Beauty from Afar

The American Society of  Plastic Surgeons (ASPS) released in April 2005 what amounted to an acknowledgment that medical tourism exists, in the form of a briefing paper that got some media attention. This was when I was in the middle of researching Beauty from Afar and was pure gold, as far as I was concerned. In the end, I quoted and commented on the entire document — which makes today’s “page” pretty long. But I thought it best to keep all the material together.

Chapter 2 Page 5 | American Doctors Speak Out

By that time, I’d spoken with enough doctors and surgeons with varying opinions on the subject of medical tourism that I was pretty sure I had a more complete and nuanced view of the subject than the ASPS could possibly put out, given that they had to present a united view … and given their constituency. I felt qualified to comment despite my lack of medical credentials.

To the credit of the ASPS, they have updated their information and resources on medical tourism over the past few years. A new link for them is in the “author’s note” for the page … and also here.

(Author’s Note: The ASPS briefing paper referenced below has been revised and augmented with audio and video since 2005. Please visit this page at plasticsurgery.org for current information. However the overall advice remains true to the original briefing paper. If I were preparing a new edition of Beauty from Afar, this section would be rewritten … but would say many of the same things.)

Chapter 2 Page 5 | American Doctors Speak Out

What are the real risks against which to weigh the considerable cost savings? In April of 2005, the American Society of Plastic Surgeons (ASPS) issued a briefing paper that overwhelmingly cautioned against traveling abroad for surgery, though not in the stark terms used regarding going to the Dominican Republic. If one read nothing else, one would conclude that traveling overseas for plastic surgery is a poor idea. In the broadest context, however,the ASPS statement is full of sound advice for anyone considering cosmetic surgery. I offer the entire briefing paper, interspersed with commentary and context.

Cosmetic surgery tourism is a price-driven phenomenon that has experienced increased growth over the past decade. Numerous companies offering all-inclusive vacation packages that include cosmetic surgery are popping up all over the world and can be easily located via the Internet. The offers generally include private hospital services and tout “highly trained” and “credentialed” medical staff. Since elective cosmetic surgery procedures are not covered by insurance, price is the major selling point of cosmetic surgery tourism, with entire vacation/surgical packages costing less than individual procedures in the United States.

This is entirely true. Clearly, however, the ASPS disapproves of cosmetic surgery being a “price-driven phenomenon,” even as its member surgeons continue to work on devising lower-cost, less-invasive techniques and procedures and to compete with each other. U.S. cosmetic surgeons, however, in almost all circumstances, are unable to compete on price with their counterparts in the nip-and-tuck nations of Central and South America and Asia.

Although there are many skilled and qualified physicians practicing all over (the) world, the ASPS cautions that it may be difficult to assess the training and credentials of surgeons outside of the United States. Patients may take unnecessary risks, when choosing cosmetic surgery vacations, by unknowingly selecting unqualified physicians and having procedures performed in non-accredited surgical facilities. The ASPS urges patients to consider the potential complications, unsatisfactory results, and risks to general health that may occur.

Yes, it can be difficult to assess the training and credentials of surgeons outside the United States. Surgeons and facilities overseas that are marketing to prospective patients in the United States, however, have made it considerably easier. Overseas surgeons offer their credentials online, and ways of verifying them are available via Internet and telephone. Prospective patients can consult directly with surgeons and staff from other countries online; references can be provided and evaluated; consultations can be conducted by phone, e-mail, Internet chat, and even via Internet video. Indeed, many ASPS members are building Internet practices in exactly this way to draw patients from around the country and from abroad.

Plastic-surgery professional organizations, no doubt, would agree whole-heartedly that the ASPS certainly can not be faulted for urging patients to consider all possible risks and to be aware of selecting unqualified physicians who operate in substandard facilities. To that I would even add a further cautionary note: People who are considering the option of going overseas for cosmetic surgery, or any other kind of health care, should keep solidly in their minds that they must be ready and willing to walk away from the decision at any point: If they come to believe they have been misled about the surgeon’s expertise, the quality of the medical facility, the procedures involved, the price, or other terms, the right decision in the end may be to walk away. A patient who has done sufficient research is very unlikely to end up in such a position, but one must be mentally prepared to not go through with surgery if one develops serious doubts — even if it means cutting your losses on the expense of traveling there.

Vacation-related activities may compromise patients’ health. Cosmetic surgery trips are marketed as vacations. Although enticing, vacation activities should be avoided after surgery. To properly heal and to reduce the possibility of complications, patients should not sunbathe, drink alcohol, swim/snorkel, water ski/jet ski, parasail, take extensive tours (walking or bus), or exercise after surgery. Yes, some firms are marketing cosmetic surgery as vacation trips, and it is also true that some patients who go abroad allow for some vacation time by arriving early or extending their stays past the period of enforced recovery. Patients can certainly arrange to recover in comfortable, even luxurious, surroundings. But your surgeon abroad is going to tell you the same thing as well. Further, patients should budget extra time at the end of their trips, bearing in mind that complications and infections are possible and that you can not absolutely count on being physically ready to go home on a pre-arranged schedule.

Cosmetic surgery is real surgery. At the highest level of care, every surgery, including cosmetic surgery, has some risks. These risks may increase when procedures are performed during cosmetic surgery vacations. Infections are the most common complication seen in patients that go abroad for cosmetic surgery. Other complications include unsightly scars, hematomas, and unsatisfactory results. Travel combined with surgery significantly increases risk of complications. Individually, long flights or surgery can increase the potential risk of developing pulmonary embolism and blood clots.

Traveling combined with surgery further increases the risk of developing these potentially fatal complications, in addition to swelling and infection. Before flying, the ASPS suggests waiting five to seven days after body procedures such as liposuction and breast augmentation and seven to 10 days after cosmetic procedures of the face including facelifts, eyelid surgery, nose jobs, and laser treatments.

All good points, but it is also the same advice you would get from a qualified surgeon in any other country. Patients shouldn’t ignore this advice. I don’t mean to place blame, but far too many cosmetic surgery horror stories can be traced, in part, to patients not following a doctor’s orders for the recovery period.

Travel can be stressful and exhausting, and attempting it too soon after surgery can impede recovery. Despite the ominous tone of this caution, individual surgeons I talked to agree with this sentiment: Follow your doctor’s orders if you want your best chance at a trouble-free recovery. Don’t travel until your doctor says it is safe to do so.

In addition, airlines make special provisions for patients who are traveling with disabilities, and that includes travelers who have had recent surgery. If you have a long trip with flight changes, for example, it may be prudent to call the airline in advance and arrange for wheelchair service.

Follow-up care and monitoring may be limited. Follow-up care and monitoring is an important part of any surgery. Cosmetic surgery vacation packages provide limited follow-up care, if any, once the patient returns to the United States. Patients who have traveled outside of the United States for cosmetic surgery and experienced a complication may find it hard to locate a qualified plastic surgeon to treat the problem or to provide revision surgeries. Local doctors may not know what surgical techniques the physician used in the initial operation, making treatment difficult or nearly impossible. Revision surgeries can be more complicated than the initial operation and patients rarely get the desired results.

In general, this is true and should be considered carefully, especially regarding follow-up care. Some patients are afraid to tell their family doctors what they are going to do, or have already done. It’s best to be as prepared as possible for complications. Many experienced patients recommend consulting with your family doctor before going overseas. Also, reputable overseas surgeons are available for consultation with you or with your doctor at home via e-mail and telephone. This is not a deal-breaker, but it is something to think about.

Bargain surgery can be costly. Patients can incur additional costs for revision surgeries and complications that may total more than the cost of the initial operation if originally performed in the United States.

Well, yes. That can happen. Bluntly, it can happen in the United States as well, and you’ll be out far more money in the end. Choosing a qualified and experienced surgeon is your best chance at minimizing the risk of bad surgery that can lead to additional rounds of expensive surgery. Good cosmetic surgeons overseas often charge far less than good cosmetic surgeons in the United States. The ASPS cannot really quite get around that fact.

You should ask your surgeon in advance what his or her policies are on revisions, should you be dissatisfied. Some will do revisions for free, in certain circumstances, or for a reduced charge. A cosmetic surgeon’s best advertisement is satisfied customers.

Surgeon and facility qualifications may not be verifiable. In order for cosmetic surgery to be performed safely, it requires the proper administration of anesthesia, sterile technique, modern instrumentation and equipment, as well as properly trained surgeons. Vacation destinations may not have formal medical accreditation boards to certify physicians or medical facilities. Many facilities are privately owned and operated, making it difficult to check the credentials of surgeons, anesthesiologists, and other medical personnel. There are no U.S. laws that protect patients or mandate the training and qualifications of physicians who perform plastic surgery outside of the United States. There may be no legal recourse if surgical negligence by the physician or institution occurs.

If the surgeon’s credentials and the quality and standards of the surgical facility can’t be reasonably verified and vouched for, you shouldn’t go. Simple.

As to legal remedies, should a patient be dissatisfied with surgery — or maimed or killed by it — it is true that it is easier and far more convenient to sue a U.S. doctor in the United States than it is to attempt to litigate outside our borders. However, suing a plastic surgeon in the United States is far from a slam-dunk, and reputable surgeons here and abroad are generally willing to extend themselves to produce a happy patient rather than a disgruntled one who will call a lawyer.

Devices and products used may not meet U.S. standards. Cosmetic surgery products or devices used in other countries may not have been tested, proven safe and effective, or been approved by the U.S. Food and Drug Administration (FDA). For example, an implant used in the United States must meet standards of safety and effectiveness, a process regulated by the FDA. Other countries may not have similar regulations.

Patients should, of course, check on what substances are injected and what devices are being inserted into their bodies. However, one of the reasons many American women have gone abroad for breast augmentation is the availability of silicone implants, banned by the FDA in 1992 but popular in other parts of the world. It is possible that silicone implants may again be widely available in the United States because the ASPS says silicone is safe and that the FDA should drop the ban, arguing that patients should have the option of choosing silicone. The ASPS says silicone implants are safe and the FDA, at this writing, seems inclined to allow wider testing. The ban could well be lifted at almost anytime.

(Author’s Note: The ban was lifted in November 2006, five months after Beauty from Afar was published.)

The ASPS briefing paper goes on to name Argentina, Brazil, Costa Rica, the Dominican Republic, Malaysia, Mexico, the Philippines, Poland, South Africa, and Thailand as cosmetic-surgery trip destinations, noting that these countries offer everything from “safari and surgery” to “tropical, scenic tour” vacation packages. It concludes with a useful checklist of questions to ask when choosing a cosmetic surgeon, clearly advocating the selection of an ASPS member. Point by point, however, the briefing paper offers advice no different than one would get from a qualified surgeon overseas — and, the ASPS, however briefly, acknowledges there are many of them.

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I have always attributed the phrase in the headline to Mark Twain, among my favorite authors … but I see by Wikipedia that it is of mixed or uncertain parentage. No matter. Please consider the link as a footnote to this post … my sixth footnote of the day. Earlier, I added what had been the five end notes to Chapter 1 of Beauty from Afar to the online pages where they belong, turning them into footnotes.

I see that I felt rightfully obligated to be fastidious about attributing statistics and numbers to their original source; and careful and fair readers should note that I chose sources that are known for doing good research and that I couch  prose that surrounds any  statistics rather carefully. There is almost nothing worse in journalism or argument than using bad statistics, or using good statistics badly, and it is done all the time.

To the extent that I am not guilty, I credit a professor of mine, Edward Tufte, whom I knew originally in the 1970s when he taught undergraduates at Yale. He has gone on to much bigger things.

Here, again, is the link to the last bit of Chapter 1:

Chapter 1 Page 9 | Medical Tourism: A Moving Target

We’ll begin Chapter 2 … oh, well. Before Monday, certainly.

There was a time when I thought that perhaps I ought to put myself forward as a reasonable candidate to be the caretaker and editor of Wikipedia’s entry for medical tourism.

Upon careful consideration, I realized that I would rather stick my hand in a bee’s nest. This is nothing against Wikipedia, which I think is a wonderful project; and I conclude Chapter 1 of Beauty from Afar with some direct quotes from Wikipedia. It was remarkable how the entry for “Medical Tourism” evolved in a short time:

Chapter 1 Page 9 | Medical Tourism: A Moving Target

… And the reasons which I am glad I did not become, or try to become, the Wikipedia editor of the page, are not yet apparent, in the above-linked passage from Beauty from Afar.

If you look at the current entry, you’ll see that it has evolved through a contentious few years. Many people have added and deleted and bitterly disputed sentences, paragraphs and sections of the entry, over time. It has been a bone over which dogs of the medical tourism industry fought. I make no apologies for the analogy. Medical tourism “experts” in every country with any claim to being a medical travel destination have vied to define the reality of medical travel. Bias was inevitable.

The entry is not so bad now as it was at a few stages in its evolution. For a partial discussion of the issue of bias, take a look at the Wikipedia “Talk” page on the Medical tourism definition/entry.

Bees sting.

Anyway — Chapter 1 of Beauty from Afar is now posted completely. It is in 9 online pages, rather than the 18 in the printed version of the book. I do have to add the end notes to the chapter but have decided to go back and insert them as footnotes to the appropriate pages in this online edition; so I’ll probably do that tomorrow, before commencing with Chapter 2.

Also, a technical note: I have made BeautyfromAfar.com a dofollow blog, which means that links on this blog have relevance to search engines. Many blogs use a “nofollow” default, meant to discourage comment spam. I don’t see the point, since I delete comment spam and blatant marketing attempts with extreme prejudice. If you have something to add to the discussion here, I want you to get credit for doing so, with a link from your name to your site, at least. (And if you don’t understand this paragraph, it probably doesn’t apply to you.)

Chapter 1 Page 9 | Medical Tourism: A Moving Target

Among the great advantages of the Internet as a publishing medium is that it can be updated quickly and efficiently, and among the loveliest examples of this is Wikipedia, the free online encyclopedia. “Medical Tourism” was born as an entry in Wikipedia in June 2004; the initial entry read, in its entirety:

“Medical tourism is the practice to visit countries with low prices and buy services in their private hospitals.”

By September 2005, the entry had expanded to:

“Medical tourism is a term that has risen from the rapid growth of an industry where people from all around the world are traveling to other countries to obtain medical, dental, and surgical care while at the same time touring, vacationing, and fully experiencing the attractions of the countries that they are visiting. A combination of many factors has lead to the recent increase in popularity of medical tourism: exorbitant costs of health care in industrialized nations, ease and affordability of international travel, favorable currency exchange rates in the global economy, rapidly improving technology and standards of care in many countries of the world, and most importantly the proven safety of health care in select foreign nations have all led to the rise of medical tourism. More and more people are traveling abroad as an affordable, enjoyable, and safe alternative to having medical, dental, and surgical procedures done in their home countries.

“Medical tourists are generally residents of the industrialized nations of the world and primarily come from the United States, Canada, Great Britain, Western Europe, Australia, and the Middle East. But more and more, people from many other countries of the world are seeking out places where they can both enjoy a vacation and obtain medical treatment at a reasonable price.

“Currently, medical tourists are traveling in large numbers to India, the East Indies, and South America — three places where the quality of health care is equal to anywhere else in the world and yet the cost is significantly lower. These regions also offer numerous options for touring, sightseeing, shopping, exploring, and even lounging on sundrenched beaches. Although India, the East Indies, and South America are currently the most popular choices for medical tourists, the industry is growing so rapidly that more and more countries and medical centers around the world are beginning to tailor services aimed specifically at medical tourists, and the expectation is that the options for where medical tourists can choose to travel will continue to increase at a rapid pace.

“A myriad of options exist for medical tourists,  from purely elective procedures such as rhinoplasty, liposuction, breast augmentation, orthodontics, and Lasik, to more serious and life-saving procedures such as joint replacements, bone marrow transplants, and cardiac bypass surgery. Medical tourists can now obtain essentially any type of medical or surgical procedure abroad in a safe and effective manner for a fraction of the cost that they would face in their home countries. The cost savings are enormous. For example, for the same price as a week-long vacation for two in Hawaii that includes airfare and boarding and lodging, a couple can travel to the natural and lush beauty of Kerala on India’s southeast coast to include airfare, boarding and lodging, personal tour guide/concierge, and Lasik corrective surgery for two.

“The average cost of private heart surgery in the United States is $50,000. That same operation with comparable rates of success and complications costs only $10,000 in the finest and most state-of-theart hospital in Bombay. A bone marrow transplant that costs $250,000 in the U.S. costs only $25,000 in India. Large price disparities such as these exist across the board for numerous medical and surgical procedures. And because of favorable currency exchange rates for medical tourists, the costs associated with accommodations, food, shopping, and sight-seeing are similarly very favorable.”

Phenomena come and phenomena go, of course. But the evidence is that medical tourism will be with us for a while. It has just begun.

(Current Wikipedia Entry for “Medical Tourism)

End, Chapter 1 Beauty from Afar

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It’s hard not to be a little pleased with myself, sometimes, as I slog through my own four-year-old prose. It looks as though I managed to not allow myself to be blinded by the sun bouncing off the shiny newness of medical tourism. I was cautious and felt my way. There’s not a lot of money in that but smugness, years later, is worth something.

I used the *T* Word — Trend — in the segment of Beauty from Afar that I just posted. Editors just love trends. They love to turn good stories into stories about trends. And I am a little guilty there — maybe even a lot guilty. After all, I took a story about going to Costa Rica for major dental work and turned it into a story about lots of people going every-damn-place for medical care. I mean, I wanted a book contract and I knew I had to … extrapolate.

But I was careful. In today’s segment:

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

… I said what a lot of people have been saying …

“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.”

But had the smarts to walk away:

“This is a highly exaggerated scenario.”

(Pats self on back. Hey, I have to come up with some motivation to do this every day.)

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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When I was writing Beauty from Afar, my publisher really, really, really wanted me to say how many people traveled abroad for medical care, surgery, cosmetic surgery and dentistry.

I probably should have accommodated my publisher’s wishes, and thrown a number out there and backed it up as best as I could. That is pretty much what McKinsey and other researchers have done since. What I chose to do has invited a lot less ridicule and a lot less controversy. I could have stood up to the former and the latter probably would have been good for book sales.

What I did, instead, is mostly in the segment/page I put online today:

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

I came up with a very reasonable estimate on the number of U.S. residents who were having cosmetic surgery abroad in 2004-2005.  I didn’t have any basis, I thought, for guesstimating how many Americans were going abroad for anything other than cosmetic surgery or dentistry. Four or five years later, I think I am still on the non-ridiculous side of the argument.

But that doesn’t keep journalists from asking the question. How many people go abroad for medical care? And the answer is — who do you want to count? I have no trouble saying “a million” — if you want to count dentistry, and cosmetic surgery, and every person who drives to Mexico for any kind of medical care at all. Throw in some millions of Americans living abroad who already get medical care overseas … you want to count them, as well? I can make the number quite large.

But the number of people who get on an airplane and fly overseas for life-saving or extending surgery, non-cosmetic surgery, is a relatively small number, no matter what you’ve read elsewhere. It is perhaps in the tens of thousands annually. It’s not trivial. But it’s not huge, either.

Most medical travel is regional. Americans are not lined up to go to the Far East for new hips or heart valves. Numbers that suggest otherwise should be looked at very carefully.

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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In Chapter 1 of Beauty from Afar, I suggested that medical tourism was already a big business in 2005 and that it might be acting as a safety valve for the U.S. health-care system. I was right on both counts.

Chapter 1 Page 4 | Patients Going Abroad: A Burgeoning Industry

Medical tourism was and is a big business and that fact has been a source of great frustration to entrepreneurs who believed then, and even today, that therefore it can be tamed, routinized and turned into a corporate profit engine.  The biggest problem with that has been that the part of medical tourism that looks like it would be very profitable — putting Americans on airplanes and sending them overseas for surgery — is not a very big part of the medical tourism business at all. It is a very small part of the picture, relatively speaking, and will remain so unless and until American businesses and government embrace medical tourism.

Most of medical tourism from the United States is still for elective procedures, dentistry and cosmetic surgery; and the Great Recession has affected that business substantially. Yes, people are more interested than ever in saving money. However, through the medical tourism boom of 1998-2007 or so — a lot of Americans were paying for their cosmetic surgery and dentistry with credit cards or by taking second mortgages out on their homes. That is not happening quite so much any more, for obvious reasons.

Yet medical tourism is working well as a safety valve for many people the world over who cannot get or afford the care they need or want locally. It has been consumer driven. It is in the hands of patients.

Big research companies talk about medical tourism being worth many billions of dollars, with many more to come. They are right, though their methodology is often deeply flawed and even laughable. But those medical tourism dollars are spread out all over the world and are very difficult to count.

The next segment will talk about spiraling medical costs in the U.S. There’s a topic that certainly hasn’t gone stale in a few years. I’ll be interested in whatever it was that I had to say. 😉