انگیزش، توجیهات، عادی: استراتژی های استفاده شده توسط گردشگران پزشکی کانادا در مورد انتخاب آنها برای جراحی زانو در خارج از کشور

Contributing to health geography scholarship on the topic, the objective of this paper is to reveal Canadian medical tourists' perspectives regarding their choices to seek knee replacement or hip replacement or resurfacing (KRHRR) at medical tourism facilities abroad rather than domestically. We address this objective by examining the ‘talk strategies’ used by these patients in discussing their choices and the ways in which such talk is co-constructed by others. Fourteen interviews were conducted with Canadians aged 42–77 who had gone abroad for KRHRR. Three types of talk strategies emerged through thematic analysis of their narratives: motivation, justification, and normalization talk. Motivation talk referenced participants' desires to maintain or resume physical activity, employment, and participation in daily life. Justification talk emerged when participants described how limitations in the domestic system drove them abroad. Finally, being a medical tourist was talked about as being normal on several bases. Among other findings, the use of these three talk strategies in patients' narratives surrounding medical tourism for KRHRR offers new insight into the language-health-place interconnection. Specifically, they reveal the complex ways in which medical tourists use talk strategies to assert the soundness of their choice to shift the site of their own medical care on a global scale while also anticipating, if not even guarding against, criticism of what ultimately is their own patient mobility. These talk strategies provide valuable insight into why international patients are opting to engage in the spatially explicit practice of medical tourism and who and what are informing their choices.

Medical tourism involves the travel of patients abroad for private medical care outside of established cross-border health care agreements (Hopkins et al., 2010). It is characterized by out-of-pocket payment and minimal or no clinical oversight from a patients' home health system (Hopkins et al., 2010 and Turner, 2013). The medical tourism industry is reported to be a multi-billion dollar sector, and involves patients travelling internationally to hospitals and clinics (Begum, 2013, Cohen, 2010 and Rahman, 2010). While systematic and reliable data on the numbers of medical tourists is lacking, reports of patients accessing hospitals abroad suggest that the industry is growing (Connell, 2006, Mainil et al., 2011 and Yu and Ko, 2012). Numbers aside, it is known that Canadians are seeking private surgeries, including KRHRR, in other countries (Crooks et al., 2012 and Johnston et al., 2011). KRHRR are surgical procedures performed to reduce pain and increase mobility in damaged or degrading joints (CIHI, 2009). The Canadian Institute for Health Information (2009) reports that 62,196 hip and knee replacement surgeries were performed in Canada (not including Quebec) between 2006 and 2007, a 101% increase since 1996–97 (p. 5). Given that the most prevalent diagnosis leading to KRHRR is osteoarthritis, procedure numbers are likely to continue increasing as the population ages (CIHI, 2009 and CIHI, 2011). Unlike hip and knee replacement, hip resurfacing has limited availability in Canada, due primarily to lack of surgical expertise (Johnston et al., 2012). Meanwhile, there appears to be growing public awareness of, and demand for, access to hip resurfacing (Black, 2013, Kirsch, 2012, Landro, 2013 and Picard, 2009). One estimate suggests an increase in this procedure in the province of Ontario alone from 200/year to 1400/year between 2005 and 2010 (Medical Advisory Secretariat, 2006, p. 11). Taken together, there is a growing need for KRHRR procedures and this is placing increased pressure upon the Canadian health care system (Hudak et al., 2008). Legislated by the Canada Health Act (n.d.), Canadians are entitled to obtain medically necessary elective and emergency surgeries in the public system with no out-of-pocket cost. Medical necessity for orthopaedic procedures is typically established by a family physician or specialist and confirmed following referral to an orthopaedic surgeon (Hudak et al., 2008). Canadians who choose to exit the public system for medically necessary procedures must typically seek them abroad as there is limited private, for-purchase care available in Canada (Steinbrook, 2006 and Turner, 2012). Patients who do this are circumventing the referral networks that make up the public health care system and jeopardizing continuity of care (Johnston et al., 2011). Meanwhile, long waiting lists for KRHRR, perceptions of long waiting lists, and/or desires to gain access to hip resurfacing drive some Canadians to seek these procedures abroad as medical tourists (Crooks et al., 2012 and Johnston et al., 2011). Canadian health care administrators and practitioners have expressed some concern about this trend as patients can be exposed to a range of health and safety risks abroad, can spread antibiotic-resistant organisms upon return home, can develop discontinuous medical records as a result of accessing care in another country, and may not be making truly informed decisions about the procedures they select (Crooks et al., 2013). We view medical tourism as an explicitly spatial practice and work from this perspective in the current article. This practice involves multiple forms of mobility and movement and also connects distant places in a relational way through the activities of patients, physicians, and other stakeholders alike, all of which reference its spatial nature (see Gatrell, 2011). It is thus not surprising that in recent years health geographers have started to empirically examine this practice from topics as diverse as consumption and promotion, emotional geographies, neoliberal governance, and patient decision-making (e.g., Warf, 2010, Kingsbury et al., 2012, Bell, 2011, Ormond, 2013, Ormond and Sothern, 2012, Crooks et al., 2010 and Johnston et al., 2012). Much research on medical tourism also contributes more broadly to health geographers' interests in understanding the spatiality of peoples' health-seeking behaviours (Cummins, 2007; Gesler and Meade, 1988; MacKian, 2002; Narayan, 1999), wherein engaging in the practice of medical tourism is an intentional interaction with an international health system in order to address a health need. In this article we contribute to these areas of health geography scholarship through our examination of how talk strategies are used by former medical tourists to discuss, and at times justify, their choices to engage in this spatially explicit practice. Though this analysis serves as a novel contribution to the medical tourism literature, there is an established area of inquiry in health geography around the theoretical and practical interconnections between language, health, and place (see, for example, Carolan et al., 2006; Gesler, 1999; Giesbrecht, Crooks, & Stajduhar, 2012; Poland et al., 2005). We situate the current analysis within this disciplinary tradition. Much of this research examines how place, and the site of care in particular, informs language use or how language is used in health care places. For example, Giesbrecht et al. (2012) looked at the ways in which language use by homecare nurses changes in different spaces of the home and how it is used to define the boundaries of their practice. In the current analysis we offer a different perspective on the language-health-place interconnection through our consideration of how talk, as an expression of language, is used to communicate about engagement in a spatially explicit transnational health care practice. In doing so we focus on ‘talk strategies’ and use the sociological construct of the co-construction of patient narratives as a conceptual framework for the analysis. Co-construction recognizes that events and occurrences, including those that are health-related, are simultaneously influenced by multiple factors, both human and non-human in nature, that “come into being together” (Rice, 2013, p. 238). In the remainder of the paper we work to illustrate what Canadians who go abroad for KRHRR have to say about why they chose medical tourism and why they chose specific destinations, how they say it via talk strategies, and who is involved in co-constructing their narratives about these choices. We do this by examining the thematic findings of 14 interviews conducted with Canadians who previously went abroad for these surgeries. In the section that follows we discuss the value of examining patient narratives and the role of co-construction in such narratives to provide context for the findings. We next introduce the study design and methods. Following this we examine in-depth the three talk strategies that emerged from the 14 narratives examined: motivation, justification, and normalization talk. We then move to discuss the ways in which these narratives are co-constructed and implications for future research. Overall, the findings contribute to our understanding of patient perceptions of care available in the Canadian health system in comparison to medical tourism destinations. They also reveal some of the factors that enable and constrain international patients' engagement in the spatial practice of medical tourism.

In this article, we have used medical tourists' narratives of KRHRR abroad to illustrate the three distinctive, yet overlapping, forms of talk they used when discussing their choice to go abroad for private medical care. These talk strategies provide important insights into why Canadians are opting for medical tourism and what their needs, concerns, and health expectations are. As the Canadian population ages the demand for KRHRR will increase and so understanding why some patients choose to go abroad and how they discuss this choice is timely. We have also argued that it is important to understand how these talk strategies and narratives are co-constructed by actors and social constructs. The findings of this analysis reveal that discontent with the Canadian health care system and a sense of entitlement to the ‘best’ care options are important facets of Canadian patients' choices to engage in medical tourism for KRHRR. Some patients perceive that there is an unmet demand for hip resurfacing in Canada, which raises important practical questions that extend beyond the scope of this analysis, such as: Is there a need for patient education around this procedure and its long term-effectiveness to enable a greater understanding of why it has limited availability in Canada (see Malviya et al., 2012 and Sehatzadeh et al., 2012 for discussions that question the long-term effectiveness of the procedure)? Alternatively, what reforms, if any, are needed to the domestic health care system in order to ensure that such demand is better met? Building on these practical questions, one can ask: would increasing capacity for hip resurfacing domestically impact the outflow of Canadians for this procedure abroad? And if this domestic capacity was altered, would justification talk strategies regarding going abroad for this procedure change at all? There is a great deal of scope for further empirical research concerning why Canadians are opting for medical tourism by health geographers and others, including how they talk about their choices to go abroad, and how patients who do and do not opt for surgery abroad view their health status and health care. We hope that this article encourages scholars and health care administrators within and beyond Canada to delve further into the reasons why patients are choosing to engage in medical tourism and become mobile patients.