Category Archives: Residency

The Importance of Refugee Care in Family Medicine

The Issue

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Jeffrey Walden, MD

Immigration as a whole, and refugees in particular, have been much in the news for the past several years. According to the United Nations High Commissioner for Refugees, as of 2018 about 68.5 million people worldwide have been forcibly displaced—more than at any other time in human history.1 Over a third of these people have crossed international borders while fleeing persecution and violence, and have therefore been labeled refugees.

While war and political upheaval have uprooted people for centuries, the plight of those fleeing persecution formally became codified into law with the 1951 Convention Relating to the Status of Refugees. Based on this definition, a refugee is someone who, “owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country.”2

The United States has historically resettled between 70,000 and 80,000 refugees per year, with a steep drop-off in the past several years due to changes instituted by the current presidential administration.3 With almost 30 million refugees worldwide, these numbers mean less than 0.3% of the world’s refugees are resettled in the United States in any given year. We as a nation can thereby exercise much discretion when selecting which refugees enter the United States. Indeed, the process to vet potential refugees involves security clearances by numerous federal agencies, including the Department of Homeland Security, and can take upwards of 18 to 36 months.

Historically, the United States has not discriminated a refugee’s case based on his or her ability to integrate. While this ensures granting the most vulnerable equal access to protection and resettlement, refugees may therefore arrive with chronic or serious health problems.4

The Importance to Family Medicine

Although all applicants for refugee status undergo health screening overseas by a trained panel physician, refugees may have had little prior care for any of their longstanding medical issues. Family physicians, whether in academic centers or private practice, therefore often encounter refugee patients after arrival in the United States. Learning to care for these—and by extension other—underserved patients serves an important part of the undergraduate and graduate medical education curriculum.

Refugees form a heterogeneous group, arising from areas of the world as disparate as East and Central Africa, the Middle East, Southeast Asia, Eastern Europe, and Central and South America. Despite these differences, they have some unifying factors—all refugees have faced persecution, by definition of their status. Many have been subjected to various diseases of poverty and nutritional deficiencies. All will face challenges when resettling in the United States with cultural issues and social determinants of health.

Culturally appropriate care—the type of care typically provided by family physicians—can help these patients better integrate into US society. Assisting refugees along their path toward self-sufficiency and citizenship requires developing strategic partnerships and community engagement. Fostering such relationships can potentially strengthen a clinic’s outreach in the community to address other social determinants of health for all clinic patients.

Involving Learners

Since 2014, the Cone Health Family Medicine Residency Program has sponsored a dedicated refugee and immigrant clinic within our larger family medicine clinic. Structured toward both learners and patients, the clinic serves as an intake evaluation to review the patients’ overseas paperwork, obtain medical and social histories (often the main difference between these patients and “regular” patients), screen for infectious disease, and identify any current needs or issues. The first 30 minutes of each clinic are dedicated to didactic teaching about a specific refugee topic, after which residents interview and examine the patient. The resident who sees that patient then becomes his or her primary care physician. All residents rotate through the clinic during their community medicine rotation:  2 weeks during their second year and 4 weeks during their third year.

Our clinic also serves as a rotational site for visiting third- and fourth-year medical students. This has provided students the opportunity to experience underserved care within a primary care and family medicine context. By working specifically with refugees, learners gain opportunities for advocacy, improvements in cultural humility and competence, and the ability to pursue global health work without needing to find the time or funds to travel.

Due to ongoing worldwide conflicts, issues of migration won’t be going away anytime soon. Exposing learners to such issues can broaden medical education while serving a community need. Beyond that, caring for refugees and learning how they have responded to persecution can teach clinicians valuable lessons about resilience in this time of perceived physician burnout.

Ways to Get Involved

  • Commit to seeing refugee patients in your clinic
  • Develop a refugee, migrant, or other underserved clinic within your program
  • Volunteer at an underserved clinic or health department
  • Conduct medical forensic evaluations for those seeking asylum
  • Complete N-648 certifications—a topic for a future blog post

Further Reading

References

  1. The UN Refugee Agency, Office of the United Nations High Commissioner for Refugees. Figures at a Glance. https://www.unhcr.org/figures-at-a-glance.html. Accessed May 22, 2019.
  2. The UN Refugee Agency, Office of the United Nations High Commissioner for Refugees. The 1951 Refugee Convention. http://www.unhcr.org/pages/49da0e466.html.
  3. Migration Policy Institute. S. Annual Refugee Resettlement Ceilings and Numbers of Refugees Admitted, 1980-Present. https://www.migrationpolicy.org/programs/data-hub/charts/us-annual-refugee-resettlement-ceilings-and-number-refugees-admitted-united. Accessed May 22, 2019.
  4. Hebrank K. Introduction to Refugees. In: Annamalai A, ed. Refugee Health Care: An Essential Medical Guide. New York: Springer Science; 2014:3-11. https://doi.org/10.1007/978-1-4939-0271-2_1

One of Those Kids in That Class Is Me and They Deserve a Chance

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Renee Crichlow, MD

In the last couple of years, I have been a co-teacher in an undergraduate program part of whose mission is to increase underrepresented in medicine (URM) students in our medical school. There are many reasons I have chosen to do this and to fully understand, I thought it would be important to share a little bit of my student career history.

To begin, nothing in here is about bragging. It’s really about sharing a story that may be similar to what others have seen.

My high school was a very high performing public school: we had 13 National Merit Scholars in the year I graduated, and I was one of them. (Except at that time in 1985 my award was called National Merit Outstanding Negro Scholar. I’m not joking. That’s exactly what it was called in 1985.) I mention this because it’s an indication of the fact that I would have been considered a very high-capacity, high-potential performer for college.

For many reasons that I won’t go into, there was no family support for me either financially or socially to enter college. So I found a way to get to college by myself. Eventually, I decided to stay in the town that I grew up in and went to school at Oklahoma University.

In order to afford food and books, I had to work night shifts at Hardee’s, closing the restaurant quite late. I didn’t have a car so if my friend couldn’t pick me up I walked back to campus. I worked multiple nights each week and carried a full credit load. I would say my grades there were mediocre at best. By the end of the first semester, it was clear to me that I was very bored staying in the same town that I grew up in. I went to the large pile of brochures that I’d been sent after winning National Merit Outstanding Negro Scholar award and I chose to apply to Boston University because it had rolling admissions and would accept me based on my ACT and SAT scores alone as my GPA was not very impressive. I ended the year with about a 3.2.

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Hashtag Mentorship

Randall Reitz

Randall Reitz, PhD

#researchismypants
#takeitlikeahurdle

Mentorship has been around since the era of The Odyssey.  In the poem, as Odysseus prepares to leave for the Trojan War, he entrusts his son Telemachus to the tutelage of his trusted colleague, named Mentor. Our modern usage of this term extends from Homer’s character, but mentorship has evolved greatly in the nearly 3,000 years since (and now occasionally involves hashtags).

I recently had the privilege of being a small-group mentor with STFM’s Behavioral Science/Family Systems Educator Fellowship (BFEF).  I worked alongside Jill Schneiderhan, MD, to provide guidance to four early career behavioral medicine faculty and it was the highlight of my year.

My own small group was smitten with hashtags. They provided a pithy lingua franca to describe and unify our experiences. The two hashtags at the top of this post linger most in my memory.

#researchismypants came from a tear-filled (joy and sadness) discussion during our final dinner together. One of the fellows declared that she had just sworn off wearing pants. I observed that “research is my pants” and that I had just sworn off research. Neither of us could further abide these noxious crimps on our preferred lifestyle.

#takeitlikeahurdle came from the ride home on Highway 5 after that dinner. One of the fellows observed that she had recently sprinted across the same interstate earlier in the day, yelling for her husband to leap over the median “like a hurdle”.

 

hashtag mentorship

Randall’s BFEF Small Group

 

These hashtags encapsulate much of the tension of early career professionalism. People entering a new field face the dual pressures of being as helpful and generous with their colleagues as possible (to ingratiate themselves to the system). They also need to begin to delimit the scope of their job descriptions so that they maintain sanity and high self-expectations for work quality. The new professional needs to bring both positive energy and expertise to the projects they take on (ie, #takeitlikeahurdle) but also assert the confidence and negotiating skill to decline opportunities that aren’t a great fit (#researchismypants).

Each of the fellows successfully navigated experiences that embodied this tension, whether it was making a tough decision to change residencies for a better fit, standing up to a challenging colleague, enduring with pride the difficulties of relationship strife, or confronting unhealthy expectations from their department. It was an honor to scaffold our mentees during these trials. It was a thrill to watch how our charges came through stronger.

By my estimation, the BFEF Fellowship is an eminent example of modern mentorship.  What does it look like?

  • Intensive face-to-face mentorship at two STFM conferences and the Forum on Behavioral Science Education
  • Individual, small-group, and large-group meetings
  • Monthly small-group phone calls
  • Weekly synchronous and asynchronous points of contact (ie, email, project feedback)
  • A professional learning contract to personalize and guide the experience
  • A community of volunteers that support the mentors

This fellowship is one of many run by STFM, including training programs for leadership, practice transformation, teaching medical students, and medical journalism. These great offerings are constantly looking for faculty, advisors, and trainees, and I highly recommend you apply. Having experienced STFM training as both a mentee and mentor, I can attest to the richness of the experience from both sides.

#mentorshipalwaysevolves
#mentorshipneverchanges