Self-directed cases with discussion prompts

Jonathon is a 40-year-old Wadi Wadi man who has recently moved to the outer suburbs of Melbourne from rural southwest NSW and presents for a health check. He lives with his wife and three young children, and works as an office manager.

Jonathon tells you he recently spent some weeks back on Country for ‘Sorry Business’ after his older brother’s sudden and unexpected death from a heart attack at the age of 47. Many of his family members talked about needing to look after their health so there would be less Sorry Business for their community. This has motivated him to attend, despite a bad experience he had with a GP some years before where his Aboriginal identity was questioned, which put him off.

Jonathon says he generally feels well. He felt renewed by being back on Country and participating in ceremony with his community, and one of the Elders treated everyone with some traditional medicines (mixed plant-based tea) to support good health for the whole family. At the last check-up he had, the GP told him he needed to start taking a medication, the name of which he can’t remember. When the script repeats ran out after six months, he did not get it renewed, as he felt the GP hadn’t really explained to him what it was for or whether he needed to keep taking it.

1. If this was the first time you had met Jonathon, how would you ask how he identifies himself or his cultural heritage? What are the barriers to a patient identifying as Aboriginal and/or Torres Strait Islander? Why might an Aboriginal or Torres Strait Islander person choose not to identify?
2. How might you build rapport with Jonathon?  
3. Consider what assumptions you have made about Jonathon (including biases and stereotypes). Where do these come from? How might you adjust your perspective?

4. Do you know what ‘on Country’ and ‘Sorry Business’ mean? How might you find out more about terminology commonly used by Aboriginal and Torres Strait Islander people in your community?
5. What kind of language and communication style does the patient use in their local community? What is your own cultural communication style? How might you adjust your natural style to accommodate your patients?

6. What are your priorities for this first consultation? Consider priorities beyond clinical investigation and management.
7. How would you tailor your history-taking to explore important sociocultural elements of this consultation?  
8. What might you need to consider if Jonathon was a member of the Stolen Generations or had only recently discovered his Aboriginal heritage?  
9. What is trauma-informed care? How might repeated episodes of grief and  trauma impact on Jonathon’s social and emotional wellbeing or mental health? How might that impact on your engagement with him?What strengths can you identify in Jonathon?

10. How might you respectfully incorporate knowledge about population-level risk factors for Aboriginal and Torres Strait Islander people into your assessment, without stereotyping the individual patient?
11. What additional conditions would you consider screening for if Jonathon lived in a remote community?
12. How would you approach the complex interplay of potential multimorbidity?

13. How might you incorporate a strength’s-based approach to manage some of the cultural determinants of health?
14. How might you respectfully incorporate Aboriginal and Torres Strait Islander models of health and wellbeing into your management plan, including use of traditional medicines, if patients choose?  

15. What is your approach to navigating differences between your own and your patient’s priorities (such as family or cultural obligations) when developing shared management plans?
16. What differences in clinical management guidelines exist for specific conditions in Aboriginal and Torres Strait Islander communities, including for patients who live rurally or remotely?

17. What do you need to learn about Jonathon’s local community both here and on Country?
18. How would you provide culturally safe care if Jonathon was unable, or preferred not, to access services provided by an Aboriginal community-controlled health organisation, Aboriginal and Torres Strait Islander health worker/practitioner, or Aboriginal and Torres Strait Islander liaison officer?

19. What is your role in helping patients to develop biomedical health literacy, without judging existing health beliefs? How will you assess and support this patient’s health systems literacy (the ability to navigate and access health services and systems)?

20. Is there a time you can think of when someone has held a belief about health/causation of disease that was different to that of the biomedical model of disease? How might you navigate these differences?
21. How might you endeavour to approach this consultation through a lens of anti- racism?
22.  How will you respond to Jonathon’s disclosure about culturally unsafe care in previous healthcare interactions?

23. What care elements can you identify that might have been culturally unsafe for Jonathon in the past? What barriers might exist in your clinic that inhibit cultural safety?
24. What Aboriginal and Torres Strait Islander-specific PBS or MBS items is Jonathon eligible for? What is the rationale for these population-specific measures?
25. What are some practical barriers to accessing healthcare services that Jonathon might have? How might you help overcome or reduce these?

26. Are there cultural considerations you might need to respond to during examinations and procedures; for example, gender preferences (sometimes known as ‘women’s business’ or ‘men’s business’)?
27. How would you negotiate what is or is not acceptable to Jonathon in the consultation? What creative solutions might you use to manage patient preferences?

28. How will you approach the issue of not knowing the previous medical history, in a culturally respectful manner?
29. How will you approach limitations in your cultural knowledge about Jonathon?
30. For example, how might you find out more about his use of and access to traditional medicines?

31. How will you assess the severity of a patient’s illness in situations where cultural differences might change the presentation of symptoms; for example, pain? Are you aware of the published coroners’ case reports on Aboriginal and Torres Strait Islander deaths due to misinterpretation of illness severity and systemic racism?
32. Do you understand the local cultural considerations for communicating with  family members, and how would you approach this with the family of a patient who is critically unwell if needed?
33. What might you need to consider if your patient requires an urgent medical retrieval from your clinic, including in rural and remote contexts?

Jamil is a 40-year-old Kurdish man from Iran who presents to your reception desk quite distressed, asking to see a doctor as he needs medicine to help him sleep.

When you call him in from the waiting room you notice that he is standing by the front door of the clinic and he appears anxious and uncomfortable.

1. How would you determine if an interpreter should be used in this consultation? How would you organise to use an interpreter?
2. If Jamil attended with his brother who speaks English, would it be reasonable to ask him to interpret for Jamil in the consultation?
3. What questions might you ask when doing a cultural assessment?
4.  Would you approach this consultation differently if Jamil was female? How would you ask about her preference to be seen by a doctor of a particular gender? How might you explore concerns about risk of family violence or previous sexual trauma in a trauma-informed way?
5.  What non-verbal cues have you noticed already?

6. How would you identify if Jamil is a refugee or seeking asylum?
7. Identify the key aspects of taking a trauma-informed history to explore Jamil’s sleep difficulties. How might you explore whether Jamil has experienced trauma to determine if this is contributing to his presentation?

8. What symptoms would make you consider a diagnosis of post-traumatic stress disorder?
9. If this was an 11-year-old child with sleep difficulties who had spent time in immigration detention, how would you approach this consultation?
10.  If Jamil presented with a history of fever and a cough, what differential diagnoses would you consider?

11. What resources could you use to give Jamil information about sleep hygiene in his language?
12. How would you approach his request for medicine to help him sleep?
13. What would you need to consider if this was a 26-year-old woman from Ethiopia who has had genital cutting or circumcision and presents at 22 weeks of pregnancy?

14. If Jamil had recently arrived in Australia, what health screening might you consider?
15. What resources could you use to ensure a rational approach to screening investigations?
16.  How would you identify what community resources might be available to support Jamil?

17. Use reflective practice to assess how you feel about this consultation. Do you have any learning needs arising from it? If this was a Muslim woman in a burqa, how would you reflect on your own cultural lens to minimise impacts on the consultation?

18. At your practice, how do you record a patient’s preferred language, ethnicity, and need for an interpreter?
19. Would you have any legal obligations to consider if Jamil presented with psychotic symptoms and was the sole carer of his seven-year-old son?
20.  What is your approach to patients who can’t afford to pay for healthcare?

21. If you were concerned that Jamil had a metabolic cause for his agitation and insomnia, how would you gain informed consent for blood tests?

22. How would you address Jamil’s concerns about destitution?
23. How would you manage Jamil if you could not exclude a mental health cause for his symptoms?

24. If Jamil spoke limited English and presented with chest pain, how would you approach the consultation?
25. If you were concerned that Jamil was at risk of suicide, how would you assess his risk and manage this?