CCFP 105 Topics: Immigrants

[Music] Welcome to yet another episode of the Generalist CFPC 105 Topics Podcast. Incoming an ear hole full of high yield information on immigrant hell. This episode was written by yours truly, then peer-reviewed by the inimitable Dr. Caleb Duzzol, himself. My name is Jeff and I'm a family medicine resident in Flunny, Ontario, where I'm trapped in an eternal struggle with my cat goose to resolve us to how many cat treats truly is enough. I believe the answer is more. This episode is thick with two C's like the cool kids say, there's plenty of material to cover, so to make it more palatable for your discerning soul science IRI case format was the way we went. You're a senior resident, busy full service family practice in Vancouver, it's 1300, you just had your fifth cup of genericly mermaid branded coffee of the day, why would you do that in Vancouver? You have so many options, but you are not tachycardic, you're not caffeine dependent, right? In walks a family with a stack of papers, your wonderful M O A's help sort the veritable Mount Everest a paperwork out and BingBang Boom, you're in the route with a 39 year old female who's a recent immigrant from Syria. You learn that this patient arrived recently alongside their partner and two children. Luckily for you, this isn't the for for her visit today. I like forafers in the emerge because it means that most one person is sick unless it's a car crash or something. So you flick through the paperwork you've got, you come to a list of vaccines. What do you do? Do you just accept them as they're written? Objective one, as part of the periodic health assessment of newly arrived immigrants, assess vaccine status and provide necessary vaccinations to update their status. It's actually pretty straightforward. According to the July 2015 Canadian immunization guide, vaccination should only be considered valid if there's a written documentation of administration of vaccine at ages and intervals comparable with the Canadian immunization schedule. And we need to painstakingly pay attention to some salient points in assessing their immunization status. We mean painstakingly because the pneumatic is pain, pa, i, n. So for p, potency, which we assume to be effective. Age at immunization? I intervals between doses. And n is the number of doses given. But wait, what if there is no documentation? Do we do serology to assess antibody titers? We do not. To quote the immunization guide again, quote, individuals who report incomplete immunization or lack adequate documentation of immunization should be considered unimmunized and start them on the immunization schedule that's appropriate for their age and risk factors. You can refer to that episode on the Canadian provincial territorial immunization schedules in the show notes to find out which immunizations are publicly funded, which immunizations you can give repeatedly without harm, and the contrary indications for repeated vaccinations. All right, you tackled that bit. No sweat. So you want to move on to the rest of the history and you want to build rapport with this patient. You find out she was displaced by civil war in Syria. She doesn't want to share much about that today. How would you approach that topic though in the future? Objective 2 as part of the ongoing care of immigrants' modifier approach has required by the cultural context. For example, history given only by the husband refusing examination by male physician or language barriers. According to migrant health framework published by Dr. Potty of the UWO in 2022, quote, cross-cultural communication in refugee health goes beyond the basic communication skills needed to provide care. And this is two Canadian-born patients. But why is this? Now there's a couple of reasons and you're going to tell us about the first one. Trauma-informed care refugee populations have a high prevalence of trauma. As such, trauma-informed approaches and clinical navigators to an overwhelming system are incredibly important to support migrant populations journeys through our often confusing healthcare systems. Next up is cultural differences, a paper by Hickenbottom in 2016, great name found that some migrant women might not seek preventive healthcare like Papsomers, for example, because they don't want to see a male physician, for example, understandable. While this might not be the only cultural difference you might encounter, it's important to understand the cultural context of the migrant patient and where possible accommodate that cultural background. The Calgary refugee health program recommends informing the patients of the confidentiality of appointments with you. I know we learned about this and it's likely that we don't mention this to most people, but in this case, it may help build trust and rapport and sometimes these patients might harbor worry that what they say could affect their refugee or resident status in some way. Yeah, it's a super good point. So you've got all this new knowledge about ongoing care of newcomers, you understand, you need to provide trauma-informed care sensitive to cultural differences, you start to build rapport with your patient over this visit. Satisfied by the care that you provided at your visit, your patient brings her mother also a recent newcomer to your practice. This time, however, the visit is complicated by a language barrier here. The elderly patient only speaks Arabic. Your elderly patient's daughter offers that she can translate in this trying time. Do you accept this offer? Objective 3. When dealing with a language barrier, make an effort to obtain the history with the help of a medical interpreter and recognize the limitations of all interpreters. Language barriers can be present, obviously, in the migrant population. It's a fact we need to manage, but given this obstacle to providing care, how should we go about overcoming it? In his 2022 paper, Dr. Potty cites a 2020 article by McFarlane at all on the barriers to the use of trained interpreters in consultations with refugees. This article points out what many of us may have already experienced. Number one, there may be a lack of trained interpreters or lack of funding sources for these interpreters. Number two, PCPs may not have confidence in interpreted consultations for various reasons and trained interpreters remain the gold standard recommended in the literature. They're a necessary feature of health services to meet health equity goals. We love them, but why is an interpreter? Some respondents to that paper that we mentioned from the primary care physician standpoint with regards to interpreters who are not professionally trained included worries that the interpreters would assert their own opinions, worries that they would change the question being asked to get a desired answer from the patient, all reasonable concerns. Confidentiality and discrimination concerns may also play a part in a primary care practitioner's hesitancy to use interpreters from small communities, or who by nature of their own cultural or ethnic background may quote unquote impinge on the quality of the interpretation. Some of the services might offer translators who come into the clinic to visit, but keep in mind in areas with only small concentrate communities of these newcomers, there might be conflicts of interest that aren't immediately apparent. Of course, the clinical resource for Canadian family physicians seeing newly arrived refugees and refugee claimants from August 2019, a document derived from consensus by the physician group at the Calgary Refugee Health Program suggests that family members may be used as a last resort. You can see this document in the show notes. Now you know you need a translator, so you secure a handy dandy translator phone, you carry out the conversation accordingly, you avoid conflicts of interest because you're slick like that, and you make your elderly patient feel as well cared for as you did her daughter. After tapping yourself on your back so hard you wonder whether or not you need a thoracic spinex, right? You pull up the EMR schedule and see what you've got. Oh, that you've got another newcomer visit. This time, patients well known to you, their recent newcomer from Afghanistan you've seen them for. You stroll into the room, but you notice something different about them now. They seem disheveled. They look this thymic. You're concerned. You sit down, you shut the door, you open the conversation. What specifically would you include as part of your care of newcomers who appear not to be coping? Objective 4. As part of the ongoing care of all immigrants, screen for depression, inquire about a past history of torture or abuse, and assess the patient for availability of resources for support. All immigrants, especially those who you may perceive to not be coping well to a significant change in their lives, should be screened for depression. A CMATCH paper by Magwood at all in 2022 states that refugees are at risk of developing common mental health disorders including depression, anxiety, PTSD and related somatic health symptoms. That same paper goes on to state that major depressive disorder and post-traumatic stress disorder presents significantly more frequently in the refugee population in comparison to the world's population. This is two to three times more than baseline respectively. Okay, so it's pretty clear that mental health needs to be screened for as part of ongoing care for all migrants. So, how do we do this? Do we just throw in a GAD7 and PHQ9? There's no convincing evidence for one versus the other. There was a paper by Hawking, not Stephen Hawking, in 2018 demonstrating robust psychometric properties. This tool demonstrated sensitivity in 93%, not bad. Specificity of 75%, not great. Another tool titled Refugee Health Screener has 13 to 15 items, it screens for depression, anxiety and PTSD, and according to Magwood, this tool showed validity in five studies. The TLDR or TLDL? Of this is that there's no evidence just yet as to which refugee mental health screening tool is the best. There are more than 75 such screening tools out there. Nevertheless, you need to make efforts to screen and where necessary to assess for support resources within the family or within the community to address these mental health concerns in a timely and effective way. One caveat in the recommendations to the CMATCH article referenced is just to reiterate the common understanding that screening should only be performed if there are resources to assist your patient. That is, if you can actually connect your patient with treatment programs with a stepped care approach. And also, if you only have professional interpretive services, not just a family member. The resource also notes that children of minority refugees and immigrants are disproportionately over-screened and over-reported as positive. Thus, they suggest not routinely screening children, but remaining alert from all treatment. Of course, makes sense. So you've got these powerful tidbits in mind. You get your patient connected with supportive resources in this community so that they might have some help to overcome the trauma they've faced in the past, and that's all in a day's work. For the next part of this episode, we'll be going through three common infectious diseases that may be acquired before immigration. Object 5. In immigrants presenting with a new or ongoing medical condition, consider any differential diagnosis infectious diseases that may have been acquired before they immigrated. In any good approach to an acute or chronic medical condition, we all know that a good history and physical are fundamental to diagnosing correctly. In migrant population, this means broadening your differential to include ideologies that you may not normally consider where you practice. Such as active tuberculosis. Where can we find it? Intermediate to high prevalence throughout Africa, Asia, not including Saudi Arabia, Oman, Qatar, and Jordan, and South America. The only exceptions to this rule are Poland, Portugal, and Mexico. And what does active tuberculosis usually look like? Caught greater than two to three weeks in duration. Look for lymph adenopathy and B symptoms. So how do we diagnose active tuberculosis? Well, number one, clinical suspicion or both of chest x-ray looking for an active TB with? Sputum specimens times three that are taken at least an hour apart for the kind of diagnostic guidelines. And each of those specimens should undergo microscopy. Each specimen should undergo solid and liquid medium cultures. And at least one of the specimens has to be sent to health Canada approved nat testing. Next up, number two, you also need an AFB smear. If the NAA is positive, TB is likely so treat while you're waiting for the sputum results. If they're nucleic acid amplification negative or invalid, an AFB negative consider empiric therapy based on other data as TB is not exclude. If that net is negative and the AFB becomes positive, then it's likely non tuberculosis, micro bacterium. So treat it pending the culture. Otherwise, if it's not positive, start TB treatment pending results. And if the net's again negative or invalid and AFB negative consider empiric therapy based on other data as TB again is not excluded. Next up, we're going to talk about Chisto somaises, something I only know from textbooks. Where do we see it? Intermediate to high prevalence throughout Africa, the Middle East, the Caribbean, Brazil, Venezuela, and large parts of the East and Southeast Asia, so pretty almost everywhere except here. But what does it look like? Patisplynomegly, fatigue, malaise, maillage, erdicarial rash, abdominal pain, eosinophilia, so those are the acute symptoms. What about chronic symptoms? It sounds like everything, everything else, very specific. Intermediate abdominal pain, chronic diarrhea, rectal bleeding, consequences of hepatisplynic disease that might look like things like pulmonary hypertension, hepatomegly and splynomegly. Okay, all right, so now that we know what it looks like, how do we diagnose it apart from all those clinical presentations? Depending how it does present, serology for an aliza, you can get a stool over on parasites, or you can do dermatologic testing, which might be included in the range of workup that you might do to diagnose something like Strangeloides, and then prefer to ID or travel medicine colleagues because this is way above my pay grade. Last but not least, malaria. Definitely not least, the classic traveler with a fever. Where do we see this? Intermediate to high prevalence throughout Africa, Asia, again, not including Saudi Arabia, Oman, Qatar, and Jordan, and South America. All right, so what does this look like? The uncomplicated formula? Well, if it's uncomplicated, then it might look like cyclic fevers and chills, so on off fevers and chills. Tachcardia. Tickipnia. Nausea and vomiting. Abopane. Splenomegly. Johndis. Diarya. And arthralges and myelges. What? If we get complicated. Altered level of consciousness. Bo-show. Anemia with intravascular Himalysis. Hypoglycemia. ARDS. Coagulopathy's. Metabolic acidosis. Circulatory collapse. Renal compromise. And epitopathy or liver failure. How do we diagnose it? The gold standard now is malaria PCR to identify the specific species in malaria that you're dealing with. However, initial diagnosis may sometimes be made on blood smear, requested as thick and thin blood smear. Classic, classic, classic. So the principles here are the same. If a system is affected, you work up the according system with the appropriate serology, pathology, or imaging. The point here is keep in mind that newcomers might have some of these unusual infectious diseases that you've only seen in textbooks, so broaden your differential when you think of these folks that are having some struggle. Objective 6. As part of the ongoing care of all immigrants, inquire about the use of alternative healers, practices, and/or medications. Last but not least, the patients might come to you with all kinds of health practices. They might take various herbal meds. They might consult spiritual heirs. They might take part in practices that you're just not familiar with. Regardless of whether or not you're familiar with their health practices or herbal medicines, the objective is simple. Need to ask. Doing this lets you gain appropriate context into their social and medical history that you need to put into place necessary and appropriate interventions to either treat or prevent the disease in the newcomer. Use your rapport and review of literature to determine if the interventions being used by your patients may interact with any therapies you and your patient elect to start the patient on. That's it. We killed it. Thanks for making this episode happen. Jeff, thanks for everyone involved, thanks for everyone doing the art and infographics. You guys are crushing it. Honestly Caleb, it's been really fun being on to talk about this topic and I learned quite a bit. Now back to my mortal struggle with my cat about whether or not his creamy treats should be scheduled or PRN. Scheduled for sure. Scheduled and PRN. So this has been the Generalist 105 Topic Podcast episode on Immigrant Health. Reach out. Give us feedback. If you want to get involved, we're always looking for awesome people to keep things going and to bring your creativity, your awesomeness, your love. Come along. All right. Bye bye everybody. Awesome. Thank you so much. [Music]