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Traveling Abroad to Teach a Medical Tourism Course

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ARTICLE Traveling Abroad to Teach a Medical Tourism Course: A Sister School Partnership Michael Guiry, PhD, Wolfgang Vrzal, MBA, & Teresa Mang, MBA

Abstract This paper discusses the conception, design, and teaching of a master’s-level Medical Tourism course at IMC University of Applied Sciences Krems in Krems, Austria, which was taught by a marketing professor from the University of the Incarnate Word in San Antonio, Texas, and sprung from the sister school relationship between the two universities. The course covered five major topics: 1) Introduction to the Medical Tourism Industry, 2) Medical Tourism Destinations, 3) Medical Tourism Consumers, 4) Medical Tourism Legal, Ethical and Social Concerns, and 5) Marketing in the Medical Tourism Industry. A variety of teaching and learning methods were used in the course: interactive lecture, in-class exercises, class discussions, individual current issues paper and presentation, group case analysis report and presentation, and individual reflection paper. Student remarks from the reflection paper assignment highlight the significant learning that took place in the course in the form of Foundational Knowledge and Application Learning.

Introduction Although people have traveled for medical treatment and health/wellness benefits since ancient times (Health-Tourism.com, 2011c; Reddy, York, & Brannon, 2010), recently, medical tourism has emerged as a significant and rapidly growing phenomenon in the healthcare industry (Lunt, Hardey, & Mannion, Address correspondence to: Michael Guiry, PhD, Associate Professor of Marketing, University of the Incarnate Word, H-E-B School of Business & Administration, 4301 Broadway, CPO #109, San Antonio, TX 78209; Tel: +1-210-930-8010; Email: [email protected]

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The Journal of Health Administration Education

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2010; Reddy et al., 2010). Broadly defined as “travel with the express purpose of obtaining health services abroad” (Ramirez de Arellano, 2007, p. 193), medical tourism demand has been fueled by a number of factors including the high cost of healthcare, long wait times for certain procedures, consumers seeking treatments unavailable at home, increased consumerism, the readily available medical and healthcare information on the Internet, the ease and affordability of international travel, and improvements in both technology and standards of care in many countries (Keckley & Underwood, 2008; Lunt et al., 2010). Key destination countries (e.g., Thailand, India, Singapore, and Malaysia) are now satisfying the growing demand for procedures such as cardiac, cosmetic, dental, and orthopedic surgeries (Crooks, Kingsbury, Snyder, & Johnston, 2010; Reddy et al., 2010). Estimates of the size of the medical tourism industry vary widely, ranging from tens of thousands to millions of medical tourists worldwide (Connell, 2011; Crooks et al., 2010). This discrepancy exists because no singular definition of medical tourism has been widely accepted, and countries, hospitals, industry firms (e.g., medical tourism facilitators), trade associations (e.g., USbased Medical Tourism Association), and consulting firms that have published industry reports (e.g., Deloitte, KPMG, and McKinsey & Company) define and count medical tourists differently (Connell, 2011; Crooks et al., 2010). For example, one country may include expatriates and/or vacationers who require hospital medical care while in the country, while another country may not include these patients in its “official” medical tourism statistics (Connell, 2011). Although there is disagreement over the size of the industry, consensus exists that the industry has grown in recent years and will continue to do so in the future (Connell, 2011; Crooks et al., 2010). In a recently published report, KPMG estimated that the global medical tourism industry caters to more than 3 million patients, is growing at a rate of 20 to 30 percent per year, and, is forecasted to be worth $100 billion by 2012, up from $78.5 billion in 2010 (KPMG International, 2011). It is generally agreed that Asia is the largest and fastest growing region for medical tourism (Connell, 2011; Johnston, Brown, & Kazmin, 2010; Reddy et al., 2010). Industry experts forecast medical tourism in Asia will grow at a rate of 15 to 20 percent each year, mainly due to the emergence of the newly rich, conspicuously consumption-driven consumers in the region, and that the industry could generate $4.4 billion in Asia by 2012 (Laurence, 2011). In addition to the positive revenue streams for countries involved in medical tourism, other potential benefits for destination countries have been noted, including healthcare infrastructure development, retention of healthcare human resources, and improving standards of care (Connell, 2011; Johnston, Crooks,


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Snyder, & Kingsbury, 2010). For consumers, medical tourism provides more affordable healthcare, reduces wait times for medical procedures, and offers access to needed care abroad that is unavailable in a patient’s home country (Connell, 2011; Johnston et al., 2010). Medical tourism has drawn its share of criticism; a variety of possible negative effects have been discussed in the medical tourism literature. For medical tourists, a number of potential risks have been identified, including risks to patients’ health (e.g., contracting an infection), risks of travel (e.g., deep vein thrombosis), and risks pre- and post-operatively in their home country (e.g., little legal recourse if complications occur) (Crooks et al., 2010). Concerns also have been raised about revenue losses in medical tourists’ home countries, due to patients taking their funds elsewhere (Johnston et al., 2010). Additionally, lax surveillance and monitoring of medical tourism could lead to an unaccounted for outflow of patients and ineffective distribution of healthcare resources (Johnston et al., 2010). In destination countries, medical tourism could lead to international patients receiving higher quality care than the local population, more intensified “brain drain,” and inequitable use of public funds by support of the private provision of medical tourism healthcare (Connell, 2011; Crooks et al., 2010; Johnston et al., 2010). The evolution of the medical tourism industry from its initial days as a grassroots movement to the highly competitive global phenomenon it is today requires industry providers to develop more complex business practices, knowledge production, and expertise to successfully compete, differentiate, and position their offerings in the marketplace (Gerl, Kunhardt, & Mainil, 2009). At the same time, the expected continued industry growth implies that there are medical tourism employment opportunities as medical tourism facilitators or agents, managers, administrators, business consultants, analysts, strategists, marketers, and client relationship managers in the public and private sector. In addition, an individual could enter the industry as an entrepreneur or self-employed professional offering medical tourism-related services to medical tourists. These market demands put universities in a position to play a supporting role to patients, employees, and providers by supplying the field with the necessary applied knowledge, skills, and tools (Gerl et al., 2009). The recent surge in published academic research on medical tourism, covering such topics as consumer decision making (Reddy et al., 2010; Veerasoontorn & Beise-Zee, 2010), service quality (Guiry & Vequist, 2011), medical tourism facilitators (Cormany & Baloglu, 2011; Gan & Frederick, 2011), brand positioning (Guiry, 2010), public and private health systems (Helble, 2011), and legal and ethical issues (Cohen, 2011), also suggests that the time has come for universities to

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offer medical tourism courses that draw on this increasing knowledge base. Even so, we are not aware of any university-level medical tourism programs or courses being offered in the United States or Austria – two countries with an inbound and outbound patient presence in the medical tourism industry. Hence, the purpose of this paper is to discuss the conception, design, and teaching of a master’s-level Medical Tourism course at IMC University of Applied Sciences Krems in Krems, Austria, which was taught by a marketing professor from the University of the Incarnate Word in San Antonio, Texas, and sprung from the sister school relationship between the two universities. Having a US professor teach the course in Austria was consistent with Özturgut’s (2008) call for more higher education faculty to have teaching-abroad experiences. This paper will provide an overview of medical tourism in the United States and Austria; summarize the authors’ respective universities; discuss the impetus for the medical tourism course; describe the medical tourism class; and provide student reflections about the course.

Medical Tourism in the United States INBOUND MEDICAL TOURISM

The United States has always been an important destination country for those medical tourists seeking complex medical treatment, due to its advanced facilities and highly educated physicians and medical staff (KPMG International, 2011). The recent economic slowdown and the decline in the value of the US dollar are again attracting foreign patients who seek access to the best technology available for their medical care, along with the services of highly developed, concierge-like international patient departments (Abratt & Firat, 2011; KPMG International, 2011). Because the United States is home to worldrenowned hospitals, physicians, and surgeons, patients with the means to do so will travel to the country seeking a specific “name brand” (e.g., University of Texas M.D. Anderson Cancer Center, Mayo Clinic, Mount Sinai Medical Center, and Johns Hopkins Hospital) (Abratt & Firat, 2011). Estimates of the number of US inbound medical tourists vary widely because of differences in data collection methods. For example, using data from the US Bureau of Economic Analysis and US International Trade Administration, as well as a survey of US healthcare providers, Johnson and Garman (2010) estimated that between 43,000 and 103,000 foreigners came to the United States for medical care in 2007, while Deloitte, using Centers for Disease Control data and in-house statistics and projections, put the number at 417,000 for the same time period (Keckley & Underwood, 2008). In a follow-up report, Deloitte estimated that the number of US inbound medical tourists will reach 561,000 by 2017 (Keckley & Underwood, 2009). Recent OECD data show that US im-


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ports of health-related travel (i.e., “goods and services acquired by travellers going abroad for medical reasons” (OECD, 2011, p.158)), grew an average of 13 percent a year from 2004 to 2009. The largest percentages of patients to the United States come from Mexico (21 percent), the Middle East (14 percent), South America (12 percent), Central America-excluding Mexico (11 percent) and Europe (11 percent) (Abratt & Firat, 2011). Regarding the type of treatment sought, oncology (32 percent), cardiology (14 percent) and neurology (12 percent) have the highest demand from foreign patients (Abratt & Firat, 2011). Medical tourists traveling to the United States for healthcare either are cash-paying patients or are covered by a global health insurance policy. While in the past many patients were cash paying, more and more foreign patients traveling to the United States for medical tourism will pay through health insurance policies (Medical Tourism Association, 2011). The growth of global health insurance policies is driven by expanding middle and upper classes in emerging countries, and an increasing awareness of the high quality, advanced medical treatment and care, and price transparency of US hospitals (Medical Tourism Association, 2011). OUTBOUND MEDICAL TOURISM

In the United States, it is estimated that more than 648,000 Americans traveled abroad for medical care in 2009 (Martin, 2010). That number is expected to increase to 1.6 million by 2012, with sustainable annual growth of 35 percent, barring any tempering factors such as supply constraints, resistance from health plans, increased domestic competition, or governmental policies (Keckley & Underwood, 2009). According to the OECD, US exports of health-related travel grew an average of 6.9 percent a year from 2004 to 2009, and overall, the United States is a net exporter of health-related travel (OECD, 2011). The primary reason that US patients travel abroad for healthcare is to pay lower prices for medically necessary or discretionary procedures (KPMG International, 2011; York, 2008). Because of their geographic proximity to the United States, Mexico, Costa Rica, Argentina, and Brazil are popular destination countries for lower cost dental and cosmetic treatments (Health-Tourism.com, 2011b; KPMG International, 2011). Given the potential size of the US market, Asian medical tourism countries are making a concerted effort to target US residents who are seeking more specialized and complex medical care (Johnston et al., 2010; Laurence, 2011). The forecasted increase in outbound medical tourism may become a notable revenue loss for the US healthcare system, given Deloitte’s estimate of a potential opportunity cost to US healthcare providers of $228.5 to $599.5 billion by 2017 (Keckley & Underwood, 2008).

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MEDICAL TOURISM IN AUSTRIA

Austria is one of the most renowned medical destinations in Europe (Bruggraber, 2009). It has internationally acclaimed hospitals and clinics, which feature top-of-the-range technology and first-rate facilities. Austria also is well-known for its holistic wellness and medical clinics, natural mineral spas and rehabilitation centers (Health-Tourism.com, 2011a). Austria enjoys a prominent position in European healthcare because of its high standards of care, rigorously trained and experienced physicians, exceptionally short waiting times for doctor consultations, very short waiting lists for surgeries, direct access to doctors and outstanding medical results (e.g., chance to survive a heart attack is as high as 92 percent, and more than 60 percent of cancer patients are still alive after five years), and reputation as a leader in cutting-edge medical research (Bruggraber, 2009; Health-Tourism. com, 2011a). One disadvantage of Austria’s healthcare system is that the cost of medical treatments and procedures is generally much higher than in Eastern European, Asian, or Latin American medical tourism destinations (HealthTourism.com, 2011a). Data on Austria’s medical tourism industry are extremely scarce. According to ABA-Invest in Austria (2010), 11 percent of tourists coming to Austria make health-related visits, making Austria one of Europe’s medical tourism market leaders. Overall, Austria is a net importer of health-related travel (OECD, 2011). Latest OECD data show that Austria’s imports of health-related travel grew an average of 13.2 percent a year from 2004 to 2009, while exports of health-related travel grew an average of 5.7 percent a year during the same five-year period (OECD, 2011). Common treatments received by medical tourists in Austria include oncology services, orthopedic surgery, fertility treatment, neurosurgery, cardiac surgery, gastroenterology care, general surgery and urology services (Health-Tourism.com, 2011a). Popular destinations for Austrians seeking lower cost medical care (e.g., cosmetic surgery and dental treatment) include the Czech Republic, Hungary, Poland, and Romania (Chiriac, 2011; hospitalscout.com, 2011; NOVASANS, 2011). Patient mobility in Austria and other European Union (EU) member states could receive a boost as a result of the Council of the European Union’s 2011 approval of the EU Cross-Border Health Care Directive (EHFCN, 2012; OECD, 2011). The Directive is aimed at facilitating access to safe and high-quality cross-border healthcare and promoting cooperation on healthcare between member states. As a general rule, patients will be allowed to receive healthcare in another member state and be reimbursed up to the level of cost that would have been assumed by the member state, if this healthcare had been provided in its territory (EHFCN, 2012). Member states have until October 2013 to implement the Directive.


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Future demand for cross-border healthcare in Austria and other EU member states is difficult to gauge because there is limited information on the current levels of EU cross-border healthcare (NHS Confederation, 2011). However, some speculate that the Directive will benefit patients seeking cheaper health services abroad, particularly those living near national borders who may find it easier and cheaper to get treatment in a neighboring country (EURORDIS, 2011). In the case of Austria, this could lead to an increase in outbound medical tourism to the Czech Republic, Hungary, and Poland. In the short term, it will take time for the Directive to be implemented, for the public to become aware of it, and for its rules to be understood (NHS Confederation, 2011). Additionally, there are uncertainties and challenges concerning how various national practices related to healthcare access, benefits, tariffs, quality, safety, patient rights, cooperation, etc. will be affected by the Directive (EHFCN, 2012; EURORDIS, 2011).

University of the Incarnate Word The University of the Incarnate Word (UIW) is a private Catholic university located in San Antonio, Texas. With a total student population of approximately 7,700, it is the largest Catholic university in the state of Texas, and the fourth largest private institution in Texas (University of the Incarnate Word, 2011a). Established in 1881 by the Sisters of Charity of the Incarnate Word, UIW aims to educate men and women who will become concerned and enlightened citizens (University of the Incarnate Word, 2011d). Much of the student population served by UIW has been drawn from South Texas and much of that has been minority (predominately Hispanic) and economically disadvantaged (Munsinger, 2003). Accordingly, UIW qualifies as a Hispanic Serving Institution, and is one of the top 100 universities serving Hispanics in the United States (University of the Incarnate Word, 2010). Currently, UIW serves a student community consisting of approximately 67 percent minorities (57 percent are Hispanic) with a growing international student population (University of the Incarnate Word, 2011c). In addition, 65 percent of UIW’s students are female (University of the Incarnate Word, 2011c). UIW offers 75 undergraduate and 25 graduate majors, including BBA, MBA, MAA, MHA, and MSA degrees in the H-E-B School of Business & Administration, and has four professional schools (nursing, pharmacy, optometry, and physical therapy) (University of the Incarnate Word, 2011c). UIW students are encouraged to learn about other cultures and broaden their global perspective (University of the Incarnate Word, 2011a). To facilitate this educational endeavor, UIW has 90 “sister schools” in 31 countries, including IMC University of Applied Sciences Krems in Krems, Austria

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(University of the Incarnate Word, 2011a). It also has international campuses in Guangzhou, China; Heidelberg, Germany; and Mexico City, Mexico (University of the Incarnate Word, 2011b). Related to this paper, UIW has a Center for Medical Tourism Research (CMTR) housed within the H-E-B School of Business & Administration. CMTR hosts an annual international medical tourism conference, and the first author serves as a CMTR Senior Fellow.

IMC University of Applied Sciences Krems IMC University of Applied Sciences Krems (IMC Krems), located in Krems, Austria, is one of Austria’s leading higher education institutions (IMC Krems, 2011c). Founded in 1994, it offers full- and part-time bachelor’s and master’s degree programs in Business Studies, Life Sciences, and Health Studies to more than 1,900 students from all over the world (IMC Krems, 2011a). IMC Krems’ key objective is to promote internationalization as a core concept in academia, research, and corporate culture (IMC Krems, 2011d). As a result, IMC Krems has a strong international network of university and industry partners, as well as a diverse mix of national and international students and lecturers (IMC Krems, 2011d). Because an international approach and practical focus are its leading priorities, IMC Krems students have the opportunity to study abroad at one of more than 85 international partner universities, including the University of the Incarnate Word in the United States, or to complete an internship with one of its 700 partner businesses worldwide (IMC Krems, 2011a). TOURISM AND LEISURE MANAGEMENT MASTER DEGREE PROGRAM

Taught exclusively in English, the Tourism and Leisure Management master’s degree program (M.A. in Business) is a two-year, 120 European Credit Transfer and Accumulation System (ECTS) full-time program that prepares students for careers in international tourism management (IMC Krems, 2011c). The program’s key competencies include: 1) Designing products, processes, and services to create value, 2) Managing organizations and projects, 3) Developing integrated marketing and communication strategies, 4) Developing effective sales designs, and 5) Fact-based decision making and a sound understanding of the tourism systems (IMC Krems, 2011e). Graduates of the program hold executive positions both in the domestic and international tourism and leisure sectors, and in international project development (IMC Krems, 2011e). Representative areas of employment include international and regional tourism project development, management of permanent and temporary leisure attractions, e-tourism planning, development and application, hotel industry and catering, travel agency and tour operation, tourism transport facilities


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(airlines, shipping lines, railways, bus companies), tourism attractions, tourism regional planning, development and marketing, sports organizations, sports marketing, casinos, theme parks, event agencies, convention centers, trade fair industry, spa operations, art and culture operations, and national parks (IMC Krems, 2011e).

Medical Tourism Courses in the United States and Europe Because we were unaware of any Medical Tourism courses being taught at the undergraduate or graduate level in the United States, Austria, or other European countries, a Google search was conducted using the following search terms: medical tourism course, medical tourism class, medical tourism program, MBA medical tourism, and master’s degree medical tourism. The search results revealed that there are no undergraduate or graduate Medical Tourism courses being taught in the United States or Europe at the present time (though, in the United States, the University of Richmond and the Medical Tourism Association are partnering to offer a new Certificate in Medical Tourism Studies beginning in Fall 2012 (University of Richmond, 2011). In addition, a Medical Tourism Magazine article discussed the development of a European joint-educational MBA program in Health and Medical Tourism/ Cross-Border Healthcare Management at Deggendorf University of Applied Sciences in Germany (Gerl et al., 2009). However, we were unable to determine if this program is up and running. Outside of a university setting, US-based Medical Tourism Training, Inc., offers five medical tourism-related online courses that can be taken individually or in any combination via the company’s website (PRWeb, 2011). As a result of our search for other undergraduate and graduate Medical Tourism courses in the United States and Europe, we assume that the Fall 2011 master’s-level Medical Tourism course taught by a US Marketing professor at IMC Krems was the first of its kind in Europe.

Offering a Medical Tourism Class via an International Partnership During the first year of the Tourism and Leisure Management Master degree program at IMC Krems, students must select two of four Specialized Tourism Business Concepts courses, and take one each semester (IMC Krems, 2011b). One of the Specialized Tourism Business Concepts courses is Health and Wellbeing Tourism, which is an ideal course to incorporate the topic of medical tourism, as medical tourism is considered a subcategory of health tourism (Smith, n. d.). Thus, the Medical Tourism module taught by the first author was built into this course during the Fall 2011 semester.

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The existing sister school relationship between UIW and IMC Krems led to the first author being invited to IMC Krems to teach a Medical Tourism module within the Health and Wellbeing Tourism course in the Tourism and Leisure Management Master degree program. More specifically, this opportunity resulted from the first author’s April 2011 participation in IMC Krems’ new seminar series, “IMC Master Days.” During this seminar, 12 visiting professors from different parts of the world–Argentina, Brazil, Canada, Finland, France, Germany, Ireland, Mexico, Switzerland and the United States–presented selected topics to IMC Krems Master students in an interactive lecture or case-study workshop format (What’s Up, 2011/2012). The classes were based on such topics as Diversity Management, Information and Communications Technology, International Marketing, Leadership, and Strategic Management (What’s Up, 2011/2012). During this three-day event, the second author met the first author and learned about his interest in medical tourism, and medical tourism research agenda, previous overseas teaching experience (China Incarnate Word and Izmir University of Economics), and participation in faculty-led study abroad courses to China, England, Germany, Mexico, and South Korea. This initial meeting set the stage for the first author to teach a Medical Tourism class at IMC Krems during the fall 2011 semester.

Medical Tourism Module COURSE STRUCTURE

The Health and Wellbeing Tourism course consisted of two modules: Part 1 Spa & Wellness Tourism, and Part 2 - Medical Tourism. The Spa & Wellness Tourism module was taught by the third author in a two-day, eight-hour time frame, while the Medical Tourism module was taught in a three-day time period and included 20 hours of instruction. Nine first-semester students, from a first-year cohort class of 31 students, were enrolled in the Medical Tourism class. The students had the following demographic characteristics and educational backgrounds: three males and six females; seven Austrians, one Romanian, and one Russian; and three students had a bachelor’s degree in Health Management in Tourism, while the others had studied Business Administration, Economics, International Business Administration, Marketing, or Tourism Management in their undergraduate program. The Medical Tourism module was developed with guidance from the third author. It consisted of five lecture topics: 1) Introduction to the Medical Tourism Industry, 2) Medical Tourism Destinations, 3) Medical Tourism Consumers, 4) Medical Tourism Legal, Ethical and Social Concerns, and 5) Marketing in the Medical Tourism Industry. Learning outcomes for the course were: 1) Be aware of definitional issues related to medical tourism, the history of medical


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tourism, types of medical tourism, and factors driving the growth of medical tourism; 2) Understand types of medical tourists, motives for engaging in medical tourism, risk concerns, decision-making processes, and evaluation of service quality; 3) Understand the nature and role of marketing in the medical tourism industry; 4) Be able to apply fundamental marketing concepts and tools in a medical tourism problem-solving and decision-making context; 5) Become familiar with legal, ethical, and social concerns related to medical tourism; and 6) Enhance skills in critical thinking, analysis, and written/oral communication. In lieu of a textbook, the first author compiled a set of academic journal articles and consulting firm publications related to the lecture topics and learning outcomes for class reading and discussion. The following teaching and learning methods were used in the course: interactive lecture, in-class exercises, class discussions, individual current issues paper and presentation, group case analysis report and presentation, and individual reflection paper. All PowerPoint lecture slides, course readings, and coursework were posted on IMC Krems’ eDesktop system before the class began. COURSEWORK

The PowerPoint lecture slides and course readings served as the foundation for bringing the five major course topics and associated subtopics (e.g., drivers of medical tourism, leading medical tourism destination countries, medical tourists’ evaluation of service quality, public policy and ethical concerns, and the role of medical tourism facilitators) into the classroom. Certain topics (e.g., what type of healthcare constitutes medical tourism, risks associated with traveling for medical care, and public policy and ethical issues) lent themselves to having more in-depth class discussions. Four of the articles in the course reading list (Crooks et al., 2010; Glinos, Baeten, Helble, & Maarse, 2010; Helble, 2011; Johnston et al., 2010) were assigned to serve as a backdrop for an in-class discussion of medical tourism legal, ethical, and social issues, which included an overview of some of the key benefits, uncertainties, and challenges related to implementing the EU’s Directive on Cross-border Healthcare. In light of patients’ proclivity to use the Internet to search for information about medical tourism destinations and overseas providers (Lunt et al., 2010), one of the in-class exercises used in the course was a role play in which each student took on the role of a potential medical tourist, selected a medical procedure to pursue, and engaged in an online search to determine which country and hospital/clinic to go to for the treatment based on a set of country and provider selection criteria determined by the student during the search process (e.g., desired medical care, distance to destination country, attractiveness of geographic location, medical tourism facilitator recommendations,

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price, perceived quality of care, accreditation, international patient services, ancillary services, and online testimonials). The follow-up discussion about the exercise focused on the ease and difficulty of the search process given the plethora of medical tourism-related information available online, and medical tourism services being high in experience and credence qualities (Zeithaml, Bitner, & Gremler, 2009). For the individual current issues paper and presentation assignment, each student found a recent business article about a medical tourism topic of interest to the student, wrote a summary and analysis of the article, and presented the article to the class. The articles covered such topics as the benefits and risks of being a medical tourist, guidelines for medical travel, quality of care and accreditation issues, foreign language skills of medical tourism providers, EU and US cross-border healthcare insurance issues., inbound medical tourism in the United States, outbound medical tourism in the United States and its effects on the US medical community and health system, positive and negative effects of medical tourism on Thailand, the potential impact of medical tourism on India’s health workforce and health systems, and various reasons medical tourists from different parts of the world travel to India for medical care. The class was divided into three three-person teams for the purpose of completing the group case analysis report and presentation. The case assigned for this project was “Promoting Healthcare Tourism in India,” by Tang and Yim (2007a), which was made available to the class through Harvard Business Publishing. This case allows students to evaluate the industry dynamics and competitive situation in order to develop a positioning and targeting strategy for India to become a leading medical tourism destination (Tang & Yim, 2007b). A key principle of student learning involves reflection on one’s own learning. Studies have shown that students benefit from regular examination of their learning process, which results in an ability to take control of their learning (Kraft & McDougall, 2005). Thus, an individual reflection paper assignment was developed for the course. The end-of-course assignment was structured based on Fink’s (2003) taxonomy of significant learning. The students reflected on and wrote about six areas of significant learning: Foundational Knowledge, Application, Integration, Human Dimension, Caring, and Learning How to Learn. A primary expected outcome from the reflection paper assignment was that students would engage in active thinking about what had occurred during the class (Daly, n.d.). In other words, through writing a refection paper, students would monitor their own understanding of course material. From a teaching perspective, the reflection paper assignment provided the added benefit of identifying important cognitive aspects of medical tourism teaching and learning that resonate with students. In the next section of the paper,


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student reflections pertaining to the areas of Foundational Knowledge and Application Learning are highlighted.

Student Reflections FOUNDATIONAL KNOWLEDGE

The Foundational Knowledge areas students most commonly discussed in their papers included learning about the major medical tourism destination countries, the risks involved in engaging in medical tourism, the amount of Internet-based information potential medical tourists have at their disposal when searching for a destination country and medical tourism provider, and the difficulty in judging the credibility of this information. The last two issues emerged as a result of the role-playing exercise described earlier, which was frequently mentioned in the papers as illustrated in the following comments: “Furthermore, the little experiment we did in the afternoon was very interesting and displayed that it is difficult to choose a suitable country and provider for medical treatments abroad.” “It was exciting to be in the situation of a medical tourist and trying to find out where you could have your surgery done. Actually, this was very complicated, because there is so much information available on the Internet and it is hard to judge which information is reliable. As this decision is about one’s health, it is not easy making it.” “Throughout the exercise, I have learned that it is really hard to gather reliable information on medical tourism destinations on the Internet. The Internet provides numerous websites about medical tourism destinations, but nonetheless it was hard to sort out this information and find a trustworthy provider. This exercise showed me that forums, blogs, social media networks, and testimonials are essential when looking for a provider, as a medical tourism provider itself only presents positive reviews of patients, which is often misleading.” The students who had a bachelor’s degree in Health Management in Tourism appreciated the practical approach to the course and how it augmented their previous health tourism knowledge, as shown in the set of remarks below: “Furthermore, the medical tourism course gave me a great insight in the topic, and the practical approach was great.”

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“In general, I enjoyed it a lot to attend a course in which I had knowledge and some rather clear ideas beforehand. This made it much easier to discuss different topics. I really appreciated the connection of health and medical tourism to business management. I think that I could profit a lot during this course, as our classes in the bachelor’s program were more content based and this class now linked the content to a business aspect.

Application Learning With regards to Application Learning, the areas most frequently discussed were improving analytical, time management, teamwork, and presentation skills. Analytical skills were honed primarily through the current issues assignment and case analysis project, as evidenced by the comments below: “Concerning the skills and abilities that I learned during this course, I think that one of the most important is working with an article or a special case. Analyzing an article and then talking about what I have learned from this article was quite new to me, but at the same time very interesting. Reading the case about medical tourism in India was even more interesting, and the analysis of it, as well as finding improvements for the situation shown in the case, was challenging.” “Applying analytical skills was required when we were dealing with the articles and a case study. Identifying important information and making deductions and generalizations was particularly important.” “Concerning the group assignment, my skills in critically discussing on marketing strategies were further improved, and also I recognized that often there is not a single correct solution and one must be open to new and creative ideas.” Comments about enhancing time management skills revolved around the amount of work to be done in a short time frame, and the need to be efficient: “I also improved my skills in working under pressure, as there was a lot to do within short time.” “I definitely further developed my time management skills, as there really was a lot of workload to deal with in a very short amount of time. Furthermore, I found out that I am capable over a certain period to push myself to the limit to fulfill deadlines and work efficiently.”


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“First of all, the short time for working on the assignments forced me to do my work in a fast way but with high quality. That was a challenge for me, but in the end it worked in a good way.” Related to the time management learning that took place were students’ remarks about improving their teamwork skills: “The course helped me to foster relationships with my colleagues. Throughout the last three days, we have been working on a case study in groups together, which I really enjoyed. Throughout the assignment, I was able to improve my social competencies by interacting with my team colleagues, by discussing the task of each person, by dividing the task, and by handing over responsibility to other team members. I am a person who is eager to complete assignments with a good outcome and therefore I often do not rely on other team members and often complete their tasks as well. As time was limited and there was a lot to do in the last three days, I had to rely on my group. The group work forced me to hand over tasks to other members and it helped me to build up trust in others. The course eventually helped me to enhance my team-building skills, which I will value for further group work.” “Managing our group task, we were highly involved in team-building, delegating responsibilities, and consolidating the results.” “Naturally, we had many group works to do in our studies before, but normally we had much time to discuss the approach and layout. After this step, we usually worked more or less alone on our part. In this course, we used a completely different approach, as we quickly discussed the main points of every chapter and then each of us wrote the summary of the discussion into his part. It has been a good method to working efficiently without losing coherence.” Having to make a presentation in English was the main reason students felt their presentation skills improved as a result of taking the class: “The two presentations helped me to increase my self-confidence and to lose my shyness concerning presentations in English.” “It was important for me to do my first presentation in the English language, and I have learned that I need to be better prepared than usual when I want to present a topic in a foreign language.”

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“The course enhanced my presentation skills, as we had to present the outcomes of two works in front of class. The course ultimately helped me to become more confident in presenting topics in front of an audience. I also found it good that [the professor] questioned us concerning our findings, and we had to defend and justify our outcomes.” SYNOPSIS

In sum, students’ remarks about the Medical Tourism course were very positive, and their reflections indicate that a significant amount of learning took place in a relatively short time frame (20 hours over three days). The most common types of learning discussed by the students seem to fall under the Level 2 category of learning identified by Burgoyne and Hodgson (1983), i.e., development of learning that is transferable from one situation to another, or the learning of application and processes (Daly, n.d.). Particularly revealing elements from the reflection papers include how students tackled challenges (e.g., time management, teamwork, dissecting and analyzing large amounts of information, and making presentations in English) in their medical tourism coursework, and how they might apply these abilities, skills, and tools in other situations.

Conclusion This paper discussed the conception, design, and teaching of the first known master’s-level Medical Tourism course in Western Europe, which emanated from a sister school partnership between an Austrian university (IMC Krems) and a US university (UIW). Student comments from the course’s refection paper assignment suggest that significant learning, in the form of Foundational Knowledge and Application Learning, took place during the three-day course. Creating and actualizing the course through an international university partnership also addressed Özturgut’s (2008) call for more higher education faculty to have teaching abroad experiences. Based on the positive response to this initial offering of the Medical Tourism module, future possibilities include offering the course a second time at IMC Krems, when the next cohort group of Tourism and Leisure Management Master degree students begins their studies; offering an MBA Medical Tourism course at UIW; and offering specialized master’s/MBA Medical Tourism courses (e.g., Medical Tourism Consumer Behavior, Medical Tourism Marketing; Medical Tourism Legal, Ethical and Social Issues; Medical Tourism Strategy). Other pedagogical tools that would fit well in this type of course to foster application and integration of knowledge include: 1) in-class debates about ethical issues (e.g., reproductive, abortion, and organ transplant tourism) and


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public policy concerns (e.g., creation of a dual market healthcare structure in emerging economies, i.e., developing a higher-quality, expensive segment that caters to wealthy nationals and foreigners, and a much lower quality, resourceconstrained segment that caters to low-income and poor local populations (Bookman & Bookman, 2007; Chanda, 2002)); 2) analysis of medical tourist blogs to understand medical tourists’ decision-making processes and perceived benefits and risks; 3) comparative content analysis of medical tourism hospital and facilitator websites to study brand positioning strategies; 4) constructing a country attractiveness matrix for the medical tourism industry to analyze countries’ strengths and weaknesses; and 5) designing an integrated marketing communications campaign for a medical tourism hospital.

About the Non-Corresponding Authors Wolfgang Vrzal, MBA is Head of Department of Business and Programme Director, Tourism and Leisure Management at the IMC University of Applied Sciences Krems, Austria (Email: [email protected]) Teresa Mang, MBA is Chairperson of Health & Spa Tourism, Tourism and Leisure Management at the IMC University of Applied Sciences Krems, Austria (Email: [email protected])

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