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January 20, 2020

Medical tourism with Janet Bristeir

More and more people are traveling abroad to get treatments and surgeries that are much cheaper. Is medical tourism right for you? On episode 417 of the 40+ Fitness Podcast, we meet Janet Bristeir and discuss her book, Medical Tourism: Surgery for Sale.

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Allan: 00:59 Janet, welcome to 40+ Fitness.

Janet: 01:01 Hi Allan. Thank you very much for inviting me on your show.

New Speaker: 01:04 Now your book Medical Tourism is something that's been kind of top of mind for me lately because I get a lot of questions about why I moved to Panama. But before I get into that, I have to get into the subtitle, which is Surgery For Sale, How to have surgery abroad without it costing you your life. That was brilliant. It opened some eyes and I like that because we moved to Panama to save money in healthcare. And a lot of people ask why and how that works and if they have to move to a country to get those same benefits. And my short answer is no. But there's a lot of things to consider before you just decided to get on an airplane and go get some surgery.

Janet: 01:46 Definitely. And basically medical tourism is when people are thinking about traveling internationally to purchase medical care. And we're usually talking about surgery. So, and the thing with that subtitle of my book is that most information people see about medical tourism is the headline. A person comes back from surgery abroad and dies of something. So that's that information there.

Allan: 02:15 I remember reading about this decades ago when it was, I guess South Africa was kind of marketing themselves as the plastic surgery capital of the world and people were flying into South Africa. They would get their plastic surgery done and granted they needed about a week or so for recovery. So they're out doing African safaris as far as any of their friends or family or maybe even doctor knew, they basically just went on a Safari and came back two weeks later looking a lot happier, tanner and maybe with a smaller this or a bigger that. Yeah.

Allan: 02:56 So let's talk about medical tourism. Cause I'm really what I would call a medical tourist. I'm a medical resident, not a medical resident in the state of actually working at a hospital. But we traveled to Panama, we were looking at our, our health insurance, me being self employed and just the overall cost structure of what was going on with the rates, everything going up every single year, double digits in the United States. And you know, I was saying, well before I'm eligible for Medicare or any assistance whatsoever, I'm going to get costed out of this model and there's just no way I can afford medical insurance itself. Not to mention medical costs under my new profile of living. And so we looked around and Panama was one of those locations where medical care is high quality, it's low cost. And I can, I can tell some anecdotal stories both that we've experienced and others have experienced here that really are kind of our model now for healthcare. But when we're talking about medical tourism, we're actually talking about traveling to another country for the purpose of having a medical procedure done. Like you said, usually surgery and then heading back home typically to finish out the recovery there.

Janet: 04:06 Very true. Yeah. And it's usually because people are frustrated with the wait times for surgery in their own country. You know, it's like, and the wait times, they have serious consequences. You've got the increased pain, suffering, mental anguish, and sometimes poor medical outcomes because the longer you wait for something, there's the potential of that disease or illness turning into something that's irreversible and you've got a permanent disability.

Allan: 04:33 I had a colleague that was working with me and he was having shoulder issues and he was like, he was in a lot of pain and they gave him some pain pills and they helped with the pain, but he couldn't drive his vehicle and he couldn't focus on work. And so he went back to his doctor and his doctor's like, well, it's a six month wait for this surgery. And he was just at wit's end and he's like, I can't not work for six months. And while I don't know about the medical leave and how that actually works in Canada, in the United States, it's 12 weeks. And so he, you know, if he said he had to be off work on a doctor's note, so he can't work for 12 weeks, that's fine. If he has the time off and can afford to be away from the office that long, most people can't.

Allan: 05:20 So he was at wit's end of, fortunately being in Canada, he was able to fly from Calgary to Toronto to find a doctor that could do the in a place that could, they could do the surgery sooner. So we didn't have to leave. He was actually looking outside of Canada to have that procedure done because he just knew there was no way he could bear the pain and there was no way that he could do the pain meds and keep his job. And that was unfortunate. But it is just kind of a reality of healthcare today.

Janet: 05:49 Well that's true. I mean, and that's the thing, you know, people have to lose their wages while they're waiting for the treatment. And so the economic cost just adds to that stress and it's terrible. And just for some data in 2018 Canadians expected to wait four weeks for a CT scan or 10 weeks for an MRI or maybe four weeks for an ultrasound. And in that same data set in 2018, they were talking about 30% of patients who required hip or knee surgery or cataract surgery didn't have the procedure done within the recommended wait times. And so what you find is that people that have the time and the financial resources, they don't want to wait. They want to get ahead of the game and they want to go and they, that's why they're looking internationally for these things.

Allan: 06:38 And then in the United States, I think the base story is that well we have the affordable care act and I don't want to get into the whole politics of, of that. Healthcare is not really affordable. We paid much more for the same procedures, for the same medicines than we would elsewhere. So the opportunities for us to save money by traveling is pretty significant.

Janet: 07:01 Yeah, it can be very much. And the other thing, you know, what we find here in Canada, you know, it's a very diverse population and sometimes people would incorporate going back to their home country and staying with relatives to have surgery or procedures. So they, they will travel abroad, they'll, they know that that country, they could get their hip surgery or cardiac surgery or whatever much more timely and they've got the family support there that they need for recovery.

Allan: 07:31 And I think that's key. That's what some of the things that you brought up in the book because it was not a direction my thought process went naturally being a resident and having access to lower-cost healthcare, it wasn't something that I thought about, but obviously one I would not take my wife or myself to a clinic that I didn't feel was capable of taking care of us. And this, one of the things I can say is in doing research on this some of the things I found is like here in Panama, if you're concerned about the quality of care, one of the hospitals that I took my wife to here to have some work done is basically a Cleveland clinic. And people from the United States might not know that name, but it's basically one of the top medical establishments in the entire United States. They have an outlet in Panama. The doctors there are the same caliber. In fact, our doctor had worked in the United States including the U S military for over 31 years. And so the quality is there. Obviously, you know, our, our hospital here on our little Island, not necessarily all of that, but if we need something, we know where to go and it's not that difficult or time crunch for us to get to high quality care. And that's going to be the case in a lot of countries, particularly the countries that are really investing in medical tourism.

Janet: 08:48 Yeah. And when you're looking at the different facilities, you know, one of the things that we're concerned about is that if someone is considering being a medical tourist, is that they actually get informed consent about the medical procedures that they're going to receive abroad. Because what you find with most of these sources of information is that it's a marketing focus and they don't actually provide enough insights into the risks involved, not just with the surgery but with the travel and things. And so that's another factor to consider when you're looking at locations and doctors and things like that.

Allan: 09:26 And I want to go down that line because you, you mentioned a lot of really important things in the book. The like I said, kind of being a resident didn't really, they didn't initially think about was what if you have a doctrine in United States and that doctor says, okay, I'm willing to do the surgery in six weeks. That's when my next availability is and you find that you can go to say Mexico and enjoy a week there and have the surgery done come back. Is your doctor actually going to want to do post-care on a surgery he or she didn't do.

Janet: 09:59 Usually, no. You have to have a very good relationship with your doctor, whether it's your GP or your specialist before you go away and there's various reasons people are told they can't have surgery as well. So it might just not be a factor to do with the wait lists. Sometimes people are told that they're not considered for surgery because they have other, what we call co-morbidities, wherever other health concerns where a surgery wouldn't be good for them at that particular time. And so it's not necessarily just the doctor said you can't have this, it's you can't have this because it would affect this, this and this and this. So then if someone jumps and goes abroad for surgery and has surgery when they come back, these things that have been a concern in this country before they go, you know, might be exacerbated. So that's the other thing to consider. But definitely having that followup care arranged before you go, whether it's with your doctor, with a specialist, a physiotherapist, you might need ongoing counseling. So you're gone for bariatric surgery. You definitely need a lot of support when you come home from like a dietician or a forum, some kind of chat group where you will get that support because it's a huge lifestyle change.

Allan: 11:22 Yeah, I think a lot of people, if you're going in for something fairly simple, which most of the time that's not where you're going to get your bang for the buck. That's worth buying an airline ticket. Most of these are going to be surgeries and in many cases a pretty major surgeries like bariatric surgery or hip or knee replacement, something like that. Maybe even some plastic surgery, but usually again, something probably a little bit bigger. The recovery is something that's really, really important to think about. And are you going to have the family support to get you through that?

Janet: 11:52 Well, that's right because if you haven't got that psychological support, especially if we're talking about bariatric surgery, you know, if you go and have the surgery and you come back and you've got these extreme changes in diet that you have to comply with, but you've got someone in the family that's always saying, well, I've made this for you, eat this, or why don't you try that? It's defeating the object. They'll just wear you down and then it won't be successful. But if you've got people at home that are supporting you and encouraging you with the diet, with the exercise, with looking after yourself, when you come back you'll have a much better recovery and a much better outcome.

Allan: 12:30 Yeah, and another thing I got into you got into is a little bit about talking about your employer and obviously you're going to have to take time and potentially a good bit of time away from work because you've got to mix in the travel time along with the recovery time along with the surgery time. And I got to thinking we would, we would let someone off of work if they had a doctor's note and say, okay, I'm going to be out for three weeks for this surgery, but is your employer going to accept the doctor's note from a doctor in Thailand or do they think you're taking three weeks to vacation on, on FMLA, you know, and I'm on medical leave.

Janet: 13:04 Well and also do you want your work to know about it? If it is a plastic surgery or something, do you want work to know? So that's the other thing is it might be something that's very important to you, but you might not want everyone talking about it around the water jug. And the other thing is if you might have already been off work with whatever's causing you to have the surgery and then the surgery, you've had the surgery, but during your recovery you might need some kind of accommodation, reduced hours or working back into the system. And is your workplace going to be able to accommodate that?

Allan: 13:39 Yeah. Well under I know under us law there's a, there's a thing called family medical leave act, FMLA, and it specifically kind of puts the parameters of how an employer treats an employee relative to their medical care to include. Then there's HIPAA. So if you have a medical issue, you should be able to go to your HR or whoever that is that would be handling that for you and your company. Give them the basic information that they need to know along with communication with your doctor and that's supposed to be a very protected area. That information is not supposed to be circulated. So it's not water cooler stuff, but just recognizing that the law is pretty specific about, you know, coming back to your job, how long they have to hold your job open, what kind of accommodations are they required to do and which ones are they not. So working carefully with HR to understand what your rights and responsibilities are, I think is a huge consideration as you go into this.

Allan: 14:39 So someone decides, okay, I definitely want to have this procedure done. My knee is bothering me, my doctor says we're not going to do this surgery until you're 63 and that means for like, if it were me, it's like that's 10 years of constant pain in this knee. If that were the case, I don't, I don't have any problems with my knees, touch wood. But if I did and the doctor says I'm not willing to do this surgery until you're 63 and then I find a doctor or find a physio and say, okay, I'll do the followup. If you go get the surgery in Panama or Thailand or wherever, Mexico, how do I decide, because again, I just listed three countries. There's different costs, structures to those. Obviously different doctor facilities available. There's just a lot of information to kind of pour through. How, how do you decide what doctor, what location and when, how do you, how do you do that?

Janet: 15:32 Well, that's what I say. I'm think one of the first things we need to touch on here is that does someone want to organize this themselves or not? Because if someone can organize their vacation really well and they always have great places to stay and stuff like that, that's great, but if you're someone that every time you book a vacation, the hotel you get is half built when you get there and there's no taxi, you have to really consider are you going to do this yourself or are you going to get something what they call a medical tourism facilitator to organize this for you. And that we can talk about afterwards as well. There's, there's a whole other problem associated with that, but things that you want to look at is how far away is the facility and will the travel to the facility you're thinking of determined, you know, it'd be detrimental to your condition before and after surgery.

Janet: 16:22 Because if you are going to be on a flight for six, seven, eight hours, just in normal fly in, there's the chance of deep vein thrombosis, which is a clot you can get in your leg and that can cause all sorts of problems. Now if you're already having problems with joints and things like that, that long flight is going to be a problem to start with. And a long flight before you're going for surgery is definitely gonna be a problem. And then after the surgery, depending on what surgery you're having, you can't fly straight after surgery. Like if you've had gastric surgery, you can't fly within a few days because the gas that they put into your abdomen for the part of the surgery has to be completely dispersed because otherwise the pressure in the airplane can create problems. So there's things like that. How far is the facility you're looking at to travel to. And also if you're going to another country, do you speak the language?

Janet: 17:22 So if you don't speak the language, how are you gonna communicate with the staff? If they have limited English is your first language. If they have limited English, how are you going to communicate them, especially when you're stressed and you're in pain. So it's things like that. And then again looking at the facility, are the surgeon and the staff licensed to be practiced in in the country that they're practicing in? If they've got the right credentials. And is the condition and the related surgery a familiar position, or procedure for them or is it something that they are just doing for a few months just to make a bit of extra cash. And then do you have contact with the surgeon pre and post op. So it's really nice to know who's doing your surgery and lots of facilities, whether you're doing it yourself or through a medical tourism facilitator.

Janet: 18:17 You're quite often have like a Skype call or at least a phone call with your surgeon before the surgery so you can get some kind of feel for, you've got some rapport with them. And then when you're looking at the facility, you want a facility that's accredited by an international certification agencies, something like joint board, international, Canadian international standards because you want that facility to be run to the highest level as far as cleanliness, staff certification and follow up like that. And then when you've had your surgery, will you be given reports of your surgery in a language you can understand to bring back home because that is going to be really crucial to your followup care. If you go to Mexico and you have a surgery and they give you your surgical report and it's in Spanish, you know, and no one can read it. Or if it's handwritten and no one can read it, you can't get your full out care done until that's been translated and transcribed. So it's things like that that you have to consider.

Allan: 19:25 Yeah, and so it's not just location. It's cool. You can say, I want to go to South Africa and have this cosmetic procedure done and then after the recovery or during the recovery time, I'll still be able to do this safari and I'll be able to go and see the beaches and then I'll travel home with a little bit of a tan and, and the surgery done. But if your recovery is going to be much more difficult than that, you have to consider that in the whole math of all of this because it's not just a pick a doctor and go, you've got to kind of do your homework.

Janet: 19:56 I think as well, you have to dispel the fact that it is a holiday. It's not a holiday, the phrase is medical tourism. This is not a holiday. This is not a vacation. You shouldn't even plan to be looking at the country and doing it. Because I think as we touched on briefly when we were talking, if you start doing trips tourist type trips before your surgery, there's a potential for you to get some kind of acquired effect infection while you're wandering around. You might eat the local food, drink the water, you might get some kind of infection or illness and that will delay your surgery. And you also got to consider most people take a caregiver with them, a companion. And what happens if your companion goes off and does touristy things and they get sick while you're away. And that's a whole nother level of stress.

Allan: 20:48 You took me on this great trip to Panama and then you got sick and I had to look after you. I basically get to sit in a hotel room and hang out with you. I don't get to actually see anything. So yeah, I totally get that as like, Hey, come down to Panama with me. It's like, Oh no, I don't want to just sit in a hotel room with you. I could do that anywhere.

Janet: 21:11 Well, and also you have to be very careful about who you choose as your companion because this is a medical procedure. You're going to be talking about some very personal things and do you want your golfing buddy, which is great to play golf and sit in the bar afterwards and yak up a storm, but you want that person in when you're being asked about your bowel movements or things like that.

Janet: 21:34 And also do you know this person will actually function in a medical facility because there's lots of people that they're the good guy, the good woman or whatever, and they walk into a medical facility and they just close up. They are totally overwhelmed with it. They don't deal with it. And so you really need to be sure who's going with you that they can be your advocate, that they can speak up for you when you can't because we'll beyond the facility.

Allan: 22:01 We've talked about this before we got on the call and it's true. Most Americans have no desire or ever will travel outside the United States. They don't even own a passport. And so you take someone who's never been outside the country, doesn't speak the local language, and while you might be able to speak the language fluently and you gave them a medical power of attorney, when the doctor comes out there and starts speaking to them and trying to explain to them what extra thing needs to happen, are they going to be able to handle the stress of being in another country having to deal with, even if it's not a language barrier, just a pronunciation issue that's asking a lot.

Allan: 22:40 So this has to be someone that you really trust, someone you know that's going to be comfortable in not just the medical perspective, but just being out of their element. Because traveling outside the United States, if it's your first time is already pretty stressful.

Janet: 22:53 Very true.

Allan: 22:55 So you talked briefly about medical tourism facilitator, and this is a little bit more than just a travel agent. Obviously they'll do a little bit of that for you too. But their job is to kind of make this process of the looking and doing the research and understanding what's going to happen and how it's all supposed to work, that they'll do a lot of that work for you.

Janet: 23:17 Definitely. And again there's all ends of the spectrum involved in this. What you want is a well established medical facilitation company and so ideally someone that's not just linked to one facility because you want someone that's got your best interest at heart that it's not that they're just sending you somewhere cause they're on commission for it. So you want someone that when you go to them and say, look, I'm looking for knee surgery. I've been thinking about going to Panama. What can you suggest? They need to discuss with you? Well, why are you thinking of Panama is an eight-hour flight away, whereas this is other hospital that's four hours away from you. Where are we could get something similar. It's someone that's got your best interests at heart, so they're looking for the best deal and the best surgery and your best outcome. Not, okay, I'm going to put you into this hospital because I get the commission from this and from the airline, from the hospital or from the taxis, whatever.

Allan: 24:17 Yeah. And so understanding who you're working with, and one, how are they getting paid, who are they loyal to? Those are all really, really important. And again, like you said, they're experienced in doing this.

Janet: 24:30 I mean, because someone, someone can be a travel agent but they can't arrange the surgery and someone can work for the surgical facility, but they can't arrange the travel. So you want someone that's got that qualification where they can put both of these together. And there are lots of really good companies where you have the initial conversation with you, they set you up, you decide what facility you're going through and from the choices they give you, you have the conversations with the surgeon. They have, sometimes companies have someone that will go with you. So instead of you find it a companion to go, they have someone that will travel with you and be with you through the procedure and come back with you and they take care of making sure that you have all the documentation to bring back with you and that it's translated and they sometimes do followup for like six months so that they check in with you afterwards to make sure you're getting that follow up.

Allan: 25:26 Not to even mention visas and everything else because that's a whole other animal as you're traveling internationally is making sure that your, when you land, they actually let you stay. Now we talked briefly, you're in Canada, so you're under a program there with your national government, in the United States we have national, when you get to the age of 63 or 65 or 67 I forget where the age is right now that you'd be eligible for Medicare, but because it just seems like 10 years, 15 years from now, I don't even know. But one of the main reasons I came down here was because when I got my insurance quotes, it was $1,600 a month and I'm going to count it by trade. And there's a rule of 72 which basically says that if something's going up a certain amount, you can expect it to double based on multiplying that by 72 so at a 10% increase, which was conservative, I was looking at my insurance doubling every 7.2 years.

Allan: 26:25 So if my insurance doubled every 7.2 years before I was eligible for Medicare, it would quadruple. It would double and then double again or even more. And so I was looking at healthcare costs well in excess of $5,000 a month. And that's, that's not even the medical procedures, copays, percentages, anything. That's deductibles, that's just for the insurance. And I was like okay, that's, that's not sustainable. I can't just keep staying in this rat race. That's part of what I was getting out of it for. And I don't want to make my wife have to do the rat race cause she doesn't want to either. We want to live simpler lives and that was part of the choice to come to Panama.

Allan: 27:06 We were talking to a realtor here and one of the cool things he said was he broke his ankle. Not cool thing, but he went over to the mainland. It's about a 30 minute boat ride from here. He went into the clinic there, they x-rayed it, they set his ankle, he went back for two follow up visits. So he did have to ride, drive his boat over there and back a few times. I'm not difficult. Like I said, half an hour, easy boat ride. He did that and his total costs for the entire procedure, including the X rays and everything was $250. My wife had x-rays for x-rays of her knees and total costs with x-rays was $130 and now she's still having problems with the knees and she wants to go in for an MRI. The MRI is $400 so out of pocket is sustainable here. Which is part of what we love about it now, we did buy these international insurance plans. Basically it works everywhere, including United States. So if I went into the United States and had a medical procedure, I've got a $5,000 deductible, so I hope I wouldn't hit that. But if I did, I know I've got insurance for something catastrophic. So I'm buying this catastrophic plan that I wouldn't be able to by living in the United States.

Janet: 28:16 Right. And I think one, one of the things about people that are looking for surgery abroad, one of my big concerns has been is what insurance they get to cover them when they're abroad. And for six years I've tried to find places that would cover them, all the big companies and that and no one would touch it. And just a couple of weeks ago I found a company here that actually has medical tourism coverage and benefits and it's really interesting because when you talk to people, as we said earlier, most people think, Oh, I'll just get travel insurance and that's it. But that's not going to cover it. You really need something where you're saying you're going for a surgical procedure and that insurance is actually going to cover anything that might go wrong where you need to come back, whether it's you or whether it's your companion and not just flying you back but covering you for maybe six months afterwards because something could happen that you get a complication, you know, a few weeks, a few months afterwards and does that insurance still kick in and this, this coverage actually seem to do that.

Allan: 29:21 And so I think that's one of the cool things is that as medical tourism is kind of growing, these insurance programs are coming about when folks do hit Medicare age. One of the programs we can buy into here is basically medical evacuation. So if we have a heart issue or something significant and just don't want to go to Panama city for it and we want to go back to the United States and utilize Medicare for example, we can have a policy that basically says in the event I have a problem, heart attack or stroke or whatever, I can be medivaced and my spouse with me to the United States and they'll take me to Houston or Miami, whichever is the most cost effective, and then I can be admitted there and they can deal with the issues. So there are these opportunities, they're forced to use the insurance.

Allan: 30:08 And I think it's something that you do have to think about because you may say, I've got the $7,000 in the bank to go down. I got my airfare, hotel, lodging, everything covered, food and the surgery. But if you end up having an infection or a complication during the surgery and you're going to spend an extra five to seven, 10 weeks, whatever, in the hospital there, do you have that? And so insurance is something to consider as you get into this because your insurance from the United States, and probably from Canada may not cover those costs and you're out of pocket on all of those.

Janet: 30:42 Very true. Yeah.

Allan: 30:44 So if someone's thinking about this and considering this, what are some of the most critical points that they should consider as they really get into it, cause we've talked a lot about talking to your doctor, making sure your family is engaged, having someone there with you, understanding the true cost of what this is. Because it's not just how much is the procedure, but what would you say if they're going to do this, what's the most critical aspects that they should just have top of mind throughout the whole process?

Janet: 31:10 I think I would say safety and that insurance coverage I think is a very good blanket too to wrap themselves. But also that checkout the facility, talk to people that have been there if you can and people that have been there recently, not someone that was there five years ago, someone that was a last week, last month, and find out what their experience was because staff change, things change. Find out about the travel arrangements, where you're going to travel. Are you going to be staying in a hotel before your procedure? Then you're going to be in hospital. Then you're going to be in a hotel for a few days afterwards. When you're in the hotel, is there someone going to be coming to check your dressing? Are you going to have drains associated with your surgery? Someone coming to check them and take them out? Will you see the surgeon the day of the next day after your surgery? Who will be telling you when you can travel home? What physiotherapy do you need? What changes of diet? These are all the things that you have to take into consideration.

Allan: 32:10 Yeah. And, and one of the cool things, like I said, in the community here in Panama, there's these open forums, these forum groups. And so you can get out there and I'm pretty certain on Facebook and otherwise there's forums of people that are doing exactly what you're trying to do, exactly where you're trying to do it. And there are a wealth of information. The same questions get asked over and over sometimes on these forums, but we put up with it and we answer the questions. But you can search these forums. Facebook's made that a lot easier to do these days. So take some time, do that base research, get to know some people. Because what I've found is internationally people just really want to help each other out. If they've experienced something that they want to share that information and help others. So reach out. You'll find folks that have gone through exactly what you're trying to do and they'll be able to give you some really good information, really good tips and steer you away from some potential problems.

Janet: 33:00 Yeah. And I think it's also very crucial that people make sure they've got followup when they get home. That they've arranged that there is a doctor that's going to see them when they come home or a surgeon, you know that someone is going to check their dressings if they've still got them, they're going to get the physio therapy cause it's usually takes a while to get into these appointments. They need to book their physiotherapy for the followup when they come home, if they've had kind of joint things happening and they have things in place. I mean and it's the day to day things as well. If you're coming home from surgery, is there going to be someone there? Is someone going to help you with the shopping, the cooking, the laundry, the cleaning. You're going to need to go to medical appointments. Who's going to take you there while you're away? Who's going to look after your home? If you've got pets, they look after who's going to water the plants. It's all of these things because you don't expect anything to go wrong, but if there is a problem, you want to know that everything's taken care of at home while you're away and also that you're taken care of when you get back. You have to line all these things up. It might be as simple as if you know that when you come back, you're not going to be able to reach the top cupboards of the kitchen. You move stuff down in the kitchen so that you can work on the top surface or the lower cupboards. Basic problems like that that people don't ever consider.

Allan: 34:18 Well and they need to. I think that's what we're really kind of coming out here is there's like a huge opportunity, opportunity to save time to get things done sooner, opportunities to save money. But you do have to do the homework. You do have to think through these and be really logical and get really deep on understanding what your process could and may look like because it's not necessarily going to go to plan. So are you in position where you can actually manage through all that? So it was a lot more considerations than I actually had originally thought this conversation was going to have before I read your book. But I really appreciate that you took the time to really go through that in detail. And so the book is called Medical Tourism and I do encourage anyone that's considering it to check out that book. But I have one last question for you, Janet. I define wellness as being the healthiest fittest and happiest you can be. What are three strategies or tactics to get and stay well?

Janet: 35:15 I think we have to be easy on ourselves. I think all of us can improve our health in some way or another. And I think it took us a while to get to the state we're in where we think we need to improve our health. So we need to be easy on ourselves and take small steps towards changing lifestyle and eating habits. Because if you do things drastically, you're not going to do it. If you're going to cut out everything to make these huge changes, you're going to resist it. You're not going to do it. And I think that you need to be working every day towards that health goal. So if you're thinking about increasing your exercise, you know, you might be thinking about walking, so park your car a couple of blocks further than where you're going and increase the distance you walk and increase that distance every day, every week or every month. Use the stairs instead of the elevator. Take it gradually so that if you're on the 15th floor, you don't try and do 15 floors in one day, but go up a few flights at a time, you know, then take the elevator, just work up to it. And that mindfulness, I think we all need to have some quiet time. We need to take some time each day to be away from electronic gadgets if possible to do maybe 15 minutes of meditation. And that just kind of resets us and of course really important to get enough sleep.

Allan: 36:29 If someone wanted to learn more about you, more about your book, Medical Tourism: Surgery For Sale, where would you like for me to send them?

Janet: 36:37 I have a website, so it's www.areusafe.ca and that's got information about my books on there. There's also, if you go on there, you can register and download a free checklist of questions that you should be asking for a facility and there's information about the medical tourism company that I mentioned so that that's on that site as well.

Allan: 37:09 Okay. Go to 40plusfitnesspodcast.com/417 and I'll be sure to have the links there. Janet, thank you so much for being a part of 40+ Fitness. Thank you very much. Good to talk to you.

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