Why I’ve learned to leave blank spots in some patients’ medical records

Several 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.

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.

Read more: Immigrants, fearing Trump’s deportation policies, avoid doctor visits

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.

“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.