J Immigrant Health (2007) 9:55–60DOI 10.1007/s10903-006-9016-8

ORIGINAL PAPER

Cultural Awareness through Medical Studentand Refugee Patient EncountersKim Griswold · Luis E Zayas · Joan B Kernan ·Christine M Wagner

Published online: 9 September 2006C© Springer Science+Business Media, LLC 2006

Abstract Purpose: This paper presents findings from aqualitative investigation of cultural awareness that medi-cal students developed in the context of providing medicalcare to refugees. Our evaluation question was: What kindsof cultural awareness and communication lessons do med-ical students derive from clinical encounters with refugeepatients? Methods: Thirty-eight semi-structured interviewswere conducted to debrief a sample of 27 medical students.A multidisciplinary research team analyzed the debriefingtexts following an interpretive “immersion-crystallization”approach. Results: Three domains in cultural awarenesstraining encompassed 13 key lessons or themes. Studentsreported enhanced awareness about the use of interpretationservices and cross-cultural communication. A second set oflessons reflected awareness of the refugees’ cultural back-ground, and a third learning component involved experiencesof cultural humility. The refugee plight prompted reflectionon the students’ own culture, and validated the rationalefor empathetic care and patient empowerment. Conclusion:As medical school curricula incorporate more cultural diver-sity training, a patient-based learning approach with selected‘hands-on’ experiences will create opportunities for studentsto increase their cultural sensitivity and competency. Thisprogram’s experiential model indicates that after refugeemedical encounters, these beginning medical students re-ported greater awareness of communication issues, and sen-

K. Griswold (�) · L. E. Zayas · J. B. Kernan · C. M. WagnerDepartment of Family Medicine, Family Medicine ResearchInstitute, The State University of New York, University at Buffalo,462 Grider Street, Buffalo, NY 14215, USAe-mail: griswol@buffalo.edu

L. E. ZayasDepartment of Anthropology, University at Buffalo,Buffalo, NY, USA

sitivity toward religious values, family patterns, gender rolesand ethnomedical treatments. It will be important to test thesekinds of preceptor/apprenticeship models of cultural sensi-tivity training at later stages of medical training; in order toassess long-term effects.

Keywords Medical education . Cultural awareness .

Refugee health . Qualitative evaluation

Introduction

Cultural competency training has become an important con-tent area in many United States medical schools. Methodscenter on lectures, workshops and standardized patient sta-tions, although most programs remain optional [1, 2]. Devel-opment of new curricula should be informed by recognitionthat different models exist and that the need for training ex-tends beyond students and residents to educators themselves.In family medicine, the need for cross-cultural training andclinical awareness has been highlighted, and includes anemphasis on medical anthropology [3, 4]. A “Global Multi-cultural Track” elective in Family Medicine and CommunityHealth resulted in participants demonstrating a higher levelof cultural competence, more tolerance of people with dif-ferent cultural backgrounds and more acceptance of thosepersons who did not speak English [5]. An informal cur-riculum implemented in 1995 at the University of MichiganMedical School found that students were receptive to dis-cussing culture and issues of power, particularly when thesetopics were embedded in patients’ personal stories [6].

Our institution is an urban academic center, serving amajor metropolitan area in Upstate New York. At our med-ical school, development of a cultural awareness and sen-sitivity curriculum is proceeding from the experience of an

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academic-community partnership to provide medical carefor the region’s growing population of international refugees[7]. This paper presents findings from a qualitative investi-gation of cultural awareness that medical students developedin the context of providing medical care to refugees. Ourevaluation question was: What kinds of cultural awarenessand communication lessons do medical students derive as aresult of encounters with refugee patients?

Methods

Refugees are resettled in our area through the Office ofRefugee Resettlement (ORR), a federal program that main-tains local community partners. Refugees served throughour local program are resettled through two organizationsin our city; these organizations refer refugees to the twoinner-city medical sites that provide the full array of pri-mary and preventive care services to the refugee population.One medical clinic is a University based family medicinetraining site, and the other is a private practice. Medi-cal services include prenatal care and delivery, in-patienthospitalization if needed, and pediatric care. The medicalclinics serve not only refugees, but the surrounding urbanpopulation. All resettled refugees are provided Medicaidcoverage for six months after resettlement; subsequently,they obtain health insurance through their respective work-places. Refugees access services by bus, or by walking tothe nearby clinic. One of the medical sites provides free vantransportation. During clinical sessions with refugee fam-ilies, experienced preceptors and medical students caredfor patients from a wide range of cultures using profes-sional interpretation services. The refugees had been in theUnited States for less than 3 months when they presented fortheir initial routine medical history and examination. Theseencounters provided a patient-based learning approach tomodel and teach culturally sensitive care for diverse pop-ulations. Curriculum goals were for students to acknowl-edge their understanding of different cultures, recognizehow culture may influence health care, enhance burgeon-ing interviewing and communication skills, and appreciatethe power differentials that may occur between provider andpatient.

Thirty-eight debriefing interviews were conducted witha homogeneous sample of 27 1st and 2nd year medicalstudents who voluntarily enrolled in the training programelective. Sixteen students had one encounter with a refugeepatient, and 11 had two encounters. The sample of 27 stu-dents (18 female and 9 male) represented all the studentsenrolled in the elective, except three who withdrew and didnot see a refugee patient. This sampling strategy is deemedhomogeneous by status, for including students at the samemedical school and beginner level. Fourteen students were of

European-American descent, three African-Americans, oneLatino-American, one Southeast Asian-American, and fourIndian-Americans. This study was approved by our institu-tional IRB.

Before the clinical encounter, a refugee social worker anda medical anthropologist briefed the student for one hour onthe refugee patient or family to be seen, what “culture” is,what it means to be a “refugee,” and how to use interpre-tation services. Then the student joined the attending med-ical preceptor. While the refugee individuals and familieswere being routinely screened by office staff (height, weight,blood pressure, growth charting for children); the preceptorand student spent approximately 15 minutes discussing thatparticular refugee’s country of origin, and common medi-cal problems screened for in refugee populations. With theassistance of a trained medical interpreter, the preceptor in-troduced the student to the patient; the student then spentabout 20–30 min taking a health history and inquiring aboutany particular problems. Preceptor and student conducted aninitial medical examination, and with the patient, identifiedany medical problems in need of management. This inter-vention took from 30–45 min. Refugee patients were encour-aged to ask questions, and provided with information aboutthe office practice. Interpretation services were in-person ortelephonic; and if possible, gender specific. About half of theencounters were held with trained interpreters translating forthe refugee; interpreters were provided by the resettlementagency. If a trained interpreter was not available, the medi-cal site had access to an interpretation line. This telephonicservice is provided for a fee, covered by the affiliated hospi-tal, and offers trained interpreters in any language to provideconfidential translation. The service is used with a speakerphone within the examining room. Each medical preceptorhad international experience in working with different cul-tures, and each has worked with local refugee populationssince 1999.

Overall, the student cohort saw 30 refugee patients orfamilies who had been in the United States for less than3 months, and were from the following countries: Iraq (7),Cuba (6), Vietnam (5), Somalia (4), Sudan (3), Bosnia (2),Ukraine (2), and Iran (1).

Students were debriefed individually or in pairs after theirclinical encounter. A semi-structured evaluation instrumentthat program personnel devised was used to identify, ratherthan measure, variable learning experiences promotingcultural awareness. This instrument consisted of sevenopen-ended questions concerning: (1) overall encounterexperience, (2) communication challenges, (3) culturallessons, (4) clinical examination, (5) psycho-social issues,(6) emotional self-reflection, and (7) suggestions for curricu-lum development. Qualitative evaluation was deemed mostappropriate because of the indeterminacy of the student-refugee interactions and the exploratory nature of the study.

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The medical anthropologist conducted most of the debriefingsessions, probing frequently to explore particular expe-riences or lessons more in-depth. These sessions lastedbetween 30–45 min, and were audio-recorded andtranscribed for analysis.

A multidisciplinary team of four key program personnelconducted qualitative analysis. The team included a primarycare physician, a medical anthropologist, a social worker andthe project coordinator, all of whom are trained in qualita-tive data analysis. Drawing from a patient-based learningmodel, the analysis followed an “immersion-crystallization”approach involving a systematic iterative process of inter-pretive review and categorization [8]. The analysts reviewedeach transcript separately and identified meaningful units ofinformation that pertained specifically to lessons about cul-ture and communication. After this initial step, the analystscollectively classified their independent findings into the-matic categories by consensus. Interpretive disagreementswere discussed and resolved by presenting supportive evi-dence. Lastly, the analysts combed the transcripts one lasttime in search of evidence that conflicted with the find-ings as a measure of trustworthiness [9]. The themes thatemerged in this analytical process represent key programlessons.

Findings

The findings are presented as thematic categories underthree general areas of cross-cultural experience in the clin-ical setting: (I) Language/communication lessons; II) Cul-tural awareness lessons; and III) Cultural humility lessons(Table 1). Overall, a total of 13 themes or key lessons—all supported by multiple examples—were identified underthese headings.

Table 1 Summary of findings

Key language/communication1. Gender match between interpreter and patient2. Differences between in-person and telephonic interpretation3. Problems with relying on family interpreters

Key cultural awareness lessons4. Religion/spirituality in health care5. Family structure and relations6. Gender roles and relations7. Ethnomedical (folk) treatments and beliefs

Key cultural humility lessons8. Awareness of privilege in light of the refugees’ plight9. Refugee patients as ‘teachers’ of their culture

10. Awareness of patients’ perception of provider11. Meeting patient emotional needs with empathy12. Concern for refugee integration into community

Narrative of findings

Key language/communication lessons

(1) Gender match between interpreter and patient. Studentscommented on the matching of refugee patients and inter-preters by gender in order to facilitate communication andtrust, and enhance the patient’s comfort level. For example,regarding an Iraqi woman, one female student mentionedthat “[with] the translator [being] female . . . she felt a lotmore open and able to talk about everything much morefreely . . . ” Another student observed that “ . . . we had anin-person Vietnamese interpreter but chose not to use himbecause he was male, and used the [telephonic] service forall three [women].”

(2) Differences between in-person and telephonic inter-pretation. Every student had the opportunity to employ in-person or telephonic interpretation services while conduct-ing the medical examination. These practical experiencesyielded a series of personal opinions on these two meth-ods, summarized on Table 2. Student assessments variablyreflected some degree of comfort, utility and perceived valid-ity with the particular interpretation method. One student, forexample, contrasted interpreter modes in two separate casesby stating that “ . . . using the in-person there’s a lot of talkingwith the patient . . . to me the phone is a direct translation. . . ” Another student who had the opportunity to employboth interpretation methods with the same Vietnamese pa-tient, however, felt that “ . . . in-person [interpretation] is a biteasier because I’m very much into [it] . . . how I use gesturesand body language . . . over the phone it took . . . extra time.”Recalling instructions to look directly at the patient duringthe process of interpretation, another student felt that “youcan’t establish eye-to-eye contact [when] you have to passthe phone back and forth . . . ”

(3) Problems with relying on family interpreters. In thetemporary absence of an interpreter it was tempting for stu-dents to consider the comments of patient’s relatives in theroom who knew some English. Students were cautioned

Table 2 Student assessments of methods of interpretation

In-person interpreter Telephonic interpreter

Too wordy More conciseMore subjective More objectiveMore personable More impersonalAllows greater patient/care

provider interactionAllows lesser patient/careprovider interaction

Includes non-verbalcommunication

Excludes non-verbalcommunication

Cost of service not a majorconcern

Cost of service was a majorconcern

Gender match important Gender match important

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about relying on non-professionals for interpretation andthey heeded that advice. One student who saw an Ukrainianwoman noted that her “ . . . son was in the room . . . mostlyfor support . . . he was interpreting a bit . . . his English waspretty good.” Still, the student waited for and continued torely on the skilled interpreter. Another student was convincedthat “[children] may be loving and concerned toward theirfamily members, but are less reliable . . . ”

Key cultural awareness lessons

(4) Religion/spirituality in health care. Students were ableto elicit important information about the patients’ religiouspractices that increased their cultural awareness. For exam-ple, regarding mortuary rites one student was excited to learnthat “the Vietnamese worship in their homes in their ownway . . . when someone passes away they celebrate . . . forthem to have a good voyage.” Such knowledge could helpcare providers to deal with end-of-life situations. Anotherstudent was embarrassingly reminded that “Pentecostals ab-stain from drinking and smoking . . . ” when probing for riskbehaviors with one refugee patient. Another refugee patientreminded a student that “[Sudan’s] north is Muslim and thesouth is Christian,” which thus guided the student’s interac-tion with that patient.

(5) Family structure and relations. Students identified cul-tural family patterns that can be instructive when consideringa patient’s medical history or identifying supportive kin. Onestudent felt that “being allowed to take the patient historyalone . . . lets us explore and learn about their culture . . .

when you take the family history of illness . . . in telling youabout [the father’s] severe stomach pain . . . they tell you allabout their father and what he does . . . and about the family.”Another student spoke about the special, revered position ofelder kin in Vietnamese culture: “they actually have shrinesfor their grandparents.” Regarding family issues in Iran, astudent said: “even if her daughter was 50 [she] would stillbe considered a child . . . it would’ve had the same familydynamic . . . my own parents and I have a very differentrelationship . . . ”

(6) Gender roles and relations. Students also spoke abouthow culture defines specific gender roles and relations. Forexample, one female student described a female/male inter-action in Arab cultures as follows: “I walked into the room. . . shook hands with the woman . . . the interpreter quicklywhispered to me not to shake hands with the [Iraqi] man.” Re-garding sexual issues, a student asked an unmarried, youngVietnamese woman if she had a “boyfriend” before probingfor sexual activity. Sensing embarrassment, the student laterrealized that “ . . . the concept of ‘boyfriend’ means marriageto them.”

(7) Ethnomedical treatments and beliefs. Students re-marked about different types of ethnomedical treatmentsduring their clinical encounters. For example, one studentlearned that the Vietnamese “have a plaster that is used forpains . . . herbal remedies that they put on as a paste . . . ” An-other student learned about folk conceptions of illness whena Sudanese refugee stated no history of serious diseases orhealth problems despite having had malaria. Because of thehigh incidence in that country, the student probed for malaria.To the student’s surprise, the refugee then admitted to con-tracting it, although “she didn’t view [it] as a disease, it’s socommon.”

Key cultural humility lessons

(8) Awareness of privilege in light of the refugees’ plight.The refugees’ stories provoked humility and self-reflectionin students. Students were impressed by the refugees’ re-silience, which led them to reflect particularly on their ownrelatively privileged background. One student, for example,was impressed by the situation of a young Somali woman:“all her family is in Somalia, her father was killed . . . she’shere all by herself . . . I’m wondering how to get home fromdowntown . . . ” Another student was moved and baffled re-flecting upon her encounter with another Somali woman:“[she] is telling me this awful stuff . . . so matter-of-factly. . . she would talk about being shot . . . as she would talkabout a rash on her skin . . . it was hard . . . ”

(9) Refugee patients as ‘teachers’ of their culture. Stu-dents recognized that the best teachers of the refugees’ cul-tures were the refugees themselves. To learn something abouta particular culture in such a limited time and context, thestudents were instructed to ask and elicit stories about therefugee’s way of life and if appropriate to inquire about theirbeliefs on specific practices and their meaning. For exam-ple, while discussing pre-natal care issues with a pregnantIraqi woman, one student heard about Middle Eastern birthpractices: “ . . . she was telling me . . . there’s a lot of homebirths . . . when you’re ready the doctor comes . . . they havemidwives . . . ”Another student noted how a Cuban familyoffered impromptu language lessons: “We tried to find wordsin common. They taught [me] some Spanish words . . . thiskind of bond was formed . . . ”

(10) Awareness of patients’ perception of provider. Whenasked how would the experience with the refugee help indealing with any other patient, one student replied: “I’m go-ing to be more conscious of how patients see me . . . [their]views . . . it adds certain sensitivity.” Another student feltthat “ . . . smiling is pretty universal, [it] gives them a senseof reassurance . . . that you’re there to be an advocate.” Al-ternatively, one medical student realized the “power” of themedical care provider by asking: “if you could take that blood

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pressure without a white coat on” for a refugee male patientwho according to staff seemed “so terrified of doctors . . . ”

(11) Meeting patient emotional needs with empathy. Justas hearing about the refugees’ plight provoked humility andself-reflection among students, the refugees’ presentation ofemotional scars also was met with empathy. One studentdescribed his reaction when an elderly Vietnamese womanwho had lost close relatives to armed conflicts suddenly ex-pressed grief: “ . . . I was going through a checklist . . . as shestarted to cry it shook me . . . I stopped the interview . . . asthe empathy kicked in, the checklist started to fall out of myhead.” Another student tried hard not to upset a persecutedSomali woman by conducting the medical history gently: “Itwas really tough to ask some questions, like ‘where’s yourhusband?’ or ‘do you know if your children are alive?’ . . .

that must have evoked incredible emotion in her . . . ”(12) Concern for refugee integration into community. Stu-

dents noted that ensuring the well-being of the refugee pa-tients also involved help with many things that most peopletake for granted, such as learning to ride the bus, shop at thesupermarket, find employment, etc. For example, one studentsaid, “I wish we had asked ‘what are you looking forward todo now you’re in America?’ . . . If there’s anything they needto attain those goals . . . language classes, [job] training, anyservices . . . ” Another student noted that “this [Iraqi] familywill do quite well . . . they’re both young and willing to learn. . . he got a job right off the bat . . . he’s going to school . . .

he speaks very well and his wife is understanding . . . ”

Discussion

The goal of our study was to determine if there were culturalawareness lessons that medical students derive from clini-cal encounters with refugee patients. The first set of lessonsexpressed by these students pertained to the use of interpreta-tion services and to appreciation of cultural nuance. Effectiveuse of interpretation services, without which communicationand cultural awareness lessons would not be possible, was ofutmost concern to all the students. The second set of lessonsreflected awareness of the refugees’ cultural background.Students identified cultural practices and beliefs, while ac-knowledging challenges in discerning the “cultural” fromthe “idiosyncratic.” And the third set of lessons involved ex-periences of cultural humility. Evidently, the refugee plightprompted reflection on students’ own culture and lifestyle,and validated the rationale for empathetic care and patientempowerment. As Carrese and Marshall [4] have noted, “Inattempting to understand others, physicians may learn abouttheir own cultural biases . . . (and) may become more sensi-tive to the authority they possess . . . ”

There is evidence that experiential learning through meet-ing and communicating with people of different cultures and

backgrounds expands the student’s awareness and skills [10].Tervalon and Murray-Garcia [11] have proposed develop-ment of “cultural humility” in multicultural medical educa-tion to promote self-reflection, redress power imbalances,and advocate partnerships in the patient-physician dynamic.

Our findings seem to agree with prior studies in that stu-dents reported awareness of communication issues and cul-tural norms of others. Students expressed heightened culturalhumility, and were sensitive to the resilience of refugees whohad often witnessed war violence, or been subjected to tor-ture. When recognized and permitted, patients can be thebest “teachers” of their language and illness concepts [12].

Being able to communicate effectively in a clinical cross-cultural encounter is important to medical students as theybegin learning about the clinical interview. Storytelling fa-cilitates and contextualizes cultural lessons, and thus renderspatients as tutors of their culture. Storytelling also human-izes the patient-physician interaction. As one 1st year studentfelt, “it’s really humbling when people share their stories withyou. You’re meeting them for the first time and yet you knowyou’ve made such a contact with them that they’re willing toopen up to you, it’s very touching . . . ”

This study has several important limitations. Because thestudents were volunteers for this project, sample bias maybe present. Also, we were unable to control for students’prior cultural training or multi-cultural experiences. Otherlimitations include a relatively small sample size of vol-unteer student participants, and inconsistencies in studentcase encounter experiences (e.g., differences in the num-ber of clinic sessions that students attended and variation ofrefugees’ cultural background). An additional limitation isthat this program is provided at an early stage of medicalstudent training, when students in effect serve an apprentice-ship role. It may be that this project is useful as a preliminaryexperience, but that cultural awareness training with clinicalpreceptors may have more robust effects at later stages ofthe students’ training. Moreover, these beginning medicalstudents have had either no, or minimal, prior clinical ex-posure, by which they could contrast their experiences withthe refugee families they saw. Nevertheless, these qualitativedata suggest that this program provided to many students im-portant cross-cultural communication and cultural awarenesslessons.

As medical school curricula incorporate more culturaldiversity training, a patient-based learning approach with se-lected ‘hands-on’ experiences will offer unique opportunitiesfor students to increase their cultural sensitivity and compe-tency by allowing patients to teach us about their culture andlearning to use interpreters early on in medical education.Future studies are needed to effectively measure and eval-uate students’ understanding of and respect for the diversevalues, beliefs and expectations of their patients followingtheir immersion experience.

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Acknowledgements We are indebted to Angela Henke for her assis-tance on this manuscript. We thank all the medical students who partic-ipated in the program, and particularly the refugee adults and childrenfor their teachings.The authors gratefully acknowledge the New YorkState Department of Health for providing training program funding,and the University at Buffalo’s Department of Family Medicine forits institutional support. We also wish to recognize the InternationalInstitute of Buffalo, Journey’s End Refugee Services, Jericho RoadFamily Practice, and Niagara Family Health Center of Buffalo for theirinvaluable collaboration.

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