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“Do your homework…and then hope for the best”: the challenges that medical tourism poses to Canadian… Snyder, Jeremy; Crooks, Valorie A; Johnston, Rory; Dharamsi, Shafik Sep 22, 2013

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RESEARCH ARTICLE Open Access“Do your homework…and then hope for thebest”: the challenges that medical tourism posesto Canadian family physicians’ support ofpatients’ informed decision-makingJeremy Snyder1*, Valorie A Crooks2, Rory Johnston2 and Shafik Dharamsi3AbstractBackground: Medical tourism—the practice where patients travel internationally to privately access medical care—may limit patients’ regular physicians’ abilities to contribute to the informed decision-making process. We addressthis issue by examining ways in which Canadian family doctors’ typical involvement in patients’ informed decision-making is challenged when their patients engage in medical tourism.Methods: Focus groups were held with family physicians practicing in British Columbia, Canada. After receivingethics approval, letters of invitation were faxed to family physicians in six cities. 22 physicians agreed to participateand focus groups ranged from two to six participants. Questions explored participants’ perceptions of andexperiences with medical tourism. A coding scheme was created using inductive and deductive codes thatcaptured issues central to analytic themes identified by the investigators. Extracts of the coded data that dealt withinformed decision-making were shared among the investigators in order to identify themes. Four themes wereidentified, all of which dealt with the challenges that medical tourism poses to family physicians’ abilities to supportmedical tourists’ informed decision-making. Findings relevant to each theme were contrasted against the existingmedical tourism literature so as to assist in understanding their significance.Results: Four key challenges were identified: 1) confusion and tensions related to the regular domestic physician’srole in decision-making; 2) tendency to shift responsibility related to healthcare outcomes onto the patient becauseof the regular domestic physician’s reduced role in shared decision-making; 3) strains on the patient-physicianrelationship and corresponding concern around the responsibility of the foreign physician; and 4) regular domesticphysicians’ concerns that treatments sought abroad may not be based on the best available medical evidence ontreatment efficacy.Conclusions: Medical tourism is creating new challenges for Canadian family physicians who now find themselvesneeding to carefully negotiate their roles and responsibilities in the informed decision-making process of theirpatients who decide to seek private treatment abroad as medical tourists. These physicians can and should beeducated to enable their patients to look critically at the information available about medical tourism providers andto ask critical questions of patients deciding to access care abroad.* Correspondence: jcs12@sfu.ca1Faculty of Health Sciences, Simon Fraser University, 8888 University Drive,Burnaby, BC, CanadaFull list of author information is available at the end of the article© 2013 Snyder et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Snyder et al. BMC Medical Ethics 2013, 14:37http://www.biomedcentral.com/1472-6939/14/37BackgroundThe appropriate role of physicians in aiding patients’ de-cisions and the informed decision-making process hasbeen the subject of considerable debate. In an era wherepatient autonomy ranks high in the doctor-patient rela-tionship, paternalistic models – where the physician dic-tates the patient’s care in what the physician sees as thebest interest of the patient – have been widely critiqued[1]. Instead, decision-making models that emphasizethe physician’s role in aiding patients’ health-relateddecision-making have gained favour. At one extreme,the physician’s role may be limited to simply providingthe patient with information with which the patient maymake an informed choice completely on his or her own.In contrast to the paternalistic model, this model hasbeen criticized as being too impersonal and having anunrealistic assumption that patients have clearly articu-lated values relating to health care [2]. In its place,shared decision-making models have been increasinglychampioned, including in Canada, where the physicianseeks to interpret the patient’s values or helps the patientto choose health-related values by sharing decision-making and reaching a consensus with the patient [3].Shared health-related decision-making can be under-stood as “a process of communication in which thephysician and patient use unbiased and complete infor-mation on the risks and benefits associated with all vi-able treatment alternatives and information from thepatient on personal factors that might make one treat-ment alternative more preferable than the othersto come to a treatment decision” [4]. This model ofdecision-making is interpersonal, allowing both patientand physician to influence one another during thedecision-making process. This process requires trust andattention to the patient’s context, meaning that it ismore likely to be successful if the patient and physicianhave a long-standing and mutually respectful relation-ship [5].Medical tourism, the practice where patients travelacross national boundaries to access a wide range of pri-vate medical care (e.g., necessary and elective surgeries,experimental treatments, dental care, reproductive/fertil-ity services, etc.) in numerous destination nations, hasbeen seen by some scholars as threatening physicians’abilities to share in and shape the informed decision-making process with their patients [6-8]. In Canada,family physicians serve as gatekeepers within the publicsystem, providing continuing care and monitoring whilealso determining access to specialist services, and thusserve a crucial role in directing the care of Canadianpatients. While patients need not consult with familyphysicians before accessing private care for electivetreatments not covered by the public system, family phy-sicians’ role in the public system is central. Becausemedical tourists are opting out of their local healthcare systems, they may not consult with their regularfamily physician prior to departing, thus missing anopportunity to make their physician aware of thetreatment, discuss care options and risks, become in-formed about how to maintain their continuing med-ical record, and prepare for postoperative follow-upcare upon return [9]. The physician’s involvement inthese patients’ informed decision-making can be re-placed by foreign providers and medical tourism fa-cilitators, each of whom have a financial interests inencouraging the patient to seek care abroad and thusmay not be able to provide the information patientsneed in order to fully achieve informed consent [6].For example, in the case of medical tourism facilita-tors, third parties who arrange for the patient’s careabroad, many do not have medical training and failto disclose the risks of treatment on their websites.Instead, these websites often include waivers of fa-cilitator liability for any ill effects from treatmentreceived abroad [10,11]. Moreover, the potentialbrevity of the interaction between the patient andphysician or clinic/hospital abroad, coupled with dif-ficulties accessing patient records from outside thepatient’s home system, may also complicate sharedinformed decision-making by the patient and physi-cians working in medical tourism facilities [6].In this paper, we present the findings of a thematicanalysis of interviews conducted with family physi-cians in British Columbia, Canada that illustrate theways in which their patients’ engagement in medicaltourism challenges their own involvement in theshared decision-making process. Given the concernswith the influence of the limited amount of thirdparty or ‘neutral’ information available about medicaltourism on medical tourists’ decision-making andabilities to provide informed consent [6,7] we con-sider the impacts of patients’ engagement in medicaltourism on the continuing relationship between fam-ily physicians in British Columbia and their patientsthat have gone abroad for care. Medical tourism cansometimes be seen as empowering patients, givingthem new care options not available or affordable athome [12]. This is frequently a message of medicaltourism guidebooks, which tout medical tourism as away of shifting authority to patients and away frompaternalistic physicians [13]. But, as we will discuss,the global dimension of medical tourism also createssignificant barriers to shared informed decision-making between patients and their regular physi-cians, which can have significant and lasting negativeimpacts on these patients’ care, welfare, and auton-omy and serve in stark contrast to viewing this prac-tice as primarily empowering.Snyder et al. BMC Medical Ethics 2013, 14:37 Page 2 of 10http://www.biomedcentral.com/1472-6939/14/37MethodsThe analysis presented in this paper contributes to anexploratory qualitative study designed to examine whatCanadian family physicians view their roles and respon-sibilities to be towards patients in their practice whochoose to engage in medical tourism. To address thispurpose focus groups were held in the spring of 2011 withfamily physicians practicing in the province of BritishColumbia. British Columbia was selected as the provincialsite for data collection because it is known that severalmedical tourism facilitation companies operate there andthat patients from the province are indeed opting to travelabroad for private medical care [14]. Six cities that spannedall five of the province’s regional health authorities and var-ied in size were chosen as locations to run focus groups inso as to capture some degree of diversity in working envir-onment amongst participants.RecruitmentParticipant recruitment started after approval for thisstudy was received from the Research Ethics Board atSimon Fraser University. After approval was granted we –a team of health service researchers with social scienceand ethics training - searched the listing of the BritishColumbia College of Family Physicians directory to iden-tify all family physicians practicing in the six cities selectedfor data collection. Letters of invitation to participate inthe focus group were faxed to all those identified. The let-ters contained basic information about the study and thefocus group time and location and asked that anyoneinterested in participating call a toll-free line or send ane-mail to reach a study investigator. People receiving theseletters were also asked to share details of the study withothers in their practice.In total, 22 family physicians agreed to participate inthe study. The focus groups ranged in size from two tosix participants. Participants had, on average, been prac-ticing family medicine for 23 years. Twenty of the 22participants had seen at least one medical tourist in theirpractices. The total number of medical tourists theyhad seen ranged significantly, though, from one to 90(median = 6).Data collectionThe focus groups were run by two co-moderators and anote-taker was also present at each. All six focus groupslasted between 1.5 and 2 hours. Consistent with thefocus group method, the conversations were structuredaround a series of probes that inquired about a numberof topics related to participants’ perceptions of and expe-riences with medical tourism. The probes were deter-mined following a detailed review of the internationalmedical tourism literature that pertained to decision-making as well as impacts on patients’ home countriesso as to establish knowledge gaps and useful areas ofinquiry. While the focus group probes guided the con-versation, the topics covered in the discussions were verymuch driven by the participants.AnalysisAll focus groups were digitally recorded and transcribedverbatim. After transcription was complete the tran-scripts were uploaded into NVivo in preparation for the-matic analysis. Transcripts were independently reviewedby all investigators, after which a face-to-face teammeeting was held in order to discuss emerging analyticthemes. Following this meeting a coding scheme wascreated by the second and third authors using inductiveand deductive codes that captured issues central to theanalytic themes identified by the investigators. Thescheme was applied to the transcripts in NVivo by thethird author with confirmation on interpretation beingsought from the second author.After coding was finished extracts of the coded datathat dealt with issues of informed decision-making,which serves as the focus of the current analysis, wereshared among the investigators in order to identify thebreadth and depth of themes central to the topic. Foursuch themes were identified, all of which dealt with theissue of the challenges that medical tourism poses tofamily physicians’ abilities to support medical tourists’informed decision-making. The interpretation of thesethemes was confirmed through review of the raw dataindependently by the investigators. In keeping with the-matic analysis, the findings relevant to each theme werecontrasted against the existing medical tourism literatureso as to assist in understanding their significance.ResultsCanadian family physicians encounter patients seekingmany different treatment types, including experimentaltreatments now approved in Canada, treatments forwhich there are real or perceived waiting times for ac-cess, and elective treatments not covered by the publicsystem, among others. Four key challenges to Canadianfamily physicians’ participation in informed decision-making with patients who engaged in medical tourismwere identified through thematic analysis. First, patienttravel abroad heightens tensions around the physician’sappropriate role in patient’s health-related decision-making. Second, the global dimension of this practiceshifts responsibility for the outcomes of patients’ deci-sions almost solely onto the patient because of the regu-lar physician’s reduced role in sharing decision-making.Third, medical tourism can put a strain on the relation-ship between physicians and patients by shifting author-ity over decision-making to be shared between thepatient and physicians abroad, potentially omitting theSnyder et al. BMC Medical Ethics 2013, 14:37 Page 3 of 10http://www.biomedcentral.com/1472-6939/14/37regular family physician entirely. Finally, Canadian fam-ily physicians are challenged in balancing patients’ hopefor better health with the best available evidence ontreatment efficacy, which is complicated by the fact thatpatients are pursuing their hopes for effective careabroad where national regulatory regimes may permitforms of care not approved in Canada. These four chal-lenges were each linked by participants to the inter-national nature of medical tourism, where domesticfamily physicians are less capable of partnering with pa-tients in determining their best course of care abroad. Inthe remainder of this section we examine the findingsrelevant to each of these four challenges to family phy-sicians’ involvement in shared, informed decision-making with patients opting for medical tourism. Weinclude verbatim quotations from the focus groups soas to enable the participants to ‘give voice’ to the issuesat hand.Reshaping the family Physician’s roleThe family physicians we spoke with had markedly var-ied views about what their role should be toward pa-tients’ decision-making around engaging in medicaltourism. For some physicians, their role was to help in-form and guide patient decision-making but, in the end,to respect these patients’ choices. One physician statedthat his duty is to “give someone the choices” as “thepractice now is not paternalism where we tell peoplewhat to do, but we give them the options and they decidewhich one to take”. Similarly, another physician framedthis viewpoint in terms of patient autonomy: “we’re sortof patient partners and so they present something, we justkind of give them our opinion… They’re adults, they’reintelligent, they make their own choices and have…au-tonomy to do whatever they want to do…so we can justcome alongside”. Both of these responses situate physi-cians as partners in decision-making rather than asexperts.When a family physician feels that s/he is not able tooffer an informed view about medical tourism and thusact as a partner in the decision-making process, the com-mon response to patients is: “you do your homework …andthen hope for the best”. This stands in contrast to theshared decision-making model that is common in Canad-ian family medicine practice in that it lessens the physi-cian’s role. For some others, though, it was thought bestthat physician take a more paternalistic role, protectingpatients from harming themselves or being defraudedof their time and money. One physician put it: “a rolefor a family physician is to protect a patient from thattype of care…for us to somehow stop those people fromdoing that”. This approach is also markedly differentfrom the shared decision-making model that is com-mon in Canadian family medicine practice in that itshifts away from a shared approach. One physiciannoted that she changed her approach depending on thepatient’s personal situation. While she is typically “deli-cate” and “tip-toey” with her patients, if the patient haslimited financial means and is considering spending alarge sum on an unproven, alternative treatment, shewill speak more forcefully as there is a “harm issuehere”.Shifting responsibility for decision-makingParticipants emphasized that family physicians in BritishColumbia typically take on a significant role in providinginformation for patients to use in their informeddecision-making process for accessing medical care inthe domestic system. In the context of decision-makingaround international travel to access medical care, how-ever, many participants found their abilities to provideinformation to be challenged because they felt unpre-pared to discuss this issue. For example, the physicianswe spoke with described the common phenomenon ofpatients arriving at their offices with stacks of internetprint-outs about the procedures and facilities abroadthat they were considering accessing: “I know and it’svery challenging to even understand it ‘cause they oftenbring you this pile, what do you think of this doctor, whatdo you think of this centre. And then so you have to kindof wade through that and figure out what’s reasonable”.Their lack of preparedness for these types of doctor-patient interactions left many wanting to take minimalor no responsibility for engaging in shared informeddecision-making around medical tourism.Because participants generally felt limited in their abilitiesto share their patients’ medical decision-making by vettingor even simply discussing procedures and facilities abroad,many emphasized that these decisions were the responsibil-ity of the patient and an exercise of the patient’s autonomy.One participant stressed that, given that physicians willtypically not be familiar with the facilities and physiciansabroad, and sometimes the procedures as well, they willnot want to “take responsibility” for the patient’s choice: “Sothe average physician will go along with the patient and justsay well, I really don’t know what it involves but if you thinkit’s a good idea then you do what you think is best for your-self, and that would be about it”. This attitude puts the re-sponsibility to find information and to ask criticalquestions solely on the patient. As one participantexplained, “I don’t hunt [for information], I just say ‘wellthere could be something and you should look’”. In othercases, the emphasis on the patient’s choice was framed lessin terms of wanting to shift decision-making responsibilityonto the patient and more in terms of supporting the pa-tient and ensuring that the patient was aware of the currentlevel of knowledge regarding a particular procedure: “Iwould say ‘you know the evidence isn’t really there but ISnyder et al. BMC Medical Ethics 2013, 14:37 Page 4 of 10http://www.biomedcentral.com/1472-6939/14/37would support you in going to get it, if that's what you thinkyou want to do”. Whatever the justification, however, therewas a clear trend among participants to minimize their in-volvement in, and thus responsibility over, the decision-making process around seeking private medical careabroad.In some instances participants spoke to their responsi-bilities in shared decision-making towards patients trav-eling abroad for experimental procedures specifically.One participant explained that it was important to tellthe patient that the current science does not support thetreatment they are seeking, but that “you have a right tomake your own choice”. The physician’s power to guidethe choices of the patient was seen as more limited inthe context of seeking experimental care because thegatekeeper function of family physicians is subverted byvoluntary and privately funded travel outside of the do-mestic system. Many of these patients do not approachtheir physicians to “ask your permission”, and the senseis that “all their plans had been laid and I, what do yousay, I’m like ‘good luck … I’ll see you when you get back”.For this physician, it was important to respect “…theconcept of informed consent…and informed decision-making” regardless of the type of procedure being soughtabroad.Straining the doctor-patient relationshipThe family physicians we spoke with felt that the inter-national and private nature of medical tourism fromCanada could alter the doctor-patient relationship, thuscomplicating the physician’s role in sharing decision-making. This relationship was felt to be very importantto the care of the patient and shared decision-making,where the physician must be able to get to know patientsand their needs well over time through establishing mul-tiple forms of continuity. When patients go abroad to re-ceive care from doctors the regular family physiciandoes not know, it can leave this physician disconnectedfrom the patient’s decision-making. In general, partici-pants were concerned that the decision to go abroad forcare was indicative of a weakened relationship betweenthe doctor and patient, either because these patientswere blaming their doctors for their ill health or becausethe physician was not facilitating patients’ access to thecare they wanted when they wanted it. In the latter case,patients might feel that the physician is “obstructing theirpath then that may fracture the relationship”.Participants raised many specific ways in which pa-tients’ engagement in medical tourism could strain thedoctor-patient relationship and its overall therapeuticpotential. In one case, for example, a participantexpressed that medical tourism was feeding into a cul-ture of “instant gratification” among patients where waittimes for procedures did not have to be endured, legalor structural barriers to care access could becircumvented, and there was less need to ensure a closedoctor-patient relationship in order to enhance domesticsystem navigation. Another participant worried that pa-tients who access care abroad that they deem of higherquality than what they can get at home will lose faith inthe Canadian system, which “destroys the relationship”between doctor and patient. This relationship may alsobe damaged by the decisions that physicians make onhow to provide care for patients after their return home,which is an issue raised by many participants across allthe focus groups. One participant noted, for example,that if he chooses not to act on the medical advice of aphysician from abroad due to lack of knowledge of thetreating physician or the merits of the treatment order,the continuing relationship with the patient may be“damaged”. Another participant noted that worriesabout damaging his relationship with his patients mightlead him to giving in to patient demands because “youdon’t want to lose that trust that you’ve built with thispatient relationship for so many years”. Only a few otherparticipants indicated that they may do the same inorder to avoid damaging an established relationship.Though not a common discussion point in the focusgroups, it was suggested that the financial implicationsof privately accessing care abroad put tension on thedoctor-patient relationship, making it more difficult toshare in decision-making. Intended medical tourists maylook to their regular family physicians to provide guid-ance on cost savings by, for example, seeking feedbackon or endorsement of low-cost clinics abroad orrequesting letters for insurance companies or govern-ment in order to seek reimbursement for this care. Oneparticipant spoke of her unwillingness to write a physi-cian’s note for a patient who had participated in medicaltourism where this document would state that the pa-tient could not access the same care locally. In this case,the patient needed the note to meet the provincial gov-ernment’s requirements for reimbursing the patient’scare as the government would not reimburse in caseswhere treatment is available in the local public system.The physician’s refusal to provide such a note led to thatpatient changing doctors “because he doesn’t think I havehis best interests at heart”.Balancing hope and evidenceParticipants explained that in some cases, patientschoose to travel abroad for care because of a seriousmedical condition that they feel could not be treated inCanada. For some of these patients, there is a tensionbetween maintaining hope that they might be cured orimprove their quality of life through seeking care abroadlies and their physician’s concern that this hope is notsupported by clinical evidence or that the patient may beSnyder et al. BMC Medical Ethics 2013, 14:37 Page 5 of 10http://www.biomedcentral.com/1472-6939/14/37exploited. Participants widely recognized the importanceof maintaining hope for their patients who want to seeklife saving or life changing procedures abroad, sayingthat they should not simply “dash their hopes” and that“all they have is hope”. This reality informed their owndecisions regarding involvement in patients’ decision-making around seeking care abroad. While participantsoften expressed concerns about fraudulent experimentalcare clinics abroad, one noted that “I’ve seen really goodresults from some of the other clinics in Germany…yesthey [patients] spent a hundred thousand dollars easilyand it buys them time and not necessarily a cure butthey’re happy with it”. This was a minority perspective,though, as most participants who discussed the pursuitof experimental care abroad by patients were concernedabout the quality of care and high costs and struggled tobalance these concerns against not eroding hope in thecourse of decision-making.Having hope in itself was stressed as having a positiveimpact on patients’ quality of life: “So you may adverselykind of affect your patient in the sense…you’re doing theright thing, but in fact you know they very much needthat hope to actually get through the next month”. Onthe other hand, most participants made clear that theycould not simply endorse a course of care that they didnot feel would work should patients consult with themabout international care options in the course ofdecision-making. In these cases, it is important tocounsel patients of their concerns because of their con-tinuing responsibility to the patient: “You have to makethem aware that you still have reservations about the ef-fectiveness of the treatment, ‘cause you’re still responsiblefor that patient”. Expressing these reservations can bedifficult. For example, in such an instance family physi-cians may not be able to offer recommendations on anyeffective treatment within Canada, which puts them “ina very bad place” in striking a balance between enablingpatients to maintain hope while ensuring they meet theirown ethical and professional obligations to the patient.When patients who are driven by the hope of finding alife saving or life changing procedure abroad turn to on-line sources for information on experimental or alterna-tive treatments it may undermine the physician’s abilityto caution patients in the course of decision-making.The concern is that patients will not be able to evaluatethe claims being made on websites, which is particularlyproblematic in cases where patients do not seek adviceon these claims from their regular family physicians orwhere the physician has expressed unwillingness to en-gage in shared decision-making around medical tourism.One participant described his patient’s point of view as,“I don’t trust you doctors who are just referring amongstyourselves and here’s someone who’s a healer and youknow and they’re doing natural things and that justseems better for me”. Another noted that if he issuggesting that a patient has a ten percent chance ofsurvival and a physician abroad is suggesting a ninetypercent chance of survival, most patients will choose tolisten to the advice of these other physicians as they are“clinging onto hope” and “gullible” and that these realitieswill weigh heavily on their decision-making processes.DiscussionOur focus group discussions identified four challengesto Canadian family physicians’ abilities to partner withtheir patients in undertaking informed decision-makingregarding medical tourism:1. Determining the physician’s role in facilitatinginformed decision-making around medical tourism.Canadian family physicians are challenged bypatients’ involvement in medical tourism in thatthey must determine to what degree their role is tofacilitate, as far as they can, informed decision-making and when dissuading their patients fromgoing abroad is appropriate;2. Identifying physician and patient responsibility forfinding information of facilities, procedures, andphysicians abroad. For physicians who see their roleas partnering in their patients’ informed decision-making around medical tourism, they are challengedin that they may have limited information to givepatients, thus shifting responsibility onto thesepatients;3. Maintaining a strong physician-patient relationshipin the face of greater patient responsibility fordecision-making. Family physicians are challenged inmaintaining a strong and positive relationship withtheir patients in a context where patients are moreempowered to make their own decisions regardingcare and ultimately take control over the entiredecision-making process; and4. Balancing between maintaining patients’ hope fortreatment abroad and concerns that these treatmentsare unproven. Family physicians are challenged bythe tension between supporting their patients’ desireto maintain hope for effective treatment while beingwary of complicity in encouraging the pursuit ofunproven treatments not offered locally and theimpact this tension has on their involvement inpatients’ informed decision-making.In many respects, the four challenges to family physi-cians in sharing the decision-making of their patientswho opt for medical tourism raised in our thematic ana-lysis are not new; instead, they are existing challenges inclinical practice that are heightened by the internationaldimension of medical tourism. Debates among familySnyder et al. BMC Medical Ethics 2013, 14:37 Page 6 of 10http://www.biomedcentral.com/1472-6939/14/37physicians regarding their role in patients’ informeddecision-making have been taking place for decades, in-cluding questions of whether physicians should take apaternalistic, hands off, or partnering role [2,15]. A dis-tinct challenge brought by medical tourism is that familyphysicians may be less familiar with the patient’s treat-ment options abroad and therefore less able to serve asa partner in decision-making. Thus, they are often leftwith two, potentially unpalatable, options: either to leavethe information gathering and decision-making almostentirely to the patient or to take a more paternalistic rolein attempting to dissuade the patient from going abroad.Physicians encountering this challenge can aid their pa-tients in identifying critical questions to ask of their pro-viders abroad, but this is very different from thepartnering role often identified as an ideal in patientdecision-making [3,4]. This diminished capacity to par-ticipate in patients’ informed decision-making aroundmedical tourism has the effect of shifting responsibilityto the patient for making these decisions. As a result,patients have been observed to take advantage of re-sources from across the globe for information aboutmedical tourism, including facilitator websites, foreignproviders, and industry sources [10,11,16,17]. As theseinternational resources are typically tied to the medicaltourism industry, responsibility for information sharingduring the decision-making process is shifted from fam-ily physicians, who would typically be expected to bemore neutral information sources, to sources with sig-nificant conflicts of interest.These physicians expressed that maintaining a strongand positive relationship with their patients that resultsin positive therapeutic outcomes where all parties havemeaningful and desired involvement in health-relateddecision-making is always challenging. The family medi-cine literature identifies some of these ongoing chal-lenges to be a lack of time to consult with patients,patients and physicians with poor communication skills,and funding structures that do not support consultation[5]. These routine challenges certainly exist in the rela-tionships between Canadian family physicians and theirpatients who are considering or have opted for medicaltourism. Meanwhile, as these same patients becomeempowered to receive opinions and treatment from out-side of Canada, they develop new relationships that holdimplications for their regular family doctors and ultim-ately the doctor-patient relationship. The findings showthat these relationships can be with physicians abroad aswell as medical tourism facilitators, with both of thesegroups playing a role in providing information to pa-tients during their decision-making processes. Canadianfamily physicians, who are used to a gatekeeping role to-ward their patients, are forced to compete with otherproviders in having involvement in shared decision-making and ultimately developing and maintaining a re-lationship, including continuity of care, with these pa-tients (see also [9]). As these foreign providers canmarket treatments and, for the patient, hopes for betterhealth that are unavailable domestically, Canadian familyphysicians face new pressures to support the hopes oftheir patients for treatment, even if they do not feel thatthese treatments are supported by scientific evidence.The global nature of medical tourism creates chal-lenges for Canadian family physicians by introducingnew partners in patients’ decision-making processes andultimately whether they are able to become truly in-formed decision-makers. This is a relatively newphenomenon for many Canadian family physicians, andour conversations revealed wide uncertainty about theappropriate roles of domestic and foreign physicians insupporting informed decision-making and providingcare for Canadian patients. While this uncertainty willlikely be reduced when and if medical tourism becomesmore common, visible, and regulated internationally andwithin Canada, gaining clarity is challenged by the myr-iad destination countries involved in this trade – anissue that has been discussed extensively in the medicaltourism literature around the legal dimensions of thisglobal practice and the lack of clarity over which juris-dictions hold legal responsibility for what [18]. Just asCanadian family physicians are uncertain as to what rolethey should take in patient decision-making, medicaltourism facilitators and other providers lack norms fortheir roles [8]. These new stakeholders inhabit verydifferent countries with very different cultures ofmedical care, further complicating agreement abouttheir appropriate roles in patient decision-making.For example, international patient coordinators indifferent countries have been found to have variedexperiences with and reactions to medical touristsand caregivers that travel with them [19]. While aca-demics have expressed concern that the privatefunding of medical tourism creates a conflict ofinterest between patients and providers and compro-mises the informed decision-making process, suchrelationships are not uncommon outside of, or evenwithin, Canada [20]. A continued conversation is ne-cessary to help develop at least broad norms andbest practices regarding informed patient decision-making and care in the medical tourism sector ifthese conflicts of interest are to be visible to pa-tients and managed in their interest. Our findingsshow that Canadian family physicians should be con-sidered a key stakeholder group in such a conversa-tion. This is not to say that these norms can orshould be incorporated into the Canadian healthcare system or family medicine practice, but theglobalization of medical care will continue to disruptSnyder et al. BMC Medical Ethics 2013, 14:37 Page 7 of 10http://www.biomedcentral.com/1472-6939/14/37the roles of family physicians in their patients’ in-formed decision-making processes and they shouldbe prepared to address these disruptions.Canadian family physicians clearly find themselveschallenged in supporting the decision-making of theirpatients. If they wish to become more involved in thesedecisions, then there is a need to better inform physi-cians of the risks presented by medical tourism and bestpractices in reducing these risks. Such information is notlikely to take the form of recommending for or againstspecific countries, facilities, or physicians abroad giventhe large number and diversity of medical tourism pro-viders and the lack of reliable measures of provider qual-ity. Rather, physicians can and should be educated toenable their patients to look critically at the informationavailable about medical tourism providers and to askcritical questions before deciding whether to access careabroad [21-23]. While this form of physician involve-ment might be seen on the one hand as paternalistic,attempting to dissuade patients from becoming medicaltourists, the critical nature of these questions can beaimed at empowering patients to be better advocates fortheir own health. On the other hand, physician partici-pation in this decision-making might be seen as an en-dorsement of medical tourism by their patients, whichraises distinct concerns around liability and the limits ofthese physicians’ professional responsibilities [24]. Whilefamily physicians may wish to be careful in seeming toendorse a practice with which they are unfamiliar or un-comfortable, partnering with patients in looking critic-ally at their decision-making regarding medical tourismand whether it is truly informed allows physicians tomaintain their relationships with their patients and notrelegate all decision-making responsibility to patientsand third party providers.In this paper we have focused on the perspective offamily physicians and the challenges that they face insharing or not sharing in the informed decision-makingof their patients who travel abroad for care as medicaltourists. As such, this discussion does not represent thechallenges and concerns of destination country physi-cians. Just as Canadians family physicians are challengedby the global nature of medical tourism and pluralismaround cultures of care, destination country physiciansare likely to face these challenges as well. Should a des-tination country physician consult with and treat pa-tients from a diverse range of countries and cultures,they will likely find it extremely difficult to cope withand support different expectations around informationsharing and decision-making. As we have already stated,our findings point to a need to inform Canadian familyphysicians about medical tourism, including the risks itposes to patients and the means of managing these risks.A similar education effort is needed for destinationcountry providers in order for them to serve as effectivepartners with their patients from abroad. Other, uniquechallenges are likely faced by these providers, and there-fore there is also great need for research into the per-spectives of destination country physicians who serveinternational patients.The discussion in this article has focused on theCanada as a country from which patients travel abroadfor private health care via the medical tourism industry.Our Canadian focus may limit the transferability of thefindings presented here to other home countries formedical tourists. In particular, the public nature ofhealth funding in Canada means that these results maynot carry over to contexts with different funding sys-tems, such as the United States [8]. Moreover, Canadianfamily physicians have a strong gatekeeping role that isnot found in all primary care tiers, meaning that Canad-ian family physicians may be accustomed to a greateramount of control over patients’ access to specialist careand surgeries and the decision-making that surroundsthis access than exists in health systems that offer pa-tients more direct access to these same types of care[24]. That said, all physicians who treat patients consid-ering engaging in medical tourism will be faced withchallenges regarding how to define and operationalizetheir roles towards these patients. The global nature ofmedical tourism creates new opportunities for patients,which can be empowering and beneficial for these indi-viduals. At the same time, the introduction of new andpotentially competing care providers may challenge therelationship between all physicians and patients alongwith the decision-making process and ultimately createpressure to match the treatments and hope offered byfacilities abroad. We expect, then, that these findings willbe applicable in other settings despite differing healthsystem, health care, and health service contexts, thoughthe relevance of each challenge will we have identifiedhere will need to be tailored to these differing contexts.We thus believe there is a strong rationale for undertak-ing similar research in other countries so as to deter-mine the role that context plays in shaping thechallenges that patients’ regular physicians are experien-cing in light of patients’ involvement in medical tourism.LimitationsThere are two main limitations of this study. First, nodata exist that enable us to know how representative theparticipants are of all family physicians in BritishColumbia in relation to how many medical tourists theyhave seen in their practice. While this is a qualitativestudy and has thus not sought to be generalizable, itwould have been very useful to have a population-levelsense as to how many medical tourists family physiciansare typically seeing in their practices each year acrossSnyder et al. BMC Medical Ethics 2013, 14:37 Page 8 of 10http://www.biomedcentral.com/1472-6939/14/37the province. Second, there are limitations inherent tothe focus group method that are relevant to this study.For example, some participants talked more than othersand in one case a particularly outspoken participant mo-nopolized a short part of the discussion. While we didour best to moderate such behaviours and to encourageconversation among all participants, they nonethelessdid occur.ConclusionsThe growing popularity of medical tourism poses signifi-cant disruptions to health systems that have evolved tomanage behaviours of care providers and health systemusers within a relatively closed domestic context. Therole of Canadian family physicians in health-relateddecision-making is one area that has been demonstratedto have been unsettled when the care their patients areseeking is outside of the country. To examine this weheld a series of focus groups with family physicians inthe province of British Columbia. The experiences andoutlooks of family physicians shared during these focusgroups suggest that: family physicians are uncertain oftheir degree of engagement with information sharingaround medical tourism decision-making; medical tour-ists resultantly shoulder a greater burden of health-related decision-making than patients who pursue carewithin their home health system; the relationships be-tween family physicians and their patients can becomestrained when patients’ expectations for their family phy-sician’s role in accessing care abroad are mismatchedwith their physician’s own knowledge and professionalnorms; and family physicians often strike a balance be-tween their awareness of the role that ‘hope from careabroad’ can play in sustaining their patients’ physical andemotional well-being with their concerns for the real fi-nancial and physical harms that certain courses of un-proven treatment available in loosely regulated contextscan inflict on patients and their families. Most familyphysicians we have talked to have adopted a hands offapproach toward their patients that have traveled abroadfor care out of the uncertainty that this practice bringswith it. Thus, medical colleges and educators can benefitfamily physicians and patients alike with the creation ofclear professional norms and standards that specificallyaddress the appropriate role of family physicians in theirpatients’ informed decision-making process when thecare they seek is privately delivered outside of thecountry.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsJS participated in three focus groups and wrote the background, results, anddiscussion sections of the manuscript. VAC wrote the grant that funded thisresearch, participated in 4 focus groups, wrote the methods section, andedited the full manuscript. RJ participated in 6 focus groups, wrote theconclusion, and edited the full manuscript. SD participated in 3 focus groups,wrote the abstract, and edited the full manuscript. All authors contributed tothe analysis of the focus group transcripts. All authors read and approvedthe final manuscript.AcknowledgementsA Planning Grant from the Canadian Institutes of Health Research fundedthis study. VAC is also funded by a Scholar Award from the Michael SmithFoundation for Health Research. Krystyna Adams, Alexandra Wright, andMelanie Ewan provided some research assistance.Author details1Faculty of Health Sciences, Simon Fraser University, 8888 University Drive,Burnaby, BC, Canada. 2Department of Geography, Simon Fraser University,8888 University Drive, Burnaby, BC, Canada. 3Department of Family Practice,University of British Columbia, David Strangway Building, 3rd Floor 5950University Boulevard, Vancouver, BC, Canada.Received: 4 June 2013 Accepted: 9 September 2013Published: 22 September 2013References1. Manson NC, O’Neil O: Rethinking informed consent in bioethics. 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Ormond M, Southern M: You, too, can be an international medical traveler:reading medical travel guidebooks. Health Place 2012, 18:935–941.14. Johnston R, Crooks VA, Snyder J, Kingsbury P: What is known about theeffects of medical tourism in destination and departure countries? Ascoping review. Int J Equity Health 2010, 9:24.15. Faden R, Beauchamp TL, King N: A history and theory of informed consent.New York: Oxford University Press; 1986.16. Turner L: Canadian medical tourism companies that have exited themarketplace: content analysis of websites used to market transnationalmedical travel. Global Health 2011, 7:40.17. Cormany D, Baloglu S: Medical traveler facilitator websites: an exploratorystudy of web page content and services offered to the prospectivemedical tourist. Tourism Manage 2011, 32(Suppl 4):709–716.18. Cohen G: Medical tourism: bioethical and legal issues. In Routledgecompanion to bioethics. Edited by Arras JD, Kukla R, Fenton E. New York:Routledge; 2013.Snyder et al. BMC Medical Ethics 2013, 14:37 Page 9 of 10http://www.biomedcentral.com/1472-6939/14/3719. Casey V, Crooks VA, Snyder J, Turner L: “You’re dealing with anemotionally charged individual…”: an industry perspective on thechallenges posed by medical tourists’ informal caregiver-companions.Global Health 2013, 9:31.20. Tuohy CH, Flood CM, Stabile M: How does private finance affect publichealth care systems? marshaling the evidence from OECD nations.J Health Polit Policy Law 2004, 29(Suppl 3):359–396.21. Turner L: ‘First world health care at third world prices’: globalization,bioethics and medical tourism. BioSocieties 2007, 3:303–325.22. Turner L: Beyond “medical tourism”: Canadian companies marketingmedical travel. Global Health 2012, 8:16.23. Crooks VA, Snyder J: Medical tourism: what Canadian family physiciansneed to know. Can Fam Physician 2011, 57(suppl 5):527–529.24. Johnston R, Crooks VA, Snyder J, Dharamsi S: “Our true role… is within theconfines of our system’: Canadian family Doctors’ roles andresponsibilities towards outbound medical tourists”. Can Fam Physician. inpress.doi:10.1186/1472-6939-14-37Cite this article as: Snyder et al.: “Do your homework…and then hopefor the best”: the challenges that medical tourism poses to Canadianfamily physicians’ support of patients’ informed decision-making. BMCMedical Ethics 2013 14:37.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitSnyder et al. BMC Medical Ethics 2013, 14:37 Page 10 of 10http://www.biomedcentral.com/1472-6939/14/37


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