Global Medical Education and Training
—By Eve Glicksman
Until hours before the Boston woman delivered her baby, not one of her physicians had noticed she had been the victim of genital cutting. The account comes from Jillian M. Tuck, J.D., who manages a national program at Physicians for Human Rights (PHR) to provide forensic medical evaluations for people seeking asylum.
In the United States, the number of torture survivors—half a million—is the same as the number of people with Parkinson’s disease, according to Steven H. Miles, M.D., professor of medicine at the University of Minnesota Medical School and chair of the university’s Center for Bioethics. “So shouldn’t physicians be able to recognize signs of torture the same way they would be expected to notice symptoms of Parkinson’s?” he asks.
Treating trauma stemming from human rights abuses can have significant benefits for a victim’s personal and professional life. But many physicians miss the signs that a patient has been tortured. Miles, who serves on the board of the Center for Victims of Torture in St. Paul, described an Eritrean immigrant who was in the emergency room (ER) for chronic pain. He said it was clear to him that the woman had been tortured and post-traumatic stress disorder (PTSD) was at the root of her pain and distress. At the ER, the staff treated her for pain, but did not refer her for the psychiatric care she needed.
“People come to the doctor with their symptoms, not their stories, ” said James L. Griffith, M.D., professor of psychiatry and behavioral sciences at The George Washington University, who has worked extensively with torture survivors.
His observation is supported by a study published last year in Academic Emergency Medicine that followed 54 self-reported torture survivors who had sought care at the emergency department of a New York City teaching hospital. Among those who had experienced torture, three out of four said that no physician treating them had ever inquired about it. The authors of the research referred to torture as “an unrecognized public health concern.”
“Medical schools and teaching hospitals should be incorporating lessons into the curriculum for identifying and treating torture survivors, ” Tuck said. Language can be a major barrier if English is not the patient’s first language. Other patients may not bring up their torture history because of feeling shame, wanting to avoid stigma, or not realizing treatment could help them. Still others may deny the impact of their abuse or wish to avoid discussing it.
Yet, simply asking someone who fits a risk profile for torture—a refugee from Africa or Tibet, where human rights violations are common, for example—often yields honest, reliable answers, Miles said. He recommends that physicians screen for a torture history if a patient from an immigrant group exhibits signs of depression or PTSD, complains of unexplained pain, or is known to be seeking asylum.
In an article Miles published last year in The Journal of Family Practice, he suggested this basic screening question: “Some people in your situation have experienced torture. Has that ever happened to you?”
Many torture survivors live in urban centers, so health care providers should not marginalize the problem, Miles continued. “Torture is one of those taboo areas [in medicine] that we need to learn how to do better.” Clinical education, research, and efforts to develop appropriate therapies for torture victims remain inadequate, he said.
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