The Intersection of Medical Education and Healthcare Access for Undocumented Immigrants

The per­sonal state­ment I wrote twenty years ago to gain entrance into med­ical school read, “Accom­pa­ny­ing my grand­mother for med­ical appoint­ments showed me first­hand unset­tling inequities in our health care sys­tem. Med­ic­aid patients vis­ited crowded clin­ics, endured long wait­ing peri­ods, and expe­ri­enced a lack of med­ical con­ti­nu­ity as her physi­cians changed from week to week. While I am aware that med­ical care for the poor presents com­plex prob­lems with no facile answers, I am eager to explore such issues and become part of the solu­tion.” Things haven’t changed so much for the poor in this coun­try, and undoc­u­mented immi­grants have been com­pletely left out of the health­care access equa­tion. How­ever, those of us involved in the par­al­lel health­care sys­tem of car­ing for undoc­u­mented immi­grants know that the issue of access for this pop­u­la­tion must be addressed.

Full dis­clo­sure: from a moral, eth­i­cal, log­i­cal and prac­ti­cal point of view, I think every­one, regard­less of socio-economic and immi­gra­tion sta­tus should have access to good, respect­ful care. I’m in good com­pany. The Ethics Man­ual of the Amer­i­can Col­lege of Physi­cians (ACP) coun­sels us that “The inter­ests of the patients should always be pro­moted regard­less of finan­cial arrange­ments, the health care set­ting or patient char­ac­ter­is­tics.”¹ More­over, the ACP’s position’s paper on National Immi­gra­tion Pol­icy and Access to Health Care states that “Access to health care should not be restricted based on immi­gra­tion sta­tus, and peo­ple should not be pre­vented from pay­ing out-of-pocket for health insur­ance cov­er­age.”² The Insti­tute of Med­i­cine has out­lined six essen­tial com­po­nents of health care: Safety, Effec­tive­ness, Time­li­ness, Effi­ciency, Patient Cen­tered­ness and Equity. If the present state of our health care sys­tem faces many chal­lenges, the sys­tem in place for our country’s most vul­ner­a­ble inhab­i­tants is failing.

Res­i­dents in the pri­mary care spe­cial­ties as well as in the med­ical and sur­gi­cal sub­spe­cial­ties have his­tor­i­cally been at the fore­front for car­ing for the un– and under-insured, and are part of the loosely meshed safety net that exists for this pop­u­la­tion. At Stam­ford Hos­pi­tal where I run the inter­nal med­i­cine res­i­dency pro­gram, the res­i­dents’ edu­ca­tional expe­ri­ence in ambu­la­tory med­i­cine is held in a Fed­er­ally Qual­i­fied Health Cen­ter (FQHC). We esti­mate that about 35% of our patients are undoc­u­mented immi­grants. It is not known nation­ally what per­cent­age of patients cared for by med­ical res­i­dents are undoc­u­mented patients, but it seems rea­son­able to assume that it is not an insignif­i­cant num­ber, given the role of med­ical edu­ca­tion in car­ing for the under­served. If res­i­dents are car­ing for undoc­u­mented immi­grants in sig­nif­i­cant num­bers, then that care must be of con­cern for those bod­ies gov­ern­ing med­ical education.

We have a spe­cial oblig­a­tion to the next gen­er­a­tion of physi­cians. How are we help­ing them to main­tain the same level of ide­al­ism under the cir­cum­stances of car­ing for com­pli­cated patients who present late in the course of their dis­ease because of con­cern over their immi­gra­tion sta­tus? Are our res­i­dents being trained ade­quately in cul­tural com­pe­tency so that they can prac­tice authen­tic patient cen­tered care? Are they given enough time to see patients who speak sev­eral dif­fer­ent lan­guages and pose unique cul­tural con­sid­er­a­tions as it relates to their med­ical care? We need to help our trainees cope with feel­ings of impo­tence that arise when needed resources aren’t avail­able. For exam­ple, when patients are not well enough to go home but not sick enough to remain in the hos­pi­tal, they often need to be trans­ferred to a skilled nurs­ing facil­ity. How­ever, the resources res­i­dents need to effec­tively facil­i­tate the tran­si­tion are often unavail­able. Sim­i­larly, patients suf­fer­ing from alco­holism may not be eli­gi­ble for post-hospital reha­bil­i­ta­tion and are read­mit­ted again and again with relapse from their dis­ease. Do our trainees believe us when we tell them that we prac­tice the same stan­dard of care for all of our patients? We have immense respon­si­bil­ity to our learn­ers to help them frame what they are feel­ing and to help them trans­form those feel­ings of impo­tence into action. Besides the eth­i­cal and moral impli­ca­tions, there are the prac­ti­cal con­sid­er­a­tions. It costs hun­dreds of thou­sands of dol­lars for read­mis­sions and to keep patients in the hos­pi­tal because there is no where else for them to go.

Being over­whelmed by the lack of appro­pri­ate resources to care for these patients can engen­der physi­cian burn-out and anger. I have over­heard physi­cians offer­ing solu­tions to astro­nom­i­cal med­ical bills that get gen­er­ated by unin­sured patients by assert­ing “shouldn’t we just invest in a plane ticket for their return trip home?” Such state­ments occur in the pres­ence of med­ical stu­dents and res­i­dents, which is prob­lem­atic because it bor­ders on unpro­fes­sional behav­ior. How­ever, it’s easy to under­stand how these state­ments are made. It is tempt­ing to want the prob­lem to just “go away.” As physi­cians who took oaths to care for the sick and to live up to the high­est stan­dards of moral behav­ior, it’s hard to look some­one in the eye and say, “I can’t deliver best prac­tices in med­i­cine to you.” How are we affected by car­ing for patients with­out access to nec­es­sary resources know­ing that our actions are wit­nessed by our trainees?

The Afford­able Care Act did not make pro­vi­sions for undoc­u­mented immi­grants, but we will con­tinue to care for them, because it is the right thing to do. Immi­grants play an impor­tant role in our soci­ety, and they are not going to leave. If home rep­re­sented edu­ca­tional and work oppor­tu­ni­ties as well as good health care access, they would still be in their native coun­tries. They came to this coun­try for the same rea­sons that our pre­de­ces­sors in this coun­try came: to make a bet­ter life for their fam­i­lies and to escape unbear­able poverty and violence.

Below is a three part approach for help­ing med­ical stu­dents, res­i­dents and the rest of us solve the inequities and dis­par­i­ties that exist in our system.

1. It is impor­tant to acknowl­edge the emo­tions of feel­ing over­whelmed and that the obsta­cles for car­ing for the unin­sured and under­in­sured seem insurmountable

2. Iden­ti­fy­ing the resources that are avail­able and stan­dard­iz­ing those resources across the board is crit­i­cal. Com­ing to terms with the con­cept that we can’t do every­thing for every­one can be soul soothing.

3. We need to begin to con­sider what our col­lec­tive respon­si­bil­ity is to the global pic­ture of health care deliv­ery to the most vul­ner­a­ble peo­ple in our soci­ety and to take steps toward that aim.

There is no ques­tion that the work is com­pli­cated and that no “facile solu­tions” exist. How­ever, more can be done to ensure that pro­fes­sion­als inter­ested in uni­ver­sal health­care access work together in col­lab­o­ra­tive and pro­duc­tive fash­ion rather than try­ing to cope with the real stresses of car­ing for a vul­ner­a­ble pop­u­la­tion, and attempt­ing to develop ad hoc solu­tions, on our own.

To quote the Ethics Man­ual of the ACP once again, “By his­tory, tra­di­tion, and pro­fes­sional oath, physi­cians have a moral oblig­a­tion to pro­vide care for ill per­sons. Although this oblig­a­tion is col­lec­tive, each indi­vid­ual physi­cian is obliged to do his or her fair share to ensure that all ill per­sons receive appro­pri­ate treat­ment.” The inter­sec­tion of med­ical edu­ca­tion and health­care access for undoc­u­mented immi­grants war­rants closer inspec­tion by those who frame health­care pol­icy – we owe it to the next gen­er­a­tion of physi­cians who must never lose the spe­cial moral imper­a­tive to care for all, and espe­cially for our most vul­ner­a­ble patients.