You know when you are talking to an assistance doctor, because their frame of reference is so undeniably different from most other doctors, in that it is truly global. They don’t just think in terms of the most appropriate medical treatment needed for any given patient, but how best to get that patient to a suitable medical facility. Take Dr William Spangler, Global Medical Director at AIG Travel, which serves more than 30 million customers annually from eight of its global service centres around the world. “Literally, if you’re in Mongolia, you cannot get from A to B unless you go by donkey; there’s no other transport, it does not exist. If you’re in Afghanistan, the roads are non-passable or might be mined. So, you will take a helicopter, but you have to wait for the military to [provide] it,” he told ITIJ. Dr Spangler spends his day reviewing cases for insured travellers with medical problems – from a heart attack to a motor vehicle accident – to determine whether the care they are receiving at the current facility is appropriate, or if they should move to a higher level of care, wherever they are.
We must have empathy and an understanding of what it means for a patient to be far away from home and suddenly hospitalised
An international focus is vital, says Dr Bettina Vadera, CEO and Medical Director of AMREF Flying Doctors, which provides medical evacuations and assistance from the African continent. She trained as a doctor in her native Germany – she has a background in emergency, tropical and family medicine – but spent gap years, electives and internships in Kenya. “When you’re travelling a lot or living in other countries and having experiences with other cultures, you can relate better to the patients’ needs and understand what might make this experience easier,” she said.
All in a day’s work
Every morning, Dr Vadera’s team gathers to review operations. “We go through the last 24 hours and project what’s in the pipeline for the day or the week. We get an update from an assistance services manager, and if any problems are flagged up I know exactly what’s going on and what resolutions are being planned.” The most common request from international companies are guarantees of payment at hospitals in the region, patient follow-ups and accessing medical records, she explains. Medical escorts on commercial flights and completing fit to fly forms for airlines are also requested. After visiting a patient in hospital, Dr Vadera might evaluate whether to repatriate the patient or move them to an African medical centre of excellence, say, in South Africa.
Primarily, however, Dr Vadera sees her job as providing peace of mind to both patients and international companies, since there is considerable uncertainty as to the standard of hospitals throughout the African continent. And there may be language barriers. “An assistance doctor must be an all-rounder,” said Dr Vadera. “We must have empathy and an understanding of what it means for a patient to be far away from home and suddenly hospitalised.”
Her background is a benefit, she says: “My origin and part of my professional career as a doctor has been in Germany, but I see things in an African context. There is trust and buy-in from the international assistance and insurance companies because I understand what is expected and what would be the best care required and what is available here on the ground.”
Understanding exactly what facilities are available, and where they are, is crucial, says Dr Simon Worrell, Global Medical Director at Collinson in the UK, whose assistance division brings together nurses, doctors, and skilled support staff in arranging around 3,000 repatriations each year. Collinson’s extensive network of healthcare facilities allows patients in resource-poor settings to be moved to a place of medical safety when they become ill. Each facility is rated against a set of criteria. So, a hospital can be rated a five-star institution – a world-class hospital – or downwards. “A two-star facility will often be the best available hospital in a very remote location,” he explained. “Together with the experience of our medical team and established network, I will evaluate the best place for the patient, sanctioning an air ambulance when needed.”
This is one of the great attractions of performing repatriations: a doctor or nurse can follow interests that would normally be impossible to squeeze into a traditional full-time medical career
In addition to these medical tasks during the day, there is usually a talk or article that needs attention. “At Collinson, we regularly give presentations to clients and organisations such as The TRIP Group, whose members are actively involved in managing the travel risk of their organisation’s travelling employees,” Dr Worrell explained. Recent presentations have covered the psychological care of employees overseas and tracking ongoing epidemics around the world – especially the Ebola outbreak in Eastern Democratic Republic of Congo (DRC). This expertise helps Dr Worrell advise his insurance division at Collinson on new wording for polices, ensuring they are medically accurate, clear and fair, he said.
Not just a 9-5
Dr Emiliano Riccardi is the Chief Medical Director at Argos Assistance, a claims management and assistance company that operates in Italy, France and Spain. As with many assistance providers, it relies on a network of local capillary providers to be able to reach very remote areas. That’s why Dr Riccardi’s job sometimes involves a lot of travel: “I often travel around Italy to carry out quality controls on the structures that we collaborate with or provide support to in managing complex situations.”
His day begins at around 7 am with an overview of what cases must be attended to that day. This might involve organising medical assistance in a large city or in a remote place. “Once, I was asked to visit a patient urgently in a gym; he was an athlete who had been injured during a training session,” he said. “Fortunately, everything went well and he could participate in his race.”
Dr Ricciardi used to work in the emergency medicine at a high-profile hospital in Rome before a friend at Argos Assistance informed him of an opening. “The job came up casually, like many things in life! I was a little tired of the hospital’s routine work and Argos were looking for someone with experience in managing emergency situations,” he said. “I had already learned how to handle patients in critical conditions. The ability to make decisions in a short time frame in serious situations was certainly crucial in this new job!”
Patience, understanding, cultural sensitivity and the ability to apply workarounds are the key skills that help an assistance doctor deal with challenges
Likewise, AMREF’s Dr Vadera jumped at the chance to provide medical escort support in Kenya. “Initially, it was just part-time and on the side I was running a clinical practice, which was awfully boring,” she said. From there, she rose in the ranks to medical director and then CEO.
Similar to Dr Ricciardi, Collinson’s Dr Worrell said he began in assistance by accident. “I first started in assistance to pay the mortgage while I was on a post-grad course at the Guildhall School of Music and Drama!” he said. “In fact, this is one of the great attractions of performing repatriations: a doctor or nurse can follow interests that would normally be impossible to squeeze in to a traditional full-time medical career.”
Dr Worrell began in the industry some 20 years ago, learning from the ground upwards as a repatriation physician. Here, he gained experience from over a decade of performing medical rescues, particularly the logistical and safety issues that must be considered when arranging repatriations from different parts of the globe. “Although some of my past has been associated with the dramatic, it is the un-dramatic that is important with assistance,” he explained. “We deal routinely in heightened life and death situations, with people in extremis. In this maelstrom, it is our privilege to be able to give straightforward help, giving them the best chances of improving. There should be no flap, and certainly no glorification.”
In good hands
Trust is the most important dynamic between a patient or their family and an assistance doctor, as well as between an assistance doctor and the providers they work alongside, explains Dr Worrell. “In emergency medical situations, where seriously ill patients are cared for many thousands of miles away from home by local hospitals or air ambulance companies, there must be trust that these institutions will look after your patient as well as possible,” he said.
Trust has much currency, he says. Although medical assistance cases routinely receive regular evaluations – assistance teams frequently phone the treating team directly – working with a well-trusted collaborator reassures everybody involved. “There is certainly some undeniable relief once we have safely moved a critical patient from a poorly equipped location to a place of medical excellence,” explained Dr Worrell. Take a severe road traffic accident patient in Laos who has been airlifted to the Bumrungrad International Hospital in Bangkok, he said: “The case is still closely followed, but there is some solace that the patient is now in good hands; that hospital has earned its trust over literally thousands of cases across the years.”
AIG’s Dr Spangler adds that patience, understanding, cultural sensitivity and the ability to apply workarounds are the key skills that help an assistance doctor deal with challenges. “Often, the medical staff at remote-care facilities won’t talk to you, or they’re speaking in a different language, and what should take five minutes takes an hour and a half,” he explained. “So, you have to be adept at speaking with professionals in other countries that have very different training, facilities and experience.”
He had already amassed 20 years of experience in emergency medicine before starting at AIG Travel in 2003 as a standard doctor on duty, so he knows that if a medical facility won’t talk to him, or the client says they aren’t comfortable, that’s usually a sign that something is not quite right. “You start to pick up on patterns that indicate lack of expertise, experience or capabilities at a facility,” he said. For example, explained Dr Spangler, in one case, a doctor in Mexico said they could fix a patient’s hip and would do it by Tuesday. “Well, it’s now Thursday. Why are we waiting so long?” he said. “The treating doctor’s response was, ‘Well we have to get some parts in here. We don’t have the right parts’.”
There are significant cultural differences, of course, that assistance doctors have to be aware of and know how to navigate. “At many hospitals in Asia, for example, we have a hard time getting doctors to speak with us,” stated Dr Spangler. “It is simply not something, culturally, that they feel they need to do. In some European countries (particularly Italy), doctors have very restrictive work schedules. So, if we don’t call the hospital on, say, a Tuesday between 2 pm and 4 pm, we’re not going to speak with a doctor.”
The ability to put yourself in the patient’s position is an essential skill for successful assistance doctors, says Dr Riccardi. “The patients that we treat every day are on holiday or in transit through a national territory. Therefore, I believe that empathy is a fundamental element for success in this work,” he said. “Having the ability to understand the requirements of the patient and create a relationship of trust in a short period of time is very important for anyone who wants to become a good doctor of travel assistance and to provide the best possible care.”
You start to pick up on patterns that indicate lack of expertise or experience or capabilities at a facility
Assistance doctors say managing the expectations of patients is a real challenge, which is made somewhat harder as many love to travel to exotic places, until they become ill. “When someone winds up in a hospital in a foreign country, they almost immediately feel uncomfortable and want to go home,” said AIG’s Dr Spangler. “We’ve had numerous examples of patients who want an air ambulance for their broken ankle and that is simply not feasible or appropriate.”
Assistance doctors like Spangler agree there is a fine balance to strike between appropriate care and cost. Dr Vadera said that managing expectations of international assistance and insurance companies can be difficult too. “You are always asked to find the best solution, but at the cheapest cost possible,” she said. But getting a European standard of care in some African countries is more expensive than it would be in Europe. State-of-the-art equipment and drugs are often imported and staff trained overseas because there are few training facilities at home. “There is this expectation that it’s Africa so it will be cheaper. Well, no it isn’t,” she explained.
Dr Worrell said the most challenging cases usually involve wading through these other concerns and demands, financial and otherwise, to establish exactly what will benefit the patient, while not wasting resources. In other words, assistance doctors must prioritise the patient and ensure their safety at all times, while also being mindful of the scope of their insurance coverage. As AIG’s Dr Spangler puts it: “We are patient advocates, and we do whatever is medically appropriate – and, financially speaking, the chips fall where they may,” he said. “If I have to sign off on a $300,000 medical evacuation, I won’t hesitate.”