For immigrants, a medical appointment is never just another routine errand. Instead, it is a challenge, a test of strength, one that provokes anxiety at every step. Will the receptionist understand my accent, or flash a toothy, disingenuous smile while asking me to repeat myself for the third time? Will the doctor ask my own child to translate my diagnosis for me, or attempt to explain using broken phrases learned from a college language class? Should I mention my traditional herbs, or will I be chastised for using “fake medicine”?
Immigrant patients face countless barriers constructed by the medical system, encompassing issues related to limited English proficiency (LEP), health literacy and cultural differences. Nearly 14 percent of the U.S. population are immigrants, and over 25 million individuals have LEP. Unfortunately, the medical system at-large provides subpar accommodations to these patients. Based on the Civil Rights Act of 1964 and U.S. Department of Health and Human Services standards, all hospitals are required to provide language services to LEP patients. Yet, in practice, there is inconsistent compliance to these requirements, and these protections have come under attack. Appallingly, over 30 percent of hospitals provide no language services at all.
However, it’s not merely language differences at fault. Instead, the underlying structure of medicine fails to account for the diverse backgrounds of the patients we treat on an everyday basis.
The issue originates in how we collect and represent information about our patients. Medicine largely relies on race-based markers to determine disease prevalence and to categorize our patients. Often a patient’s country of origin and migration history is nowhere to be found in the medical records. While nearly all hospitals collect data about race and ethnicity, more than half do not even collect rudimentary information about birthplace.
As I scroll through patients’ electronic medical records, I am presented with demographic variables at the top of each file, including ethnicity, race and religion. Yet based on these characteristics, I, an American-born individual, appear to have the same needs as my mother, who grew up amongst the turmoil of China’s Cultural Revolution and who relies on my assistance to understand her diagnoses.
We must also continuously question why we distill the complex heterogeneity and diversity of our backgrounds into inflexible racial categories. As medicine grapples with using race in clinical algorithms, we should evaluate how this impacts our immigrant patients.
During my clinical skills training in medical school, I received extensive guidance on how to gather a patient's social history, detailing everything from their relationships to their occupation. But what about migration experiences? These migration histories are often complicated and a source of trauma. Yet medical students barely receive any education on the best practices to collect this sensitive, yet crucial, information. As clinicians, we may also encounter situations when it is in the patient’s best interests to minimize explicit documentation of immigration status. However, all physicians should be equipped with an understanding on how to discuss migration history, archive this information if safe to do so, and recognize how this information impacts patients’ medical care.
Unfortunately, throughout my formal preclinical education, I have not once heard how patients’ countries of origin affect their health risks—even though several diseases primarily afflict immigrants.
Hepatitis B is one. While the estimated U.S. prevalence of chronic hepatitis B virus (HBV) infection is only 0.3 percent, in Asian Americans and Pacific Islanders (AAPIs) it is 8.3 percent. AAPIs make up 5 percent of the U.S. population, but account for more than 50 percent of Americans with chronic HBV. The CDC officially recommends that anyone born in high-prevalence regions, including many countries in Africa and Asia, should be actively tested for HBV. However, this recommendation depends on physician awareness to be implemented, which can be difficult to achieve. As my parents’ medical advocate, I was shocked to discover that my mother was never immunized nor screened for HBV, even though my father was infected with it, it has a high prevalence in China, and it can be transmitted through families. This oversight heightened her risk of severe complications, including cirrhosis and liver cancer.
Another example is Chagas disease, one of the most common causes of cardiomyopathy in Latin America. The medical literature advises physicians to suspect Chagas in every patient coming from Latin America with chronic heart failure, and screening data suggest that 1.24 percent of Latin American immigrants are infected. However, many physicians never consider the risk of Chagas disease, lack knowledge about it and often fail to treat it before debilitating complications appear.
The fact that these insidious diseases and their impact are rarely discussed in preclinical medical education demonstrates how immigrant health issues are devalued and underemphasized. Clinical algorithms with guidelines for screening and care for immigrants, including the CDC Refugee Health Guidelines and CareRef tool, are available in some clinics, but should be more routinely incorporated into medical education and practice.
Just like countless first- and second-generation immigrant health care providers, I was motivated to pursue medicine because of my family’s dismal experiences in the medical system. I wanted to be part of the change, someone who delivers the compassionate and comprehensive care that I wish my parents had received. However, now that I’m in medical school, I feel inadequately prepared to take on this enormous task.
So, medicine, please teach me how to care for immigrant patients. Don’t just teach me about cultural competency. Instead, empower me with the tools to provide nuanced care for each individual and their distinctive stories. Educate us on how to use medical interpreters in a manner that centers the patient. Standardize the collection of migration history into a patient's social history and medical records. Train medical providers and students how to conduct targeted screenings based on their patients’ immigration background.
If we pride our nation as a land of diversity, let’s ensure that the medicine we practice reflects these values.