GPs and registrars play a crucial role in refugee health. They are often the first health care point of contact for newly arrived refugees and asylum seekers. Dr Graham Emblen, GPTQ’s Deputy Director of Medical Education, and Dr Jamie Nuttall, a GPTQ registrar, share their experiences and tips when caring for refugee patients.
The perception of refugee health is not always right
Having done his first two GP terms at Inala Primary Care, a non-for-profit preventative health clinic with a large patient load of migrants and refugees, Jamie is quick to dispel a common misconception about refugee health.
“Often the first thing that crosses your mind is refugee health might be confronting or harrowing but that’s not the experience I’ve had at all. People have come from shocking circumstances and have been through appalling experiences but once they’re here, they’re often really excited and grateful about all the ways their lives are changing for the better,” he says. “They are really appreciative of the help you give them and that’s really rewarding.”
Graham, who practices at the World Wellness Group (a Brisbane-based social enterprise set up to specifically support refugees) agrees, saying he’s amazed at his patients’ resilience and intelligence.
“There was one lady I spoke to who was from Afghanistan and I asked how she relaxed. She said she listens to Indian music so I said, ‘Oh you speak Hindi then?’ and she said ‘Yeah, I speak five languages and I’m now learning English.’”
Communication can be a barrier when treating refugee patients
According to Graham and Jamie, the language barrier is the most difficult issue GPs encounter when helping refugee and asylum seeker patients.
“Probably 50 to 70 percent of my consultations are done with telephone interpreters and occasional onsite interpreters,” Graham says. “Having to go through another person just to get the message across can be difficult, but if you have any doubt about your patient’s English ability, use an interpreter as early as possible. You’ll find that actually speeds things up. You’ll make fewer mistakes and provide better health care as a result.”
Jamie says there are other differences when it comes to communication too.
“There are also different cultural practices and beliefs about health that create another communication barrier. Compounding this is the fact that refugees’ health literacy can vary widely. It’s partly because people haven’t had much exposure to a Western medical system. They may not be aware of things you take for granted living in Australia – simple things, like not knowing about paracetamol for headache,” he says.
Jamie believes the key to overcoming these issues is to ‘be really meticulous’ in your consultation communications and avoid making assumptions about your patient’s health care knowledge and values.
“The important thing is to ask very open ended questions, making sure that they understand and are on board with everything you’re telling them. Take your time because you can’t rush, especially when using an interpreter. You’ll be doing longer consultations with refugee patients because you can’t do most of what you need to do in just 15 minutes,” he says.
Mental health is a big issue
Apart from dealing with physical ailments and nutritional issues, Graham says many of his refugee and asylum seeker patients suffer from trauma. Their mental turmoil doesn’t end once they reach our shores.
“We tend to think that once they get here, they should be ok but the whole process of learning English, establishing themselves in Australia, building networks and learning how to function here is an ongoing and stressful process. It probably takes between five to ten years to fully assimilate,” Graham says.
Asylum seekers have limited access to the healthcare system
Accessing healthcare services in Australia can be difficult for those classified as asylum seekers.
Graham says: “The refugee often has appropriate visas; many have permanent residency or a guarantee that they are able to stay. The asylum seeker has come from a dangerous and difficult place and are here in a limbo situation. There are frequent periods where they don’t have Medicare and GPs are very limited with what they can do because they don’t have money for investigations or medication – and they can’t go to the hospital without getting a massive bill.”
In these situations, Graham says health care is often reduced to a very basic level.
“It becomes very challenging in that space. About 20 percent of the work I do is pro bono as I can’t bill my patients because they don’t have any money,” he says.
Graham says one of his patients aptly sums up the struggles asylum seekers face when referring to himself as ‘stateless’.
“He says he has no state or no home. He’s not welcome back in his own country; he’s not welcome here. The stress and the problems that produces on top of all of the other things is immense,” Graham adds.
4 tips for caring for refugee and asylum seeker patients
1. Use interpreters
Graham advises to use interpreter services early. “Even people who seem to have reasonable English skills don’t have a vocabulary large enough when it comes to medical terms and you’ll often find that there’s major misunderstandings,” he says.
2. Link with other service providers
Find support services for your patients. Graham says: “PHNs provide both education and resources to support refugees. There is a faculty of special interest within the RACGP in refugee health and they provide great resources. The Mater Hospital in Brisbane has a specific clinic that supports refugees with complex needs and you can refer to them. The whole goal is to share the work around. The more people that can appropriately support refugees and asylum seekers, the better quality of care they receive.”
3. Seek out other sources of help
Jamie encourages doctors to take advantage of online resources, such as the Refugee Health Network’s Guide to treating patients from such backgrounds.
“There are good health assessment guidelines available for working with refugees too. They can help you to be more systematic about your assistance,” he says.
4. Get experience
Graham says he enjoys the complexity of the presentations he sees at his World Wellness Group practice.
“I don’t like just doing the easy stuff. I like taking on a challenge and refugee health certainly provides me with that,” he says. “Each Monday, I go in thinking ‘what am I doing, why am I doing this?’ because I know it’s not going to be easy. But I come home at the end of the day thinking it was all worthwhile, I’ve made a difference. I didn’t always have that feeling when I worked in other general practice clinics.”
Graham hopes his passion and experience working in refugee and asylum seeker health may inspire registrars to work in this area too.
“Refugees are being settled all across the country. Be aware that you probably have some refugees in the practice that you’re already working in,” he says. “Don’t be frightened of the complexities in communication and in understanding the social context. You’ll find people with fascinating stories, you can build a long-term relationship with them and you can make a difference.”