The Internationalisation of Healthcare and Business Aspirations of Medical Professionals

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published online 13 June 2014SociologyLila SkountridakiProfessionals

The Internationalisation of Healthcare and Business Aspirations of Medical

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The Internationalisation of Healthcare and Business Aspirations of Medical Professionals

Lila SkountridakiUniversity of Strathclyde, UK

AbstractInterest in international patient travel and trade in healthcare has grown considerably over the past decade. Whilst the field is under-researched, patients’ motivation to travel to seek healthcare solutions has attracted significant attention. In contrast, the perspective of the medical doctors (MDs) remains unexplored. This article directs attention to medical professionals as key players in the internationalisation of private healthcare provision. Through the lens of the sociology of the professions, it examines the ongoing initiatives of MDs in Greece to attract patients from abroad. Findings indicate that international patient movement has given an incentive to MDs to exhibit an entrepreneurial approach. Their attitudes portray professionals with business aspirations which go well beyond their role as medics, and stand in contrast to the traditional image of medical professionals. In addition, it fosters competition among professionals at a domestic and international level, threatening the cohesion of the medical community.

Keywordsinternationalisation of healthcare, medical professionals, medical tourism/travel, professional entrepreneurship

Introduction

Interest in international patient travel and trade in healthcare has grown considerably over the past decade. Other than the business interest it attracts, the phenomenon is of importance to a number of academic fields. Whilst the field is under-researched, patients’ welfare and motivation to travel has attracted considerable attention. In contrast, the perspective of the medical doctors (MDs) involved remains unexplored. This article directs attention to medical professionals as key players in the internationalisation of

Corresponding author:Lila Skountridaki, University of Strathclyde, 199 Cathedral St, Glasgow G4 0QU, UK. Email: [email protected]

535863 SOC0010.1177/0038038514535863SociologySkountridakiresearch-article2014

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2 Sociology

private healthcare. Drawing on an example of MDs in Greece, it suggests that they play a pivotal role in developing and building the new market. This takes place through entre-preneurial tactics and a business approach.

The sociology of the professions serves as a body of theory that usefully frames the qualitative data. It assumes a dominant position for medics within the healthcare system and examines the changes taking place in healthcare, the economy, and society more broadly. Recent contributions highlight both continuity and change in the professions (Evetts, 2011), but also mutation and adaptation of professionals with respect to the changing environment (Adler and Kwon, 2007). This article focuses on professionals in a private healthcare setting, where MDs work in collaboration but independently from large organisations and avoid bureaucratic control. Within that setting, the professional value of disinterestedness is examined vis-a-vis the perceived opportunity for interna-tional trade in healthcare. Findings indicate that patient travel lays bare entrepreneurial incentives: profit generation and self-interest are not perceived as taboo, while profes-sional success is considered in business terms. Furthermore, it illustrates professionals who advance the commodification of health services through commercial initiatives. The findings show, thus, a case of enterprising professionalism with elements of commercial-ism and entrepreneurship clearly manifested. This does not mean, however, that MDs do not strive to offer the highest quality of care. Nevertheless, it highlights a practising professionalism which isolates expertise from the sense of servicing community (Brint, 1994). Two debates in the sociology of the professions are most relevant here. The first is whether professionalism is mutually exclusive to commercialism and bureaucracy (Freidson, 2001) or whether elements of all three may co-exist (Adler et al., 2008). Evidence presented here suggests that commercialism (expressed through entrepreneur-ship and self-interest) and professionalism (dedication to high-end results) intersect (Hanlon, 2004). In light of this, the contention that disinterestedness comprises the soul of professionalism (Freidson, 2001) deserves re-examination. The second debate revolves around whether professions, over time and amidst socio-economic change, are losing their dominant position. Whilst commercialism may imply loss of public trust, broader trends need to be evaluated before drawing any conclusion.

Overall, as observed in a number of other countries, MDs’ entrepreneurship is not unique to the Greek case. Medical doctors appear to be behind medical providers’ initia-tives to open up services to patients from foreign countries elsewhere; for example, South Africa (Crush et al., 2012), Costa Rica (Ackerman, 2010), or Singapore during the 1980s (Chee, 2010). The contribution of this article is related to MDs’ initiatives to build the market. Through qualitative interviews it offers insights into the way MDs think and act with regards to the international movement of patients, and discusses potential impli-cations for professional power and the commodification of healthcare.

The Development of International Patient Travel as an Emerging Opportunity for Business

In the early part of the new millennium, scholars, mainly from the USA, began to observe a growing trend for patients to go outside their home country for medical care. Media reports provide evidence, for example, of Americans and Canadians moving to Asian or



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Latin-American countries for cheaper dental care, cosmetic surgery, timely hip replace-ment, accessible fertility treatment, and affordable cardiovascular surgery. Most observ-ers employ the term medical tourism to refer to the phenomenon where patients move to a foreign country with the purpose of receiving medical treatment. According to Carrera and Lunt (2010) it puts ‘an emphasis on clinical, surgical, and hospital provision’.

Patients decide to travel for various reasons. Long waiting lists, high treatment costs, and the need for privacy comprise important push factors. In addition, changes in life-style increase the market demand for cosmetic surgeries, dental care, and wellbeing activities (Garcia-Altes, 2011). Coupled with financial factors such as low-cost airfares, price differences in healthcare services between countries, favourable exchange rates and ease of communication via the internet (Lunt et al., 2009), there has been an increase in the transnational demand for medical services. This trend increases the expectations of business in the private sector, governments and some medical doctors. It gives a financial incentive to invest in new facilities and market services abroad. At an institutional level, transnational organisations make significant efforts to facilitate patient movement. The World Trade Organization promotes opening up trade in services, including the health sector (Labonté and Gagnon, 2010; Smith, 2012). At the same time, the European Commission has made clear steps in encouraging patient movement (Jarman and Greer, 2010) with the rationale that patient mobility within the European Union is a citizen right.

Overall, the expansion of patients travelling to foreign countries is expected to have a significant impact on involved stakeholders and civil society more broadly. It has the potential to affect the national healthcare systems, the life of patients travelling abroad, policy making, medical practices’ operation, and the hospitality sector. Moreover, schol-ars have voiced concerns over lack of any sort of regulation in terms of patient protection (Cortez, 2010), incidents of malpractice (Barrowman et al., 2010; Birch et al., 2010), and negative effects on the populations of host countries (Sengupta, 2011).

Academics are paying increasing attention to the emergence of medical tourism with an expanding number of studies exploring its demand, its driving forces, the conse-quences for stakeholders, and the ethical dilemmas involved. Less emphasis is placed on the perspective and role of small medical providers and, in particular, of medical doctors. A central argument of this article is that MDs are not only a key component of the sup-ply-side of global healthcare provision but also a key actor in its emergence. To better understand the argument it is fruitful to consider at this point some basic features of the organisation of international provision (supply-side). It is also important to place Greece within the broader map so as to make the example more illustrative.

Medical providers servicing the international demand are located in a number of countries. The size of providers, the phase of development of the sector in each country and the government involvement are important elements of this supply. For example, in one group of country-destinations large hospitals concentrate the bulk of inbound patient flows (e.g. Turkey, India, and Thailand). These large organisations may be owned by foreign investors or local entrepreneurs. There is another group of destinations where small providers attract the bulk of inbound patients. These practices are typically run by MDs who carry out the medical procedures but also undertake managerial tasks and marketing initiatives. Their aim is to increase their clientele. Whilst in some countries



4 Sociology

small providers account for the bulk of inbound flows in the start-up phase, later large providers expand significantly (i.e. Costa Rica and Singapore). The reverse may also hold. According to the vice-president of Thailand Medical Tourism Federation in 2011, there is an interest in encouraging smaller providers to engage with foreign patients. State involvement is also significant. The establishment of special boards and national programmes, the provision of tax incentives, the organisation of marketing campaigns, easing visa restrictions for foreign patients, or relaxing advertising restrictions in the healthcare sector are examples of interventions aiming to boost the sector (Chee, 2010; Crush et al., 2012; Lautier, 2008; Sengupta, 2011).

In Greece the sector is in its infancy. Small providers led by MDs currently account for the inbound flows. Despite their considerable capacity and strength, large private hospitals have only recently started seeking opportunities in foreign markets. It was also only at the end of 2013 that the state announced that a national programme was under-way. This development presents the group of MDs who have been active in the field for an estimated five to 10-year period as the ‘pioneers’. It is notable that the debt crisis has no small role to play in the recent interest of the state, large providers, and medics. Crippled domestic demand has intensified medics’ interest in the international demand. Larger providers are also increasingly considering agreements with foreign insurance funds as a result of payment delays by local funds. Simultaneously, the government per-ceives medical tourism as a lucrative market worthy of support. The current study research findings suggest that medical doctors in Greece deploy reputational capital, existing cross-border networks, newly established collaborations with intermediaries, and marketing techniques to increase their share in the international market. With regards to the sociology of the professions, the findings de-emphasise the argument that MDs employ a discourse of disinterestedness. Rather, they suggest a changing professionalism and call for an examination of the consequences on professional power.

The Sociology of Professions: The Case of Medical Doctors

The professional code of ethics and claim of disinterestedness remain at the centre of sociological discussions over the role and position of professions within society. The ethic of service has been characterised as the ‘soul’ (Freidson, 2001: 216), or ‘core’, of professionalism (Timmermans and Oh, 2010). Freidson (2001) defines professionalism as a mode of production where the producers have control over their work, the labour market, and the production of knowledge in their field. Simultaneously, their work requires discretion, is based on abstract knowledge, and deemed to be dedicated to a higher mission. As a result, it is suggested that the logic of professionalism is distinct from that of bureaucracy and the market. Various schools of thought perceive profes-sional disinterestedness in different terms. Professions have been praised for their ‘traits’ and service to society (Saks, 2012), even when appraisal has been accompanied with scepticism (Crompton, 1990). Professions have been criticised for using the rhetoric of disinterestedness to advance their own position within society regarding status, influence and financial rewards (i.e. neo-Marxists Johnson, 1972 and Larson, 1977) (Hafferty and Light, 1995). It is argued elsewhere that promotion of self-interest and public interest are not, per se, mutually exclusive (Saks, 1995). In mainstream economics, professions are



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portrayed as a cause of structural inefficiencies, which increase costs and reduce availa-bility for consumers (Feldstein, 1983: 393). Nevertheless, professionalism has been rec-ognised as a preferred way of organising specific functions of society, such as healthcare. Freidson (2001) suggests professionalism, based on morality and collegiality, is not only a distinct but also a superior logic over that of the market and bureaucracy. Many econo-mists also consider the market mechanism unsuitable to regulate healthcare provision (Arrow, 1963; Krugman and Stiglitz, 2012).

Irrespective of the debate on the nature of disinterestedness (is it real or merely pro-fessed), it is generally accepted that the inability of professions to convince others of their altruistic incentives would weaken their (dominant) position. Professional power is based on autonomy, whereas autonomy is granted on the premise of servicing commu-nity (Wolinsky, 1988: 44). Disinterestedness becomes, thus, a means to elevate political power, and MDs attempt to demonstrate that what is in their interest is in the interest of society as a whole (Light, 1995: 27). Professionalism is a dynamic process (Dent, 2007: 102) and professional dominance is ‘contextual’ in nature (Light, 1995: 26), therefore renegotiated as changes occur in the socio-economic environment (Dent, 2007; Light, 1995). The changing priorities of state policy, introduction of management and hierarchi-cal structures, corporatism, the shift in public opinion, consumerism and the increasing power of stakeholders such as insurance firms, have all been discussed in terms of chal-lenging the power of medical professionals. Despite the challenges, Hafferty and Light conclude that, according to most commentators, their dominance in the USA and abroad is maintained (1995: 135). At the same time, empirical studies capture significant changes in the values and identities of professionals who find themselves engaged in differenti-ated tasks. Whilst during periods of change individual and collective resistance is often observed, research findings stress that professionals adopt new roles and undergo muta-tion (Adler and Kwon, 2007). For example, Muzio and Flood (2012) show that within law firms, collegiality was developed in the relatively stable economic environment of the 20th century, and acted to brand a firm’s reputation and effectiveness. In sharp con-trast to the ‘professional organization man’ of the 20th century, however, professionals working in big firms during the 19th century are depicted as individualistic and entrepre-neurial (2012).

A significant change for professionals in a number of countries has been the introduc-tion of management structures. For example, research on clinical doctors’ first manage-rial appointments within the market-inspired British NHS shows that MDs appeared overwhelmed by how differently they had to think of their work and were unprepared for management roles (Dawson et al., 1995). Nevertheless, some clinical managers – young in age – seemed to embrace the new type of power stemming from the emerging organi-sational setting. Dawson et al. recognise that this opportunistic behaviour could down-play collegiality. Hoff’s (1998) study of US physicians holding executive positions reflects, in general, positive attitudes towards managerialism. His findings indicate com-mitment not only to the profession but also to the employer; additionally, a weaker belief in professional values by young professionals. Other perceptive work from Hoff, on soli-darity among physicians in clinical practice versus those taking over additional manage-rial tasks, highlights fragmentation and competition rather than collegiality (1999: 326). The importance of the workplace has been also emphasised. Wallace’s (1995)



6 Sociology

comparison of lawyers working as employees in lawyer firms as opposed to corporations reveals differentiation in commitment to professionalism. Lawyers working in a nonpro-fessional environment appear to be relatively less committed to professional norms, which might be explained by better opportunities for promotion and perceived legiti-macy of the reward system in law firms. This line of analysis implies that professional groups exhibit a tendency to adapt to their environment.

Partial adaptation to changing environments is often observed, a phenomenon described as ‘hybridisation’. Kurunmäki suggests that, when confronted with the intro-duction of managerialism, MDs in Finland ‘willingly’ adopted accounting techniques but not relevant abstract knowledge, leading to a ‘hybridisation of medical expertise’ (2004: 343). This analysis implies a form of conciliation from the medics. Similarly, according to Muzio and Ackroyd (2005), lawyers in management positions in large law firms have acquired managerial attitudes and tasks. The authors note carefully, however, that even though managerialism and entrepreneurship have ‘infiltrated’ professional practice, the process has actually enabled the profession to maintain control over its work.

The above empirical findings suggest adaptation to new situations and roles which is often relevant to adoption of new identities and values. Hanlon uses the term ‘commer-cialised professionalism’ to depict the situation in which the ethics of servicing commu-nity are downplayed as new roles gain importance. Research on accountants suggests that professionalism is perceived as completing tasks skilfully or ‘expertly’ (Hanlon, 1996) centred on client satisfaction (Anderson-Gough et al., 2000). This understanding of professionalism does not include moral aspects of servicing. Light and Levine (1988: 19) refer to Derber’s ‘ideological proletarianisation’ to describe disassociation from pro-fessional ends and a ‘narrower conception of service’ (Scott, 2008: 233). These empirical contributions depict significant changes in the nature of professionalism. Either enforced by external pressures or more willingly adopted as a means to maintain control, they emphasise a co-penetration of the logic of professionalism, commercialism and bureaucracy.

If it is accepted that established professional values lie at the heart of claims to power, then these changes carry an important weight in terms of alterations to professional power. However, if the values of other individuals and groups move along the same lines, then medics’ power might not be challenged but perhaps differentiated. It is these dynam-ics that this article explores, drawing on MDs’ narratives of entrepreneurship within the internationalisation of healthcare. Before discussing in more detail the research findings, the research method, participants, and some background to the organisation of the health-care sector in Greece are presented.

Methodology

The empirical findings of this article are based on semi-structured interviews conducted in Greece during the spring and summer of 2012. Participants were 32 health profession-als, mainly MDs working in private practices. The medical specialisations included aes-thetic and reconstructive plastic surgery, ophthalmology, fertility treatment, hair transplantation, dental care, and cardiac surgery. Interviews were also conducted with a psychologist and a midwife working in private medical practices, and two (private)



Skountridaki 7

hospital managers. Interviewees were located either in Athens, a metropolitan area, or the island of Crete, an area in the periphery with relatively good healthcare facilities and high international tourism demand. The public sector is not examined in this study.

An online search was conducted through the Google search engine using keywords such as ‘surgery’, ‘treatment’, ‘dental care’ in combination with location names (i.e. ‘Athens’, ‘Crete’, ‘Rhodes’) to enlist potential interviewees. The interviewees were approached based on their professional webpage and the criterion employed was whether the website had a foreign language(s) version. This was perceived as a sign of interest in foreign markets. It was shown that only in two cases there was no real interest. The num-ber of MDs fulfilling this criterion at the time slightly exceeded 100 for Athens and Crete. This implies that the number of 32 interviews is satisfactorily high as a sample. Nevertheless, while the criterion is acknowledged as resourceful it has its limitations. Formal and informal interviewees mentioned cases of MDs who have special agreements with foreign insurance funds. These are not widely known and no form of evidence is publicised through the press or other sources. Therefore, exploration of the conditions under which such agreements are signed and through which patient flows are established has not been possible.

All interviewees, except for three, had specialist training or work experience in other western countries, mainly the UK and USA. Almost all the research participants are well-respected professionals receiving generous fees for their services. They typically offer services on a fee-for-service basis and their clientele is based on word of mouth or, less frequently, media appearances. Advertising is restricted for MDs. They are in close collaboration with one or more private hospitals and use their facilities extensively. Private hospitals benefit from the MDs’ clientele coming for examinations and treatment and hire a relatively limited number of practitioners. All practitioners work in the private sector by choice, although they generally have the option to work for the NHS, at least in the countryside. The Greek NHS, however, is not always a particularly attractive choice – not only because remuneration is low, but also because of perceived inefficiencies (Economou, 2010) and widespread corruption (Liaropoulos et al., 2008). The private sector is remarkably developed. This is shown by the over-supply of MDs, where Greece is ranked top of the OECD countries with 6.13 MDs/1000 inhabitants (OECD, 2013). This ‘impressive’ ratio also accounts for the limited concerns over the recent migration of thousands of practitioners to Northern Europe and America.

Interviews were overall a pleasant experience and the interviewer was well accepted as an educated individual with expertise in a new field. In several cases, rapport had to be built during the discussion, given that most participants were unfamiliar with the research method of qualitative interviewing. Interviews lasted from 20 minutes to two hours and were transcribed. As themes started to emerge in the data analysis, confusion arose with regards to literature on the professions. The honest reference of participants to profit making was somewhat surprising, when a rhetoric of disinterestedness instead of self-interestedness was anticipated, at least formally. Professionalism in Greece does not take the form it does in the UK, partly because there is a strong private sector, which was the focus of the study. Initial biases over what professionalism is, clearly spurred by the focus of the literature on ‘professionalism of old’ which ‘is grounded in autonomy and dominance and houses an immense disdain for commercialism’ (Castellani and Hafferty,



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2006: 12), soon came to an end. Nevertheless, the explanatory power of the literature on ‘professionalism of old’ was minimal, while most recent contributions from the USA over MDs as businessmen or new interpretations of professionalism through examples of different country cases and work settings proved informative.

Analysis: Entrepreneurship as a Professional Value

Data analysis revealed consistent themes arising spontaneously out of the data. The emerging themes were interrelated and explored through the theory of professions. Framing the data with theoretical themes such as commercialised professionalism, hybridisation of professional values and adaptation to (a commercialised) environment allowed an understanding of the interrelation between international trade and profession-als. The findings highlight the importance that MDs place on entrepreneurship and are presented in three thematic parts. These include, first, medical professionals’ perception of ‘selling’ their services in the (international) marketplace; second, the link between entrepreneurship and success; and third, a service ethic void of disinterestedness.

Selling Services in the Marketplace

Throughout the interviews MDs often discuss healthcare as a market. This reflects to an extent the very nature of private healthcare provision but also MDs’ perception of health-care as a business sector. It is indicative that the language employed by participants reflects a business orientation. The 2008 financial crisis, the Greek debt crisis, the over-valued euro and the potential impact of ‘emerging economies’ are all phenomena that seem to preoccupy interviewees. ‘Competitiveness’, ‘cost reduction’ and ‘exchange rates’ are terms frequently used to describe perceptions at the macro-level. Additionally, interviewees draw on marketing terminology such as ‘target groups’, ‘promotion’, ‘value for money’ and ‘marketing campaign’. Most, but not all, refer to their patients as clients and to healthcare as a market. For example, an IVF expert notes:

It is a market – healthcare is also a market – and everybody is looking for the best [quality] and pricewise most advantageous. (Medical Professional 14)

A dental surgeon expresses her concern about the negative implications of advertising restrictions:

A website that targets foreign markets needs to be a bit more [commercial] … it has to sell more. Not just to present who we are […] I wouldn’t like to be promoted in a foreign market in the same way the next-door dentist is. (Medical Professional 23)

With regards to the 2008 crisis, a plastic surgeon explains:

We used to be 50% cheaper in comparison to the UK, now we are only 10–15% cheaper. In essence, there was currency devaluation in the UK in response to the [international] crisis, which strengthened their market and weakened ours. (Medical Professional 2)



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The majority of MDs employ business terms, highlighting a professionalism that goes beyond ‘a third logic’ as presented by Freidson (2001). The initiatives to attract foreign patients are also worthy of note. MDs in Greece take a number of actions depending on their individual circumstances and skills. For example, three interview-ees claim that their international reputation is the reason why foreign patients consult them. A number of study participants who worked for a period in a foreign country (e.g. Germany, the UK, Belgium) explain that they maintain connections with their old clientele; patients or people from the patients’ environment fly to Greece for consulta-tion. Several note that web marketing (in multiple languages) and collaboration with specialised ‘medical tourism’ portals secure a share in the international demand. Two practitioners explain that they have (or have had in the past) individual agents repre-senting them in a foreign country. In a few cases, it is their peers abroad that introduce them to patients for a commission. Local practitioners benefit from foreign house own-ers too. Foreign nationals who spend a short period every year in Greece, and most importantly family and friends who visit them, plan and undertake treatment during their stay. There are also cases of agreements between MDs and foreign insurance funds or general tourism operators. MDs developed plans even during the period of the interviews. For example, several seek collaborations with agents. Others consider ways to advertise their services to particular markets (e.g. the UK), or make agree-ments with foreign MDs who would channel patients to Greece. Whilst the way MDs develop connections with foreign patients is a topic to be analysed elsewhere, these examples illustrate how MDs build and develop a niche market. Interviewees essen-tially run their practices as a business, which is expected to a certain extent within the private sector. The nuance, however, is that they are now orientated to exporting their services to foreign ‘markets’. The endeavour requires a combination of established approaches to clientele development mixed with new techniques from the world of business. Entrepreneurship becomes ever more important as a prerequisite for increas-ing their share in the international market.

Business Success Requires Entrepreneurship

The market forces of the private sector within which MDs offer their services (in solo practices or partnerships) influence medics into developing a business mind set. At times, efforts to approach clientele from abroad are justified as ‘proactive’. Given the turbulent environment of the marketplace such actions are considered a necessity, even when believed to be in contradiction to the philosophy of a medical professional. A young dental surgeon explains why marketing his practice (at an international scale) is essen-tial: ‘… we are part of the economy therefore one cannot pretend to be “above” market-ing’ (Medical Professional 13). The market pressures are intensified due to the debt crisis, increasing the interest of MDs in foreign markets. Severe income cuts to locals have crippled the domestic demand for private healthcare:

[…] locals come for surgery and unfortunately cannot afford it. This forces MDs to orientate themselves abroad … to bring in foreign currency. (Medical Professional 3)



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Well, it is not the crisis that initiated the efforts … but due to the crisis there is, if you wish, abundant personnel … and the lack of work makes the search of an alternative necessary. (Medical Professional 25)

There was always an interest. Since Crete is a tourism destination we have always been in contact with foreigners […] But the interest is intensified due to the crisis. (Medical Professional 26)

In some cases pressures are described as high and advertising as a realistic necessity forced by the adverse economic conditions:

It is Friday and we do not have work in the practice. Aren’t we going to mobilise whatever mechanisms we can so that we have? We will not care about the medical association and the possibility that it will object to it [marketing practices]. When this will be done by many, because it doesn’t concern only us [the partnership], we will be led to new things. (Medical Professional 23)

The latter statement reveals a dynamic force which may bring a shift in the advertising bans. It stresses the matureness of medical professionals in making a step further in the formal institutionalisation of healthcare marketisation.

The crisis plays, thus, the role of a catalyst by intensifying interest. In most cases foreign markets are not first considered due to the recession. A doctor involved in setting up a clinic explains that his investment decision is related to increased international patient flows:

[This clinic – treating foreigners] is what I wish to create and the reason I came to Greece. I have already bought the building to make something on my own. (Medical Professional 7)

Two more MDs share that they moved to Greece, considering the international patient movement as an important part of their work:

I know of specific surgeons who take along specific patients. Like me. You know, I do not really advertise outside the country but I have my patient base outside the country. That’s what I bring in. (Medical Professional 4)

Coming back from the UK, because this is where I was specialised, I thought, why not? Prices were 50% lower at the time … they may undertake a surgery and spend the rest of the budget on vacation […] I had not seen that somewhere else, I thought, why not create a site to attract patients from the UK? (Medical Professional 2)

Establishment of regular inbound flows is perceived primarily as a source of increased revenue with prestige, recognition and business success also accounted for. The eye sur-geon below has aspirations to develop a ‘medical tourism’ unit with international impact:

I have put too much effort in it … I have been to Doha, to Moscow, I have been to Berlin. […] If we want to be competitive – because all right, here, as a small clinic I can play this game and bring in 50 people. But this does not make any difference to me. Here we should create a medical city. (Medical Professional 30)



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For a few, creating large patient flows is a matter of showing off ‘leadership’ in their field:

Sometimes I think that someone else [plastic surgeon] is going to do it [big investment] and this is going to hurt me … ’cause I have made such a detailed plan. (Medical Professional 9)

Well, there are IVF centres that advertise that they have patients from abroad. For example Dr Y advertises it … Dr K from XYZ clinic even talks on TV about helping couples from Italy. (Medical Professional 1)

Other participants are not so eager to commit themselves to non-medical activities. Some argue that medical doctors do not possess the know-how, or that it is not their role to do business. Preoccupation with business activities would restrain the time they dedi-cate to medical work and may cause loss of medical skill (Hughes, 1958: 134). Nevertheless, reluctance to dedicate their own time does not mean they are indifferent to exporting services. Instead, they consider professionals specialising in the fields of man-agement and marketing necessary:

[The MD] has to hire a person to organise [patients’] reception. The MD cannot do those things. The MD might give the idea and find the suitable person to be in reception and also be salesman. (Medical Professional 18)

I am looking for a person to organise the inflows of patients because at the moment they come arbitrarily. This person has to be abroad […], have an office, collect cases, take a commission, and send patients South. (Medical Professional 31)

Well think of having emails to answer a day that I have surgeries. You need a team of 2–3 capable people to handle this. (Medical Professional 9)

MDs stress the necessity of entrepreneurial skills (Hanlon, 1998). In essence, an entrepreneurial spirit is considered a cornerstone for success. An IVF expert claims that ‘most successful gynaecologists are successful more due to entrepreneurial inspi-ration. They promote themselves better’ (Medical Professional 14). For whatever rea-son that entrepreneurship might be pursued (ambition, necessity or realism), success is conceptualised to a great extent in business terms. Entrepreneurship, therefore, emerges as a new value linked to success. ‘The tension between medicine as a scien-tific profession and medicine as a business’, to paraphrase Stone (1997: 536), seems to be reconciled. How success is defined reflects the values that inspire and guide professionals; that is, in terms of excellent medical results which enhance patients’ lives and benefit the community broadly, or the increased prestige that a professional enjoys among their colleagues, or by increased profits (generated either due to excel-lent results or successful self-promotion). The quote above illustrates that success is perceived with reference to an extended clientele: it is not medical doctors with the best medical results who are most successful but those who can promote their services better.



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Professional Ethics Void of Disinterestedness

In the private sector healthcare is offered on the basis of purchasing power instead of need (Hanlon, 1996). During the interviews most MDs are explicit about their interest in profit making. Nevertheless, as Anderson-Gough et al. note for accountants, the com-mercial character of medical services does not mean it is void of a ‘service ethic’ (2000: 1152). Attention to medical ethics and moral concerns in the private sector begin after the patient is admitted for treatment. In this case, a call for high quality of service dominates; most MDs might not aspire to serve all members of society according to need but may aspire to offer the highest quality of service to their clientele. The practitioner below resents the possibility that the country will exit the euro as it would unavoidably force her to compromise quality:

There are [imported] medical materials which, if we enter drachma, we will not be able even to access … prices […] I want everything to look natural. This is possible only with one-two materials. (Medical Professional 12)

The statement shows a dedication to the highest quality of service; it is not perceived as an expensive product of high standards provided to a segment of the population. The dental surgeon appears committed to deliver what she is supposed to (with reference to her teachers and the profession) and to satisfy patients that ‘decide’ to pay the price. The considerations of a fertility treatment expert over his services and patients are relevant. The expert explains that foreign patients endure the difficulties of the trip to visit his practice because of his reputation and relatively low prices. He perceives fertility treat-ment as an elective, non-medicalised state-of-the-art procedure:

They can be better called clients […] these people are not patients. They undergo a therapy that is not related to a health problem, it is an issue with fertility that they have. (Medical Professional 20)

The participant’s view openly de-emphasises the role of the medic in favour of the role of the expert. This view arguably undermines the social importance of the service. As Brint has discovered through interviews with professionals in the USA, professionalism is centred on good medical results, whilst only a few professionals ‘remark on the social importance of their work’ (1994: 10).

Patient welfare remains, nevertheless, important for a number of reasons. First, there are psychological reasons related to MDs’ work satisfaction and self-esteem. Second, high quality of services means serving not only the interests of the patient but also those of the doctor. Reputation is of great importance for an MD ‘[…] for his career is his ultimate enterprise’ (Hughes, 1958: 135). Patients’ welfare is translated into a marketable attribute; it increases the value of the service offered within a competitive marketplace (Anderson-Gough et al., 2000: 1167). Satisfied clients set in motion a word of mouth mechanism which is important not only for the domestic clientele but also the interna-tional. To a certain extent this is what brings in patients from abroad:

… afterwards foreigners do the work, since they are satisfied, they communicate it [the satisfaction], and you see that this Briton, or this German or this [patient] from UAE […]; they



Skountridaki 13

write [in forums] that I went there and I solved my problem. These [comments] are circulated, others read them, and they come. (Medical Professional 3)

[Word of mouth] is what I count on to be honest. My work. Happy clients. They come from Sweden and they tell me, do you know something? You are renowned there. They write in forums for you, everywhere. (Medical Professional 7)

The fact that reputation is connected to career often functions as a quality standard mechanism. As the surgeon’s statement below illustrates, it is also connected to a respon-sibility towards the patient:

… there are surgeries that require seven days to see if there will be any [after-surgery] problem and other surgeries that require two. I keep her seven days. I tell her that if you do not stay seven days so that I cut the stiches myself you cannot go, simple as that. Or do not do it with me, go somewhere else. It depends on the personality of the doctor; his ethos. (Medical Professional 29)

Even though some medical mistakes can be relatively easy to conceal or responsibil-ity easy to divert away from the medical doctor, establishing a reputation would require relatively good medical results and high success rates. In a competitive international environment high standards of services alongside reasonable (if not low) prices are expected.

Discussion and Conclusion

The data analysis indicates enterprising tendencies which emphasise co-penetration of commercialism and professionalism. The enterprising attitude of medics in relation to the internationalisation of healthcare has some practical implications. Overall, commer-cialisation is linked to the internationalisation of healthcare in a mutually reinforcing mode (Chee, 2010). This study shows how enterprising professionals accentuate the commodification of health. Accentuated commercialisation, however, may also weaken professional power, in two ways: increased international competition among practition-ers may breed segmentation; and lack of commitment to the value of disinterestedness may pose a threat to the medic’s public legitimacy.

To better illustrate the accentuation of commercialisation by MDs, one could consider how their initiatives might be understood if they were to take place at a national level. For example, participation in a local portal that advertises surgeons or clinics alongside their price lists is not possible due to law restrictions. In particular, there is either an annual fee for the advertising services, or a commission per patient, alongside options to advertise better for higher payments. At the same time, portals outside Greece that list medical providers encourage and present reviews of patients and ratings in a very similar fashion to hotel ratings found in tourism portals. Again, such a portal would not be per-mitted at this time in Greece. Similarly not allowed in Greece is the case of medics’ agreements with general tourism operators, who receive a fee to channel tourists to MDs’ practices or sales representatives in distant geographical areas. Taken together, such arrangements accentuate commercialisation within the country. Furthermore, there is



14 Sociology

little doubt that these initiatives create the conditions and place pressures for the future abolition of advertising restrictions domestically.

One implication of advanced commercialisation is the reinforcement of interna-tional competition among peers and the related segmentation across national borders. While a number of MDs invest time and resources in creating the market, other practi-tioners publicly take a negative stance towards it. There are online posts by MDs warn-ing patients of foreign practitioners for quality and safety matters.1 There are also publications by surgeons concerned with increased malpractice cases after overseas treatment (Barrowman et al., 2010; Birch et al., 2010). Guidelines for medical travel-lers are issued by medical associations (Foss, 2012). Simultaneously, an enterprising professionalism may carry negative implications for the legitimacy of medics’ social and financial rewards. In reality, however, it remains questionable whether public opinion is negatively affected by non-altruistic initiatives. Expertise increasingly becomes the ‘basis of distinction’, replacing authority legitimised by disinterestedness (Brint, 1994: 10). Furthermore, the market values become widespread; thus, profes-sionalism void of disinterestedness might not be necessarily reprehensible as entrepre-neurship becomes increasingly accepted. Abercrombie (1991) suggests that the enterprise culture observed [in British society] is not the result of political initiative but of ‘fundamental changes’ in society itself. Arguably, even when the enforcement of market practices on healthcare is understood as a top down process, market values are increasingly diffused within society. Certain groups and individuals are clearly opposed to neoliberal practices and market mechanisms permeating every sector; nevertheless, entrepreneurship is advanced as a feature connected to wealth, success and personal achievement and is appraised as moving the economy forward. Universities increas-ingly promote entrepreneurship to their students and partners and are partly trans-formed into business enterprises. In Greece, entrepreneurship is now depicted as a way out of the crisis, with various programmes announced to support young entrepreneurs and ‘innovative’ ideas. Such initiatives are widespread in Europe and elsewhere. As far as patient travel is concerned, in destination countries, inbound flows of patients are presented by the media and perceived by the governments mainly as a promising sector for the national economy (e.g. in Greece, India and Singapore). In the countries of origin, the people who decide to travel might think positively of the opportunity to have treatment abroad, despite any resentment they may retain for not being able to access healthcare at home. The sceptics of cross-border care base their critique on health risks, lack of regulation and ‘unjustified’ rising costs for the local healthcare systems. There is also critique of the practice as a business activity that does not suit healthcare provision and medical ethics. In contrast, the powerful voices of transna-tional regulatory bodies such as the WTO and EU take initiatives in the international regulation of patient movement – initiatives in support of rather than opposition to the marketisation of healthcare. Regulation encourages the practice by setting up the rules of the game. Therefore, assessing whether an enterprising professional attitude would coincide with an erosion of the legitimacy of medics would require a deeper under-standing of the changing public consciousness. Little doubt remains, though, over its role in the accentuation of commercialisation of healthcare.



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Acknowledgements

I would like to thank Professor Sharon Bolton and Professor Daniel Muzio for their perceptive feedback on my work.

Funding

This research was funded by a PhD scholarship from the Athens Institute for Education and Research.

Note

1. For example, ‘With diseases like HIV and increasing rates now of Hepatitis A,B,C,F&G abroad, as well as the further East you go the more resistant infections are to any medi-cal treatments back here in the UK (eg: TB, Bird Flu, Conjunctivitis), such risks can infect family members and others too!’. Available at: http://www.smilespecialist.co.uk/dental-dangers-abroad-cheap-dentistry-tourism-warnings-safeguards.html (accessed 3 November 2012).

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Lila Skountridaki completed her PhD at the Department of Strategy and Organisation, Strathclyde University Business School, UK. Her PhD examined the role of medical professionals in the inter-nationalisation of healthcare and the entrepreneurship of medical doctors. She has studied Economics at the Athens University of Economics and Business and the University of Amsterdam. Her research interests include the internationalisation of healthcare, medical travel/patient mobility, and the professions. Before starting her PhD studies, Lila worked for Quality Control and Accounting Departments in the private sector in Germany and Greece.

Date submitted June 2013Date accepted April 2014

Documents

The Internationalisation of Healthcare and Business Aspirations of Medical Professionals