Retired nurse Marlene Driscoll spent the holiday season celebrating a different kind of gift: a brand new knee, delivered by her Calgary surgeon at a private hospital in the Caribbean. The December surgery came with a hefty price tag of about $40,000 for the flights, hospital care and accommodations in the Turks and Caicos. But it also gave her something not for sale back home — a two-week wait for a procedure with her own Calgary surgeon that would have taken at least seven months in Alberta while she was in so much pain it was difficult just to walk. Driscoll says she understands the quandaries that surround paying cash for a surgery abroad the way she can’t in Alberta, but says her decision was about more than dollars and cents.“Let’s face it. If you are in pain, if you are desperate to have a procedure like this, then you’ve got to make choices,” she said. “I’m off the wait list here. Someone else is going to take my place in July,” said Driscoll, who said having a Calgary surgeon made all the difference in deciding to go. While the debate around medical tourism has raged for years, a new type of practice has begun to emerge in Calgary in which surgeons who work in the public system get licensed to practice medicine in the Caribbean, then, for a fee, actually fly out with their patients to perform shoulder, knee, hip and other operations. Back in Calgary, they perform post-op care for their patients, only this time, within the public system. One of the surgeons, Dr. Jim MacKenzie, said his decision to take on a few patients at the Caribbean hospital came down to serious problems back home: too many surgeons, too few operating rooms. “For the number of surgeons we have and the population we’re trying to look after, we don’t have enough operating rooms. That’s what in my days off prompted me to start looking where else my time could be utilized,” said MacKenzie, 53. This new kind of health tourism is coming to light even as prominent Calgary surgeon Dr. Robert Hollinshead made the surprise announcement in December that he’s leaving Medicare altogether. Long waits for patients and scarce jobs for young doctors led him to make the unprecedented decision to opt out of the public system and offer surgeries for a fee right in Calgary, he said in announcing his decision. As required under legislation, Hollinshead, 65, advised the province of his intentions to opt out in July 2014, after a surgical career spanning more than three decades. Health Minister Fred Horne said this newest round of “boutique medicine” involves doctors entitled to take on private ventures. He insisted that within the public system, wait times are going in the right direction — down. “When it comes to to the public health-care system, there are many, many physicians and others who work in the area of orthopedics who have actually brought down waiting times in the province,” he said. But health-care observers suggest that if Calgary surgeons are going to such extraordinary lengths to deal with what they say are untenable waits for care in the province, Alberta must ask some hard questions about what kind of access to health care it’s providing residents.

“If it is something that causes Albertans to question whether or not they’re actually having the right kind of access to the kinds of services that surgeons ... are providing, that expands the debate,” said Antonia Maioni of the Institute for Health and Social Policy at McGill University in Montreal. “When that happens, then the government does have to, in fact, weigh in,” she said.In Quebec, one of Canada’s top private orthopedic surgeons offered Hollinshead a piece of advice when it comes to leaving Medicare behind: “Welcome to the political circus.” Dr. Nicholas Duval helped break new ground in Canada when he opted out in 2002, later setting up a medical clinic with four operating rooms years when Quebec allowed private insurance. Hollinshead’s complaints about long waits and lack of jobs “are exactly the beliefs I had in 2001 before opting out,” Duval wrote in an e-mail to the Herald.Though he recently began offering jobs to young orthopedic surgeons, Duval said he doesn’t expect private surgical care to take off in Canada anytime soon. Costs are rising, wait lists for “so-called non-urgent care” are growing, and “the only logical solution is to steadily increase doctors’ salary so they deal with the everlasting same situation and they shut up,” Duval contended. “That’s what provincial governments do. That explains why after more than 10 years I am still sitting almost alone as a private orthopedic surgeon.” Calgary shoulder surgeon Dr. Ian Lo, 43, has been to the Caribbean twice since this summer and operated on about 10 patients who came from back home. Part of the appeal of involving himself in medical tourism is that accompanying patients for surgeries “provides better care,” by allowing proper post-op work to take place back in Calgary. “You would think it’s the ‘ultra-rich,’ but it’s the people who just don’t have the time to wait anymore,” said Lo, who said he charges the same rates he gets paid by the Alberta government for the Turks and Caicos jobs. Lo said he also wants the government to pay heed to long wait lists. “It’s ridiculous that you have to travel to Turks and Caicos to get your surgery done, that’s absolutely ridiculous.” The head of the Alberta Medical Association said the move by surgeons to find new ways to take on wait lists could mean it’s time for the province to start looking at “different” solutions — including a public, private mix. “That does not mean American-style pay-as-you-go care. It means, is there is some way of delivering care other than the one that we’re using that would get us good results,” said Dr. Allan Garbutt, a family physician in the Crowsnest Pass. “If you acknowledge the current system doesn’t work in the sense we don’t get quick care, we don’t get outstanding quality measures, once you acknowledge that, then you can’t automatically exclude something because it has private attached it.”

Medical tourism is already gobbling up dollars from Alberta patients willing to go as far abroad as India for care if they can’t spend it at home, Garbutt noted. “You can’t call it good care if when your knee goes bad you can spend months until you have a functioning again. You can’t call it good care when a really, really disabling bad back ... will take you three years — literally three years — to get it fixed.” For Driscoll, the pain was sudden, and extreme when it hit in early 2012. A private MRI (ordered in June after her doctor told her she faced an eight-month wait in the public system) revealed her knee had become “an absolute train wreck” and she needed a joint replacement. Her condition deteriorating, the Calgarian found herself totally reliant on her husband and woozy from pain medication that made it even more difficult to get around. Driscoll waited another five months to get in to an orthopedic surgeon, MacKenzie. He told her she was looking at another seven months for the operation. Then, he mentioned the Turks and Caicos option. “We immediately said yeah, we’ll go. Two and half weeks later we were in the Turks and Caicos,” Driscoll said. After a long career as a nurse and many hours still spent volunteering in the health-care system, Driscoll said she’s still a champion of public care but questioned whether authorities really understand the impact long waits can have on a patient. “I believe we have the greatest system going. The problem is, you can’t get access, it’s very difficult to get access,” said Driscoll. “There’s an awful lot of pressure on you, and it’s not just the pain.” NDP MLA Dave Eggen called the recent decisions by surgeons to explore more private care a provocative step and a “red light” over tight capacity in the province’s public system. “This is an indication of how this PC government has been starving our hospitals for surgical capacity. These doctors are responding to a shortage of capacity that this government has put in place over quite a long period of time,” Eggen said. “The population has grown and our acute care capacity in the province has not grown. This is a consequence of that. It’s not a positive development.” According to Horne, the province has already increased the volume of hip and knee operations by five per cent in the last three years. That’s meant wait times have come down by about nine per cent, he said. While more work remains, Horne said he’s putting resources into the public system and not looking to private enterprises for help. “Albertans support a publicly funded, universally accessible system that’s based on your need and not how much money is in your pocketbook,” said Horne. “That’s firmly the position of this government.” Even if the number of surgeons willing to look outside public health-care is likely to remain small, Alberta is in for some intriguing test cases, said Maioni. In Hollinshead’s case, she noted, “What we’re looking at now in terms of the kind of opting out … in Alberta is a thin wedge, a very limited niche,” Maioni said, adding that the surgeons need to be able to make a living outside the system.