Originally published April 2012
Foreign medical tourism can have an impact on Canadian physicians' practices and entail medico-legal consequences, in particular when patients return to Canada for follow-up care from medical procedures performed in other countries. Faced with incomplete or missing clinical documentation, and at times dealing with emergent complications, Canadian physicians may be challenged with how to handle such situations while arranging appropriate continuity of care for their patients.
Why do Canadians seek care abroad?
Medical tourism refers to patients travelling abroad to obtain timely medical services that are often not paid for by the Canadian healthcare system.
Canadians engaged in medical tourism often see it as an alternative to lengthy waiting lists or as a way to obtain treatment that may not be covered by their provincial health plan. Some individuals also seek procedures that may be unavailable domestically. Patients receive treatments ranging from cosmetic procedures and diagnostic examinations to organ transplants, in vitro fertilization, cancer and neurologic therapies, and bariatric surgery.
Duty of care
Most patients who return home following out-of-country procedures are likely to seek continued care from their Canadian physicians, possibly including treatment for complications and other issues.
When a patient seeks healthcare elsewhere, this does not necessarily negate the existing doctor-patient relationship. The duty of care that arises from the doctor-patient relationship imposes an obligation on physicians to appropriately treat patients in accordance with current and accepted standards of practice in Canada. Although the Canadian physician may not have provided or recommended the out-of-country treatment, the goal is always to provide continuity of care to the extent possible. Physicians and patients share this responsibility.
Referrals and coordination of care
Physicians have a general right to refuse to treat patients in specific circumstances.
There are exceptions, such as in cases of emergency or where an existing relationship requires the physician to provide care. When there is an existing doctor-patient relationship, there is an obligation on the part of the physician to provide reasonable care irrespective of where the patient may have received earlier treatment.
Canadian physicians may be aware that treatments recognized as safe and effective are offered abroad, but be unfamiliar with the quality and experience of a specific physician or facility providing the service. Consequently, Canadian physicians may be reluctant to provide a referral. Similarly, if physicians believe they do not have the knowledge required to provide an opinion on a particular treatment, including the potential risks and benefits, they should advise the patient accordingly and make a note in the medical record. A reasonable approach might be to inform the patient that such facilities exist, but that the physician does not have sufficient information to recommend or endorse them. The patient is then in a position to investigate and arrange for the treatment.
Occasionally, patients will want to avoid lengthy wait times by seeking a referral to an out-of-country specialist. If, in the physician's judgment, the wait time and treatment options in Canada are reasonable given the patient's circumstances, the physician may consider declining to formally initiate an out-of-county referral. Whether or not a referral is made, physicians may want to advise patients to check with their provincial health plan concerning eligibility for possible reimbursement of medical expenses paid abroad.
A patient may learn of healthcare services available abroad via the Internet, e.g. through the websites of medical tourism brokers. A recent analysis of Canadian broker websites suggests this information is generally biased, favouring the benefits of the foreign treatment while downplaying or omitting the clinical safety risks.1 Reliance on such information may lead patients to underestimate the risks and consent to treatment without being adequately informed.
Irrespective of whether the physician refers the patient for care outside of Canada, the duty of care to the patient is not necessarily negated when the patient decides to go abroad as a medical tourist. The CMA Code of Ethics and Québec's Code of ethics of physicians stipulate that a physician's responsibility toward the patient continues until such time as another physician has assumed responsibility for that patient. The CMA also suggests that a physician should cooperate with the subsequent treating physician to ensure that the patient has continuous care. The failure to coordinate the care of a patient, to ensure an appropriate handover of care, or to ensure appropriate communication among healthcare providers, may expose the physician to a legal action or complaint to the provincial or territorial medical regulatory authority (College).
Impact on the transferring physician
While the receiving physician has a responsibility to obtain information pertinent to making a diagnosis and treating the patient, if the transferring physician continues to advocate for the patient and help to ensure a smooth handover, the medico-legal risks to the transferring physician in the event of an adverse outcome will be minimized.
When a patient is deciding whether to pursue out-of-country medical care, Canadian physicians may be asked to provide professional advice. The patient should be generally encouraged to think carefully about the risks and benefits of the treatment, if known, and of receiving medical care abroad.
If the patient chooses to pursue the out-of-country treatment, whether on their own or with a referral from their Canadian physician, it is appropriate to assist the patient by honouring the request to provide pertinent information from the physician's medical record to a specified individual or company.
The transferring physician may consider discussing with the patient strategies for minimizing the health risks of going abroad, such as obtaining vaccinations before leaving Canada, taking anti-rejection drugs for organ transplantations, and seeing a Canadian specialist before departure to help prepare for the possibility of post-operative complications. Physicians should try to keep the lines of communication open to the extent possible, keeping in mind the principle of patient autonomy — the right of patients to make decisions about their personal health based on information, but not influence, from their physicians.
Any discussions concerning the availability, nature, benefits, and risks of out-of-country medical services should be documented in the patient's medical record.
It is appropriate for Canadian physicians to request that patients provide information about the out-of-country medical care, including from their foreign medical record.
Such information can assist in providing follow-up care. As noted earlier, in the context of an existing doctor-patient relationship, the physician owes a duty to provide reasonable care to the patient. A physician should generally use reasonable care and diligence in treating a patient within the limits of the physician's knowledge and resources.
The way ahead
Guidelines on medical tourism from the Public Health Agency of Canada may help both physicians and patients appreciate and mitigate the risks of seeking medical care abroad.2 Physicians may want to contact their College about any relevant guidelines or policy statements, or both.
Members are also encouraged to contact the CMPA for advice about their particular situation.
Penney, K., Snyder, J., Crooks, V., Johnston, R. "Risk communication and informed consent in the medical tourism industry: A thematic content analysis of Canadian broker websites", BMC Med Ethics, 2011; p 12-17.
Public Health Agency of Canada. See http://www.phac-aspc.gc.ca/tmp-pmv/info/care-soin-eng.php