AUSTRALIA’S growing cultural and linguistic diversity adds significant nuance to the principles of effective communication in health care. It has been stated that as much as 70% of medical malpractice results from poor communication. Inadequate communication can jeopardise quality of care, patient outcomes and clinical processes. Professional education, training and standard setting play a key role in ensuring that medical practitioners have the knowledge, tools and resources to effectively communicate with, and provide equitable care to, migrants and refugees in Australia. We present a vital step toward meeting this challenge.
Australia is a highly multicultural nation, with first or second generation migrants comprising 49% of the population. Many of this cohort are culturally and linguistically diverse: 300 languages are spoken across the country and 21% of Australians speak a language other than English at home every day. In this context, interactions between medical practitioners and people from culturally diverse migrant and refugee backgrounds are increasingly common, and effective communication is key.
Language differences between clinician and patient can pose substantial barriers not only to adequate understanding of the patient’s needs and problems but also to patients understanding clinician’s recommendations. In one case, a 35-year-old migrant woman died from complications attributed to failed communication over language barriers.
However, language is only one of the factors affecting migrant and refugee health. Pre-migration experiences, especially of trauma, adversely affect this cohort’s health status and require clinicians’ attention. While trauma-informed care is universally recommended, practitioners must equally recognise the heterogeneity of migrant and refugee experiences. A patient’s cultural background may impose stigmas on some health conditions and affect help-seeking behaviour. Similarly, previous experiences of health care have an impact on expectations of and response to that provided in the Australian health system.
In one study, Sudanese refugees expressed concern over not receiving injections during consultations with medical practitioners, which they regarded as a routine feature of health care in Sudan. This expectation meant the Sudanese patients left consultations feeling dissatisfied and hesitant about seeking future care. Other migrant groups identified similar concerns over the discord between their traditional health care practices and medical practices in Australia.
“I worry why so much blood is taken … I worry they will sell the blood like in Sudan … people buy blood there. We don’t understand what will happen when we go to see the doctor … we need information, we worry …”
The confluence of these factors poses distinct challenges when considering the health of Australia’s migrant and refugee population. Communication and cultural barriers may leave concerns unexplained, with consequent distrust of and disengagement from the Australian health system. Studies confirm that culturally and linguistically diverse patients generally delay health care, have lower rates of accessing preventive care, are less satisfied with health services, and experience poorer health outcomes compared with English-speaking patients.
Beyond quality of care and health outcomes, cultural considerations have been shown to affect clinical processes. Communication barriers obscure diagnosis, with research suggesting clinicians may perform or order unnecessary and costly tests to compensate for uncertainty stemming from what they regard as inadequate patient history. In hospital settings, communication difficulties have also been shown to correlate with increased length of stay and increased readmission rates.
Decreased efficiency and unnecessary financial costs are not the only concerns. Communication barriers increase medico-legal risks, especially regarding informed consent, when working with culturally and linguistically diverse patients. In a study looking at incidents of adverse outcomes as a result of failure of appropriate interpreter use for health consultations with migrants and refugees, 62.5% of reported incidents involved lack of informed consent. For example, a woman underwent a gynaecological procedure without knowing that it was permanent. Her spouse was used as an interpreter to gain consent – a perfect example of why using a relative as an interpreter is not appropriate.
Without taking appropriate measures, such as engaging a professional interpreter, clinician–patient miscommunication will be more likely when interacting with people from migrant and refugee backgrounds. Along with poorer patient outcomes, the inappropriate practice that such miscommunication can contribute to represents a further source of undesirable costs and disruption to clinical practices.
It is thus essential that the complexities and considerations involved in migrant and refugee health care should be adequately addressed through standards of medical practice. Medical education and training should provide practitioners with the knowledge, tools and resources they need to deliver equitable care to migrants and refugees in Australia.
Recognising this need, the Migrant and Refugee Health Partnership brings together representation from peak professional bodies for clinicians and the community sector to address the systemic barriers to health access for migrants and refugees. After 2 years of extensive collaboration and consultation, the Partnership released a Competency Standards Framework, Culturally responsive clinical practice: working with people from migrant and refugee backgrounds, in January 2019.
Supported and endorsed by the majority of the medical colleges, the framework represents an unprecedented collaborative effort to facilitate the provision of culturally responsive care to migrants and refugees in Australia. The framework establishes recommendations and optimal practices for clinicians in all health care settings to inform clinical education, training, professional development and competency standards.
Culturally responsive clinical practice — the provision of medical care that respects and is sensitive to cultural difference — is at the heart of the framework. Loosely following the CanMEDS model – originally developed by the Royal College of Physicians and Surgeons of Canada in 1996 – the framework embeds the tenets of culturally responsive clinical practice across six domains of the medical expert role, with a strong focus on communication throughout. By adopting this model of culturally responsive care, clinicians can become more aware of the unique social, economic, cultural and personal factors that influence migrant and refugee health, and as a result will be better equipped to provide equitable care to migrants and refugees.
The Framework is consistent with the Medical Board of Australia’s Good Medical Practice code of conduct, which includes a dedicated discussion of effective communication (s3.3) and culturally safe and sensitive practice (s3.7), and establishes imperatives to ensure strong communication and understanding, the engagement of interpreters and awareness of the impacts of culture on health.
As a further resource to facilitate communication between clinicians and patients in situation of language discordance, the Partnership also published a Guide for clinicians working with interpreters in healthcare settings. The guide provides information on how to assess the need for an interpreter, the importance of engaging an appropriate interpreter and the risks of failing to do so, the parameters of an interpreter’s role in clinical practice, and practical information on accessing and working with interpreter services.
Improving communication with and providing culturally responsive health care for migrant and refugee patients are significant challenges in contemporary clinical practice in Australia. It is vital that these challenges are met and the framework aids clinicians in doing so.
Dr Kym Jenkins is Chair of the Migrant and Refugee Health Partnership and Chair-Elect of the Council of Presidents of Medical Colleges
The author would like to acknowledge the research assistance of the Migrant and Refugee Health Partnership Secretariat in preparing this article.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.