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“Their Stories Have Changed My Life”:

Clinicians’ Reflections on Their Experience
with and Their Motivation to Conduct Asylum
Evaluations

Article in Journal of Immigrant and Minority Health · December 2014

DOI: 10.1007/s10903-014-0144-2 · Source: PubMed

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J Immigrant Minority Health
DOI 10.1007/s10903-014-0144-2
ORIGINAL PAPER
‘‘Their Stories Have Changed My Life’’: Clinicians’ Reflections
on Their Experience with and Their Motivation to Conduct
Asylum Evaluations
Ranit Mishori • Alisse Hannaford • Imran Mujawar
Hope Ferdowsian • Sarah Kureshi
 Springer Science+Business Media New York 2014
Abstract Many clinicians perform asylum evaluations
yet no studies describe the motivation to perform them or
their perceived rewards. The number of asylum seekers in
the US is increasing and more clinicians are needed as
evaluators. A survey to an asylum evaluators’ network
asked participants to qualitatively reflect on their experi-
ence and motivation. Answers were analyzed for themes
and sentiment. Respondents cited commitment to human-
istic and moral values, noted personal and family experi-
ences, having skills, expertise, and career interests as
drivers. They found the experience very rewarding per-
sonally and professionally, and in their perceived benefit to
asylees. Negative sentiment was less frequent and centered
on emotions related to client narratives. Process-oriented
frustrations were also noted. This is the first published
study describing clinicians’ motivation and experience
R. Mishori (&)
A. Hannaford
S. Kureshi
Department of Family Medicine, Georgetown University School
of Medicine, Pre-Clinical Building, GC-01D, 3900 Reservoir
Rd. NW, Washington, DC 20007, USA
e-mail: mishorir@georgetown.edu
A. Hannaford
e-mail: alissedhannaford@gmail.com
S. Kureshi
e-mail: sk795@georgetown.edu
I. Mujawar
Department of Psychiatry and Behavioral Sciences, Memorial
Sloan Kettering Cancer Center, 1275 York Avenue, New York,
NY 10065, USA
e-mail: mujawarimi@gmail.com
H. Ferdowsian
Department of Medicine, George Washington University,
5100 Wisconsin Ave NW, Washington, DC 20016, USA
e-mail: hopeferdowsian@sprintmail.com
•
with asylum evaluations. It may illuminate clinicians’ drive
to volunteer, and serve as a resource for organizations for
recruitment and education.
Keywords Asylum evaluation
Volunteerism
Asylum
seekers
Human rights
Underserved care
Introduction
Health care professionals often volunteer for humanitarian
assignments, to work in developing countries, and to pro-
vide pro-bono services to marginalized and underserved
populations in the US and abroad. There are few studies
exploring clinicians’ motivation to engage in these types of
volunteer work.
One study from Scandinavia found several themes that
included a desire to contribute, a search for personal
development and self-knowledge, for new experiences and
for more satisfying and stimulating work, compared to their
routine jobs. [1]. Similar sentiments related to ‘‘giving
back’’ to the world, sharing skills and knowledge, learning
about different cultures, addressing dissatisfaction with
their regular job, charity, and personal growth have been
noted in other articles discussing reasons for clinicians to
volunteer overseas. The rewards of volunteering in these
settings have been described, often, as gaining more than
giving [2–8].
There are several models for health care provider vol-
unteerism and humanitarian work. These include working
in the developing world, participating in disaster relief,
working with refugee, marginalized and under-served
populations abroad and at home. Opportunities also exist to
work with asylum seekers and torture survivors. A small
number of physicians have anecdotally described their
123

work and engagement with asylum seekers [9–11], and
only a handful of articles describe or explore this type of
volunteer work [12, 13], or the benefits or practice of
teaching it to health professional learners [14, 15].
Asylum seekers are individuals who leave their home
countries as political refugees and seek asylum in another
country. The United Nations High Commissioner for Ref-
ugees (UNHCR) estimated that more than 600,000 asylum
applications were registered in 2013 in 44 industrialized
countries [16]. This was an increase of 28 %, compared
with the previous year, and the third consecutive year in
which a significant increase in the number of asylum
seekers was observed. According to the UNHCR report, the
US alone has seen a 25 % increase in the number of asylum
claims in 2013 compared to 2012.
US government estimates state that the total number of
persons granted asylum in the United States increased from
24,873 in 2011 to 29,484 in 2012 [17], an increase of
18.5 %. The leading countries of origin for persons granted
asylum in the US for 2010–2012 were China (34 %), Egypt
(9.8 %), Ethiopia (3.8 %), Venezuela (3.7 %), and Nepal
(3.3 %).
In the United States, an individual may be eligible for
asylum if s/he meets the definition of a refugee [18]; spe-
cifically ‘‘any person outside their country of nationality, or
if none the country of last habitual residence, who is unable
or unwilling to return… because of persecution or a well-
founded fear of persecution on account of race, religion,
nationality, membership in a particular social group, or
political opinion…’’. Persecution involves threat to life or
freedom of, or the infliction of suffering or harm upon,
individuals. Well-founded fear may be based on previous or
potential persecution. In order to obtain asylum in the US
applicants sometimes undergo a medical and/or psychiatric
or clinical psychological evaluation that seeks to establish
evidence of persecution or potential for persecution. Health
care professionals document forensic evidence of various
forms of harm, including torture. The process of conducting
an asylum evaluation and writing a medico-legal affidavit
can be quite time consuming (3–6 h per case) and may incur
an emotional burden on the expert evaluator due to the nature
of patients’ histories that often include rape, torture and other
forms of maltreatment. Vicarious trauma has been reported
as a possible clinician outcome [19].
There are certain benefits to the asylees of including a
medical assessment as part of their case. One study [20] has
shown that the likelihood of obtaining asylum is higher
among those who receive a medical evaluation when
maltreatment is alleged.
Two organizations currently provide training for potential
clinical evaluators: Physicians for Human Rights (PHR), and
Health Right International (HRI). Their networks span the
continental US and include hundreds of clinicians
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J Immigrant Minority Health
(physicians, psychologists, other mental health providers,
and nurses). Yet despite the training and recruitment efforts
there is a reported shortage of providers who can expertly
and adequately participate in the asylum process and
respond to the increasing demand (Personal communication.
PHR asylum network, March 2014).
No studies to date have described what motivates cli-
nicians to volunteer their time to work with this unique and
complex population and, in the process, expose themselves
to the often gruesome histories and physical signs of tor-
ture, ill-treatment and sexual violence. There are also no
documented explorations of how clinicians who perform
these services perceive of their experience and characterize
the rewards of such work.
Methodology
We designed a general survey about attitudes towards
asylum work which was distributed to members of the
asylum network of PHR. The survey was distributed
through an email with a link to www.surveymonkey.com.
An initial announcement was sent, followed by two
reminders between May and July 2012. The survey inclu-
ded a personalized greeting, a consent form and a link to
the survey. Non-responders were sent up to two follow-up
emails encouraging participation. At the time the survey
was sent, the PHR asylum network had 449 known mem-
bers: 286 physicians, 86 psychologists, 38 social workers,
and 39 were unidentified (Personal communication. PHR
asylum network, February 2012). They survey was
approved by the Providence Hospital Internal Review
Board, in Washington, DC.
The survey included questions about demographics, as
well as on self-reported vicarious trauma (results were pre-
viously published [19]). We also sought responses to the
following open-text questions in the survey (responses were
mandatory): (1) ‘‘Please reflect on your experience per-
forming asylum evaluations.’’ (2) ‘‘Describe why you were
interested in conducting an asylum evaluation.’’ Respon-
dents were allowed to provide as much narrative text as they
desired, and were not limited to a specific number of lines or
thoughts. All responses were entered into a database. We
conducted a thematic content qualitative analysis. We
manually sorted the answers looking for themes within the
data. We worked through several phases: data familiariza-
tion, generation of initial themes/codes, identification of
general themes, theme reviewing, generation of sub-themes,
theme definition and naming. Finally, responses that were
similar in nature and sentiment were condensed and redun-
dancies were eliminated to reflect general themes.
In addition, we performed a basic sentiment analysis of
the free text looking to see if the expressed opinions and
J Immigrant Minority Health

feelings of the respondents could be classified as a positive, Themes

negative or mixed in attitude.
Motivation

Results When asked to comment about the reasons for their partic-
ipation in asylum evaluations, responses varied and fell into
The survey was sent to 449 individuals of which 211 began different categories, some deeply personal, others, related to
the study (47 %) and 197 completed it (44 %). We attribute work, professional interests, and career enhancement. More
the drop out to survey fatigue, time constraints and a internally driven, ‘‘Personal’’ themes, included: (1) Moral
possible reluctance to provide open-text answers. The first and ethical Duty; (2) Personal or family connection.
set of analyses look at the respondent sample. The ‘‘Professional’’ themes related to issues inherent to
Most respondents were affiliated with psychiatric or the person’s skill-set, past work experience, work schedule
psychological health professions. There were more women and career-related pursuits and interests.
who responded to the survey than men and a greater pro- We identified 7 common career-oriented themes: (1)
portion of younger individuals (39 or younger) were among Skills and experience; (2) Interest in refugee, immigrant
the responders. An overwhelming majority of responders and underserved health; (3) Interest in human rights; (4)
described themselves as White. The majority of responders Interest in policy; (5) a global health opportunity; (6)
were in practice for more than 10 years (Table 1). Flexibility; (7) External recommendation.
Table 2 is a detailed summary of the themes with
selected quotes for illustration.
Table 1 Descriptive statistics by gender
Female Male Total Experience
N (%) N (%) N (%)
The second open-ended question asked respondents to
Age describe their experience.
39 or younger 42 (31.6) 21 (27.6) 63 (30.0)
40–49 25 (18.8) 16 (21.1) 41 (19.5)
50–59 32 (24.1) 16 (21.1) 49 (23.3) Sentiment Analysis
60 or older 34 (25.6) 23 (30.3) 57 (27.1)
All 133 (100.0) 76 (100.0) 210 (100.0) Clinicians used both positive (e.g. ‘‘gratifying’’) and neg-
Race or ethnicity ative (e.g. ‘‘difficult’’) terms to describe the experience of
Missing 2 (1.5) 0 0 2 (1.0) conducting asylum evaluations. As the word cloud (created
Asian 11 (8.3) 5 (6.6) 16 (7.6) via http://www.wordle.net/) suggests (Fig. 1), the senti-
Black 4 (3.0) 2 (2.6) 6 (2.9) ment was overwhelmingly positive, with positive words
Hispanic 3 (2.3) 4 (5.3) 7 (3.3) appearing in higher frequencies, and thus highlighted and
Other 10 (7.5) 5 (6.6) 15 (7.1) in bold in the visual representation.
White 103 (77.4) 60 (78.9) 164 (78.1) Terms used frequently to describe the experience of
All 133 (100.0) 76 (100.0) 210 (100.0) conducting asylum evaluations included: ‘‘rewarding,
Specialty meaningful, inspiring, satisfying, eye opening, positive,
Missing 27 (20.3) 13 (17.1) 40 (19.0) wonderful, important, worthwhile, powerful, interesting,
Family medicine 19 (14.3) 12 (15.8) 31 (14.8) engaging, emotional, moving, useful, productive, touch-
Internal medicine 20 (15.0) 15 (19.7) 35 (16.7) ing’’. The positive sentiment included a few sub-categories:
Other 24 (18.0) 12 (15.8) 36 (17.1) (1) Emotional reaction and outlook on life, (2) A learning
Psychiatry or 43 (32.3) 24 (31.6) 68 (32.4) opportunity, (3) Enhancement of the clinician’s profes-
psychology sional role, (4) View of the asylees as ‘‘courageous’’ and
All 133 (100.0) 76 (100.0) 210 (100.0) comments about their resilience (Table 3).
Years of practice Negative sentiment (Table 3) encompassed apprehen-
Missing 18 (13.5) 8 (10.5) 26 (12.4) sion about the process itself: administrative tasks, sched-
\5 years 17 (12.8) 9 (11.8) 26 (12.4) uling and coordination. Also highlighted was an
5–10 22 (16.5) 9 (11.8) 31 (14.8) acknowledgement of the painful the emotions elicited in
[10 years 76 (57.1) 50 (65.8) 127 (60.5) the clinicians during the evaluations, using the terms:
All 133 (100.0) 76 (100.0) 210 (100.0) ‘‘depressing, hard, harrowing, challenging, difficult, taxing,
painful, draining, devastating’’.

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 J Immigrant Minority Health

Table 2 Categorized and sub-categorized qualitative responses to: ‘‘Describe why you were interested in conducting an asylum evaluation’’
Theme Quotes

Professional
Skills and experience ‘‘Meaningful application of my skills’’
‘‘I have the expertise to do and so should do this’’
‘‘Provided a way to put medical skills to use in a way that could have a tremendous impact on the lives
of some of the most vulnerable people in our society’’
‘‘It seemed like a natural extension of my work with abused and neglected children, and I had a skill set
that I could offer’’
‘‘It combines my medical skills with my political activism and interests’’
Interest in immigrant, refugee and ‘‘Interested in issues of migration and health and this work allows me to contribute while living in the
underserved health United States and simultaneously working in other areas’’
‘‘Interest in minority health, immigrant rights, medical care for underserved populations’’
‘‘To provide a service to people who are marginalized and would otherwise be unable to access needed
care and assistance’’
Interest in human rights ‘‘Commitment to human rights and social medicine’’
‘‘Interest in human rights and women’s rights in particular’’
‘‘It has been for me, a way to stay engaged with human rights work while not having much time as a
resident’’
Response to and interest in policy ‘‘Many asylum seekers are in danger and need assistance. Unfair U.S. immigration laws, often unfairly
issues administered, mean asylum seekers need all the help they can get’’
‘‘I was appalled at the actions of the Bush administration’’
‘‘Concerned about unfair application of US immigration policy’’
‘‘My original interest grew out of my political beliefs and my revulsion to torture’’
Interest in global health, multi-cultural ‘‘General interest in ‘global health’ which I believe includes asylum evaluations’’
issues ‘‘A way to practice international medicine while still at home’’
‘‘Interest in global health and politics’’
‘‘I am very interested in trauma and international medicine. I am interested in people’s stories’’
‘‘I learn a great deal about the world’’
Flexible, easy to integrate to work ‘‘I always do some kind of pro bono work. Asylum work was flexible and interesting. I did not know
routine then that it would be life-changing and a primary professional focus’’
‘‘As a physician this is a small way in which I can help that I can fit into my busy schedule’’
‘‘I thought it was an important job and I had the time do to it’’
External suggestion ‘‘I heard a radio broadcast about PHR and decided I could help as well’’
‘‘My brother participated as a law student and alerted me to the possibility of helping PHR with asylum
evaluations’’
‘‘A friend with experience conducting evaluations brought me to a meeting. Powerful video ‘‘Well-
Founded Fear’’ was shown and was very influential’’
‘‘My mentor during medical school was involved with PHR and that’s how I became involved’’
Personal
Moral and ethical duty ‘‘I felt an obligation, as a physician’’
‘‘Sense of personal responsibility and values’’
‘‘This is one small way to do something about the massive injustices that exist in our world’’
‘‘I feel a moral obligation to help others when I can, particularly in my capacity as a physician’’
‘‘Lifelong commitment to help victims of oppression and injustice no matter where they occur’’

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J Immigrant Minority Health

Table 2 continued
Theme Quotes

Personal, family, religious or ethnic
connection
‘‘My cousin…applied for asylum from Uganda’’
‘‘My family and I emigrated from Bulgaria a decade ago and while we were not asylum seekers, the
stories of other immigrants have always fascinated me’’
‘‘Am Jewish. Had to do with my childhood growing up in/after World war II’’
‘‘Personal family history’’
‘‘My father was an immigrant and refugee’’
‘‘I became interested in this work because my father’s family was granted asylum from Nazi Germany’’
‘‘America to me is the ‘great melting pot’ of cultures and the disenfranchised. It saved my parents and
their families and it should welcome all who seek opportunity to pursue their potential… It is my
answer to ‘Never Again’’ after the Holocaust’’
‘‘I believe giving persecuted populations a chance to live in a free world without fears is the ultimate
human gift…Those who assisted my family gave us that gift…and I want to pass it on to others’’
‘‘I am an immigrant myself and understand the trials and tribulations people have in trying to establish
themselves in this country’’
‘‘Having grown up with my own family history of immigration (my grandparents’ generation) played a
part in my motivation for working with this particular population’’

Fig. 1 Word cloud created

from free text: ‘‘Please reflect
on your experience performing
asylum evaluations’’. The larger
words represent terms used in
higher frequencies

Many participants acknowledged the presence of dual Discussion

emotions and the co-existence of both positive and nega-
tive feelings about the experience, for example: ‘‘harrow-
ing but rewarding’’, ‘‘It has been both the most horrible and
most gratifying experience of my life’’ (Table 3).
Of interest, the issue of the credibility of the asylum
seeker has come up with several respondents who noted an
inner struggle with their ability to verify the asylee’s his-
tory and assuage an occasional skepticism. Several
respondents noted New Yorker and New York Times
articles [21, 22] about asylum seekers who lied and con-
fessed to falsifying their history, as a pivotal moment that
made them reflect more critically on the process (Table 4).
Clinicians who perform asylum evaluations view their
experience extremely positively in areas of personal and
professional growth as well as in their perceived benefit to
individuals from vulnerable populations. Negative senti-
ments, which were noted less frequently, revolved pri-
marily around the emotional difficulty of encountering the
client narratives. Some were related to process-oriented
and administrative frustrations.
Respondents cited commitment to humanistic and moral
values, personal duty, personal and family experiences, as
well as their professional skills and expertise, and career-

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Table 3 Sentiment analysis: ‘‘Please reflect on your experience performing asylum evaluations’’
Sentiments Quotes

A. Positive
Personally meaningful
Raise awareness about the world
Enhancing physician
professional role
Respect for survivors; resilience
of victims
‘‘Their stories have changed my life’’
‘‘Performing asylum evaluations and preparing the cases pro-bono is the most meaningful work I have done
in medicine’’
‘‘I consider my experience of doing asylum evaluations as being probably the most important contribution I
have made in my clinical career. Most of the people I have interviewed faced imprisonment and probable
death had they not been able to get asylum’’
‘‘May be the most important life or death work I do as a primary care physician’’
‘‘When asylum is granted, I am happy that I helped another human being to rebuild his/her life’’
‘‘It has changed my life; I am a different person. My gratitude and life perspective are more positive and
sustained’’
‘‘The best, most fulfilling work I have ever done as a physician’’
‘‘Very rewarding…The time I spend with these patients is the kind of time I wish I spent with all patients’’
‘‘It has also enhanced my own appreciation of the life I lead and comforts I am blessed to have’’
‘‘It has really made me see a side of humanity that I had only read about or watched on TV. It brought their
stories to life to hear from someone that personally went through these awful experiences’’
‘‘It has been a sobering and eye-opening experience. I have learned a lot about the ‘‘third world’’
‘‘Has opened my eyes to political and social issues around the world that I had been unaware of, has made me
much more aware of the traumas my own clinic patients may have suffered in their past (but never talked
about)’’
‘‘Doing asylum evaluations broadens my awareness and perspective on the world, puts my own life
experience in a different context’’
‘‘Intellectually challenging work that has allowed me an intimate window into various parts of the world-
politics, religion, social structures, etc. A privileged glimpse into suffering and a brief meaningful
opportunity to work toward a remedy’’
‘‘A profoundly affecting and informative undertaking for which I am grateful’’
‘‘I grow as I learn of varied forms of abuse around the globe’’
‘‘It is interesting to learn about the situation of people in very difficult circumstances and very rewarding to
be able to help them with what may be a matter of life and death’’
‘‘It is at time harrowing work but always worthwhile in that I feel a sense of transcendence to a broader
perspective of the world’’
‘‘It reminds me of why I want to be a physician’’
‘‘It was definitely a learning experience which I believe will supplement my medical education and make me
a better doctor’’
‘‘It’s really helped me reflect on the lives of my patients and all the challenges they encounter… in turn,
making me a more empathetic physician’’
‘‘It has enhanced my career’’
‘‘Feel inspired by asylum seekers’ courage’’
‘‘It has been an enriching, humbling experience which has given me profound respect for the resilience of the
many survivors with whom I have interacted’’
‘‘Am in awe of the strength and courage of those seeking asylum’’
‘‘The stories are horrifying and ghastly but in interacting with the victims, the stunning resiliency of the
human spirit is breath taking’’
‘‘I feel touched by the suffering of the applicants and deeply admire their courage in standing up for their
beliefs in their home country’’
‘‘I am inspired at times by the courage people show in dealing with all kinds of oppression’’
‘‘I have met a number of brave people through conducting asylum evaluations. The stories are varied, but I’ve
noticed that in most cases, strength of spirit prevails’’
‘‘I am humbled and grateful to people who put themselves in my hands. I am privileged to meet these brave
people who are trying to find a better life against great odds. I cannot imagine doing what they do’’

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Table 3 continued
Sentiments Quotes

B. Negative
Emotionally difficult for the ‘‘I find the evaluations very depressing as reminders of the cruelty with which we treat other human beings’’
clinician ‘‘It is often very difficult—the trauma that individuals have experienced is simply horrific and I would prefer
to not know that this kind of evil even exists’’
‘‘Sometimes draining, require a lot of patience, sometimes difficult to not become emotionally involved’’
‘‘Emotionally difficult for me and the patient’’
‘‘Each interview is incredibly draining. I always intend to write the affidavit immediately afterwards, but
have never been able to do so’’
Process and procedure ‘‘I find it frustrating that it is so challenging to conclusively validate a person’s story through physical exam’’
‘‘Less satisfying experiences have occurred when the lawyers involved were not helpful, and when I felt
could not fully trust the asylum seeker’’
‘‘The work was interesting but hard to get the patients to talk fully and difficult to get scheduling done’’
‘‘Frustrating to interact with the court system’’
‘‘Writing the reports is tedious’’
‘‘Hate testifying’’
‘‘Applicants have been poorly screened by attorneys, and some were found to provide false info, which leaves
me skeptical across the board’’
C. Mixed
‘‘The experiences have been hard but rewarding’’
‘‘It has been both the most horrible and most gratifying experience of my life’’
‘‘My experience has been that the work is both exhausting and at the same time very rewarding’’
‘‘It is as intimidating but extremely rewarding’’
‘‘Never easy or pleasant, but life-affirming and deeply humbling—this work is deeply satisfying’’
‘‘I am inspired, saddened, enraged by what I hear and see–all of which deepens my commitment to the work’’
‘‘I found it exciting and challenging at the same time’’
‘‘It’s been enlightening and sad’’
‘‘They are emotionally devastating but on some level uplifting…’’
‘‘It was traumatic and stressful but very rewarding and informative’’
‘‘Rewarding, disturbing, worthwhile, profound’’
‘‘Moving, difficult, heart-wrenching, hopeful’’

oriented interests as reasons they pursued this line of vol-
unteer work.
To our knowledge, this is the first published study
describing and documenting clinicians’ motivation for and
experience of conducting asylum evaluations. This descrip-
tive analysis reveals an overwhelming positive sentiment
about performing these evaluations. Health care practitio-
ners engaged in this activity perceive of it as valuable and
beneficial not only to the clients but also to themselves.
Many find the activity is aligned with their professional
responsibilities and identities and are driven by universal
humanistic values.
This study has several weaknesses. The overall response
rate was 46.9 % (211 out of 449), which, though low, is not
unusual when it comes to online surveys. Despite the fact
that many individuals taking the survey did not complete
all the answers, those who provided answers gave us a lot
of narrative data to work with.
Methodologically, we performed only a basic content
analysis. As for the determination of themes and sub-
themes—though two of the authors reviewed each narra-
tive statement and reached a consensus on where it
belongs, we did not perform inter-rater reliability on the
themes. Further, the determination of sentiment (positive,
negative, mixed) was also very basic and relied solely on
key-word spotting, which doesn’t lend itself to much depth
of analysis. We did not use scaling, measures of potency or
polarity of the various sentiments. This analysis, therefore,
reflects only on our own judgment and interpretation, likely
affected by internal biases.
Our data about the motives behind health professionals’
motivation for and experience with asylum evaluations was
obtained from written answers. While many responses had
emotional depth, it is hard to extract emotion or feeling
from written responses. More in-depth, face-to-face inter-
views may have yielded additional information and could

123

Table 4 Credibility concerns
‘‘On a few occasions I have been skeptical about the victim’s
story/report or whether it was grounds for asylum’’
‘‘I have a creeping feeling that some applicants may have
concocted a story… (It) has had some undermining effect on my
motivation.’’
‘‘Applicants have been poorly screened by attorneys, and some
were found to provide false info, which leaves me skeptical
across the board’’
‘‘I feel that as a physician I should just retell the history and report
the physical as objectively as possible. I am thankful that I am
not a judge. I do not know if I could make those calls. I decided
to err on the side of being taken for a ride than having defenses
up against an innocent or injured person’’
‘‘After reading a NY Times article about an asylum applicant who
lied about being raped in order to get asylum, I did start
wondering whether at times I have been used by a client who
was not honest’’
have deepened our understanding of the underlying
motives and experiences shared through this questionnaire.
Of note, the issue of asylees’ credibility and truthfulness
has come up several times and merits additional scrutiny,
perhaps via more formal and structured addressing during
asylum evaluation training. While it is impossible to know
how common this is, or how clinicians reacted to such
instances, it is fair to assume that being lied to would be
enormously discouraging to clinicians and a disincentive to
continue to perform evaluations.
As with any qualitative study, the results may not be
generalizable and only apply to those who responded.
However, the narratives and reflections described in this
study may provide a window into the motives and drivers
of a self-selected, socially-conscious, deeply-committed
group of health care professionals who conduct asylum
evaluations. Sharing this study’s findings with colleagues
and learners (students, residents) may provide them with
examples of meaningful professional opportunities—not
often encountered in health-profession schools and resi-
dencies—that may be pursued after graduation, or while
practicing.
This study may also shed light on clinician volunteer
behavior. Previous work [23, 24] noted several motivating
factors for volunteering in general, and linked them to a
functional framework. One such framework [25] noted six
domains associated with the motivation to volunteer: Val-
ues (altruism), Understanding (new learning opportunities),
Social (working with colleagues, being viewed favorably),
Career (benefits and use of skills), Protective (reducing
guilt about being more fortunate), and Enhancement (per-
sonal development). Though this study was not intended as
an in-depth psycho-social probe of this matter in our
population, the six functions noted, and validated, by Clary
et al. are certainly consistent with and reflected in the
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J Immigrant Minority Health
answers provided by the clinical volunteers in our sample.
Future studies may seek to further explore clinician moti-
vation to volunteer with specific populations and in specific
settings, and the impact of altruism versus. more self-
serving professional gains on decisions to volunteer [26,
27].
Finally, the abundance of overall positive attitudes about
the experience, as exemplified through the specific quotes
and sentiments in this manuscript, may be used as a starting
point for organizations engaged in asylum work to create
recruitment programs, messages and educational interven-
tions. It has been suggested that the volunteer motivation
domains mentioned above be useful for consideration by
volunteer administrators [28] as an approach for the
recruitment, placement, and retention of volunteers.
This is particularly important at a time when asylum
provider organizations are struggling to expand their pool
of participants in an effort to respond to a reported increase
[29] in the number of asylum seekers in the United
States—both children and adults.
Acknowledgments We would like to thank Christy Fujio, Kelly
Holtz and Jillian Tuck for their assistance with survey distribution,
and all the clinicians of the PHR asylum network who responded to
the survey. We would like to thank Pamela Saunders PhD, for her
review of the manuscript and her helpful comments.
References
1. Bjerneld M, Lindmark G, McSpadden LA, Garrett MJ. Motiva-
tions, concerns, and expectations of Scandinavian health profes-
sionals volunteering for humanitarian assignments. Disaster
Manag Response. 2006;4(2):49–58.
2. Kelly NA. Deciding to become an overseas volunteer. Hosp
Physician. 2000;36(6):72–8.
3. Woods JE, Kiely JM. Short-term international medical service.
Mayo Clin Proc. 2000;75(3):311–3.
4. Bartels-Rabb, L. To the service of humanity: volunteering in the
third world. Bulletin. 1996;40:71–7 (Health Education Center,
Institute for Research and Education, Health System Minnesota).
5. Setness PA. A flood of rewards: volunteers set an example for all
of us [editorial]. Postgrad Med. 1997;102:13–6.
6. Elseed E. Volunteerism among physicians: motivational causes
and reaped benefits. Outstanding Honors Theses. 2012. http://
scholarcommons.usf.edu/honors_et/89
7. Mitka M. Volunteering overseas gives physicians a measure of
adventure and altruism. JAMA. 2005;294(6):671–2.
8. Vu MT, Johnson TR, Francois R, Simms-Cendan J. Sustained
impact of short-term international medical mission trips: resident
perspectives. Med Teach. 2014;29:1–7.
9. Roth K. Giving refuge: reflections on working with asylum
seekers. J Pain Symptom Manage. 2010;40(1):149–54.
10. Webber R. Evaluating asylum seekers: an interview with Dr.
Arno Vosk | Sampsonia Way Magazine. http://www.sampsoni
away.org/blog/2013/05/09/evaluating-asylum-seekers-an-interview-
with-dr-arno-vosk/
11. Eisold B. Evaluating asylum seekers. http://www.apadivisions.
org/division-39/publications/newsletters/activist/2012/04/evaluating-
asylum-seekers.aspx
J Immigrant Minority Health
12. Asgary R, Smith CL. Ethical and professional considerations
providing medical evaluation and care to refugee asylum seekers.
Am J Bioeth. 2013;13(7):3–12.
13. Wild V, Heilinger J-C. Cosmopolitanism within borders: a nor-
mative foundation for health care for asylum seekers? Am J
Bioeth. 2013;13(7):17–9.
14. Asgary R. A call to teach medical students clinical human rights.
Academic medicine. http://journals.lww.com/academicmedicine/
Fulltext/2013/03000/A_Call_to_Teach_Medical_Students_Clinical_
Human.9.aspx
15. Asgary R, Saenger P, Jophlin L, Burnett DC. Domestic global
health: a curriculum teaching medical students to evaluate refu-
gee asylum seekers and torture survivors. Teach Learn Med.
2013;25(4):348–57.
16. United Nations High Commissioner for Refugees. UNHCR
Global Trends 2013. UNHCR. 2014. http://www.unhcr.org/
5399a14f9.html
17. Department of Homeland Security. Refugees and asylees 2012.
Annual Flow Report, April 2013. http://www.dhs.gov/sites/
default/files/publications/ois_rfa_fr_2012.pdf. Accessed 08 April
2014.
18. United States Citizen and Immigration Services (USCIS): Refu-
gee, Asylum, and International Operations Directorate—officer
training. March, 2013. USCIS Publications.
19. Mishori R, Mujawar I, Ravi N. Self-reported vicarious trauma in
asylum evaluators: a preliminary survey. J Immigr Minor Health.
2013;16(6):1232–7.
20. Lustig SL, Kureshi S, Delucchi KL, Iacopino V, Morse SC.
Asylum grant rates following medical evaluations of maltreat-
ment among political asylum applicants in the United States.
J Immigr Minor Health. 2008;10(1):7–15.
21. Mehta S. The asylum seeker. The New Yorker. 2011. http://www.
newyorker.com/magazine/2011/08/01/the-asylum-seeker
22. Dolnick S. Immigrants may be fed false stories to bolster asylum
pleas. The New York Times. 2011 Jul 11. http://www.nytimes.
com/2011/07/12/nyregion/immigrants-may-be-fed-false-stories-
to-bolster-asylum-pleas.html
23. Unger LS. Altruism as a motivation to volunteer. J Econ Psychol.
1991;12(1):71–100.
24. Clary EG, Sydner M. The motivations to volunteer: theoretical
and practical considerations. Curr Dir Psychol Sci. 1999;8:156.
25. Clary EG, Snyder M, Ridge RD, Copeland J, Stukas AA, Haugen
J, et al. Understanding and assessing the motivations of volun-
teers: a functional approach. J Pers Soc Psychol. 1998;74(6):
1516–30.
26. Haski-Leventhal D. Altruism and volunteerism: the perceptions
of altruism in four disciplines and their impact on the study of
volunteerism. J Theory Soc Behav. 2009;39(3):271–99.
27. Tsuei SH, Tsai AP. Examining altruism in medical student vol-
unteer work: a reply to pham’s article. In-Training. http://in-
training.org/examining-altruism-medical-student-volunteer-
work-reply-phams-article-4293
28. Clary EG, Snyder M, Ridge R. Volunteers’ motivations: a
functional strategy for the recruitment, placement, and retention
of volunteers. Nonprofit Manag Leadersh. 1992;2(4):333–50.
29. United Nations High Commissioner for Refugees (UNHCR).
Children on the run. Division of International Protection. Geneva,
Switzerland. March 2010. http://www.unhcrwashington.org/sites/
default/files/UAC_UNHCR_Children%20on%20the%20Run_
Full%20Report.pdf. Accessed 08 May 2014.
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