On the first day of my pediatric rotation at an urban clinic, I assumed that it would be just another third-year rotation. Walking into the room, I gave my greetings to a tired-looking 14-year-old boy and his young mother and began the patient interview. The young man tried valiantly to stay awake as I inquired about his medical history. When he lifted his arms to stretch, his large, irregular scars on his right bicep immediately caught my eye. I asked, “Can you tell me a little about these marks on your arm?” Without skipping a beat, the boy’s mother answered, “That is where the soldiers shot at him.” When I asked the question, I knew the answer may be uncomfortable, but I never expected that I would encounter a child shot by soldiers in a clinic in Buffalo, New York. I could not conceal the surprise on my face, but I took a deep breath and asked, “I want to make sure the scars aren’t causing you any problems. Is this something you are comfortable talking about?”
As I reflected on the encounter that evening, I realized that given the rich diversity of my city’s population, I should not have been surprised to encounter patients who are survivors of human tragedies. After all, the state of New York is the fourth-largest recipient of refugees in the nation, and one-third of these arrivals settle in Buffalo’s Erie County. As a result, over 80 languages are spoken in Buffalo public schools. From that day on, I resolved to work with an increased awareness of the pediatric refugee population.
One of the first lessons I learned while working with pediatric refugees was to avoid making assumptions about my patients’ records of primary care visits. Some children from wealthier backgrounds had regular pediatric visits and had received all required childhood vaccinations, while others had few prior encounters with health care practitioners. For example, families from conflict-affected countries reported that their routine care was compromised due to a shortage of physicians, as local medical professionals attended to the casualties of violence. I was surprised to meet a five-year-old patient whose only medical encounter occurred at birth in a temporary missionary-run clinic. As I encountered more stories like these, one lesson became readily apparent: it was necessary to set aside plenty of time for a thorough medical history, even for young patients. Others managed medical conditions with treatments that are not well-known or approved in the United States, and I documented and researched the unfamiliar. These experiences taught me to take my time with the past medical history portion of the exam in order to get a complete picture of my patient.
I also learned to allocate space for diagnoses that sound less common to my American ears. I remember my first-year classmates chattering in shock during lectures about the miseries of childhood diseases that we did not experience as a result of antibiotics and vaccinations. During my pediatric clerkship, seeing children with incomplete vaccination histories made me realize that diseases that had been eradicated in the United States still pose a significant danger in other countries. I remember a three-year-old patient with subclinical jaundice, fatigue, nausea, and increased irritability facing a case of Hepatitis B reactivation, which was a diagnosis that I did not expect. In discussing this case, my attendings shared that they have seen everything from Haemophilus influenzae-induced epiglottitis to rare systemic parasitic infections. These stories made me realize that if I do not expand the breadth of my differentials, I will miss diagnoses that lie beyond the standard ones that I learned for the Step 2 Clinical Skills exam.
A third lesson I learned is the necessity of growing more comfortable with asking uncomfortable questions. Early in my medical training, students were asked to team up in class to practice the patient interview checklist. We easily proceeded from question to question until we reached the sexual history section and awkwardly stumbled through the required prompts. While we matured through these experiences en route to becoming physicians, I realized that there were questions to be addressed in the pediatric refugee population that were significantly more uncomfortable. Did the patient have access to basic food and water? Did the patient see or experience violence or torture? Was the patient a witness to or a victim of sexual violence? This encounter made me realize I need to get more comfortable with difficult questions in all my patient encounters.
As a child, my most pressing concerns included the death of my pet goldfish or sneaking junk food and soda from the pantry. In contrast, many pediatric refugees watched their loved ones die in front of them or experienced unfathomable deprivation or abuse. As I come from a privileged background, I initially found it difficult to ask these questions and even more challenging to listen to the answers. I soon realized that setting aside my own privilege and comfort to ask and listen to these emotionally difficult topics was an essential part of compassionate care. As future medical professionals, we cannot exhibit compassion without sitting with and listening to the pain of others. Even though the conversation may be difficult, the dialogue itself is the first step towards healing, in which we must gather information to help our patients receive the assistance they need.
In my journey to become a doctor, I realized that I have had a hyperlocal focus on the patient experience. New York is my home, and my goal has always been to support my community. However, after serving children from diverse backgrounds, I acknowledge that it is not enough to concern myself with the predominant health issues of the immediate region. When I spoke to that 14-year-old boy about whether he was comfortable talking about scars, I learned that I had to be comfortable with asking about them as well. I must expand my perspective to make space for world views, in which there are countless stories concerning the frailties and triumphs of the human condition waiting to be told. Armed with these lessons learned from my experiences with the young refugees I had the privilege to meet, I must be ready to listen to the stories of others.