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October 29, 2012

Why Patients Travel a Long Distance for Care

The decision for a patient to travel hours away for their medical care is a highly personal decision or a matter of necessity, especially if the care is unavailable locally.

Assuming care IS available locally, based on my own personal observations, the reason to travel for medical care ultimately is due to level of anxiety... either the patient or the surgeon.

Patient A:

I recently saw a patient with a small parotid tumor... about 1.5cm in size that was confirmed on needle biopsy to be a pleomorphic adenoma. Ultimately, the decision for surgery was pursued... but the patient wanted to go elsewhere to have the surgery done even though the patient understood I was perfectly competent to perform the resection.

Why? Because of the high anxiety and concern for the risk of facial paralysis associated with the surgery. The patient perceived her risk of this complication would be smaller if she went elsewhere.

Such patients, like Patient A, typically have certain characteristics:

• Type A personality
• Young (20-40s)
• Never had surgery before
• Surgery has a significant risk associated with it

Patient B:

In another patient who I saw a few months prior to patient A, same scenario, but the parotid tumor was 4cm in size and located in the deep lobe. Decision for surgery was also pursued, but this time, I as the surgeon recommended the patient to go elsewhere to have the surgery done.

Why? Because of the high anxiety and concern for the risk of facial paralysis associated with the surgery. I perceived the risk of this complication would be smaller if he went elsewhere where this type of surgery is frequently performed. This particular patient desperately asked and ultimately begged that I perform the surgery. He really did not want to travel to get the surgery done. However, I explained to the patient that based on size and location, the risk for facial paralysis was quite significant. If it was smaller, like in Patient A, I would have felt perfectly comfortable in performing the surgery.

Patient B ultimately did go elsewhere to have the surgery done... and did, unfortunately, suffer from facial paralysis afterwards.

However, I was happy to provide routine post-op follow-up care given it was more geographically convenient for the patient.

Such patients, like Patient B, typically have certain characteristics:

• Older (50+)
• Has had surgery before



Issues With Long-Distance Care

Regardless of innate patient characteristics, having surgery done a long-distance away is a pain for the patient. Think of the travel, expense, missed time from work, etc NOT just for the surgery, but for any post-operative problems that develop. Oftentimes, the patient concern ends up being unfounded and only reassurance is required, but in order to make that determination, the surgeon needs to do an exam. Imagine the frustration of the patient when a surgeon requests a visit before answering a question about a post-surgical concern... hours of driving to the office, waiting in the exam room, being seen by the surgeon for a few minutes only to hear that everything is fine and normal, and finally driving hours back home.

Even in the hands of the BEST surgeon, problems can arise after surgery. Is the surgical wound becoming infected? Where is that fever coming from? There's a little drainage occurring... is that normal? Why is the skin red? There's a lot of pain and his medications aren't working.

To complicate things further, narcotic pain killers can NOT be called in by federal rules. A hardcopy prescription is required. Now, wouldn't that be mighty inconvenient if a patient (who mind you is in pain), needs to drive hours to the surgeon's office just to pick up a hardcopy narcotic prescription.

The logistical difficulties of dealing with post-operative care after patient discharge is tremendous for both the surgeon as well as the patient if the distance between the two is large.

How to Make Long-Distance Care Easier for the Patient

DO see your most appropriate local doctor and discuss your medical case with him/her. If decision to pursue surgery a long-distance away is made, DO keep your local doctor in the loop.

Routine post-operative care can all be provided locally. Suture removal can be done locally. Infection evaluation can be done locally.

The decision to have surgery a long-distance away was due to concern of risks inherent to the surgery itself... not the care afterwards and as such, such post-operative care can all be provided locally by a competent physician.

Of course, if there's significant concern, the patient can always travel back to the original surgeon, but most often, this travel is unnecessary.

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids. Google+ Christopher Chang, MD Bio

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