Mandi Irwin is a family physician at the Nova Scotia Health Authority's Newcomer Health Clinic, in Halifax, NS
Elizabeth Munn is a medical student at Dalhousie University
Hamid Abdihalim is a medical student at Dalhousie University
Matthew Ta is a medical student at Dalhousie University
Human displacement as a consequence of war, natural disaster, civil conflict or political instability is not a new problem. The ongoing war in Syria has brought this issue into mainstream view recently. This and other protracted and escalating conflicts have resulted in the displacement of over 22.5 million refugees globally, as estimated by the United Nations High Commissioner for Refugees. In 2016 alone, almost 190,000 refugees were resettled in new countries around the world. This includes resettlement in Canada, which has welcomed over 25,000 refugees from Syria .
We often fail to appreciate that once refugees arrive in their countries of resettlement, they face substantial challenges with employment, education, healthcare, and language. These undermine their ability to integrate, rebuild and thrive in their new communities. These challenges have a face in the people we have met through clinical work, political advocacy and research in refugee health. In 2015, two of us attended a Summer Institute in Refugee Healthcare hosted by the World Health Organization, the University of Ottawa and the Canadian Council of Immigrant & Refugee Health. Based on training we received at the Institute, we developed a community-based service learning program for medical students in our city. The program was modelled after the Community Service Learning Program developed by the University of Ottawa. With the support and existing infrastructure of the local resettlement agency, the Immigrant Services Association of Nova Scotia, we were able to run a successful pilot program in 2016.
The program consists of a yearlong “reciprocal mentorship” between medical students and newcomer families. Groups of 2-3 medical students are matched with a refugee family identified by the local resettlement agency as most likely to benefit from additional support. Prior to meeting their family, the students participate in training sessions that cover the program’s structure and some basics of refugee health, including the legal basis of humanitarian protection, Canadian demographics, and social determinants of health. There is a meet and greet where the student-family pairs are introduced to each other, and from there, the program becomes flexible: students and families meet throughout the school year based on their interests, goals, and availability.
In this blog we outline what we have learned from the first year of this program.
Lesson 1: There’s a gap in the medical curriculum
We can depend on medical schools to make us technically excellent physicians – to teach us the anatomy, pharmacology, and physiology we need to know to care for patients. What we cannot assume is that they will teach us the social side of medicine. As many of us are aware, addressing the social determinants of health is a critical component to providing effective care. Refugees are disproportionately impacted by social determinants of health like income, immigration status, and language. These seriously impact their health outcomes and access to care.
These barriers are not experienced to the same extent by most physicians and medical students. This idea is supported by the available literature on Canadian medical student demographics. A 2001 survey to Canadian medical students indicated they were more likely to come from a higher socioeconomic status compared to the general population, as measured by their parents’ education, occupation and household income. A more recent CMAJ commentary highlighted that 52% of medical students come from families with annual incomes of more than $100,000, whereas only 23% of Canadian households fall into that same high-income bracket.
It is uncommon for physicians and medical students to have lived experiences of poverty and social exclusion to the degree that someone arriving as a refugee may have. There are even fewer medical students whose parents were refugees, or who themselves had this experience. We have seen this create a gap between refugee patients and those caring for them, whether they be a staff member or a student. We ourselves have felt this gap, and it can be staggering. It can manifest itself as a lack of understanding or compassion of the patient’s situation; frustration or dismissal; judgment; and fatigue.
Lesson 2: You get a different perspective when you visit people in their homes
With each successive year of medical learning, we find ourselves increasingly comfortable in the hospital environment – in seeing ourselves as physicians, and others as patients. The family match program is a step away from this paradigm. It is intentionally and exclusively community-based and non-medical. Students usually meet families in their homes. There is a shift in the power dynamic when you enter someone’s home as a guest – particularly when that someone is a recent acquaintance from a different sociocultural and linguistic group than your own. It was not uncommon for students to feel some trepidation at the first visit (“what if I say or do the wrong thing?”). We were certainly pushed outside of our comfort zones.
The fact that the program was community-based meant that students participated in a broad range of activities with their families. They shared meals, explored museums, and visited the local library. They explained the bus system and practiced English, helped kids with homework, and set up parents with computers. They talked about life back home and life in Canada, about how their upbringings were similar and different. Seeing families at home – in their element – helped break down the barrier that the hospital environment can sometimes put up between people when they have labels like “physician” and “patient” (or “refugee”, for that matter).
Lesson 3: Communicating across language barriers is hard but not insurmountable
Only two medical students in the program spoke Arabic, which was the primary language of all families. While this did present a challenge, we were ultimately heartened by how surmountable it was. Most of the groups used smartphone translation apps, like Google translate. Over time, students and families taught each other words in their respective languages. As we got to know one another, the ability to communicate through expressions, gestures, and shared words increased. Of course, this would not be appropriate in a clinical situation (where best practice is to use trained medical interpreters) but it worked well for these social encounters.
What became clear to us was how debilitating a language barrier can be. It is a constant challenge that affects all aspects of life, for as long as it takes to learn the local language. It impacts the ability of newcomers to meet their neighbours, get to appointments, buy groceries, find a job, help their kids with homework, and succeed in school. Learning a new language is no easy task, and it takes time.
A number of provinces fund in-person or telephone interpretation services so they are available at no charge to hospital and clinics. We implore all medical students and physicians to familiarize themselves with the options for professional interpretation available at their institutions.
Lesson 4: Exposure equals awareness
Not every student who comes through the program will dedicate their future practice to newcomer or refugee health. Furthermore, being involved in the program does not make us “experts” in these areas. This is not something the program claims to provide, nor is it a goal.
The value of the program is that it provides early sensitization and experience in an area that many students would not otherwise see. Creating this opportunity for medical students can increase their knowledge, awareness, and interest in newcomer health. Regardless of the speciality, we believe that the medical students involved in the program are more likely to become the physicians that get a translator when a patient has poor language proficiency; that ask about migration history; and that are comfortable working across cultures.
It is unreasonable to expect all physicians and medical students to have a comprehensive understanding of immigrant or newcomer health. But it is reasonable to expect that we recognize this gap: that we may not know enough about the context of patients’ lives, and that this context may be very relevant to their health. We hope this program encourages us to ask questions that shrink the gap moving forward.
In conclusion, we feel that our community-based ‘mentorship program’ between medical students and newcomer families has been valuable. We have demonstrated it’s feasibility and built on the strong example of the University of Ottawa, with crucial support from the Immigrant Association of Nova Scotia. Medical students are well-placed to help new families with community navigation and integration. They act as welcoming and familiar faces – personal manifestations of Canada’s message of welcome for refugees. In turn, families provide students with a rich and personal example of the strengths they bring to our community and the challenges that come with such a difficult transition. These are experiences of value regardless of medical specialty.