Medical Malpractice in Thailand

Little did Margaret Richter know that the night she assisted her sick husband onto the flight to Bangkok would be the last she would ever see him alive. She stayed with her husband Roy to the last possible moment, embracing him prior to his boarding the 22 hour flight to Thailand . During the embrace, noticing how stiff and hollow his body felt, she whispered in his ear that everything would be okay and he would receive the treatment he needed in the Thai hospital. Her husband’s once powerful frame now looked bent and reed-like as he entered the airplane ramp among the throng of tourists, holiday makers, and beach goers. The 10,000 mile trip had a completely different significance for them. Throughout much of her life, Margaret’s husband Roy was the strong one in their marriage but roles had reversed. Now Margaret was the caretaker of the family, juggling bills, medicines, work and care of their teenage son. Although a successful restaurateur, Roy was one of several million Americans that fell through the cracks of the American health care system. The family was not destitute, far from it. However, due to a pre-existing medical condition, a sluggish economy and the prohibitory expense involved in maintaining health insurance, the couple had opted for medical treatment abroad.

Margaret and Roy had both watched a TV documentary about an international hospital in Thailand which advertised quality health care as a safe and economical alternative for medical care in their own country. Former hospital patients returning to the US gushed with praise about the high level of care and the professionalism of the Thai doctors and staff. Digging further, she found the hospital’s sleek website and impressive credentials. Soon thereafter, Margaret contacted the hospital to arrange appointments with a specialist and confirmed arrangements for the trip to Thailand .

Now some 2 years later, Margaret enlisted the services of a Thailand lawyer and was in a Thai courtroom giving testimony regarding how she learned of her husband’s death, the result of a series of botched medical procedures at the hospital she had placed so much faith in, caused by errors that the supposedly qualified medical personnel should never have let happened.

Behind the Medical Tourism Boom

Bangkok hospitals have undergone an image revolution that is most apparent in their decor. Along with orderly rows of plastic seating and ubiquitous stainless steel, there are Starbucks and Burger King outlets. Patients gaze at LCD screens showing CNN and there are life-sized cardboard cutout signs advertising the latest procedures, a nip and a cut here, or perhaps a pre-cancer screening at a special discount rate. In the more upscale hospitals, service resembles a first class hotel. Private rooms are carefully decorated with pastels and the bathrooms have brass fixtures and hairdryers.

Medicine in Thailand is big business and the medical and hospitality business have formed a synergy in the field ironically termed “medical tourism,” a pastime that combines a vacation with a medical procedure or operation.

While in years past this medical tourism phenomenon was mainly the domain of those traveling to another country strictly on the basis of need or quality of care, today’s medical tourists are more often guided by price and as such, are traveling in increasing numbers to Thailand . Considering the ease of travel provided by modern passenger jets, the allure of recovery in an exotic locale, the 5-star level accommodations offered at some of the private Thai hospitals, and medical tour companies that will plan everything from your doctor visits to tour tickets, it’s easy to see why millions of people from around the world are booking appointments with Thai doctors and specialists.

In 2004, one of former Prime Minister Thaksin Shinawatra’s main initiatives was a plan to make Thailand a “medical hub” by using government money and resources to promote a state of the art private healthcare system that would be attractive to foreign patients. The plan has worked, bringing in an estimated 50 billion baht per year. While Thailand has been a popular destination for Americans seeking low cost surgery, and Canadians and Brits looking to cut wait times, an increasing number of patients from the Middle East are making the pilgrimage to Thailand for treatment. Post 9/11 visa restrictions have kept many in the region from traveling West for care and are now choosing Thailand , influenced in part by the efforts of the newly opened Tourism Authority of Thailand (TAT) office in Dubai.

Thailand hospitals’ massive marketing efforts include news documentaries on Western TV, online videos and websites, and flashy brochures. The patients and their families who have not been satisfied, due to a botched operation or procedure, do not receive the same air time. Another area that gets less than stellar coverage is the ability of aggrieved patients and families to obtain redress for personal injury with the assistance of a Thailand lawyer in a legal system that bears little resemblance to what a medical tourist may be used to at home.

Thailand’s main selling point to potential medical tourists, in particular the over 46 million uninsured Americans, is price. According to the Public Health Ministry, a heart valve replacement in Thailand costs a mere $10,000 compared to $160,000 in the US, and heart bypass surgery costs $11,000 as compared with $130,000 in the US. Hip and knee replacements run about $12,000 and $10,000 respectively, in Thailand, while in the United States they cost roughly four times as much – $43,000 and $40,000. With prices so low, 75% of foreign patients pay in cash, reducing the cost of processing insurance claims and further helping to keep costs down. The low cost of surgeries in Thailand combined with the high standard of service that the top private hospitals offer – foreign trained doctors, state of the art equipment and nurse and doctor to patient ratios much closer to 1:1 than most Western hospitals – has not only caught the attention of uninsured Americans, but also the insurance companies who cover the other 250 million and who are desperately attempting to cut costs. Blue Cross Blue Shield of South Carolina currently covers major procedures at an internationally run hospital in Bangkok for its 15 million customers, and Florida based United Group Programs, a small business insurance provider, also has deals in place with a hospital in Thailand. In addition, the West Virginia and Colorado state legislatures are considering bills which would provide incentives for state employees to travel to Thailand for medical care.

While the price of operations and service at private hospitals are indeed attractive, there are numerous drawbacks to traveling to Thailand for surgery that have given both potential patients and their insurance companies pause. According to experts, if the cost of surgery is more than $6000 dollars cheaper in Thailand, then it will be worth the trip, money wise. Anything less than $6000, you should seek care at home, although this number may rise along with the rising cost of travel. For many, especially those living on the east coast of the US, total trip time to Bangkok can stretch to over 24 hours. Plane rides of the length required to cross the Pacific Ocean or Asia can exacerbate medical conditions. Patients seeking care at hospitals looking to maximize their patient load through minimizing recovery time may find themselves back on a plane soon after surgery – a potentially dangerous situation, especially for those with heart conditions. Another potential danger for prospective patients is what attracts many tourists to Thailand, namely vice. The chances for debauchery – drinking, drugs, prostitution – are rife. Indulging in these can cause serious complications in the preparation for and recovery from surgery. There is also the question of language. While many Thai doctors are foreign trained and most can speak at least a little bit of English, the same cannot be said for most Thai nurses who are the ones who attend to patients day to day needs. Difficulties communicating between the patients and medical staff are all too common and these breakdowns can sometimes have tragic consequences.

What most experts consider the most serious drawback to medical tourism in Thailand is directly related to its biggest draw – price, and that is a lack of recourse for patients if something goes awry.

Victims in Paradise : Why Doctors Hate Lawyers Worldwide

What many medical tour companies and hospitals gloss over in their slickly produced websites, and is often overlooked by potential medical tourists, is the difficulty in obtaining legal redress for personal injury with the assistance of a Thailand malpractice lawyer if something goes awry. Although legal procedures for obtaining compensation do exist, they are often inconvenient and impractical (particularly when the injured patient is a foreigner) and the amount of money for damages awarded by courts is often less than what exists in Western countries.

Thai doctors pay very little for malpractice insurance, compared with Western doctors, which in turn helps keep the cost of medical care down. Foreign victims of medical malpractice also have limited options upon their return to their home countries, as most insurance plans will not cover repairs needed to fix overseas surgeries. Foreign governments whose health care plans do cover such repairs have recently begun to fight back against medical tourism in Thailand by discouraging their citizens from receiving medical care in the Kingdom. In 2006, Australia issued a travel warning regarding cosmetic surgery in Thailand, after a spate of cases where Australian women returned home needing repairs to poorly executed cosmetic surgeries, repairs that were covered by Australia’s Medicare system.

The principle government oversight body of the medical community in Thailand is the Thai Medical Council. Statistics are kept concerning doctor misconduct and there is also a complaint procedure. In cases where a patient claims that they were a victim of medical malpractice, the Thai Medical Council will first investigate the claims against the doctor or doctors in question in order to determine, in their judgment, whether malpractice did indeed occur. The council may then advise the police as to the necessity of a criminal investigation. Critics of the Medical Council believe that the agency is not transparent and would benefit from having members in key positions that do not have vested interests in protecting the medical profession. In many other jurisdictions, to prevent perceived protectionism by the medical community, hearings are heard by non-medical lay persons in addition to medical doctors.

Obtaining legal redress for medical malpractice is not simply an issue for foreigners in Thailand, but also Thais. A recent court decision, however, might change the way that malpractice claims are adjudicated. Last year, a Nakhon Si Thammarat court sentenced a doctor to three years in prison without probation for the 2002 death of an elderly patient. The doctor administered a spinal anesthetic to the patient, who was admitted for appendicitis, which led to cardiac arrest and her subsequent death. The court ruled as it did in part, it said, because the doctor refused to admit that she was at fault, an admission that would be tantamount to losing face. In Thailand’s hierarchically structured society, saving face is extremely important, especially for those in high profile professions such as doctors or surgeons.

In response to this decision, a bill is under consideration in the legislature that attempts to balance the desire of the medical profession to protect overworked doctors from malpractice suits and the desire of human and victims’ rights groups to protect the legal rights of patients who claim to be the victims of negligent malpractice. Dubbed a “no-fault” bill, the Medical Malpractice Victim’s Fund Bill would provide a non-tort avenue for potential malpractice plaintiffs to be compensated without holding the doctor in question responsible. Under this bill, a fund consisting of money donated from government run hospitals, as well as private hospitals that wish to be covered, would be created to distribute amongst those who claim to be victims of malpractice (cosmetic surgery is not covered). Appropriate compensation would be determined within two months of a complaint being filed, with delivery of funds within five months. One potential stumbling block is a clause introduced by the Public Health Ministry which would bar the victims from pursuing a criminal or civil judgment against a doctor or hospital after claiming compensation under the bill, a right that victims’ rights groups feel must be upheld.

Since 1990, over 3,000 ethics complaints have been filed against Thai doctors and hospitals, and in recent years, over 75 doctors in public hospitals have had malpractice suits brought against them resulting in at least 13 convictions. In light of these numbers, the Health Ministry is worried that the tort system could decimate the understaffed health system by not only jailing competent doctors who make mistakes, but also by causing future doctors to quit medical school and current doctors to switch professions out of fear of malpractice suits.

Ironically, the public health system is understaffed in large part due to the success of Thaksin’s plan to make Thailand an international medical tourism destination. Critics claim that the medical hub plan was created under the false assumption that Thailand had excess medical resources, human and otherwise, that could be diverted from the public to private health care systems without any negative effects on the former. However, as an increasing percentage of Thailand’s healthcare system caters to foreigners and the rich, care for ordinary Thais has suffered. Thai doctors, specialists in particular, have been leaving public hospitals and teaching positions at medical schools and moving to private hospitals, where they can earn three times as much. At the same time, the government’s introduction of the 30 baht per visit health plan has overloaded public hospitals with patients, providing added incentive for doctors to move to private hospitals with a much lighter workload. The increasing prices for treatment at these private hospitals, while still relatively cheap for Westerners, prices out many middle class Thais, who in turn have to seek treatment at public hospitals, further overcrowding the system.

These issues will have to be dealt with soon as the medical tourism sector seems likely to see continued growth in the foreseeable future. Fewer restrictions placed on experimental surgeries means that many in the West will look to Thailand for potentially lifesaving, or quality of life improving, procedures, such as stem cell therapy for heart conditions. Also, doctors and hospitals in the West have been slower to adopt less invasive cutting edge surgeries than their Thai counterparts. This is not only due to questions of safety, but also due to being more focused on the bottom line – reduced patient recovery time results in less revenue for hospitals as patients check out more quickly – and therefore is not as profitable as other medical services. And as more patients return home safely from cheap and effective surgeries overseas, insurance companies are likely to start encouraging medical travel to Thailand by covering travel costs and providing liability protection. However, with more patients come more opportunities for medical malpractice to occur. As the Thai courts begin to address more and more cases of medical malpractice involving medical tourism, it is expected that verdict amounts will increase. This too may lead to further safeguards in the system.

Epilogue

Margaret sat in the court’s witness box, which consisted of a raised platform surrounded on three sides by intricately carved teak wood railings located in the center of the courtroom. The judge, a 50-ish man with speckles of gray dotting his military style crew cut peered at the hospital’s lawyers through his black, marble-like eyes. Margaret’s Thailand lawyers gave her an encouraging look in preparation for the cross examination. The lawyer for the hospital hovered over Margaret and with a dramatic flourish of his hands and a feigned look of surprise on his face, asked Margaret: Thailand lawyers “Didn’t you know that the hospital doesn’t specialize in these types of medical conditions before sending your husband to Thailand ?” The judge, leaning forward, interjected abruptly before Margaret had a chance to respond: “Are you saying that your hospital is not qualified to handle patients but accepts them anyway? It is not the patient’s responsibility that the hospital’s doctors be qualified, it is the hospital’s responsibility to provide quality care to all persons it accepts as patients.” The judge paused and leaned back, allowing his words to sink in and inquired further: “Would you like to withdraw the question?” The defense lawyer, looking like a rookie put in his place, stuttered meekly, “Yes, yes judge, I withdraw the question.”