Moving Toward Inclusion: Access to Care Models for Uninsured Immigrant Children.

Policy Points Models for access to care for uninsured immigrant children that mitigate structural and sociopolitical barriers to inclusive health care include funding structures (e.g., state-sponsored coverage) and care delivery systems (e.g., federally qualified health centers,). Although the quintessential model of access to care necessitates health coverage for all children regardless of immigration status or date of United States entry, incremental policy change may more realistically and efficiently advance equitable access to high-quality health care. Intentional advocacy efforts should prioritize achievable goals that are grounded in data, are attentive to the sociopolitical milieu, are inclusive of diverse perspectives, and would meaningfully impact health care access and outcomes.

Supporting DACA recipients and international students pursuing careers in medicine: A pilot program for advisors.

The United States (U.S.) health professions are becoming more invested in diversity. Information on students who are undocumented or recipients of Deferred Action for Childhood Arrivals (DACA), and international students on student visas entering U.S. medical education is sparse. Few programs offer targeted training for educators on advising students who are undocumented, DACA recipients, or on a visa. We piloted a virtual program for pre-health advisors and educators on supporting students who are undocumented or recipients of DACA and international students transitioning to medical school. Program evaluation consisted of an anonymous retrospective pre-post survey. Of 117 registrants, 40% completed the survey. Prior to the program, most participants indicated that they were unsure or thought students were ineligible for financial aid during medical school if they were DACA recipients (40% unsure, 26.6% ineligible) or on a student visa (30% unsure, 30% ineligible). After the program, most respondents reported students were eligible for merit scholarship or private loans with DACA (66.6% eligible) or an international student visa (60% eligible). Perceptions of students with DACA being able to lawfully practice medicine in the U.S. changed from pre-program (43.3% unsure or not eligible) to post-program (90% eligible). Participants indicated they were more confident advising DACA recipients and international students post program. This virtual program was an effective step in providing support for advisors who are assisting non-citizen or permanent resident students start their careers in healthcare. Our findings show the need for more information on advising students who are DACA recipients, undocumented, or on student visas prior to matriculating to medical school and throughout training.

Putting ethics and clinical decision making before politics: requiring COVID-19 immunization for Solid Organ Transplantation (SOT) Candidates and their Support Team.

We recommend that vaccination for COVID-19 should be a requirement for waitlist activation for solid organ transplant (SOT). We also recommend that such vaccination be required of the primary member of the in-home support team. We argue that these requirements are consistent with current standard practices that draw on a well-established ethical framework. As a result, these recommendations should be easily received and are only controversial owing to the inflamed and politicized state of public discourse.

How Should History of Physician Involvement in the Holocaust Inform How Physicians Approach Employers?

In response to a case involving an advertisement for a physician to work in a private detention center housing asylum seekers and immigrants, this commentary considers ethical obligations of physicians responsible for detainees' health care. The commentary also suggests key points a physician should make during a job interview at a detention center and concerns a physician might articulate about caregiving practices for detainees.

Addressing Systemic Health Inequities Involving Undocumented Youth in the United States.

The Deferred Action for Childhood Arrivals (DACA) program has dramatically improved the lives of undocumented youth in the United States. In particular, DACA has improved these young adults' health by improving the social determinants of health. Furthermore, as health professionals, DACA recipients increase the diversity of medicine and the health professions and are thereby suited and well positioned to promote health equity. The medical profession should continue its support for ad hoc legislative remedies, such as the DREAM Act, which target relief for particular populations of undocumented youth. In addition, the medical profession should highlight the need for a legislative solution that goes beyond a one-time fix and corrects the systemic marginalization of undocumented youth.

The Termination of Deferred Action for Childhood Arrival (DACA) Protections and Medical Education in the U.S.

The termination of the Deferred Action for Childhood Arrivals (DACA) immigration policy poses unique challenges for medical education and healthcare. A survey on DACA was administered online using Qualtrics Software System to 121 unique U.S.-MD granting medical school admissions leadership using e-mails between January 2018 and April 2018. A total of 39 individuals out of 121 (32%) responded to the survey; 23 (59%) of respondents identified as medical school admissions deans, 11 (28%) identified as directors and 5 (13%) as staff/officers. During the past 4 years, 19 (49%) reported having accepted DACA students. The majority either incorrectly answered or were otherwise unsure about the effect of DACA on medical education. The correlation between perception of understanding DACA and mean knowledge composite score was 0.38, P < 0.05. This study found that U.S.-MD granting medical school admissions leaders self-reported knowledge was moderately correlated with actual knowledge about DACA.

"We Have a Lot of Power ": A Medical School's Journey Through Its New Deferred Action for Childhood Arrivals (DACA) Initiative.

Purpose To describe and analyze qualitatively the impact of implementing the "Stritch Deferred Action for Childhood Arrivals (DACA) Initiative" (SDI) at the Stritch School of Medicine (SSOM), Loyola University, Chicago in 2012. The SDI is a three-step process that included: 1) opening the Stritch admissions policy to welcome DACA students to apply, 2) evaluating DACA applicants equitably with all other applicants, and 3) seeking funding to enable these students to matriculate.  Method Focus groups and in-depth interviews were conducted to explore DACA and non-DACA students' experience of the SDI on their medical school journey and the institutional culture. During the study (in 2017-18), the medical school year (M)1-M3 cohorts included DACA students, while the M4 class did not. A grounded theory method was used to summarize and analyze qualitative data. Results Four major themes and 11 subthemes emerged from the data analysis. "Beliefs and Attitudes" included the subthemes of motivation to become physicians, resilience, and the mission and values of individuals and the institution. Students noted "obstacles" in reaching medical school, along with those they encountered within it. They also noted multiple "opportunities" presented through the SDI and the importance of mentors and allies. Lastly, the "impact" of the SDI on individuals, the institution, and the wider community was discussed by participants. Conclusion Enacting the SDI enabled cohorts of DACA recipients to matriculate at SSOM. Both DACA and non-DACA students in this study identified the importance of including these students as future physicians and articulated the impact of this change on them, their classmates, the institution, and the community as solidarity was formed and students' awareness of their power as future physicians to advocate for underserved populations developed.

Everything I Really Needed to Know to Be a Clinical Ethicist, I Learned From Elisabeth Kübler-Ross.

I analyze the insights present in Elisabeth Kübler-Ross's seminal work, On Death and Dying that have laid the foundation for contemporary clinical bioethics as it is practiced by clinical ethics consultants. I highlight the landmark insight of Elisabeth Kübler-Ross that listening to dying patients reveals their needs and enables them to enjoy a better death. But more important for contemporary clinical ethics is that the text highlights three tensions that the clinical ethicist must navigate but can never truly resolve. Clinical ethicists must balance: (1) the need to hear the patient's voice with the temptation to overly medicalize the case, (2) helping the patient achieve a better death with enabling the patient to die in the way he or she chooses, and (3) keeping professional distance with engaging the patient in a way that respects the intimacy of the patient's disclosures.

What Is the Minimal Competency for a Clinical Ethics Consult Simulation? Setting a Standard for Use of the Assessing Clinical Ethics Skills (ACES) Tool.

Background: The field of clinical ethics is examining ways of determining competency. The Assessing Clinical Ethics Skills (ACES) tool offers a new approach that identifies a range of skills necessary in the conduct of clinical ethics consultation and provides a consistent framework for evaluating these skills. Through a training website, users learn to apply the ACES tool to clinical ethics consultants (CECs) in simulated ethics consultation videos. The aim is to recognize competent and incompetent clinical ethics consultation skills by watching and evaluating a videotaped CEC performance. We report how we set a criterion cut score (i.e., minimally acceptable score) for judging the ability of users of the ACES tool to evaluate simulated CEC performances. Methods: A modified Angoff standard-setting procedure was used to establish the cut score for an end-of-life case included on the ACES training website. The standard-setting committee viewed the Futility Case and estimated the probability that a minimally competent CEC would correctly answer each item on the ACES tool. The committee further adjusted these estimates by reviewing data from 31 pilot users of the Futility Case before determining the cut score. Results: Averaging over all 31 items, the proposed proportion correct score for minimal competency was 80%, corresponding to a cut score that is between 24 and 25 points out of 31 possible points. The standard-setting committee subsequently set the minimal competency cut score to 24 points. Conclusions: The cut score for the ACES tool identifies the number of correct responses a user of the ACES tool training website must attain to "pass" and reach minimal competency in recognizing competent and incompetent skills of the CECs in the simulated ethics consultation videos. The application of the cut score to live training of CECs and other areas of practice requires further investigation.

Clinical Ethicists Awakened: Addressing Two Generations of Clinical Ethics Issues Involving Undocumented Patients.

Because the United States has failed to provide a pathway to citizenship for its long-term undocumented population, clinical ethicists have more than 20 years of addressing issues that arise in caring for this population. I illustrate that these challenges fall into two sets of issues. First-generation issues involve finding ethical ways to treat and discharge patients who are uninsured and ineligible for safety-net resources. More recently, ethicists have been invited to help address second-generation issues that involve facilitating the presentation for care of undocumented patients. In the current environment of widespread fear of deportation in the immigrant community, ethicists are working with health care providers to address patient concerns that prevent them from seeking care. I illustrate that in both generations of issues, values implicit within health care, namely, caring, efficiency, and promotion of public health, guide the strategies that are acceptable and recommended.

Good Sanctuary Doctoring for Undocumented Patients.

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.

Operation Homefront: Meeting Clerkship Competencies with Home Visits to Families of Children With Special Needs.

OBJECTIVE: We assessed how third-year medical students' written reflections on home visit experiences with families of children with special needs demonstrate evidence of exposure to 9 selected competencies for pediatric clerkships designated by the Council on Medical Student Education in Pediatrics. METHODS: We reviewed written reflections from 152 third-year medical students. For each competency (2 related to communication were combined), we tabulated the number of reflections in which a given competency was demonstrated. Within each competency, themes are described and presented with exemplary quotes to provide a more robust picture of students' exposure and experience. RESULTS: Of 152 reflections, 100% demonstrated at least 1 of the 8 expected competencies. Each reflection exhibited an average of 3 (3.1) competencies (range: 1-7). The competencies most frequently mentioned were demonstration of respect for patient, parent, and family attitudes, behaviors, and lifestyles (90%) and demonstration of positive attitude toward education (76%). Less frequently mentioned competencies included demonstration of behaviors and attitudes that promote patients' and families' best interests (41%), demonstration of effective verbal and nonverbal communication skills (a combination of 2 communication-related competencies) (33%), and description of barriers that prevent children from accessing health care (37%). The following competencies were least often mentioned: description of a pediatrician's role and responsibility in advocating for patients' needs (10%), description of the important role of patient education (8%), or description of the types of problems that benefit from a community approach (17%). CONCLUSIONS: Our analysis demonstrates that community-based home visits can provide medical students with opportunities to meet required pediatric clerkship competencies.

Ending DACA Has Pragmatic and Ethical Implications for U.S. Health Care.

In 2012, Loyola University Chicago's Stritch School of Medicine became the first medical school in the United States to actively recruit and accept undocumented immigrants who received protections granted under the Deferred Action for Childhood Arrivals program that was established by presidential memorandum. By 2016, sixty-one medical schools were considering applications from DACA recipients for admission, and more than 110 students applied. According to the American Association of Medical Colleges, sixty-five DACA recipients matriculated in U.S. medical schools in the 2016-2017 school year. These students contribute both diversity and talent to our medical community; they could also have a significant impact on the care of underserved and immigrant populations. The recent decision by the Trump administration to rescind DACA therefore comes with serious pragmatic and ethical ramifications, impeding our medical community's efforts to develop a diverse and representative workforce committed to improving access to quality care for all patients.

Navigating Clinical Ethics: Using Real Case Constellations to Guide Learners and Teachers in Medicine.

Case-based learning is a staple of clinical ethics education in medicine. The sources for medical educators generally are lengthy case books or single, often rare, case analyses in the literature. Busy clinicians may not have the time or inclination to sift through case books to find suitable teaching material, and the latter present unusual cases that many physicians may never encounter in their own practice. Relatively few articles present multiple cases involving ethical issues that are likely to appear in everyday practice in an accessible format for teaching. To fill this gap, we developed a series of paradigmatic cases based on the recurrent themes we identified through a systematic analysis of our clinical ethics consultations in a 5-year period and our collective clinical ethics judgment. We constructed four amalgam "bread-and-butter" ethics cases that are not overly service specific and can be used in medical and residency education along with specific questions for discussion. Topics include decision-making capacity, withholding and withdrawing life-sustaining treatment, patient wishes and do not resuscitate orders, and brain death. Our objective was to help a range of residents and other physicians become more confident and facile in identifying and addressing recurrent ethical issues in their practice.

How Medicine May Save the Life of US Immigration Policy: From Clinical and Educational Encounters to Ethical Public Policy.

Medicine has a conceptual contribution to make to the immigration debate. Our nation has been unable to move forward with meaningful immigration reform because many citizens seem to assume that immigrants are in the United States to access benefits to which they are not entitled. In contrast, when medicine encounters undocumented immigrants in the health care or medical education setting, it is obvious that their contributions to our health care system are denied by exclusionary laws. When the system is amended to be inclusive, immigrants become contributors to the systems that they access. I illustrate this thesis concerning the benefits of inclusion through an examination of the issues of forced medical repatriation, access to health insurance, and the access of undocumented students to medical education.