Refugee clinic fills needs for both patients and physicians-in-training

When Sachin Jain, M.D., M.P.H., asked his patient about her eating habits, she consulted with her interpreter, who answered, “A typical Iraqi diet.”

“What’s that?” Jain pressed, eliciting a list that included meat, starch, vegetables, and fried foods.

He then asked questions that don’t usually come up in a medical visit: Had she ever been a victim of violence? Ever witnessed it? Did she feel safe now?

Jain is one of the resident coordinators of the Adult Refugee Clinic, which serves eight patients each week in Yale-New Haven Hospital’s Primary Care Center. (A pediatric refugee clinic, which provides medical screening and primary care for children in newly arrived refugee families, shares the space.) About 200 refugees settle in Greater New Haven each year, with Iraqis forming the largest group. The refugees also come from such countries as Afghanistan, the Democratic Republic of Congo, Cuba, Ethiopia, Iran, Somalia, and Sudan.

The adult and pediatric clinics offer physicians-in-training an opportunity to see latent tuberculosis, various parasitic infections, and undiagnosed congenital disorders—diseases and conditions that are relatively rare in the United States. For the residents, however, the most important lessons involve communication. Understanding the patient’s story is essential to providing care, many clinic staffers said, and language is only part of the challenge.

Intern Sara Schwab, M.D., groaned on a recent shift when told she’d be using a phone interpreter—it’s always better to have a live interpreter in the room because they can pick up on nonverbal cues like body language. Schwab walked toward the exam room asking people, “You don’t speak Arabic, do you?”

But whether on the phone or in person, standard questions can be mired in misleading assumptions. For example, a physician might ask, “Have you ever been hospitalized?” But in some countries hospitalization is a rare event. “There is a lot more detective work,” said Katherine Yun, M.D., HS ’09, a postdoctoral fellow who serves as an attending in the Pediatric Refugee Clinic.

The adult clinic got its start in 2007 when Teeb Al-Samarrai, M.D. ’06, HS ’09, who was born in Iraq, was recruited to translate in the pediatric clinic during her residency. Al-Samarrai, now a CDC Epidemic Intelligence Service Officer at the New York City Department of Health and Mental Hygiene, learned that refugee patients often ended up in the emergency room because it was difficult to get appointments with primary care providers. An adult refugee clinic at Yale had closed when its organizers left the medical school, so Al-Samarrai recruited residents and faculty to fill the need. Last year, the adult clinic became part of the ambulatory care curriculum so that it will have ongoing coverage.

That reorganization creates an opportunity for residents not only to treat a diverse population but also to change the way they interact with all their patients. Jain recalled a lifelong New Haven resident who had various complaints and a reputation for noncompliance. “I went into my refugee line of questioning,” Jain said. The patient recounted an adolescence marred by violence and memories of being mistreated by the health care system.

Symptoms that had frustrated other doctors suddenly made sense to Jain, who had finally gotten the whole story.