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It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.
—Attributed to Sir William Osler1
Recent years have seen an increase in people traveling away from their home region for healthcare, often for care that is less expensive or unavailable where they live.2–4 Many Americans seek care abroad (engaging in “medical tourism”); conversely, the United States annually receives thousands of foreign travelers for medical evaluations, a trend projected to increase.2,3,5 Additionally, US healthcare providers often see foreign travelers for unexpected ailments that develop during their time here.
Traveling for healthcare can be stressful for patients, and caring for international patients may pose challenges for providers and medical centers. On the other hand, such encounters also provide many mutual benefits. Unfortunately, there is little published guidance addressing these issues.2 In this article, we therefore discuss many of the benefits and challenges, with the hope of improving the quality of care delivered and the clinical experience for both providers and patients.
CHALLENGES FOR INTERNATIONAL PATIENTS AND THEIR PROVIDERS
Some scenarios that illustrate challenges faced by international patients and their healthcare providers are presented in Table 1.
For patients, heightened anxiety
Many international patients feel anxious, isolated, and vulnerable, particularly if they have never been away from home before. These feelings arise from multiple factors, including the stress of traveling, lack of family or social support, an unfamiliar environment, contrasting cultural practices, and high expectations.3,4 Language barriers, especially for patients who speak uncommon dialects, and lack of continuously available interpretive services often augment the unsettled emotions of international patients.
Cultural differences
International patients may quickly notice significant differences from their home country in how healthcare is practiced and culturally applied.4,6 Such differences may include dress codes and the comparatively equal role of women vis-à-vis men in the Western medical profession.
For cultural, personal, or religious reasons, some patients feel uncomfortable with healthcare providers of the opposite sex. This discomfort can be heightened if the patient needs a potentially uncomfortable and humiliating procedure such as a gynecologic or rectal examination.
The multidisciplinary team approach to healthcare, which can include trainees, nurses, and pharmacists, may leave patients confused about who their primary health provider is.
Decision-making also has cultural implications. In Western medicine, we respect individual autonomy and expect patients to participate in decisions about their care. However, in many areas of the world, medical decision-making is deferred to extended family members or cultural leaders.2 Additional and often repeated conversations may be needed with both the patient and family members to ensure appropriate understanding and ethical consent for care.
Some international patients may have expectations that are quite different from those of the healthcare provider and that are sometimes unrealistic.2,6
Institutional challenges
Many medical conditions require prolonged treatment and longitudinal care, a notable challenge when that care is delivered outside of one’s home country. Practice models within a clinic may not allow for prolonged subsequent visits, which may be needed to accommodate language-translation services. Complex multidisciplinary plans of care must somehow effectively utilize available appointment slots and be time-efficient.
Criteria for hospitalization differ widely among different countries, often based on resources, and may necessitate additional dialogue between the patient and healthcare provider.
Obtaining, interpreting the patient’s record
Medical records from foreign institutions are often unavailable, incomplete, or illegible. Further, depending on the country, it may be difficult to contact local providers for supplemental information. Differences in time zones, limited access to technology, language barriers, and handwritten notes all pose problems when trying to obtain additional information.
Many under-resourced foreign medical centers cannot duplicate medical records and radiographic films for the patient to bring to the United States. Medical records from foreign laboratories often raise questions about the quality, accuracy, and methodology of the testing platform used.2 Thus, the provider may need to start over and repeat the entire clinical, radiologic, and laboratory evaluation.
Communicating with the patient
Difficulties in communication between patients and providers can hinder the development of a positive and productive relationship, reducing patient autonomy and complicating informed consent.2 Obtaining a medical history from non–English-speaking patients can be arduous and time-consuming. Colloquial language may further alter interpretation and understanding, even for formally trained interpreters. Language differences may make it more difficult to explain differential diagnoses, diagnostic approaches, and management plans.
Many US medical centers provide interpreters for many languages, but the great number of languages spoken around the world ensures that barriers in communication persist. Telephone language lines and other commercial language services are available but may feel less personal to patients or evoke concerns about medical confidentiality. For less commonly spoken languages and dialects, appropriate translation services may not even be available.6
Filling in information gaps
Medical conditions, medications, and treatments may have different names in different countries. The quality of pharmaceuticals in some regions may be questionable, and herbal supplements may be unique to a particular location. Many medications available abroad are not available in the United States, potentially confusing US providers as to medication appropriateness, efficacy, and potential toxicities.
Lacking adequate medical records and trying to obtain a new medical history from patients and their family members, providers may struggle with continued gaps of information, hindering a timely diagnosis and composition of an appropriate management plan.
A culturally sensitive but complete physical examination
Every effort should be made to complete a thorough and comprehensive physical examination, even if the patient’s culture differs on this point. This may require a “chaperone” to be present or, if available, a clinician of the same sex as the patient to perform the examination. A compromised examination will impede making the correct diagnosis.
Religious, cultural, and other patient-specific attitudes and beliefs that may affect a medical evaluation should ideally be addressed before scheduling the appointment. A preexamination discussion with the patient and family can help avert unintentional actions and behavior misperceived as offensive, while strengthening the level of trust between patient and provider.2
Money matters
Foreign patients typically have limited or no medical insurance coverage and thus may be paying out of pocket or through limited governmental subsidies. Many refugees and asylum-seekers have no insurance or money to pay for care. (A full discussion of refugee care is beyond the scope of this article). Thus, it is necessary to ascertain in advance who will pay for the care.
Clinicians must be sensitive to the exorbitant costs of medical care and medications in the United States, particularly from the perspective of foreign patients. We strive to provide the best cost-effective care, but what is considered cost-effective and standard care for a patient with US health insurance may be viewed differently by international patients. For some foreign patients, some tests and treatments may be just too expensive, raising personal and institutional ethical concerns regarding how best to evaluate and manage these patients. Ideally, these issues should also be addressed before the patient’s appointment is scheduled.
Clinicians must optimize diagnostic and medical management while minimizing unnecessary testing. This principle further underscores the importance of obtaining a complete medical history and physical examination within a time-sensitive and well-coordinated plan of care.2,4
Continuity of care after the patient leaves
As the medical evaluation and care plan approach completion, ensuring some form of continued medical care can become challenging. Some foreign patients may have the financial or legal means (eg, through an extended medical visa) to remain for further care and follow-up, but most do not.
Finding an available, willing health provider in the patient’s native country for continued management may be difficult and time-consuming. Most US medical centers have no established system to identify available foreign health providers, and usually the patient and family are responsible for arranging continued healthcare back in their home country.
Opportunities for possible improvement of care are noted in Table 2.
ADVANTAGES OF CARING FOR INTERNATIONAL PATIENTS
Despite the possible challenges, there are many benefits of caring for international patients.
Gaining medical knowledge
In US medical centers caring for both regional and referred patients, providers are often exposed to medical conditions that range from common ailments to the rare conditions (or “zebras”) taught during residency training. From the medical education standpoint, international patients provide US health providers heightened opportunities to encounter diseases not commonly seen in the United States (eg, infections such as malaria, schistosomiasis, drug-resistant tuberculosis, and advanced or end-stage forms of noncommunicable diseases). Although not limited to international patients, chronically neglected diseases often give providers first-hand experience in the natural history of select disease progression.
Gaining cultural knowledge
Caring for international patients also enables health providers to learn about different cultures, societal norms, and regional beliefs affecting healthcare. In essence, international patients enable US providers to become more diversified and enlightened with communication skills and assorted managerial strategies on a global scale.
These patients remind us of the stark differences regarding access and quality of medical care globally, particularly in lesser-resourced locations. In a busy domestic medical practice with its own daily challenges, many of us forget these international healthcare disparities, and often take for granted the comparative abundance of healthcare resources available in the United States. Provider frustrations about domestic policies and concerns for a “broken” healthcare system often blind us to the available resources we are fortunate to have at our disposal.
Further, as members of the global community, we have the opportunity to learn from international patients while broadening our view of humanity, thereby enhancing our awareness and empathy toward patients and communities struggling with under-resourced healthcare systems. Healthcare providers are often touched by the gratitude of patients for the opportunity to receive treatments that may otherwise be unavailable. Such experiences may motivate many US health providers to become more engaged in coordinated strategies for global health improvement.
Reimbursement is possible
Caring for international patients should not financially deter US health care centers. Complex, multidisciplinary care evaluations may incur notable expenses; however, alternative and more lucrative payer systems, including government subsidies, can be involved to maintain revenue, reimbursements, and even possibly lead to increased donations.3–5 Given the potential for high costs to be incurred, US providers and institutions need to continually ensure appropriate evidence-based use of resources and cost-effective care without compromising the quality of care provided. The price of certain drugs has been rising astonishingly in the United States, and some patients may therefore prefer to obtain them for long-term use upon return to their home country.
High-quality cost-effective care is satisfying to the patient, provider, and institution, and also may save money that can be reallocated.4 Providers also may find personal fulfillment in striving for and achieving such goals, despite the potential challenges throughout the course of care.
Opportunities for improvement
Regardless of the challenges presented by international patients, participating medical centers often enjoy the prestige and credibility of becoming an “international healthcare center.”4,7 From the standpoint of medical education, these centers have the potential to train providers with increased clinical and cultural competencies along with expanding healthcare services to include clinical, educational and research opportunities abroad.
Research is needed to provide evidence-based guidance on best strategies for patients, clinicians, and healthcare systems to effectively care for international patients.
Suggested opportunities for maximizing advantages are noted in Table 3.
- William Osler. BrainyQuote.com, Xplore Inc, 2016. www.brainyquote.com/quotes/quotes/w/williamosl391388.html. Accessed September 21, 2016.
- Martin DR. Challenges and opportunities in the care of international patients: clinical and health services issues for academic medical centers. Acad Med 2006; 81:189–192.
- Bower LC, Johnson TJ, Hohmann SF, Garman AN, Allen M, Meurer SJ. An evaluation of international patient length of stay. Int J Healthc Manag 2014; 7:200–205.
- Satjapot SP, Johnson TJ, Garman AN. International medical travelers, length of stay, and the continuum of care: inquiry and comparison. Qual Manag Health Care 2011; 20:76–83.
- Donohoe M. Luxury primary care, academic medical centers, and the erosion of science and professional ethics. J Gen Intern Med 2004; 19:90–94.
- Dogan H, Tschudin V, Hot I, Özkan I. Patients’ transcultural needs and carers’ ethical responses. Nurs Ethics 2009; 16:683–696.
- Bauer AM, Alegria M. Impact of patient language proficiency and interpreter service use on the quality of psychiatric care: a systematic review. Psychiatr Serv 2010; 61:765–773.
It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.
—Attributed to Sir William Osler1
Recent years have seen an increase in people traveling away from their home region for healthcare, often for care that is less expensive or unavailable where they live.2–4 Many Americans seek care abroad (engaging in “medical tourism”); conversely, the United States annually receives thousands of foreign travelers for medical evaluations, a trend projected to increase.2,3,5 Additionally, US healthcare providers often see foreign travelers for unexpected ailments that develop during their time here.
Traveling for healthcare can be stressful for patients, and caring for international patients may pose challenges for providers and medical centers. On the other hand, such encounters also provide many mutual benefits. Unfortunately, there is little published guidance addressing these issues.2 In this article, we therefore discuss many of the benefits and challenges, with the hope of improving the quality of care delivered and the clinical experience for both providers and patients.
CHALLENGES FOR INTERNATIONAL PATIENTS AND THEIR PROVIDERS
Some scenarios that illustrate challenges faced by international patients and their healthcare providers are presented in Table 1.
For patients, heightened anxiety
Many international patients feel anxious, isolated, and vulnerable, particularly if they have never been away from home before. These feelings arise from multiple factors, including the stress of traveling, lack of family or social support, an unfamiliar environment, contrasting cultural practices, and high expectations.3,4 Language barriers, especially for patients who speak uncommon dialects, and lack of continuously available interpretive services often augment the unsettled emotions of international patients.
Cultural differences
International patients may quickly notice significant differences from their home country in how healthcare is practiced and culturally applied.4,6 Such differences may include dress codes and the comparatively equal role of women vis-à-vis men in the Western medical profession.
For cultural, personal, or religious reasons, some patients feel uncomfortable with healthcare providers of the opposite sex. This discomfort can be heightened if the patient needs a potentially uncomfortable and humiliating procedure such as a gynecologic or rectal examination.
The multidisciplinary team approach to healthcare, which can include trainees, nurses, and pharmacists, may leave patients confused about who their primary health provider is.
Decision-making also has cultural implications. In Western medicine, we respect individual autonomy and expect patients to participate in decisions about their care. However, in many areas of the world, medical decision-making is deferred to extended family members or cultural leaders.2 Additional and often repeated conversations may be needed with both the patient and family members to ensure appropriate understanding and ethical consent for care.
Some international patients may have expectations that are quite different from those of the healthcare provider and that are sometimes unrealistic.2,6
Institutional challenges
Many medical conditions require prolonged treatment and longitudinal care, a notable challenge when that care is delivered outside of one’s home country. Practice models within a clinic may not allow for prolonged subsequent visits, which may be needed to accommodate language-translation services. Complex multidisciplinary plans of care must somehow effectively utilize available appointment slots and be time-efficient.
Criteria for hospitalization differ widely among different countries, often based on resources, and may necessitate additional dialogue between the patient and healthcare provider.
Obtaining, interpreting the patient’s record
Medical records from foreign institutions are often unavailable, incomplete, or illegible. Further, depending on the country, it may be difficult to contact local providers for supplemental information. Differences in time zones, limited access to technology, language barriers, and handwritten notes all pose problems when trying to obtain additional information.
Many under-resourced foreign medical centers cannot duplicate medical records and radiographic films for the patient to bring to the United States. Medical records from foreign laboratories often raise questions about the quality, accuracy, and methodology of the testing platform used.2 Thus, the provider may need to start over and repeat the entire clinical, radiologic, and laboratory evaluation.
Communicating with the patient
Difficulties in communication between patients and providers can hinder the development of a positive and productive relationship, reducing patient autonomy and complicating informed consent.2 Obtaining a medical history from non–English-speaking patients can be arduous and time-consuming. Colloquial language may further alter interpretation and understanding, even for formally trained interpreters. Language differences may make it more difficult to explain differential diagnoses, diagnostic approaches, and management plans.
Many US medical centers provide interpreters for many languages, but the great number of languages spoken around the world ensures that barriers in communication persist. Telephone language lines and other commercial language services are available but may feel less personal to patients or evoke concerns about medical confidentiality. For less commonly spoken languages and dialects, appropriate translation services may not even be available.6
Filling in information gaps
Medical conditions, medications, and treatments may have different names in different countries. The quality of pharmaceuticals in some regions may be questionable, and herbal supplements may be unique to a particular location. Many medications available abroad are not available in the United States, potentially confusing US providers as to medication appropriateness, efficacy, and potential toxicities.
Lacking adequate medical records and trying to obtain a new medical history from patients and their family members, providers may struggle with continued gaps of information, hindering a timely diagnosis and composition of an appropriate management plan.
A culturally sensitive but complete physical examination
Every effort should be made to complete a thorough and comprehensive physical examination, even if the patient’s culture differs on this point. This may require a “chaperone” to be present or, if available, a clinician of the same sex as the patient to perform the examination. A compromised examination will impede making the correct diagnosis.
Religious, cultural, and other patient-specific attitudes and beliefs that may affect a medical evaluation should ideally be addressed before scheduling the appointment. A preexamination discussion with the patient and family can help avert unintentional actions and behavior misperceived as offensive, while strengthening the level of trust between patient and provider.2
Money matters
Foreign patients typically have limited or no medical insurance coverage and thus may be paying out of pocket or through limited governmental subsidies. Many refugees and asylum-seekers have no insurance or money to pay for care. (A full discussion of refugee care is beyond the scope of this article). Thus, it is necessary to ascertain in advance who will pay for the care.
Clinicians must be sensitive to the exorbitant costs of medical care and medications in the United States, particularly from the perspective of foreign patients. We strive to provide the best cost-effective care, but what is considered cost-effective and standard care for a patient with US health insurance may be viewed differently by international patients. For some foreign patients, some tests and treatments may be just too expensive, raising personal and institutional ethical concerns regarding how best to evaluate and manage these patients. Ideally, these issues should also be addressed before the patient’s appointment is scheduled.
Clinicians must optimize diagnostic and medical management while minimizing unnecessary testing. This principle further underscores the importance of obtaining a complete medical history and physical examination within a time-sensitive and well-coordinated plan of care.2,4
Continuity of care after the patient leaves
As the medical evaluation and care plan approach completion, ensuring some form of continued medical care can become challenging. Some foreign patients may have the financial or legal means (eg, through an extended medical visa) to remain for further care and follow-up, but most do not.
Finding an available, willing health provider in the patient’s native country for continued management may be difficult and time-consuming. Most US medical centers have no established system to identify available foreign health providers, and usually the patient and family are responsible for arranging continued healthcare back in their home country.
Opportunities for possible improvement of care are noted in Table 2.
ADVANTAGES OF CARING FOR INTERNATIONAL PATIENTS
Despite the possible challenges, there are many benefits of caring for international patients.
Gaining medical knowledge
In US medical centers caring for both regional and referred patients, providers are often exposed to medical conditions that range from common ailments to the rare conditions (or “zebras”) taught during residency training. From the medical education standpoint, international patients provide US health providers heightened opportunities to encounter diseases not commonly seen in the United States (eg, infections such as malaria, schistosomiasis, drug-resistant tuberculosis, and advanced or end-stage forms of noncommunicable diseases). Although not limited to international patients, chronically neglected diseases often give providers first-hand experience in the natural history of select disease progression.
Gaining cultural knowledge
Caring for international patients also enables health providers to learn about different cultures, societal norms, and regional beliefs affecting healthcare. In essence, international patients enable US providers to become more diversified and enlightened with communication skills and assorted managerial strategies on a global scale.
These patients remind us of the stark differences regarding access and quality of medical care globally, particularly in lesser-resourced locations. In a busy domestic medical practice with its own daily challenges, many of us forget these international healthcare disparities, and often take for granted the comparative abundance of healthcare resources available in the United States. Provider frustrations about domestic policies and concerns for a “broken” healthcare system often blind us to the available resources we are fortunate to have at our disposal.
Further, as members of the global community, we have the opportunity to learn from international patients while broadening our view of humanity, thereby enhancing our awareness and empathy toward patients and communities struggling with under-resourced healthcare systems. Healthcare providers are often touched by the gratitude of patients for the opportunity to receive treatments that may otherwise be unavailable. Such experiences may motivate many US health providers to become more engaged in coordinated strategies for global health improvement.
Reimbursement is possible
Caring for international patients should not financially deter US health care centers. Complex, multidisciplinary care evaluations may incur notable expenses; however, alternative and more lucrative payer systems, including government subsidies, can be involved to maintain revenue, reimbursements, and even possibly lead to increased donations.3–5 Given the potential for high costs to be incurred, US providers and institutions need to continually ensure appropriate evidence-based use of resources and cost-effective care without compromising the quality of care provided. The price of certain drugs has been rising astonishingly in the United States, and some patients may therefore prefer to obtain them for long-term use upon return to their home country.
High-quality cost-effective care is satisfying to the patient, provider, and institution, and also may save money that can be reallocated.4 Providers also may find personal fulfillment in striving for and achieving such goals, despite the potential challenges throughout the course of care.
Opportunities for improvement
Regardless of the challenges presented by international patients, participating medical centers often enjoy the prestige and credibility of becoming an “international healthcare center.”4,7 From the standpoint of medical education, these centers have the potential to train providers with increased clinical and cultural competencies along with expanding healthcare services to include clinical, educational and research opportunities abroad.
Research is needed to provide evidence-based guidance on best strategies for patients, clinicians, and healthcare systems to effectively care for international patients.
Suggested opportunities for maximizing advantages are noted in Table 3.
It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.
—Attributed to Sir William Osler1
Recent years have seen an increase in people traveling away from their home region for healthcare, often for care that is less expensive or unavailable where they live.2–4 Many Americans seek care abroad (engaging in “medical tourism”); conversely, the United States annually receives thousands of foreign travelers for medical evaluations, a trend projected to increase.2,3,5 Additionally, US healthcare providers often see foreign travelers for unexpected ailments that develop during their time here.
Traveling for healthcare can be stressful for patients, and caring for international patients may pose challenges for providers and medical centers. On the other hand, such encounters also provide many mutual benefits. Unfortunately, there is little published guidance addressing these issues.2 In this article, we therefore discuss many of the benefits and challenges, with the hope of improving the quality of care delivered and the clinical experience for both providers and patients.
CHALLENGES FOR INTERNATIONAL PATIENTS AND THEIR PROVIDERS
Some scenarios that illustrate challenges faced by international patients and their healthcare providers are presented in Table 1.
For patients, heightened anxiety
Many international patients feel anxious, isolated, and vulnerable, particularly if they have never been away from home before. These feelings arise from multiple factors, including the stress of traveling, lack of family or social support, an unfamiliar environment, contrasting cultural practices, and high expectations.3,4 Language barriers, especially for patients who speak uncommon dialects, and lack of continuously available interpretive services often augment the unsettled emotions of international patients.
Cultural differences
International patients may quickly notice significant differences from their home country in how healthcare is practiced and culturally applied.4,6 Such differences may include dress codes and the comparatively equal role of women vis-à-vis men in the Western medical profession.
For cultural, personal, or religious reasons, some patients feel uncomfortable with healthcare providers of the opposite sex. This discomfort can be heightened if the patient needs a potentially uncomfortable and humiliating procedure such as a gynecologic or rectal examination.
The multidisciplinary team approach to healthcare, which can include trainees, nurses, and pharmacists, may leave patients confused about who their primary health provider is.
Decision-making also has cultural implications. In Western medicine, we respect individual autonomy and expect patients to participate in decisions about their care. However, in many areas of the world, medical decision-making is deferred to extended family members or cultural leaders.2 Additional and often repeated conversations may be needed with both the patient and family members to ensure appropriate understanding and ethical consent for care.
Some international patients may have expectations that are quite different from those of the healthcare provider and that are sometimes unrealistic.2,6
Institutional challenges
Many medical conditions require prolonged treatment and longitudinal care, a notable challenge when that care is delivered outside of one’s home country. Practice models within a clinic may not allow for prolonged subsequent visits, which may be needed to accommodate language-translation services. Complex multidisciplinary plans of care must somehow effectively utilize available appointment slots and be time-efficient.
Criteria for hospitalization differ widely among different countries, often based on resources, and may necessitate additional dialogue between the patient and healthcare provider.
Obtaining, interpreting the patient’s record
Medical records from foreign institutions are often unavailable, incomplete, or illegible. Further, depending on the country, it may be difficult to contact local providers for supplemental information. Differences in time zones, limited access to technology, language barriers, and handwritten notes all pose problems when trying to obtain additional information.
Many under-resourced foreign medical centers cannot duplicate medical records and radiographic films for the patient to bring to the United States. Medical records from foreign laboratories often raise questions about the quality, accuracy, and methodology of the testing platform used.2 Thus, the provider may need to start over and repeat the entire clinical, radiologic, and laboratory evaluation.
Communicating with the patient
Difficulties in communication between patients and providers can hinder the development of a positive and productive relationship, reducing patient autonomy and complicating informed consent.2 Obtaining a medical history from non–English-speaking patients can be arduous and time-consuming. Colloquial language may further alter interpretation and understanding, even for formally trained interpreters. Language differences may make it more difficult to explain differential diagnoses, diagnostic approaches, and management plans.
Many US medical centers provide interpreters for many languages, but the great number of languages spoken around the world ensures that barriers in communication persist. Telephone language lines and other commercial language services are available but may feel less personal to patients or evoke concerns about medical confidentiality. For less commonly spoken languages and dialects, appropriate translation services may not even be available.6
Filling in information gaps
Medical conditions, medications, and treatments may have different names in different countries. The quality of pharmaceuticals in some regions may be questionable, and herbal supplements may be unique to a particular location. Many medications available abroad are not available in the United States, potentially confusing US providers as to medication appropriateness, efficacy, and potential toxicities.
Lacking adequate medical records and trying to obtain a new medical history from patients and their family members, providers may struggle with continued gaps of information, hindering a timely diagnosis and composition of an appropriate management plan.
A culturally sensitive but complete physical examination
Every effort should be made to complete a thorough and comprehensive physical examination, even if the patient’s culture differs on this point. This may require a “chaperone” to be present or, if available, a clinician of the same sex as the patient to perform the examination. A compromised examination will impede making the correct diagnosis.
Religious, cultural, and other patient-specific attitudes and beliefs that may affect a medical evaluation should ideally be addressed before scheduling the appointment. A preexamination discussion with the patient and family can help avert unintentional actions and behavior misperceived as offensive, while strengthening the level of trust between patient and provider.2
Money matters
Foreign patients typically have limited or no medical insurance coverage and thus may be paying out of pocket or through limited governmental subsidies. Many refugees and asylum-seekers have no insurance or money to pay for care. (A full discussion of refugee care is beyond the scope of this article). Thus, it is necessary to ascertain in advance who will pay for the care.
Clinicians must be sensitive to the exorbitant costs of medical care and medications in the United States, particularly from the perspective of foreign patients. We strive to provide the best cost-effective care, but what is considered cost-effective and standard care for a patient with US health insurance may be viewed differently by international patients. For some foreign patients, some tests and treatments may be just too expensive, raising personal and institutional ethical concerns regarding how best to evaluate and manage these patients. Ideally, these issues should also be addressed before the patient’s appointment is scheduled.
Clinicians must optimize diagnostic and medical management while minimizing unnecessary testing. This principle further underscores the importance of obtaining a complete medical history and physical examination within a time-sensitive and well-coordinated plan of care.2,4
Continuity of care after the patient leaves
As the medical evaluation and care plan approach completion, ensuring some form of continued medical care can become challenging. Some foreign patients may have the financial or legal means (eg, through an extended medical visa) to remain for further care and follow-up, but most do not.
Finding an available, willing health provider in the patient’s native country for continued management may be difficult and time-consuming. Most US medical centers have no established system to identify available foreign health providers, and usually the patient and family are responsible for arranging continued healthcare back in their home country.
Opportunities for possible improvement of care are noted in Table 2.
ADVANTAGES OF CARING FOR INTERNATIONAL PATIENTS
Despite the possible challenges, there are many benefits of caring for international patients.
Gaining medical knowledge
In US medical centers caring for both regional and referred patients, providers are often exposed to medical conditions that range from common ailments to the rare conditions (or “zebras”) taught during residency training. From the medical education standpoint, international patients provide US health providers heightened opportunities to encounter diseases not commonly seen in the United States (eg, infections such as malaria, schistosomiasis, drug-resistant tuberculosis, and advanced or end-stage forms of noncommunicable diseases). Although not limited to international patients, chronically neglected diseases often give providers first-hand experience in the natural history of select disease progression.
Gaining cultural knowledge
Caring for international patients also enables health providers to learn about different cultures, societal norms, and regional beliefs affecting healthcare. In essence, international patients enable US providers to become more diversified and enlightened with communication skills and assorted managerial strategies on a global scale.
These patients remind us of the stark differences regarding access and quality of medical care globally, particularly in lesser-resourced locations. In a busy domestic medical practice with its own daily challenges, many of us forget these international healthcare disparities, and often take for granted the comparative abundance of healthcare resources available in the United States. Provider frustrations about domestic policies and concerns for a “broken” healthcare system often blind us to the available resources we are fortunate to have at our disposal.
Further, as members of the global community, we have the opportunity to learn from international patients while broadening our view of humanity, thereby enhancing our awareness and empathy toward patients and communities struggling with under-resourced healthcare systems. Healthcare providers are often touched by the gratitude of patients for the opportunity to receive treatments that may otherwise be unavailable. Such experiences may motivate many US health providers to become more engaged in coordinated strategies for global health improvement.
Reimbursement is possible
Caring for international patients should not financially deter US health care centers. Complex, multidisciplinary care evaluations may incur notable expenses; however, alternative and more lucrative payer systems, including government subsidies, can be involved to maintain revenue, reimbursements, and even possibly lead to increased donations.3–5 Given the potential for high costs to be incurred, US providers and institutions need to continually ensure appropriate evidence-based use of resources and cost-effective care without compromising the quality of care provided. The price of certain drugs has been rising astonishingly in the United States, and some patients may therefore prefer to obtain them for long-term use upon return to their home country.
High-quality cost-effective care is satisfying to the patient, provider, and institution, and also may save money that can be reallocated.4 Providers also may find personal fulfillment in striving for and achieving such goals, despite the potential challenges throughout the course of care.
Opportunities for improvement
Regardless of the challenges presented by international patients, participating medical centers often enjoy the prestige and credibility of becoming an “international healthcare center.”4,7 From the standpoint of medical education, these centers have the potential to train providers with increased clinical and cultural competencies along with expanding healthcare services to include clinical, educational and research opportunities abroad.
Research is needed to provide evidence-based guidance on best strategies for patients, clinicians, and healthcare systems to effectively care for international patients.
Suggested opportunities for maximizing advantages are noted in Table 3.
- William Osler. BrainyQuote.com, Xplore Inc, 2016. www.brainyquote.com/quotes/quotes/w/williamosl391388.html. Accessed September 21, 2016.
- Martin DR. Challenges and opportunities in the care of international patients: clinical and health services issues for academic medical centers. Acad Med 2006; 81:189–192.
- Bower LC, Johnson TJ, Hohmann SF, Garman AN, Allen M, Meurer SJ. An evaluation of international patient length of stay. Int J Healthc Manag 2014; 7:200–205.
- Satjapot SP, Johnson TJ, Garman AN. International medical travelers, length of stay, and the continuum of care: inquiry and comparison. Qual Manag Health Care 2011; 20:76–83.
- Donohoe M. Luxury primary care, academic medical centers, and the erosion of science and professional ethics. J Gen Intern Med 2004; 19:90–94.
- Dogan H, Tschudin V, Hot I, Özkan I. Patients’ transcultural needs and carers’ ethical responses. Nurs Ethics 2009; 16:683–696.
- Bauer AM, Alegria M. Impact of patient language proficiency and interpreter service use on the quality of psychiatric care: a systematic review. Psychiatr Serv 2010; 61:765–773.
- William Osler. BrainyQuote.com, Xplore Inc, 2016. www.brainyquote.com/quotes/quotes/w/williamosl391388.html. Accessed September 21, 2016.
- Martin DR. Challenges and opportunities in the care of international patients: clinical and health services issues for academic medical centers. Acad Med 2006; 81:189–192.
- Bower LC, Johnson TJ, Hohmann SF, Garman AN, Allen M, Meurer SJ. An evaluation of international patient length of stay. Int J Healthc Manag 2014; 7:200–205.
- Satjapot SP, Johnson TJ, Garman AN. International medical travelers, length of stay, and the continuum of care: inquiry and comparison. Qual Manag Health Care 2011; 20:76–83.
- Donohoe M. Luxury primary care, academic medical centers, and the erosion of science and professional ethics. J Gen Intern Med 2004; 19:90–94.
- Dogan H, Tschudin V, Hot I, Özkan I. Patients’ transcultural needs and carers’ ethical responses. Nurs Ethics 2009; 16:683–696.
- Bauer AM, Alegria M. Impact of patient language proficiency and interpreter service use on the quality of psychiatric care: a systematic review. Psychiatr Serv 2010; 61:765–773.
KEY POINTS
- Challenges in caring for international patients include cultural differences, institutional barriers, communication difficulties, sparse medical records, and financial considerations.
- Understanding should be reached beforehand on potentially sensitive issues such as physical examinations, payment, tests, and treatment.
- Benefits to the provider and institution include enhanced medical skills, cultural competency, personal satisfaction, and institutional prestige.
