Medicine is the science of uncertainty and an art of probability.
Today, this quote applies beyond the practice of medicine to how we view access to medical education. One would argue that the academic medicine community is more tolerant of uncertainty. Does this tolerance extend beyond the clinic and laboratory to the classroom? In their article in this issue, Nakae and colleagues1 respond to the uncertainty often encountered by medical students with Deferred Action for Childhood Arrivals (DACA) as they prepare for residency and by the program directors who receive their applications. The authors aim to fill the void of information about DACA and the graduate medical education process. Their recommendations focus on developing organizational capacity to reduce the barriers for applicants with DACA.
With a new administration at the helm of our federal government, there is greater uncertainty about the future of the DACA policy. Opponents of DACA frequently question the constitutionality of the mechanism used to create this program—an executive action issued by former President Obama—rather than the merits of helping undocumented youth work, attend school, and serve in the military. In light of this uncertainty, medical schools have tried to better understand how they can support trainees with DACA.
In 2014, the Association of American Medical Colleges (AAMC) fielded a survey amongst admissions professionals to better understand how medical schools were working with applicants and medical students with DACA. The unpublished data from this survey showed that an overwhelming majority of institutions lacked knowledge about DACA and that this influenced their admissions process and the route to residency. These data helped to inform a variety of AAMC efforts to support students with DACA, which Nakae and colleagues describe in their article. Discussions with key partners have also contributed to increased access to existing programs. Specifically, the Robert Wood Johnson Foundation Summer Health Professions Education Program (http://www.shpep.org), a national academic enrichment program for college students interested in medicine, and the National Medical Fellowships (https://www.nmfonline.org) have expanded eligibility to include students with DACA.
Nakae and colleagues also offer recommendations for best practices to support trainees with DACA. We want to expand on these important considerations, based on our experiences at a national level. We argue that core values in academic medicine, the student voice, teamwork, and wellness are also relevant to building and sustaining institutional capacity to support DACA recipients during these uncertain times.
Values Drive Decision Making
Support for trainees with DACA is strongly rooted in academic medicine’s commitment to “advancing a well-trained, culturally competent, and diverse health and biomedical workforce that leads to improved health for all” as articulated in the AAMC’s guiding principles.2 Predicted physician workforce shortages and health disparities require that we cultivate talent from diverse communities. In less than 10 years, the need for physicians will exceed supply by up to 94,700 doctors.3 Although data show some improvements, disparities in health quality and access to care continue, particularly among Latinos, African Americans, and individuals living in poverty.4
Nakae and colleagues note the value that students with DACA bring to academic medicine. Data show that individuals from Mexico, El Salvador, Guatemala, Honduras, and Peru constitute about 90.5% of approved DACA applications to date.5 Students with DACA are talented individuals who may contribute a unique perspective on the issues of acculturation, trauma, and resilience, and may offer increased access to health care to the underserved. Providing access to medical education to trainees with DACA aligns with the values of the academic medicine community.
The Student Voice Is Critical
Pre-Health Dreamers represents a network of “over 800 health career bound undocumented students across 42 different states.”6 They identified gaps and opportunities in the medical education continuum, based on their collective experiences, and reached out to the AAMC for support. This relationship helped the AAMC examine its own policies and explore how to leverage, expand, and enhance existing services for students and medical schools. The courageousness of Pre-Health Dreamers has brought to light the challenges students face in finding medical school and residency program policies to guide their decision making, securing financial support, and the lack of knowledge that persists about their lawful presence and future employability.
Student activism historically has spurred changes within higher education. Students with DACA are no different. DACA has stimulated movements across the United States that have centered on supporting young people’s right to achieve their career aspirations. Engaging the student voice is critical to understanding the DACA experience along the medical education continuum and to identifying opportunities to inform administrators and educators. This will help facilitate a welcoming climate and culture that is responsive to the students’ needs. Providing trainees with DACA a seat at the table is critical to facilitating a relevant and culturally responsive solution to help them achieve their goals of becoming physicians and to help us achieve our goals as educators.
Teamwork Is Essential
Nakae and colleagues argue that continuing education is critical for decision makers and program directors. We expand this point by noting how essential it is to engage a diverse team across academic medicine with varied expertise. Along with the student voice, addressing and tracking the complexity of such policy issues requires knowledge and representation from leadership within admissions, diversity, legal, financial aid, student affairs, faculty, and residency programs.
Leveraging our varied expertise, we have both learned about the nuances in policy, process, and structures that present barriers and uncovered opportunities to support trainees with DACA. Taking a team-based approach also expands the locus of responsibility and allows for a broader consideration of how the DACA impacts the institution and health care system. Working on issues like DACA has required teams to demonstrate flexibility and tolerance for leading in uncertain times. Within a rapidly changing political landscape, teams that maintain constant communication will be the best prepared to address the needs of trainees with DACA.
Wellness Deserves Attention
Nakae and colleagues highlight the “vulnerable status” of trainees with DACA, and the significance of respecting their autonomy and privacy. We propose that this vulnerability also calls for attention to the trainee wellness. Medical students’ transition to the clinical years is time-intensive and requires them to adapt to the culture of the wards. Coping skills for medical students can be diminished by physical and mental fatigue as well as sleep deprivation.7 Therefore, it is no surprise that medical students have a higher prevalence of psychological distress compared with the general population and age-matched peers.8 Approximately 50% of medical students experience burnout,9 25% to 60% report mild depressive symptoms, approximately 13% to 14% report moderate to severe depression,10 and 9% report suicidal ideation.9 Data for residents are similar. Factors that affect learner wellness include but are not limited to demanding workload, bullying in the medical school environment, limited control, and low pay.11,12
In addition to the potential exposure to these stressors, trainees with DACA are likely to experience a unique set of pressures, including the lack of stable and reliable funding mechanisms (e.g., federal financial aid) and the threat of the DACA policy being rescinded. The uncertainty and lack of control over their immigration status and that of their family members, with the threat of deportation to a country that is unfamiliar, has the potential to exacerbate any existing distress.13 Institutions should ensure that trainees have access to health and mental health resources while being cognizant of the barriers that might prevent them from seeking support, including but not limited to fear of a lack of confidentiality, stigma, and cost.
Considerations for the Future
As of May 15, 2017, U.S. Citizenship and Immigration Services is accepting and processing DACA applications. In the 115th Congress, Senator Lindsey Graham (R-SC), Senator Dick Durbin (D-IL), Representative Mike Coffman (R-CO), and Representative Luis V. Gutiérrez (D-IL) introduced the bipartisan Bar Removal of Individuals who Dream and Grow our Economy (BRIDGE) Act (S. 128, H.R. 496), which would grant individuals who are eligible for DACA a “provisional protected presence” and employment authorization for a temporary period. AAMC President and CEO, Darrell G. Kirch, MD, lauded the introduction of the BRIDGE Act, and letters from the AAMC to President Trump and Congress called for a permanent fix, such as the passage of the Development, Relief, and Education for Alien Minors (DREAM) Act. The AAMC also encouraged President Trump’s administration and Congress to grant DREAMers eligibility for federal student loans, reflecting the values of the academic medicine community to promote both accessibility and affordability of medical education.14
Nakae and colleagues report that the number of medical school applicants with DACA continues to increase. Although only 65 matriculated to medical school in 2016, DACA demographics show that the vast majority of the 750,000 DACA applicants are college age or younger.15 The authors also highlight the need to build capacity through policy and systems in support of students and trainees. Academic medicine is part of a larger movement with partners across the health professions and higher education focused on advancing the values of access and opportunity for all. While there is discomfort in the community because of the unknown fate of DACA, we argue that remaining steadfast in our commitment to our core values in medicine will allow us to successfully navigate these uncertain times.
Acknowledgments: The authors thank the leaders of the Pre-Health Dreamers for their contributions in support of aspiring health professionals.
1. Nakae S, Rojas Marquez D, Di Bartolo IM, Rodriguez R. Considerations for residency programs regarding accepting undocumented students who are DACA recipients. Acad Med. 2017;92:1549–1554
4. Agency for Healthcare Research and Quality. 2015 national healthcare quality and disparities report and 5th anniversary update on the national quality strategy: Quality and disparities in quality of health care. http://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/quality.html
. Reviewed May 2016. Accessed March 16, 2017.
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