(00:45) Dr Billy is keen to understand how Dr Singleton became involved in the field.
Dr Singleton became interested in this specialised area through her awareness of the vulnerability of refugees and asylum seekers held on Nauru and Manus Island, who had limited access to healthcare. The controversy around the repeal of the Medevac bill created a groundswell of support for GPs and specialists who wanted to do something about that situation. She was one of those who wanted to make sure that these people were able to secure access to appropriate health care.
Dr Singleton acknowledges that Australia does it’s part by accepting between 13,000 and 16,000 people into the country annually through humanitarian programmes, but she notes that many of these people in our communities, for all sorts of different reasons, struggle to get access to health care. She feels that it's important for all of us to have some understanding of the issues facing these people and find it compelling.
(03:58) Dr Billy asks what GPs should be looking for in this particular population?
Dr Singleton suggests first and foremost that we must remember that these are people who might present with ordinary problems but that there could be hurdles in the way of their routine diagnoses. From language barriers, where interpreters are required, to mental health issues and the management of traumatic experiences from the past or even uncertainty with their current living conditions. One of the most valuable tools in understanding these cases is simply taking the time required to get to know what’s under the surface. Gill suggests putting yourself into the shoes of a patient and think how difficult it might be for them.
(04:44) Dr Billy asks where to learn more about refugee health?
Dr Singleton mentions the Australian refugee health desktop guide, which was written for GPs as a resource and lists all the things that a primary care physician would need to consider. Their guest Dr Kate Walker, has been involved with putting it together. 3
(07:35) Dr Billy Stoupas asks what happens when someone of refugee or asylum seeker status may not have medicare coverage?
Dr Singleton notes that refugees should have a Medicare card. But it's those who are seeking asylum (and there are thousands of individuals and families in Australia who don't have access to Medicare) who are at risk. Each state has charitable services that offer health care, but they're not broadly available, particularly in regional areas. So, it often comes down to the goodwill of the GP to provide care for them without charge.
(09:03) Dr Stoupas ponders advice to young GPs, registrars, or students who are thinking about getting involved in refugee health?
Dr Singleton says that for her, the motivation and benefit is being able to provide healthcare to those who might otherwise not be able to access it.
Introduction of Dr. Kate Walker
(10:15) Someone who’s been making a huge difference in this space over many years is Dr Kate Walker, a GP, Chair of the RACGP Refugee Health Specific Interests network, and one of the authors of the Australian refugee health desktop guide.
(11:03) Dr Singleton introduces Dr Walker and muses that a sense of curiosity is important in dealing with refugee health.
Dr Walker concurs that curiosity is in fact a great way to approach these consultations. And one of the first questions that always needs to be asked is, ‘Would you like an interpreter to help you understand what I'm saying?’
(12:26) Dr Stoupas digs a little deeper on the logistics of actually getting an interpreter for a consultation.
Dr Walker explains that every GP is eligible to get a ‘test code’ which allows registration for the telephone interpreting service. The interpreter would be pre-booked and it can be done quickly. In most cases in just a matter of minutes. In the case of more uncommon languages or where an on-site visit is required, the lead time might be a bit longer.
(13:34) Dr Singleton inquires as to Dr Walker’s original involvement with refugee care.
As a general practice registrar interested in cross cultural experiences and working in the inner west suburb of Footscray in Melbourne, Dr Walker was in the perfect place to align with a refugee health nurse who was very happy to send more and more patients her way.
And that became the joy of the job. She was hearing about experiences of recent history from all over the world, and stories of resilience and survival. Along with a myriad of medical problems that made the work quite interesting. Even an everyday cough or cold might present in a different way, and lots of other issues could come up.
(15:00) Dr Singleton delves into the issue of trauma with these patience and how Dr Walker approaches that.
For Dr Kate, it’s important to ask patients when they are originally from. And if they hail from Iran, Iraq, Afghanistan, Syria, and have arrived in the last two or three years, you can assume from basic current events that they've likely been exposed to significant trauma. She feels you don't necessarily need to go into the detail of their experience. Best to simply relate to the current complaint and hear the background the patient offers which might be helpful as context.
(16:06) Dr Singleton adds that a patient's need to feel safe is an important one and has to be carefully managed.
Dr Walker is equally focused on creating safety in the consultation. Building the rapport, creating safety around language, particularly working with interpreters and explaining how the GPs role fits into the healthcare system are critical parts of developing that personal safety.
(16:50) Dr Singleton raises the issue of some GPs being slightly wary of taking on refugee or asylum seekers’ cases because of their potential complexity.
Dr Walker reminds us that often the most important thing with these patients is to tackle the presenting complaint. While it is important to consider specialised screening at some point and there is a Refugee Health Assessment Template which offers some guidelines on all the things that people from refugee backgrounds should be screened for – this does not have to be done all in one instance.
It’s recommended that refugee patients have screening consultations within one month of arrival, but it’s equally important to assess if they've ever had any sort of comprehensive health checks or vaccinations done. For these patients, the understanding of the role of primary care and preventive model of disease management is a place to start.. Then checking in to see if they've had the appropriate screening according to age and gender is important for their ongoing health.
(21:04) Dr Singleton is reminded of an acronym that Dr Walker relayed which helps get to the heart of dealing with patients from refugee or asylum seeker backgrounds.
Dr Walker credits it to her colleague, Dr. Joanne Gardner but the acronym is A.S.K.
A is for ask.
- Do they want an interpreter?
- What is their presenting problem that day?
- What is their country of origin?
- What is their country of transit?
- What is their visa status? (Particularly important for asylum seekers and eligibility for Medicare)
- What are their current stresses?
- What is the presenting issue?
S is for screening.
- Have they had a comprehensive post-arrival health assessment?
- Have they been screened for psychosocial problems?
- Have they been screened for their level of healthcare literacy
K is for kindness.
- This speaks to the trauma-informed interpersonal care GPs have with their patients.
- Going the extra mile for a patient – which might mean helping them understand a script, the location of the local pharmacies, where to go for the investigations, reminders for hospital appointments, etc.