Impact on Medical Students Participating in Forensic Examinations of Asylum Seekers: A Pilot Study

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Introduction
In 2010, medical students at Weill Cornell Medical College established the country's first student-led asylum clinic.The goal of the clinic was for clinicians to perform pro bono forensic evaluations of asylum-seekers to document direct evidence of their previous abuse and torture as part of their legal case for asylum.While clinicians have been performing these types of evaluations for decades, the Cornell clinic was the first to formally involve medical students in the process. 1 Similar student-run clinics have since expanded to over 15 medical schools across the United States (US), and in 2017, students at another private medical school in the US founded an asylum clinic.Under the guidance of a faculty leader, medical students manage clinic operations and assume the logistical tasks of scheduling evaluations and assisting clinicians in the evaluation process.Approximately 30 students have participated in evaluations through this school's asylum clinic annually, most frequently by conducting portions of the interview and drafting the formal write-up of the evaluation, more commonly referred to as the medical affidavit.Little is known about what motivates students to participate in these forensic evaluations or what emotional impact such evaluations have on the students involved.One study of medical students involved in a student-run asylum clinic found that their participation enabled acquisition of clinical skills outside traditional medical learning settings and positively shaped their professional aspirations. 2A 2018 study of psychiatry residents who participated in their residency's asylum clinic found that participants often had a history of immigration themselves, wanted to use their professional position to advance a moral good, and were interested in performing future asylum evaluations in their career. 3tudent-run asylum clinics continue to manage an increasingly large number of forensic medical evaluation requests nationwide, with comparable asylum grant rates to those performed by independent clinicians. 4Understanding medical student motivations for participating in asylum clinics, as well as the emotional impact of student involvement could help educators provide an emotionally safe experience for students and offer insight into ways to improve the experience for those who participate in the future.In this study, we surveyed medical students who had participated in forensic evaluations of asylum-seekers through the Harvard Student Human Rights Collaborative Asylum Clinic about their backgrounds, motivations, and their experiences with the forensic evaluation process.

Methods
Forty-six students participated in at least one forensic evaluation through the asylum clinic between the clinic's inception on June 1, 2017, and March 1, 2021.During our survey period from August 2020 through March 2021, forty of these students were currently enrolled or had graduated in the past year.The 40 students were sent emails asking them to participate in the study during this period.Two students who were sent survey requests were excluded as they were found to have expired medical school email addresses after emails were sent.
A 36-question mixed methods survey was developed in Qualtrics (2020, Seattle, WA), version August 2020 by adapting the survey used by Patel et al to assess psychiatry residents' experiences with asylum evaluations to the medical student population (see online appendix A). 3 Survey responses were anonymous.The survey collected data on medical student demographics, student countries of origin, factors leading to student involvement, and student confidence in working with patients with significant physical or psychological trauma before and after participating in forensic evaluations.The survey also asked medical students about the impact of their asylum clinic work on their plans for performing forensic evaluations as a physician, in testifying on behalf of asylum-seeking clients, and in conceptualizing their role as a future provider.Responses were either multiple choice, 10-point Likert scales, or free text responses.No confidential or identifiable data were obtained.The Institutional Review Board of Harvard Medical School determined that this survey did not qualify as human subjects research.
Survey data were analyzed in Microsoft Excel (version 16.28, Redmond, WA) by tabulating counts and percentages for multiple choice responses and frequencies for 10-point Likert scale responses.For free responses, two study staff were assigned to each question and separately identified preliminary major themes among question responses using inductive qualitative theme approaches.The reviewers then together reviewed associations between their generated themes and revised them until one set of discrete themes was determined for each free response question.Reviewers then separately recorded question responses using this shared theme bank and met again to assess interrater reliability and reach consensus.

Student Background
Eighteen of 40 students (45%) who were sent emails responded to the survey.Each survey question was optional, and not every student completed each question.Seventeen students completed the survey in its entirety, while one did not fill out certain parts of the survey.Of the respondents, ten identified as female, six identified as male, and one identified as nonbinary.Eleven identified as a non-White ethnicity.At the time of their survey response, four were first-year medical students, three were second-year students, five were third-year students, four were fourthyear students, one had graduated, and one was in graduate study in an MD/PhD program.The number and format of evaluations in which students participated is summarized in Table 1.Seventy-two percent participated in their first medical evaluation in their first year.Six out of 17 respondents were born outside the United States, and 13 out of 17 respondents had a parent who was born outside the US.Sixty-seven percent of respondents had lived outside the US for greater than 12 months (see online appendix B for full list of countries).
Regarding their motivations for participating in asylum evaluations as a student, 16 of 17 respondents indicated that they were interested in learning more about the asylum process and 15 out of 17 thought they would want to conduct asylum evaluations in the future.Only four participants identified that they had undertaken similar work previously.Fourteen out of 17 respondents had personal or familial experience with immigration.Among this group, four noted an aspiration to give back to immigrant communities.One described a desire to conduct evaluations to "help other immigrants in [a] meaningful and immediately useful way."Another theme that emerged among individuals with immigrant experiences was recognition of the opportunities available to them as a result of living in the US.One student whose parents immigrated to the US because of political turmoil in their home country wrote: "I am grateful for the opportunities that I have had here in the US, and it makes me uneasy that it seems so arbitrary that I've been gifted these opportunities over others based on where we're born.This motivates me to work with asylum seekers so that they can have better access to opportunity."

Student Roles
The different ways that students participated in interviews with asylum-seekers and affidavit writing are summarized in Figure 1.Students assumed a variety of roles, from observation to conducting parts of the exam to recording notes.Sixteen out of 17 wrote the first draft of the medical affidavit, and 70% of the seventeen respondents found the writing process challenging.Two challenges students identified regarding affidavit writing were using appropriate formatting and terminology for a legal document (2/6) and ensuring an appropriate level of detail, including how to handle dates and chronology of narrative (4/6).One respondent also noted the emotional challenge of summarizing an asylum-seeker's story in an affidavit, noting the difficulty to "capture such a painful narrative for a legal purpose."

Student Experiences
Students were asked to identify the most important things they learned from their experience.Major themes included education about the asylum process (6/15) and appreciation for the resilience of asylum-seekers (5/15).Four out of 15 students expressed recognition of the diversity of experiences of individuals applying for asylum, with one respondent emphasizing the importance of "understanding the minor nuances."Another five students noted that they learned to be better advocates, one citing the "breadth of tools" physicians have to advocate for those in need and the "importance of collaborating with lawyers, social workers…and other human rights activists."Other themes included learning to navigate interviewee trauma (4/15) and conceptualizing the role of the physician in legal and political situations (4/15).Prior to their experiences with asylum evaluations, a significant majority of students did not feel very confident working with patients with significant physical or psychological trauma.On a scale with 0 listed as "not at all confident" and 10 listed as "extremely confident," 12 out of 17 respondents self-ranked between 0-3.Following their participation in asylum evaluations, 12 out of 17 respondents ranked their confidence working with patients with significant physical or psychological trauma between 6-10.Seven out of fourteen respondents identified the emotional burden of the interview as one of the most challenging aspects of the experience.One student described, "Listening to the asylum seeker as they sobbed, knowing that they had been through so much.Being able to write down the psychological symptoms and match them to a diagnosis when right in front of you is just pure emotions."Six respondents noted that feeling unable to help asylum-seekers beyond the evaluation was another one of the most challenging aspects of their experience.One student who had noted the difficulties of listening to traumatic experiences wrote, "It also felt strange not to be able to offer psychiatric or medical treatment to my clients since as a healthcare professional I am primed to want to help and treat someone who is suffering."Another student described the uncertainty of "not knowing what will happen to those we evaluated, not knowing how they will be supported next."Another theme that emerged is in three respondents' top challenges was the difficulty in remaining neutral as a forensic evaluator.One respondent noted the challenge to "stay objective" in their language during the interview despite "very emotionally-charged" content.For A-C, students were asked to select every role that was applicable to their experience and could thus select more than one answer.For D, before participating in an asylum evaluation (blue) and after participating in an asylum evaluation (red).
Respondents indicated a rating on a 10-point Likert scale, with 0 labelled as "not at all confident", 5 labelled as "moderately confident", and 10 labelled as "extremely confident."Students were also asked if assisting with asylum evaluations changed how they conceptualized their role as a future provider.Six of 13 respondents said the experience highlighted the unique role of physicians in supporting vulnerable populations, with one noting physicians' "important role in observing, documenting, treating, and organizing against political and social injustices."Two other themes raised were better care of individual patients and the larger role of a physician as a human rights advocate.Four of 13 wrote explicitly that they would like to continue asylum evaluations in the future.Only one student indicated that the experience had not changed the way they viewed their role as a future provider.
Students overall reported varying degrees of feeling prepared for the evaluation process, and 15 students identified knowledge that would have been helpful to learn before participating in asylum evaluations.Three of 15 found that more clinical experience or physical exam skills would have been useful prior to their experiences, and two students noted that a better understanding of trauma-informed care would have been helpful.Nine of 15 noted that they had benefited from additional guidance on affidavit writing, with five reporting that reviewing an example affidavit or template beforehand was a useful experience.One student cited that the time spent meeting with their faculty clinician beforehand to review expectations was a beneficial experience.

Discussion
For students in our sample, the desire to engage in asylum work was frequently personal, with most surveyed students being first-or second-generation immigrants.Of the seventeen respondents to the question about time spent living outside the US, sixteen reported living outside of the US for at least two months (see online appendix B).In describing their motivations, students raised their personal privileges living in the US as much as their professional ones as future physicians.
Studies have reported the presence of vicarious trauma among clinicians conducting forensic asylum evaluations. 6Many students in our cohort also raised the difficulty of listening to the traumatic narratives of asylum seekers.This finding is consistent with a survey of fourth-year students at the Mount Sinai Human Rights Program, another student-run asylum clinic, where two of fifteen participants noted "the cumulative emotional toll" of documenting evidence of violence in evaluations. 2Of note, the students in our cohort also highlighted components of the forensic process that contribute to this emotional burden, notably the requirement to remain neutral and the inability to provide additional assistance beyond the evaluation despite a clinician's traditional role as caregiver.Recognizing the potential emotional stress for student participants, the student-run asylum clinic at the Warren Alpert Medical School of Brown University has set up case discussions and debriefing opportunities to build "vicarious resilience." 7Our asylum clinic similarly has hosted sessions on trauma-informed care at our annual student-faculty trainings and case conferences, and currently plan to organize additional targeted sessions for students to better address some of these challenges.
Notably, despite the nuanced emotional difficulties raised in our study, the students we surveyed unanimously reported improvement in their confidence working with patients who had experienced significant trauma.Asylum seekers frequently report a history of torture, abuse, and sexual violence and often meet diagnostic criteria for posttraumatic stress disorder. 8,91][12] Asylum clinics offer experiential learning opportunities for trauma-informed care principles that may help address this curricular gap, particularly in preparation for clinical rotations.The majority of participants in our survey were first-year medical students who had not yet started on the wards.
Our study had several limitations.Our sample size was small, and we used a convenience sample, accounting for only asylum clinic volunteers who responded to the electronic survey.In addition, participation in our asylum clinic is voluntary and limited to a small number of medical students each year.We might expect students with a prior interest in human rights and asylum medicine to self-select to participate in forensic evaluations.Thus, generalizability to all medical students is limited.In addition, our study only surveyed student reflections on their direct participation in forensic evaluations.We did not assess the impact of other Harvard Student Human Rights Collaborative Asylum Clinic student activities, such as logistical coordination of the clinic, student advocacy, and research.
As the demand for forensic evaluations exceeds the supply of trained clinicians, studentrun asylum clinics will play an increasingly important role in the asylum process by enabling medical students to assume responsibility for portions of the interview and affidavit-writing process so that clinicians may take on more evaluations. 13Our findings suggest that this active role for students is meaningful for professional and often personal reasons.Moreover, participation in asylum clinics during medical school fosters student interest in performing future evaluations.Yet the technical and emotional challenges of assisting with the forensic evaluation process necessitate that asylum clinic programs ensure adequate preparation and support for students.Given the rising interest in asylum clinic participation among medical students, we believe it is important to continue to elicit the perspectives and experiences of those involved.For next steps, we recommend conducting this study at multiple other student-run clinics to capture variability across medical schools.We also hope to re-survey this cohort of students in the future to see how their thoughts and career plans have evolved and materialized based on current desires and work.

Figure 1 .
Figure 1.Comparison of self-reported student contributions and educational experiences during a forensic asylum evaluation A. Roles of student during the asylum-seeker interview B. Roles of student during preparation of the affidavit

Table 1 .
Personal and evaluation of characteristics of surveyed student volunteers at the asylum clinic (n=18) *Percentages in each category may not sum to 100 due to rounding Journal of Student-Run Clinics | Impact of Medical Students Participating in Forensic Examinations of Asylum Seekers: A Pilot Study journalsrc.org | J Stud Run Clin 9;1 | 6