There are certainly checklist-worthy aspects in the clinical care of immigrant patients. The Communicable Disease Control & Prevention (CDC) publishes recommended screening and testing for recently arrived immigrants and refugees. The American Academic of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP) publish similar peer-reviewed guidelines. Making sure individuals and families are well-protected with vaccinations and screened for treatable illnesses are vital first steps in early primary care, as well as school- and employment-entry. However, the utility of checklists often ends here, beyond which there is exceptionally little guidance for care of immigrant patients. Pivotal to the care of immigrant communities is an understanding of the relational aspect of medicine. This is not to detract from how important the humanistic and relationship aspect is for all patients, but I would argue it is especially important for immigrant communities.
Immigrant individuals are an exceptionally heterogenous population. I am interested in exploring how to provide high quality primary care to immigrants in low-wage employment, those with low literacy and those who have precarious immigration status. It is this group which may have significantly more challenges to accessing care, particularly high-quality care. Barriers to access have been well-studied and include the challenges related with low-wage employment and low literacy; namely, lack of control/flexibility over one’s time (i.e. paid time off from work), competing demands for high-priority needs (i.e. maintaining housing), worries about incurring additional bills, difficulty obtaining reliable information, and fear (i.e. of detection, deportation or family separation). In addition, immigrants may have histories of trauma and prior experiences of discrimination which make it even more difficult to advocate for healthcare on one’s own behalf.
Given the number and degree of challenges facing immigrant patients, I would argue that it is not only necessary for primary care providers to improve upon our own individual practices, but community health centers, as an organizational system, must make changes. What I can do by myself to help an individual is miniscule in comparison to what I’m able to do within a prepared and supportive system. The ability to link patients to colleagues in social work, case management, patient navigation, psychiatry, and dental, as well as legal and social services is paramount. If I have a patient who needs urgent dental work, my efforts to manage chronic diseases and complete routine screenings will fall short. If I have a patient on the verge of eviction, or struggling with child custody, addiction, a psychiatric illness, or worried about immigration authorities, our time spent on their uncontrolled diabetes likely won’t matter. Checklists are a helpful beginning, but organizational systems are an important framework within which high quality care can be provided.
Primary care is distinctly unique among many other clinical specialties. It is based upon establishing, developing and maintaining relationships with patients whom you may see for years to decades. Primary care is not “done” in a single visit, but often relies on repeated follow-up visits. Beyond “showing up,” patients also need to feel comfortable and safe sharing sensitive information. This can be an extraordinarily high bar for any individual, especially if language, literacy, history of trauma, and fear are additional barriers. Qualities of trust and sensing that you matter to your healthcare provider are necessary to overcome these barriers.
Unfortunately, much of the burden of the relational aspect of care is placed on the shoulders of individual staff and healthcare providers. This includes the responsibility of providing “culturally competent” care. The aim of many health centers is to ensure providers/staff attend a training in cultural competence. Yet, few health centers take a systems level approach.
I’ve often said that were it not for the structure and capacity of the community health center where I work, I wouldn’t be able to do what I do. The energy and effort required to meet the needs of individuals who are impoverished, or homelessness are high. Burnout, frustration and exhaustion would quickly ensue. However, if my relational work is “buffered” by a prepared and supportive organizational structure, my skills are leveraged over time. This is similarly true when working with immigrant patients. If my health center is prepared to help me address the legal, linguistic, economic and social needs of my immigrant patients, my work can be exponentiated and patients’ primary care outcomes have a better chance of improving. This is not to say that burnout, frustration and exhaustion don’t occur when systems are prepared and supportive, but their effects can be significantly attenuated. The benefit of individuals and organizational systems working in concert with one another is that it is advantageous for everyone, not only our immigrant patients.
Author bio: Margaret (Maggie) Sullivan, MS, RN, FNP-BC is a third-year doctoral candidate in public health at Harvard T.H. Chan School of Public Health. She is a family nurse practitioner with an interest in serving immigrant patients and their families. She received her B.A. from Barnard College in comparative religion and art history. She later completed her master’s in nursing science at the University of California – San Francisco (UCSF) with a sub-specialty in women’s health. In 2005, Ms. Sullivan completed a fellowship in farmworker health in the Salinas Valley of California. Ms. Sullivan served as a clinical adviser for Partners In Health in Chiapas, Mexico and Guatemala. She continues to practice at Boston Health Care for the Homeless, providing primary care to patients in shelter-based clinics. Ms. Sullivan’s research interests include the health of undocumented immigrants, day laborers and their sending communities. Publications include:
