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Patient Experience & Hospitality

Cultural & Linguistic Competency and Medical Tourism's Bottom Line

Patient Experience & Hospitality

Granted, medical tourism is a relatively new, but rapidly growing industry with unlimited potential. Still, the industry has been neglecting two “soft” aspects essential to its long-term growth and success.

When I began to talk to hospitals in culturally diverse Los Angeles about the impact of language access and cultural appropriateness on successful medical outcomes and patient satisfaction way back in 1993, I remember the director of one of the most diverse and prestigious hospitals patting me on the back in a dismissive manner and telling me, “Don’t worry, we treat all our patients exactly the same!”

That was the major problem!

Experience and tracking of medical outcomes and patient satisfaction in treating patients of diverse cultural and language backgrounds have proven that equal care is not equally effective for or viewed as quality care by all groups.

Now, 20 years later, almost every hospital in the United States, and in most other countries with diverse immigrant or migrant populations, have either an entire department or at least a director of cultural and linguistic competency to insure that patients are treated in a culturally appropriate manner.

Most have staff interpreters or contracts with an off-site service. Why? Because failure to attend to these two aspects of patient care can be very costly to the institution’s reputation and bottom line!

Because medical tourism has been viewed as separate from domestic patient care, these “soft” aspects of quality care have not really drawn industry attention.

Medical tourism is profit-driven and very competitive, making cultural and linguistic competence even more essential to every organization’s bottom line.

Poor Linguistic and Cultural Competence = Waste of Marketing Budget!

The Internet is the main source for marketing to potential patients, hospitals and insurance agencies in medical tourism. However, most organizations seeking foreign patients through the internet are often marketing in a foreign language and

The Internet is the main source for marketing to potential patients, hospitals and insurance agencies in medical tourism.

targeting people/organizations that belong to cultures different from their own. It’s important for healthcare facilities trying to build their images in the medical tourism marketplace to realize that people reading their web sites will measure the quality of care provided by the quality of their web site.

The culture of these potential clients will determine what types of services and benefits they expect and value most. The language, or actual words and phrases used to describe these benefits and services, will determine whether or not that particular location or facility will attract clients and encourage them to consider care at that site.

Correct use of the primary languages of the targeted audiences is essential, as well. Sloppy grammar or use of unidiomatic phrases results in negative, rather than positive advertising! It tells perspective patients and medical partners that the care provided is also sloppy and uncaring, that the organization does not pay attention to detail, and that patient/ physician communication will be far from adequate at that facility.

Organizations seeking patients from abroad can only expect to “attract” rather than “discourage” prospective patients and, thus, get the “best bang” for their marketing budget by making sure their web sites — and all other marketing materials — appeal specifically to the culturally determined values and measures of quality of that targeted audience, and are written by a trained native speaker of the language of the targeted patient population!

Use your knowledge of culture and language to maximize the effectiveness of your marketing budget:

  1. Study the values, “buzz words” and positive images of your targeted market (these will be different for every cultural group). Design your web page to appeal to these values in a way that will be most attractive to this group. Even responses to color, amount of animation and types of links are culturally determined.
  2. Work with a native speaker of the targeted audience’s language to design and not merely “translate” your domestic web page. You need a web page that “fits” the unique cultural values of the people you wish to attract.
  3. Check the meaningfulness of the finished product with at least two other members of that culture/language group to be sure
  4. the language is correct and idiomatic
  5. it uses words and images that are considered attractive by that population
  6. it says what you wish to say in a manner that is linguistically and culturally appropriate

Cultural and Linguistic Competence = Greater Patient Satisfaction, Fewer Medical Errors, More Return Patients & Patient Referrals

Both the ability of medical and non-medical staff to communicate effectively in the patient’s language is valued as second only to proof of medical expertise for someone in search of treatment abroad. Seeking care in another country is a pretty scary proposition. It is difficult to trust a physician who you cannot understand; especially one who cannot understand you! Clear physician/patient communication also lowers the risk of medical errors.

Luckily, language access in medical tourism is a lot more “manageable” than for immigrant patients in diverse countries, such as the United States or Great Britain, where these patients may come from hundreds of different cultural, religious and language backgrounds. It is fairly common for countries and hospitals seeking to expand medical tourism to target patients from a limited number of geographical areas. Therefore, the number and cultural backgrounds and languages spoken are usually finite and can be anticipated in advance.

Medical facilities can develop patient information packets, signage and staff language and cultural training programs that focus on the needs and expectations of these targeted patient groups. It is also easier and more cost-effective to hire and train medical interpreters for those few languages. It is important to recognize that, although a bilingual staff is the best way to assure patient/caregiver communication, it is not enough for organizations to allow staff to self-evaluate their fluency in another language.

The culture of these potential clients will determine what types of services and benefits they expect and value most.

All “bilingual” staff must be formally tested by a professional who can accurately evaluate their ability to communicate effectively with patients in that language. Also, culture will impact the interpretation of specific words because some speak the same language, but come from different cultures or even social backgrounds.

While most countries do not have the stringent malpractice laws that exist in the United States, certainly a hospital’s record of medical errors and the patient’s satisfaction with his/her ability to communicate with both medical and non-medical staff have a strong effect on both the hospital’s and the country’s medical tourist growth and return on investment.

Knowledge and the ability to accommodate the patient’s cultural needs and expectations regarding both medical care and auxiliary services are also important factors in patient satisfaction and gaining referrals directly from former patients or from their local physicians.

Even cultural factors, such as the appropriate form of address, knowledge and considerations of religious beliefs, taboos and dietary customs and restrictions, have a tremendous impact on patient satisfaction.

It is important, for example, to know that prior to first obtaining permission, staff must not cut a Sikh’s hair or remove the bracelets that may be attached to his wrist. Or, in which cultures it is necessary for a female physician to attend to a female patient, or even when the patient’s religion forbids the eating of certain foods.

Culture also determines patient decision-making practices, and how actively they expect to participate in the development of their treatment plan. Billing, systems of payment, and to whom payments are made require knowledge of both the patient’s cultural and home medical systems.

For example, in Mexico, where I am currently located, payment is made immediately after treatment and, if a hospital stay is involved, prior to leaving the facility. Often, the physician collects the money personally. American patients who Mexican hospitals target are not used to paying when services are rendered, but instead expect to be billed and pay at a later date; meaning the physician never personally handles money.

These cultural differences in medical systems might encourage American patients to wonder whether the hospital is a fly-by-night operation that might disappear after money is collected!

When I was participating at a medical tourism conference, in Puerto Vallarta, Mexico, last year, there was a talk by a facilitator representing Thailand. When asked what was behind Thailand’s rapid growth and industry success, the speaker attributed it to “Service, service, service!”

However, culture determines how the patient defines both good and bad service. People from certain cultures may view touching as a display of affection while those from other cultures do not. Members of some cultures and social stratum want to be addressed by their first names.

Still, others believe respect is shown by using their family names. People from some cultures view the physician as “the knower” and measure “good care” by the level of their decision-making because authority “knows what is best.”

People from other cultures define good service and care as the physician’s willingness to form a partnership with them, to disclose all news, both good and bad, and share responsibility in making medical decisions. Patients from some cultures will show respect for the physician by never disagreeing or asking questions.

When asked if they understand or agree to follow a specific treatment plan, they will respectfully say, “Yes”; even if they do not understand instructions or have no intention to comply. Failure to comply with this medical advice may result in a negative outcome.

Meet MT patients’ cultural needs and wants — if they are pleased with the care and services you have given them, they will refer friends and relatives and help expand your client base and international reputation and, thus, boost your bottom line!

  1. Study and compare the domestic medical system of your targeted client base with your own. Learn what patients complain about related to their local systems and what they expect as a demonstration of good care and service. Can you avoid the negative aspects of domestic care while, at the same time, provide all those defined as good? Can you do this at a substantially lower cost and in the patient’s own language? These are the “pluses” to focus upon in your marketing materials.
  2. Make sure the patient is comfortable being in a foreign country and with the customs and languages that they do not know.
  3. Have someone ready to greet them in their language.
  4. Make sure forms and medical information including follow-up and billing is provided in their native language.
  5. Try to insure that both the physicians and nurses who attend to them can communicate effectively in their language or through a professionally trained medical interpreter. Train physicians and nurses how to use interpreters effectively.
  6. Train both medical and non-medical staff in the cultural and religious beliefs and taboos that may affect satisfaction and compliance with care.
  7. Train both medical and non-medical staff in the language skills required to communicate with that population group.
  8. Even if your country doesn’t have malpractice laws, avoid risks of medical error through miscommunication. Hire professionally trained medical interpreters or contract with an outside face-to-face, phone or video interpreting service.


Although the “soft skills” of cultural appropriateness and language access have, up to now, been largely ignored in favor of a focus upon marketing medical and technical know-how and lower cost, they impact every facet of both financial success and customer satisfaction in medical tourism. Without them, marketing attempts will fall flat and may even steer prospective clients away from entire countries as well as individual medical facilities.

Unless these facilities can promise and deliver appropriate care that meets the cultural needs, values and expectations in a language that is understood, medical tourists will not feel satisfied with care and will not recommend these facilities to friends, family and their local physicians. Cultural and linguistic competency may be “soft skills,” but they are necessary elements to growth of patient base, reputation and your bottom line.

About the Author

Suzanne Salimbene, Ph.D., president of Inter-Face International, holds a doctorate from the University of London, Institute of Education in the Teaching English to Speakers of other Languages. She developed an interest in cross-cultural business communication after living and working in many countries. She began to focus on linguistic and cultural competency in healthcare, in 1993, and has written and trained exclusively in that field since 1994.

Under contract to the U.S. Department of Health and Human Services, she wrote the first implementation guide to the Culturally and Linguistically Appropriate Services Standards, for the Office of Minority Health, in 2001. The first edition to the book, “What Language Does Your Patient Hurt In? A Practical Guide to Culturally Competent Patient Care,” was published by Diversity Resources, in 1998 and, the second edition, in 2005. She also published a newsletter, “Culturally Competent Care,” for 10 years and has developed the content for the training game, “Healthcare Diversopy,” as well as a multimedia training course for nurses.

When she moved to Mexico in 2008, she began to utilize her vast experience to assist the country in growing its medical tourism industry. For a complete CV listing her experience and publications, please contact her English-language web site or her Spanish-language web site She can also be contacted by email at or by telephone in the United States at 1-815-282-2433 or in Mexico at 33 3165 0069.

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