Emma came to see me after a holiday in the States. She was in New York when cystitis struck. She’d had it a couple of times during her undergraduate years so she knew what to do. She upped her water intake, went to Walmart for cranberry juice, and when those measures failed she took herself along to the nearest emergency room to get treatment.
That was where any similarity with her UK experiences ceased. Her NHS doctors had managed her previous bouts with a brief chat and a prescription for an antibiotic. Her American physicians appeared a whole lot more concerned. She had a pelvic examination, urine and swab samples sent to the lab, blood tests, and a first dose of antibiotics, administered with a drip. They’d wanted to do a scan, too, but had reluctantly agreed to her deferring this until she was back in Britain. Just as well, really. She’d already racked up over $500 in charges. An ultrasound would have taken her comfortably over the $1,000 mark.
To Emma, there seemed only two explanations possible: either the NHS had woefully undertreated her in the past, or my American colleagues had been wilfully overdoing it in order to maximise their income. The reality lies somewhere in between. UK medical culture takes a low-key, “common things are common” approach to many illnesses, investigating in more detail only when it becomes clear that it is required (which might be after there’s a lack of response to an initial course of treatment). Across the Atlantic, patients are usually worked up exhaustively at the outset, as though each and every one is going to prove to be that rare case with something much more complex underlying it.
There is a consideration of income in this – American doctors are, broadly speaking, paid for their activity, whereas their British counterparts are encouraged to conserve resources. Of equal importance, though, is the medico-legal culture. American society is unforgiving of any apparent delay in definitive diagnosis, so the doctors practise defensively, with the spectre of lawsuits ever hanging over them. In the UK, it is accepted that diagnosis is often a multi-stage process. This is good for most patients, who avoid the considerable harms that can arise from unnecessarily invasive investigations. The flipside is that there may be a time lag in picking up significant pathology.
Being young and on a tight budget, and given the premiums charged for cover in the States, Emma had travelled uninsured – something she was now regretting at leisure. Had she holidayed in Europe, she would have found insurance considerably cheaper. Not only is European medical culture closer to that at home – though I did once have a patient return from Bulgaria clutching three different drugs and a set of CT scans following a simple bout of sinusitis – but British travellers can apply for a European Health Insurance Card (formerly known as the E111), which entitles them to state health care if they’re taken ill in a participating country.
The EHIC doesn’t obviate the need for travel insurance, though. In the UK, the idea of paying to see a doctor is still anathema, but most European countries levy consultation and hospital inpatient charges on their citizens, so state provision often carries significant costs. France and Germany are among the most expensive; Ireland, Portugal, Italy and Greece are virtually free (which must say something about the origins of the eurozone crisis).
Those holidaying in more exotic locations may be exposed to infectious diseases that can be life-threatening. Rather than the first-world problem of overzealous doctors, health-care provision may be sparse and very basic in the destination country. Vaccination, pre-travel advice and information, and adequate insurance to cover medical evacuation, are important preparations. I’ll be in Zambia this summer, hoping none of what I’ve put in place will prove necessary.
If you’re travelling, too, wherever you’re going, I wish you a happy and healthy trip.