Language and cultural barriers
Although the hospital has interpreter services, it was not always possible to find an interpreter for a particular language when needed.
'The language barrier is an enormous problem. It makes it almost impossible even to assess a case history. So (when we have no interpreter available) we look to see whether there is anyone who works in the hospital who knows this particular language. We may find a doctor, for example, who does, and we consult her. But this is not always possible. And then you have to do the best you can and simply get on with the investigations and ultrasound and all that. And somehow you get a picture of this pregnancy and this woman.' (Interview 4, Midwives/Nurses Team)
Whenever possible, patients for whom no interpreters were available were given follow-up appointments with trained interpreters present. But this was not always feasible:
'The people were really nice ... but I just didn't understand them, and I felt that one should understand them, but I simply couldn't. My aim, to do the right thing for a patient, could not be reached. I think that this is what has made me, in the long term, a little hostile when I meet such patients - not actually towards the patients themselves, but simply because I was not able to fulfil my task.' (Interview 9, Physicians' Team)
This illustrates how frustration over communication difficulties can lead to negative feelings linked to the situation being projected on to the migrant patient.
Conflicting roles of physicians
Besides linguistic difficulties, physicians faced a range of sometimes conflicting demands that forced them to play a "triple role". In the interviews, they described the potential conflicts between their task of providing patient care, their role in the provision of certificates of health for the asylum authorities, and finally the task of ensuring cost efficacy in the HMO model. As in Switzerland only physicians can issue prescriptions and order exams and treatments, this 'triple role' was particularly a problem for physicians. They were also usually the members of the team required to write official certificates.
Several interviewees stressed their commitment to fulfilling their role as providers of clinical care, irrespective of the patient's residency status. 'I have accepted the task, from the patient or her family, to care for her... I therefore want to do all that I possibly can to ensure that she remains healthy and that things go well for her. That is my duty as a physician.' (Interview 2, Psychosomatics Team)
Physicians were sometimes required by the authorities in charge of the asylum decisions to assess the state of health of an asylum-seeking patient, along with her prognosis, and write a certificate which could potentially be used in the asylum process. This required a change of perspective: 'I am not being objective when I am caring for a patient. I am on her side as far as the medical aspects are concerned. I just want to help her. And then when at the same time such questions come from the Federal Office for Refugees, something different is expected - in fact an objective opinion. And that is not easy. Somehow one then tries to give consideration to both sides, and that always leads to conflict.' (Interview 2, Psychosomatics Team)
The third role of physicians is that they are expected to manage financial resources. The basic document of the Basel HMO model for asylum seekers was based on the principle that asylum seekers should receive 'as much [medical care] as necessary'. No list was included of medical services to withhold from HMO patients. It was left to the judgement of each physician to interpret 'as much as necessary' with regard to everyday clinical practice.
'From the way I see my task, it is in fact more a question of preventing duplications and redundancies, rather than just limiting them ....I would have been a bit concerned - and we have also discussed this - if I had in fact had the feeling that I now have to limit the care being provided. We of course always have to be careful that we do not somehow create a second-class medicine.' (Interview 2, Psychosomatics Team).
Other interviewees also describe efforts to treat patients insured under the HMO model according to the same standards as patients with standard insurance coverage:
'Not that one would have specially reduced any of the investigations. I can't remember that ever happening... In our clinic every woman gets what she needs.' (Interview 8, Physicians' Team) However, the physicians were aware that treatment of HMO patients 'should cost as little as possible.' (Interview 9, Physicians' Team)
Combining the three roles was demanding for the physicians involved:
'These requirements differed: on the one hand to be the care giver, to be the patient's advocate in fact, and on the other to act as advocate of the Federal Office for Refugees, and thirdly to be responsible for the organisation, to save costs for the health insurance. But that is simply not possible.' (Interview 9, Physicians' Team) And: 'A lot was expected of me. [I had to know] all the things that I could do for asylum seekers, with some kind of certificate or something else. And it takes a lot of strength for one to be aware - to make oneself aware - of what one can offer and what one cannot offer. (Interview 2, Psychosomatics Team)
Working under these conditions was difficult. The problem of conflicting roles meant that beyond their normal commitment to the care of their patients, physicians had to make additional efforts to fulfil the tasks assigned through the government and the HMO model.
Coping with the patients' history
Other members of the team caring for asylum seekers did not have to write certificates, but they too had to cope with various problems, including their own response to the patients' often tragic histories. An interpreter said:
Maybe in the beginning it was so difficult because I would always translate for the same patients, who had survived the war. The entire hour they just cried and cried and cried. I remember a woman who had lost her 12-year-old girl during the war. She would say: 'they killed her in front of my house door' and then she cried and cried. Honestly, I would have preferred not to translate for this woman any more. Not because I did not like her but because it was so extremely draining (Interview 1, interpreter).