![\"Sirey](\"https:\/\/geiselmed.dartmouth.edu\/news\/wp-content\/uploads\/sites\/2\/2023\/12\/SireyZhang_web.jpg\")
<\/a>Recruited by Zuckerman, Zhang was a perfect fit for the study\u2014he studied medical anthropology as a Dartmouth undergraduate where his research and scholarly interests focused on understanding healthcare experiences in the context of the socio-economic, cultural, and political conditions that manifested in structural inequities.<\/p>\n
Patients who agreed to having a medical student take part in their care met with Zhang. From July 2022 through August 2023, he interviewed 18 patients and four caregivers\u201410 patients agreed to audio-recorded interviews and eight shared their stories informally. Interpretation services were available when needed. Zhang also spent 42 hours observing clinical team meetings and direct patient care.<\/p>\n
Though Zhang acknowledges it is statistically difficult to show their stories are significant, he maintains they are because individual stories are true and meaningful.<\/p>\n
Here\u2019s what he learned.<\/p>\n
Patients mostly felt supported, but with a few caveats.<\/p>\n
\u201cThe patients I talked with have been in the U.S. from a few months to decades\u2014some were documented, some were not, and some were relocated through a refugee program,\u201d he says. \u201cAs I got to know them better, we started talking about issues not directly related to their care but that were a big part of their lives. It became clear to me their life stories mattered.<\/p>\n
\u201cThrough their stories, I found three factors across the clinics that shaped the care they received\u2014clinical, community, and bureaucratic.\u201d<\/p>\n
Clinical factors that augment the experience for immigrant and refugee patients, Zhang says, describe a perceived power dynamic, whether people feel insecure about their illness, or belittled, and found \u201cthat was never the case in our clinics.\u201d<\/p>\n
Historically, the staff \u201cdid a terrific job of building empowerment\u2014when patients arrived nobody commented on their illness. But over the past few years, a challenge arose,\u201d Zhang says, \u201ca turnover in healthcare workers due to many factors, including burnout. Because of this, some patients felt it difficult to open-up to new providers.<\/p>\n
\u201cImmigrant communities in the Upper Valley and other areas in NH are small and close-knit, and people rely heavily on these close relationships for support,\u201d Zhang explains. \u201cIn the clinic, the social effects of staff turnover engendered fear among some patients about sharing something important in their life with a stranger, which became an impediment.\u201d<\/p>\n
Zhang also talked about the importance of community. \u201cGiven that immigrant communities are small and people rely on their close-knit community for support, there was a fear that having their diagnosis of HIV shared would cause them to lose their support system, so many people adopted \u2018double lives,\u2019 hiding medications when their community members came over for significant holidays, for example, or turning away in-person interpreters who they did not know out of fear that there were only had a few degrees of separation. This, I felt, was the most important factor that impacted their care experiences surrounding HIV.\u201d<\/p>\n
And lastly, the bureaucratic factors that include undocumented immigrants. \u201cAs an immigrant, it's hard to ask for help,\u201d a patient explained, \u201cand it\u2019s even harder when you are undocumented, because you feel that you don't deserve it, even if you feel respected. Embarrassed to share about my lack of documents, I went almost two years without medications \u2026 an up-front conversation would have been helpful when I first started.\"<\/p>\n
Another mentioned financial insecurity, \u201cIt was so difficult getting papers that allowed me to get adequate insurance here, and I am very worried about how I will pay for healthcare once I obtain a job and my insurance expires. I want to work but I do not want to lose healthcare.\u201d<\/p>\n
Zhang notes this is a common dilemma, \u201cThey want to work, but by getting a job they would lose their insurance, leaving them to choose one over the other.\u201d<\/p>\n
The clinics did a good job of welcoming all patients into a safe, non-judgmental space\u2014but some still felt a bit ashamed asking for care because they were undocumented and, Zhang says, believed they deserved less.<\/p>\n
According to one provider: \u201cWe had a formerly steady client who dropped out of contact, and it took a year for them to get back in touch\u2014they were afraid of getting picked up by immigration enforcement. We are fortunate that they haven\u2019t been.\u201d<\/p>\n
Zhang appreciates the immigrant and refugee patients with whom he talked and says they deserve \u201ca special thanks for sharing their stories because they are the heart of this work.\u201d<\/p>\n
Based on the study\u2019s findings, next steps include continuing to engage the clinical team in discussion; identifying avenues to intervene on community and bureaucratic factors, for example, during new intake, establish a sense of support and security in terms of documentation status, offer mechanisms for the clinical team to involve family\/community members; and establish a mechanism to monitor and report outcomes.<\/p>\n
\u201cWhat drove me to medicine is understanding how these inequities from political and economic forces shape individual care,\u201d Zhang says. \u201cThat\u2019s something I hope people keep in their mind as they interact with individuals throughout their careers in medicine.<\/p>\n
\u201cThis is important to me and frames how I want to carry myself into the future.\u201d<\/p>\n