Practice Reflection: Ranjit Lehal and Kristina Piccsalu

1. What population groups do you primarily work with? Please describe your work setting a little.

Our clinics provide primary health care for Government Assisted Refugees. Fraser health operates two New Canadian Clinics, one located in Burnaby and the other in Surrey.  The ethnic origin of Clinic populations vary somewhat.  The Burnaby Clinic has patients who typically originate from Afghanistan, Iraq, Somalia, and Eritrea while the Surrey clinic serves a population primarily from Burma (Karen and Rohingyan) and Somalia.

Both clinics operate with daily scheduled appointments and some time for walk-ins. The Surrey Clinic is co-located within a non-profit community services organization called DiverseCity.  DiverseCity provides services essential to our patients, such as: settlement, ESL classes, daycare, trauma counseling, and parenting groups. The Burnaby Clinic is in a medical building shared with a community pharmacy, medical specialists and rehabilitation services.  Mosaic, which provides settlement services and ESL classes, is readily accessible across the street. Both clinics are NP led with a sessional physician who works one day per week at each clinic. Until recently, the clinic also included a primary care nurse whose role was to support patients in accessing community partners, maintaining continuity of client care through case coordination as well as provide patient education and health promotion services. Unfortunately this role has been eliminated. We work very closely with our community partners including Mosaic, DiverseCity, public health units, and school settlement workers in order to provide comprehensive primary care for our complex patient population.

2. Culture is an overarching term that often describes communities that may share common race, beliefs or values. As a health care provider working with a culturally defined/diverse population, what are some key approaches you incorporate in your client encounters to bridge any gaps in communication?

On a strictly practical level, we use trained interpreters with every visit either in-person or via phone services through Provincial Language Services. Working with interpreters is a skill that requires recognition of the need for more time to explore symptoms, provide explanations and confirm understanding.  As well, it is important to recognize the value of silence in eliciting information when interacting with a patient with whom you do not share the same language.

Additionally, as practitioners we have taken it upon ourselves to learn a few words in the languages we predominantly hear. Being able to share a greeting in a patient’s mother tongue, a thank you and a goodbye – goes a long way to building relationships and establishing trust with our population. It is wonderful to see how facial expressions and some body language are universal!  While we recognize that all ethno-cultural groups are heterogeneous, it is useful to become familiar with some cultural norms or traditions, as they may impact a patient’s health in order to demonstrate understanding and objectivity to our patients.

Finally, similar to any patient encounter, when working with diverse cultures it is important to be non-judgmental, respectful, and to approach the encounter with humility and curiosity. It is through our interactions with others that we learn about ourselves and continue to grow as people and practitioners.

3. Culture may shape or influence one’s outlook on health and illness. Subsequently, priorities might be different between client and health provider. When such differences in perspective become apparent, how do you reconcile these differences?

We operate from a social determinant of health and inequities lens, recognizing that gender, culture, education, housing, and literacy have a very strong impact on health. Like any practitioner, we initially attempt to address our patients’ most pressing concern.  While this issue may not be within our scope or realm of influence, at the very least the patient should feel heard and a plan identified.  The plan could include a letter of support, other advocacy work, and/or referral to community partners for assistance.  Once the patients’ priorities have been addressed we can then move to discuss other health issues as needed.

4. Do you have specific tools and resources you find useful, which you could recommend to your colleagues?

Both clinics are participating in health literacy-based research to gain a better understanding about our population’s health literacy and self-management strategies (e.g.) managing appointments, wayfinding and medication management. There is a paucity of research in the area of heath literacy specific to refugee populations. The goals of this research are to evaluate the use of health literacy tools such as the western calendar and medication list (these tools were developed by Lynn Farrales, MD) as well as continue to develop/refine health literacy tools.

Other useful tools include the following: