Conceptualising difference: a qualitative study of physicians' views on healthcare encounters with asylum seekers.

Objectives: In many high-income countries, structural, legal, social and political barriers to adequate healthcare interfere with the ability of health professionals to respond to the healthcare needs of a fluctuating and superdiverse population of asylum seekers. However, the relationship between individual, interpersonal and structural factors is not well understood. We explore the views and experiences of physicians working with asylum seekers in Germany and aim to identify how these may impact the provision of medical care.

Methods: A secondary analysis of 16 semistructured interviews conducted in two qualitative studies was performed. These explored the delivery of medical care to asylum seekers in Germany. In order to examine physicians' views towards their work with asylum seekers, we analysed evaluative judgements on interpersonal relationships, workplace factors, the external environment, the physician's own self and individual medical conduct. Analysis was conducted by identifying cross-cutting themes through thematic analysis and mapping these onto a framework matrix.

Results: Physicians perceive the provision of medical care to asylum seekers as 'different'. This 'difference' is conceptualised at three levels: patients' perceived cultural attributes, the workplace or contextual level. Evaluative judgements on patients perceived as 'other' and the difference of the space of care provision were found to impede appropriate care, while physicians emphasising contextual factors reported more responsive medical practices.

Conclusions: Concepts of difference at patient level resemble processes of 'othering' asylum seekers as a 'different patient group', while differences in rules, norms and practices in settings of medical care to asylum seekers create heterotopic spaces. Both appear to endanger the doctor-patient relationship and responsiveness of care, while an understanding of differences attributed to context seemed to foster a more caring approach. Training in contextual competence, sufficient physical and human resources and encouraging support between physicians working with asylum-seeking patients could counteract these processes.