Published on: October 15, 2012

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.

Ref­er­ences    (↵ returns to text)
  1. 1. Amer­i­can Col­lege of Physi­cians. Ethics Man­u­al, Sixth Edi­tion.  Ann Intern Med 2012; 156: 73–104.
  2. 2. Amer­i­can Col­lege of Physi­cians. Nation­al Immi­gra­tion Pol­i­cy and Access to Health Care. Philadel­phia: Amer­i­can Col­lege of Physi­cians; 2011: Pol­i­cy Paper. (Avail­able from Amer­i­can Col­lege of Physi­cians, 190 N. Inde­pen­dence Mall West,Philadelphia,PA19106.)

Suggested citation

Maria Maldonado, M.D., F.A.C.P., "The Intersection of Medical Education and Healthcare Access for Undocumented Immigrants," Undocumented Patients web site (Garrison, NY: The Hastings Center), originally published on: October 15, 2012. Available at http://undocumentedpatients.org/commentary/the-intersection-of-medical-education-and-healthcare-access-for-undocumented-immigrants/