Preparing Clinicians to Conduct Forensic Medical and Mental Health Evaluations for People Seeking Asylum

As the unprecedented number of displaced persons globally grows, leaders in graduate medical education must prepare trainees to care for these populations.¹ Training clinicians to conduct forensic medical and mental health evaluations (FMEs) for people seeking asylum develops competencies essential for working with displaced populations, such as trauma-informed interviewing and examination, cultural competence, and helping them to defend the fundamental human right to asylum.^2–10

In an FME, a clinician evaluates an applicant for evidence of alleged persecution and documents their findings in a medico-legal affidavit.² Traditionally, training involved day-long sessions with expert speakers, though few participants conducted FMEs afterward.¹¹ In 2022, the Asylum Medicine Training Initiative (AMTI)¹² sought to improve the existing training paradigm by bringing together 80 stakeholders across more than 40 institutions to create an interdisciplinary, consensus-driven, virtual curriculum that can be paired with experiential learning in a flipped classroom format to better prepare learners.^13–15 AMTI has been adopted as the training standard by Physicians for Human Rights, an organization that hosts the largest referral network for pro bono FMEs nationally. However, the AMTI has not been evaluated as a tool in graduate medical education. A few curricula designed to train residents in FMEs have been described,^16–18 but they predate the development of the AMTI.

We piloted a year-long, interdisciplinary, graduate medical elective in asylum medicine by pairing AMTI’s curriculum with experiential learning in the form of skills practice and mentored FMEs. Our objectives were to determine if (1) participants acquired knowledge essential for conducting FMEs, (2) participants felt more comfortable with key skills in asylum medicine, and (3) the curriculum helped learners feel prepared to conduct independent FMEs.

We piloted the elective at an academic safety-net hospital from September 2022 to June 2023. Our cohort included three internal medicine residents, two family medicine residents, two psychiatry residents, and one clinical psychology postdoctoral fellow. We selected amongst interested trainees by lottery.

The elective featured a flipped classroom design informed by experiential learning theory and supported by evidence demonstrating the success of this approach in health professions education.^14,19 In semester one, participants independently completed AMTI’s five core modules, then met virtually for four 90-minute small groups (blocks A-D) for skills practice and discussion with faculty experts. In semester two, participants performed three mentored FMEs with increasing independence.

We designed a formative, mixed-methods evaluation to assess knowledge acquisition, skills comfort, and perceived effectiveness in preparing participants to conduct FMEs. The evaluation included surveys at the end of semesters one and two (40-items and 38-items; respectively), a 20-minute semistructured exit interview, and AMTI’s pre-post assessment (68-items).

Surveys and interview questions were developed iteratively with faculty. Questions assessed demographics, prior FME experience, FME skills comfort, elective experience, perceived elective effectiveness, future intentions, and burnout using Likert scales and free-text.

The AMTI assessment was developed iteratively with a national stakeholder working group. Questions assessed demographics, FME knowledge and skills comfort, and direct knowledge acquisition using Likert scales and multiple-choice. 

We assigned numerical values to Likert questions and compared pre-post change scores using Wilcoxon Signed-Rank tests. Knowledge acquisition was assessed using AMTI scores with a paired samples t test for normally distributed data, with significance at P<.05. Free-text responses and interviews were analyzed using a grounded theory approach to develop a codebook. Two researchers double-coded data in Dedoose software (Los Angeles, CA: Sociocultural Research Consultants), systematically identified emerging themes, and resolved discrepancies through consensus. The Cambridge Health Alliance Institutional Review Board approved this study.

The response rate was 100% (8/8). Half of the participants identified themselves or their parent/guardian(s) as refugees or immigrants, and none had previously conducted a FME (Table 1).

During semester one, AMTI’s direct knowledge assessment revealed a significant increase in knowledge necessary for conducting FMEs. After the elective, participants reported high comfort levels with many key FME skills and 75% (6/8) felt “prepared” or “completely prepared” to conduct FMEs independently. Most participants reported they were likely to use the skills in their future careers and an increased likelihood of working with displaced persons in the future (mean scores: 9.6 and 9.3 on an 11-point scale; Table 2).

Qualitative analyses revealed seven themes (Table 3). Participants were motivated to participate by their lived experiences and desire to benefit displaced populations. They felt their learning was enhanced by the experiential learning components of the course but desired a stronger sense of community than the fully virtual format created. They identified two barriers to conducting FMEs in the future: lack of protected time and ongoing mentorship. Nevertheless, participants felt they would be able to use the skills acquired in work with displaced populations.

Our study addresses a literature and training gap by presenting a curriculum that integrates AMTI with experiential learning to equip interdisciplinary trainees with essential knowledge for conducting FMEs and enhancing comfort with skills relevant to working with displaced populations. The results of our formative evaluation, though limited by small sample size and a reliance on self-assessment,²¹ suggest that incorporating experiential learning helped participants feel more comfortable with FME skills and prepared to conduct independent FMEs.^9,22

Participants identified lack of protected time and ongoing mentorship as barriers to conducting future FMEs. However, they reported an increased likelihood of working with displaced populations and rated themselves highly likely to use skills learned in the elective, with the potential to decrease burnout.²⁰ Thus, this curriculum has the potential to better equip trainees to deliver general clinical care in today's era of unprecedented migration.^23–26

Strengths of this study include the interdisciplinary cohort. Limitations include the small sample size, singular site, and reliance on self-assessment.²¹ Participants also opted-in, so the results are not generalizable to nonelective contexts. Next steps include direct skills and longitudinal assessments using a larger cohort to determine if/how the skills participants acquired are applied.

To our knowledge, this is the first study evaluating FME training in graduate medical education using the AMTI curriculum.¹³ This elective could be replicated at other institutions due to AMTI's accessibility and the use of virtual spaces for small groups and mentored FMEs.