AMA Journal of Ethics^®

Abstract

Clinicians whose practice includes a significant immigrant population report a climate of fear adversely affecting their current patients. Increased immigration enforcement targeting undocumented immigrants increases these patients’ stress and negatively affects their willingness to seek medical care. To address these concerns, this article draws upon the literature and the authors’ experience to develop guidance on sanctuary doctoring. These materials provide opportunities for patients to open a dialogue about their immigration concerns and can assist clinicians in connecting patients to networks and resources that can address their needs. The materials are designed to be used in single, brief clinical encounters.

Health Challenges Facing Undocumented Immigrants

An estimated 11 million undocumented immigrants make the United States their home.¹ Approximately two-thirds of adults in this population have been in the US for more than 10 years, including many young adults who have spent most of their lives in this country.¹ While most undocumented immigrants are long-standing contributing members of our communities, they face barriers to good health. For instance, undocumented people are uninsured at high rates, as they often work in low-wage jobs that do not provide insurance and are ineligible to participate in the insurance exchanges of the Affordable Care Act.²

Of more immediate concern, in the United States, undocumented immigrants and immigrants in “mixed-status” families (ie, in which at least one member is undocumented) are now in increasingly vulnerable situations because the deportation efforts of the federal government have increased. It is relatively unpredictable whether a particular undocumented immigrant will be the target of Immigration and Customs Enforcement (ICE). The previous administration had deprioritized the apprehension and deportation of immigrants who have lived in the interior of the United States for an extended period and had no major criminal offense. Unfortunately, all undocumented immigrants now seem to be priorities for deportation.³

This situation has two consequences that health care professionals should consider addressing. First, immigration-related stress can impact health negatively much like any long-term uncertainty and uncontrollable stressor.⁴ Second, immigration-related fears can cause patients to avoid medical care because they might not be sure if a hospital or clinic cooperates with immigration authorities and might place them in jeopardy.^5,6

It is well established that there are general values and ethics that govern the health care environment. Whatever the prevailing ethos of society, we wish health care professionals and institutions to guard health. This requires that health care professionals and the organizations for which they work be seen as welcoming lest patients’ avoidance of them leads to the spread of contagion and illness. We expect health care institutions to accept and treat those in extremis, to place primacy on the health of the community, and to seek to do so in an efficient manner. Upon reflection, caring, public health, and efficiency are among the elements of the mission of nonprofit hospitals.^7,8

We developed the sanctuary doctoring approach to enable clinics and health care professionals to fulfill their mission by promoting these values so that patients will not hesitate to present for their medical needs. We created an online toolkit including a 10-minute lecture that provides an overview of key objectives to be accomplished in a short clinical encounter with a patient who is an undocumented immigrant.⁹ The toolkit also provides training materials such as a demonstration video that clinicians can use to prepare themselves for these interactions and templates of a brochure for patients and lapel buttons that clinicians can wear to prompt discussion of immigration-related concerns.

What Is Sanctuary Doctoring?

The sanctuary doctoring approach combines the emotional support of an empathetic physician-patient relationship with patient empowerment by supporting patient networking and identifying helpful actions the patient can take.⁹ Sanctuary doctoring works on the precept that health care should be a safe environment that provides support and resources to help patients deal with chronic stress and its sources. The materials in this toolkit—ie, a brief lecture outlining the objectives of the intervention, a demonstration video, and templates of a patient-centered resource brochure and clinician lapel buttons—were designed by drawing on suggestions for addressing needs of undocumented immigrant patients as articulated by experts in public health,¹⁰ law,¹¹ and advocacy¹² and modestly adapt the principles common to public health awareness campaigns.^13,14 The patient needs to feel safe enough to present for care and able to trust that what he or she says to a physician will not be used by the physician to harm him or her. As stress can take a significant toll on a patient’s health and well-being, physicians can and often do become skilled at addressing common sources of stress among their patients. However, creating such a dialogue can be difficult and facilitating its establishment is the first goal of a sanctuary doctoring approach.

Establish a dialogue. Some immigrant patients may have fairly limited experience with health care systems, with the result that their expectations are not well developed. They might not be sure whether they can trust a physician with information. This lack of a shared framework can make it somewhat perilous for the physician to be forthright in probing immigration-related concerns. In a worst-case scenario, the physician’s well-intentioned effort to open a dialogue could lead to patients avoiding the clinic because they fear being asked about their immigration status. As a result, we suggest creating an environment that enables patients to initiate a conversation about their concerns.

We suggest utilizing written materials, signage, and wearable buttons that transmit a clear message to patients that they are welcome to raise immigration-related concerns.⁹ We have focused on developing a brochure that can be left in clinic waiting areas and on buttons to be worn on the white coat. The brochure displays this statement on its cover: “If you would like to talk to your doctor about problems having to do with immigration, just take this sheet into the exam room and hand it to the doctor.” To hand a physician a brochure is a simple exercise and spares the patient the difficulty of trying to find the right words with which to open the dialogue. Similarly, we have utilized buttons that say, “Immigration worries? Talk to me.” This language is at once inviting and enables the patient to signal a desire for a dialogue with minimal verbal effort. Simply gesturing toward the button can invite a physician to open a discussion of the subject.

Provide reassurance. Once the patient signals interest in the topic, the physician has an opportunity to address the patient’s particular experience, which could include a sense of shame, isolation, and trepidation. We suggest that contextualizing the patient’s situation helps the patient to see his or her situation as commonplace. Physicians can simply address a sense of isolation by saying, for example, “Many people are going through similar struggles right now. You are not alone.” Explaining that there are medical reasons why physicians wish to discuss these matters can contextualize and normalize this conversation. Physicians should make clear to a patient that they are motivated by health concerns, by saying, for instance, “This kind of anxiety can influence your health.”

Of course, patients might be concerned that physicians, while well intentioned, could inadvertently place them in jeopardy by letting others know of their undocumented status. As a result, physicians should reassure a patient that they will not record the patient’s immigration status within the health record.^15,16 This assurance of confidentiality is important. The physician could say, for example, “I will not write your immigration status in the medical record. Only health-related issues will be recorded.”

Provide resources. While human connection and the supportive understanding of a physician is important to establishing dialogue, it is also important to refer the patient to appropriate resources. A physician cannot be expected to be an expert on matters such as immigration law but can provide leads as to how such resources might be accessed in the community. We designed the sanctuary doctor brochure template⁹ that contains 2 kinds of information: (a) networking resources for undocumented youth, including Deferred Action for Childhood Arrivals (DACA) recipients (sometimes called “Dreamers”) and (b) resources related to law.

Young people who have grown up in the United States as undocumented immigrants may benefit from being encouraged to network with advocacy and informational organizations relevant to their situation. As is true of adult patients, undocumented young people benefit from knowing that there are many others experiencing similar challenges and that their common experience represents an opportunity to gain information. As an example, undocumented youth can utilize networks to access information regarding scholarship opportunities and welcoming colleges and universities.^17-19 They can also utilize networks to monitor legal and political changes in the DACA program.^20-21 For instance, many DACA recipients are unaware of their current eligibility to renew their 2-year grant of deferred action that was created by district court decisions.²² Being in touch with advocacy organizations and Dreamer networks provides a flow of information as events take shape, which enables these young people to take advantage of developing opportunities.

The legal resources section of the brochure encourages patients to take advantage of what is called know-your-rights (KYR) training. Such training sessions typically empower immigrants by providing them with knowledge of important facts, including their right not to open the door to their home to federal agents unless presented with a valid judicial warrant. The brochure can be altered to add information regarding local organizations that may offer in-person training as well as local immigration attorney services. We suggest that physicians avoid endorsing specific private-practice attorneys. However, there might be reputable and established nonprofit organizations that serve as a clearinghouse for pro bono or sliding-scale legal services locally. By identifying these local resources and listing them in the brochure, clinicians would be offering a great service.

Develop an accepted emergency plan. People who fear sudden detention and deportation might live with a myriad of related fears concerning, for example, what will happen to their children in such an event. It would be beyond the scope of most physicians to help the patient develop a comprehensive emergency plan. However, via the brochure, the physician can provide contact information for local legal advocacy that may be very important in any emergency. The physician should also address updating emergency contacts at a patient’s children’s schools or day care centers in the event the patient is unexpectedly detained. Doing so could prevent such potential unfortunate occurrences as the children being taken into the custody of the local child welfare agency.²³

Information regarding how to develop a more complete emergency plan is often available as part of a KYR training session, and the physician might note this in closing as something the patient might wish to consider.

Beginning to Use the Sanctuary Doctoring Approach in Clinical Practice

The sanctuary doctoring approach provides some simple steps and resources to enable a physician to support his or her patients who have immigration-related concerns. The physician is addressing a true medical problem because anxiety, fear, and stress can have a significant effect on the health and well-being of a patient.⁴ As these particular stressors are socially determined, the primary means to address them is by encouraging patients to access networks and resources. This approach has 2 implications.

First, while willing clinicians can be helpful by using this approach and a brochure appropriately tailored to their locales, a physician is likely to be more comfortable and effective if he or she is reasonably networked and knowledgeable about current developments. Thus, physicians who begin using the brochure and wearing the button may wish to continue their own professional development by, for example, going through KYR trainings, developing a reading list, and becoming more engaged in advocacy.²⁴

Second, increased engagement with immigrant patients and supporting networks inspires new advocacy efforts outside of the exam room. For instance, physicians may wish to offer occasional KYR training sessions at the clinic. Using the clinic setting for dissemination of information may enable patients to keep their concerns private in a way that being seen entering the office of an advocacy organization might not. As a result, physicians might find that the clinic increasingly becomes a “sanctuary” for addressing immigration-related concerns.

In sum, at a time when many patients feel the stresses of their immigration status and fear sudden loss of control of their lives or removal from their community, physicians have an opportunity to play an important role by utilizing the simple techniques and materials of sanctuary doctoring to provide emotional support and resources to their immigrant patients.