never sell a large amount of copies, I feel like I have accomplished a lot – I have brought some well deserved attention to some great physicians.  Many of these people do things, ever single day that would be considered extraordinary at home.  Others have invented or performed procedures that are used around the world to help others.  Others make the world, and Bogota, a better place, just by listening to their patients, giving freely of their time and caring.  That’s no small feat in today’s world of medicine, and for me, no small feat to write about.

I hope that the readers of this book are able to get a sense of the information I am trying to convey, and that it helps them with their healthcare decisions.  If I have done that, and sell ten copies – then I have succeeded beyond my wildest dreams.

Thank you to everyone following my blog, and I hope you’ve enjoyed reading it as much as I have enjoyed writing it!

New short on YouTube : The Thoracic Surgeons

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New short film on YouTube featuring many of the thoracic surgeons you’ve seen profiled here on BogotaSurgery.org – Dr. Nelson Renteria, Dr. Stella Martinez, Dr. Andres Jimenez, Dr. Mario Lopez, Dr. Juan Carlos Garzon, and Dr. Ricardo Buitrago.

Hoping the next film is ‘live action’.

Meeting of the minds – thoracic surgery

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Attended the monthly thoracic surgery meeting led by Dr. Juan Carlos Garzon yesterday for case discussions.. Several interesting cases presented.  More importantly, I met and set up interviews with the last few thoracic surgeons; Dr. Beltran and Dr. Rodolfo Barrios (that I hadn’t met previously).  Should be an interesting week in the south end of the city..

On the topic of thoracic surgery – I am soliciting articles from thoracic surgeons, and other practitioners on the site – not just here in Bogota, but from around the world as part of the mission of the site.  I’ve already had some great feedback from some American surgeons.

Over at cartagena surgery we are talking about the recent announcement by the International Diabetes Federation on treatment recommendations for diabetes including the endorsement of Bariatric Surgery.

International Diabetes Federation supports Bariatric Surgery for treatment of Diabetes

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In a 180 shift from the position adopted by the American Heart Association who remains firmly rooted in the idea of bariatric surgery as a ‘last resort when all options have been exhausted’ the International Diabetes Federation (IDF) has taken the unprecedented and progressive step forward to recommend bariatric surgery as a form of aggressive treatment for Diabetes, (which is now only suboptimally controlled with multiple medications in the majority of people.)

In a re-post from Medscape, an article by Robert Lowes “Bariatric Surgery Recommended for Obese Patients With Type 2 Diabetes” reports that surgery is now being endorsed to prevent the devastating complications of this disease.

In this ground-breaking move, hope is being offered to the millions of people diagnosed with this disease.

Article re-post below:

March 28, 2011 — Bariatric surgery is an appropriate treatment for people with type 2 diabetes who are obese, the International Diabetes Federation (IDF) announced today.

Although such operations cost anywhere from $20,000 to $30,000, they will reduce healthcare expenditures in the long run, according to a new IDF position paper on the subject. The surgery, the IDF explains, often normalizes blood glucose levels and reduces or avoids the need for medication.

Dr. Francesco Rubino

In addition, curbing diabetes can stave off costly complications such as blindness, limb amputations, and dialysis, said Francesco Rubino, MD, director of the IDF’s 2nd World Congress on Interventional Therapies for Type 2 Diabetes, meeting today in New York City.

“When we talk about whether we can afford bariatric surgery, we have to ask what will be the cost if we don’t treat the patient,” Dr. Rubino told Medscape Medical News. “Studies have shown the surgery to be cost-effective. So there is a return on investment.”

The IDF puts the lifetime cost of diabetes in the United States at $172,000 for a person diagnosed at age 50 years and $305,000 at age 30 years. More than 60% of this amount is incurred in the first 10 years after diagnosis.

Under the new IDF guidelines, patients with type 2 diabetes warrant bariatric surgery when their body mass index is 35 kg/m2 or higher, or when it is between 30 and 35 kg/m2 and their diabetes cannot be controlled by medicine and lifestyle changes. This latter indication is even stronger when there are other major cardiovascular risk factors, including hypertension, hyperlipidemia, and a history of heart attacks, said Dr. Rubino, chief of the Gastrointestinal Metabolic Surgery Program at New York-Presbyterian Hospital/Weill Cornell Medical Center.

The body mass index action points can be reduced by 2.5 kg/m2 for Asians.

The guidelines were drawn up by an IDF taskforce of diabetologists, endocrinologists, surgeons, and public health experts who met in December 2010.

Trials Needed to Compare Surgical Procedures

The new recommended indications for performing bariatric surgery on patients who are both diabetic and obese match those announced last month by the US Food and Drug Administration  for expanded use of the Lap-Band Adjustable Gastric Banding System (Allergan) to treat obesity.

The US Food and Drug Administration originally approved the product, designed for laparoscopic adjustable gastric banding (LAGB), for adults with a BMI of 40 kg/m2 or higher and those with a BMI of 35 kg/m2 or higher who have additional risk factors. Under the expanded indications, the LAGB system also can be used for adults with a BMI of 30 to 40 kg/m2 and 1 additional obesity-related condition who have failed to lose weight despite diet, exercise, and pharmacotherapy.

The use of bariatric surgery to treat diabetes has sparked controversy in healthcare circles. Critics question the wisdom of wielding a scalpel to solve a medical problem, especially when clinicians have more drugs at their disposal to deal with diabetes.

At the same time, a study published online last week in the Archives of Surgery has raised doubts about the efficacy of LAGB. Researchers following 151 patients who underwent LAGB for obesity concluded that the procedure yielded “relatively poor long-term outcomes,” with nearly half the patients needing their bands removed and 60% overall requiring some kind of reoperation. The authors, who performed the surgeries in question during the mid-1990s, added a caveat: they had used an older dissection technique.

“The band is only one option,” Dr. Rubino told Medscape Medical News, noting that gastric bypass procedures have demonstrated a greater endocrine effect than LAGB. “We are learning that some types of diabetes are well treated by lap-banding early in the disease process. The answer is in patient selection.”

The IDF taskforce calls for randomized controlled trials to compare different bariatric procedures for diabetes between themselves, “as well as emerging non-surgical therapies.”

Robert Lowes

Freelance writer, St. Louis, Missouri

Disclosure: Robert L. Lowes has disclosed no relevant financial relationships.

Dr. Nelson Renteria, Thoracic and Vascular Surgeon

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What a delightful afternoon with Dr. Renteria and Dr. Cecilia Villasante (Radiology)!  Dr. Renteria works at the Centro Vascular del Country, which led me to suspect that he may no longer practice thoracic surgery.. But, happily, I was wrong.

While I enjoy meeting all the wonderful and interesting people from all surgical specialties (like the orthopedic surgeons I met with today), I can never deny how much I enjoy talking to people from my home specialties.  Maybe it makes me a little less homesick for my patients because it’s all so familiar.. And it’s always thrilling to meet people who find empyemas,  VATS and all these other things thoracic as interesting and engrossing as I do, especially when you meet people like Dr. Renteria, who still loves what he does as much as I do.  He still enjoys discussing cases, and has a real enthusiasm for his patients.

And – He does esophagectomies!  (Not many thoracic surgeons in Colombia perform esophageal surgery which is kind of like the ‘open heart’ surgery of thoracics*.)  He completed his fellowship training in esophageal surgery at Toronto General Hospital with Dr. Pearson (Dr. F. Griffith Pearson of Pearson’s Thoracic and Esophageal Surgery) and currently does esophagectomies here in Bogota.  (This is much bigger news than it sounds – finding qualified thoracic surgeons that perform an adequate number of esophagectomies can be difficult even in large centers.  Currently, in my home state of Virginia  – University of Virginia is home to the largest esophageal surgery center with three dedicated thoracic surgeons.  Even my beloved Duke only does about 75-76 cases a year.)

So, I admit I lost a bit of my professional cool (if I ever had any).  I was like a kid in a candy store – talking about pre-operative optimization, Ivor -Lewis versus Transhiatal approaches, node dissection and other minutiae that I enjoy.

I must say – I am looking forward to following him to the operating room soon!

** Studies show a significant decrease in morbidity and mortality when esophagectomies are performed by thoracic surgeons (versus general surgeons).

In the OR with Dr. Mauricio Largacha, Orthopedic Surgeon

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The rest of Bogota may be quiet for the Easter holidays (la semana santa) but the operating rooms were busy at Unidad Medica Cecimin.

Dr. Mauricio Largacha, Shoulder and Elbow surgeon

I spent an interesting and enjoyable morning in the operating room with Dr. Mauricio Largacha, MD for an arthroscopic Rotator Cuff Repair. Dr. Largacha is a natural teacher, and did an excellent job at explaining different aspects of the procedure, expected post operative outcomes, and specialized equipment – since I am less familiar with shoulder and elbow surgery than other surgical procedures. (Unsurprising since as I mentioned previously, he is an expert in this area, and the author of several chapters in multiple orthopedic surgery textbooks on elbow, shoulder and ankle surgery).

Dr. Mauricio Largacha (left) and author

Surgery went beautifully, and surprisingly quick.. No intraoperative complications.