Being an emergency room physician, particularly I have to say that one of the challenges is we're in a really busy emergency department. We have incredibly 90,000 patients a year. Any given shift you're running around the whole ER, on a 12-hour shift, you might see up to 60 patients, so one of the things that real challenging is finding the time.
Dinali Fernando,MD the Medical Director for the Libertas Center for Human Rights at Elmhurst Hospital in Queens New York. Dr. Fernando is the recipient of the 2018 Pearl Birnbaum Hurwitz Humanism in Medicine Awards by the Arnold P. Gold Foundation, presented at the Planetree International Conference on Person Centered Care.
Dr. Dinali Fernando at the Libertas Center for Human Rights
The work that our Human Rights Center does is really focusing on individuals who've suffered severe human rights violations or torture in their home countries for a whole host of reasons. It could be because of their political opinion, their race, their religion, the ethnicity, the gender, membership in a social group, etc.. What we do at our Center is we really provide them with comprehensive care, which is medical, mental health, legal and social services to really help them to rebuild their lives to gain independence and to contribute back to our society. A lot of these individuals are really incredible, really resilient and what they were being persecuted for oftentimes is the work that they were doing back in their home countries, which was advocating for the rights of their own people and got persecuted for that. They have so much that they can give back to our communities if they just get the support that they need to go through their process of healing after all that they’ve endured.
Background Working with Health Disparity Populations
I'm originally from Sri Lanka, I came here with my sister to go to college. Coming from a developing country and having seen, really the healthcare disparities between the developing world and the developed world, it was always my intention to contribute back to that community, to the underserved in some way, shape or form. So, throughout my education and my training, I’ve kind of had that always. Thats been at the forefront of everything I've done, I really wanted to do global health work, I got involved in doing global health work in grad school and then also in medical school and residency.
When I was a resident, I had two mentors my attendings at the time who were the two individuals who started the Libertas Center and they started it as a volunteer program. They asked any of his residents who were interested in doing this type of work to work with them. I started working with them as a resident and then I was exposed to this particular population, then just seeing how incredible the patient's themselves were and the really unbelievable experiences that they have had. Their ability to recover and our ability to help them in that process in how impactful that can be is really what kept me with this work and kept me motivated to continue doing it.
Barriers to Serving High Needs Populations
My particular specialties are; I'm an emergency medicine physician and this program was started out of the emergency department. The reason it was started out of the emergency department is because we're based in a public hospital, which is a safety net hospital. The community that we're in is largely, almost exclusively immigrant and so there's a large number of individuals in our community who are undocumented. The hospital exists so that these individuals can come to the hospital and get medical care and healthcare even if they're undocumented, even if they don't have insurance, because it's a public hospital.
Its for anyone who needs care. The thought was that survivors of torture don't speak language, they don't have access to health care, they're not going to know how to get connected to a clinic even if it's not an emergent health need. They're going to walk in through our ER doors, which is exactly what we found when we did the studies to evaluate for that. However, being an emergency room physician, particularly I have to say that one of the challenges is we're in a really busy emergency department. We have incredibly 90,000 patients a year. Any given shift you're running around the whole ER, on a 12-hour shift, you might see up to 60 patients, so one of the things that real challenging is finding the time.
We're very focused on what a patient comes into the ER, just for time reasons and when you're working with this population, you have to go a step above, you have to ask a few more questions to really identify them as a survivor. This is really one of the challenges for me and other providers working in such a fast-paced setting, it's having the time to do that and learning the skill set to do that effectively and quickly in a sensitive way. The key is, if we can identify them in the ER or even in the clinics which are really, really busy. If you can do the first step, in just identifying that this is a torture survivor. And, if you can connect the patient with the program such as ours where we have the time to spend several hours with them to really address all of the other needs that's already doing a huge service. It's really getting the training, the mindset and learning the skill set to do it effectively, sensitively very quickly. I think that's a challenge that can be overcome but it's having the time.
The Importance of Cultural Sensitivity
I feel really fortunate because I'm at this hospital, because of where it’s located 71 percent of the residents in the Elmhurst area are foreign-born. Similarly, between Flushing, Corona, and Jackson Heights its between 60 to 68 % foreign-born. We are the most ethnically diverse neighborhoods in the country. I think the hospital, the administration and the providers throughout the hospital are very aware that this is the population that they're serving. Majority of our patients throughout the hospital don't speak English, we need interpreters for the bulk of our patients require interpretation.
I think inherently providers who are drawn to working with this population are the ones who come to Elmhurst who stay at Elmhurst Hospital and the administration is very aware of this. So they've really incorporated cultural sensitivity. The staff at the hospital come from very diverse backgrounds, have a huge language capacity amongst them and that's really a lot because it's not just a language capacity because they all come from different cultures. They're inherently aware of the cultural differences. In addition, our training with our residents and our medical students that's really incorporated about understanding different idioms of distress or different ways that patients might or might not express their pain in their symptoms and that's a very important thing for us as clinicians to learn with our program and in general.
For example, and I hate to stereotype but we found that with the older Asian population they don't complain of pain, they can have three bones fractured, they don't, they're very stoic because culturally in that day and age in their countries that's how they were raised. So we have to be extra sensitive about asking them; Do you want pain medication? That's really incorporated into the training because the administration, the residency program directors and the leadership recognizes that. That's really a key component to providing adequate care and effective care for our patients.
Human Rights Research, Resources, Utilization & Outcomes
A lot of the research work that we've done around the human rights work has really been looking at program evaluation, really looking at what works and what doesn't work for our clients. Looking at how we can better improve our program and better improve our services. We've looked at it in terms of how the resources are utilized and now we're looking at how resource utilization by our patients is affecting their outcomes. We're also in the process of trying to publish a lot of the data that we've had. We've had one or two studies published in the literature and then we're in the process of putting the rest of it out. We do have some preliminary data on our website, if anyone wants to learn more, we’re happy to talk with them if they contact us.
Critical Roles of Leadership & Training on Care Delivery
We think there's multiple folds but if I had to break it down, I would take two big components of that; the first is really having institutional support and that's key because having your leadership from the top up support you in what you're doing is really what you need in order to be able to start a program like this. We are a grant funded program, however we get an incredible amount of in-kind support from Mount Sinai Hospital which is our affiliated teaching hospital and without that level of support from the top up we would not be able to do the work. Having buy-in from your leadership, I think is really, really key.
Secondly, training and education, I think that's a second a really big component because where we get grant funding for our Center. We don't work in a vacuum we work within this big Hospital and we can't work in a vacuum so in order for us to effectively do our work, for us to get referrals throughout the hospital as these patients are getting care all over the hospital. Similarly, as our patients in our center they don't just get care in our Center, we give them services throughout the hospital in order for them to get effective care, culturally sensitive care. For providers to be trained and how to work with the complex needs of the patient. Education and training are key and that has to happen at the attending level, the resident level, medical student, nurses, all your auxiliary staff and so I think the second biggest component really is training and education and that has to be an ongoing basis especially in a teaching hospital where you have a lot of turnover.
Leadership Style Impact
There are several people who have had really an impact on my life and an impact on my leadership style but I would say it starts with my parents. It starts with my dad, who always saw the best in people who was very collaborative and really went out of his way to help everyone. He always instilled in me if someone is not acting right or doing right or something is not right, don't just judge them, always try to find out what else is going on because we're all human and when people are not acting as you would expect them to it’s because they’re probably having other stresses in their life. He would say, try to take the time to understand that before you judge them or get upset with them. Both my parents have always instilled in me be kind, because they always said you can get an education you can get money you can get rich but if you're not kind to other human beings that's what life is really about.
Then my mentors, I've had really amazing mentors throughout my training, I've been really fortunate in multiple levels and my two mentors who started the Libertas Center, I mean I really hold them in such high esteem because there are individuals who do the work for the work. They don't do the work for fame, they don't do the work for glory, they're so humble and down-to-earth and they do the work because they want to help the patients. It's not about what they gain from it, but it's what they can do for the patients. Seeing that kind of leadership style, I've been fortunate to have all of them as role models really to in fact influence my style of work.
Drive for Addressing Health Disparities
What really keeps me passionate about this work is the patients who we work with, despite the incredible adversity that they've gone through, really the unthinkable atrocities that they've had to face, really inhumane at every level, they rise above it. They survive it and they make their way here, they still have hope, they have so much resilience that they don't even recognize that they have but the fact that they've made it through multiple countries, lost family members, seen their family members tortured and they still made it here and they still have a smile on their face.
To me it is amazing, really seeing the fight in them, even if it might not seem like they have a fight in them, they clearly do because they made it this far. In seeing their determination, their hope and their resilience, it's really what makes the work worth it. These are incredible human beings that I think all of us have the opportunity to meet them we’re really privileged, we are privileged to have met them. That said, If I wasn't a doctor, I think I would be either in the field of public health or social work because I think those are two fuels where I believe that you can have a really profound impact on a very large scale, on an individual level and a large scale.
Connecting Torture Survivors to Care
My last words would be for all of us in the healthcare field, in the Social Work field or legal field, if you have the opportunity to identify these survivors, consider it a golden opportunity. It's really our responsibility if you’re the person first point of contact for those patients. It's your and our responsibility to help them get connected to service, they might not encounter a professional who has the ability to do that for quite a while. Because, of language barriers, cultural barriers, not having access to resources when they get here. If you have the opportunity take that opportunity. It might not seem like you're doing much but if you can get them connected to the right services you can change their lives so just bare that in mind and take the time, even if it's a few minutes to do that.