2. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation1 Fostering Cultural Awareness in Medical Education through Refugee Patient Encounters in the Primary Care Setting Frances Saad, B.A., Psychology, MSW student, School of Social Work Family Medicine Research Institute Department of Family Medicine University at Buffalo Program website: www.refugeehealth.com

3. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation2 Refugee Health and Cultural Awareness Training Program Training Program Description NYS DOH funded Community-based medical student training Collaboration with refugee resettlement agencies Volunteer student participation Weekly “Refugee Health Nights” Mostly 1 st year medical student participation

4. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation3 Refugee Health and Cultural Awareness Training Program Program Goals Self-awareness regarding one's own ethnicity/culture Understanding and appreciation for cultural diversity in the health care setting Enhanced communication skills Ability to utilize interpretive services Establishing collaborative partner- ships between care providers and patients

5. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation4 Refugee Health and Cultural Awareness Training Program Cultural Immersion Experience Refugee Health Nights Pre-clinical cultural orientation and post-clinical debriefing Identify cultural, communication and psychosocial issues in health care delivery to diverse populations Storytelling sessions Health presentations Mentoring / Tutoring Monthly discussion / Educational presentations

6. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation5 Research Evaluation Question What kinds of cultural awareness lessons do medical student derive from their clinical encounters with refugee patients?

7. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation6 Design and Methods Homogeneous sample of 1 st and 2 nd medical students (N=27) in an elective rotation Sixteen students (one refugee encounter) Eleven students (two refugee encounters) Intervention Briefings on culture, communication, refugees (1 hr) 38 clinical encounters with refugee (1½ - 2 hrs) Refugees’ country of origin (N=30) Cuba (6), Sudan (3), Vietnam (5), Iran (1), Bosnia (2), Iraq (7), Somalia (4), Ukraine (2)

8. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation7 Data Collection Student debriefing after the refugee health evaluation (1/2 hr) Debriefing topics: General experience Cultural issues Communication challenges Clinical problems Psycho-social issues Student’s emotions

9. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation8 Text Analysis Four text analysts Project Dir ( MD, MPH ), Culture Instructor ( PhD ), Project Coordinators ( 1 MSW, 1 BA ) Immersion-crystallization approach Culture and communication theme search Critical assessment of learning experiences Trustworthiness Multiple analysts Search for disconfirming evidence

10. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation9 Cultural Awareness Experiences Key Language/Communication Lessons Effective use of interpretive services was of utmost concern Key Cultural Awareness Lessons Challenge discerning what is “cultural” and what is not Key Lessons in Cultural Humility Refugee plight provoked self-reflection and cultural humility

11. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation10 Key Communication Lessons Gender match between interpreter & patient Staying focused while using an interpreter Differences between in-person and telephonic interpretation Problems with relying on family interpreters

12. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation11 Key Communication Lessons Gender match between interpreter & patient “…we had a Vietnamese interpreter but chose not to use him because he was male, and used the [phone] service for all three [women].” Staying focused while using an interpreter “The most trouble was thinking of things to ask…you are worrying about the interpreter, the patient…you tend to forget the important stuff…”

13. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation12 Key Communication Lessons Problems with relying on family interpreters “[They] may be loving and concerned toward their family members, but are less reliable…” Differences between in-person and telephonic interpretation “…using the in-person there’s a lot of talking w/ the patients…to me the phone is a direct translation…”

14. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation13 Student Assessment of Methods of Interpretation In-Person Too wordy More subjective More personable Allows greater patient- care provider interaction Includes non-verbal communication Cost of service not a major concern Gender match important Telephonic More concise More objective More impersonal Allows lesser patient- care provider interaction Excludes non- verbal communication Cost of service was a major concern Gender match important

15. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation14 Key Cultural Awareness Lessons Religion/spirituality in health care Family structure and relationships Gender roles and relations Ethno-medical (folk) treatments and beliefs

16. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation15 Key Cultural Awareness Lessons The role of religion/spirituality in health care “The Vietnamese worship in their homes in their own way…when someone passes away they celebrate...for them to have a good voyage.” “Pentecostals abstain from drinking and smoking…” Family structure and relationships “in Iran, even if her daughter was 50 [she] would still be considered a child…it would’ve had the same family dynamic…my own parents and I have a very different relationship…”

17. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation16 Key Cultural Awareness Lessons Gender roles and relations “I walked into the room...shook hands w/ the woman …the interpreter quickly whispered to me not to shake hands with the [Iraqi] man.” Ethno-medical (folk) treatments and beliefs “[The Vietnamese] have a plaster that is used for pains…herbal remedies that they put on as a paste…” “She didn’t view malaria as a disease, it’s so common [in Sudan].”

18. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation17 Key Lessons in Cultural Humility Awareness of privilege in light of refugees’ plight Refugee patients as ‘teachers’ of their culture Awareness of patients’ perception of provider Meeting patient emotional needs with empathy Concern for refugee integration into community

19. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation18 Key Lessons in Cultural Humility Awareness of privilege in light of refugees’ plight “…all her family is in Somalia, her father was shot and killed…she’s [here] all by herself…I’m even wondering how I’m going to get home from downtown…” Refugee patients as ‘teachers’ of their culture “…we tried to find words in common. They taught [us] some Spanish words...this kind of bond was formed...” Awareness of patients’ perception of provider “I’m going to be more conscious of how patients see me,…the patient’s views…it adds certain sensitivity.

20. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation19 Key Lessons in Cultural Humility Meeting patient emotional needs with empathy “I was going through the checklist…as she started to cry it shook me…I stopped the interview…as the empathy kicked in the checklist started to fall out of my head.” Concern for refugee integration into community “…I wished we had asked ‘what are you looking forward to do now you’re in America?’…If there’s anything they need to attain those goals…language classes, [job] training, any services…”

21. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation20 Study Limitations Potential bias of volunteers Small number of study participants Variability in the number of clinical encounters

22. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation21 Developing Cross-Cultural Patient Care Skills by Immersion Experience Highlights challenges in cross-cultural communication in the health care setting Facilitates learning about other cultures through patients’ stories about family, community and way of life Allows recognition of personal biases and first-hand appreciation of cultural diversity

23. © 2005 CDHS College Relations Group Buffalo State College/SUNY at Buffalo Research Foundation22 Reflections –“–“…It’s really humbling when people share their stories like that with you. You’re meeting them for the first time and yet you know you’ve made such a contact with them that they’re willing to open up to you, it’s very touching…” - 1 st yr. medical student