Health travel planners answer to many names: brokers, facilitators, agents, ex­peditors. Throughout this book, we use the phrase “health travel planner” or “health travel agent” to mean any agency or representative who specializes in helping patients obtain medical treatment abroad. Before engaging the services of a health travel agent, ask yourself these questions:

Whether to use a health travel planner

• Will a health travel planner save me time?
• Am I willing to pay for the convenience of a health travel planner’s services?
• Will I feel more confident about health travel if I use the services of an agency?
• Does the agent I’m considering have the knowledge and experience I need?
• Does this planner have a track record of successfulservice to the health traveler?
• Does this agent speak my language well enough for us to converse comfortably?
• Can I get at least two recommendations or letters of reference from former clients of this agency? Have I checked these references?
• Can I get at least two recommendations or letters of reference from treatment centers that work
  with this agency? Have I checked these references?
• Can this agency give me complete information about possible destinations and options for my procedure?
• Will this agent put me in touch with one or more treatment centers and physicians?
• Will this agent work collaboratively to help me choose the best treatment option?
• Is this agent responsive to my questions and concerns?
• Does the service package this agent is offering meet my needs?
• Does this agent have longstanding affiliations with in-country treatment centers and practitioners?
• Has this planner negotiated better-than-retail rates with hospitals, clinics, physicians, hotels, and (perhaps) airlines?
• Can this agent save me money on other in-country costs, such as airport pickup and dropoff or
  transportation to my clinic?
• Can this agent provide personal assistance and support in my destination country?
• Is this planner willing to work within the constraints of my budget?
• Do I know (and have in writing) the exact costs for this agency’s services?
• Do I have a suitable contract or letter of agreement with this agency?
• Do I feel comfortable with this agency? Have we built a sense of trust?

Paying for a Health Travel Planner’s Services
Some planners offer “all-in-one” package deals, which are fine. However, at tax time, you may need to show your itemized cost breakdown, including treatment, lodging, meals, transportation, and health travel agent fees. Spreadsheets are universal these days. Ask your planner to give you a detailed expense log.

Costs and payments are usually handled in one of three ways:

• Membership, upfront fee required. This arrangement re­quires the patient to pay a non-refundable membership fee (often in the US$50–300 range) before any services are ren­dered. The membership fee is usually folded into the pack­age price if you engage that agent.
• Membership, upfront fee required. In this arrangement, an agent first provides enough information to get you well along your path: data on specific treatment centers and physicians, advice on medical records and in-country proce­dures, and perhaps even a telephone consultation with your candidate physician or surgeon. At that point, if you decide to engage the agent, you’ll be asked to submit a deposit, per­haps 25–50 percent of the entire package price. Another pay­ment is due prior to treatment, and the remainder is payable when you leave the hospital or clinic.
• Pay as you go, direct to third parties. A handful of planners act more as referral services than as full-blown brokers, pro­viding information about hospitals and physicians, airfares, and vacation opportunities, without doing much of the real legwork. They usually charge you a commission or set fee on any service you engage.
• If you’re dealing with a reputable agent, all these fee structures get you to much the same place. Beware, however, of agents asking for 100 percent up front. You should see evidence of performance, communicate with all the parties personally (via telephone or email), and know that your hard-earned money is going where it should.
• Although a deposit of up to 50 percent of the total package cost is usually required, you should reserve at least 25 percent of the total bill for final payment. In other words, as with most other services, don’t pay the entire bill until you’re satisfied and all the services you were promised have been provided. Most planners accept credit cards, but before you use yours, ask your agent about any surcharges associated with credit card payments.

• Of all the services a health travel planner offers, the most important are related to your treatment. Start your dialogue by asking the fundamental questions: Do you know the best doctors? Have you met personally with your preferred physicians and visited their clinics? Can you give me their credentials and back­ground information? What about accommodations? Do you provide transpor­tation to and from the airport? To and from the treatment center? If an agent is knowledgeable and capable with these details, the rest of the planning usually takes care of itself.
• Does my health travel lanner providee this service?
• Treatment options from which to choose destination countries, hospitals, and physicians best equipped to meet my needs
• Information on hospital accreditation and physicians’ credentials, board affiliations, number of surgeries performed, association memberships, and ongoing training
• Appointment scheduling and confirmations for tests, consultations, and treatments
• Teleconsultation with physicians or surgeons to review my medical history and discuss my procedure
• Transfer of medical records, including history,
  x-rays/scans, test results, recommendations, and other documentation
• Travel arrangements, including airline and hotel reservations, tickets, and confirmations; also including local in-country transportation
• Visa or passport facilitation
• Onsite pre-treatment assistance, including a local representative to accompany me to appointments, expedite hospital admission, arrange local transportation, and assist with my hospital discharge
• Recovery arrangements, including local transportation, lodging, meals, and any nursing services required during recovery
• Amenity arrangements, including “concierge services,” such as take-out food from restaurants, tickets for events, and dry-cleaning and laundry services
• Communications arrangements, including telephone, cell phone, and Internet services
  Leisure or vacation planning (if desired)
• Aftercare and followup once I’ve returned home, including post-treatment liaison for information retrieval and making arrangements for a return trip should complications arise

Although each journey varies according to the traveler's preferences and pocketbook, good planning is essential to the success of any trip. That goes double for the medical traveler. This checklist covers some of the planning you'll need to do to become a fully prepared and informed global patient.

Why should you plan at least three months in advance?

• The best physicians are also the busiest. If you want the most qualified physician and the best care your global patient money can buy, give the doctors and treatment centers you select plenty of time to work you into their calendars.
• The lowest international airfares go to those who book early. Booking at least 60 days prior to treatment avoids the unhappy upward spiral of air travel costs. If you're planning to redeem frequent-flyer miles, try to book at least 90 days in advance.
• Peak seasons can snarl the best-laid plans. International tourism attracts large numbers of people, and you can encounter problems if you want or need to travel during the busy tourist season.
• Everything takes longer than you think it will. It's simply a fact of life.

For Big Surgeries, Think Big

• You want to be certain you're getting the best. For big surgeries, we advise heading to the big hospitals that have performed large numbers of exactly your kind of procedure, with the accreditation and success ratios to prove it. A hospital accredited by the Joint Com­mission International (JCI)-such as Bayındır Hospital Söğütözü and Kavaklıdere in Ankara-carries the neces­sary staff, medical talent, administrative infrastructure, state-of-the-art instrumentation, and institutional follow-up you need.
• Be sure to ask about the success and morbidity rates for your particular procedure, and find out how they compare with those at home. If you are having surgery, ask your surgeon how many sur­geries of exactly your procedure he or she has performed in the past two years. While there are no set standards, fewer than ten is not so good. More than 50 is much better.
• Have I completeded these planning steps?
• Engaged the services of a health travel planner
  (if desired — see Checklists 1 and 2)
• Obtained a second opinion — or a third if necessary — on
  diagnosis and treatment options
• Considered a range of treatment options and discussed each option with potential providers
  Reviewed the various hospitals, clinics, specialties, and
  treatments available to select an appropriate destination
• Chosen a reliable, fun travel companion
• Obtained and reviewed the professional credentials of two or more physicians or surgeons
• Selected the best physician or surgeon for the treatment I need
• Researched the history and accreditation of the hospital or clinic
• Checked for the affiliations and partnerships of the hospital or clinic
• Learned about the number of surgeries performed in the
  hospital or clinic (generally, the more the better)
• Learned about success rates (these are usually calculated as a ratio of successful operations to the overall number of operations performed)
• Gathered and sent all medical records and diagnostic information that my physician or surgeon needs to plan my treatment
• Prearranged travel, accommodations, recovery, and leisure activities (if desired)
• Prearranged amenities, such as concierge services in-country or wheelchair services on the return trip
• Packed the essentials (see Checklist 4)
• Double-checked everything - then checked again

Responding to a global demand for accreditation standards, in 1999 the Joint Commission launched JCI, its international af­filiate accreditation agency. In order to be accredited, an inter­national healthcare provider must meet the rigorous standards set forth by JCI. At this writing, some 240 hospitals, laboratories, and special programs outside the US have been JCI-approved, with more coming on board each month.

Although JCI accreditation is not essential, it's an important new benchmark and the only medically oriented seal of approval for international hospitals and clinics. Learning that your treat­ment center is JCI-approved lends a comfort to the process, and the remainder of your searching and checking need not be as rigorous. That said, many excellent hospitals, while not JCI-approved, have received local accreditation at the same levels as the world's best treatment centers.

JCI's Web site carries far more information than you'll ever want to explore on accreditation standards and procedures. To view JCI's current roster of accredited hospitals abroad, go to www.jointcommissioninternational.org/JCI-Accredited-Organizations.

Alternatives to JCI

When researching hospitals and clinics abroad, you'll often come across the phrase “ISO-accredited”. Based in Geneva, Switzerland, the International Organization for Standardization (ISO) is a 157-country network of national standards institutes that approves and accredits a wide range of product and service sectors worldwide, including hospitals and clinics. ISO mostly oversees fa­cilities and administration, not healthcare procedures, practices, or methods.

Other organizations in other countries set standards and accredit hospitals. Organizations that accredit in non-JCI countries include the International Society for Quality in Healthcare, the Australian Council of Healthcare Standards, the Canadian Council on Health Services Accreditation, the Council for Health Services Accreditation of Southern Africa, the Egyptian Health Care Accreditation Organiza­tion, the Irish Health Services Accreditation Board, the Japan Coun­cil for Quality Health Care, and many more. If you are considering a hospital accredited by any organization, it's wise to investigate the criteria applied to the accreditation and determine to your own sat­isfaction that the standards are sufficient and appropriate to your needs.

You’ve likely heard the cardinal rule of international travel: pack light. Less to carry means less to lose. Don’t worry if you leave behind some basic item, such as shampoo or a comb; you can always pick it up at your destination. That said, this checklist covers the items you absolutely, positively shouldn’t forget—and make sure you carry these things in your carry-on bag. A prescription or pass­port lost in checked luggage could spell disaster.

Is this item packed in my carry-on bag?

• Passport/Visa (if required)
• Travel itinerary
• Airline tickets or eticket confirmations
• Driver’s license or valid picture ID (in addition to passport)
• Health insurance card(s) or policy
• ATM card or traveler’s checks
• Credit card(s)
• Enough cash for airport fees and local transportation upon arrival
• Immunization record
• Prescription medications
• Hard-to-find over-the-counter drugs
• Medical records, current x-rays/scans, consultations, and treatment notes
• All financial agreements and hard copies of email correspondence
• Phone and fax numbers, mailing addresses, and email addresses of people I need or want to contact in-country
• Phone and fax numbers, mailing addresses, and email addresses of people I need or want to contact back home
• Travel journal for notes, expense records, and receipts

Now that you’ve made appointments with one or more physicians, booked your flights and hotel, and arranged transportation, the hard part is behind you—except, of course, for the treatment itself. You’ll find that once you arrive in Tur­key, you will be greeted graciously with help and support from hotel and hospi­tal staff, your health travel agent, and sometimes even a friendly bystander. Plus, all signage at Turkey’s international airports is in English, so no worries!

If you haven’t done much international traveling prior to this health journey, keep in mind that you don’t need to be a seasoned travel veteran to have a suc­cessful trip. Getting things done cooperatively and efficiently will help you and your companion preserve your physical and mental health. Knowing a little something about the culture, history, geography, and language of your host country will buy you boatloads of goodwill and appreciation.

Tick off the items on this checklist to make sure you stay safe, happy, and well before and during your trip.

Preparations for my trip

• Have I read (or at least skimmed) a travel book or some brochures about the history, culture, and government of my destination country?
• Have I learned a few phrases, such as “please” and “thank you,” in the local language?
• Have I studied a map of the city or country?
• Do I know what the local currency is, what the exchange rate is, and how I can pay for my needs in my destination country?
• Do I know the rules about the amount of cash I can carry into and out of my destination country?
• Have I found out what extra fees I will be charged for using my credit cards or ATM cards abroad?
• If I want to use traveler’s checks, am I sure that my service providers will accept them? (Some don’t.)
• Am I leaving my valuables at home?
• If I must carry valuables, am I sure that a hotel safe or a safe-deposit box will be available to me?
• Am I prepared to drink only bottled water and eat only cooked foods? (This is a wise precaution for both the health traveler and the companion.)
• Have I packed a sanitizer for cleaning my hands everywhere I travel?
• Have I packed comfortable clothes that are sensitive to local customs of dress?
• Have I made arrangements for telephone and email services that will allow me to stay in touch
  with friends and relatives back home? With service providers in-country?
• Am I sure my cell phone will work in-country?
• Have I informed my doctor of all my pre-existing health conditions, such as diabetes, heart disease, ulcers, and others?
• Have I informed my physician about all prescription and over-the-counter drugs I am taking, including vitamins, minerals, and herbal supplements?
• Am I following my doctor’s instructionspre-treatment, such as going off certain drugs,
  losing weight, or avoiding alcohol?

Continuity of Care-Critical to Success

Continuity of care can be a challenge for patients who travel for medical procedures, say Steven Gerst, MD, and John Linss of MedicaView International (www.medicaview.com). Typically, the pa­tient’s primary physician diagnoses the condition and then suggests treatment. But when the patient chooses to travel to another loca­tion or country to receive the treatment, the primary physician is too often left out of the process.

Similarly—and amazingly—many traveling patients engage a fa­cility to perform a procedure without speaking directly to the sur­geon before arriving. The patient and the hospital’s international patient services coordinator may use email for preliminary commu­nications. There may also be a telephone call or two with the coor­dinator. But the surgeon may not become actively involved until the patient arrives at the facility.

Too many patients make the assumption that a diagnosis is “the end of the story” and that contact with the coordinator is all that is required. They could not be more wrong!

Establish Communication!

Insist on speaking to the surgeon who will perform the procedure before you schedule your travel. You may communicate via telecon­ference, videoconference, or voice over Internet protocol (VOIP).

It is equally important that you establish communication between your primary (local) doctor and your in-country surgeon, so follow-up care will be prearranged. Because of time zone and language dif­ferences, this advance planning may be difficult, but it is essential. Complications and misunderstandings can arise if your doctors are not communicating properly. For example, after a knee replacement or a kidney transplant, many concerns and complications can arise during the long recuperation period. Lack of communication can result in unnecessary hardships and potential returns to surgery.

Once you choose to go outside your physician’s primary network, few mechanisms currently exist to encourage and facilitate ongoing consultations. You must establish your own. Critical information about your case can be lost if you don’t. Be proactive! Here and abroad, it is usually up to you to keep the dialogue going between your physicians.

Persistence is important, and the time-delayed effectiveness of email comes in handy-once you get the doctors in the habit of emailing each other and you. A secure online collaboration tool is even better, because it can keep all communications in one place and available to all participants at any time.

Have Your Most Current Medical Records

Once you have established contact with a doctor (or surgeon) and fa­cility abroad, provide them with your most current medical records. If you have a chronic condition and you’ve finally said “enough”, your medical records may be a year or more old. If they are, visit your local physician to obtain new laboratory tests, x-rays, or scans-whatever your in-country provider needs.

Medical records can be transmitted in two ways: you can send paper copies or disks by postal service, or you can send electronic documents via a secure online service. An online service is prefer­able for several reasons. First, it gets the records in the hands of the surgeon more quickly. Second, it creates a secure repository that can be accessed by both your local and overseas doctors. Third and most importantly, digital records create a foundation for aftercare collaboration.

Collaboration Between Your Local Doctor and Your Doctor Abroad

Transferring your medical records may get your local doctor com­municating with your in-country doctor for the first time. This com­munication can be achieved through email, telephone, or a private group set-up in an online environment specifically designed for that purpose. Often such an environment is part of an online repository system that provides a secure place for collaboration between the doctors via protected blog, chat, email, and VOIP. Ask your doctor or health planner if such a system is available for your destination.

The next collaboration between doctors should occur after sur­gery. The surgeon should notify your local physician, preferably through an online system, of the details of the surgery and the af­tercare protocol.

Once you return home and are again under the care of your local physician, this collaboration and consultation should continue until you are released from care with a clean bill of health.

Complete Documentation

Frequently, when such a repository system is not utilized, patients return home lacking the complete documentation their local phy­sician needs to oversee ongoing care. The absence of information compromises the physician’s effectiveness and threatens the pa­tient’s health.

Be sure to ask the surgical facility if access is available to an elec­tronic system of medical record-sharing and physician collaboration. If not, request that your healthcare providers abroad subscribe to one to ensure that you can keep your local physician informed.

At a minimum, make sure your in-country facility provides you with complete records when you return home. Also make sure to keep your local physician involved from the first day. Good continu­ity of care is essential for a successful outcome.

Remember, as a patient, you need to take responsibility for the qual­ity and consistency of the care you receive. If you don’t, no one else will!

• Have I received all my doctor’s instructions for my post-treatment care and recovery? Do I understand them all?
• Am I following all of my physician’s instructions to the letter?
• Do I know what post-treatment signs and symptoms are normal?
• Do I know what post-treatment signs and symptoms indicate a need for prompt medical attention? (See “Post-Treatment: Normal Discomfort or Something More Complicated?” below.)
• Do I have copies of all my medical records and treatment records, including x-rays/scans, photographs, blood test results, prescriptions, and others?
• Do I have itemized receipts for all the bills I have paid?
• Do I have itemized bills for all the costs I have not yet paid?
• Do I have completed insurance claim forms (if applicable)?
• Have I allotted ample time for recovery?
• Do I know how to prevent blood clots in the legs after surgery and on the airplane? (See “Caution: Blood Clots in the Veins” below.)
• Do I know what followup treatment I will need when I return home, including physical therapy?
• Have I let my family know what help I will need when I return home?
• Have I checked in with my local doctor to share information about the procedure I had and my post-treatment care needs?
• Am I staying mentally, physically, and socially active following my procedure?

• minor local pain and general achiness
• swelling
• puffiness
• bruising, swelling, and minor bleeding around the incision
• headaches (side effect of anesthesia)
• urinary retention or difficulty urinating (side effect of anes­thesia and catheters)
• nausea and vomiting, dry mouth, temporary memory loss, lingering tiredness (all common side effects of anesthesia)
• hunger and under nutrition

Most surgically induced discomforts recede or disappear alto­gether during the first few days after treatment, as the body and spirit return to normal. Be sure, however, to report discomforts that persist or become more pronounced, as they might be early warning signs of more serious complications.

Complications vary according to the type of surgery, and you should make sure you’re aware of the more common ones. Complications are scary, and many doctors would rather not go into morbid detail about them unless pressed. Complications are rare; most arise in less than 5 percent of all cases-and gener­ally among patients who are aged or infirm in the first place. So while it’s wise to be informed and vigilant, there’s no need to worry yourself sick anticipating the worst. Common symptoms of complications include the following:

• infection, increased pain, or swelling around the incision
• abnormal bleeding around the incision
• sudden or unexplained high fever
• extreme chest pain or shortness of breath
• extreme headache
• extreme difficulty urinating

If you experience any of those symptoms, call your physician immediately.

Caution: Blood Clots in the Veins
Recent surgery and the immobility of long flights increase the risk of deep vein thrombosis (DVT), which is the formation of a clot, or thrombus, in one of the deep veins, usually in the lower leg. The symptoms of DVT may include pain and redness of the skin over a vein, or swelling and tenderness in the ankle, foot, or thigh. More serious symptoms include chest pain and shortness of breath.

You can take preventive steps to reduce your risk of DVT, such as wearing compression stockings and moving about frequently when on planes and trains. Ask your doctor about how soon after surgery you can safely undertake a long, sedentary trip.

OTHERWAYS TO REDUCE DVT RISKS
Before you travel:

• Stop smoking.
• Lose weight if you need to.
• Get enough exercise to be at least minimally fit before your surgery and your travel.
• Discuss stopping birth control pills and hormone replace­ment therapy with your doctor.
• Travel on an airline that provides sufficient leg room.
• Wear loose clothing.
• Reserve an aisle seat on the airplane so you can get up and move around easily.
• Ask your surgeon about using a pneumatic compression de­vice during and after surgery.
• Before your flight home, ask your surgeon if you need an anticoagulant.
• Walk briskly for at least half an hour before takeoff.

On the plane:

• Don’t stow your carry-on luggage under your seat if that will restrict your movement.
• Flex your calves and rotate your ankles every 20–30 minutes.
• Walk up and down the aisle every two hours or more frequently.
• Sleep only for short periods.
• Do not take sleeping pills.
• Drink lots of water to avoid dehydration.
• Avoid alcohol, caffeine, and diet soda.
• Wear elastic flight socks or support stockings.
• Don’t let your stockings or clothing roll up or constrict your legs.
• Take deep breaths frequently throughout your flight.

The Straight Dope on Pharmaceuticals

• True or false: When traveling, it’s okay to take small amounts of prescription drugs back into your home country.
• True or false: It’s legal to order prescription drugs from repu­table online pharmacies outside your home country.
  Believe it or not-for many Western countries-the answer is false on both counts, though with some favourable caveats.

Many international travelers like to purchase their prescrip­tion medications less expensively while abroad. While that’s technically illegal in the US and some other countries, consumer activists have turned the issue into a political hot potato. Conse­quently, at this writing, customs inspectors in the US are often reluctant to bust granny with her two vials of benazepril, and in most instances they turn a blind eye to folks entering the coun­try with prescription medications purchased abroad. Thus, it’s become a gray area, with customs inspectors empowered to use “general discretion” when prescription drugs are found. Most often, the offending pharmaceuticals are simply confiscated, and the traveler must decide whether its worth all the red tape re­quired to petition for their return.

The overwhelming majority of tourists carrying pharmaceu­ticals purchased abroad re-enter their home country with no trouble, usually unnoticed. The best advice is to use common sense. You’re far less likely to be hassled for carrying a single prescription of amoxicillin than if your suitcase is bursting with enough tramadol to supply the streets of Los Angeles for a year. And as always, if you’re carrying drugs that are illegal-prescription or otherwise-you may be subject to arrest, as well as seizure of your medications.

Similarly, it’s technically illegal in the US and some other countries to purchase any pharmaceutical of any kind from any mail-order pharmacy outside the country. Again, highly vocal activists have prevailed politically in the US and elsewhere, and only a small fraction of prescription drugs purchased from for­eign pharmacies is seized. In those cases, the pharmacies often double-ship the order, so the buyer usually doesn’t even know the purchase was interrupted. (It’s perfectly legal to purchase prescription drugs online from authorized mail-order pharma­cies inside your home country.)

Again, until the laws change, you’re advised to use good judg­ment. Purchase only from reputable pharmacies, using legitimate prescriptions from your physician-and anticipate the outside chance you’ll be among the few every year inconvenienced by border seizures of prescription drugs.

For specifics about bringing controlled substances into the US, call 202 307 2414. US citizens can obtain additional informa­tion about traveling with medication from any FDA office or by writing to the US Food and Drug Administration, Division of Import Operations and Policy, Room 12-8 (HFC-170), 5600 Fish­ers Lane, Rockville, MD 20857. For further information on pre­scription drug rules and regulations, US citizens can contact the FDA’s Center for Drugs at 888 INFO.FDA or visit www.fda.gov/cder. Citizens of other countries are encouraged to contact the appropriate government office for full rules and regulations.

Taking Drugs into Turkey

Can you carry drugs into Turkey? Yes, but limit drug transport to small bottles of medications prescribed by your doctor, carried in their original, labelled vials, and accompanied by their prescrip­tions. Carry with you a letter signed by your doctor that explains the reason why you need a particular medication. Antidrug laws are stringent in Turkey, and penalties for possession of illicit drugs are harsh. Don’t risk being stopped in customs with an unlabeled bottle of a narcotic or psychotropic substance

A person who accompanies a health traveler gives a great gift. Here are some questions for potential companions to answer before they commit themselves to accompanying a health traveler abroad.

Travel companion’s considerations

• Am I sure I want to go? Am I sure I’m up to the task?
  (If you hesitate in answering either question, you may want to reconsider.)
• Am I willing and able to take responsibility for handling details, such as obtaining visas and passports?
• Do I feel comfortable acting as an advocate for the health traveler at times when he or she may need assistance?
• Have we agreed on the costs of the trip and on who is responsible for paying what?
• Do I feel sufficiently confident about handling experiences and challenges in a foreign country,
  such as getting through airports, arranging for taxis, or finding addresses?
• Do the health traveler and I communicate well enough to identify problems and solve them together amicably?
• Am I prepared to listen to and record doctor’s instructions and provide reminders for the health
  traveler when needed?
• Can I help the health traveler stay in touch with family, friends, and healthcare providers back home?
• Have I allowed for “down time” and time for myself during the medical travel?
• Do I have the patience to help the health traveler through what might be a long and difficult recovery period, both abroad and back home?