Imagine how an American hospital might appear to a refugee, perhaps someone still struggling with English who has recently left a war-torn and unsettled country. In this strange building, people shuttle in and out of rooms, and there's poking and prodding for tests and procedures, along with seemingly endless questions and intimidating paperwork.
A hospitalist's ability to effectively treat such refugees often relies on a good interpreter but also an awareness of the potential mix of customs and prior experiences that might impact patient care, said Peter Cronkright, MD, FACP, an associate professor of medicine and family practice at Upstate Medical University at State University of New York in Syracuse, N.Y.
For instance, he typically doesn't wear his white coat “so I don't look like I'm somebody from the state or some type of authority,” said Dr. Cronkright, who treats refugees as part of an outpatient residency training facility at Upstate. Given what patients might have experienced in their home countries, “They don't have a real reason to trust authority.”
About 3 million refugees have moved to the United States since the Refugee Act of 1980 formalized the resettlement process, including nearly 85,000 in the most recent fiscal year, according to the Pew Research Center. The refugees' home countries have shifted through the years depending upon areas of conflict, with the largest numbers recently arriving from the Democratic Republic of Congo, Syria, and Myanmar.
Refugees face a number of health care challenges. Amid the turmoil of resettlement, some might have sidelined their own physical and mental health needs. Once they arrive in the United States, they might find the logistics of a new health system daunting. Even calling to schedule an appointment in an unfamiliar language can feel overwhelming, leading patients to allow symptoms to escalate, said Aniyizhai Annamalai, MD, who directs the Yale Adult Refugee Clinic based at Yale New Haven Hospital in Connecticut.
Some refugees have been raised in countries without an established health care infrastructure. Dr. Annamalai recounted treating some women, originally from Afghanistan, who had never seen the inside of a hospital although they had borne several children.
Thus when symptoms do flare, an ED might seem like the logical place to go first, as it's most similar to the walk-in clinic they used back home. “They can just show up—you simply go when you're sick,” Dr. Annamalai said.
Tackling physical symptoms
Dr. Annamalai co-authored a study that found a strong need for acute care shortly after resettlement. Of 248 refugees recently arrived in Connecticut, 41% had made at least one hospital visit—to the ED or for a nonelective hospital admission—within eight months of their arrival. The admissions were most commonly due to mental health or substance abuse issues, followed by abdominal pain, according to the study, published online in April 2017 by the Journal of Immigrant and Minority Health.
Nearly two-thirds of the refugees, 60%, reported having at least one chronic health condition—back pain, hypertension, and headaches/migraines were the three leading symptoms. That's striking, Dr. Annamalai said, given that the median age of the refugees was 30.
When meeting refugee patients for the first time, hospital physicians should try to get a window into their journey to date, Dr. Cronkright said. Along with asking where they were born, find out where they have traveled, in order to gain insights into potential disease exposure.
Refugees undergo a medical evaluation before arriving in the United States, primarily to exclude communicable disease such as active tuberculosis, assure refugees are not a risk to themselves or others, and identify any pressing medical issues, Dr. Cronkright said. After settling in his community, they are tested for tuberculosis again. Patients with latent tuberculosis infection receive chemoprophylaxis and reassurance, as they might have witnessed firsthand that tuberculosis can be a killer. “We have to educate them that it's just lying dormant there, and we're going to treat it so it doesn't become a problem,” he said.
Patients traveling from Africa will typically get prophylactic treatment for parasites common there prior to arriving in the U.S. But refugees coming from central or western Africa might not be treated presumptively for a potentially dangerous parasite, Strongyloides, Dr. Cronkright said.
Hospital physicians should be aware of that possibility, and test patients arriving from the Democratic Republic of Congo and nearby countries. Otherwise, a patient who comes to the hospital with asthma symptoms could be given immune-suppressing steroids, thus inadvertently accelerating parasitic spread, which can be life-threatening, he said.
For more garden-variety ills with no palpable symptoms, such as hypertension, the challenge is convincing recent refugees to get treatment amidst the strain and swirl of settling into a new country, Dr. Cronkright said. When physical symptoms do develop, whether it's insomnia or back pain, doctors should remain attuned to the possibility that it might mask an underlying mental health issue, he noted, echoing a point made by other physicians.
“Typically it's chronic pain—it's not uncommon that people who have been through a lot of suffering will present with pain complaints,” he said. “Or medically unexplained complaints, so they may have chest pain or dizziness or fatigue.”
While some refugees will avoid medical care until their symptoms become urgent, the opposite scenario can occur as well, said Tarrie Burnett, a program director in Albuquerque, N.M., for the Lutheran Family Services Rocky Mountains Refugee & Asylee Programs.
Doctors “are held up as deities in some ways,” she said, and refugees “want to talk about everything. All of their case management issues, all of their mental health issues, all get stockpiled, saved, and dumped into the medical provider's lap. That's really overwhelming and time-consuming.”
Flagging mental health strain
To get a sense of refugees' psychosocial circumstances, Dr. Annamalai recommended asking about their home environment, to figure out if they live with family members or have arrived alone. Then follow up with a few other questions, she said. What has life been like since they arrived? Has resettling gone as anticipated? What are their expectations for the future?
The answers might shed light on post-traumatic stress disorder or other mental health stressors, particularly among those from cultures where such symptoms are not discussed or perhaps even acknowledged, Dr. Annamalai said.
Another strategy that Dr. Cronkright employs is to ask: “How well are you sleeping?” If patients report insomnia, he'll follow up by asking if they are “thinking a lot” rather than directly asking about their mood. Hopefully that line of questioning will trigger a broader mental health discussion, he said.
Sometimes refugees remain emotionally resilient until several months after they arrive, when the full extent of starting over, landing a job, and struggling day to day in an unfamiliar language hits them full force, Dr. Annamalai said. “That's when we actually see some people's health condition worsening.”
As physicians order tests and procedures, they should always be aware that the patient might have suffered some form of prior abuse or torture, said Genji Terasaki, MD, an ACP Member and an internist who practices in the international medicine clinic at Harborview Medical Center in Seattle.
It's not easy to ask people if they've experienced or witnessed any trauma, Dr. Terasaki said. “I think we're all afraid that we're going to retraumatize the person in the process of asking about it.” But if someone reacts in an abnormal way to a medical procedure or interaction, that possibility definitely should be considered, he said.
There are certain hospital tests or procedures that can be particularly unsettling for traumatized refugees, Dr. Terasaki said. Consider the rattling noise and restraints involved with an MRI, he said, or the invasiveness of a biopsy, a blood draw, or placement of electrodes for an electrocardiogram. Even being told not to eat prior to surgery can feel different to someone who has experienced starvation.
Prior sexual trauma is also a possibility, said Dr. Cronkright, who still vividly recalls an older woman who “just disassociated totally” during a pelvic exam he performed to check out worrisome physical symptoms.
“It's very important I think to recognize that you are entering a space of the body” that may have been violated, Dr. Cronkright said. The doctor might not ever know, even if he or she has taken a medical history, because the patient prefers not to share or has suppressed the memory, he said.
Navigating cultural differences
When treating a refugee, access to an interpreter is crucial, even if it's only by telephone, said Ms. Burnett. Doctors shouldn't rely on children to translate, even if they are handy, particularly if delving into sensitive issues such as sexually transmitted diseases or family planning, she said.
Sometimes the cultural hurdles involve more than just language differences. Dr. Cronkright has had visits in which a female patient speaks to her husband, who then relays the information to the interpreter for translation. “It would be a red flag to us in our society to say that this is quite a dominating and not a healthy relationship,” he said. “And yet in certain cultures, it is not a red flag necessarily.”
Determining whether a couple's interaction is concerning, Dr. Cronkright said, requires time to build trust and a relationship, something that's typically not available to a hospitalist. But sometimes important information comes out in unexpected ways, he said.
In one such four-way interaction, Dr. Cronkright thought that his patient had reported—via her husband—no struggles with depression. But while she was waiting to get her annual flu shot, he handed her a mental health screening in Arabic to fill out.
The feedback was illuminating and a reminder of the distance that language and cultural barriers can sometimes foster, Dr. Cronkright said. “It was markedly abnormal for severe major depression,” he said. “But it was not going to come out in that crowd [in the physician office].”