American College of Physicians: Internal Medicine — Doctors for Adults ®

Wednesday, August 28, 2013

Medical tourism--some ideas, and maybe what not to do

There are many ways to visit exotic destinations, including cruises, tours, adventure travel, business-related meetings and just plain going there. I always thought it would be most interesting to visit a place and practice medicine, since it would give me the opportunity to meet interesting people, do interesting things and maybe actually help. I first went overseas as a doctor about 23 years ago after finishing my medical residency. I traveled north from Bangkok to Chiang Mai where I found my way to the McKean leprosy hospital. There I spent a week rounding with the American physician who was the medical director, surgeon and primary doctor for all of the leprosy patients. There were also visiting dentists from Germany and other people who helped in various ways, including carrying on a religious mission for the Episcopal Church. It was one of the most memorable weeks of my life and flavored my ideas about medicine for the decades I have practiced since then.

I have looked for ways to visit developing countries in a medical capacity and learned about what seemed to me to be a disturbing development: medical tourism. For a significant chunk of change, a physician can visit some out of the way destination, be assured of room and board and expect to work as a doctor. I have nothing against paying for travel or donating money to worthy overseas medical causes, but it seemed to me that, if it cost thousands of dollars to go far away and do good, perhaps I ought to just donate that money and stay home. Also it seemed that if it was so very expensive to go ply my trade, perhaps my expertise wasn't actually very valuable in those places.

Haiti in 2010 offered me the opportunity to be a doctor in a faraway place without actually resorting to a medical tourism agency. I traveled with friends to evaluate the needs of a few small communities on the island of La Gonave off the coast of Port Au Prince. My friends' projects included women's rights, gardening and the economics of arts and crafts. I brought a suitcase full of remedies which seemed like they might be useful, saw patients, visited dysfunctional health centers and observed the work of a group of flying doctors who come in for 2 weeks every year to treat patients who lined up for hours to be seen. It turned out that what I could do medically in 2 weeks was close to nothing, since people needing acute care couldn't get to me or had died or gotten well all on their own. Many people did need help, but it was more of an ongoing need, and not something I could provide in the time I was there. There were some advanced cancers, HIV, non-healing wounds and severe hypertension. Undoubtedly there were tropical diseases which I couldn't recognize and there was chronic pain, mainly headaches and belly aches.

When I made the trip a year later I brought close to no remedies and saw only a few patients in a clinic setting. I concentrated on talking to people about their existing health care and its obstacles, encouraging sanitation projects and handing out condoms. I sat in meetings with women and men in which I tried to address their concerns by blowing up condom balloons and telling stories with the help of a skilled creole translator, which made them laugh and perhaps dispelled some rather physiologically implausible myths. In other meetings we talked about what they had and didn't have and what they wanted and what seemed possible and sustainable. Although I can't confidently say I did no harm, we did engage in mutually satisfactory dialogue.

The problem with going to places to help is that it can set up a relationship of dependence, especially if the help that is provided is something that is necessary and not otherwise available in that place. And that kind of help is also exactly what we would want to provide. Our natural impulse is to share our tremendous wealth with people we see as being helpless and destitute. The projects that are most successful in this capacity, I think, are projects that can be completed in a limited amount of time such as cleft palate repairs or cataract extractions, or ones that develop staffing and infrastructure in the country they serve that is at least partly self-sustaining.

Paul Farmer has done this in Haiti, dealing with many aspects of chronic diseases in hospital/health care center settings, as has Jill Seaman in her work treating the deadly tropical disease Visceral Leishmaniasis in South Sudan. Provision of medical care in disaster settings is also a good idea, since its scope is usually time limited, supporting an overwhelmed medical system at a vulnerable time. Providing a higher level of care briefly in a setting where it is needed long term is not particularly useful and can upset the progress in healthcare that may have been developing organically.

Recently I visited Tanzania with some medical students who taught ultrasound to Tanzanian students and medical professionals (see the separate post here), kind of an introduction to bedside ultrasound class. I felt like the techniques were really powerful and the students made sure to coordinate with a school there and a radiologist who would probably continue with the teaching. Ultrasound machines are not so very expensive in the developing world, especially as newer, smaller machines are replacing older, still adequate ones. Increasing the baseline competence of people who will be delivering care has the potential to reduce suffering and improve patients' lives in a country with a staggering deficiency of doctors. The motivation for the project was beautiful in itself, medical students bringing the cool thing they had just learned to a place where it could really make a difference.

Another issue with medical projects overseas concerns scarce resources. When I was in Haiti I noticed that there were lots of small, short haired, gentle dogs who barked at intruders and ate garbage. Most of them were thin, and about half of them eventually had puppies. The puppies were incredibly cute and were treated with complete indifference by most people, even as they appeared to cling so very tenuously to life. Undoubtedly most of the puppies died. We were the only people to feed the puppies food scraps because there wasn't enough food for all of the people, or even the mother dog. If all of those puppies survived, a person would not have been able to put a foot down without stepping on a dog.

The human infant mortality rate in Haiti is high and lifespan is short, which results in a pretty stable population in the very resource limited island I visited. If medical care is really successful and the very young and the old live longer there will not be enough food or anything else to support everybody. In some places healthier people produce more food and shelter which offsets this problem, but we need to be very careful about how we focus our philanthropy. If babies are to survive in families that can care for them, there must also be adequate birth control and improved gardening and other industry.

Should we doctors just stay home? No. Emphatically. Unless we want to. But those of us who are motivated to go forth and help people should pay attention to the complexity of the systems we are driven to change. We should open our hearts to the possibility that it is we who are benefited most by our adventures as we meet, care for and in turn are cared for by people whose backgrounds and social contexts are very different from our own.

Janice Boughton, MD, ACP Member, practiced in the Seattle area for four years and in rural Idaho for 17 years before deciding to take a few years off to see more places, learn more about medicine and increase her knowledge base and perspective by practicing hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling. Disturbed by various aspects of the practice of medicine that make no sense and concerned about the cost of providing health care to every American, she blogs at Why is American Health Care So Expensive?, where this post originally appeared.

Labels: , , , ,


Anonymous Arlen Meyers, MD, MBA said...

A few comments:
1. The term "medical tourism" typically refers to patients leaving home for care. Humanitarian care or international charity care is a more appropriate term for what you describe.
2. The other side of this coin is doctors leaving home to take care of patients who pay for care at the destination.

August 29, 2013 at 10:14 AM  
Blogger Dr. Gene Delaune said...

As a doctor I would also like to volunteer my services in areas that are short on medical facilities. But it is not as easy as it looks. I read your article very closely and realized that as doctor sitting in a remote village with no access to modern and latest facilities, is the same as no doctor at all.

November 19, 2014 at 12:14 AM  

Post a Comment

Subscribe to Post Comments [Atom]

<< Home

This is a printer-friendly version of this page

Print this page  |  Close the preview




Contact ACP Internist

Send comments to ACP Internist staff at

Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

Powered by Blogger

RSS feed