PHS250: Reflective practice- Culture and Communication
Part 1: Personal Experience of Australian Healthcare
My personal experience with the Australian healthcare system stems from two main engagements. The first being my own personal history with migraines and the second being a carer to a close friend of mine who was terminally ill with lung cancer before passing away. In the first instance, I did not consult any medical professional until many years later when the migraines became debilitating to my everyday life. After initial medical follow ups with the G.P.’ I was sent home with an inadequate appraisal. It was only after I stressed how painful and debilitating my migraines had gotten that I was referred to a neurologist for further consultation. I was finally told that I had cluster headaches; a rare condition with an unknown cause or solution. However, upon a second consultation with another neurologist, I was diagnosed with migraines instead. My third neurologist in the several years of trying to find an answer said he was unsure, and could not rule out either one. This experience as a whole left me somewhat dissatisfied with the medical system overall, but also opened my eyes from the naivety of belief that the medical profession was concrete in its capacity to deal with all medical problems.
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My second major engagement with the healthcare system showed me something similar. As a carer I found that the service experience from the healthcare professionals was always of a high quality (with genuine personal care too), but there were other problems in the periphery. I felt that the medical professionals were always overworked and could never be pinned down unless forced too. I found that as a carer I wasn’t given much support for my own mental health. I felt that at times the healthcare system was a little fragmented. I found that we had to constantly navigate between health departments and medical professionals, including having to navigate between private and public services. Again, after dealing with all of these things, I felt somewhat distant with the healthcare system as a whole.
I believe that, in both cases, the results of my experiences with of the healthcare system comes down to it being a system of processes that individuals are trying to fulfill in order to provide a service that is needed. I believe that if the processes of the system were different, my concluding feelings of the Australian healthcare system would be different too. If the systems had a humancentric element, where the divide between a medical professional and an individual patient was not so distinct, my interactions with the healthcare system would have yielded more benefit. I would have had the incentive to interact with the system without such a big inertia, or anxiety towards it.
Part 2: Reflection of Aboriginal and Torres Strait Islander Peoples
1. How you think a similar health experience might be for:
i) An Aboriginal person from a remote community who has had very little contact with health institutions;
Those who live in rural areas lack in equal opportunities and access to health care facilities and services in comparison to those who live in metropolitan regions (AIHW, 2015). This commonly results in “shorter lives and higher levels of illness and disease” (AIHW, 2015). A study by Kelaher, Ferdinand and Paradies, showed that in comparison to the non-Indigenous population, the Indigenous population have a higher mortality rate (2014). Specifically, males have 12 years less and females 10 years less of a lifer expectancy for the Indigenous population (AIHW, 2011).
Beyond this initial stark reality, due to the geographical location, residents from rural and remote areas are also disadvantaged in terms of their social and economic wellbeing (Humphreys & Wakerman, 2008). Residents in rural areas face difficulties accessing these health facilities also due to lack of adequately trained medical and healthcare workforce. The range of health and medical access and facilities for those from these communities is far less in comparison to metropolitan areas, even if adequate access to quality of Primary Health Care services is available to remote areas (Humphreys & Wakerman, 2008). According to Hampton, Toombs and Crawford (2013), even though non-indigenous residents from remote areas faced similar experiences in terms of lack of services, they were able to better overcome these deficits in comparison to those from an Indigenous background.
Additionally, cultural aspects play a huge role in Indigenous healthcare. Based on the yarning session with Yalmambirra, a local Wiradjuri Elder, many Indigenous people,- especially elders in remote locations regard hospitals as places to be avoided; it is where you go to die. It is prevalent that many western healthcare practitioners lack cross cultural sensitivity. This may present a hospital as inhospitable and make individuals of minority backgrounds (including those of Indigenous population) feel unwelcome. This, in turn, likely will affect the health outcome of the patient (Hampton & Toombs, 2013, p.94).
The gap in health care status between Indigenous and non-indigenous Australians has been identified as a human rights concern by the United Nations in 2010 (The National Association of Community Legal Centres & The Human Rights Law Resource Centre, 2010, pp. 41-43).
ii) An Aboriginal person living in Sydney and working at Sydney university.
Even if individuals of Indigenous background live and work in a metropolitan area such as Sydney, inequality in healthcare status amongst Indigenous Australians has been linked to ‘systematic discrimination’ (Calma, 2007). In a 1989 National Aboriginal Health Strategy, members from the Indigenous community stated that their health status was not
“…merely a matter of the provision of doctors, hospitals, medicines or the absence of disease and incapacity.”
It is linked to “…control over physical environment, of dignity, of community self-esteem, and of justice.”
A study conducted by the Medical Journal of Australia on racism as a social and emotional determinant for the wellbeing of Aboriginal Australian youth aged 16-20 years, showed 32% of participants reporting racism in conjunction with symptoms of anxiety, depression, suicide risk and overall poor mental health (Priest, Paradies, Gunthorpe, Cariney & Sayer, 2011).
Studies show there are sections of Sydney, such as the Western Sydney/Blacktown area and outer Southwest Sydney/Fairfield area, being less tolerant and harbouring more racist sentiments in comparison to other areas of Sydney (Dunn, Forrest & McDonald, 2013). Majority of the respondents who identified as Caucasian, agreed on a survey presented that Indigenous Australians were treated “overly generously” by the Federal Government. To emphasise this, 104 incidents of racial discrimination were reported in Inner Sydney compared to a mere 2 incidents between the years 1996-1997 (Dunn, Forrest & McDonald, 2013).
In terms of instituitional racism in healthcare, the cost of Medicare Benefits Schedule and Pharamceutical Benefits Scheme in Double Bay (a suburb in Sydney), is $900 per head per year, as opposed to $80 in Katjungka (a rural area in Western Australia) (RACGP, 2018).
According to a national survey conducted by the The Royal College of General Practitioners (RACGP), racial discrimination was reported by 32.4% of Indigenous Australians in the medical setting (RACGP, 2018). These types of discrimination not only negatively impact Indigenous Australians’ wellbeing, through barriers to healthcare access, but also impact the development of trust towards modern healthcare. Especially in a field dominated by non-indigenous health care workers.
2. How the current culture of the physiotherapy profession may contribute to this situation.
Within the physiotherapy profession, there is a huge discrepancy in the distribution of jobs between rural and metropolitan areas. This leads to a divide in how the system interacts with many of the issues discussed above. The profession does not engage with rural Australian Indigenous people to the same extent as many other medical professions in Australia, adding to the inaccessibility and misunderstanding issues reviewed earlier.
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The culture within the physiotherapy profession currently has no real holistic foundation that deals with cultural appropriate assessments, in which a broader interaction with the social, spiritual and cultural aspects can be engaged as part of general practice. This may be contributing and exacerbating some of the miscommunication and marginalisation of Indigenious peoples and western medical sciences.
There needs to be a more conscious holistic approach to physiotherapy to empower individuals to manage their pain and build a greater understanding of their bodies and overcome any fears that is associated with pain. This may also include working with Indigenious belief systems, healers and community leaders. By incorporating both conventional physiotherapy tools with holistic tools such as mindfulness and introducing the Biopsychosocial Model of Health into current allied health practices, a greater quality of life can be achieved (Engel, 1978).
Part 3: Communication Scenario Responses
1. What worked in this scenario to improve the relationships?
This scenario began to improve when a degree of meaningful communication started to happen. It began with the doctor speaking to his patient in medical terms without realising that his patient may not comprehend the entirety of what he was saying, The scenario began to change when the nurse started to talk to the patient. The dynamic between the patient and the nurse set the tone for understanding. It began a little shaky at first, with the nurse unsure how to respond to her patients ‘black’ joke, but with some further dialogue a degree of the ‘human’ element in the human care service began to show itself between the two. The patient and the nurse were able to establish a relationship that allowed for a more open communication between the two. This trust made evident of the how the patient was really feeling about the whole medical experience, and allowed for a two-way conversation to finally develop. It ended with the patient being confident in himself to be able to ask about his own medical issues, and to be able to form a relationship with his doctor that brought in a ‘human’ element to the healthcare services based on trust, and open effective communication.
2. Reflect on your response in part 1 in light of this scenario.
My response in part one is highly similar in characteristic to this scenario. I explained how my experience with the Australian healthcare service felt inadequate as I felt that I was dealing with a series of processes. I felt that there was a medical divide between the medical professional and the patient. This scenario demonstrates exactly what I felt in my experiences.
What can be taken from this parallel is that it is not merely about communication. In my instance, I was educated enough to have a fair understanding of what the doctors were explaining to us. The difference comes down to effective communication for the targeted patient. In the instance of the described scenario, that would entail being culturally aware of the possibilities of a lack of medical understanding. In my experience it would mean providing a more humanistic and personal approach to the individuals involved, as opposed to just a medically informative approach.
3. How can you change your practice as a result of this reflection? /What strategies do you feel may help you develop these skills?
This communication scenario demonstrates that the practitioner-patient relationship needs to incorporate a holistic relationship-building assessment process. The DSM-5 framework elaborates a need to take into account of the ‘biological, psychological, social, cultural and spiritual’ factors’ when making assessments. (Adams et. al 2014) This is even more true when dealing with Aboriginal and Torres Strait Islander people; people with a migrant background; or marginalised individuals; especially where such factors may impede upon the communication and assessment processes.
In these instances, the practice should change to involve a practitioner knowing about their intended demography of patients. In cases of culturally diverse demographics, the practice should focus on rapport building and cultural protocols (Hampton & Toombs, 2013). Building a rapport with the patient will help gain the individuals trust, and make the process personal. This simple practice will allow the individual to feel comfortable with their health provider, allowing them to open up, and remove any insecurities they may have when dealing with the health system.
Implementing cultural protocols as part of a standard practice entails the development of formal and informal processes that work to adjust for the individuals cultural differences. This will help avoid ‘cultural miscommunications’. (Adams et. al 2014). These processes can be introduced at practice level, and be simple procedures such as checks on whether the language used is appropriate and being understood by the participant. It can also be a holistic approach to providing the health service, such as a proactive engagement with the community members to better bridge the cultural divide through programs, or community engagement between the health services and the community. These efforts should help a practice evolve in being more user friendly, and help reduce some of the inertia that may arise from cultural/social differences.
- Adams, Y., Drew, N., Walker, R. (2014). Working Together: Aboriginal and Torres Strait Islander Mental Health and Wellbeing Principles and Practice (2nd ed.)(pp. 271-288). Canberra: Commonwealth Government.
- Australian Institute of Health and Welfare (AIHW). (2011). The health and welfare of Australia's Aboriginal and Torres Strait Islander people: an overview. Canberra: Australian Institute of Health and Welfare. Retrieved from https://www.aihw.gov.au/getmedia/677d394f-92e1-4ad5-92b4-c13951b88968/12222.pdf.aspx?inline=true
- Australian Institute of Health and Welfare (AIHW). (2015). The health and welfare of Australia's Aboriginal and Torres Strait Islander people: an overview. Canberra: Australian Institute of Health and Welfare. Retrieved from https://www.aihw.gov.au/getmedia/584073f7-041e-4818-9419-39f5a060b1aa/18175.pdf.aspx?inline=true
- Brondolo, E., Rieppi, R., Kelly, K. and Gerin, W. (2003). Perceived racism and blood pressure: A review of the literature and conceptual and methodological critique. Annals of Behavioural Medicine, 25(1), pp.55-65.
- Calma, T. (2007). Social determinents and the health of Indigenous peoples in Australia- a human rights based approach. Retrieved from Australian Human Rights Commission: https://www.humanrights.gov.au/about/news/speeches/social-determinants-and-health-indigenous-peoples-australia-human-rights-based#endnote3
- Engel, G. (1978). THE BIOPSYCHOSOCIAL MODEL AND THE EDUCATION OF HEALTH PROFESSIONALS?. Annals of the New York Academy of Sciences, 310(1), pp.169-181. Retrieved from https://nyaspubs.onlinelibrary.wiley.com/doi/abs/10.1111/j.1749-6632.1978.tb22070.x
- Francis, A. (2014). Strength-based assessments and recovery in mental health: Reflections from practice. International Journal of Social Work and Human Service Practice, 2(6), 264 - 271.
- Gibson, C. (2015). Communicating and working in partnership with Aboriginal and Torres Strait Islander peoples. CSU powerpoint presentation. [Available on Interact subject site]
- Hampton,R and Toombs, M. (2013). Indigenous Australians and Health: The Wombat in the Room. Oxford University Press, pp 90-94.
- Heuvel , A. V., Cargill, J., Stylianou, M., Harvey, M., & Oliver, T. (2015). The health and welfare of Australia's Aboriginal and Torres Strait Islander Peoples. Canberra: Australian Institute of Health and Welfare.
- Kelaher, M., Ferdinand, A. and Paradies, Y. (2014). Experiencing racism in health care: the mental health impacts for Victorian Aboriginal communities. The Medical Journal of Australia, 201(1), pp.44-47.
- Munns, Ailsa and Wyatt, Janine and Garvey, Darren and Thomas, Ann-Marie and McMillan, Faye. (2013). Indigenous Australians and Health: The wombat in the room. R.Hampton. & M.Toombs (Ed.).Melbourne: Oxford University Press.
- M.Dunn, K., Forrest, J., & McDonald, A. (2001). Sources, causes, forms of contemporary manifestations of racism, racial discrimination, xenophobia and related intolerance. Sydney: Australian Geographer.
- Priest, N. C., Paradies, Y. C., Gunthorpe, W., Cairney, S. J., & Sayers, S. M. (2011). Racism as a determinant of social and emotional wellbeing for Aboriginal Australian youth. Body Mind Matters.
- Royal Australian College of General Practitioners (RACGP). (2018). Position Statement- Racism in the healthcare system. pp 1-6. Retrieved from https://www.racgp.org.au/FSDEDEV/media/documents/RACGP/Position%20statements/Racism-in-the-healthcare-sector.pdf
- Springer, S., Smith J. D. (2016). Chapter 6: Working with Indigenous people. In J.D. Smith (Ed.). Australia's rural, remote and Indigenous health (3rd ed.) (pp124-154). Chatswood: Elsevier.
- The National Association of Community Legal Centres & The Human Rights Law Resource Centre. (2010). Dignity: Action. NGO Submission to the UN Committee on the Elimination of Racial Discrimination [PDF file]. Retrieved fromhttps://balitngulu.org.au/assets/2015/05/Elimination-of-Racial-Discrimination-report-to-the-United-Nations.pdf
- Wakerman, J., Humphreys, J.S., and Wells, R. (2008). Primary health care delivery models in rural and remote Australia – a systematic review. BMC Health Serv Res 8, 276. doi:10.1186/1472-6963-8-276
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