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“You don’t want to lose that trust that you’ve built with this patient…”: (Dis)trust, medical tourism,… Crooks, Valorie A; Li, Neville; Snyder, Jeremy; Dharamsi, Shafik; Benjaminy, Shelly; Jacob, Karen J; Illes, Judy Feb 25, 2015

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RESEARCH ARTICLE“You don’t want to lose th:naraKeywords: Trust, Physician-patient relationship, Medical tourism, CanadaCrooks et al. BMC Family Practice  (2015) 16:25 DOI 10.1186/s12875-015-0245-6stem cell interventions, and routine procedures that areBurnaby, BC V5A 4X9, CanadaFull list of author information is available at the end of the articleBackgroundPeople have long traveled in search of improved healthand wellbeing, whether going to the neighborhood doc-tor’s office for a routine appointment or going abroad tovisit places known for their healing properties. In recentyears, the popularity of a particular global health caremobility known as medical tourism has risen signifi-cantly. Medical tourism involves patients’ independentpursuit of health care abroad, and is distinguished fromarranged cross-border care as it is privately paid for[1-3]. The industry is global in scope, with revenues re-ported to be growing rapidly [4-6]. Hospitals, clinics,and service providers from an ever-expanding list ofcountries seek to attract international patientsa, andmarket directly to them through the Internet and viaintermediaries such as facilitators [7,8]. Patients can pur-chase a range of procedures from medical tourism facil-ities, including unproven interventions that areunavailable or illegal in their home countries, such as* Correspondence: crooks@sfu.ca1Department of Geography, Simon Fraser University, 8888 University Drive,AbstractBackground: Recent trends document growth in medical tourism, the private pursuit of medical interventions abroad.Medical tourism introduces challenges to decision-making that impact and are impacted by the physician-patient trustrelationship—a relationship on which the foundation of beneficent health care lies. The objective of the study is toexamine the views of Canadian family physicians about the roles that trust plays in decision-making about medicaltourism, and the impact of medical tourism on the therapeutic relationship.Methods: We conducted six focus groups with 22 family physicians in the Canadian province of British Columbia.Data were analyzed thematically using deductive and inductive codes that captured key concepts across thenarratives of participants.Results: Family physicians indicated that they trust their patients to act as the lead decision-makers about medicaltourism, but are conflicted when the information they are managing contradicts the best interests of the patients. Theyreported that patients distrust local health care systems when they experience insufficiencies in access to care and thatthis can prompt patients to consider going abroad for care. Trust fractures in the physician-patient relationship can arisefrom shame, fear and secrecy about medical tourism.Conclusions: Family physicians face diverse tensions about medical tourism as they must balance their roles in:(1) providing information about medical tourism within a context of information deficits; (2) supporting decision-makingwhile distancing themselves from patients’ decisions to engage in medical tourism; and (3) acting both as agents of thepatient and of the domestic health care system. These tensions highlight the ongoing need for reliable third-partyinformational resources about medical tourism and the development of responsive policy.built with this patient…”tourism, and the CanadiarelationshipValorie A Crooks1*, Neville Li1, Jeremy Snyder2, Shafik Dh© 2015 Crooks et al.; licensee BioMed Central.Commons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.Open Accessat trust that you’ve(Dis)trust, medicalfamily physician-patientmsi3, Shelly Benjaminy3, Karen J Jacob3 and Judy Illes3This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,mation source while distrust is the lack of such belief. InCrooks et al. BMC Family Practice  (2015) 16:25 Page 2 of 7readily available where they live, such as orthopaedicsurgeries [9,10].Promotional materials aimed at international patients,such as websites and brochures, cast medical tourism asa highly positive and trustworthy practice [11,12]. Muchscholarly research points to the lack of balanced infor-mation available to prospective medical tourists, whichin turn fuels unfettered expectations at the cost of in-formed hopes [12,13]. Media-generated hype furthercomplicates the landscape of endorsement, portrayingsome interventions as imminent and risk-free cures,and often focusing on the financial costs of proceduresrather than possible risks [14-16]. Meanwhile, thisoften hype-driven, biased information is commonlyused by prospective medical tourists when deciding onwhether or not to pay for private care abroad [17];though other sources of information, such as the opin-ions of their regular physicians at home, are also takeninto consideration [18,19].The medical tourism industry operates vigorously des-pite the veil of concern and criticism that surrounds it.Some of these concerns pertain to the impact that theindustry has on destination countries, in which thehighly privatized industry draws resources and healthworkers away from public health systems [1,20]. Otherconcerns focus on the impact that the industry has onthe home countries of medical tourists, such as the pub-lic health risks associated with infections acquiredabroad that may spread locally [21,22], the burden ofproviding either simple or complex follow-up care[23-25], and the impact that patients’ decisions to goabroad for care have on the ongoing relationships theyhold with their regular physicians [19,26]. Despite theseand other concerns, promotional materials aimed atinternational patients cast medical tourism as a highlypositive and trustworthy practice, which has led someresearchers and health professionals to speculate thatprospective medical tourists are not being providedwith the information they need to make truly in-formed decisions [12,27,28].Recent studies provide examples of family physiciansdeclining to care for returning medical tourists or refus-ing to coordinate their follow-up care, citing both theweight on the personal-professional relationship, as wellas the difficulty of integrating any acquired medical ben-efits and harms into the responsibilities they holdtowards these patients [18,29]. Physician-patient rela-tionships are formed over time on the “expectation thatthe other person will behave in a way that is beneficial,or at least not harmful, and allows for risks to be takenbased on this expectation” (p.148) [30]; in other words,they are formed on a basis of trust in the fiduciary rela-tionship. Physicians’ trust in patients in turn enhancespatients’ trust in their physicians, and such mutual trustsome cases these patients look to their regular familyphysicians to help them in the decision-making process,to prepare their medical records to be taken abroad, toprescribe medications that destination facilities want pa-tients to have on-hand, to review their medical recordsfrom abroad, and to refer them for local follow-up care.In other cases, patients opt not to tell their family physi-cians about their participation in medical tourism untilreturning home, if at all, out of concern that these physi-cians will be unsupportive or judgmental [18,19,34].Building on past research in this area, we advance theunderstanding of why and how the establishedphysician-patient relationship, a relationship foundedon trust, is impacted by a patient’s decision to partici-pate in medical tourism.MethodsIn 2011, we held six focus groups in six different citieswith family physicians in the Canadian province ofBritish Columbia to explore what they identified as theimplications of the global health service practice ofmedical tourism on their practice. The cities selectedfor data collection for this qualitative exploratory studyvaried in size and spanned all five of British Columbia’sregional health authorities responsible for health ser-vice administration and delivery. British Columbia wasselected as the province of data collection becauseexisting research and media coverage have shown thatmany medical tourism facilitation companies operatethere and that some residents are opting to engage inmedical tourism [8,35]. Family physicians practicing inthis province, therefore, are likely to encounter formermedical tourists and questions about medical tourismenhances cooperation [31,32]. A recent systematic re-view found that trusting relationships facilitate shareddecision-making, open communication, minimization ofpatients’ fears, and better adherence to health advice[33]. The formation of a trusting relationship betweenphysicians and patients is thus the foundation uponwhich truly beneficent health care can be built, andthus it raises cause for concern if a patient’s decision toparticipate in medical tourism threatens its develop-ment or continuance.In this article we examine the roles of trust and dis-trust in decision-making, information exchanges, andhealth care in the context of Canadian family physicianswho are faced with addressing questions about medicaltourism from their patients, or who are treating formermedical tourists in their practices. We conceive of trustas a belief in the soundness of a person, issue, or infor-in their practices in addition to being involved in dis-cussions about medical tourism with colleagues.Crooks et al. BMC Family Practice  (2015) 16:25 Page 3 of 7Participant recruitmentFollowing approval from the Research Ethics Board atSimon Fraser University, we obtained a list of all familyphysicians practicing in the cities selected to host focusgroups from the British Columbia College of FamilyPhysicians directory. We faxed a letter of invitation toeach family medicine practice or family physician listedin the directory in each city, along with details about thestudy and how to express interest in participating. Theletter explained that having seen significant numbers ofmedical tourists in their practices was not a pre-requisite for participating in the study. The letter alsoprovided a brief description of the team’s previous re-search on the local and global equity and ethical impactsof medical tourism and a link to the research website.We also requested that recipients share the letter withcolleagues to increase the number of potential partici-pants receiving study information.Family physicians interested in participating in a focusgroup were asked to call a toll-free number or send ane-mail to request more information. After such expres-sions of interest were received a team member followedup to ensure eligibility (i.e., that the person was indeedpracticing family medicine in one of the 6 cities of focus)and to relay information about the focus group time andlocation. Reminder e-mails or phone calls, depending onthe participant’s preference, were sent to those who hadagree to participate a few days in advance of the focusgroup and again on the day of the meeting.Data collectionSix physician focus groups lasting from 1.5 to 2 hourseach were hosted in a meeting room at a centrally lo-cated hotel in each city. The participants each signed awritten consent form at the start of the meeting. Twoco-moderators and a note-taker ran the groups, whowere drawn from VAC, JS, SD, and two research assis-tants working with VAC and JS. The lead co-moderatorfacilitated the group while the second co-moderator (re)focused the discussion when necessary. One co-moderator was always a faculty member with previousqualitative data collection experience (VAC [a health ser-vices researcher], JS [a bioethicist] and SD [a globalhealth researcher]) while the other was a highly qualifiedgraduate student who had worked with the team on pre-vious studies. All investigators had previously studiedmedical tourism, including the graduate students, andhad publication records in the field.Probes designed to explore participants’ experienceswith and perspectives about medical tourism guided thefocus group discussions. The probes were developedbased on an extensive review of the international med-ical tourism literature [25,35], as well as insights gleanedfrom a previous study that identified family physicians assometimes being involved in Canadian patients’decision-making around medical tourism [17]. Given theexploratory nature of this study, the probes wereintentionally broad and inquired into: existing know-ledge of medical tourism and experiences with medicaltourists in their practices (e.g., what is medical tourism?Tell us what you know about it based on your experi-ence); perceived and experienced impacts of medicaltourism on the physician-patient relationship (e.g., ask-ing participants to talk about information sharing andexchange, assisting with decision-making, patient educa-tion, and advising for or against medical tourism);provision of follow-up care for returning medical tour-ists (e.g., asking participants to talk about continuity ofcare, care quality, patient risks, and access to follow-upcare); and the impacts of medical tourism for localhealth care more broadly (e.g., asking participants totalk about why patients are going abroad as medicaltourists). Following conventional methods for focusgroups, the probes were intended to stimulate discus-sion while participants drove the scope and breadth ofthe conversations.Data analysisVerbatim transcripts of the focus groups were producedfrom digital recordings. Following completion of datacollection, the lead investigators independently reviewedall transcripts and a team meeting was held to identifyemerging themes for further analysis. A coding schemewas created using deductive and inductive codes to cap-ture key concepts. The transcripts were then uploadedinto the qualitative data management program NVivoand coded using the consensus-based scheme. To en-hance consistency, a single investigator was the primarycoder while another investigator provided confirmationon interpretation wherever necessary.Three thematic findings for full analysis were identi-fied through the process of independent transcript re-view and team discussion. Coded data pertaining to eachthematic analysis were extracted from the main datasetand reviewed in detail for key emerging findings. Thefoci of these three analyses were: (1) the roles and re-sponsibilities of family physicians towards patients en-gaging in medical tourism, within which we identifiedparticipants’ understandings of pre- and post-trip rolesand responsibilities towards medical tourists in theirpractices; (2) the challenges medical tourism poses tofamily physician involvement in informed decision-making, wherein we examined issues such as the shiftingof responsibility for health outcomes from the familyphysician to the patient in light of the decision to goabroad and the ethical tensions that family physiciansface in treating medical tourists in their practices; and,(3) family physicians’ perspectives about the complexfrom 1 to approximately 90, with a median of 6. In theAs one participant pointed out, “they [the patients] haveCrooks et al. BMC Family Practice  (2015) 16:25 Page 4 of 7to make the decision.” Participants commonly did notbelieve that family physicians should be central topatients’ decision-making processes given all the uncer-tainties surrounding medical tourism, and instead familyphysicians should “give them [the patients] the informa-tion so that they could make an informed decision …” Asone participant stated: “ I make sure that when theyleave [my office] they understand that what I’ve tried todo is help them make an informed decision.” Participantsshared that trust is fostered by answering patients’ ques-tions as best as possible, providing information aboutwhich they feel confident, and respecting patient auton-omy. However, as we discuss later in greater detail, theremainder of this section we examine the ways inwhich participants raised issues of trust and distrust inthe focus group discussions, and ultimately their reflec-tions on how patients’ decisions to engage in medicaltourism may impact the ongoing trusting physician-patient relationship.Issues of trustAlthough the concept of trust was not a specific probe,issues relevant to trust emerged as a topic of concern ineach of the focus groups. There was consensus amongthe participants that it is important for family physiciansto trust their patients’ abilities to make beneficenthealth-related decisions about medical tourism and tobe the lead decision-makers around treatment abroad.roles that trust plays in their interactions with prospect-ive or former medical tourists. This article examines thethird, trust-focused analysis. The other two have beenpublished elsewhere [18,19].All authors reviewed coding extracts related to thetrust-focused analysis independently and as a group toachieve consensus on analytic scope. The final analysiswas organized around the sub-themes of trust, distrust,and implications for trust in the physician-patient rela-tionship. Wherever possible direct quotes from partici-pants are used to illustrate findings. The quotes wereselected from the data extracts reviewed by all authors.ResultsA total of 22 family physicians participated across the 6focus groups. Participants had been engaged in practicefor an average of 23 years. Of the 22 participants, 20 haddirect experience caring for medical tourists in theirpractices while all had heard about medical tourismprior to participating in the focus group. The number offormer medical tourists they had encountered variedformation of such trust is challenged when physicians donot support the choice for medical tourism or areconcerned about the safety and efficacy of the treatmentbeing sought.Participants readily acknowledged that the degree oftrust a patient has in a physician or a clinic abroad heav-ily influences decision-making. The medical tourismindustry attempts to foster such trust by trying to ensurethat the patient is “sold by the beauty of it…the recover-ing on the beach…[and] excellent care.” Participants fur-ther acknowledged that repeated positive experienceswith a country’s health system could enhance the senseand development of trust. For example, if patients“came from India…[or] frequently make trips to…Indiaand they trust the system there” or are “from Taiwan,you know the place, you went back there and you get asurgery there.”Participants expressed that a patient’s trust in physi-cians, clinics, or treatments abroad can override com-mon sense. For example, one participant spoke of apatient who obtained repeated treatments for a chronicillness in a private clinic in the United States over aperiod of several years, but showed no clinical improve-ment. Nevertheless, the patient continued to undergotreatment because “she really believes in them [physi-cians abroad].”Issues of distrustThere was a sense among the participants across all ofthe focus groups that the perceived limitations in BritishColumbia’s health care system led to distrust amongsome patients and served as an impetus for medicaltourism. Patients who do not find the system to be reli-able search for care options elsewhere. Such distrust canstem from a multitude of factors, including “insufficiencyin our system”, “outdated procedures”, “discrepancies [inaccess to services] across the [provinces]”, and being“frustrated by this…feeling that they’re not cared for,they’re not important enough, their conditions aren’timportant enough” because of waiting lists. In fact, par-ticipants were concerned that returning medical touristsmay foster such distrust in the local health systemamong others in their networks by talking about “howmuch better it can be [abroad] and how much cleanerand more modern the hospitals can be, how the equip-ment can just be so much more up-to-date” abroad. Gen-erally, participants felt that the development of suchdistrust in the system as a whole is understandable, butthey were also concerned that it may also make patientsvulnerable to exploitation by physicians and clinicsabroad that prey on desperation.While participants made it very clear that they did notwant to play a significant role in patients’ decision-making around medical tourism, they recognized thattheir own degree of (dis)trust in the procedure, clinic, orphysician abroad was important to share with patients.Crooks et al. BMC Family Practice  (2015) 16:25 Page 5 of 7They viewed doing so as an opportunity to provide po-tentially new or unconsidered information, while ideallytrusting the patient to ultimately come to a sound deci-sion. As a participant explained, “I usually look for redflags in the material that they bring in, and if I see that Isay ‘look, I’ve got to warn you about this place’.” One ofthe most common distrusts discussed across all focusgroups pertained to the quality and reliability of pharma-ceuticals available at clinics abroad: “I have no way ofknowing that these [drugs being given to patients] arefrom a reputable manufacturer.” Participants reportedsometimes doing extensive research on clinics and pro-cedures on their own in order to identify concerns theywished to share with their patients, concerns that alsoshaped their own level of trust in the procedure or clinicabroad. They also indicated that their previous experi-ences with medical tourists in their practices impactedthis level of trust, specifically indicating that theysometimes drew on past experiences with patients’poor health outcomes in speaking with prospectivemedical tourists.Trust fractures in the physician-patient relationshipParticipants indicated that ‘trust fractures’ could occurin the ongoing relationships they have formed with pa-tients as a result of patients’ decisions to pursue medicaltourism, including the act of simply considering suchinternational care options. Fractures could occur in caseswhere physicians did not act on follow-up care ordersadministered by care providers abroad for any numberof reasons. In such cases patients’ expectations are notmet and trust erodes because, as one participant ex-plained, “he [patient] doesn’t think I [physician] have hisbest interests at heart.” Trust fractures can also arisewhen patients are concerned about being judged nega-tively for their decisions to go abroad, or when they optnot to disclose their decision prior to departure and con-sequently threaten continuity of care. As one participantexplained: “they [patients] feel, to some extent…ashamed…like in some way uneasy to reveal this infor-mation…because of perceived betrayal of the Canadiansystem [by leaving the public Medicare system to pay forprivate care elsewhere].” In addition to shame, such fearalso leads to secrecy because “they [patients] may beafraid, and…I think in some cases it would be true, be-cause some doctors would say ‘well if you’re going theredon’t be coming back here for me to look after you’.”Participants indicated that family physicians ought toundertake active measures to mitigate possibilities offracturing a trusting relationship because of patients’involvement in or consideration of medical tourism. Ap-proaching conversations with tact and being mindful ofpatients’ needs and circumstances was seen as import-ant: “I’m delicate with most of those patients because if Ilose my patient [and] my doctor-patient relationship,then I lose everything with that person. So sometimes I’ma little bit, you know, tip-toe-y.” Another commonly sug-gested measure focused on providing information andsupport to patients while being transparent about per-sonal opinions, acknowledging patients’ autonomy andtrusting in their abilities to make sound decisions. Oneparticipant described this approach as “com[ing] along-side” the patient, while another emphasized that they“didn’t push them, didn’t pull them, I just helped them tomake that decision.” Other measures undertaken by par-ticipants included: communicating with physiciansabroad to facilitate information sharing; undertakingadditional, but not overly time-consuming, research soas to enhance or augment the patient’s existing informa-tion; and avoiding making judgmental statements aboutmedical tourism with patients. Such measures were alsothought to aid in avoiding furthering patients’ distrust indomestic health care.DiscussionAcross the six focus groups held with family physiciansin British Columbia, issues of trust and distrust emergedin ways that ultimately complicate the physician-patientrelationship. We heard about the importance of respect-ing patient autonomy in decision-making about medicaltourism, concerns about the risks to the patient as wellas the therapeutic relationship and noted measures thatphysicians undertake to protect against trust fractures.The participants with whom we spoke were particularlyconcerned that patients’ distrust in British Columbia’shealth care system may push them to consider partici-pating in medical tourism. Other research also confirmsthis concern, wherein interviews with former medicaltourists from across Canada found that inequities andlimitations in the domestic health system were cited bythese individuals as a fair justification for their decisionsto go abroad for care [36]. Even if Canadians do feel jus-tified in participating in medical tourism because of per-ceived limitations of the domestic health system, ourfindings show that this can influence the trust in thephysician-patient relationship.Our findings point to a number of tensions that familyphysicians must negotiate when dealing with intendedor former medical tourists in their practice, and espe-cially in order to not cause a trust fracture in the estab-lished relationship. We highlight the three mostsignificant here. First, participants wanted to supportpatients’ decision-making about medical tourism, butthere were limits to and limitations on that support. Akey reason for this tension is participants’ distrust in thequality of information available about destination clinicsand physicians, particularly when there are few reliablesources of information they can turn to when consultingCrooks et al. BMC Family Practice  (2015) 16:25 Page 6 of 7with patients who are considering medical tourism. Infact, much existing research attention has been given tothe lack of third party or neutral information available tothose considering medical tourism [6,28,37,38].Second, while participants expressed a desire to sup-port patients’ decision-making about medical tourismand to trust in their decisions, they also desired to bedistanced from the decision itself but not the patient.Participants typically did not want to be seen as endors-ing destination physicians or clinics. Instead, they wantedto be open with patients about their own reservations, andthey wanted to offer support where appropriate and ultim-ately trust in their patients’ decision-making abilities; butthey did not want to take on significant responsibility inthe decision-making process.Third, significant tension exists between participants’roles as agents of the patient and their roles as agents ofBritish Columbia’s public health care system. This ten-sion left some participants uncertain about the responsi-bilities they hold towards medical tourists in theirpractice, an issue that has been examined elsewhere insome depth [18,19,34]. Arising from this tension is theconcern that a lack of shared goals between both partiescan compromise trust in the physician-patient relation-ship, which is an issue that has been raised in the schol-arly literature [26]. The findings shared above point tothe fact that such compromise can actually lead to thisrelationship becoming fractured.The findings of this study, as with others that precedeit [6,39,40], underscore the need for unbiased, high qual-ity information about medical tourism to be madeaccessible to all those who have a potential stake in thisglobal health services practice. Consideration must begiven to who is in a position to create trustworthy infor-mation, how that information should be disseminated,and how it can be kept up to date. The findings highlightconcern and confusion around family physicians’ re-sponsibilities to medical tourists in their practices, andhighlight the fact that informational interventions areneeded to clarify home country liability on advising pro-spective medical tourists about destination clinics andfor caring for returning medical tourists. Finally, thefindings also suggest that greater physician introspec-tion about personal biases regarding medical tourismwill yield benefits to the trusting relationship theyshare with patients.Canada has a national public health care system andfamily physicians in this system serve as gatekeepers tosecondary and tertiary care [19,41]. Future studies ofmarkedly different health system contexts, such as highlyprivatized systems, are key to the unfolding trust storywe introduce in this analysis. Moreover, not all medicaltourism procedures or patients are alike, regardless ofsimilarities in infrastructure for health care. For example,in the case of patients facing debilitating or life-limitingillnesses who seek unproven interventions abroad, suchas stem cells and chronic cerebrospinal venous insuffi-ciency procedures, physicians must ground patients’hopes for therapeutic solutions in current clinical real-ities [42]. In instances of patients obtaining transplantsthat involve purchased organs abroad, physicians mustbalance their moral beliefs against their legal and prac-tical responsibilities [43,44]. Procedure-specific concernsmay raise new issues of trust or distrust that impact theongoing physician-patient relationship that should beexplored in future research.ConclusionsConversations about medical tourism raise salient con-cerns about trust and distrust that impact the physician-patient relationship that medical tourists have with theirregular physicians at home. Unique tensions surface asCanadian family physicians must provide counsel aboutmedical tourism as experts, in the face of significant def-icits of reliable information. They must facilitate patientdecision-making while hoping to distance themselvesfrom patients’ decisions to engage in medical tourism.They must also manage fiduciary responsibilities both asgatekeepers of health care for patients and as agents ofhealth care systems. Such tensions necessitate theprovision of centralized and reliable information, andthe development of clear policy surrounding liability.Pragmatic responsiveness will empower physicians asthey walk the fine line of trust and distrust in the ever-changing landscape of biomedicine today.EndnotesaIn this article we use the word ‘patient’ as it was theterm most commonly used by study participants whenreferring to those they treated in their capacities asfamily physicians.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsVAC, JS, and SD were involved in conceptualizing the study and conductingthe focus groups. VAC, NL, JS, SD, SB, JKK, and JI were involved in reviewingthe data and identifying themes under the leadership of VAC. VAC and NLcompared the thematic findings of this analysis to the existing literature withinput from the other authors. VAC and NL led drafting this manuscript whileSB, JKK, and JI drafted the abstract and conclusion in addition to providingcritical feedback on multiple drafts. JS and SD provided critical feedback onmultiple drafts. VAC, NL, JS, SD, SB, JKK, and JI have all reviewed andapproved of the final manuscript.AcknowledgementsThis study was primarily funded by a Planning Grant awarded by theCanadian Institutes of Health Research (FRN 22829 [VAC, JS, SD]). Additionalsupport was made available through Stem Cell Network Public Policy ImpactGrant Program (#13/5226 PP63 [JI]). VAC is funded by a Scholar Award fromthe Michael Smith Foundation for Health Research and holds the Canada21. Hall CM. Health and medical tourism: a kill or cure for global public health?Crooks et al. BMC Family Practice  (2015) 16:25 Page 7 of 7Research Chair in Health Service Geographies. JI holds the Canada ResearchChair in Neuroethics.Author details1Department of Geography, Simon Fraser University, 8888 University Drive,Burnaby, BC V5A 4X9, Canada. 2Faculty of Health Sciences, Simon FraserUniversity, 8888 University Drive, Burnaby, BC V5A 4X9, Canada. 3Faculty ofMedicine, University of British Columbia, Vancouver, BC, Canada.Received: 17 November 2014 Accepted: 18 February 2015References1. Pocock NS, Phua KH. Medical tourism and policy implications for healthsystems: a conceptual framework from a comparative study of Thailand,Singapore and Malaysia. Global Health. 2011;7(1):12. DOI: 10.1186/1744-8603-7-12.2. Sobo EJ. Medical travel: what it means, why it matters. Med Anthropol.2009;28(4):326–35. DOI: 10.1080/01459740903303894.3. Whittaker A, Manderson L, Cartwright E. Patients without borders:understanding medical travel. Med Anthropol. 2010;29(4):336–43.DOI: 10.1080/01459740.2010.501318.4. Hanefeld J, Horsfall D, Lunt N, Smith R. 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