When newly graduated medical students begin training in the field of pediatrics, their three-year residency will include rotations in emergency care, adolescent medicine and the neonatal intensive care unit, among others.
But the scope of education may need to expand. Other than scattered programs across the country, there is no standardized curriculum that addresses immigrant and refugee health (IRH).
In a 2017 national survey, the American Academy of Pediatrics found one-third of pediatricians reported “not at all” or “slightly” prepared to care for children in immigrant families. The following year, an American Board of Pediatrics survey indicated that more than three-quarters of pediatricians do care for immigrant children.
“I talk with and teach residents that we have a real opportunity in those visits,” said Lisa Gantz, MD, an assistant clinical professor of pediatrics at the David Geffen School of Medicine at UCLA, “to not only address their symptoms but also to recognize that a family might be facing certain challenges.
“We can help them understand our health system and the resources and programs that are available to them to help their children thrive.”
Dr. Gantz and colleague Sural Shah, MD, MPH, are internal medicine and pediatrics physicians at Olive View-UCLA Medical Center, and founding faculty of UCLA’s Immigrant Youth Task Force. They surveyed current curricula and proposed a three-tiered system of IRH education to incorporate into pediatric residency programs.
Their study was recently published in the journal Academic Pediatrics.
“The goal of the curriculum is to help residents feel empowered to make a difference, to provide care and to address the underlying social drivers of health that we know really have a big impact on how children and their families do,” said Dr. Shah, the senior author of the study.
She recalled a patient from early in her career. A 6-year-old girl was experiencing frequent stomachaches and headaches. At the hospital, the family told Dr. Shah that immigration officials had recently visited their home and taken the girl’s father into custody.
“The little girl witnessed her father being taken away, and she was terrified about what was going to happen to her family,” said Dr. Shah. “The immigration status of the child's family really affected her health. Stomachaches and headaches are presentations of emotional and mental stress in children.”
She observed that IRH reflects a broad range of experiences.
“There is no singular narrative for the immigrant experience,” she said, noting that she is the child of parents who emigrated to the U.S. “One of the predominant narratives is of immigrants that come across the border, seeking asylum or other forms of immigration relief.
“But there are many who come through different paths – parents seeking employment or education, people coming with refugee status. All of those experiences have different impacts on the ways in which children access health care services, the education system and social services.”
Current limitations
The study’s literature review yielded 37 unique IRH curricula, including three in pediatrics residency. The researchers saw immigration status cited often as a social driver of health.
“Immigration status directly impacts their ability to access social services, medical services or mental health benefits,” said Dr. Gantz, first author of the study. “It is not traditionally thought of as a social determinant of health, but for a lot of these children and families it is a central variable that impacts so many different facets of their life.”
Even after physicians recognize this, there may be a gap in knowing how to provide appropriate clinical care as well as the resources and programs that are available. Trainees may just refer the patient to a social worker. Or they call on an “immigrant champion” like Dr. Shah or Dr. Gantz seeking help.
The study noted that academic medical centers have so far not incorporated IRH into pediatrics education because of factors such as limited funding, competing training demands and lack of sufficient faculty with IRH experience.
“It can feel overwhelming for trainees and it’s really clear that they are facing challenges,” said Dr. Shah. “Because of that, there's always a risk that the patient doesn't get enrolled in the medical services that they should get enrolled in. They maybe don't access nutritional resources that a child might need because they don't know their rights or protections.”
To further assist IRH providers in L.A. County, Dr. Gantz led the development of an immigrant health toolkit through the local California chapter of the American Academy of Pediatrics which provides a centralized list of resources for recently arrived immigrant children and their families.
Three tiers of learning
In their study, the researchers proposed a tiered approach to training pediatrics residents in IRH.
Tier 1 would be a required course that covered a wide range of topics such as working with interpreters, the resettlement process and trauma-informed care. Tiers 2 and 3 would be offered on an elective basis to learners who wanted to advance their education, including immigration law, cross-cultural pharmacotherapy and asylum/forensic evaluations.
Underlying the training are four core tenets: cultural humility, social determinants of health, access to care and language access.
“Cultural humility is having an overall respectful attitude and an openness to understanding that what I experienced in my life is different for somebody else,” said Dr. Shah. “It's an ongoing process of being open to learning from others and to having other perspectives. So obviously it extends to more than just the immigrant experience. It's something that is a useful skill for all of us.”
Cultural humility is also a core skill set in global health education which is already incorporated in many residency programs and may provide a roadmap for the introduction of IRH. In fact, the researchers found that of existing IRH curricula, many were either nested in global health or labeled as local global health.
“Over the past 20 years, we've seen this huge explosion in rigorous studies of global health curricula,” said Dr. Gantz. “I think we're sort of at the infancy of immigrant and refugee health curricula. There's clearly an interest and an appetite among learners, and there's clearly the need to produce physicians who are equipped to care for this population. I think it's really exciting to see how we standardize IRH education and prepare academic medical centers to better train physicians to care for our communities.”
