Tag Archives: medical tourism

Medical Tourism Taking a Back Seat to Wellness Tourism

I rarely do this, however am making an exception in this case because I feel it is that important. Rather than just giving you a link to an article, I am retyping the entire article here for you (with attribution, of course). It is from today’s (Feb 20, 2012) Manila Standard Daily newspaper and titled, Tourism plan zeroes in on ‘wellness.’

The reason this is important is because it shows that what the research from the Global Spa and Wellness Summit has been predicting, is, in fact now happening. I don’t think many people really “got it” before because it was more theoretical however this is reality. The spa industry should be all over this – and making sure that government entities recognize how valuable it would be for them to help promote their country’s spa tourism.

Tourism plan zeroes in on ‘wellness’

Medical tourism is likely to take a backseat to health and wellness programs because the Aquino administration intends to focus on those booming tourism sectors, an official said Sunday.

Tourism Undersecretary Daniel Corpuz said most of the Philippines’ major hospitals were internationally accredited but only a few foreigners were going here for treatment.

“So we would rather concentrate on non-invasive procedures or the health and wellness [programs] than procedural operations.” Corpuz told reporters at the sidelines of the National Tourism Statistics conference 2012 in Manila.

He made the statement even as Tourism Secretary Ramon Jimenez said his department would be pushing the municipality of Oslob in Cebu as a tourist destination because of its famous whale sharks. Tourists visiting the area and Donsol in Sorsogon in Sorsogon could swim with the giant but docile creatures.

Corpuz described medical tourism was a complicated market segment and therefore hard to push. The Tourism Department launched its medical tourism program in 2007 to boost the country’s tourism industry. It pushed aesthetic surgery, complex orthopedic procedures and cancer and cardiovascular care among other things.

The department said the country’s beaches and resorts, world-class facilities and friendly people would entice foreigners to come here for treatment. Macon Ramos-Araneta.

(Published in the Manila Standard Today newspaper on /2012/february/20.)

Medical Tourism Will Force Health Care Change: Spas Benefit

I had a big “ah ha!” recently. It came after reviewing my notes and reflecting on what I heard and learned at the World Medical Tourism & Global Healthcare Congress I attended in Chicago a few weeks ago.

It was the revelation that because of medical tourism – people traveling across borders eitherinternationally or domestically for medical care – we can eventually expect a dramatic improvement in the health care crisis in the U.S. and around the world!

That was a major wow – and it gives me great optimism not only for our country but also for the spa and wellness industries as a whole.

Bottom line, medical tourism is now creating competition – true competition – and that is spilling over causing health care all over the world to respond. Add to that some of the changes in both the European and the U.S. health care systems and we are approaching a tipping point. Prices will come down and quality of care will go up. Here are some things I learned at the conference that bring me to that conclusion:

The quality of hospitals and doctor’s skills around the world is increasing so quickly that in many places it has not just caught up with the U.S., it is now surpassing it! That is a game changer.
Patient care is more caring in many parts of the world. Due to lower labor costs there are more people to care for each patient in places like the Philippines, Thailand, India, Barbados, etc. Patients get more time with their doctors, access to more thorough testing and are taken care of from the minute time they arrive in the foreign country until the time they leave.
The Internet is helping all of this along…the power is now shifting into the consumer’s hands and they are looking (and finding) places for cheaper, quicker, or better medical care.
90 different countries attended this conference. That’s huge! It means that 90 countries are interested in medical tourism which will fuel even more competition.
Insurance companies are beginning to embrace medical tourism by helping their policy holders find overseas solutions. This is new. (There were quite a few insurance companies at this conference.) The lower costs are just as attractive to insurance companies as they are to individuals!
Businesses that are self insured are fostering relationships with specific countries for their health care needs. Blue Lake Casino works with a medical facility in Costa Rica for all their orthopedics issues. B & H Photo of NY has 1700 staff. 50% are Jewish so they decided to work with a hospital in Israel for their health care needs.
Many places offer quicker service. Some countries (Canada, UK) have long waiting lists…going abroad can solve that.
Often lower costs can be found abroad. For example, dental work (often not insured in the U.S.) is becoming as good as or better in Mexico than in the U.S. at a fraction of the cost.
One can get access to new cutting edge medical options that may not be available in one’s home country. Example: stem cell medicine which is growing very fast.
Transparency is greater abroad. As one speaker explained – just try finding out the cost of a colonoscopy here in the U.S. It’s almost impossible because of the various entities involved in that procedure. You can easily get an all inclusive colonoscopy price quote in from many countries.
Executive physicals are popular. One research report found that 45% of medical tourists are interested in Executive Physicals, 33% interested in Dental procedures, with lower percentages for oncology, orthopedics and cosmetic surgery. The physicals are more comprehensive and cheaper. There is more time to discuss results with a doctor and some tests aren’t available anywhere else.
Areas of specialties are arising both domestically and internationally. Brazil is known for plastic surgery, Korea is known for living donor liver transplantation and robotic surgery, and Oklahoma is positioning itself as the medical tourism destination for oncology care in the U.S. Missouri’s Hospital Association found that domestic medical travel created over 3,000 jobs and generated $124 million in non-medical travel expenditures in 2009.
Hospitals are doing deals and getting creative. Lowe’s just struck a deal with Cleveland Clinic making it the first time a national company selected one specialist hospital. Mayo Clinic is planning to build a destination Medical Community as they now realize that if they don’t get involved with people post stay at Mayo, it will affect future customers. A company in Boston that talked about sending their employees to Thailand for orthopedic procedures found that a hospital in Boston was willing to match the price.

The last session of the conference really hit home – it was called “Meet the Medical Tourist.” There were several people who had taken trips abroad for medical care sharing their experiences. The most memorable was the couple from London who had not been able to get pregnant despite 3 cycles of IVF. They decided to try a well known fertility clinic in Barbados that had a very high success rate. The baby on their lap gave away the result.

Of most interest to me was the mother’s summary. In Barbados she had a more thorough evaluation, much greater interaction with the doctor and a more extensive preparation strategy. They took time to improve odds by monitoring aspects of her physiology that the doctors in London didn’t seem to have time or interest in doing.

I think medical tourism is something the spa and wellness industry should wholeheartedly support. Why? We benefit directly because medical tourists often travel with a companion and sometimes an entourage. Once someone has experienced a country – whether for a medical procedure or a spa vacation – it is reasonable to assume that they will feel more comfortable selecting it for the other. According to the GSS research, wellness tourism ($106B) is already twice the size of medical tourism ($50B). Medical Tourism doesn’t have a lot of repeat business – wellness tourism does. By supporting medical tourism, we will encourage people to think about their health when traveling.

Medical Tourism leads to Wellness Tourism. And Wellness Tourism leads to Medical tourism. And all of it will be a positive for the health care situation in the future.

I feel like kicking up my heels.

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Latest Spa News from Germany and Austria

Impressed with…Surprised by…Suggestions for…

I thought it might be fun to review my whirlwind trip to Austria & Germany in the next few blogs with the above headlines in mind. Here are the stops I made:

The famous Lanserhof Health and Medical Centre in Austria

The New Schloss Elmau Luxury Resort and Cultural Hideaway in the German Alps

Klafs in Austria, the proud manufacturer of sauna, wellness and spa products

Toskanaworld, Bad Orb in Germany, a new spa with warm thermal salt water

The AHGZ German Wellness Conference I attended and at which I spoke

First stop Lanserhof located in a little community called Lans near Innsbruck.

I WAS IMPRESSED WITH… the famous Lanserhof program and especially its founder and visionary, Andreas Wieser. This successful property (that I would label a destination spa with medical components) has been around for 27 years. They require a minimum two week stay, and have had an impressive occupancy rate of over 95% for decades. The food I experienced at lunch was magnificent – and their new cookbook, Energy Cuisine, just came out.

Their mantra is “medicine of the future” and they describe themselves as Europe’s leading health center for regeneration and preventative medicine. I noticed some predictable offerings such as detox, movement therapies, executive health, sleep medicine, aesthetics, nutrition and such and then some novel terms such as Body Memory, Burn Out Program, Vital Aging, and Alzheimer Prevention.

I was impressed with how much time Andreas spent with me as he had just returned from a three week vacation hiking through the Alps by himself. While I would have probably been a crazy person getting back into work mode, here was someone clearly in a state of mindfulness. Andreas had remarkable vision when he started the Lanserhof program almost three decades ago, but he seems to have maintained his ability to think ahead – maybe even way ahead. His discussions regarding Body Memory, Fluid Dancing and Energy in general reminded me that he may be one of the most important visionaries in our industry – yet he is “understated” in his approach and manner so it isn’t as obvious. It was very helpful for me to spend some time getting to know him on this visit and at the subsequent Wellness Conference we both attended the next day. It gave me a better sense of his pulse on the future.

I WAS SURPRISED BY… Lanserhof’s stunning setting with picture-postcard-views of the Alps from almost every room! Did I miss this when I went to their website? I don’t remember seeing this in any of their brochures – in fact checking their main brochure I realized that most of their photos were taken on a cloudy day. A pity.

There are some spas where I get a clear picture in my mind of their setting because they have successfully used one fantastic image (sometimes with what looks like a bit of “color enhancement”) over and over again – in some cases for decades! Examples include: Sanctuary Camelback Mountain Resort & Spa with that turquoise pool in front of some very red rock (we even used it for the cover of one of our SpaFinder Directories), Six Senses Soneva Gili with a waiter appearing to walk on water between a pool and the brilliant color of the ocean water in the Maldives, or the natural rock cave of Grotta Giusti in Italy.

I really had no idea what to expect at Lanserhof so when I found a drop dead gorgeous view of the Alps as a major centerpiece, it was definitely a surprise.

I was also surprised (and thrilled actually) to learn that Andreas is going to be opening two more Lanserhof properties with a similar program in the next couple of years – one near Tegelsee that will be another destination spa and another near Hamburg that will be their first day spa. Interesting that this brand extension comes now…after 27 years. It reminds me that our 2011 SpaFinder Spa Trend forecast that included “The Spa Brandwagon” was really right on.

I was also surprised at how similar much of their program seemed to be to the many destination spas I am familiar with in the U.S. And then came an even greater surprise (although it explained the former one) – before Andreas opened Lanserhof all those years ago, he visited North America and stayed at the Golden Door, Canyon Ranch, Rancho La Puerta, The Oaks, the Cooper Clinic and the Greenhouse! It was heartening to know that he speaks of this fondly and with great gratitude for the hospitality and openness shown him while he was doing his research.

I HAVE SOME SUGGESTIONS FOR… the future based on my experience seeing the lifecycle of destination spas in the U.S. I remember the years when the destination spas Andreas visited also had very high occupancy rates. At that time they did almost no advertising. They lived off of PR which was plentiful back then. However the landscape began to change in the 80’s and 90’s as competition heated up with many new spas coming to market and people’s busy schedules shortening the time they would spend away at a spa. As a result, all the destination properties that had such high occupancy rates in the early years began to invest in advertising. The Greenhouse in Dallas even had to close.

With two new Lanserhof spas on the drawing board, it is likely that there will be some cannibalism of current guests from the established location at the same time the competitive landscape could increase. It is also more challenging to run three operations than it is to run one – and the day spa is an animal of a different kind from the destination spa. Planning to invest in a strategy for marketing and advertising now might be a good idea for the long term.

Another suggestion I have is a result of a funny moment that happened during my visit. I was getting ready to present Andreas with the award I had brought along that announced Lanserhof as this year’s SpaFinder Readers’ Choice Award for Favorite Spa in Austria. I asked him where would be the most picturesque spot for our photograph of me handing him the award’s plague. To my surprise, he didn’t know! It dawned on me that when you don’t do a lot of promotion or advertising, and have lived in these surroundings for so long, perhaps you aren’t even aware of the best photo opportunities at your property. So I looked out at the magnificent view and suggested, well how about we do a photo with the Alps in the background. Duh!

‘Spas’ and ‘Medical Tourism’

‘Spas’ and ‘Medical Tourism’
Two Booming Industries With Strikingly Parallel Paths and Issues

By Susie Ellis, President of SpaFinder Inc. – the world’s largest spa media, marketing and gifting company

Am currently attending the 3rd annual Medical Tourism Conference in LA. While I will summarize the very latest information in an upcoming blog, I thought it would be valuable to post 2 articles that I have written on the topic of comparing the spa industry and the medical tourism industry because they will serve as foundational information.

I know this post is lengthy, I apologize for that however it is the entire article I wrote for Medical Tourism magazine last year. Most in the spa industry have never read it…so here it is for those interested in a conversation that is of increasing interest to more in the wellness arena. (This year their conference includes a track on wellness and spas.)

The global spa industry, with $60 billion-plus in core revenues and another $194 billion in spa-related hospitality, tourism, etc. is a vibrant and fast-growing global industry, clocking an average yearly growth rate of 20% for the past two decades. The same vitality is, of course, seen in the booming global medical tourism industry, also currently estimated as a $60 billion market – and expected to grow to $100 billion by 2010.

While each category is unique, these vast, growing global markets are increasingly intersecting and interweaving in creative and potentially synergistic ways. And while both the modern spa and medical tourism industries are in early phases of development, each sector’s growth is being galvanized not only by the rapid globalization of all economies, but also consumers’ quickening desire for diverse, meaningful health and wellness alternatives.

Because these industries have much to learn from each other, and because it’s a critical time to jumpstart a dialogue between stakeholders to help shape a mutually beneficial future, in the first installment of my two-part discussion I will present some background on each sector and in the second part suggest ways the industries could work together. What quickly becomes clear is that not only are both industries of strikingly similar size and scope, they share unusually parallel paths, and confront analogous key issues.

Both…
…Are ancient, and yet, distinctly young industries
…Share terminology and conceptual challenges
…Have a critical need for supporting, credible research
…Share a need for expert facilitators and agents to guide consumers and grow industry

Ancient, and Yet So Young
Both the spa and medical tourism industries can trace their roots back to the earliest historical epochs; people have always sought places for the renewal of body, mind and spirit (spas) just as they have, for centuries, been traveling across borders for medical reasons (medical tourism).

Greek writers spoke of a variety of baths as early as 500 BC. Later the Roman emperor Agrippa was credited with developing the first ‘thermae,’ a large-scale spa with numerous bathing stages including hot and cold baths and massage. From taking the waters in Europe, to onsen bathing in Japan, to temescal sweat lodges enjoyed by Native Americans, to the hammams of the Arab world, the idea of visiting a place designed for relaxation and rejuvenation is nearly as old as human civilization.

The concept of medical tourism is equally ancient, dating back thousands of years. Some commentators peg the Greek pilgrims traveling to the Saronic Gulf (called Epidauria, the territory of the healing god Asklepios), as the official birthplace of medical tourism. Others would argue that people journeying to India for yoga and Ayurveda were among the first medical spa travelers. Cairo’s Mansuri Hospital, constructed in the 13th century AD, represents an early example of an advanced hospital that attracted health travelers from distant lands.

Also of interest, both spa and medical tourism’s histories directly intersect in towns such as St. Moritz, Baden Baden, and Bath, which attracted royals from across borders to their healing baths.
But while each concept boasts an ancient history, both spa and medical tourism have witnessed a distinct, more recent development timeline that could properly be called the ‘modern spa industry’ or the ‘modern medical tourism industry’ –more properly measured in decades rather than centuries.

The modern global spa industry is often pegged to 1986 when the first company to aggregate spa going opened its doors. Called SpaFinder, it was designed as a new kind of travel agency specializing in spas; it published its first worldwide spa catalog that same year. Following this conceptual breakthrough, the term ‘spa’ was adopted by an exponentially greater number of establishments, and the term and concept caught on with both consumers and the media, first in the U.S., and then around the world. Less than 25 years later, there were are now approximately 72,000 spas around the world in 2007 and that figure is estimated to have increased to approximately 80,000 at minimum today..
chart.2 ‘Spas’ and ‘Medical Tourism’
In a similar vein, the modern concept of medical tourism emerged only recently, perhaps even more recently than the spa sector. Fueled by a variety of factors such as the high cost of health care, long wait times for certain procedures, the ease and affordability of international travel, and improvements in both technology and the standards of care in many countries, medical tourism has become a term talked about around the world in the last decade. Key developments which supported the emergence of medical tourism as a defined industry include the Joint Commission International (JCI) inspecting and accrediting health care facilities outside of the U.S. in 1999 and the launch of the Medical Tourism Association in 2007. Several key studies from 2008, including McKinsey’s ‘Mapping the Market for Medical Travel’ and Deloitte’s ‘Medical Tourism, Consumers in Search of Value’ gave further exposure and shape to the young sector.

Terminology and Definition Challenges
Perhaps it isn’t surprising that when a modern new industry emerges, and expands its offerings and focus at breakneck speed, that there would be debates over terminology and definitions. This has certainly been the case in the spa arena, and it is becoming evident in the evolving world of medical tourism. Both industries are marked by disagreements about what, in fact, to call themselves, as well as what the concept actually encompasses.

There is general consensus that the origin of the term ‘spa’ hails from Europe as an acronym for the Latin sanitas per aquam, which literally means health through water. The term is also linked with a mineral-springs-rich town in Belgium, which christened itself Spa in the 16th century.

The United States adapted the term ‘spa’ when Saratoga (in upstate New York) opened, fashioning itself after European towns where people went to ‘take the waters.’ Others, however, later used the term more broadly to describe destinations with a focus on exercise, weight loss, or beauty. And when the Jacuzzi brothers developed their hydrotherapy machine in the 1950s, dubbing their home whirlpool contraption a ‘spa,’ the line was blurred even further.

Given the etymological history of the term, it’s not surprising that one of the key debates has been whether an establishment that did not incorporate natural mineral waters could legitimately dub itself a ‘spa.’ Additional terminological nitpicking arose when spa associations began springing up around the world, and, having to decide who could gain admission to their organizations, began crafting their own definitions. Some insisted that a proper spa must offer water treatments; others believed that an establishment must offer two out of three of these services: massage, facials and body scrubs while others argued a true spa most offer at least 5 treatment rooms, etc.

As the industry exploded, and new concepts like destination spa, hotel spa, resort spa, day spa, club spa, cruise ship spa, and spa living real estate hit the scene, there was a need for more precise categorization to help consumers distinguish between the ever-multiplying menu of offerings. And, specially germane to the topic of this article, in the 90s the concept of the ‘medical spa’ and medi-spa’ were introduced.

So, while one can still hear murmuring about the water/ no water debate today, the general consensus seems to be that using the broadest definition of the term ‘spa’ is the smartest solution, with narrower subsets then carved from that umbrella. Industry experts finally realized that consumer perceptions and preferences were worth taking into consideration. Real-world spa-goers did not demand strict definitions; they knew a spa when they saw one.

The issue was ultimately put to rest when the respected research firm SRI International (formerly the Stanford Research Institute) issued the first Global Spa Economy Report in 2007. Having studied this global debate, SRI analysts concluded that the following broad definition would satisfy consumers, while still allowing industry professionals to carve out meaningful niches:

“Spas are establishments that promote wellness through the provision of therapeutic and other professional services aimed at renewing the body, mind and spirit.”

The medical tourism industry also finds itself embroiled in debates about core definitions, as well as whether other, more appropriate terms should prevail. Here are just a few examples of terms vying for supremacy: ‘Medical Travel,’ ‘Health Travel,’ ‘Health Tourism,’ ‘Global Healthcare,’ and ‘Medical Treatment Abroad’ – not to mention upstarts like ‘Wellness Tourism/Travel,’ ‘Medtrotting,’ or ‘Cross-Border Health Tourism.’ Some argue the term ‘tourism’ should not be used at all.

Some leading definitions:

“Traveling internationally for medical care” (Medical Tourism Association)
“The idea of traveling around the world for medical treatment” with ‘medical travelers’ defined as “people whose primary and explicit purpose in traveling is medical treatment in a foreign country.” (McKinsey)
“Healthcare consumers leaving home for treatments and care abroad or elsewhere.” (Deloitte)

Travel agencies and the mass media seem to be settling on the term ‘medical tourism’ – and 50 countries have identified ‘medical tourism’ as a national industry – and South Korea has even established a ’medical tourist visa.’ With the World Health Organization having a stake in keeping the term ‘tourism’ in the mix and the Medical Tourism Association holding its third second global conference using that name, the ‘medical tourism’ designation should be further solidified.

While it will be interesting to watch the terminology debates unfold, personally I think it’s difficult to put the genie back in the bottle. The momentum among consumers and the media is unmistakable, and my prediction is that the terms ‘spa’ and ‘medical tourism’ will prevail. Establishing industry consensus on definitions and language (which consumers and the media have already accepted) represents a positive step, and is likely to move the industry’s growth along more quickly than the costly branding of new terms that can cause confusion.

The Need for Credible, Supporting Research
In a young industry’s early stages, information and data tends to be fragmented and scattered, if it’s even available. An entrepreneurial spirit prevails and decisions are made from the ‘gut.’ It takes time for all the diverse industry participants to understand the value of supportive, authoritative research, but data and expert industry analyses uniquely benefit a growing industry, helping all players make better decisions by establishing benchmarks.

The spa industry identified this need early on, and much credit needs to be given to the International Spa Association (formed in 1991), which was responsible for the first U.S. spa industry research. ISPA continues to invest in various research projects, building a credible information database that’s widely available to its members today. In time, other organizations and countries around the world began following suit. And by 2007, the first truly global industry data was aggregated and presented at the second annual Global Spa Summit, held in New York. (For a complete list of spa research go to the resource section of www.globalspasummit.org.)

While the even younger medical tourism arena is in an earlier phase of data gathering, things are changing. For instance, both Deloitte and McKinsey contributed valuable reports to the conversation this past year. And while their vastly different numbers underscored that agreements on industry definitions and measurement remain unsettled, progress is being made. The Medical Tourism Association recently reported the results of their first survey, which should help galvanize ongoing research. Also of note, Dr. David Vequist is squarely addressing the need for data through the foundation of the Center for Medical Tourism Research, the first such research center in the world.

Going forward both spas and medical tourism need to pursue, underwrite, and promote as much consumer-facing data and information as possible as well as continue to encourage industry studies.

Travel Agents and Medical Tourism Facilitators
In the spa world, consumers often make their own travel arrangements, especially with the advent of the Internet and, additionally, the recent rise of spa reviews online. But with thousands of spas worldwide, travel agents (in particular spa travel specialists such as those trained by SpaFinder) are often vital in facilitating a great match between travelers and their ideal spa experience, especially if it includes traveling overseas.

While there’s no mandated license for travel agents, there are various best practices (such as being bonded), which have made agents a trusted, reliable way to book travel and accommodations. Despite recent changes in the way some agents exact their commission, the fact that they have been around for almost a century has ensured a great deal of transparency in the system.

With medical travelers facing an even more complex process (foreign countries, languages and currencies, and serious procedures), many people choose to rely on help – and that has come in the form of the ‘medical tourism facilitator.’ As with travel agents there is no required licensing, and because the industry is so young, the ‘facilitator’ can range from a Mom-and-Pop operation that threw up a website, to a seasoned professional that has assisted with hundreds of successful experiences. With the ‘facilitator’ industry less than a decade old, there are potential quality problems, and the revenue and commissions often remain less-than-transparent. Nonetheless, industry progress is being made, and initiatives such as the Medical Tourism Association’s efforts to establish accreditation programs will no doubt be helpful.

The spa and medical tourism industries – unique, distinct market concepts – are increasingly intersecting and dovetailing as the march to find powerful health and wellness options continues. In Part II of my discussion I will discuss what’s percolating on the spa-medical tourism world stage today, propose some partnership models which are likely to work best, and point out a potential pit-fall to avoid. Discussions now can ensure a very bright future for both industries.

My twitter address: @susieellis

Stanford Medical School Graduation Speech Alludes to Welcoming Spas

I received a link to the commencement speech given to the graduating class at Stanford’s School of Medicine last week. The link was sent to me by Dr. Ken Pelletier, one of the popular keynote speakers at this year’s Global Spa Summit in Istanbul, who “gets it” about the value of spas to medicine. The graduation remarks were made by Atul Gawande who is a surgeon, a professor of surgery at Harvard Medical School and a staff writer at The New Yorker (among many other accomplishments).

His remarks struck a nerve. Indeed, not only with me, but with many others given that I am passing this along as enthusiastically as it was passed along to me. It is precisely what I feel rings true for so many people when it comes to their own personal health, and, I believe, gives us a glimpse into the future of how spas and medicine could work together.

I will let you experience his remarks for yourself and only share with you the 3 terms he used that resonated the most with me as they relate to our industry: teamwork, right process, and humility. The era of spas and medicine working together is approaching. Judging from Atul Gawande’s words, he does as well.

The Velluvial Matrix
Posted by Atul Gawande

Atul Gawande gave the commencement speech at Stanford’s School of Medicine last week. Here is what he told the graduating class.

Many of you have worked for four solid years—or five, or six, or nine—and we are here to declare that, as of today, you officially know enough stuff to be called a graduate of the Stanford School of Medicine. You are Doctors of Medicine, Doctors of Philosophy, Masters of Science. It’s been certified. Each of you is now an expert. Congratulations.

So why—in your heart of hearts—do you not quite feel that way?
The experience of a medical and scientific education is transformational. It is like moving to a new country. At first, you don’t know the language, let alone the customs and concepts. But then, almost imperceptibly, that changes. Half the words you now routinely use you did not know existed when you started: words like arterial-blood gas, nasogastric tube, microarray, logistic regression, NMDA receptor, velluvial matrix.

O.K., I made that last one up. But the velluvial matrix sounds like something you should know about, doesn’t it? And that’s the problem. I will let you in on a little secret. You never stop wondering if there is a velluvial matrix you should know about.

Since I graduated from medical school, my family and friends have had their share of medical issues, just as you and your family will. And, inevitably, they turn to the medical graduate in the house for advice and explanation.

I remember one time when a friend came with a question. “You’re a doctor now,” he said. “So tell me: where exactly is the solar plexus?”
I was stumped. The information was not anywhere in the textbooks.
“I don’t know,” I finally confessed.
“What kind of doctor are you?” he said.
I didn’t feel much better equipped when my wife had two miscarriages, or when our first child was born with part of his aorta missing, or when my daughter had a fall and dislocated her elbow, and I failed to recognize it, or when my wife tore a ligament in her wrist that I’d never heard of—her velluvial matrix, I think it was.

This is a deeper, more fundamental problem than we acknowledge. The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.

Half a century ago, medicine was neither costly nor effective. Since then, however, science has combatted our ignorance. It has enumerated and identified, according to the international disease-classification system, more than 13,600 diagnoses—13,600 different ways our bodies can fail. And for each one we’ve discovered beneficial remedies—remedies that can reduce suffering, extend lives, and sometimes stop a disease altogether. But those remedies now include more than six thousand drugs and four thousand medical and surgical procedures. Our job in medicine is to make sure that all of this capability is deployed, town by town, in the right way at the right time, without harm or waste of resources, for every person alive. And we’re struggling. There is no industry in the world with 13,600 different service lines to deliver.

It should be no wonder that you have not mastered the understanding of them all. No one ever will. That’s why we as doctors and scientists have become ever more finely specialized. If I can’t handle 13,600 diagnoses, well, maybe there are fifty that I can handle—or just one that I might focus on in my research. The result, however, is that we find ourselves to be specialists, worried almost exclusively about our particular niche, and not the larger question of whether we as a group are making the whole system of care better for people. I think we were fooled by penicillin. When penicillin was discovered, in 1929, it suggested that treatment of disease could be simple—an injection that could miraculously cure a breathtaking range of infectious diseases. Maybe there’d be an injection for cancer and another one for heart disease. It made us believe that discovery was the only hard part. Execution would be easy.

But this could not be further from the truth. Diagnosis and treatment of most conditions require complex steps and considerations, and often multiple people and technologies. The result is that more than forty per cent of patients with common conditions like coronary artery disease, stroke, or asthma receive incomplete or inappropriate care in our communities. And the country is also struggling mightily with the costs. By the end of the decade, at the present rate of cost growth, the price of a family insurance plan will rise to $27,000. Health care will go from ten per cent to seventeen per cent of labor costs for business, and workers’ wages will have to fall. State budgets will have to double to maintain current health programs. And then there is the frightening federal debt we will face. By 2025, we will owe more money than our economy produces. One side says war spending is the problem, the other says it’s the economic bailout plan. But take both away and you’ve made almost no difference. Our deficit problem—far and away—is the soaring and seemingly unstoppable cost of health care.

We in medicine have watched all this mainly with bafflement, even indifference. This is just what good medicine is like, we’re tempted to say. But we’d be ignoring the evidence. For health care is not practiced the same way across the country. There is remarkable variability in the cost and quality of care. Two communities in the same state with the same levels of poverty and health can differ by more than fifty per cent in their Medicare costs. There is a bell curve for cost and quality, and it is frustrating—but also hopeful. For those getting the best results—the hospitals and doctors measured at the top of the curve for patient outcomes—are not the most expensive. They are sometimes among the least.

Like politics, all medicine is local. Medicine requires the successful function of systems—of people and of technologies. Among our most profound difficulties is making them work together. If I want to give my patients the best care possible, not only must I do a good job, but a whole collection of diverse components must somehow mesh effectively.

Having great components is not enough. We’ve been obsessed in medicine with having the best drugs, the best devices, the best specialists—but we’ve paid little attention to how to make them fit together well. Don Berwick, of the Institute for Healthcare Improvement, has noted how wrongheaded this is. “Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,” he says. He gives the example of a famous thought experiment in which an attempt is made to build the world’s greatest car by assembling the world’s greatest car parts. We connect the engine of a Ferrari, the brakes of a Porsche, the suspension of a BMW, the body of a Volvo: “What we get, of course, is nothing close to a great car; we get a pile of very expensive junk.” Nonetheless, in medicine, that’s exactly what we have done.

Earlier this year, I received a letter from a patient named Duane Smith. He was a thirty-four-year-old assistant grocery-store manager when he had a terrible head-on car collision that left him with a broken leg, a broken pelvis, and a broken arm, two collapsed lungs, and uncontrolled internal bleeding. The members of his hospital’s trauma team went swiftly into action. They stabilized his fractured leg and pelvis. They put tubes in both sides of his chest to reëxpand his lungs. They gave him blood and got him to an operating room fast enough to remove the ruptured spleen that was the source of his bleeding. He required intensive care and three weeks of hospital recovery to get through all this. The clinicians did almost every single thing right. Smith told me that to this day he remains deeply grateful to the people who saved him.

But they missed one small step. They forgot to give him the vaccines that every patient who has his spleen removed requires, vaccines against three bacteria that the spleen usually fights off. Maybe the surgeons thought the critical-care doctors were going to give the vaccines, and maybe the critical-care doctors thought the primary-care physician was going to give them, and maybe the primary-care physician thought the surgeons already had. Or maybe they all forgot. Whatever the case, two years later, Duane Smith was on a beach vacation when he picked up an ordinary strep infection. Because he hadn’t had those vaccines, the infection spread rapidly throughout his body. He survived—but it cost him all his fingers and all his toes. It was, as he summed it up in his note, the worst vacation ever.

When Duane Smith’s car crashed, he was cared for by good, hardworking people. They had every technology available, but they did not have an actual system of care. And the most damning thing is that no one learned a thing from Duane Smith. For we have since had the exact same story occur in Boston, with an even worse outcome. Indeed, I would bet you that, across this country, we miss the basic, unglamorous step of vaccination in probably half of emergency splenectomy patients.
Why does anyone receive suboptimal care? After all, society could not have given us people with more talent, more dedication, and more training than the people in medical science have—than you have. I think the answer is that we have not grappled with the fact that the complexity of science has changed medicine fundamentally. This can no longer be a profession of craftsmen individually brewing plans for whatever patient comes through the door. We have to be more like engineers building a mechanism whose parts actually fit together, whose workings are ever more finely tuned and tweaked for ever better performance in providing aid and comfort to human beings.

You come into medicine and science at a time of radical transition. You have met the older doctors and scientists who tell the pollsters that they wouldn’t choose their profession if they were given the choice all over again. But you are the generation that was wise enough to ignore them: for what you are hearing is the pain of people experiencing an utter transformation of their world. Doctors and scientists are now being asked to accept a new understanding of what great medicine requires. It is not just the focus of an individual artisan-specialist, however skilled and caring. And it is not just the discovery of a new drug or operation, however effective it may seem in an isolated trial. Great medicine requires the innovation of entire packages of care—with medicines and technologies and clinicians designed to fit together seamlessly, monitored carefully, adjusted perpetually, and shown to produce ever better service and results for people at the lowest possible cost for society.

When you are sick, this is what you want from medicine. When you are a taxpayer, this is what you want from medicine. And when you are a doctor or a medical scientist this is the work you want to do. It is work with a different set of values from the ones that medicine traditionally has had: values of teamwork instead of individual autonomy, ambition for the right process rather than the right technology, and, perhaps above all, humility—for we need the humility to recognize that, under conditions of complexity, no technology will be infallible. No individual will be, either. There is always a velluvial matrix to know about.

You are joining a special profession. Doctors and scientists, we are all in the survival business, but we are also in the mortality business. Our successes will always be restricted by the limits of knowledge and human capability, by the inevitability of suffering and death. Meaning comes from each of us finding ways to help people and communities make the most of what is known and cope with what is not.

This will take science. It will take art. It will take innovation. It will take ambition. And it will take humility. But the fantastic thing is: This is what you get to do.

My twitter address: @susieellis

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