Interview with International Medical Travel Association President, Dr. Steven Tucker (transcript)

Interview with International Medical Travel Association President, Dr. Steven Tucker
David E. Williams: This is David E. Williams, CEO of MedTripInfo.com.

I spoke recently with Dr. Steven Tucker, an oncologist who is Medical Director of the West Clinic Singapore and President of the International Medical Travel Association.

Dr. Tucker spoke with me about what it's like to practice medicine in Singapore, how medical tourism and medical travel are evolving, and the role he hopes the International Medical Travel Association will play. Listen in and hear what he has to say.

Dr. Tucker thanks for speaking with me today.
Dr. Steven Tucker: You're welcome. Thank you for inviting me.
David: You're a US trained and board certified medical oncologist so, why are you working in Singapore?
Dr. Tucker: The West Clinic has a vision of expanding access to quality cancer care and expanding access to oncology clinical trials. So it was logical that we moved into Asia; and Singapore was an ideal destination to create our hub for cancer services across Asia.
David: What made Singapore ideal?
Dr. Tucker: Singapore's medical system, both in terms of medical training, language, ease of travel, all combine to make Singapore a great destination not just for patients but also for physicians who are interested in practicing in environments outside of North America or Europe.
David: And is there any impact in terms of government policy, in terms of encouraging that and also related to any issues with stem cell treatment or stem cell research?
Dr. Tucker: The government of Singapore has an ambitious plan to become the biomedical hub of the future, and they've made it... There is an easily reproducible path for the creation of health care entities.

Not to say that the process is easy, but that the process is identifiable and transparent, how you can build a health care entity in Singapore. Nothing about our endeavor had any particular relation, however, to stem cell biology.
David: The center where you are, what kinds of patients are you typically working with? Where are they from and what sort of things are they being treated for?
Dr. Tucker: I see cancer patients, and I see cancer patients who are in the midst of treatment, who are newly diagnosed, second opinions. I'm seeing patients from North America, Australia, all over the South East Asia, from Dhaka and Colombo, Ho Chi Minh City and Hanoi, Manila, Kuala Lumpur, Jakarta, Surabaya ‑‑ the whole panoply of South East Asia.

And these are patients who are either looking for access to health care, because quality health care or evidence based health care does not exist in their home, or they are patients who are seeking second opinions; that would likely gone to the West Coast of the United States for second opinions, but now are realizing that there's an American oncology center in Singapore, that can provide the exact same quality of opinion and the same guidelines, without the need for traveling to the United States.
David: Now I can understand that patients from South East Asia are coming to Singapore for that reason. You mentioned also the patients from North America. What would be the motivation of a North American patient to come visit you?
Dr. Tucker: I've had a very strong internationally flavored practice in North America, and I have a lot of patients with breast cancer and prostate cancer, who continue to seek my opinion. But we also had other patients who are Americans around the region, that are coming to Singapore for follow‑up care or directly for care for newly diagnosed disease.
David: Are there certain cancers where that makes more sense, just in terms of the length of treatment, or whether they need the extensive follow‑up?
Dr. Tucker: Yes. Specifically one can broadly divide cancer treatments (or cancer patients) into treatment with curative intent, and then there's really everyone else.

Patients who are treated with curative intent, for example would be the vast numbers of women with breast cancer, who will go ahead and have surgery for what doctors would describe as early disease, and then receive four to six months of chemotherapy as a preventive policy, to decrease the odds of the breast cancer reoccurring in the next five years.

So those are a much healthier group of patients, and contrasted by patients with metastatic disease, meaning disease that has either recurred or spread from the organ of origination to another organ. Now this is not always, by any means, a death sentence. Cancer has truly become a chronic disease in the United States.

And the majority of patients who are diagnosed with cancer are alive and well more than five years later. So there are a lot of patients with metastatic disease, who are traveling for an additional opinion or to decrease ‑‑ believe it or not ‑‑ to decrease the cost of care.

But there are also a subset of patients for whom medical travel is not safe. Patients who are closer to the end of life or have co‑morbidities that prohibit them from traveling.
David: You have mentioned somebody going abroad to reduce the cost of care. What are the prices like in Singapore compared to the United States or Europe?
Dr. Tucker: They are significantly less. I don't know the exact percentages, and it changes based on disease or drugs, but I think that your readers and listeners would be well aware of any of the published, even simple figures on the cost of, for example, bypass being probably somewhere between 60 and 80 percent less in Singapore than in the United States, and that the costs are even lower in other South East Asian countries.

Singapore is actually perhaps somewhat more expensive that other South East Asian countries, but there is an incredibly high degree of quality available in Singapore, which justifies the high end of the inexpensive market.
David: Are there different treatments or procedures that are available in Singapore or other countries that would also compel someone to travel?
Dr. Tucker: I think the answer to that is no, but the perception may be yes. We practice evidence‑based medicine in Singapore, and we also are creating a clinical trials program for expanded access to newer medications. But everything we do parallels the cancer community in the United States, and there's nothing available to me in Singapore, first of all, that's not available in the United States, and there's nothing additional available to me in Singapore over the United States.

I think the issue that comes up is the perception of access to care or drugs in the patient's mind, or perhaps there are limitations on the style of practice in the United States, based upon the current health care insurance industry. But we still practice evidence‑based guidelines. We want to provide cost‑effective, quality care to cancer patients and their families.
David: You mentioned that some patients are not good candidates for travel because perhaps they are too sick; it's not safe for them to travel. How does someone determine if they are in fact a good candidate for medical travel, and then how should they pick where they would go?
Dr. Tucker: That's not a question that patients can particularly answer for themselves. I think that a physician needs to be involved in that decision‑making process; whether that's a physician on what I'd call the outbound side, or a receiving physician on the inbound side. Somebody either needs to examine the patient or have a telephone discussion with the patient regarding realistic expectations.

All it takes is a telephone call to say, "Are you lying in your bed and unable to walk?" That patient, clearly, is not appropriate for medical travel. Or, a patient who says they can walk 10 feet, but then they get breathless. That patient is probably not appropriate for medical travel either.
David: What's been your experience with, as you call them, outbound physicians? Are physicians willing to coordinate with you, or with other providers, maybe who are not from the United States, in order to coordinate the care with their patients, and then also to do follow‑up when the patient returns home?
Dr. Tucker: I can't speak for any other physicians, but in my own experience, it has been very, almost easy, to partner with physicians anywhere in the world, to provide quality medical care. What is required is going the extra distance, in terms of creating a relationship with another physician and providing treatment and partnering for patient care.

This is not a situation of one doctor working for another. I think when it's put in terms that here is a patient, this is what they'd like, here's what we are suggesting; how can we make this work for the patient? I think it always works out.

I think if a patient or physician puts up an adversarial relationship, then you're doomed from the beginning.
David: It sounds like it makes most sense for a patient to work with their own physician in the US. Is it practical for a patient to contact an overseas facility directly, or does it make more sense for them to work with a medical travel facilitator?
Dr. Tucker: It all depends on the specific situation. But I think that at the end of the day, you need to start the process by having a doctor‑patient relationship. Everyone else becomes, for lack of a more articulate term, a middleman. There are very few middlemen who have the same knowledge and understanding of both sides of the transaction; that is, both the patient and the doctor side.

I think that you can really do a great job organizing flights, translators, transports, etc. But all of that is to create a doctor‑patient relationship. If the doctor‑patient relationship doesn't exist, then you're going to have a poor medical outcome and you're going to have an unhappy customer for the middleman.
David: What role do you see some of these accreditation bodies playing; people like JCI and maybe groups from other places like Trent System Accreditation Group? Are they complementary or are they in conflict if the hospital, lets say, wanted to be accredited by more than one international accreditation body?
Dr. Tucker: I'm not familiar with the specifics of the Trent System, but from what I've heard in conferences, I find them to be complementary. Certainly there is nothing untoward about having multiple levels of accreditation. It doesn't detract in any way, for a facility to have more than one accreditation.
David: Do you have a sense of what the outlook is for insurance companies actually paying for patients to go overseas? There's been a lot of talk about it in the US, but I haven't seen that much in the way of practical actions.
Dr. Tucker: Again, the insurance industry looks to drive down costs of medical care, and if the care can be provided in a non‑traditional location at a significant savings, that will motivate a for‑profit insurance company.

The key as a physician is to make sure that there is no difference in how that procedure is performed, how the process is executed, and to make sure that quality is the first issue. Cost cannot be the sole driving factor here. It's got to be cost effective, and quality is the issue that remains most important in medical care, regardless of the presence or absence of medical travel.
David: I want to ask you a little bit about the International Medical Travel Association where you're the president. What is the concept behind that organization?
Dr. Tucker: The International Medical Travel Association was created to really be an industry forum, to be a tool for both health care providers and those members of the hospitality industry, whether they be airlines, hotels, travel agents, to strengthen those industries, all for the betterment of patient care.

So, as patients increasingly travel from point A to point B, they are continually utilizing health care as traditionally defined, but are increasingly utilizing hospitality in a way that is non‑traditional. And it's important that both groups, that both industries be able to communicate and have a common set of expectations, which again, all goes back to improving quality patient care across the globe.
David: What sort of activities have you undertaken and what's the membership like?
Dr. Tucker: Well, I would say that in the few months that we've been established, we've been mostly and deeply introspective; that we are working on finding what will be the right path to get this message across. At the moment, we are organizing a series of small meetings, for the creation of some white papers on general topics of interest. So, we're not looking to be some grand convention device with 5,000 members all showing up every year in a different city, to promote medical tourism.

I think we're much more interested in being a small body that continually asks questions For example... The first issue I'm working on: International Patients' Bill of Rights. It's absolutely astounding how many patients are not provided their medical records on request in various countries. In order for patients to travel from point A to point B, we have to have quality medical records.

So, there are a variety of issues for medical travel, starting with the Patient Bill of Rights. If we propose, in a white paper, our version of a Bill of Rights, I hope it will spark conversation amongst JCI, Trent, hospital systems, insurance groups, and perhaps there will be voluntary adoption of the IMTA Patient Bill of Rights.
David: I've seen in articles where you've called for an economically sustainable, excellent and ethical medical travel industry. It sounds like part of what you're addressing in the white paper, with the Bill of Rights, has to do with the ethical aspect of it. Can you describe a little bit what you mean by economically sustainable?
Dr. Tucker: I think that medical travel, when done properly over time, will actually provide more infrastructure in places where quality health care does not currently exist. At the end of the day, it's always better for people to be treated close to home. We will never erase medical travel and medical tourism, as patients will always have a perception that they need to go somewhere to get a second opinion. You'll never stop someone from leaving the UK to go to the Mayo Clinic, for example.

But, if patients continually move from Dhaka to Singapore for cancer care, ultimately it's my goal to establish a cancer treatment center in Dhaka so that those patients don't have to travel. If a patient has to come to Singapore for therapy because it does not exist in Bangladesh, to the quality that is matched in Singapore, then the patient is going to come to Singapore.

But the patient never comes alone. The patient will come with a son or a daughter, a helper, children... And just when the family needs extra money to help pay for expensive care, expensive medications, they're being hit with a situation where they have to take leave from work. And, they incur extra expense by being abroad.

So, if we can redirect that care to say, a West Clinic Bangladesh, then, not only is the patient treated closer to home, the West Clinic contributes to the development of the medical infrastructure of Bangladesh. Families continue to work. All around, outcomes become better.

So, I think that when done properly, we will be able to diffuse high quality health care back to the point of origin where the patients exist. I think that in a period of a decade, we will reduce the amount of medical travel, while increasing the quality of medical care across the globe.
David: What kind of impact are you seeing in some of the lower and middle income countries like India, or Philippines, or Malaysia, that are embarking on a medical tourism strategy as a country? Are you seeing some of the positive impact in terms of what happens with the local infrastructure and access to care?
Dr. Tucker: It's too early and I've generally not monitored those countries to see where they were and where they're going, based upon a medical travel policy or a government mandated consumer medical policy.
David: What do you see in terms of the impact on the US health care system, by the fact that patients are starting to go abroad for care? Does that have an impact in terms of physicians or hospitals thinking about competition or looking for ways to be more efficient, or reduce their costs?
Dr. Tucker: Well, clearly, the US system is increasingly expensive. The quality can be exceedingly high, but often it's also somewhat coming down to the averages. There are clearly patients in the United States, Canada, and Europe, who are being disenfranchised by the health care system, or more directly, by the health insurance system. They're moving abroad and hospitals, hospital systems, medical groups, insurance companies, are trying to recapture those patients by providing lower cost alternatives in non‑traditional sites.

So, I think you'll see an evolution in the US health care system. It remains an incredibly bloated and expensive system. And, not surprisingly, there's some dissatisfaction amongst the physicians, which can make it more enticing for American‑trained doctors to practice abroad.
David: I'm wondering about what the opportunity is for Central and South American countries to take advantage of medical travel. It seems like an awfully long distance to travel to Singapore or other parts of Asia when Central and South America have been successful competing for cosmetic surgery. Do you see an opportunity to have first class providers for cancer treatment or orthopedics, for example, closer to the United States?
Dr. Tucker: I'm certain the opportunities are available, but I'm not very well versed at this time on the growth of the medical travel industry in South America. As you pointed out, they have high quality elective procedures, cosmetic procedures. They have top institutions in terms of academic oncology. Where patients get treated on a regular basis, I'm not familiar with.
David: I've been talking today with Dr. Steven Tucker, Medical Director for the West Clinic Singapore and President of the International Medical Travel Association. Dr. Tucker, thanks for speaking with me today.
Dr. Tucker: Thank you.