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everal weeks ago, I treated a patient from Medellín, Colombia, who had escaped narco-terrorism and political violence to find a home in the US. But he was living here undocumented — and caring for him taught me what it means to do no harm.

In my first year as a resident at Cambridge Health Alliance, I often treat people new to the US who come here without documents. I’m thankful that I can provide health care to my patients in what I believe is a safe setting. But these patients change the way I practice medicine, because they change the way I document medicine. This is something I never learned about in medical school.

Normally, hospitals are safe zones, free from immigration enforcement efforts. But this is a tenuous agreement — if the government wants to, a place of healing can become a place to detain.

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To protect those living without documents, I’ve had to learn to exercise caution about how I record a patient’s social history in our files. “If you don’t document it, it’s not discoverable,” said Dr. Robert P. Marlin, the director of the Coordinated Care Program for Political Violence Survivors and the Refugee Health Assessment Program at CHA.

Looking back, I realized I’d never seen this aspect of my Colombian patient’s history documented in his charts. While knowledge of legal status often helps medical providers connect our patients with valuable resources and care, that information has often been missing. Now I know why. While HIPAA typically protects patient health information, it’s not an unconditional legal shield. For these patients, given the current immigration climate, it’s better to be safe than sorry.

Earlier this year, President Trump signed an executive order effectively empowering immigration and customs officials to detain and start deportation proceedings on undocumented people in the US who have been charged with a crime, who have been convicted of a crime, who have received public benefits, or who have misrepresented themselves. For physicians who practice social justice, this order is at odds with our vows to “protect our undocumented patients, advocate for their rights, and continue to serve them as healers.”

At a recent seminar on immigration and asylum at the hospital, Dr. Marlin and others taught attendees how much of a lifeline the cellphone can be to an undocumented patient. I now know to counsel patients to memorize important phone numbers — family, friends, and a trusted immigration lawyer, as one of the asylum speakers suggested. The sad reality is that this advice can be particularly important for children, making sure they know how to get help if their parents don’t come home.

And for all the documentation that doesn’t happen, there is one piece of paper that needs to be really accurate — emergency contacts. For example, if something were to happen, children may get stranded at day care, said Marlin. He even suggested setting up a lifeline, a system of friends and family that keep tabs on each other every day, with the idea that “if you don’t hear from me in 24 hours, I might not be safe.”

Another thing I’m learning — if a patient doesn’t show up for important medical care, I might need to reach out to them. With the threat of heightened surveillance some patients may be afraid to seek any services, even in a sanctuary city like Cambridge. Even if these patients have support from grassroots medicine all the way to Boston’s hospital leadership.

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“Leave them a message, asking if everything is OK,” Marlin said.

What I’m realizing is that maybe this is what preventive medicine looks like in 2017. Not only does my work mean I’m preventing disease, but I’m also preserving families. I’m also protecting health care as a human right. I’m trying to live the idea that America’s doctors do not equate “not American” with “not human.”

My patient from Medellín experienced unrelenting violence that I cannot begin to fathom, and he needed my help for a serious injury. My oath and my conscience dictate I care for him as a human being, and because of the risks he faces in having his undocumented status documented, I did this by sharing his relevant personal history orally. I am moved by his suffering and motivated to ensure that his health care, this one aspect of his experience, will be free of trauma and terror.

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  • Pharmvet1 your rebuttal is objectively false. Documentation is required for medically relevant facts. Immigration status is not required. Even not stating the patients race is not legally required. Patient’s race is regularly nondocumented or is accidentally MISdocumented in most hospital notes: e.g. white non latino vs latino, biracial, south asian vs middle eastern vs non white latino. It’s something that cannot be regulated because it is subjective and actually irrelevant to day to day care.

    Documentation is meant to prove due diligence and note care given. If a patient has sickle cell or may have the disease noting their race cannot be equated to treating them properly. If a patient is racially “white” do you think that is a legal excuse for not recognizing they may have Sickle cell disease or developed potentially fatal sequelae? I have an MD and am intimately aware of the process. Are you?

    • I am a PhD pharmacologist who has served as expert witness in many cases. Sticking with the hematological analogy, let’s say you have a patient with suspected Beta Thalassemia who is an undocumented alien from the Middle East. The patient begs you not to put on the chart that he is from a middle east country that is on a government watch list because he doesn’t have proper papers. Your job is to make the diagnosis, and if that diagnosis hapens to be suspect Thalassemia then noting that the patient is from Iran (eg), where the disease is endemic will actually expedite the diagnosis You may feel altruistic about the omission from the chart, but you can’t compel the compulsive med student or resident doing the workup to feel the same way, and so the country of origin will find it’s way into the chart eventually, and your altruism will have succeeded only in delaying the diagnosis.

      You will not be off the hot seat either. When the case comes up for utilization review and it is noted that the patient spent three extra days in the house because you chose to omit key information from the diagnostic workup you will get some questions. You will REALLY get ripped on grand rounds if you present the case with missing key information, but your conscience will be clear.

  • Obgyn attorney is wrong. If a black patient had potential sickle cell crisis and the doctor chose to omit the patient’s race for altruistic reasons, and that omission led to the patient’s death then that is called a crime of omission. Likewise are numerous other diseases in which blacks respond differently to certain drugs than whites. Guess they didn’t teach pharmacogenetics in law school, counselor.

  • It is beyond my understanding that people can live in the society experiencing this and not understand they are standing in a grotesque mimicry of what lead to the publication of such things as Anne Franks Diary….. strangely enough many perfectly normal people felt, just as many commentators on this thread do, that the people trying to something to support the persecuted were in someway at fault. A small number chose to do what they felt was right regardless, Their names echo in history as heroes. I can only hope that the small number will be enough this time and there will be something left to save when enough people take action from the outside. God-bless the people acting to protect the innocent, including those, like this doctor, following the spirit of the law above the letter.

  • Why people throw away their livelihoods for what they think is “I’m so awesome/caring/charitable/secret” is beyond me. Medical records can be subpoenaed. If you’re intentionally omitting data, that is falsifying a medical record. I doubt you are the only med school student that has treated this guy. It will likely be cross-referenced should all those records get pulled by an attorney and you could lose your license because of intentional deception. You flat out admitted to trying to deceive others in his article.

    Do yourself and all of us a favor and get out of the medical field. No one wants a doctor that is unduly influenced by politics. Bet that “refugee” never offered you any type of payment for your services? You would have made it your main point had that happened, right?

    • “No one wants a doctor that is unduly influenced by politics.”

      What would you think of a doctor in Nazi Germany who left the fact of someone being a Jew off their medical record? This is an extreme analogy, but sadly in this country, people are forced to deal with government overreach. If you don’t believe it, look at how badly the US is slipping in world rankings of personal freedom. Once near the top, it is in danger of falling out of the top 20, if it hasn’t already.

    • This is why we have a flood of illegal aliens seeking medical care in US. But under Trump this will hopefully all change. Does anyone know where the money comes from to treat illegal aliens? The answer is something called the Emergency Medicaid Fund, which gives money to hospitals for this purpose. This money is pretty high on the hit list once Obamacare is replaced. Even if Obamacare stays, congress will defund the program and doctors won’t have to worry about taking their social history cause these patients ain’t gonna get past the admissions desk.

      http://www.pbs.org/newshour/rundown/how-undocumented-immigrants-sometimes-receive-medicaid-treatment/

    • have you ever tried like you know feeling empathy towards other human beings

      you should try it sometime, it’s nice

    • These comments show you are neither a doctor nor a lawyer. “Falsifying records” requires just that–inputting intentional false information or altering information after the fact to be intentionally misleading. Not documenting information is not a crime. By definition doctor notes are meant to be judicious and brief which requires the omission of details at your discretion. You cannot be prosecuted for not reporting information you are not mandated to report.

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