AMA Journal of Ethics^®

Abstract

Undocumented immigrants are part of the health care workforce, whether they are eligible to work in the United States through the Deferred Action for Childhood Arrivals (DACA) program or other visa programs or permits. This case commentary considers whether—and if so, when—a clinician should reveal her immigration status to patients. After reviewing the literature on clinician self-disclosure, this commentary discusses how sharing immigration status could benefit the patient—particularly if the clinician has an immigration status that could interrupt care—but could also draw the focus away from the patient, possibly eroding trust between patient and physician. Finally, this commentary addresses mental health burdens experienced by undocumented and “DACA-mented” trainees and considers the roles that hospitals, residency programs, and health professions schools should play to support them.

Case

Dr T has a busy morning ahead of her in the cardiology clinic. Her first patient is Mr B, a 67-year-old man, for whom she has been caring since he suffered a heart attack 3 years ago. Dr T always enjoys seeing Mr B, and they have developed a good relationship over the years. Dr T walks into the exam room, greets Mr B, and notices that he isn’t his usual jovial self. “What’s wrong, John?”

Mr B responds, “I saw you in the newspaper the other day, Doc. The article mentioned that you were an illegal immigrant and were one of those ‘Dreamers.’ I’ve told you some pretty personal things about my life, and I feel like that was something you should have told me.” Dr T has recently become active in advocating for immigrants’ rights and, as a Deferred Action for Childhood Arrivals (DACA) recipient herself, she has been vocal about her own status as undocumented. Until now, she had not considered how her immigration status might affect her relationships with her patients. She wonders if she should have disclosed her immigration status to Mr B earlier and how to address his concerns now.

Commentary

This interaction between a patient and his physician raises important questions that this paper seeks to answer. What information can physicians disclose about themselves to their patients within the clinical encounter? What are the advantages and disadvantages of self-disclosure? Is immigration status a part of Dr T’s identity that she should disclose to her patients? This last question leads to a broader question regarding the extent to which a physician can or should disclose her own political views within the patient encounter. Finally, we discuss the challenges of a career in medicine for undocumented and “DACA-mented” trainees and physicians and suggest how programs can support trainees.

Physician Self-Disclosure of Personal Information in a Clinical Context

Physicians have grappled with the question of how to approach types of self-disclosure and whether there is an optimal amount of self-disclosure that is appropriate within the patient encounter, partly because many physicians initially entered the medical profession motivated by their own personal experiences with illness and their desire to be advocates. Disclosing details about one’s own life, family, relationships, and interests is a natural part of human relationships and can be a healthy part of relationships with patients as well. Self-disclosure can contribute to a greater sense of closeness with patients and can create a therapeutic relationship built upon mutual respect and trust. Some types of self-disclosure can have clear benefits in the clinical encounter. For example, one study showed that physicians’ disclosure of healthy personal behaviors can improve their credibility and their ability to motivate patients.¹ Physicians can also use personal disclosures to reveal how they handled an event in their family life or to lend authority to their clinical recommendations.²

Although self-disclosure is beneficial in some contexts and can be used as an effective tool to improve quality of care, it should be exercised with caution. One study of 113 patient visits to primary care physicians showed that physicians shared personal information in 34% of visits and that patients described 85% of those disclosures as not useful and 11% as actually disruptive of the visit.³ Another study found that patients were less satisfied with primary care appointments in which self-disclosure occurred and reported feeling less warmth, comfort, and reassurance during those visits.⁴ It is unknown why physician self-disclosure led to less positive feelings for patients in these studies, but one could postulate that the physician’s shifting the focus of the visit to her own experiences could make the patient feel less heard. Additionally, if the disclosures are too personal, patients could feel a break in their therapeutic relationship with their physician. In fact, Kelly Curran suggests in “Too Much information—The Ethics of Self-Disclosure” that self-disclosure be used as a tool to enhance the patient encounter only after the physician has carefully considered her rationale for and potential risks of disclosure and weighed self-disclosure against other ways of addressing patient’s needs.⁵ In addition, the physician should consider whether disclosing this information truly serves the patient instead of serving her own therapeutic purpose.⁵

Weighing Whether to Reveal Immigration Status to Patients

The notion of self-disclosure of a physician’s immigration status presents additional potential advantages and disadvantages. One potential advantage of Dr T sharing her immigration status with Mr B would have been transparency in the amount of continuity of care that she could provide for her patient. The DACA program, which was initiated by President Obama in 2012,⁶ has been in a state of flux, with President Trump ending the program in September of 2017 only for it to be upheld the following year by federal courts.^7,8 Dr T knows that, depending on politics at the state and federal levels, she might or might not have work authorization renewal options available to her, and Mr B’s care could be interrupted. In this context, disclosure of her status is beneficial for her patient. There are potential disadvantages related to this disclosure as well. Because being undocumented carries a negative stigma, it would not be unreasonable to assume that this disclosure could negatively impact the patient-physician relationship.⁹

Dr T made the reasonable choice not to disclose her immigration status, perhaps because she chose to keep the focus on the patient within the clinical encounter. Even if the patient had been accepting of Dr T’s immigration status, revealing this information in any context could trigger further lines of questioning that could have derailed the patient encounter and shifted focus away from the patient and his medical issues. Now that Mr B is aware of her status, it would not be unreasonable for Dr T to address his concerns and discuss how her immigration status may or may not affect Mr. B’s continued care, all the while paying attention to how this information could change the nature of the patient-physician relationship.

Weighing Whether to Reveal Political Views to Patients and to Advocate for Patients

In entering into a conversation about her own immigration status with her patient, should Dr T address her own political beliefs? This question stems naturally from considerations about self-disclosure—how much should a patient know about his physician and what is at stake, especially given the possibility of discordance in political views between patient and physician? The root of the ethical arguments for and against physicians openly expressing their political views are, on the one hand, freedom of speech and, on the other hand, physicians’ position of power and the negative effect on the physician-patient relationship of expressing discordant political views. The AMA (American Medical Association) Code of Medical Ethics suggests that physicians consider context, including patients’ preferences and emotional pressures due to “significant medical circumstances,” as cues to determine whether to engage in political discussion.¹⁰ The context depends in part on the particular relationship that the physician has with the patient, the stakes of the political issue being discussed, and the severity of the clinical context. Because physicians can direct the script of the clinical encounter, they should exercise judgment about whether to discuss their political views with their patients. In an increasingly connected world, it will become easier for patients to find out the political leanings of their physicians, even though the physicians’ political activities transpire outside the exam room.

Whether physicians have an obligation to be politically engaged is another question. For example, it has been suggested that physicians have an obligation to advocate for increased access to care and improvement in socioeconomic conditions that affect their patients’ health.¹¹ The toll that fragile documentation plays in the mental health of immigrants has been widely documented.¹² Dr T is thus within her right as a citizen to advocate for the rights of undocumented immigrants. She has appropriately not raised the issue or advocated for her political views in the context of the clinical encounter, but she should be aware that Mr B and her other patients have access to information about her political advocacy. She should therefore be prepared to address questions or concerns that patients might have about her views, provided that these questions continue to allow her to maintain a therapeutic relationship with her patients. Should Mr B decide subsequently to transfer his care to another physician or not to return to care, it would be difficult, given the information presented in the case, to discern whether his choice had to do with a perceived breach of trust, a discordance in political opinion or, worst of all, his beliefs about Dr T’s right to be a physician given her immigrations status and nation of origin.

In summary, physicians should not feel obligated to disclose their immigration status to their patients and, in fact, physician self-disclosure has been linked in some studies to decreased patient satisfaction. If Dr T felt that sharing this information would have been of benefit to her patient or would have spared him harm or inconvenience, she could have considered revealing this information, weighing how it could affect her own comfort and safety as well as the dynamic of the patient-physician relationship. Dr T is within her right as a citizen to advocate publicly for the rights of undocumented immigrants. She has, until now, kept her political views from her patients, thus avoiding potential patient alienation and discomfort, but she should feel empowered to share these views if she deems unprompted disclosure is appropriate or if she is asked by her patient to explain her views.

Changing the System

Dr T should not be alone in handling situations like the one above, and she should count on the support of her peers and mentors when confronting difficult patient encounters, when facing discrimination or hate speech because of her immigration status, and when advocating for herself, her patients, or other vulnerable populations. As the number of undocumented or “DACA-mented” immigrants in residency programs increases beyond the more than 50 medical schools accepting applications from DACA recipients,¹³ academic institutions and hospitals should become equipped to address legal, logistical, and mental health issues that can be associated with the stressors of being a practicing physician with fragile documentation.¹⁴