The expanding international refugee phenomenon is producing a growing need for physicians well-versed in the health problems of refugees. Various initiatives have been implemented throughout the world, including the countries of Great Britain, Canada, Australia, New Zealand [10
] and the United States, to raise awareness of the culturally diverse societies in these countries [12
]. Some medical schools have addressed multicultural issues with cultural immersion programs [13
], international electives, discussions, and formal pre-clinical cultural competence seminars in which students discuss racial, religious, and sexual diversity in society [11
]. But unlike cultural diversity discussions, refugee health has been much less studied and is a rarely taught component of medical education. Few medical students and physicians know how to appropriately treat refugees [4
] or identify those who have undergone torture or related trauma [1
]. Physicians untrained in issues sensitive to refugees and cultural diversity can have a deleterious effect on refugees. Prior research found that ineffective interactions with refugees resulted in longer office visits, delays in obtaining consent, unnecessary testing, and patient non-adherence. Medical residents also found it difficult to assess the degree of patient understanding of their illnesses and felt less prepared to care for those who hold different beliefs. Conversely, other reports have shown that many immigrants and refugees reported feeling misunderstood by their physicians [26
]. Poor communication often exists between physicians and refugees, and patient satisfaction, adherence, and health outcomes have been tied to communication [6
In a similar elective, Griswold described a unique 'Refugee Health Night' applying both academic seminars and clinical encounters for medical students at the State University of New York, Buffalo in 2003 [2
]. Based on self-reported feedback, these students had an overall positive impression of their experience [2
]. Griswold found a change in medical student attitudes towards cultural awareness, increased communication, and increased sensitivity to religious values, family patterns, and gender roles both before and after their interactions with the refugees [27
We successfully developed and implemented a medical school elective course to expose the medical needs of refugees by 1) educating medical students about refugee medical and mental health issues, as well as cultural diversity issues and 2) providing students with an opportunity to interact with refugees. Through our questionnaires, we showed that the elective increased student comfort interacting with foreign-born patients and their knowledge of refugee medical and mental health issues. It also improved understanding of cultural differences in medicine and alternative/traditional medical practices, and increased awareness of the logistical, cultural, and social hindrances to medical care and compliance. Lastly, we showed that medical students acknowledged that their race, religious background, and gender may have an effect on their interaction with patients after learning about refugees' perceptions of medical care personnel.
Participating students were more likely to feel that their personal religion, ethnicity/race, and gender would affect their interactions with patients. This suggests that learning about refugees and cultural diversity led to an increased recognition of these personal factors. Previous research has shown that gender concordance results in more effective communication, respect, and trust [27
]. Similarly, racial concordance can improve satisfaction with the delivery of health care services and shared-decision making [29
]. While one cannot change their gender or race for each given patient interaction, recognition of the impact of these identifiers on the doctor-patient relationship is essential.
Our results are congruent with other projects aimed at multi-cultural medical education [13
], and more specifically, health care for refugees [27
]. These studies support the proposition that student attitudes about refugees change following coursework or clinical encounters with refugees.
The overwhelming majority of students reported that this elective helped prepare them for their last two years of medical school and that they anticipated working with refugees in the future. This reflects other studies which have found that long-term medical education programs can have a positive effect on student motivation to work with the underserved [34
The primary advantage of our intervention study is that we assessed the same cohort of students prior to and following the course elective. To thoroughly consider what may have affected our findings, the role of self-selection bias must be addressed because this course was not mandatory. Those who enrolled in the elective may have been initially more interested in refugee health issues or have had prior experiences with refugees thereby making them more inclined to enroll in the elective. We also adjusted for student race and multilingual abilities. For example, those who enrolled in the elective felt more able to identify alternative and traditional medical practices. Following adjustment for race and multilingual status, this difference was no longer significant. The lack of significance following adjustment, despite that medical practices were addressed in the course, suggests that these particular student-held-attitudes may have been inherent among students with multi-racial backgrounds and those who were multilingual.
It is also plausible that the experience of being a medical student, regardless of enrollment status, during the study period accounts for some of the non-significant findings between those who did and did not enroll in the elective. For example, there was no statistical significance found between those who did and did not enroll in the elective regarding understanding cultural and social hindrances to medical follow-up and compliance. This finding suggests that knowledge was likely acquired through either other medical school courses or experiences resulting in an overall greater awareness of these factors over time.
Although this was a preliminary investigation as to how an elective focused on refugees would influence medical students' knowledge and perceptions, there are several disadvantages inherent in this study. The primary disadvantage is that we were unable to assign study identification numbers to link pre- and post-study questionnaires. Secondly, we did not obtain other demographic variables (age, gender, year of medical schooling, religion, future medical specialty interest). In our future investigations, we will incorporate more demographic variables so that we can determine which potentially confounding personal factors are associated with enrolling in a Refugee Health Elective. As this was the first time the Refugee Health elective was offered, our sample size (42 students) was limited; therefore, we were at a disadvantage to measure all the student differences and to precisely estimate the degree to which attitudes changed during the course of the semester. Additional analyses as the elective continues to evolve would give the project additional validity. Since 41 of the 42 (97.6%) participants indicated a desire to work clinically with refugees in the future, a long-term study analyzing the career paths of these future physicians would demonstrate the long-standing effects of this and similar elective courses. In addition, we believe that incorporating other health care professionals, such registered nurses, in the elective would have provided the students with additional perspectives especially as nurses are often the mediators of the patient-physician interaction process.
In terms of the elective course curriculum, and the limited contact with refugees, we would have also have liked to have included additional clinical experiences. However, in our situation, sensitivity and privacy issues led to limited established avenues by which students could participate in delivering medical and mental health care to refugees.