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.

[[1]]1. American College of Physicians. Ethics Manual, Sixth Edition.  Ann Intern Med 2012; 156: 73-104.[[1]]

[[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.)[[2]]