Commentary on: Complications From International Surgery Tourism

In their article “Complications From International Surgery Tourism,” Drs. Melendez and Alizadeh describe the results of a survey of members of the American Society of Plastic Surgeons (ASPS) to determine the impact on their practices from treatment of patients who have traveled abroad for cosmetic surgery. The authors point out the need for more complete data on outcomes from medical procedures (including aesthetic surgeries) performed outside patients’ country of residence. They also highlight the negative repercussions of surgical complications stemming from medical tourism—for patients as well as follow-up physicians and national healthcare services, which often must assume the financial burden of treatment.1 The actual number of patients who seek healthcare abroad is unknown. One recent report from the University of Iowa Carver College of Medicine suggests that the number of patients may be much smaller than previously estimated.2 However, medical tourism, in general, is predicted to increase in the future due to several factors: (1) rising US healthcare costs, (2) more international facilities being accredited by US agencies, (3) government encouragement of tour operators who bring revenue to the countries visited by patients, and (4) encouragement from US insurers and employers. As an example of the last point, BlueCross BlueShield of South Carolina has established a subsidiary company, Companion Global Healthcare, designed to facilitate medical tourism. At least one supermarket chain has also been reported to offer an international option for hip replacement in its employee healthcare plan.3 Even if the quality and reliability of medical tourism on a broader scale may be improving, the field of cosmetic surgery is likely to lag behind any such positive trend. Just as we continue to face a struggle within the United States to appropriately regulate who performs cosmetic surgery and where, these same battles are being fought in virtually every country around the world in which cosmetic surgery is a sought-after service. Because of lax governmental regulations, cosmetic surgery patients may be less able to ascertain the qualifications of doctors performing cosmetic surgery in other countries—unlike patients seeking orthopedic or cardiac care, who are likely to utilize doctors within recognized institutions. This may be particularly true if patients conduct their own research online to find an international doctor and make their decision based solely on information provided by the doctor’s personal Web site.4 Furthermore, cosmetic surgery patients may have a greater tendency to downplay potential risks and complications, believing that, after all, cosmetic surgery is not “real surgery.” As a consequence, they may be less likely to ask the necessary questions and make the appropriate arrangements to help ensure safety in both the operative and postoperative phases of treatment. I always find it somewhat uncomfortable when a patient consulting with me about cosmetic surgery offhandedly mentions that he or she has thought about going abroad for the operation. This usually means that the patient is still actively considering the option of medical tourism. As a frequent guest and attendee of international plastic surgery meetings, as well as being foreign-born myself, I am extremely well aware and admiring of the many skilled surgeons practicing outside the United States. I would therefore be the last person to automatically dismiss the notion of undergoing surgery in a foreign country. At the same time, however, I am a firm believer in the importance—even the sanctity—of the doctor-patient relationship.5 Medical tourism generally does not further the development of a responsible doctor-patient interaction, because of the inherent inattention to follow-up and outcomes, as described by Drs. Melendez and Alizadeh in the main article. Furthermore, as the authors point out, the frequent lack of compensation for physicians treating complications of surgery performed abroad not only is unfair and exposes treating physicians to potential liabilities but also may alter the doctor-patient relationship in ways that are detrimental to the patient’s best interests. This is not to suggest that physicians provide a lesser quality of care to patients under such circumstances, only that the prerequisite relationship of communication and trust has not been established before dealing with complications that are often physiologically serious and/or psychologically difficult. Therefore, it can become more challenging to successfully guide patients through recovery and long-term resolution of any residual health or aesthetic concerns. The authors stress the need for better reporting of data internationally, observance of consensus surgical protocols, and consumer education. With regard to the last point, a number of organizations have issued guidelines for consumers who wish to consider cosmetic surgery outside the United States. If someone seeing me in consultation expresses an interest in medical tourism, I make such guidelines readily available to him or her by having a copy in my office. I do this not because I want to encourage patients to seek surgery elsewhere, but because I feel a strong responsibility to educate them about the process, should they ultimately decide to go that route. What I have found, for the most part, is that when patients read guidelines on medical tourism provided by a respected organization such as the American Society for Aesthetic Plastic Surgery (ASAPS)6 or the International Society of Aesthetic Plastic Surgery (ISAPS)7 they understand that it is not as simple as they might have thought. They also understand that arrangements should be made in advance to deal with any problems that could arise upon their return to the United States. I join with the authors in encouraging plastic surgery organizations to continue efforts to monitor and report on medical tourism—its frequency, outcomes, and complications. Furthermore, I encourage all plastic surgeons encountering patients who may be considering surgery abroad to offer them a copy of the guidelines of ASAPS, ISAPS, or ASPS. This may serve as a starting point for a conversation in which the patient readily drops the notion of seeking care elsewhere. At the very least, the patient will leave your office with a better understanding of questions to ask, risks to consider, and his or her personal responsibility regarding follow-up care. The authors, in their excellent survey data, have provided information that supports the need for all of the above actions—but these data are only a starting point. In a significantly expanded and validated format, this type of information should assist in future efforts to more uniformly regulate the practice of cosmetic surgery worldwide. The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. The author received no financial support for the research, authorship, and publication of this article.

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