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Congressional Report: Congress Has Some Unfinished Business as New Term Begins AAMC Efforts Help Roll Back CMS Paperwork Requirements Innovations in Medical Education: Doctors-in-Training Learn How to Tell Stories Healing Deep Wounds: Program at Bellevue / NYU Provides Care for Torture Survivors Nursing Shortage Prompts Creative Solutions Author Q&A: 'Sometimes Wrong, Never in Doubt' 'Flagging' Debate Continues; Data Show Score Fluctuations A Word from the President "A Day in the Life of a Medical Student"
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Healing Deep Wounds: Program at Bellevue / NYU Provides Care for Torture SurvivorsBy Martha Frase-Blunt According to leading international human rights organizations, torture is practiced in more than 90 countries around the world. It is estimated that there are 400,000 to 500,000 torture survivors living throughout the United States, with the majority clustering, untreated, in the refugee communities of large urban areas.
The trauma of torture can cause physical symptoms ranging from musculoskeletal pain to neurological complaints. The psychological effects can be more devastating: Nightmares, flashbacks, uncontrolled anger, guilt, and suicidal thoughts are common. Each year, hundreds of survivors find their way to New York City, and, ultimately, to the Bellevue/NYU Program for Survivors of Torture. Together, Bellevue Hospital and the NYU School of Medicine operate one of the largest torture-survivor treatment centers in the country, with an active caseload of more than 300 survivors ranging in age from 6 to 72. Many have been subjected to beatings, rape, imprisonment under inhumane conditions, and all manner of injury and deprivation. Some have witnessed the torture and murder of their own family members. The program integrates medical, mental health, and social services, and also helps survivors achieve asylum status. "With many patients, it's hard to delineate where medical issues end and psychological and social issues begin," says Allen S. Keller, M.D., director of the Bellevue/NYU program. "Someone who was arrested for their political beliefs and brutally beaten may suffer flare-ups of severe musculoskeletal aches years later, which will bring up intrusive thoughts and symptoms of post-traumatic stress disorder." Conversely, fears about political asylum being denied and having to return home can flower into physical symptoms. "We really try to integrate care, including often having a medical and mental health provider seeing the client together," Dr. Keller says. At intake, clients are paired with a primary-care physician for a thorough medical evaluation. The physician provides and coordinates ongoing medical care, referring clients to Bellevue's subspecialty clinics. Children who have been tortured and the children of torture survivors receive specialized pediatric medical care. Inpatient and emergency care is also available. Many languages, culturesClients needing mental health services are matched with appropriate providers for individual, group, or family therapy; psychiatric evaluations; and psychopharmacological consultations. The program has recruited and trained a multilingual cohort of volunteers - fluent in Tibetan, French, Russian, Spanish, Krio, Wolof, Albanian, Greek, and other languages - who are available to accompany clients to appointments and therapy sessions. Staff and volunteers provide social services directly, and clients are eligible to receive services through Bellevues social work department. Legal services are coordinated with the Lawyers Committee for Human Rights and other non-profit agencies. Central to the program's mission is educating students and professionals in this still relatively new medical and psychological discipline. Beginning in the first and second years, medical students are encouraged to join the program's active volunteer mission, teaching language and computer classes and helping develop basic health education materials for this audience. Third- and fourth-year students and residents staff a Monday evening clinic, providing ongoing primary care to survivors and working with psychology interns and externs. "This clinical opportunity gives them hands-on, direct experience in a cross-cultural, integrated care environment," Dr. Keller explains. "They also learn important lessons in caring for an extremely vulnerable population."
Each year, the program provides direct clinical training and experience to more than 30 medical students, residents, psychologists, and psychiatrists. Additionally, hundreds more health professionals and resettlement workers likely to come into contact with clients who have experienced extreme trauma receive training through seminars and conferences. As a result, a growing number of local healthcare providers are identifying torture survivors for referral to the program. Alyssa Finlay, M.D., is a chief resident in primary care and a General Internal Medicine Fellow at Bellevue. She has worked in the weekly clinic for more than three years, seeing patients and teaching students and residents as they rotate through. The clinic is an important lifeline for the survivors. "We provide primary care, and also write affidavits for them, documenting evidence of trauma for their asylum applications." As a French speaker, Dr. Finlay cares for a number of survivors from West Africa. Many are women who have been separated from children and husbands. "I recently treated a woman with a history of imprisonment and rape. She had been burned with cigarettes, scalded with boiling water, and beaten, at one point miscarrying a pregnancy after a prison beating to her back and stomach." Although the woman's wounds had healed, Dr. Finlay took the woman's history as part of her asylum application, "documenting the scars I could see, and writing about the ones that no one can see." Dr. Finlay recently heard from the woman - her asylum had been granted, and now she was working to bring her family to the United States and out of danger. "This is an incredible opportunity for a physician to make a difference to entire families," she asserts. In addition, Dr. Finlay feels that treating survivors of torture makes her a better primary-care provider on the whole. "There are cultural differences in how PTSD, anxiety, and depression manifest in patients. I am learning how to recognize and treat these disorders as they can present differently in individuals from other cultures." For example, she has observed that different somatic complaints, depression, and suicidal ideation can be linked to a patient's asylum status. Dr. Finlay has also gained valuable experience being part of a multidisciplinary care team. "Every week we have case discussions as a group - residents, students, experienced primary-care providers, psychiatrists, and psychologists - and we talk about different approaches to the patient's care. We always come up with solutions I know we wouldn't have been able to get to on our own." Screening - and learningMost learners who rotate through the program go on to practice in primary-care settings, remaining aware of the subtle signs that may indicate a patient has been tortured. "Physicians who are working with an immigrant or refugee population of any size are treating torture victims and may not know it," says Dr. Keller. "It's important for primary-care physicians to keep this in mind as part of the screening process." For her part, Dr. Finlay makes a point to probe the backgrounds of patients in her daily practice. "If they are from countries where I know torture is practiced, I will ask patients if they have ever experienced torture or trauma. I know residents from the program have discovered and referred survivors this way." Providing services to torture survivors is financially challenging. The vast majority of the program's clients are not eligible to work in the United States and cannot afford to pay, so staff raise funds from private donors and philanthropic foundations to cover medical costs. Since passage of the Torture Victims Relief Act in 1998, federal funds are now available to support torture-treatment centers. Once clients obtain asylum, program staff help them apply for Medicaid or insurance through employers. Staff also raise funds to cover salaries and administrative costs. In the seven years since its inception, the Program for Survivors of Torture has cared for more than 700 men, women, and children from more than 60 countries, and receives some 10 referrals a week. Often the wait can be two months or longer. "The world being what it is today, we are quite busy," says Dr. Keller. "Right now, we are seeing many from Tibet and Sierra Leone; a few years ago Kosovo was the hotspot." Most torture survivors cared for in the program are able to regain a level of physical and psychological health, and go on to live meaningful, independent lives as contributing members of U.S. society, he reports. There are more than 20 torture-survivor treatment centers around the United States and, therefore, a growing need for a formal curriculum for treating survivors, Dr. Keller notes. "We are currently working to refine curricula that could be disseminated to other academic medical centers and incorporated into rotations like ambulatory care and psychiatry. The truth is, the knowledge and skills you learn from treating survivors of torture will serve you in caring for other [patient] populations." Dr. Keller believes the experience can also reframe a student's perspective on the physician's role in promoting health. "Once they appreciate the relationship between health and human rights, they become advocates. It vastly broadens their perspective." |
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