Result of Survey of ISTM Members on the Role of Post-travel Medicine in ISTM's Strategic Planning

The ISTM should increase opportunities for members who wish to become more knowledgeable in post-travel medical issues while keeping in mind that numerous members are not trained in handling such problems or do not see the volume of such patients necessary to make it a practical or professionally honest endeavor.

This summarizes the thinking of the eighty members, mostly from North America, who responded to our latest email query. The query asked three questions:

• Should the ISTM place more emphasis on post-travel health issues and, if so, what should the Society do?"
• "Do you manage patients with post-travel health problems in your office/clinic? Would additional training help you to more efficiently manage such problems? "
• "Are the ISTM meetings, Journal, ListServ, and examination too focused on the pre-travel segment of travel medicine?"

Please note that this issue of NewsShare contains an article by our President and one about our President-elect. Both state that that their main goal is for ISTM to continue to be an all inclusive Society where there is a home for every individual who is interested in travel medicine. The ISTM has grown in numbers and strength to the point where new areas of interests are under consideration. (The topic of discussion in the next issue of NewsShare: medical tourism, people traveling to other countries to receive medical and health-related treatments that are too expensive or not readily available at home. Is this travel medicine?)

> More emphasis on post-travel issues would be an excellent idea with direct relevance to me as a GP. Over the years I have seen a large number of patients with extremely varied post-travel problems, from malaria to dengue, coral cuts to depression, pneumonia to cutaneous larva migrants (?), etc.

Post-travel medicine is, in my opinion, `real' travel medicine. Pre-travel preparation is essential, of course, but it is mostly counseling. Post-travel problems are challenges: triage, diagnosis and prompt management, and sometimes treatment of life-threatening conditions.

We don't need the level of knowledge required by infectious diseases (ID) physicians; we must know when to refer, how to recognize patterns of symptoms and signs, and how to take epidemiological factors into account. Many post-travel problems have nothing to do with infectious diseases, making travel medicine a unique specialty.

The Listserve features interesting cases. The Journal has case reports, but the emphasis on post-travel issues could be greatly increased. The exam was quite well balanced, with a fair number of good post-travel questions. The CISTM10 Conference had some very good workshops on post-travel problems, but post-travel issues did not feature prominently in the plenary sessions.

> An up-to-date Rolodex of local specialists is the most important post-travel medicine instrument for many - perhaps a majority - of our members. I am an internist and have practiced part-time travel medicine for about ten years. I have seen over 3,500 travelers. The next case of malaria I see will be my first. Should I be treating that patient? A majority of the pre-travel patients I see are referred to me; they are not my regular patients. When they come home ill, they see their own physicians, not me. This greatly reduces my reservoir of such patients. … I am typical of half a dozen or so travel medicine docs I know.

> Holders of an ISTM Certificate in Travel Health have proven their competency in pre-travel medicine only. We must be careful if we change the ground rules of our Society and emphasize post-travel issues. Would ISTM have to re-test members who hold our Certificate?

> Pre-travel counseling and prevention are the key components of travel medicine and should remain as such. Shifting emphasis into the "post-travel" arena would preclude some, if not a majority of practitioners in the field. This may even decrease the "preventive measures" that we all concentrate on, which clearly is the single most important factor in our industry.

> Good idea but we must be careful not to create an elitist group within our Society.

> Offering additional training would be intellectually stimulating and at times helpful in more efficiently managing or identifying post-travel health issues. However, referral to "specialists" should not be delayed as we might "fumble around" looking for something that is common place to the practice of such "specialists".

> I chose the ISTM as it more clearly represents my practice, and what appears to be the primary goal of many practitioners in the ISTM. If I wanted to concentrate on post-travel issues or tropical medicine, I would have become a member of a tropical medicine society.

Travelers who come home ill do not necessarily have a travel-related illness. Therefore, the field of post-travel medicine includes everything under the sun, figuratively and literally.

> The best way to help travelers returning home sick (and promote the field of travel medicine) is not by teaching more post- travel medicine to travel medicine practitioners. Rather, we need a program to make primary care health practitioners aware of the fact that their patients travel and may come home ill. Practitioners must ask every patient a four-word question, "Did you travel recently?" Just look at the data on the delay in the diagnosis of malaria.

> Since "Travel Medicine" can be defined as the field of research and medical service that improve the health and manage the diseases among international travellers, pre-, peri- , and post-travel medicine should all be part of this field. I know of numerous cases of misdiagnoses by domestically-focused emergency doctors and infectious disease specialists of imported illnesses (SARS, Hepatitis A, Typhoid Fever, for example). Though I am not an infectious disease specialist, colleagues see me as a specialist in primary post-travel screening and management, knowledge I have acquired doing travel medicine.  The "post" part of travel medicine is a blind spot where we can competently fill the gap. We can provide specialists with a clear international overview and help them make more prompt diagnosis.

> Monitoring post-travel issues in our own patients allows us to assess the quality of our own pre-travel care, a built-in quality improvement loop.

> I am retired physician and still enjoy reading NewsShare as well as the listserv.  In an informal way I am sure that the listserv helps with care of returning travelers but when I was practicing I was very glad to have a tropical medicine specialist to call and refer patients to.

> Post-travel health issues other than cursory mention should not be part of the ISTM listserve.  The mission statement of ISTM does not include post-travel health issues other than preventive and curative interventions that are part of the pre-travel phase of travel medicine.

(Editor's note: This responder is not entirely correct. The ISTM mission statement seems to include all phases of travel medicine: It says:

• Promote travel health
• Develop guidelines for travel medicine practice
• Educate health care professionals, public health professionals, and the travel industry
• Provide a scientific focus for travel medicine
• Stimulate the professional advancement of travel medicine practice
• Promote distribution of rapid information exchange related to travel medicine issues
• Facilitate international contacts between practitioners of travel medicine
• Promote development and evaluation of safe, effective, preventive and curative interventions
• Foster research in travel medicine, including the promotion of international collaborative studies

> Our patients with post-travel health problems are referred to infectious disease or other sub-specialists. We do make ourselves available for consultations with the referring physicians to discuss pre-travel issues.

> The issue of post-travel care is far more complicated than giving pre-travel advice and immunizations. Since many of the ISTM certified practitioners are nurses and some are pharmacists it would be improper for them to be involved in the diagnosis and treatment of travellers returning with medical problems. These practitioners are certainly capable of recommending post-travel tuberculosis skin tests as part of their pre-travel counseling.  I do not recommend we focus on post-travel care as I fear it may encourage people to get in way over their heads. 

> I do not see patients post-travel, but do need more education in this area.  I think it makes us better pre-travel advisors knowing all possibilities post-travel.  I plan on taking a tropical med course bit by bit next year.

> Pre-travel medicine is only complete if travelers are specifically apprised of post-travel symptoms specific to their trip and where to go if symptoms occur. Pre- and post-travel services should be in close communications with each other but need not be performed by the same individual(s) or be physically in the same location. 

> Although the Society has filled an important role in standardizing an evidence-based approach to pre-travel consultation (i.e., risk assessment, etc.), it is reasonable for the Society to begin to enhance its focus on post-travel issues.

> Our clinic focuses strictly on pre-travel health. We are mostly nurse run. We rely on the infectious disease specialists to look after post-travel health issues. Although I can understand a need for a forum for those providing post-travel care, I feel that focusing more on these issues in the Journals, ISTM conference, etc. would take away from the capacity to cover the pre-travel issues. 

> ISTM members will have to decide whether we want to duplicate what tropical medicine societies do. Pre-travel consultation done appropriately is important to avoid diseases and accidents. Post-travel problems are better taken care by specialists. From reading the listserve it appears that a lot of pre-travel counseling is done by nurses. If we want the ISTM clinics to do post-travel counseling/treatment these clinics will have to change the way they practice and hire more physicians. The ISTM exam is a fair exam with adequate emphasis on the pre-travel counseling and the presence of diseases.

> We see very little "post-travel" patients.  I find the services ISTM currently provides very useful.

> Personally, I would like more emphasis on post-travel illness. Pre-travel vaccine decision-making is an odd mix of intuition/personal experience, versus actual data reflecting side effects of the vaccine, versus also the true risk of the illness one is trying to prevent. Examples are typhoid, yellow fever, Japanese encephalitis vaccines and, with malaria, prophylaxis. Do you need YF vaccine if you change planes in Nairobi, or make a port of call to Rio while on a cruise ship? Post-travel illness is the real thing - a person is actually sick, and we need to make a diagnosis, and treat to cure, or refer to someone else who can. So, I would have loved to have seen a set of post-travel workshops at ISTM, with a variety of cases presented, at least on the major topics of the returned traveller with fever, cough, diarrhea, skin rashes, and STDs.

> In my clinical practice, I see equal numbers of returnees to pre-travel clients, some for asymptomatic screening, some with symptoms at first presentation or after a visit to a primary care clinic that did not have expertise. We manage those we can, as far as we safely can, as outpatients and refer on as appropriate and for in-patient care of course. There is little available specific to Travel Med docs dealing with returning travellers and so we have all done the DTM&H and look to keep up our skills through further training/updates/journals in tropical medicine.

> Keen to be involved should there be any opportunities in post-travel medicine to develop this area within ISTM. Please be in touch if I can be of service.

> Great discussion! ISTM should not push farther into post-travel care.  The strength of ISTM is pre-travel care from people of a variety of backgrounds (not all prescribing clinicians managing sick patients).  I would focus ISTM on its strengths while keeping some awareness of major post-travel points.  I would leave further forays into post-travel care for ASTMH and ID sorts of groups.

> I strongly feel the Society should confine itself mainly to pre-travel issues.  We need to counsel people about avoiding tropical diseases and how to get treatment when necessary. But I have no interest or need to know how to treat people myself after they return.

> I am a physician doing Travel Medicine since 1983, seeing over 5,000 patients a year (and often over 10,000), and have never done a post-travel consultation on a patient. I refer to two outstanding experts in tropical diseases practicing in my city - and both are ISTM members. I am a member of ASTMH but have no interest in their conferences except an occasional review conference because they are not at all related to what I do. I delete the listserve messages about diagnosing diseases after travel since I have no need for this information. There is already too much post-travel on the exams. I know many of the academic physicians who are in the Society do tropical medicine, but at least in Canada most of the travel clinics are staffed by nurses or family physicians who have little interest in tropical medicine. Putting more tropical medicine on the exam would mean they would never be able to get a certificate in travel health.

> I have no problem with a tropical medicine interest group in the Society for those who want more exposure. Maybe we can consider doing a pre-conference review course or mini course for those who want to learn more tropical medicine. BUT there are already courses and exams in tropical medicine for those who want to do it. If people want to compete with the ASTMH (and other groups) for international tropical disease members, let them do this outside the ISTM.  If the society became too much more focused on Tropical Medicine, I would have to seriously consider resigning my membership, and I have been to every conference since Zurich.

> More emphasis on post-travel issues is fine with me, but it is unlikely to help me or my practice. I'm a GP and see about 400-500 pre-travelers a year, and a few who come home ill. I keep up with medicine as it is relevant to my practice. I can handle the simple illnesses that people come home with. I am very impressed by the knowledge that some of our members display on the listserv. But, short of going back to school for a few years, I fail to see how more articles in our journal or more courses at CISTMs is going to meaningfully raise my knowledge of post-travel medicine. Moreover, if I attend courses on post-travel medicine it probably would be at the expense of time spent at pre-travel courses. There is just so much time.

> Our ultimate goal would be never to have any post-travel problems! But as that day is far away, we should be trained to recognise and act on them.