Beauty from Afar

Chapter 2 Page 8 | If You Can’t Beat Them …

Oscar Suarez, M.D., is head of the Department of Plastic Surgery at CIMA Hospital in San Jose, Costa Rica. CIMA is a modern, private facility where a number of Costa Rican surgeons cater primarily to patients from the United States.

“The surgeons in the United States, the ones I talk to, are of two minds about medical tourism,” Dr. Suarez said in an interview. “Some are against it. And others, they want to be part of it.” Dr. Suarez said he has been contacted by a number of peers in the United States who are interested in partnerships or opening facilities in Costa Rica.

That a patient can find experienced and talented cosmetic and aesthetic surgeons in a number of countries around the world is not a matter in serious dispute. Surgeons can disagree as to the risks involved in traveling and as to the difficulty of choosing a good surgeon. In the end, however, those are considerations for individual patients to weigh. Prominent, qualified, and experienced surgeons from all countries emphatically counsel patients that they should not choose a surgeon based on price alone.

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Chapter 1 Page 8 | Tip of the Iceberg — and a Trend

Global competition for health-care dollars is relatively new. The balance is shifting. From the perspective of many health-care professionals in the United States, Canada, and the nations of western European, this is unsettling. It highlights some of the deficiencies in western medical systems: In the United States, high costs and a high number of uninsured; and in Canada and western Europe, long waits and similarly high costs for elective procedures. At one time, only a small number of people from the developed nations went abroad for inexpensive plastic surgery, while a large number of wealthy people from countries with lesser medical care came to the West for advanced care, treatment, and surgery. The estimated 100,000 people (and growing) who now leave the United States annually for plastic surgery only represents the tip of an iceberg for medical tourism as big business.

There are already large success stories that have legitimized this point of view. Bumrungrad International Hospital in Bangkok, Thailand, is the best known; in 2004 it boasted treating more than 350,000 patients from 150 countries. India is hurrying in the same direction, projecting that medical tourism could be a $2.2 billion business by 2012. Put this way, it sounds huge and economically threatening to the United States and its medical-care system. One can imagine that 10 years from now, the lion’s share of the U.S. cosmetic and other elective surgery businesses will be offshore; that U.S. insurers and Health Maintenance Organizations (HMOs) will be putting a hefty percentage of nonemergency-care patients with expensive treatment or surgical needs on airplanes out of the country rather than sending them to local doctors, hospitals, and surgeons. This is a highly exaggerated scenario.

Medical tourism, as such, does not represent a substantial immediate threat to the medical system of the United States, or any other country for that matter. What, after all, is a few billion dollars compared to the $1.7 trillion spent on health care in the United States each year? The billions represent a small shift in revenues in a worldwide multi-trillion dollar health-care system. By serving the uninsured and the underinsured in the United States and by providing an alternative to long waits for treatment or surgery in Canada and western Europe, medical tourism in a sense is augmenting the health-care systems of developed countries, filling and bridging gaps, providing another safety net.

As for aesthetic and cosmetic surgery — the “tip of the iceberg” for the medical tourism phenomenon — overseas surgeons are filling a need. Time and time again, I have heard from surgeons in Mexico, Brazil, Costa Rica, and the Dominican Republic: We are not taking patients away from U.S. plastic surgeons. Our patients come to us because they cannot afford U.S. prices. If not for us, they would not have surgery at all.

There are many doctors and surgeons in the United States who would prefer that medical tourism just go away. And cosmetic surgeons, personally and through their membership organizations, have thus far expressed most of the public concern and opposition. This is understandable, but there are degrees of opposition, and one would be mistaken to think that all are of the same mind. It is reasonable to suspect that, as time goes on, more medical professionals in the United States will take a less U.S.-centric position and, generally accept that they have an international community of peers.

Just a few months after I returned from my dentistry adventure in Costa Rica, I had an appointment with my ophthalmologist. I am extremely nearsighted and have been from an early age. I’ve worn contact lenses for 36 years, which seems an impossibly long time. In the last several years, my eyes changed such that I was perilously close to requiring bifocals or, as an alternative, reading glasses to wear with my contact lenses. My eye doctor, on this visit, told me that I was an excellent candidate for Lasik eye surgery. I knew what Lasik was, certainly. I knew a lot about it. What lifelong myopic didn’t read up on that when it came out? But I had never before been told I was a good candidate for it.

“It’s improved a great deal in the last two years,” she told me, in response to my questioning about the procedure’s reliability and success rate. “They’ve refined it. We probably won’t see it get much better than it is right now, not anytime soon.”

I knew that Lasik surgery costs more if one is severely nearsighted. She nodded when I guessed the cost. “Yes, you’d probably be paying around $4,000.”

I hesitated, and then told her my Costa Rica story, the short version. And I asked, point blank if she would help and support me if I chose to get Lasik surgery done overseas? Would she work with the foreign doctor, help me get the best care I could? Because I didn’t have $4,000 for Lasik surgery.

She looked me right in the eye.

“Absolutely,” she responded, firmly, surprising me a little. And we had a long talk about where would be the best place to go. My ophthalmologist had a slight preference for India, though we agreed, laughing, that as a second-generation Indian, she perhaps has a prejudice.

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Chapter 1 Page 7 | 100,000 Fellow Travelers — or More

(Author’s Note: The reader should be aware that the following numbers were calculated for 2004-2005. I do not claim they are representative for any other time. If I had to guess right now, in 2009, a time of global recession, I’d say that cosmetic surgery abroad might well be in the doldrums, just as it is within individual countries such as the United States.)

Today, with access to the Internet, the millions of prospective and actual cosmetic surgery patients in the United States can be remarkably well-informed before ever setting foot in a surgeon’s office. They are familiar with the procedures;  they’ve seen before-and-after pictures. The Internet and television have supplemented traditional word-of-mouth marketing of cosmetic surgery, and many U.S. doctors build their practices substantially through their Web sites.

But the Internet also opened up this vast U.S. market to aesthetic and cosmetic surgeons abroad.  And in increasing numbers, they are going after the U.S. market directly.

How many people from the United States are actually going south of the border (or anywhere else) to save money on liposuction, face-lifts, tummy tucks and the like? In recent news stories, the conventional line, almost to the point of cliche, was  “no one knows.” I have been told by several U.S. surgeons who cared to speculate that the numbers are negligible;  however, these have been the same surgeons who are most concerned about (or opposed to) people going overseas for surgery. Some doctors and journalists have guessed it to be in the  “low thousands”.

This is almost certainly bad guesswork, though it all depends on who and how one wishes to count.  Consider, and do the arithmetic along with me: Costa Rica, the “Beverly Hills of Central America,”  where there are perhaps 35 to 40 cosmetic surgeons who work primarily on patients from the United States. The best and most experienced are busy constantly, and some will do several surgeries a day. These board-certified surgeons each handle as many as 40 to 50 U.S. patients a month.  Even accounting for slackers, one cannot put the annual total at less than 5,000. It could be double that or more.  A prominent surgeon I know puts the total at more than 20,000.

One can speculate conservatively that a similar number of people visit Costa Rica for just dental work, as I did. There are a lot more dentists,  according to one surgeon, and there is some overlap, as many patients will have both plastic surgery and dental work done on the same trip. Many procedures are also done by non- board- certified physicians and surgeons.

Brazil,  a mecca for cosmetic and plastic surgery with a reputation that precedes and, in much of the world, overshadows that of Beverly Hills:  There are more than a million Brazilian-Americans in the United States. The population has tripled since 1990.  Perhaps there was a time when only hundreds or a few thousand U.S. residents traveled to Brazil for cosmetic surgery annually, but that time is past. Brazilian surgeons are polishing their English and their Web sites and building new facilities. Count another 10,000 and growing.

Mexico, the most telling of all: There, more than 900 board-certified plastic and cosmetic surgeons ply their trade. Despite a stream of cautionary and negative news reports about the practice through the years, undoubtedly far more U.S. residents visit Mexico for cosmetic and plastic surgery than any other country. There are more than 30 million Mexican-Americans in the United States, as a receptive base market. Mexican surgeons advertise in the United States and even visit our country regularly on marketing expeditions, mostly in the South and West. It is not reasonable to guess that “a few thousand” U.S. residents head for the border annually for cosmetic surgery. I venture an educated estimate that the number is at least 40,000.

Tourists seeking liposuction or face-lifts do not declare their intentions at the border, and I have run across only a few doctors and surgeons abroad who can give a good estimate of the number of U.S. patients they see themselves, let alone an aggregate number for their country.  But the number for Mexico adds up quickly. I’m told that perhaps half the doctors do little or no work on patients from the United States.  Still, if the other half averages two U.S. patients per week, the total would come to nearly 50,000. This does not account for cosmetic dental work or the number of patients who get cosmetic surgery from non-board-certified physicians.  It also ignores the fact that there are hundreds of thousands of U.S. citizens living in Mexico, perhaps as many as a million, who presumably are likely to seek medical care, including cosmetic surgery, from local doctors and surgeons.

The Dominican Republic, another medical tourism destination that has been vilified, more often than not, in the popular media in the United States:  There are approximately 60 busy cosmetic surgeons in and around the capitol, Santo Domingo. For many of them, more than half of their patients come from abroad, mostly from the United States. Moreover, there are more than a million Dominicans residing in the United States, at least 600,000 of them in the New York City metropolitan area alone.

Dominican surgeons travel to New York regularly to make presentations to prospective patients.  The prices of even the best, most-qualified surgeons in the Dominican Republic for common surgical procedures are 50 to 70 percent less than what is charged in the United States. Business is booming. It is not unreasonable to guess that board-certified plastic surgeons in the Dominican Republic, plus other doctors and surgeons who perform cosmetic procedures,  see at least 10,000 patients a year from the United States, not including dental patients.

The rest of the world: A “few thousand”  more from the United States travel to other Central and South American countries, all of which are represented in the United States by growing immigrant groups. Destinations in the Far East are growing in popularity;  Eastern Europe and South Africa are more popular with western Europeans as places to go than they are with Americans, but surgeons in those countries have only just begun competing for the huge North American market.  And Malaysia and Thailand are both increasingly popular destinations. Add another 10,000 to 20,000 to the total, easily.

I am comfortable, then, in conservatively guesstimating the number of U.S. citizens currently traveling abroad for plastic and cosmetic surgery at something in the high five figures, approaching 100,000. This would be about 5 percent of the 1.7 million estimated cosmetic surgeries performed in the United States.

I don’t have a similar feel for the total number of U.S. patients who go abroad for dental care, other than to suspect that it is similarly substantial. Certainly, at least a dozen major dental practices in Costa Rica thrive on serving the U.S. market.

An assertion that the number of U.S. residents, mostly women, who would travel abroad for cosmetic surgery might be rapidly approaching 100,000 annually, or even higher, will no doubt nettle some doctors and surgeons in the United States. Yet how are we to get a grip on the phenomenon (or “problem,”  if that is your point of view) if we do not attempt to get a handle on its size?  Until the last decade, the story of what is now called medical tourism was mostly about people in other countries coming to the United States for sophisticated medical treatment, if they could afford it. And the traffic has by no means completely reversed.  Many thousands of people still come to the United States for health care, including cosmetic surgery. Almost certainly, far more money comes into the United States from abroad to pay for medical care than leaves the country.

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Reading back over today’s segment:

Dear Dr. Rubinstein …

… made me remember just how nervous I was, originally — just how strange it felt — in 2004, to head off to Costa Rica to spend thousands of dollars to get my teeth fixed. Even though, as I briefly mentioned, I’m no stranger to travel or adventures. At 20, I’d run off to South Africa for a job, knowing only one person there, and I had an amazing time there. I’ve called it the best year of my life, out of many good ones …

But anyway, going to Costa Rica for dental work was also a life-changing experience for me, because,  besides getting my smile back, better than ever, I never would have gotten to write Beauty from Afar if I hadn’t gone. I still like the magazine piece I wrote about the trip better than how I handled it in the book but that’s because it was more concentrated, more detailed, more about … well, me.

In the book, Prisma Dental comes up a few times. I sort of deliberately broke up the experience. It comes here, in Chapter 1, just by way of telling readers how I came to be a medical traveler, a dental tourist. There is much more about Prisma and Drs. Rubinstein and Cordero later, in the chapter about Costa Rica.

I was in Costa Rica in June and met a gentleman from Cheshire, Conn., who had read my original article about getting my new smile back in 2004, and had finally, in 2009, decided to do what I had done. I asked him if he felt as though the article had been accurate, had prepared him for his own journal and dental work. He said that it absolutely had. So I felt good about that.

We’re up to page 32 of the book, by the way.

Chapter 1 Page 6 | Dear Dr. Rubinstein …

When I contemplated traveling abroad for dental work, it took me a month of research on the Internet before I was finally ready to make a direct inquiry. A month — and that was just to feel confident about choosing a country from which I would select a dentist! I picked Costa Rica over Thailand because proximity to the United States played a big role in my thinking. “I don’t want to go too far if I don’t have to.” This, from someone who had thought nothing of taking off for Africa for a year, at age 20. (Which is a whole ‘nuther story.)

There was a wealth of information available on dentists and dentistry in Costa Rica at the time, more so than anyplace else (except for the United States, of course).  I wrote to the aforementioned Telma Rubinstein, D.D.S., of Prisma Dental in San Jose, Costa Rica, on February 16, 2004.  Prisma had a Web site.  I confess I chose them as first contact because they had a female dentist. I felt sure I would have a lot of questions,  and my instinct was that a woman would be more likely to be patient with me.

Dear Dr. Rubinstein,

I am writing to inquire about having cosmetic dental work done at your practice in Costa Rica.

My dentist here in Connecticut, two years ago, had taken a mold of my bite and recommended, as I recall, eight or 12 porcelain crowns. I must say I concur with his opinion. My teeth are quite worn and small, at 47 years of age. I also have a badly chipped front tooth. I could send you digital photographs, if you’d prefer to see that way.

My dental insurance at the time would not cover any of the considerable fee, however. I now find myself without dental insurance at all, but I recently heard that practices such as yours could do a fine job on the work I require at a significant savings. What can you tell me beyond what I have read on the Internet? How would we proceed?

Thank you for your time,

Jeff Schult

I never had to write to another dentist in Costa Rica or elsewhere. During the next 6 weeks, I peppered Telma, as she asked me to call her, with more than 20 e-mails filled with questions about her credentials and experience,  my teeth, prices, travel and accommodations, and Costa Rica in general, and she patiently answered every one.

Still, I didn’t really make up my mind until after I asked her if she had any problems with my writing a magazine article about my experience.  She had no qualms at all, and I took that as a sign of her complete confidence in her ability. I realized that I already knew more about Telma Rubinstein than I had ever bothered finding out about any doctor or dentist who had treated me in the United States.  Later, I felt kind of bad about having been so difficult.  “I put you through the wringer,”  I told her when we finally met. She laughed. I had been easy, she said, compared to many of her other prospective patients from the United States: “Some of them, Jeff, they ask me so many questions that I feel I have been stripped naked!” Since then, I have heard similar stories from doctors, dentists, and surgeons around the world who treat patients from the United States.

As I’ve already stated,  I believe that the United States has the highest quality of medical care in the world, the most and the best medical facilities, the highest level of technology, and the most stringent regulations and standards. Does that mean that all doctors and dentists and surgeons in the United States are better than all of their peers abroad, or even that most of them are?  I do not think even the most xenophobic member of the American Medical Association (AMA) would dare make such an assertion in intelligent company.  Even the most vociferous critics of medical tourism acknowledge that there are many fine doctors, surgeons, and dentists around the world working in facilities that are as modern as anything in the United States.

But the official party line of the medical establishment in the United States is:  Traveling abroad for surgery is generally far more risky than having surgery in the United States. Bad things are far more likely to happen. You shouldn’t do it.

The recent history of medical tourism in the United States suggests that more and more prospective patients for elective surgery, particularly candidates for cosmetic and plastic surgery, are rejecting the medical establishment’s No. 1 considered wisdom in this matter.  By far, the No. 1 reason they are doing so is cost. Aesthetic and cosmetic surgeries are elective services, paid for out-of-pocket by patients. Wealthy patients are not so price-sensitive, but procedures are no longer for just the well-to-do.

The demand for aesthetic and plastic surgery has skyrocketed in the United States and around the world.  U.S. surgeons performed three times more face-lifts in 2004 than in 1992;  nearly eight times as many people had liposuction. (5) A whole new business in so-called minimally invasive procedures (like Botox and injectible fillers) was born in the space of a few years. In 2004, U.S. cosmetic plastic surgeons performed more than 9.2 million separate procedures.  The most visible sign of the broad acceptance of aesthetic and cosmetic surgery in mainstream society was the emergence of several popular (and controversial) reality television shows such as Dr. 90210, The Swan, and Extreme Makeover. The Swan and Extreme Makeover were short-lived, but that they made it to television at all was a sure sign that plastic surgery is no longer seen as just for the affluent.  Americans of more modest means also want to look good — but price matters.

(5) American Society of Plastic Surgeons Statistics. at www.plasticsurgery.org.

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When it come to writing about places to which I have traveled, I have almost always chosen to write about the people I encounter and what it is like to be *me* when I travel. This is perhaps remarkably egocentric, yet I don’t see an honest way out of it. People can have wildly different experiences from a trip that is supposed to be more or less the same for anyone. I imagine that most people have very similar trips to DisneyWorld, for example. Yet my first visit there was on a belated honeymoon, nearly a quarter of a century ago; and my strongest recollection of the trip is a fabulously nonsensical fight I had with my then-wife over a game of miniature golf. This is not Disney’s fault; for all that they try to homogenize the American Vacation Experience, not everyone leaves with the intended memories.

Anyway –  I tried to make Beauty from Afar as much a book about compelling personal stories as it is a general guide to traveling overseas for cosmetic surgery, dentistry and medical care. So Chapter 1 starts out at a breakfast table at Las Cumbres Inn in Costa Rica, with patients sharing experiences, before I head in to Prisma Dental for a long second day with my mouth open.

Chapter 1 | Medical Tourism: Here, There and Everywhere

We’re up to Page 23 of the actual book, out of 220.