Oct 20

Chapter 3 Page 2 | The Pioneers

Brazil, in particular, gradually became known internationally for the expertise of its aesthetic and plastic surgeons, but it was not a fame that extended to the mass consumer markets of the more economically developed world. Prof. Dr. Ivo Pitanguy is not a household name outside of his home country, where he is revered. Dr. Pitanguy has performed or guided thousands of surgeries in a storied, five-decade career and has trained more than 500 plastic surgeons from more than 40 countries who practice internationally, making cosmetic surgery expertise and technique one of Brazil’s best-known exports.

Among his peers, Dr. Pitanguy is regarded as the father of modern cosmetic surgery. He also has become the father of modern medical tourism, for those he has trained are among the most sought after surgeons in the world. Yet his name and his work, outside Brazil and South America, are familiar primarily only to other plastic surgeons, Brazilians living abroad, and the families and friends of his patients — not to the millions of potential plastic surgery patients in the United States who are far more likely to know the names of surgeons on Dr. 90210 or The Swan.

In the United States, if one had to name a doctor who was famous in international medicine during the 1960s, perhaps the only household name was Christiaan Barnard, M.D., the South African who performed the world’s first heart transplant in 1967. Notably, Dr. Barnard trained in the United States, as did Dr. Pitanguy, before heading home to eventual renown.

I cite Dr. Pitanguy and Dr. Barnard as pioneers not so much for their unquestioned skill as surgeons but because they achieved the kind of international fame that, for most of the 20th century, was reserved for doctors and scientists only in the West (North America and Western Europe) and, to a lesser degree, the East (mostly the former Soviet Union). Patients in Eastern bloc countries frequently traveled to the then-USSR and its allied nations for advanced medical care. For all of the 20th century, and even into the beginning of the 21st century, the vast majority of medical tourists were not jetting to South America or Africa, let alone the Far or Middle East. They were coming to the world’s great doctors and hospitals in the United States and in Europe.

From the perspective of the United States, in particular, this state of affairs served, and still serves, to reinforce the generally held belief that the United States has the finest medical care in the world. In the last 50 years, only Dr. Barnard’s achievement challenged this notion in the popular imagination. People were oddly comforted when Drs.  and Michael DeBakey started transplanting hearts in Houston, Texas, almost in the same way they were when the United States finally answered the Soviet space challenge of Sputnik.

Meanwhile, Dr. Pitanguy just kept doing what he was doing. Patients spread the word. Brazil was and is the mecca of plastic and cosmetic surgery, challenged only recently by Southern California. The surgeons Dr. Pitanguy trained spread out through South and Central America and around the world. Over time, a second essential precondition for medical tourism to emerge as big business was met — medical talent spread out, belonging less exclusively to the developed world. In economically emerging nations, improving health care was a priority — which meant building more modern medical facilities.

The quality of care in the less-developed world rose steadily, at least in metropolitan areas, but prices for medical services remained low, relative to the United States and Europe.

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Sep 28

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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