Stickman Readers' Submissions August 17th, 2007

Thai Hospitals, Western Hospitals and Medical Misadventure: A Perspective

A recent reader submission and Stick's also recent misgivings about the quality of care in Thai hospitals stimulated this submission.

Although personally I've mostly enjoyed good health, I've had reasonable experience of the medical systems both public and private, in New Zealand and Australia, as well as some "medical tourism" or rather in my case, dental tourism at Bankgok Pattaya Hospital in 2005 and 2006. I've been responsible for global mobility programs for a couple of multinationals and so also been acquainted both with the hospital assessment processes of global expatriate organisations like SOS, and a number of their expat's medical misadventures. Furthermore, I have some personal friends in the medical profession…None of which qualifies me to comment, but I DO find it an interesting issue, and I can't resist offering my take.

He Clinic Bangkok

I'll begin with my own experiences: first growing up in a small New Zealand town with a local hospital and General Practitioners who both did house calls, and minor surgery in their own premises. I had my adenoids and tonsils removed by the family GP in his small surgery, a couple of years later my tonsils removed again (they grew back!) And my eardrums grommeted in the same small surgery a couple of years later, all without complication. At twelve I broke my arm which was x-rayed and strapped without a long wait in the local hospital where I also returned for free physiotherapy. These days most small town hospitals are closed, and if you can find a GP in a small town it is unlikely he or she does housecalls and almost a certainty he does not perform surgery!

In my twenties, in Wellington, I had a cyst near the base of my spine that needed to be removed – nothing urgent – but the wait for a public hospital solution was two years. I had private medical insurance through my employer so I opted for a private hospital. I got the same surgeon who did these operations in public hospitals but only a one month wait and had a nice private room to recover in. The "gap" between the bill and the insurance payment was not small…

In my forties, while living in Sydney, my GP came to the conclusion I suffered from sleep apnea, or breathing obstruction at night caused by collapse of the airway. He referred me to a specialist who saw me in three weeks, and within another two weeks I was in the local public hospital overnight for a sleep study. All very efficient and inexpensive until the "cure" was pronounced! I had to purchase a CPAP machine – a kind of air pump which one wears at night with a mask to force the airway open – seems counterintuitive that one can breath out against the pressure but it's possible. Expensive – almost A$3,000, not covered by the public health system and probably wasn't going to make for a great sex life I moaned, as I went back overnight to hospital for my second sleep study to calibrate the machine pressure. "Don't worry, you can put this on after" cracked the nurse. Well, faultless care really, but an expensive solution that I was never able to tolerate – along with almost 50% of other CPAP users – although it seems to be the effective cure for those who can put up with it. In the end it was easier for me to just lose 10kg, which moderated but didn't remove the symptoms and I remain sleep deprived ever since.

CBD bangkok

Also living in Sydney I became close friends with a very good brain surgeon, previously a flying doctor (and a sensational guitarist to boot). His work was fairly depressing – a mix of motor accident head injury patients (often drunk drivers or victims of drunk drivers) and brain tumour patients. With the latter, either he got all the tumour or the tumour got all the patient. What blew me away (apart from his lead guitar breaks) were his liability insurance premiums – well over $A100,000 a year. Imagine complex brain surgery that doesn't go as well as hoped – should the surgeon have done better, could he have done better? Australia has gone down the American path where the injured aggrieved resort to the courts and a jury of laymen decide if the doctor was at fault and award millions. Most small to mid sized towns in Australia no longer have obstetricians – because while the size of the practice and the average local income can deliver the good birth specialist annual fees approaching $A150,000 which seems a decent amount, the $A110,000 liability premium just puts too much of a dent in it. So poor mothers in births gone wrong face emergency ambulance and plane rides of several precious hours to get to proper medical help.

On the other hand one reads some appalling statistics of systemic failures in Australian hospitals covered up by management, and incompetent doctors doing good imitations of the local butcher with a hangover, still protected by a medical brotherhood behaving like a secret society, and the occasional charlatan trading snake oil cures and leaving a bloody trail of disfigurement and even death. Ah, thank God we can sue for justice! Or does that just make it more likely that mistakes and incompetence will be covered up? So back to our beloved NZ, home of countless socialist experiments, among them the no-fault accident compensation system, whereby the state pays to undo the results of medical misadventures in its usual miserly and twisted way, that lets work avoiding malingerers receive weeks or months of wages at taxpayer expense, whilst denying victims of major misadventure proper satisfaction. Ah, but this at least will erode the code of silence and encourage speaking out, and exposure of unsafe practices! If only!!!

In 2002 the New Zealand Health and Disability Commissioner wrote "The reality is that, compared with many other countries, New Zealand has a head start in moving away from a culture of blame, toward a culture of learning. Accident compensation laws have effectively barred medical malpractice litigation in New Zealand since 1974. The accident compensation scheme means that persons injured by medical misadventure are entitled to 'no-fault' compensation. Claims may be accepted on the basis of a 'systems error' without attributing medical error to an individual health professional." The Commissioner further writes in the same place "The fear of medico-legal consequences and professional sanctions is sometimes cited as an impediment to candour. Such perceptions are largely medico-legal myth rather than reality, but nevertheless inhibit discussion of medical error. In a Commonwealth Fund study in 2000, 46% of New Zealand specialists reported that they were either discouraged or not encouraged to report medical errors, compared with 44% of United States specialists. It is surprising that New Zealand appears to have a similar trend of under-reporting to the United States. Evidence suggests that even in the highly litigious United States environment, candour about medical error may actually reduce the likelihood of litigation." In other words, whether doctors get sued for malpractice as in the US and Australia, or are supposedly fostered in the no-fault ACC environment makes not a whit of difference!. The rate of cover up in the US and in NZ is virtually identical! So what about Thailand? In 2005, I had lost my marbles over a Pattaya bargirl and was in the process of losing my money when a friend who lived there suffered Bell's Palsy (a paralysis of the facial muscles) and received excellent treatment at Bangkok Pattaya hospital. I had suffered bad teeth for many years and had been putting off the necessary comprehensive solution requiring about 17 dental crowns and other work owing to the high cost – in Sydney about $1200 each crown! Later when back in Auckland I decided to check out the restorative dentistry department of the same hospital. Initially I contacted them by email and that to be honest was a disappointing experience. Frustrated, I telephoned and from that call was able to arrange an appointment for my next visit to Thailand. Just to be sure I wasn't making an awful mistake I contacted SOS, a specialist organization advising expatriates about medical assistance and security; their verdict was that Bangkok Hospital was pretty good. I kept my appointment, and came away very impressed with the standard of service I received, the training and attentiveness of the dentists, and not least the cost – less than a third of what I would pay down under – even after including two return airfares. All in all I had four replacement root canals, seventeen porcelain crowns and one porcelain inlay installed efficiently and painlessly. One crown subsequently broke and my good Thai dentist cheerfully admitted hospital liability and replaced it under guarantee! That was not something I would have expected in Thailand.

The work was done in two stages – about three quarters completed in 2005, and the remainder more than six months later in 2006. I noticed that prices seemed to have gone up in 2006 by rather more than inflation – still a lot cheaper than down under…but not quite as cheap as before. Stick has alluded to some ghastly mistakes in the blue-chip hospitals of Bangkok. This doesn't seem to me very surprising and happens in all hospitals. I think one has to accept that medical mistakes will happen simply because human beings are involved. Medical professionals are no less human than the rest of us, they have bad days, get tired, feel unwell, have slips of attention and sometimes when having to make a complex judgement just get it wrong. As the good NZ Health Commissioner writes, "Even the best doctors make mistakes, and adverse events are a reality of general practice."

wonderland clinic

Mistakes by individuals however are only one aspect of medical misadventure. There is a lot of research about systemic error. John Morton writes in the NZ Medical Journal that while adverse treatment events that arise through medical error are sometimes unavoidable, "harm might occur less commonly if the precipitating factors predisposing to error were better understood. Systems can be designed to anticipate the potential for mistakes and take corrective action before harm occurs". Regardless of whether the cause is a systems failure, like unavailable supplies or inadequate treatment protocols, or human error like a wrong diagnosis or a slip of the scalpel in surgery, the global research indicates on average 4.5% of hospital admissions result in highly preventable adverse events of which 15% will result in death. The issue then is not so much whether mistakes happen – they do, but how they are dealt with. Here as I have already alluded to, there is a global problem. The NZ Health Commissioner writes "Doctors may avoid telling patients about an adverse event to protect patients from anxiety, and because they fear losing patients' trust. Doctors have high expectations of themselves and, not surprisingly, find it difficult to acknowledge errors openly before patients. However, failure to disclose medical error involves tacit deception and may suggest that professional interests take priority over patient wellbeing. Respect for patient autonomy supports a truthful and sensitive discussion about what went wrong and why".

That is certainly how it should be, but as we have already noted, whether in the US or NZ, under-reporting is the norm, despite the opportunity reporting provides for systems improvements and learning.

So how about those blue-chip hospitals in Thailand? Generally the facilities seem impressive, and the staffing also. The building infrastructure in Thailand enjoys a pricing advantage from the low cost of labour, and remarkably, the good supply of Western trained Thai doctors seem to be content to live in Thailand on incomes substantially less than their expertise could readily command in Western cities. That price advantage does not extend however to the medical technology. For example if I had chosen titanium implants rather than porcelain crowns, I would have paid prices much closer to those of Sydney – because the titanium implants are not sourced in Thailand and are the most expensive element of the procedure, not the labour.

Do things go wrong in these hospitals? Of course they do. I have no idea how the statistics compare with those above – even if the Thai authorities are open about such things, which I doubt, I can't read Thai, – but surely nothing gives reason to think it would be any better. The real question is not whether mistakes happen, but how they are dealt with. Again, I have no accessible research to quote, I can merely speculate based on my general experience and knowledge of Thai behaviour and here is where I'd be concerned. If Nong resident sees Pee senior surgeon doing something a little dubious is he going to remonstrate? Somehow I don't think so. And when it transpires that swab was left in Yankee All Star's fat chest cavity by Pee Nurse Ratt, is Nong Nurse Noy going to rat her out? Again, probably, no. And if a few medical tourists get upset by their AE's are the medical authorities going to act to protect their reputation among those farang short-timers, or are they going to act to protect their face in their own country? I think we all know the answer to that one too. Moreover, the influx of medical tourists isn't going to dry up through a few AE's, as long as the price advantage remains…

Now if I should ever have the fortune to be back on an expat package or have boodles of travel insurance, the place I want to get sick is Singapore. The doctors there are as good as the finest anywhere else, and the Singaporeans know how to supplement their own expensive and somewhat stuck up local nurses with attentive eye candy from the Philippines. But the systems…oh yes, if there's one thing they can do well in Singapore is design a system that works – just take Changi Airport for example and compare it with anywhere else.

Meanwhile, as long as it remains significantly cheaper than home, I'll have my minor operations done at Bangkok Pattaya hospital and hope like hell I'm don't become one of the 4.5%.

Stickman's thoughts:

I really liked your references to the pee and nong as well as the farang short-timer! I do have reservations about what could go wrong, and as you alluded to, the clash of the culture versus what should happen – in our Western minds.

nana plaza