Seeking Medical Care Abroad: A Challenge to Empathy

Barriers and how to break them

U.S. map of boundaries of donation service areas and lung transplant centers

By Nizar N. Zein, MD


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In 2015, patients from more than 100 countries traveled to Cleveland seeking care at Cleveland Clinic. But medical travel was part of the practice of medicine long before major U.S. hospitals became destinations for international patients, and it has been refined over the years.

Ancient cultures had a thriving tradition of patients traveling long distances for the best and most advanced medical treatment. In ancient Greece, people from all around the Mediterranean came to the city of Epidaurus to be cured in its famous temple of Aesculapius, built as a medical center.

Similarly, early Islamic cultures established a healthcare system that catered to foreigners. A noted example is the Mansuri hospital in Cairo, built in 1248 C.E. and considered the most advanced hospital of its time. Accommodating nearly 8,000 patients, the Mansuri hospital became a healthcare destination for foreigners regardless of race or religion.

Europe also had a great tradition of providing medical care to foreign patients. Between the 15th and 17th centuries, belief in the healing power of mineral water led to the establishment of spas and the rise of spa towns, particularly in the south of France near mineral springs. The poor sanitary conditions of Europe at the time may have prompted the interest in the healing effect of mineral spas, but wealthy individuals from all over the world traveled to these destinations, creating local prosperity due to medical tourism.

The city of Bath, England, is a great example. In the 1720s, Bath was a popular destination for those traveling for healthcare. It became the first city in England to build a covered sewage system, ahead of London by several years. It also had paved roads, lights, hotels and restaurants in much greater numbers than other cities in England, a likely result of prosperity associated with medical tourism.


All patients want to be treated with respect and kindness

While medical knowledge and health delivery models have changed over the years, caring for foreign patients is perhaps as old as medicine itself. The central focus of restoring health is certainly not unique to international patients, but understanding their unique needs is important in order to achieve the best outcomes.

A number of studies have addressed the question of what patients really want. Responses were surprisingly consistent: they want to be treated with respect and kindness. In other words, they want empathy, and this is true of all patients regardless of ethnicity or background. Empathy is a tremendous therapeutic force and can narrow what may look like an unbridgeable gap between patient and physician.

Empathy requires effective communication

Empathy, though sometimes innate, requires effective communication and shared experiences. Neither of these two requirements is easily achievable in the care of foreign patients.

Communication is hampered by language barriers, although it can be enhanced significantly by language translating services and the work of certified medical interpreters. These often-invisible heroes should be recognized as essential members of the medical team. Their work requires cultural sensitivity and formal training to avoid miscommunication and medical errors. Codes of ethics for medical interpreters include confidentiality, accuracy in conveying the content and spirit of the message, freedom from personal biases, cultural training, and professional boundaries.

Toward cultural competency

Lack of shared experiences between the foreign patient and care provider is an even greater obstacle to overcome in eliminating any empathy deficit. Shared experiences, whether cultural, religious or social, help us to see the world through the eyes of the patient.


International patients may differ from us in background, ethnicity, religion, dress, expectations and other areas. Cultural and religious backgrounds often dictate certain behaviors in the event of critical illness or death. Even in routine and less acute medical care, the background of a foreign patient may lead to logistical quandaries such as the need for same-sex caregivers or a private room.

A paradox currently exists in our efforts to meet patients’ needs and desire for empathy. While culturally empathic care is necessary to achieve the best medical outcomes, this topic is not yet part of the curriculum for physicians or other healthcare providers in training. A culturally sensitive institution has many business advantages. Thorough and focused cultural training of medical staff is essential. Shared experiences can potentially be fashioned through a well-designed cultural competency training program to enhance empathy for foreign patients.

A service-oriented approach

Besides cultural competency and language training, a service-oriented approach to accommodate the needs of medical travelers and their family members is of paramount importance. Many of the complaints and burdens of medical visitors concern services that are not medical in nature, such as daily living necessities. Transportation, religious services, banking, extended-stay facilities, cell phone service, legal services, shopping, dining and entertainment are among many other living needs for those receiving medical care abroad. These services are inconsistently provided throughout medical institutions in the United States, which provide care to thousands of international patients annually.

Unique challenges of providing medical care to international patients have direct effects on medical outcomes. A population-based cohort study of U.S.-born and foreign-born adults with lung or colorectal cancer suggested disparities in quality and type of care. Foreign-born patients reported lower-quality care and were less likely to receive complex cancer treatments recommended by clinical guidelines. The authors proposed that quality of care and outcomes may be improved with greater emphasis on coordination of care and improving communication. Similar findings were reported in foreign-born patients with breast cancer.

‘What would you think to be used thus?’

Four hundred years ago, in the play Sir Thomas More (a collaboration between several Elizabethan playwrights), the title character confronts a mob of anti-immigrant rioters, and in a speech believed to have been written by William Shakespeare (Act 2, Scene 4), asks them to imagine themselves banished to a foreign country and subjected to hostility such as they were meting out:

“…What would you think
To be used thus?”

Empathy for foreigners seeking medical care is not merely an act of kindness; rather, it is a central piece of healing. Medical institutions interested in providing healthcare to this unique group of patients should take these principles into account and carefully examine their ability to deliver compassionate care collectively to local and foreign-born patients alike.

This article originally appeared in the November 2016 issue of Cleveland Clinic Journal of Medicine.

Dr. Zein is Chair of Global Patient Services and the Mikati Foundation Endowed Chair in Liver Diseases in the Department of Gastroenterology and Hepatology.


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