Refugee-care docs spread thin

Treating immigrant patients a special brand of medicine

By Sam Solomon

Tied to the roof, she was forced to watch as her husband was tortured to death beside her. Her two children were nowhere to be seen. Finished with her husband, the attackers moved on, joining the growing mob spreading violence and terror across the countryside. It was 2002; the Ivory Coast civil war had begun.

That woman was one of Dr Lavanya Narasiah's first patients.

Haunted by visions of her husband on the roof, experiencing physical symptoms likely tied to post-traumatic stress disorder and still unsure of her children's fate, the woman decided to flee the country as the violence continued. Her children were safe, she learned, hidden far away by sympathetic neighbours. She set out for Canada.

"There are so many things ethically you can't do, like giving her money or getting involved personally," Dr Narasiah says. "But it's almost like those rules don't count. If I had cash on me, I would give her what I had."

Dr Narasiah, a young woman of Indian heritage, is a family physician in Montreal who specializes in refugee healthcare at the city's main clinic for such patients.

UNIQUE DEMANDS
That Ivorian woman was one of some 230,000 immigrants and refugees who arrive in Canada every year — a population with medical and social needs as diverse as the hundreds of countries they come from. "You're really dealing with the complexities of the world in this field," says Dr Kevin Pottie, a University of Ottawa family medicine professor and one of Canada's leading experts in a developing discipline called Migration Medicine and Health. Doctors who specialize in caring for migrant populations must learn an entirely new set of skills, above and beyond their medical training.

Not surprisingly, there's a drastic shortage of doctors with such training — a shortage that may be even more pronounced in family medicine, according to Dr Pottie. The reasons, he says, are that the field is particularly complex and has not received a great deal of national attention.

CULTURAL BARRIERS
Immigrants and refugees comprise 19% of the total population and account for fully 60% of the country's population growth. The majority of new arrivals are in good health, but a basic cultural divide can endanger the crucial level of trust between doctor and patient, and therefore the quality of care.

One of the biggest barriers to providing effective care is the immigrants' failure to negotiate the Canadian healthcare system, which can be confusing for people from disparate backgrounds or who can't speak English or French fluently. Those patients are at risk of being alienated from the system and may very well end up without a family doctor, relying on ER and walk-in clinic visits, or dropping off the radar altogether.

To improve immigrant patients' access to and compliance with the Canadian system, Dr Pottie and Dr Narasiah agree that treatment must be adjusted to fit their expectations. "The standards of care could be correct but the mediation to the approach may be missing," Dr Pottie explains. Dr Narasiah's practice incorporates social workers, nurses and cultural mediators — people who understand the patients' home countries' healthcare system as well as the Canadian one.

MENTAL HEALTH
That first visit with an immigrant or refugee patient can be demanding, lasting well beyond the typical 8-minute consult to an almost unimaginable 45 minutes or an hour. Patients' medical records are often either incomplete, unclear or entirely absent. The Canadian government will have already screened applicants from overseas refugee camps for tuberculosis, HIV, syphilis and other conditions that could place a large burden on the Canadian healthcare system. But immunization and medical history reports are unlikely to be comprehensive.

With such little information to go on, it's important to pick up on non-verbal communication during the visit, says Dr Narasiah, and to ask lots of questions about mental health. "Even if they just come in for stomach pain or something small, it could be related to post-traumatic stress disorder or depression. We told our nurses to ask about sleep problems and diet and about eight times out of ten, something comes up."

In some cultures, women will not discuss sexual or reproductive issues when a man is present. And likewise, some men will not disclose sexual or mental health issues to female interpreters or doctors. It's important to try to accommodate patients' cultural beliefs if you can arrange it, says Dr Narasiah.

"IT'S THE PASSION"
One of the biggest hurdles for doctors working in immigrant and refugee healthcare to overcome is the lack of available training. "There are many doctors in Canada who have experience and knowledge in the field," says Dr Pottie, "but most of that has not been effectively translated in training or CME."

He's currently developing evidence-based guidelines and clinical tools through his Ottawa-based Immigrant Health Network, with funding from the Public Health Agency of Canada. With help from colleagues, he has created a checklist intended to help train students and young doctors on how to care for immigrants that's already being used in 10 clinics across Canada, as well as preventive care handouts for immigrants and their doctors.

Dr Narasiah's clinic is also finalizing a set of clinical guidelines for treating refugees.

It's not easy work, she says, and there's not enough government support for doctors who do it. "It's the passion that keeps me in it. We're paid by the hour so this isn't where you go to make money," she says. "We don't even have a secretary for eight doctors. We do our letters by hand. It's really, really tough, but I couldn't see myself working anywhere else. The rewarding part is working with the people."

To request a copy of Dr Pottie's immigrant care guidelines, email [email protected]. To request Dr Narasiah's refugee care guidelines, call 514-731-8531.