Peter von Kaehne is a general practitioner working with refugees in Glasgow. He tells you what you need to consider if you are thinking of working with this challenging yet needy group of people

"A neighbour came and drank the bottle of wine from home, so I got you some French wine for Christmas, I hope you will like it anyway," the lady said. Being given presents from patients is probably always a humbling and possibly embarrassing experience, but when your patients live on vouchers valued at two thirds of the lowest level of income support and get wine sent from home just to give it to you, it becomes even more so.

My patients are all refugees or asylum seekers, and I am one of five salaried general practitioners in Glasgow caring for one of the larger contingents of dispersed refugees. Two of us work at one medical centre (the other three are elsewhere in the city) and our practice has a list size of about 5000, with 1800 refugees on the list. Both of us work mostly with the refugees, while the two partners remain more involved with the original patients. The refugees come from about 50 different countries and speak dozens of different languages, but most are Iranians, Afghans, Arabs, Kurds, Turks, Kosovaris, and Somalians.

When I tell people what I do, most respond with "That must be very difficult" or "How do you deal with all the languages?" In fact, I find it no more difficult than most other general practice work, and I don't often have to deal with the other languages. I do speak some of their languages, but I also have translators and many patients pick up English fairly rapidly. For example, one illiterate farmer from central Asia speaks five languages fluently, including my own, German. He said he used tapes to learn it.

Misleading rumours and negative media coverage has led to many distorted views of refugees. A few are, as in any group of people, "chancers" who, though they may present differently from the usual Monday morning punter asking for a "line," are equally transparent. Some are very special people, having withstood harassment, arrests, jail, and torture with their convictions intact. Most, however, are ordinary people with extraordinary experiences, like political oppression, war, and ethnic strife. In any case my job is not to judge why people are here but to provide medical care.

What are the main challenges?

When you take up a job like mine, you need to know if you are able to cope. Some things are obvious:

You should have a good sense of humour, be patient, be a good communicator, know possibly one or two other languages, and be able to cope with organisational chaos. While chaos may not be a constant feature of your work, it will probably be more common than in other posts. Many refugees find it difficult to deal with our appointment system, and translators may not turn up, making immediate treatment difficult. You should also appreciate and enjoy contact with people from different cultures and understand and be able to deal sympathetically with somatisation complaints and mental health issues. Most refugees will at some time seem depressed and may present with any number of vague symptoms. Most will simply need a friendly ear; only a few will need drug treatment.

Your work will probably be mainly surgery based. I am doing eight sessions a week of surgeries, one session of paper-work, and possibly one house call a week. Most patients are young and can manage to come to the surgery. We are still experimenting with finding the right balance between emergency appointments and booked appointments. Appointments of 15-20 minutes are necessary to provide decent care with the help of a translator.

You will have more than the usual amount of paperwork. I probably refer two or three times more patients than expected for the age group, mainly because of interrupted secondary care in their home country or illness neglected during war and flight. I also write one or two, often lengthy, medical reports weekly.

What does the work involve?

A major component of the work is medicolegal. Some patients will have been tortured and have the scars to show it. A good detailed medical report can go a long way to help them prove their case. It is neither difficult nor a high art to write high quality reports on torture victims; all you need is time to listen, good examination skills, and a strong stomach. Some stories are hard to listen to and will remain with you for a long time. The Medical Foundation provides helpful material about writing such reports. Many dispersed asylum seekers fear that the quality of medical reports will not be as good as those done in London or by the Medical Foundation. It is up to you to ensure that you make a good case for your patients as there is often no one else in your area to write an adequate report.

Working with translators is a skill that you will have to learn. Translators come in all shapes and forms, including university graduates with a doctorate in English, nurses with good English, little children who have picked up the language faster than their parents, neighbours, and friends. It is good practice to insist on high quality translation, but this is sometimes difficult to achieve, especially when a patient is seriously ill. You will have to tease out a history from a bad translator, but you also have to keep an eye on even good translators. You will be surprised how much you learn just by observing the interaction between translator and patient and how much you can pick up from any language just by listening. After a few months in the job you will know when a translator is consulting on his or her own.

For many patients, you may be the first official in this country who is nice. The result might be that patients come with all sorts of non-medical issues, which you will have to channel in the right direction. A few good leaflets and good contacts with local agencies can help a lot. Sometimes, after I have explained a letter or telephoned the education department, a social worker, or the Scottish Refugee Council, I am left wondering what my medical contribution was. However, I am sure that I have helped improve the patient's sense of well- being.

You should also be able to work in a team. The health visitor and district nurse are probably more important team members than you, though the patients might not believe this.

The biggest problem is professional isolation. Many colleagues will not understand what you are doing and will treat you with a mixture of admiration and pity. This is not helpful. You will need to make sure that you find other people who are in a similar line.

Training needs

Some general practitioners who do this kind of work have done a course in tropical medicine. I have not. I am an ordinary general practitioner with the normal training, but at no stage during the past year did I feel inadequately prepared. Horrible and strange diseases do appear occasionally, but unusual presentations of common illness are much more usual. I have found that Georgian women seem to suffer memory problems when they are depressed, while dizziness seems to be the Arabic male equivalent, and Afghans complain that they keep on thinking and that they have to hit their heads to stop the thoughts. These are obviously generalisations, but help to give a picture.

Medact, a London based charity concerned with questions of social justice, has organised several study days that cover issues on refugee status and health and are well worth attending. The next is on 9 April in London. We have also very recently had our own conference in Glasgow and hope to organise another.

The Medical Foundation for the Care of Victims of Torture can arrange for your attachments and has produced useful publications. Queen Margaret University College in Edinburgh has a department for international primary care that runs several interesting courses. There should be similar courses in other parts of the country.

Research opportunities

There are many research opportunities if you are so inclined. The whole concept of consulting with the help of a third party is little explored. The impact of dispersal, or the voucher system, on health is hotly disputed among non-governmental organisations and advocacy agencies, but there is a lack of medical research. General practice departments in universities may be helpful and interested.

Practicalities

Posts in this area are organised in various ways. General practitioners in inner Lon- don might simply have large numbers of refugees on their lists without making any fuss about it (such as writing a Career focus article). General practitioners in Glasgow are salaried assistants attached to practices that have agreed to accept a specified number of refugees. General practitioners in Margate are employees of a primary care trust that runs an assessment centre dedicated to refugees. Different models have different advantages and disadvantages. Before you commit yourself to a specific post, check the small print. Most importantly, the contract should offer sufficiently long appointment times and regular provision of translators.

In summary, I can recommend this kind of work. You will meet very interesting people, most patients will be extremely grateful, you will meet stimulating medical and intellectual challenges, and you will have the satisfaction of observing people putting their lives back together. In our practice we have a group of refugee doctors, most of whom suffered greatly before they came here. Now one has passed his first exams, and others are preparing for them. Over the next year or so, most will probably return to medical practice. It is a privilege to be involved with such people.