University of Colorado School of Medicine Course Description: World disasters, conflicts and persecutions have resulted in growing refugee populations worldwide. According to the Colorado Department of Human Services, the U.S. admitted 80,000 refugees in 2011, 2534 of which were anticipated to resettle in Colorado 1. In 2008, Florida received the largest number of arrivals, followed by California, Texas, New York, Michigan, and Arizona 2. Future medical professionals will need to be trained to provide culturally effective care to this population. This curriculum is designed to introduce medical and other health professions students to the common medical, dental, and psychosocial issues faced by refugees in the United States. Each of the eight topics is presented in a one-hour session, in either a lecture or a panel presentation format. At the University of Colorado School of Medicine, this elective was originally offered to first- and second-year medical students. However, all health professions students would benefit in some way from the topics presented. Speakers were recruited from local clinics, resettlement agencies, and refugee populations to give presentations and discuss the various topics. Each had a presentation or case from their personal experience with refugees; the panelists discussed their work and obstacles to providing optimal resettlement or medical care to refugees. The refugees themselves described their own backgrounds to the extent they felt comfortable with, and relayed their experiences with healthcare in the United States. The attached resources provide goals, assessment questions, and a suggested time frame for each session. ACGME Core Competencies Addressed By This Course: Medical Knowledge - Students will learn about medical, dental, and psychiatric diagnoses that are common among refugee populations Patient Care - Students will become familiar with the variety of backgrounds that refugees come from and the process that refugees go through once they arrive in the United States. This knowledge will help students to provide more compassionate, appropriate, and effective care to patients. Professionalism, Interpersonal and Communication Skills - The focus on developing advanced attitudes and beliefs for providing culturally effective care will facilitate the students growth in the areas of professionalism and interpersonal communication. Students will have the opportunity to discuss and think through challenging cases and ethical dilemmas. This will prepare them for facing similar situations in the healthcare setting. Systems-Based Practice - Through lectures and panels, students will gain an understanding of the system in place for health-screening refugees within the first eight months of arrival in the US, as well as how this system functions as part of the greater system of helping a refugee get established in their new home. Beyond this, students will learn about some of the barriers faced by both the refugees and the providers, and thus be aware of some of the areas of the system that need improvement, hopefully encouraging the students to pursue solutions. 1
Course Overview: Session Topic 1 Lecture: Intro: Refugee Health and Resettlement Programs in the U.S. 2 Panel: My Life As a Refugee 3 Panel: Refugee Resettlement in the U.S. 4 Lecture: Medical Care of Refugees 5 Panel: Refugees and the Healthcare System 6 Lecture: Common Oral Health Problems of Refugees 7 Lecture: Refugee Mental Health 8 Lecture: Challenges and Ethical Dilemmas of Providing Culturally Effective Care Session 1 Lecture Intro: Refugee Health and Resettlement Programs in the U.S. Course Overview: 12:00-12:10 Lecture: 12:10-12:50 Short Quiz: 12:50-12:55 Recognize the definition of "refugee" and the circumstances that lead refugees to the United States. Describe the difference between a refugee and an immigrant. Describe the various refugee populations represented in your city and/or state. 1. Define refugee and provide a few reasons a refugee might immigrate to the USA. 2. List the three most common groups of refugees currently arriving to your city and/or state. 2
Session 2 Panel My Life As a Refugee Introduction of Panel: 12:00-12:05 Panel Discussion: 12:05 1:00 Describe the refugee experience of moving to and living in the USA from the perspective of a refugee. Panel Guidelines: The ideal panel would represent the diverse refugee populations found in your city and/or state. This diversity includes culture, socioeconomic status, and age. However, children should not be considered candidates for the panel. Each panelist can discuss their culture, their personal experiences surrounding and including their move to the USA, and any message that they believe would be beneficial to pass on to the students. The panel will be an open forum with questions accepted at anytime throughout the discussion. Securing panelists can be challenging, and you may be tempted to send out a slew of invitations. Balance this with the time limits of your session. The ideal panel size will take into account the amount of time required to create an enriching experience for the learner and a rewarding experience for the refugee panelist. In a one hour period, we recommend a maximum panel size of four. The guidelines for panel members include the following: Each panel member should represent a different culture. The minimum age is 18. Highlight the fact that refugees have differing levels of education and training and a variety of lifestyles before resettling in the USA. 1. How is the refugee experience similar or different from what you expected? What aspects of the refugee experience most surprised you? 2. In what ways does your life differ from that of a refugee? Are there any ways in which your life is similar? 3. Identify one new piece of knowledge about refugees that you learned today. 3
Session 3 Panel Refugee Resettlement in the U.S. Introduction of Panel: 12:00-12:05 Panel Discussion: 12:05 12:50 Short Quiz: 12:50 12:55 Identify the local and/or state agencies that are involved in resettling refugees. Describe the barriers refugees face when integrating into the community. Panel Guidelines: The panelists will discuss their respective roles in helping refugees get oriented and integrated into life in the USA. They will discuss the resources available and any limitations. Ideally, the representatives would discuss these topics through a story, using a specific family as an example and highlighting common themes. Representatives from local resettlement agencies. (To locate agencies in your city/state, please visit http://www.acf.hhs.gov/programs/orr/state-programs-annual-overview or contact your local government.) An ideal panel includes a Case Manager, a Health Services Representative, a Cultural Orientation Representative, and a Language Teacher. 1. List a few of the agencies that help refugees adjust to life in the USA. Describe a few things that the agencies do to help the refugee populations they serve. 2. What are some common barriers refugees encounter when integrating into the community, from the panelists viewpoints? How do these compare with the experiences described by the refugees themselves (see prior week s panel)? 4
Session 4 Lecture Medical Care of Refugees Lecture: 12:00-12:50 Short Quiz: 12:50-12:55 Identify common physical ailments affecting refugees. Describe special issues common to refugees that may affect physical and emotional health. Identify the major medical illnesses that refugees should be screened for. Lecture Guidelines: Secure a health professional (physician, nurse, physician s assistant, etc.) who works with the refugee population in your city/state to lecture on the common health needs found among refugee populations, required screening procedures upon entry into the USA, and other issues as relevant to the physical health needs of the local refugee population. The most recent health screening guidelines for refugees can be found at: http://www.cdc.gov/immigrantrefugeehealth/guidelines/domestic/domestic-guidelines.html 1. List three common physical ailments that refugees are screened for when they arrive in the USA. 2. Identify two special health issues affecting refugee populations. Session 5 Panel Refugees and the Healthcare System Introduction of Panel: 12:00-12:05 Panel Discussion: 12:05 12:50 Short Quiz: 12:50 12:55 Describe the barriers refugees encounter in accessing healthcare. Examine the limits encountered by healthcare professionals who care for refugees. Panel Guidelines: A panel of healthcare professionals who regularly see and treat refugees will describe the unique aspects of caring for this population, relating their own experiences to the data presented in the first session. Have panelists identify limitations that they face in meeting the needs of the refugee population. Engage the group in brainstorming and problem-solving ways to address these limitations. Ideally, the panel will include physicians, PAs, nurses, social workers, medical assistants, and/or psychologists from local clinics that treat a large volume of refugees. 5
1. According to the research data presented in the first session, what are some of the significant health issues affecting refugees? 2. Describe a few reasons why refugees face barriers to accessing healthcare. 3. What are a few limiting factors that healthcare professionals face? Session 6 Lecture Common Oral Health Problems of Refugees Lecture/Dental Screen: 12:00-12:50 Short Quiz: 12:50-12:55 Describe common dental problems refugees face. If screening is taught: Perform a basic oral screen. Lecture/Dental Screen Guidelines: Secure the participation of a local dentist that serves a refugee population. It may be helpful to ask healthcare providers (contacted via the resources listed above) if they know dentists who treat refugees. Topics to address include: why basic oral health is important in general, and in particular for refugee populations, what types of diagnoses are seen most commonly in newly arrived refugees, and if there are cultural practices that affect the oral health of specific refugee populations (e.g. chewing quat in the Somali culture). 1. Describe some common dental problems seen in refugee populations. 2. What cultural practices may affect the oral health of specific people groups? Session 7 Lecture Refugee Mental Health Lecture: 12:00-12:50 Short Quiz: 12:50-12:55 Describe the common psychological issues affecting refugees, such as PTSD, abuse, and rape, and how these are affected by moving to a new country. Identify the mental health resources that refugees have access to. 1. What are some common psychiatric issues that refugees are screened for in our city/state? Across the USA? 2. What mental health resources are available to refugees? 6
Session 8 Lecture Challenges and Ethical Dilemmas of Providing Culturally Effective Care Lecture: 12:00-12:40 Wrap-Up: 12:40-12:50 Describe methods to address ethical dilemmas when conflicts arise between your own beliefs and those of the refugees. Discuss the challenges students will face in providing culturally effective care and the rewards of knowing how to approach these challenges with the goal of providing the best healthcare possible. Culturally Effective Medicine includes the values of competency (race, ethnicity, socioeconomic status, language (limited English proficiency) and access to care) and focuses on outcomes of the physician-patient interaction. 3-5 There have been a variety of terms, like cultural competency, cultural sensitivity, and culturally effective care to describe this concept. The term cultural competency creates an idea that there is a level to be reached rather than the journey and constant learning experience that truly exist. 6 In contrast, culturally effective care focuses on the outcome of the interaction between the healthcare provider and the patient. It moves beyond race and ethnicity to an expanded definition of ethnicity, language, religion, sexual orientation, gender, disability and socioeconomic status. It acknowledges that other attributes affect the delivery and quality of care, and it recognizes that other cultural groups have health disparities. 6 Discussion points and core concepts: Culture is not static; it consists of multiple variables Culture should be reframed with a perspective beyond race and ethnicity The patient s perspective is illness, while the physician views the same issue as a disease Core cultural issues include misunderstanding in situations, interactions and behaviors Kleinman questions 7 - use as a framework for understanding the refugee perspective: What do you call this problem? What do you believe is the cause of this problem? What course do you expect it to take? How serious is it? What do you think this problem does inside your body? How does it affect your body and your mind? What do you most fear about this condition? What do you most fear about the treatment? Social factors of disease Negotiating across cultures with the goals of mutual agreement, relationship building, agendasetting, assessment, problem clarification and closure 7
The Culturally and Linguistically Appropriate Services (CLAS) Standards: For a resource on these national standards, guidelines, and implementation strategies, visit: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=1&lvlid=3. (Or, from www.minorityhealth.hhs.gov, click on the Cultural Competency tab.) Suggested activity: Work through a clinical situation that presents at least one ethical dilemma to the medical professional. Discuss your gut reaction and alternate ways that the situation could be handled, taking cultural differences into account. 8
References: 1. Colorado Department of Human Services. The Colorado Refugee Services Program 2012. Colorado Government Website. Available at: http://www.colorado.gov/cs/satellite/cdhs-selfsuff/cbon/1251580884704. 2. Sebelius K. Report to Congress on the Refugee Resettlement Program. 2011:1-157. 3. Boutin-Foster C, Foster JC, Konopasek L. Viewpoint: physician, know thyself: the professional culture of medicine as a framework for teaching cultural competence. Academic medicine : journal of the Association of American Medical Colleges. 2008;83(1):106-11. Available at: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=18162762&retmode=ref&cmd=prlinks. 4. Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: a patient-based approach. Annals of internal medicine. 1999;130(10):829-34. Available at: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=10366373&retmode=ref&cmd=prlinks. 5. Britton CV. Ensuring culturally effective pediatric care: implications for education and health policy. Pediatrics. 2004;114(6):1-11. Available at: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=15574635&retmode=ref&cmd=prlinks. 6. American Academy of Pediatrics. Ensuring Culturally Effective Pediatric Care: Implications for Education and Health Policy. Pediatrics. 2004;114(6):1677-1685. Available at: http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2004-2091. 7. Kleinman A, Benson P. Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS medicine. 2006;3(10):1-4. Available at: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=17076546&retmode=ref&cmd=prlinks. 9