Thursday, March 26, 2015

Medical School Dreams & DREAMers: What the New Contributors to Medicine Have Taught Us

Mark Kuczewski & Linda Brubaker
Mark Kuczewski, PhD & Linda Brubaker, MD, MA
(Remarks delivered at the 19th Annual Meeting of the National Hispanic Medical Association, March 28, 2015)

What We’ve Learned from these Medical Student DREAMers
In the early fall of 2011, we received an email from Professor Herbert Medina, chair of the mathematics department at Loyola Marymount University in Los Angeles. In the e-mail he described a student whom he had characterized as one the best students he’d ever had. She had a very high grade point average, was a double major in biology and Spanish, had significant service involvements, and a variety of other qualifications. We have told this story in several places. (1, 2, 3) But it bears repeating that this student, who also happened to be a DREAMer, captured our interest for several reasons intrinsic to the mission of a medical school.
  1. Best and brightest – Isn’t that who we all seek to recruit?
  2. Unique Skills – Such students are bi-lingual, bi-cultural and understand our large, recent immigrant patient populations. 
  3. Service to patients – DREAMers usually are persons of color from underserved communities and thereby fit the profile of potential physicians who are more likely to desire to serve underserved populations
  4. Fairness for this DREAMer – This student has all the talents and qualifications to become an outstanding physician in addition to being incredibly motivated in the face of seemingly insurmountable barriers. On what grounds could we justify her exclusion from the profession?
However, in 2011, a DREAMer could procure no authorization to work in the United States and therefore would be denied a license to practice medicine by every state medical board. As a result, we did not think it would be wise to admit and utilize copious school-based aid to graduate a physician who could not practice. Fortunately, on June 15, 2012, President Barack Obama granted a kind of temporary reprieve to “DREAMers” when he created the Deferred Actions for Childhood Arrivals Program which has become commonly known as DACA. As is well-known, DREAMers are young people who were brought to the United States without authorization as children and have lived and been raised here for more than five years. They have often received a substantial part, if not all, of their education in the United States and become integrated into the fabric of their communities. The DACA program is an exercise of prosecutorial discretion that removes any concern of deportation for eligible DREAMers during the covered period (originally two years but it is now conferred for three).  In addition, DACA status includes conferral of an Employment Authorization Document (EAD) and the recipient may apply for a social security number.

Because DACA alleviated the barrier to practicing medicine, the Loyola Stritch School of Medicine became the first medical school in the country to openly accept applications from DREAMers of DACA Status shortly after the creation of DACA. While some schools quietly accepted an occasional DREAMer, we felt it was important to be open and clear about our intent. We characterized this effort as “bringing them in the front door” or a “front-door approach.” Seven such DACA-documented DREAMers are currently thriving as they complete their first year at Loyola Stritch School of Medicine.

We think that on a societal level, the Loyola Stritch DREAMers are very important because they help us to move beyond the “makers” versus “takers” debate in which our political dialogue is mired. The Loyola Stritch DREAMers highlight that the image of undocumented immigrants as “takers” is mistaken. They are not here to take something to which they are not entitled. They are talented contributors. Their story shows that to a large extent, whether one becomes a maker or a taker is society’s self-fulfilling prophecy, and this is not exclusively (or at all) related to immigration status. Society can be inclusive and provide the conditions that enable these young people to use their God-given talents and motivations to serve sick patients and improve health within communities and populations. Or it can continue to reinforce barriers such as not allowing access to the same funding mechanisms that enable nearly all medical students to secure their educations, e.g., federal student loans. We sometimes half-jokingly say that the Loyola Stritch DREAMers are superheroes. They have hurdled so many barriers and obstacles on their way to a college education and a level of achievement that simply makes it unthinkable for us to turn them away from our medical school. “Leaping tall buildings in a single bound” seems like child’s play next to their accomplishments. But, even they needed the protections and opportunities that DACA affords them and a medical school - state partnership that provides a realistic funding vehicle. (4) They remind us of the many undocumented young people who are not superheroes like the Loyola Stritch DREAMers, but ordinary people like us. For ordinary people, removal of such artificial barriers is even more important to reaping the benefits of their contributions to society.

Society must own up to its responsibility in deciding whether it will enable our undocumented neighbors to be makers or will shackle them and demand that they be takers. This dynamic is also in effect in other sectors of health care.  For instance, we can bar the door to the opportunity to buy health insurance through the provisions of the Affordable Care Act and complain about the burden they pose on our emergency room charity care systems or we can provide the conditions for these neighbors to take responsibility for their health. (5) The choice is ours, not theirs.

The Importance of the Loyola University Chicago “Front Door Approach”
With the realization that the medical profession and the medical education community is engaged with individuals being marginalized unfairly by society, a “front door approach” to their plight is morally required of us.

First, the front door approach means that we welcome these students for who they are.  Our admissions policy states that applicants of DACA status are welcome to apply and we recognize them as their own category of applicants. (6) We are not trying to force them into an international student category but recognize that they bring their own particular qualities to the table and that they are best considered in terms of being evaluated by the same criteria we apply to citizens and permanent residents, not students applying from other countries.  This is a pragmatic consideration. But, we must not make too sharp a distinction between pure pragmatism and idealism.  Injustice has very pragmatic consequences as health and health care disparities demonstrate. In terms of ideals, our medical schools must not simply be a tolerant community; we must be a hospitable and welcoming community. Imagine if we were living in the era before desegregation. It would not be enough to occasionally entertain an application from an African-American, have them check boxes on their applications indicating that they are from racial or ethnic groups to which they do not actually belong, and pretend that they are white after matriculation. No, they must be welcome for who they are. This will entail a commitment to educating the entire medical education community (and our alumni community) lest the environment simply mirror much of the prejudice and implicit hostility of the larger society. (7) For instance, at Loyola, we have made a conscious effort not to use the common method of describing DREAMers as young people who were brought to the United States “through no fault of their own” as if migrating to feed one’s family is a fault and their parents are guilty of it. We will not speak that way in our institution. Thus, the issues that DREAMers confront and the larger context of immigration in the United States will become a thematic focus of education at all levels on the campus of our health science centers. Of course, this will yield the additional benefit that all health-care providers on the campus will likely become more culturally aware and competent in caring for immigrant patient populations.

Second, a front-door approach is important in gathering support.  Medical students of DACA status, like all medical students, are raw assets to our society. But we must invest in them in order to develop them into physicians who can serve the community.  DACA status students are denied access to basic resources such as federal student loans. We need support from the community such as medical school alumni, friends, and related health-care institutions. It’s hard to know how one gathers support without articulating commitment. Clearly our ability to partner with the Illinois Finance Authority to provide loans to these students was dependent on our public commitment.

Finally, the presence of such DREAMers ultimately is transformative for our campus, for medical education, and for medicine. One cannot look at the contributions of these students, come to understand the realities of immigration in the United States and globally, and simply remain indifferent. We must advocate for change and for justice.  As we’ve seen, these injustices have implications for the health of our communities and for the development of physicians and health-care professionals to treat our communities. And beyond those pragmatic aspects, we find ourselves looking at a situation that is just plain wrong. To look at the Loyola Stritch DREAMers is to immediately recognize how wrong it is that they live with the insecurity of a temporary immigration status subject to the will of the nation’s chief executive. And while they are rapidly becoming community leaders, they lack the basic right to self-determination through voting or participating in systems in which we are all commonly invested, such as social security. While we live in the practical and pragmatic world of advocacy and in that world, we often confine our speech to the art of the politically possible, we must never stop simply saying the truth. As academics and health care professionals we must never stop saying that our present immigration policies from the militarization of our southwest borders, through the lack of qualified and effective representation of immigrants in our courtrooms, to the confining of migrants for long periods in our detention centers and prisons, to the failure to provide a path to citizenship for long-time members of our communities, are unhealthy and just plain wrong. These injustices must be changed.

1. Mark G. Kuczewski, Linda Brubaker. (2015) Equity for ‘DREAMers’ in Medical School Admissions. AMA Journal of Ethics 17(2): 152-156. Article  |  Podcast

2. Mark G. Kuczewski, Linda Brubaker. (2014) Medical Education for “Dreamers”: Barriers and Opportunities for Undocumented Immigrants. Academic Medicine 89(12): 1593-1598.

3. Mark G. Kuczewski, Linda Brubaker. (2013) Medical Education as Mission: Why One Medical School Chose to Accept Dreamers, Hastings Center Report 2013;43(6): 21-24.

4. Kristen Schorsch, “A Year Later, Loyola Still Alone in Enrolling Undocumented Students.” Crain’s Chicago August 9, 2014

5. Mark G. Kuczewski. (2011) Who is My Neighbor? A Communitarian Analysis of Access to Health Care for Immigrants. Theoretical Medicine and Bioethics 32(4): 327-336.

6. DREAMers of DACA Status Welcome.  Loyola University Chicago Stritch School of Medicine Website.

7. “Loyola University Chicago Medical Students Show Support for DREAMer Peers”, Ignatian Solidarity Network, August 14, 2014.

Mark G. Kuczewski, PhD is Fr. Michael I. English Professor of Medical Ethics, Director of the Neiswanger Institute for Bioethics & Health Policy, and Chair of the Department of Medical Education at the Loyola University Chicago Stritch School of Medicine. Follow him on Twitter: @BioethxMark

Linda Brubaker, MD, MA, is the Dean and Chief Diversity Officer of the Loyola University Chicago Stritch School of Medicine and she also currently serves as the Interim Provost for the Health Sciences Division of Loyola University Chicago. Follow her on Twitter: @StritchMedDean

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