Commentary on: Complications After Cosmetic Surgery Tourism

Despite negative reports in the popular media and multiple consensus statements by medical organizations about the dangers of medical tourism, the incidence of global travel for cosmetic surgery continues to rise. Medical tourism is clearly a price driven phenomenon that appeals to an audience who may not be as educated or care about the importance of quality in determining outcome. Like many other disruptive technologies, the consumer is willing to pay less and not expect as good a quality for their service.¹ As consumers we make such choices every day when we decide to choose Airbnb (Airbnb, Inc., San Francisco, CA) over an established hotel or get a ride with an Uber (Uber, San Francisco, CA) driver over the official taxi which is regulated by the city and state laws. We are usually willing to sacrifice regulated services from institutions as long as we can improve convenience and price for a given product. And here lies the problem: medical tourism is not a product but a highly complex and potentially life altering service that has become commoditized by internet marketing and forces of disruption. While performing a search on this topic I was bombarded by ads for medical tourism with one stating: “Have your vacation surgery abroad and save over 90% on medical tourism.” The key drivers for this trend are therefore price, ease of travel, and positive image internet marketing.

Therefore, I believe the most important role of physicians is to educate the public and governing bodies about the dangers of mixing commoditized marketing with an adequate surgical outcome. Harvard University strategist, Michael Porter has defined health care value = outcomes/costs, as perceived by the patient.² Since the patients know that the cost is lower, they therefore mistakenly believe that the value must be better. What is not known to the patients is whether the quality is lower which would then drive the value lower and potentially change the mind of the consumer. As a consumer, we may elect to purchase a cheaper airline ticket with a lesser known airline as long as we know that they are bound by Federal Aviation Administration rules and the airplane has to be safe. But we may not be willing to travel on a much cheaper flight that was piloted by a private enterprise since “the value” may not be worth the risking our life. The same is true in medical tourism in that adequate public education and regulation will force a change in behavior when it comes to saving lives. Good examples are seat belt and anti-smoking campaigns.

This is why I applaud Klein et al on their paper, “Complications After Cosmetic Surgery Tourism” in this journal because they attempt to show once again the dangers in lack of care and quality in patients who have undergone surgery abroad.³ They retrospectively studied 109 patients at the University Hospital in Zurich, Switzerland and noted similar findings to our study published 5 years earlier which found an increasing trend in patients with complications requiring multiple operations with breast surgery (62.4%) being the most frequent procedure and infection (25.7%) being the most common source of complication.⁴ What was new in this study was the report on the additional cost and even profit of treating such patients in a tertiary public hospital as well as the rising trend of injectable complications (13%) which are reportedly offered to the patients as a “to-go” intervention during their stay abroad.

Innovative technology is the usual driver for patients seeking distant medical care. It is not uncommon in the United States for a patient to travel across the country to have access to a new chemotherapy regimen offered under a “new” clinical trial. However, what is now emerging is access to a new technology or procedure not yet approved in the United States or Western European countries. A patient may travel to a country to get an unapproved injectable that is purported to be “safe” based on marketing, not scientific claims. This almost distorts the aforementioned value equation in that the patients mistakenly believe that they are getting “better” technology at a reduced price.

The same is true in any country in the world where the patients travel locally to find “the latest magical procedure” that is scientifically unproven. There has been a flood of patients to clinics that sell “stem cell rejuvenation,” for example. The detractors would say that the delivery of care is even more complicated and fault the authors of this paper for not comparing a similar group of patients who developed complications in Zurich during the same time period. For example, one could argue that if we extrapolate the number of procedures done at that hospital over 5 years, there would be 8250 procedures performed (1650 procedures done in 2015 as quoted in paper) which would result in a 1.3% complication (if the study N = 109 patients developed poor outcomes). This is an acceptable rate and the problem is that we simply do not know the complication rates of any of the clinics that perform global cosmetic surgery. We all know that in any given geographic area, there is wide variation in the quality of care based on the hospital or the health care team. A recent study showed that the quality of care may even change within the same institution depending on which time of the year one receives their care.⁵

What has not changed since our initial report five years ago in this journal is the need for Plastic Surgery organizations to engage in conversations with international governing bodies that allow the gathering and reporting of data on an annual basis which will provide a platform to educate the consumer on potential pitfalls and complications. The American College of Surgeons’ consensus statement and the American Medical Association’s guidelines together provide an important set of principles for consideration by patients, employers, insurers, and other third-party groups responsible for coordinating such travel outside of the country.⁶ Consequently, established regulations can minimize risks in cosmetic surgery.⁷

There needs to be a clear, consistent, and frequent message for improved public awareness and education in medical tourism and I encourage our colleagues to continue reporting on this phenomenon.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.

Author notes

Corresponding Author: Dr Kaveh Alizadeh, 1165 Park Avenue, New York, NY 10128, USA. E-mail: