S03E26 Is Traveling For Surgery Safe?

Welcome to another episode of Botox and Burpees. I'm Dr. Sam Rhee, plastic surgeon and CrossFit coach, host of this podcast where we talk about plastic surgery, CrossFit and everything in between. You can find more information at our website, botoxandburpees.com, and make sure to like and subscribe wherever you listen to our podcast.

A growing number of patients are traveling to get their cosmetic plastic surgery procedures done. Whether overseas or more recently to surgery centers in Florida, patients see fantastic pictures on social media, travel for surgery, and then return home - sometimes with problems that their local surgeons are forced to address. Is traveling for surgery safe?

Our latest episode is with special guest @bajajplasticsurgery Dr. Anu Bajaj, MD MBA FACS. She is a board certified plastic surgeon in Oklahoma City. Dr. Bajaj is a past Chair of the Ethics Committee of ASPS (American Society of Plastic Surgeons) who recently wrote an article "The rise of domestic medical tourism - and the ethical questions raised." (link in bio)

We examine the complex problem of domestic medical tourism, the issues about educating patients, and the role social media plays in leading (or sometimes misleading) patients into choices which may result in problems.

You can get every episode of Botox and Burpees wherever you listen to podcasts, YouTube, or go to botoxandburpees.com. Thanks for watching and listening!

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Dr. Bajaj’s article is available HERE.

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S03E26 Is Traveling For Surgery Safe?

[00:00:00] Dr. Sam Rhee: Welcome to another episode of our podcast. I have a very special guest today, Dr. Anu Bajaj . She is a board certified plastic surgeon practicing in Oklahoma city, Oklahoma.

Her Instagram handle is Bajaj plastic surgery. And her website is Bajaj plastic surgery.com. And you've been in practice for how long now, how many.

[00:00:18] Dr. Anu Bajaj: 16 or 17. I started practice in 2004 and I started in academics for three years. And then I started my private practice in 2007.

[00:00:27] Dr. Sam Rhee: Your specialty includes breast surgery and reconstruct. And cosmetic surgery, as well as facial surgery, body sculpting and minimally invasive procedures. Your training, you did your undergrad at rice university, and you got your MD at university of Pittsburgh school of medicine. You did your residency in plastic surgery at Loma Linda.

Medical center in California. And then you did your microsurgical fellowship at MD Anderson in Houston. And you also got an MBA fairly recently at Oklahoma city university, as well as. That's

[00:00:58] Dr. Anu Bajaj: correct. I think I graduated last December then with the pandemic you lose track of.

[00:01:05] Dr. Sam Rhee: And then yes, you were in academics for all.

You served as an assistant professor of plastic surgery at university of Cincinnati, as well as chief of plastic surgery at the VA. The veteran affairs medical center in Cincinnati and. Since 2007, you've been in Oklahoma city and you've held a number of positions in organized plastic surgery. Or you've been on the editorial board of plastic surgery at a global open.

You're the chair of the ethics committee in 2018. You serve as a reviewer for PRS or journal for plastic surgery. Just on a side note, I saw that you are a dog lover fashionista, and you've done over 30 marathons. Completely inconceivable to me. I can't even run a 5k without breaking down. So that's amazing.

[00:01:44] Dr. Anu Bajaj: That's true. This is actually the first year in over 20 years that I have not run a marathon like in this calendar year, which is kind of weird.

[00:01:53] Dr. Sam Rhee: So the reason why we're talking today thank you for coming on is basically this article you wrote. Is an excellent article. I, it was very thought-provoking to me, especially because I'm dealing with these issues more and more in a lot of other plastic surgeons are as well.

It was in the September, 2021 plastic surgery news, which is the publication published by the American society of plastic surgery for plastic surgeons. And the article was titled the rise of domestic tourism and the ethical question. Raised. The first thing I would want to ask you, Dr. is what is domestic medical tourism exam?

[00:02:28] Dr. Anu Bajaj: So domestic medical tourism is basically exactly what it sounds like. It's when patients leave their hometown to go and travel, to go have plastic surgery. And while this isn't something new, lots of patients. For example, when I was at MD Anderson, patients would travel from all over the country to have their cancer treatment at MD Anderson, because it's a specialized center.

What is becoming new is that it's. It's more commonplace and people are traveling for very different reasons than they used to in the past.

[00:03:04] Dr. Sam Rhee: Now. What would be the difference between say domestic medical tourism and international medical tourism, which is what we've also seen in the past. And this is typically for cosmetic surgery, is it not where people are.

Going very far away, typically fairly long plane rides to different destinations where they're having cosmetic surgery. And then they're flying back to their hometown shortly after going through some fairly invasive procedures.

[00:03:33] Dr. Anu Bajaj: So the common thread for the. Medical tourism related to cosmetic surgery is patients are traveling either within the U S or outside of the U S to have cosmetic procedures like abdominoplasties or tummy tucks, Brazilian butt lifts, which is fat grafting to the buttocks area and those kinds of complex procedures.

And they're traveling primarily because they're finding the cost of having these procedures at those remote locations is cheaper than what they're able to obtain in their hometown. And that's one of the primary motivators for their traveling. The other primary motivation, I think, is what we see about the selling of plastic surgery on social media.

Today, we are able to follow influencers or follow some individuals who have over a hundred thousand followers, and we assume that those are the best people to go to, to have surgery.

[00:04:29] Dr. Sam Rhee: Yes. I am coming from a particular viewpoint myself because I am a plastic surgeon in New Jersey and I see an increasing number of patients not only traveling overseas, which used to be very common to Latin America or south America, but an increasing number of patients who are

going to mostly Florida, south Florida, where they're having exactly the same the procedures, you mentioned the BBLs, the tummy tucks, breast work, body contouring, and then coming back. And I think for all of us as plastic surgeons, we have had plastic surgery patients come from distances whether it's relatively short, like for me, it might be Queens or Staten island, or it might be farther.

Maybe it's Massachusetts, but the issue which you raised and what w what's bothering a lot of us as plastic surgeons is the lack of aftercare and the significant number of complications that we're seeing and being forced to manage as part of this trend. What is your experience with it? And what do you think about.

[00:05:35] Dr. Anu Bajaj: I completely agree and understand what the plight is because the issue is say you are, I may have patients who travel. I'm in Oklahoma city. I'm in Oklahoma city is a location where there's a lot of rural population and the rural populations only access to plastic surgery may be to drive two or three hours.

But when they come and see me in my office, we have a set program of, if we're going to do surgery, you have to stay this many nights in the city. We will have this many follow-ups you have, you are obligated to drive to me for those followups and we have to maintain contact. And what I find is when people are traveling to, for example, Florida, They're going into some of these chain plastic surgery venues.

In other words, they're plastic surgery facilities owned by corporations rather than plastic surgeons, which is how they're able to undercut regarding price because they produce in large quantities, like it's quantity over quality per se. And so there is no discussion with the patient of you can't get on a plane.

Two days later, you need to stay here for follow-up or Hey, if this is a potential complication, if this arises, you need to call me, there's none of that discussion. Rather patients go home, and then they start looking at the phone book when they have questions to see what to do, or, Hey, I've got a seroma or, Hey, my wound is breaking up and what do I do?

They are able to get in contact with their original surgeon. And that's where the ethical dilemma is coming in is that's a form of patient abandonment.

[00:07:07] Dr. Sam Rhee: I think you hit the nail on the head that social media has made the world smaller in the sense that someone from any location in the world can advertise and can reach out to potential patients and sell themselves in terms of their work.

I will tell you that I've seen some of these Instagram accounts. Some of these patients that have gone to these different as you mentioned, chain plastic surgery locations and these results. I don't know for sure, but they look completely believable. They look literally like a computer graphics, design person had made up some of these pictures and these patients are believing all of these

in my opinion, extremely unrealistic results. And there's really nothing I can say, because as a physician, when I look at these and I tell them, I think this looks fake, they look at me like, how do you know? And I say, I don't know. It just looks fake to me and based on my clinical experience, but they're just willing to believe it and just go with it at that point.

[00:08:15] Dr. Anu Bajaj: That's so true. And what you're finding is that we're living a world where if you say. And you say it often enough. It's true. And that's exactly what's happening with the proliferation of social media and these pictures, or you say it and you post it enough. It's got to be true. And unfortunately, the surgeon or the professional has the eye to say these pictures are inconsistent or this doesn't make sense, but the lay public doesn't have that knowledge or that eye to see that.

They're not your one person, whereas the followers are a hundred thousand. So they say that you don't know what you're talking about, even though you're a professional.

[00:08:59] Dr. Sam Rhee: Okay. So let's give an example here. So and This actually has happened to me. We have a patient and that patient went to Miami for a plastic surgery procedure, like a BBL or something like that.

And they develop a wound infection as a result of that plastic surgery procedure, they're in the emergency room because that's where most patients would go if they have some sort of problem. And as a plastic surgeon, the ER, calls us and says, I have a person who underwent a cosmetic surgery somewhere else and has this big infection and you're the plastic surgeon on call and I'm calling you to take care of this. You discussed this in the article, but it's very distressing as a plastic surgeon. What is our obligation in regards to this patient?

[00:09:48] Dr. Anu Bajaj: So from an ethical standpoint, you're obligated to take care of emergent care.

Once the care becomes elective, you have everyday. To say no. And that's the problem is when the patient shows up in the ER, under most hospital bylaws and policies, you're going to be obligated to at the very least evaluate the patient and ensure that the patient is not in a life-threatening situation and manage the acute issue.

But then once the acute issue is managed, it is within your rights to refer the patient back to the original.

[00:10:25] Dr. Sam Rhee: It's such a difficult situation because Fortunately, or unfortunately I stopped taking call at our local ERs about two years ago. I'm not in that situation, but I have gotten calls frequently from people that I know or patients who have referred other people who have had issues elsewhere, and then they're seeking acute care and it's difficult for me because.

I want to help people, but I also don't want to get involved in a really sticky nightmare of a mess, because if you start treating a patient, you basically own that patient. That's really the philosophy and the truth. It's the truth of the matter. And there are some legal issues. And there was a great article by Dr.

A Reisman who also wrote in the same publication, any actually, he does a number of legal cases and he discusses them. And he actually discussed one. And I assume that this is a true case that he pulls. Cause I guess he pulls true cases. It just changes the information. And I wanted you to comment on it because this was something.

It seems like it's a no win situation for some of us in plastic surgery, especially because most plastic surgeons do take ER call and this would be something that they would be obligated to take care of. The case goes as such, Chavonne traveled south of the border to have a suction lipectomy and tummy tuck at anesthetic clinic that advertise in our local paper and online, the ad claims that the surgeons and staff were trained in the UK.

Practice in a modern facility and provide services that could be expected at home. She travels with a friend, has a surgery and returns to a Texas home. Two days later, she starts to experience swelling, fever, and other signs of illness. The abdominal incision opens and drains prompting a visit to the local ER, there she's told her insurance will not cover the complaint as it arose from a cosmetic procedure, the plastic surgeon on call reluctantly consults and discusses the proposed plan for a hospital admission and the inherent costs and fees with no obvious alternative to consider Chavonne agrees, three surgeries and a huge bill later, she heals, but with terrible abdominal scars and contour issues, although she hired an attorney, there is no possibility of a claim against the foreign care providers.

The attorney then pursues the American plastic surgeon who cared for her as he quote, should have done more to lessen her damage. How do you feel about, us as plastic surgeons being on the hook for just doing nothing more than taking care of patients that we're obligated to take care of.

[00:12:45] Dr. Anu Bajaj: I think it's very disturbing. To be honest, when I read that case, it was it's upsetting to me. Because the doctor who's trying to do the right thing is the doctor that's getting screwed, not the doctor who didn't do the right thing and, I don't know what we can do to prevent that, but that's something that as surgeons and as a society, we should probably take up in the courts and legally, because there have to be legal protections for surgeons who are taking care of people who choose to travel. Somebody has to suffer the consequences, but it shouldn't be the person who's helping the patient. I do believe that the patient has some of the burden, because the patient is the one who chose to travel. And then the operating surgeon has the burden and the surgeon who's just taking care of the patient, preventing a severe illness or treating a severe illness is not the one that should be punished.

[00:13:37] Dr. Sam Rhee: I think one of the big issues is patient knowledge and information because I don't think patients are actually aware or even think about many of these issues. I know that for a fact that most patients that see me, don't ask if I'm a board certified plastic surgeon. I don't even know if they would know the difference between someone who's board certified in another specialty versus being board certified in plastic surgery.

I think there's a tremendous issue in terms of information being passed to the consumer about all the. Issues. Some of it is that maybe no one really wants to talk about potential complications after cosmetic surgery. We do as part of our informed consent as part of informing our patients.

But if we had a big campaign saying you could have serious issues and horrible results after plastic surgery, so make sure you go local. What kind of confidence are we building with our patients? So my question is what can we as a society, our plastic surgery society, or as we, as a group can do to help get this information out, because I think we're stuck in a lot of ways.

I don't think we have very many options in terms of information providing for these patients.

[00:14:52] Dr. Anu Bajaj: You bring up a very difficult point because there's a lot of conflicting variables, right? We have to do a better job of educating the public about the difference between board certified plastic surgeons and non-core surgeons, for example, or non-core specialties.

But the issue is even the most educated of individuals don't understand the distinctions between the different board certifications and what they mean. That's one component. Yes. We do need to do a better job of educating our patients. Yeah. Cosmetic surgery and the potential complications. And we are probably hesitant to do that because we're worried that's going to scare patients away.

I get that. And then the other issue is there are a lot of our own society members with a large national following who do have a large number of patients who travel to see them for surgery on a regular basis. And if we come out and say, as a society, oh no, you shouldn't be encouraging that. That's all, a lot of our members are probably going to be very upset about that.

[00:15:54] Dr. Sam Rhee: It's very difficult and that's a really good point. I think there are. Probably a fair, I did not think about a fair number of plastic surgeons who have patients who come from quite a distance, but what is the obligation have you seen?

Okay, so we know about the people who have are the egregious offenders who are not board certified in plastic surgery, who are practicing way outside their expertise or their scope of practice who are obviously providing substandard care. What is it for us as board certified plastic surgeons who pride in doing the right thing? When we do have patients that do come from a distance how do we best take care of our patients in terms of managing potential issues and complications?

[00:16:40] Dr. Anu Bajaj: In our code of ethics, doesn't fully address the issue of of domestic traveling for plastic surgery. What's the word tourism, right?

Our code of ethics doesn't specifically address it. It does say that you shouldn't abandon the patient. And then the American college of surgeons has issued guidelines regarding abandonment and states the postoperative care as part of the surgical process. And I talked about it. I quoted what the American college of surgeons said regarding that.

And they stated that in their whole PR they talk about domestic traveling for surgeries, and they said the responsibility of the operating surgeon to establish communication, to maintain proper continuity of care, and that the same circumstances apply for elective surgery.

Basically what they're saying, it's the obligation of the operating surgeon to develop a plan for postoperative care and to provide adequate post-operative care. And the AMA has a similar philosophy. The issues regarding patient abandonment are typically addressed via state laws. So it's the state medical licensing boards that would address cases of medical abandonment, which is in the case of the patient that you're talking about in Florida would mean that patient would have to bring a case against her operating surgeon in Florida for abandonment due to her complication.

And I think that a lot of these patients just don't have the ability to do. Your original question is what is our obligation for patients who travel? Going back to that issue, I would say that our obligation, when we have patients who travel is to have a thorough informed discussion with them about the implications of their traveling, what, how long they're going to have to stay.

Locally in our city, how, when sutures are going to come out, when drains are gonna come out and when you are going to clear that individual to travel back home and I don't think for most of these major procedures, I don't think 24 or 48 hours is enough. A major procedure as the case that Dr.

Reesman illustrated can have complications three or four days later. So then you, and we all know that we all know that infections will show up a week. So there has to be a minimum period of time that we talk to about our patients staying with us or staying in our local city for that appropriate.

Follow-up

[00:19:03] Dr. Sam Rhee: I feel like this pandemic has helped us streamline some of our remote care better. I do know a lot of my colleagues are doing remote consultations, they are doing a lot more remote aftercare visits as well. How do you feel about that either helping or hurting us in terms of providing close care for our patients?

[00:19:27] Dr. Anu Bajaj: I think it's a great tool. I mentioned that Oklahoma, a lot of my patients live two or three hours away and it's a great opportunity to do a virtual visit when things are growing well, so that they don't have to make that drive. Most of my. I understand though, if there's something of concern that they're going to have to come and see me in person, because I can't diagnose everything over a video.

So I think there are pluses and minuses. I think the concept of being able to do things remotely and virtually has been a real app. I think that we can't get too complacent that it's going to replace in-person in-person hands-on care. And I would say the same thing for those who travel for surgery.

Yes. You can travel to Miami and have surgery and leave after a couple of weeks and have your virtual visits, but that may not necessarily replace the hands-on contact that you get with the local surgeon.

[00:20:19] Dr. Sam Rhee: I'm biased. I'm sure, because I'm only seeing a subset of these travel domestic medical tourism patients.

But I tend to see a fair number of them have maybe not horrendous horrific or life-threatening complications, but really results that they dislike tremendously. Either scarring that's really unaesthetic or the results were not even close in terms of volume for BBL or the results of their tummy tuck or even I recently saw a severe capsular contracture after very shortly after breast dog.

And then they learned their lesson. Most of them actually having gone, the ones that I've seen that have gone to south Florida will not go back there for a second procedure. And many times they're coming to local plastic surgeons here in our area to address and fix complications left by the original procedure.

If we did a better job as a society, as. And uh, particularly in social media, I think some of it is not, I don't want to say fight fire with fire, but I think we need to do a better job in terms of educating our plastic surgeons in terms of reaching out to patients. And I think traditionally, I've talked to some of my senior plastic surgeons, the ones that I trained with and they found it very difficult to to accept social media as an important tool for outreach for our specialty. I think, we are not necessarily reaching patients well in terms of our message. And then in terms of our publicity, because we're not using the same media that the people who are causing these problems are using. How do you feel about us? I know ethically there, there may be some issues associated with it, but I think we should be exploring how best as a society we could we could fully engage ourselves in these new formats.

[00:22:12] Dr. Anu Bajaj: Oh, I think we have to engage ourselves. So we're not going to engage ourselves in these formats. We're going to get left high and dry. I, what I struggle with is, I don't know how a lot of these individuals. What I mean, and I'm saying this personally have achieved such high levels of success via social media.

Some of them have like over a hundred, 200,000 followers and that's, I'll try my best with social media to educate. And I think most of our society members are doing that as well, but for some reason we aren't reaching that same critical threshold university.

[00:22:48] Dr. Sam Rhee: There was an interesting article in wired.

I don't know if you saw it. It actually was about a Toronto plastic surgeon who recently got cited for multiple issues including not appropriate permission from patients or maybe, tantamount to coercion. I think if you actually read the article and I feel these are very difficult subjects for us to navigate because you're right in order for us to be, to become popular, we have to be, I don't want to say aggressive, but we have to be creative in what we do, but we have to remain plastic surgeons first, as you said, we're not entertainers and we're not influencers the way some many popular people on Instagram or Snapchat are, but we also have to be able to provide skills because it is a skill to be able to communicate well.

It used to be that we, they used to have us gauge how good we we're with a patient on a one-on-one basis. Always going to be the case. But there may be some need to help all of us in terms of our training, in terms of reaching out to patients with these other new digital, social media type of formats, where we can also be able to communicate better with patients.

[00:24:05] Dr. Anu Bajaj: It's true. I think a lot of residency programs are trying to incorporate. Or teach the residents about the responsible use of social media? It's a difficult, it's just a very difficult issue.

[00:24:18] Dr. Sam Rhee: What recommendations do you have for patients regarding domestic medical tourism? So you have a patient

and this has happened a lot. They see you for consultation, but maybe, and sometimes they don't. They say, you know what, I've also been interested in possibly going to another location in Florida to have my procedure done. What can you say to them without making it sound like it's serving your own self-interest by saying don't go down there, but also informing them of all the potential issues that can be.

[00:24:45] Dr. Anu Bajaj: I think I would encourage the patient to consider that traveling for surgery is more than just the cost of the surgery. If you're to travel safely, not only are you talking airfare, hotel and surgery. But I think you're talking about having to stay in that location for approximately two weeks, if, especially if you're having a major surgery.

Let's not even it's not even the surgical complications we're talking about too. We also have to think about risks of DVT or deep venous thrombosis and pulmonary embolism in individuals. Who've had a major operative procedure and then go sit on a plane two days later. That's another huge risk.

It's very much out there. So I do think that the patients have to look at more than just the actual cost of the operation. And I don't know how else. Yes, it is a little self-serving so I'd rather they stay here. But it's more than that. They don't have to come to you as the surgeon or me as the surgeon.

It's just, they need to find somebody that they're comfortable with. And that is a qualified surgeon in their local.

[00:25:55] Dr. Sam Rhee: I really hope that we can Marshall, some more resources. We can use our society in a better way, because I feel as surgeons, we have so much expertise in terms of doing these procedures and doing them well, that we almost don't do such a great job.

At least a lot of the surgeons that I know in terms of competing in a information. Publicity PR manner. And is there anything that we can do as a society like the ESPs right now, that would be helpful for us as plastic surgeons,

[00:26:28] Dr. Anu Bajaj: as a society? I think, and I think this is where the conflicts arise.

I do think that ASP could take a stand and make a part of its public educational effort. Related to domestic. Toward medical tourism. I think there's a lot of hesitancy within the society to do that because it may affect some of our own members. But I think as a society, ASP S has the potential and the resources to be able to do that as part of its public education campaign.

But that's something that its members are going to have to ask for. If enough members are upset about having to take care of patients who are traveling to Miami or to south Texas, or I don't know wherever the cheap plastic surgery is, and then they're coming back and those members are having to take care of them and have suffered legal ramifications along the lines of what Dr. Russman has discussed. I think that there will be enough of an impetus for that to become an issue for public education.

[00:27:30] Dr. Sam Rhee: I agree. I think there's, it's not going to be an easy row to hoe for us as a society, but we need to take some steps. I think it's only going to get worse if we don't actually try to address this.

And I also hope that we can try to get the message out to plastic surgery patients as well. And publicize the fact that, like you said, the cost is just not the airplane flight and the procedure itself. There's a whole lot more and significantly, sometimes even worse consequences, which I've seen personally.

I'm sure you have as well. And I hope that we can do right by our patients and continue to work on this issue and make it better. I appreciate your article, Dr. because I think it really highly. An issue that is only the tip of the iceberg at this point, especially with more social media making this even a bigger issue in terms of patients seeing and deciding where they want to go for their plastic surgery.

And I hope that you, as the former chair of the ethics committee of ESPs, as well as someone who is a frequent contributor can continue to make your voice heard so that we can we can be better with our patients.

[00:28:31] Dr. Anu Bajaj: Thank you so much. Thank you for hosting me too.