Medical Tourism and Family Medicine

Perhaps you have heard about it from Robin Cook's latest medical thriller, "Foreign Body," or from Atul Gawande's description of the Shouldice Hernia Clinic in his book "Complications", or in news articles about Coretta Scott King's death at the Santa Monica Hospital in Rosarito, Mexico...medical tourism, the travel of patients (mostly from the USA) abroad for medical care, is on the lips and in the minds of hospital administrators, insurers, and health care professionals all over the United States of America. Two recent articles in the Economist, "Importing Competition" and "Operating Profit" (both from Aug. 14th, 2008), describe an unprecedented globalization of health care that will see 10 million people (mostly US citizens) traveling abroad for medical care, a total estimated market size of $21 billion.

So how will this new movement affect physicians and physicians-in-training domestically? The two MD's hosting the "MBA for MD's" seminar at theis year's AAFP national conference believe that, just as we have seen the outsourcing of medical transcription, record-keeping and radiological interpretation, we will see increased outsourcing of non-urgent surgeries. While these jobs will be in jeapordy in the US, they predict a surge in the need for primary health care providers to take care of these patients post-op. Perhaps the more efficient (and effective) private clinics outside of the US will, in their quest to provide the highest quality services, help to compensate primary health care practitioners at home. So, this is seemingly good news for the field of Familiy Medicine.

But what about the effects of medical tourism in the host countries? The Economist article author's predict a potential for a win/win situation. They claim that an increased demand for medical specialist services in host countries will force a reverse brain-drain, where former ex-patriot physicians will be able to return to their home countries to practice medicine. This could potentially increase funding for medical education institutions as well.

Indeed there are examples of successful Centers of Excellence abroad, including the Heart Institute of the Caribbean in Jamaica and the Arvind Eye Clinic in India. Both of these clinics use a "Robin Hood" mission to provide the highest quality specialty medical services to everybody that enters their doors (i.e. "Excellent care without exception"). Each of these clinics offer a sliding-scale payment structure, similar to many Community Health Centers in the US, to share the cost of relatively expensive services across their population; the higher-income patients pay for the lower-income patients. But do all of the international specialty service clinics share this philosophy? Is their mission to provide lower cost services to medical tourists and to the local population?

As stated in the articles, medical tourism is bringing the international competitors to the local health care market. The local hospital is in direct competition with the Bumrungrad hospital in Bangkok, which claims to be the world's largest private clinic. We are no longer able to view the fast-paced innovations in health care abroad as quaint or interesting, nor can we ignore the impacts of our domestic health problems on the exodus of our "medical refugees."

Let us know what you think about this new "flattening of the health care world."

• Will the ex-patriot doctors now returning home still be mostly treating the wealthy who previously sought treatment in the US?
• How will medical tourism affect our future job opportunities as physicians?
• Will Primary Care see an increase in pay scale over the next 5-10 years?
  
• Should FMIG host a talk/discussion to bring these issues to the table at BUSM?

FMIG Kickoff Event!

Tuesday's kickoff event for FMIG, "What is Family Medicine", had a great lineup of panelists who demonstrated the diversity of opportunities in practicing family medicine. Over 120 BUSM students came to hear what the panelists had to say, and to enjoy the free Thai food. (By the way, we are sorry for those of you who didn't get food -- we were expecting 80! We'll make sure you are well fed at our next event.) Dr. Brian Penti is currently a hospitalist in Family Medicine at BUMC. He spoke about his wealth of international experiences in Bolivia, Guatemala, Vietnam, and Cambodia and his current involvement in training programs for doctors in Vietnam. Dr. Alysia Green shared her stories of "sideline medicine" as a sports medicine family doctor and how her passion for sports had a major impact on her career choice. Dr. O'Brien shared her career path, which began in rural private practice and has led her to BUMC where she is involved in Labor and Delivery and pursuing her MPH in Maternal and Child Health. Dr. Shah discussed what life is like in a community based health center in Boston and gave advice to the students on how to key into their personal interests in a career path. Finally we got to hear from Kevin Kless, a fourth year at BUSM, who shared his own reasons for choosing family medicine. After hearing from first and second years after the panel, the event turned out to be an incredibly informative first glance at Family Medicine.

Pictures from "What is Family Medicine?" Panel

We just completed our first FMIG event: "What is Family Medicine?" Panel. We had five panelists come and speak.The Panelists represented a broad spectrum of family medicine. From left to right in the photo below:

1. Dr. Brian Penti: Family Medicine with a focus on International Health
2. Dr. Alysia Green: Family Medicine with a focus on Sports Medicine
3. Dr. Michelle O'Brien: Family Medicine with a focus on Obstetrics. Currently completing a MPH in Maternal/Child Health.
4. Dr. Madhavi Shah: Family Medicine practicing in a community health center
5. Kevin Kless: 4th year medical student applying for family medicine residency
   

Photos of all the students who attended the lunch talk.

One of the student leaders, Marcel Tam, introducing the speakers.
Come back soon for a more complete executive summary of the panel.

"What is Family Medicine?" Panel

The Family Medicine Interest Group (FMIG) is presenting a "WHAT IS FAMILY MEDICINE?" speaker panel next week, Tuesday, August 19th, in room L-110 (first classroom on your right to the left of the security desk), from 1130am-1230pm.

Come listen and learn and ask questions about family medicine, and what doctors are doing with family medicine: sports med, international work, research, community vs. private practice. NO COMMITMENT needed to attend (we won't make you go into family medicine because you came to the talk)--come see if family medicine is something you would be interested in, or to come learn something new!

Food and drink will be provided so come by for our first lunch talk of the year!

Reflections

Now that my sleep deprived self is back in Boston I wanted to share some final reflections:

Through this conference, the importance of family medicine became very apparent. From the opening talk on family medicine's contributions and roles to the different workshops that explain family medicine's approaches to the plethora of family medicine residency programs at the exhibit, the different structures that make up family medicine became apparent. And family medicine no longer seems like the "dead end" road that it has been touted as by so many. There are academic tracks, rural tracks, urban tracks, international opportunities, double board with preventive medicine tracks, residencies with dual MPHs or MBAs.

I entered into this conference not really with a directed purpose. I wasn't a fourth year medical student desperately trying to impress residency directors at the exhibits, I wasn't a delegate fighting for an elected position on AAFP (I wasn't, unlike Marcel, trying to blog every second of my time at the conference). But I came away with a better sense of the scope of family medicine and the impact it has on individuals and families' lives. Mentally, I revisited my med school applications and looked at my motivations for becoming a doctor throughout the conference - and I realized that family medicine and my motivations fit like an fitted enzyme-substrate complex.

NC'08...We're all in this together

As the last couple of sessions draw to a close, the crowds are getting scarcer and scarcer. MS-4s have walked the exhibit hall floor in their sleep, chanting "Hi, I'm a 4th year student at____, and I'm interested in ______. Tell me about your program." Residents know the lines and have perfected their responses and the way they will integrate the variety of brochures, freebies, and posters into their sales pitch. The military recruiters are still in full dress. Conference organizers are taking down the now-outdated session posters. The last of the Monopoly-like food tickets are being used at the food stands. Yes, the the 2008 AAFP National Conference for Residents and Students is almost over.

People attended sessions ranged from "Reading a 12-Lead ECG" to "Financial Planning for Residents and Students." In doing so, as with most conferences, a sort of group culture was developed. With the conference theme being "Global Health," one of the major group perspectives was that the field of Family Medicine has the unique position to be a potential coordinator & bridge-maker for groups from different backgrounds that need to work together in the field...whether that is internationally or domestically, in rural or urban environments, or with people of all ages, genders, and ethnic backgrounds.

Given this movement of students/residents/faculty/practitioners, Boston University School of Medicine has a great potential to become a bastion for Family Medicine, and thus, the future of medical practice. We have strong international collaborations, a history of working with community clinics in Boston, an excellent School of Public Health only steps away, and integration into a hospital with progressive programs in health care that have national renown. Perhaps Boston University faculty, residents and students can be a major force at the 2009 AAFP National Conference.

Yes, the sessions were interesting, the variety of residency programs was impressive, and the featured speakers were inspiring. However, the most important and immediate result from this conference was the personal bonding that occurred between people interested in providing primary health care for other people. MS-4s discovered people and programs that they only dreamed existed. MS-2s connected with students, residents, and faculty members from their own schools and in sharing trials and experiences, emerged more unified and optimistic. This showed that there's a great potential for changing the world, and changing ourselves, if we choose to work together.

MBA for "MD-ummies"

The University of Missouri-Kansas City Family Practice Residency program offers a MBA that's integrated into their 3-year program. The residency director and one resident, both who have completed the MBA program, gave their version of the...
Top 10 Things a Medical Resident and Student Should Learn from an MBA.

#1 Change Management
#2 Marketing
#3 Leadership
#4 Economics
#5 HIPAA/EHR/Technology
#6 Outsourcing & Offshoring
#7 Quality
#8 Balance Sheet
#9 Advocacy
#10 When you don't know why something is the way it is...Money is the answer.

The skills that they talked about directly related to the practice of Family Medicine. They made a strong argument for understanding these concepts, if not for getting an MBA. It was stressed that the residents who got an MBA didn't do so to go into finance or insurance or some other higher-paying job, but to be more effective in their current positions as administrators, patient advocates, and physicians.

Given some of the ties between BUSM and the BU School of Management, it might be interesting for FMIG to host a workshop/lecture on the "Business of Family Medicine."

Workshop: Dental Emergencies and Procedures

Two months ago I would have wondered why a workshop on dental care was relevant to a medical conference. But having researched on the effects of dental problems for the past 7 weeks, I was delighted that such a workshop was included!

Why is dental care important to a family doctor?

• dental problems is the most common childhood disease (40% prevalence)!
• rural communities and minority groups often do not have access to dentists
• dental pain can interfere with intellectual, social, emotional development and daily functions
• even in places where there are dentists, family doctors often serve to screen for dental problems in check-ups
• the teeth are a part of the body and affect the rest of the body holistically; it cannot be looked at in isolation from the rest of the body by dentists only

The speaker was from rural Maine where almost no one has access to dental care and he does dental screening, extractions, anesthesia and other basic dental procedures. He spoke about diagnosing different dental problems and discussed that antibiotics are over prescribed by most medical doctors for dental problems when they are not effective.

To learn more about oral health to treat your future patients: www.fmdrl.org or stfm.org/oralhealth.

Global Health Panel

This panel is talking about Global Health in general and the Family
Physician's role in health care internationally. They mention WONCA (http://www.globalfamilydoctor.com), an international organization or organizations of which the AAFP is a member.

Q&A:

A comment was made by a student from Alabama about the importance of recognizing underserved populations domestically that have very similar problems to those internationally.

(applause)

Q: What value does an "outside" health care professional offer to a population internationally?
A: The goal is not to bring US system abroad, but to listen to the community and provide necessary resources for the local population. This includes education and material support. The first step is listening.

Q: What is the Family Medicine community doing to be more known in the field of Global Health?
A: WONCA is part of the WHO and are trying to implement policy to promote FM. There is also a lack of individual promotion of work being done by Family docs internationally.

Some publication that were mentioned:
- "Health System Change: the contribution of Family Medicine" (WHO & WONCA)
- "Directory of Residencies with International Rotations" (AAFP)

Closing Remarks:
We have a responsibily to promote FM without paternalism & arrogance. We have a lot to learn about health care as a human right, about equity in a society, and about population medicine. So, at the end of the day, let's make sure that wherever we go, that place is better off for us having been there.

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Comments:
The Global Health movement is combining international health with health of underserved populations domestically, realizing that they have similar challenges. I can imagine that the next step in this logic is really redifining "health care" as a human right. That a human is a human is a human, no matter the geography. That the health of a population, as determined by system-wide structures, matters to the health of an individual. I see Family Medicine as uniquely poised to lead the way in this movement and that's why I am choosing this path!