Diversity in the clinic: analysis of transcultural consultations

requested by primary care physicians

Dhina Asmaa*, Norambuena Julieta*, Dominic Dao Melissa*
Geneva University Hospitals & University of Geneva
* Theses authors contributed equally to this work.

Background
Because of current geopolitical context and migratory
fluxes, primary care physicians (PCP) encounter an
increasing amount of culturally diverse patients in their
practice. If not addressed adequately, the issues
brought up by these cultural differences can adversely
affect the quality of health care.
At the Geneva University Hospitals, a transcultural
consultation (TC) is available since 2006 for
practitioners encountering difficulties with culturally
diverse patients.
The CT consultants perform a cultural evaluation of the
situation using the Cultural Formulation Outline1. They
provide feed-back through multidisciplinary meeting.
Identified issues and subsequent recommendations are
documented in a CT report in the patients medical file.
1 Lewis-Fernandez & Diaz, Psychiatry Quarterly, 2002. Mezzich, Carrachi, Fabrega &
Kirmayer. Transcultural Psychiatry, 2009.
Objectives
Identify the type of difficulties encountered by PCP caring for
culturally diverse patients.
Evaluate their relevance for cultural competence training of PCP.
Methods
Retrospective study of transcultural consultations requested by PCPs
between 2006 and 2015.
Data: consultation request intake forms and consultation reports
issued to the PCP.
Quantitative analysis: patient and provider characteristics.
Qualitative analysis: motives of consultation, issues identified by the
cultural evaluation and recommendations issued.
Outline for Cultural Formulation:
Cultural identity and history of migration
Cultural explanations of illness
Cultural factors related to psychosocial environment
Cultural elements of the patient-provider relationship

Results: analysis of 32 consultations requested by PCPs (75% HUG and 25% private practice), 50% done through an interpreter
Patients :
Aged from 18 to 86 years (median 46), 50% female. 50% originated from Africa, 41% were Muslim.
48% migrated because of political instability or war. 16% were naturalized Swiss, 22% had no legal permit.
22% suffered from a medically unexplained symptom, 16% from chronic pain, 19% from a neurological disease and 16% a
psychiatric condition.
Souleymane, 37 years old, suffers from tonic-clonic
Main reasons for TC request : epilepsy after undergoing surgery for cerebral arterioveinous
Understanding of patients socio-cultural context malformation. His lack of compliance to antiepileptic medication
Exploration of patients explanatory model of illness frequently leads him in the emergency room. His PCP questions whether
Improve patients non-adherence no treatment cultural factors contribute to this problem and wishes to learn
Feeling dead-ended and wanting a strategy to move on more about the patients context.

Main issues identified by the TC :

High level of socioeconomic vulnerability interfering with health care management
Undiagnosed or untreated mental health problem and/or history of trauma/violence
Divergent explanatory models between patient and PCP Souleymane is now an illegal migrant and homeless. Moreover
Language barrier and lack of interpreter the TC detecte severe depressions signs currently untreated. This
Patient mistrust of health care providers impacts his capacity to store medication and to take them with regular
High level of stigmatization related to diagnosis meals. Also he believes that his epilepsy comes from having studied
too much in the past.
Main recommendations made by the TC :
Explore/include patients social dimensions in illness management
The TC propose to improve his social situation
Refer to social and community services by calling his lawyer and procure him a humanitarian
Modify illness management including referral to mental health specialist permit (He couldnt receive an adequat treatment in his
Change communication strategies and/or include an interpreter country). A psychiatric and a neuropsychiatric evaluation could
Explore and account for patients (and his familys) model of illness also improve his care including a thymic follow-up and
an adapted neurologic treatment.

Conclusion and practice implications

PCPs refer to TC as a resource in complex clinical situations where they perceive the patients culture as a potential barrier to care.
The cultural evaluation revealed a number of issues, not all pertaining to the patients culture, left unexplored or unaccounted for
by the PCP.
PCP confronted with culturally diverse patient population need additional knowledge and skills in order to: 1) identify the impact of
socio-economic vulnerability on illness management, 2) explore and account for patients models of illness, 3) understand the
impact of culture on the expression of distress. These cultural competences should be included in future PCP training programs

Website: www.hug-ge.ch/consultation-transculturelle-interpretariat