Guest Editorial

Family Physicians Have Role in Care of Undocumented Patients

December 09, 2019 01:28 pm Allison Estrada, M.D., M.A.; Lilian Milanes, Ph.D.; Roshni Kakaiya, D.O.; Aisha Van Pratt Levin, M.D.; Ana Ortiz, M.D., M.P.H.; Cecilia Vazquez; and Shaila Serpas, M.D.

Immigration is a social determinant of health that dramatically shapes immigrant communities' experiences when accessing health care. Recently, the landscape of immigration policy in the United States has been shifting rapidly; with the mass incarceration of undocumented immigrants in detention centers and recent alterations to the asylum-seeking process,(www.nytimes.com) it can feel overwhelming and emotionally draining for physicians to know how to care for their undocumented immigrant patients. However, family physicians have a unique and timely opportunity to think critically about the implications these policies have on patient care and to take steps to ensure patient safety.

[young woman discussing checkup with physician]

We -- a group of family medicine residents who serve predominantly immigrant communities -- partnered with two specialists in anthropology and immigration to answer questions that may arise when caring for undocumented immigrants and their families. We hope this can help you start important conversations in your workplace to create a safer environment for undocumented patients.

Q: What's the appropriate way to refer to a patient without legal status?

A: Among immigration activists, the accepted term used for immigrants who are not citizens, permanent residents or visa holders is "undocumented." You might hear patients refer to their legal status more informally as "not having papers." Other terms include "illegal" and "alien," however, these labels dehumanize undocumented patients and should be avoided in clinical settings.

Respectful terminology is crucial because it sets the tone for how we speak with and care for patients. If you hear colleagues use charged terminology in reference to undocumented patients, we advise you to address it promptly and directly to establish a respectful climate for all patients and clinical staff. Also note that only a subset of immigrants are undocumented, so do not assume a patient's legal status. Always approach all patients with compassion and humanism.

Q: Should I ask my patients about their documentation status? What if patients self-disclose their immigration status?

A: Given the delicate nature of the current political climate, we do not recommend asking your patients if they are undocumented. Asking about documentation status may instill fear in your patients, thereby disrupting your doctor-patient relationships. It can also expose your patients to increased risk of detention and deportation, especially if this information travels outside the exam room via word of mouth or charting. If a patient self-discloses his or her immigration status to you, take the opportunity to connect the patient with resources in your area but do not share this information with anyone outside the exam room.

Q: Should I be documenting patients' immigration status in my charting?

A: Although patients' privacy is protected under HIPAA, it is essential to be cautious when discussing and documenting a patient's immigration status. If an immigration official were to enter your workplace, any information in plain sight -- including paper charts left open on a desk or medical records open on a computer -- can be grounds for detention and deportation. Charting patients' status may prove harmful for them or their families, especially if inappropriately disclosed to immigration officials. Ask yourself what the purpose of documenting immigration status on charts would be.

Q: What if I am approached by immigration officials in my clinical setting?

A: First, remain calm. Document the name of officers with whom you interact, as well as their contact information, badge number and supervisor's name. Immediately contact a clinic supervisor, manager or designated point person for assistance. (If you don't have a point person assigned, it may be a good idea to do so.)

Next, request and review any warrants an officer may carry. Immigration officers are allowed to enter public spaces without a warrant, however, they may not enter or search private spaces without a valid warrant signed by a judge. It is important that clinical spaces -- whether exam rooms, hallways or waiting rooms -- be classified as "private" in a clinic's written policies.

Lastly, keep in mind that HIPAA requires physicians to respect and protect patient privacy; avoid disclosing medical information to officers unless such information is explicitly listed in a warrant.

The American Civil Liberties Union created a pamphlet(www.aclunc.org) with information about protecting patients and employees should immigration officials enter your clinical facility.

Q: What can I do as a family physician to best protect undocumented patients?

A: By providing patients with high-quality clinical care and connecting them with social services, you help affirm the dignity and humanity of all patients. Providing educational materials or know-your-rights cards helps create a supportive environment for all patients, regardless of immigration status. If your medical facility does not have policies to facilitate safe and appropriate interaction with immigration officials, we encourage you to develop a protocol with your clinical team.

Outside the clinic, family physicians are uniquely positioned to lobby for undocumented patients because we are often intimately aware of the unique health and social challenges that immigrant communities face. We encourage you to learn about community organizations that serve immigrants in your area and to get involved in patient advocacy at the local or state level. Above all, staying informed and implementing safety policies are among the best ways you can advocate for undocumented patients.

We hope we have encouraged you to think critically about your role in caring for undocumented patients and have empowered you to take meaningful steps in your organization to create a safe and welcoming environment for immigrant patients and their families.

Allison Estrada, M.D., M.A.; Roshni Kakaiya, D.O.; Aisha Van Pratt Levin, M.D.; and Ana Ortiz, M.D., M.P.H., are family medicine residents at Scripps Mercy Hospital in Chula Vista, Calif., where Shaila Serpas, M.D., is an attending family physician. Lilian Milanes, Ph.D., is a medical anthropologist and assistant professor at William Paterson University in Wayne, New Jersey and has worked with immigrant communities in Chicago. Cecilia Vasquez is a cultural anthropologist and Ph.D. candidate at the University of Massachusetts Amherst.

The authors hope to develop hospital-wide policies for interacting with immigration officials and a toolkit for other hospitals to implement similar policies. Feel free to contact them at ProyectoPr2mesa@gmail.com for further resources or to share policies on caring for immigrant patients and their families.

Related AAFP News Coverage
Caring for Immigrants at the Border and on Capitol Hill
(10/7/2019)

Leader Voices Blog: Our Treatment of Immigrants Should Reflect Our Values
(9/6/2019)

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