Letters To The Editor
Stereotyping is too often mistaken for cultural sensitivity.
Kelly A. Cawcutt, MD
Assistant Professor, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha
John W. Wilson, MD
Associate Professor, Division of Infectious Diseases, Mayo Clinic, Rochester, MN
Address: Kelly A. Cawcutt, MD, 985400 Nebraska Medical Center, Omaha, NE 68198; firstname.lastname@example.org
ABSTRACTIncreasing numbers of international patients are receiving care at US medical centers, entailing various challenges and benefits to all involved. Despite the potential challenges, the collective experiences can transform healthcare providers and their institutions into better physicians, better medical centers, and overall better members of a global society with increased awareness of the global human experience.
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.
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.
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
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.
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.
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
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.
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
Stereotyping is too often mistaken for cultural sensitivity.
We fully agree about the dangers of blurring sensitivity and stereotyping in medicine.
Of the seven deadly sins, the worst is pride—avoid a chauvinistic attitude when caring for international patients.