A student‐led refugee initiative: Addressing lack of health disparities awareness among medical trainees via community‐embedded service

The Accreditation Council for Graduate Medical Education's (ACGME) 2021 Clinical Learning Environment Report (CLER) found that recognition of health care disparities and social and environmental impacts of health among medical residents and fellows remains limited.1 Given the increasing population of older individuals and individuals of non-White backgrounds, medical educators must promote innovative educational strategies that facilitate students' ability to provide effective care and better outcomes. While didactic learning about social determinants of health (SDH) is critical for medical education,2 understanding the ways SDH contribute to health disparities may be best achieved through community-embedded experiences for students3 (Figure 1). Our experience leading a community-based initiative with resettled refugees has been a powerful means of understanding and intervening in the structures, institutions and social processes that generate health disparities. Our experience leading a community-based initiative with resettled refugees has been a powerful means of understanding and intervening in the structures, institutions and social processes that generate health disparities. The PSCOM Refugee Initiative (RI) began in 2016, and is a free-standing, medical student-led organisation of approximately 10 volunteers funded by a Pennsylvania state grant secured by student leaders.4 Originally, a dozen resettled Syrian refugee families in Harrisburg, PA, were enrolled in the RI, receiving tutoring services at a local mosque and carpooling to a farmer's market to buy fresh subsidised produce. Due to increased needs, the programme has evolved beyond tutoring and food security to include transportation, volunteer assistance with adult English learning, medical translation and donations of clothing and furniture. However, in spring 2020, our organisation and the families we served faced new challenges due to the COVID-19 pandemic.5 As the pandemic unfolded, the farmers' market we had visited weekly for years closed, and several families lost their only source of income due to COVID-19-related layoffs. With looming deadlines for rent and utilities, we were initially overwhelmed by the urgency to provide assistance, since we lacked the power to redirect our funds due to the state grant's funding structure. However, thanks to our broader community, we used an online crowdfunding platform to fundraise over $10,000 in rescue funds in 3 days. In November 2020, we resumed market trips, contributed donated funds towards basic needs like housing and utilities as they arose and assisted families with unemployment assistance applications. However, even for native English speakers, this proved difficult. Online forms were surprisingly complex, and calling social services was futile due to consistently busy phone lines. Meanwhile, ad hoc interpretation by bilingual volunteers helped communication between refugees and social services in the short term, but we experienced stress and occasional inaccuracies in employing these informal translation services. Working closely with populations in need helped us better appreciate the SDH, inequities and challenges faced by resettled refugee populations. Navigating complexity across multiple domains presented us with a real-time window for seeing and responding to exigent SDH in ways that were instructive for our pedagogical development. We engaged in interdisciplinary teamwork, working with refugee families, non-profit organisations, state grant officers and community members to help secure food, housing and employment. Through it all, we observed parallels between coordinating with community partners to help refugee families and working in inpatient interdisciplinary teams to treat patients. As a result of this experience, we are well positioned to care for vulnerable populations with SDH in mind. As future residents and fellows, our awareness of SDH will impact the health outcomes of our future patients (Figure 2). Through it all, we observed parallels between coordinating with community partners to help refugee families and working in inpatient interdisciplinary teams to treat patients. We have considered our experience with the RI's model, including its advantages and drawbacks. Ultimately, having a free-standing, student-led organisation provided ample opportunity for creative freedom, flexibility and improvisation among the student volunteers in coordination with refugee families. Service learning, in which structured community service projects are integrated into the medical curriculum, has been established as a valuable model for incorporating community perspectives into medical education.6, 7 However, we have found value in having students self-select for service on the basis of their intrinsic passion rather than formal requirement. Lack of formality is a double-edged sword, and there are inherent limitations to this more free-standing model. In our experience, these included challenges in maintaining sustainable community-academic partnerships and reliable student volunteer commitments. Throughout our term, students created connections between the RI and the state Department of Health's refugee services team, local places of worship and non-profit organisations. However, because students commence core clerkships after a 1-year leadership term, these connections are difficult to sustain. Prior initiatives have shown that establishment of a multi-disciplinary executive board composed of not only transient student leaders, but committed faculty and agency staff has been effective in mitigating this issue.8 Our experience suggests that other key stakeholders might include refugees, public health officials, and community organisations. Subsequent selection of a student volunteer base—supervised by the longer-term executive board—who agrees to a partnership with a refugee family for a one-year term has also been effective in other organisations.8 In addition to the value in having refugee initiatives run by medical students that are free-standing and voluntary, it is also worth thinking about ways concepts from this work could be fruitfully integrated into medical curricula to benefit the broader student body. At PSCOM, we shared the benefits of our community engagement by including refugee families as part of PSCOM's ‘Patient Navigation’ programme, which pairs students with patients to help them navigate the health care system. Other avenues may be to integrate modules about refugee populations into existing coursework in Clinical Skills, Humanities, or Health Systems courses. Problem-based learning (PBL) sessions, case studies or panel discussions could also be built based on real-world student experiences with SDH to provide simple and effective administration of key takeaway points to the entire class. Such refugee health modules have been successfully implemented at other institutions.9 In addition to the value in having refugee initiatives run by medical students that are free-standing and voluntary, it is also worth thinking about ways concepts from this work could be fruitfully integrated into medical curricula to benefit the broader student body. We have presented our work at national public health conferences and continue to collaborate with colleagues at other institutions and agencies across the country to improve similar refugee initiatives. Through a high standard of constant evaluation and innovation, our RI and similar programmes can uplift the competency of graduating medical students in applying SDH in their future medical practice. Mariam A. Shalaby: Conceptualization; project administration; writing—original draft; writing—review and editing. Kayla J. Krause: Conceptualization; project administration; writing—original draft; writing—review and editing. Raisha Ismail: Conceptualization; project administration; writing—original draft; writing—review and editing. Jed D. Gonzalo: Conceptualization; resources; supervision; writing—review and editing. Daniel R. George: Conceptualization; project administration; supervision; writing—original draft; writing—review and editing. The authors would like to thank Daniel Wolpaw, MD, for his support and editorial comments, their fellow student leaders of the Refugee Initiative, the organisations with whom they worked and the refugee families with whom they collaborated during 2020-2021. Thanks is also owed to Noha El Komi for her design of the figures featured in this article. The authors have no conflicts of interest to report. This article does not describe human subject research, but rather experience with community engagement. As such, human subject protection approval was not warranted. The names and identifiable information of individuals with whom we worked are omitted here to preserve privacy.