For the last eight years, Dr Nikita Trehan, a gynaecologist and laparoscopic surgeon practicing in New Delhi, has been flying to Dubai every month. There, she spends two days at the International Modern Hospital, operating on four to five patients.

Trehan admits that to her, “fame is more important than money” and said her quest for global recognition led her to appear for an exam to practice in Dubai. “There, I get to operate on patients from different nationalities,” she said. “Also, you are known everywhere.”

Trehan is part of a growing breed of doctors who, over the last decade, have been developing medical practices outside India alongside their operations within the country.

Global recognition

Dr Anup Ramani, who specialises in robot-assisted surgery, has on several occasions been flown business-class to Dubai by his patients. Like Trehan, Ramani makes monthly visits to the emirate, where he works at the Medicity Welcare Hospital.

“I have excellent surgeons there who screen the patient,” said Ramani, who said associating with a hospital in Dubai is an “ego-boost” for him. “I meet the patients in the evening and operate on them the next morning.”

Ramani holds a post-graduate degree in medicine from a university in the US and was not required to appear for a licencing examination. However, he said the internal scrutiny system of the hospital was fool-proof. “In my initial surgeries, senior doctors from the management were in the operation theatre observing me,” he said.

While Trehan said her decision to practice in Dubai was not motivated by better pay, Ramani said the remuneration – almost double of what he makes in India – was a compelling factor, but it is the hospitality he receives here that keeps him coming. Ramani is put up in five-star hotels and given a chauffeur-driven car during his stay.

After establishing two clinics in Mumbai, dermatologist Dr Ruby Tandon chose Dubai instead of New Delhi to set up her third. “I had offers from both places but it [Dubai] is a prime market and people there don’t mind paying,” said Tandon who has studied in the US. She spends at least 10 days in Dubai every month.

Joining the chain

Many healthcare chains in India have also started expanding to foreign territories.

“Countries in the GCC [Gulf Cooperation Council – Saudi Arabia, Kuwait, the United Arab Emirates, Qatar, Bahrain, and Oman] are focusing on developing their healthcare industry,” Dr Harinder Sidhu, vice president- corporate development, Apollo Hospitals Group. “While they have been able to build the buildings and infrastructure, they do not have the clinical workforce to provide the services. So, they are looking for doctors from all over the world, and Indian doctors are always a preferred choice.”

According to the Dubai Health Authority annual report in 2015 about 75.4% of physicians working at the eight major hospitals were non-nationals.

Sidhu said specialists from hospitals operating by the mutli-speciality chain in Hyderabad and Chennai go to Muscat almost every month and work for a few days at the Apollo Hospital there. The Apollo group also has operations in Bangladesh, Kuwait and Qatar.

Compromising care?

Not everyone in the Indian medical circles is happy with this new trend.

“This is a scam,” said Dr GS Grewal, president of the Punjab Medical Council. “They [Indian doctors] get connected to local doctors in Middle Eastern countries and start going there to perform surgeries. What about medical care before and after the surgery?”

The physical presence of a surgeon, many feel, is crucial if a patient develops a complication after a surgery. With doctors shuttling between two countries, this is not always possible and even a video consultation with the surgeon may be inadequate.

Dr Rishma Pai, president-elect of the Federation of Obstetric and Gynaecological Societies of India, said such “flying models of healthcare” do not work. “As a surgeon, I am equally responsible for the post-operative care,” said Pai. “It is still okay for doctors involved in non-surgical practice to travel but not surgeons.”

“It is definitely not a good clinical practice,” said Dr Sanjay Nagral, surgeon and publisher of the Indian Journal of Medical Ethics who has written extensively on unethical medical practices. “For some doctors, it [surgery] is a skill and you have to sell it. The idea, I think, is that there is an untapped market then why not go and sell it there,” he said.

However, Maria K Todd of Mercury Healthcare International, a healthcare and medical tourism management and marketing consultancy headquartered in the US, insisted that “care is not compromised by this approach.” With regard to post-operative care, Todd, who has worked with healthcare institutes in India said in an email to “Professionals in healthcare have an ethical duty to establish all continuity of care measures for follow up prior to ever beginning and scheduling the surgery.”

Ramani echoed this. “The urologists attached to the hospital in Dubai are excellent doctors who ensure that follow-up care is administered to the patients, I operate,” she said. “After operating for so many years, we know if a complication is to occur and directions are already given to address it.”

A senior member of the Indian Medical Association, Dr S Utture said he found nothing wrong with the practice as long as the operating doctor ensures that a qualified team of medical health professionals takes care of the patient after the surgery. “It is a grey area though,” he said, adding that the local medical council of the country in which Indian surgeon is operating is responsible for ensuring that healthcare standards are maintained. “If doctors from outside came to India and practiced for short durations, the local councils would look into it,” he said.

Utture said doctors working with government hospitals cannot indulge in such practice as their service rules disallow it, but “a private practitioner is a businessman and he is doing a business that can take him to Mumbai or Dubai.”

Reverse medical tourism?

What does this trend mean for India, which has been working hard to become a leading medical tourism destination and on attracting patients from foreign countries for treatment?

Those working in medical tourism companies in Mumbai and Bengaluru said they were happy as long as Indian doctors were not shifting their entire practice to foreign countries. “If doctors operate in other countries, they get famous and it automatically helps them to attract more patients to their Indian hospitals,” said Hidayath Ulla, director of Mediniq, a medical tourism consulting company that works with several private hospitals in metro cities.

Sidhu of the Apollo group said that the branching out of Indian hospitals abroad would in turn the country too. “The opening up of new facilities in other countries will help patients in those countries have better access for many conditions, but there remain some complex medical cases for which they will continue to come to India,” he said.

Many medical practitioners said that a handful of doctors had already moved their practice entirely abroad, while many others were contemplating shifting.

“This is the start of globalisation of healthcare,” Dr Prem Jagyasi, a medical tourism consultant from Mumbai. “By traveling abroad, these doctors are not neglecting healthcare here. They are learning international practices which will improve the quality of healthcare here.”

Tandon, who operates a clinic in Dubai, said that many of her patients from US and London find it easier to come to her facility in the emirate than to India. The doctor, who is also a partner in Lavie clinic in Dubai, plans to recruit more Indian doctors who like her can dedicate a few days a month to work abroad. “Earnings are 30% more, there better infrastructure and it is like a weekend getaway,” she said.