I entered medical school with the lofty goal of having an impact on individual patients and populations through medicine, research and policy change. Defining impact is difficult, however following my interests which became passions allowed me to believe I could meet this goal. As a first-year student, I sought opportunities to connect with the community, as most of our time is spent learning about medicine through lectures and not through direct patient care at this point in the curriculum. I began working with the University of Michigan Asylum Collaborative and the Michigan Immigrant Rights Center to provide medical evaluations for those seeking asylum. Medical affidavits documenting the physical and psychosocial signs of human rights abuse and its sequalae can drastically increase the chances of being granting asylum in the U.S. This was impactful work for both me and each person we worked with. However, as I continued to observe injustices play out time and time again for this population, I saw the opportunity to make an impact beyond the individual.
I was introduced to Mateo,* a 25-year-old father and agricultural worker in Michigan, who received a new diagnosis of End Stage Kidney Disease (ESKD). Within days of his initial symptoms, his life was uprooted by his disease, and as his condition worsened hastily, he presented to his local hospital for care. There, he was greeted with a multitude of questions, many of them not pertinent to his symptoms and care, but instead about his citizenship status. After his initial hospitalization and diagnosis, Mateo underwent placement of a temporary central venous catheter, an IV in the large veins of his neck through which he would receive emergency hemodialysis, the only treatment available for his life-threatening diagnosis. Mateo improved rapidly, only to find out that he would need the same treatment three times a week to stay alive. As an undocumented immigrant in the U.S., he could not receive chronic (long-term, ongoing) hemodialysis, the standard of care for ESKD. Instead, Mateo’s discharge plan was to seek dialysis every week when he felt ill enough to come to the emergency department. At 25 and with a family to care for, the prospect of a life of uncertainty was devastating.
Undocumented immigrants residing in the U.S. are dying from ESKD because unjust state legislation is excluding them from accessing life-prolonging interventions such as dialysis and transplantation. Grounded in the firm belief that health care is a human right, I sought to understand the root cause of this problem. At the start of training, medical students are in the position to listen to our patients’ stories and provide a humanistic perspective. We closely observe the societal problems affecting patients in our learning environments, but are rarely placed in a position to help fix them. Training hospitals are not always equipped with the tools to allow students to solve the problems they observe in the clinical environment.
To this point, medical education institutions have a responsibility to decrease the barriers for advocacy engagement for trainees of all levels. I partnered with another medical student, Amalia Gomez-Rexrode, and began to learn more about the systematic nature of this coverage issue. We wondered how we could impact change from our position. We learned that several states had already proposed legislation to ensure these patients have access to life-saving treatment. While this problem was new to us, it was not new to the community or the experts in the field. Our resident and faculty mentors encouraged us to find additional expertise and guidance, and to seek collaborations with community partners. Consistently, we were empowered to take on the task of seeking justice ourselves. Despite common misconceptions about the limited agency of students, no problem is too big, or too bureaucratic, for trainees to become involved in the solution.
Over two years, we transformed our interest into concrete deliverables including a policy brief, interviews with affected patients, cost analyses, grants and countless meetings with a coalition of attorneys, physicians, community stakeholders and advisors, which helped to shape how we will practice medicine and provide care to all patients. We successfully advocated for a change to Michigan Medicaid, which became effective April 1, 2022. Now, all people in the State of Michigan can access dialysis regardless of immigration status.
The Michigan Capstone for Impact (CFI) curriculum was developed for students to explore what they are most fundamentally passionate about. This work uniquely combined my interests of working with the Asylum Collaborative, transplantation health services research and health policy. I had opportunities to work with leaders in diverse fields and gain knowledge that will be critical to being an effective patient and policy advocate going forward in my career. Fighting for change shaped my medical education and gave me a unique perspective to experience the forces of the larger system that surrounds us all. By centering advocacy in my life as a budding clinician, I plan to continue to build space into my future practice to fight for patients and empower others to do the same.
There will never be a better time to learn and grow as an advocate than to start now. When an issue feels larger than yourself as a trainee, it might be one most worth trying to fix.
Acknowledgements: Thank you to Dr. Valeria Valbuena (General Surgery PGY6), Amalia Gomez-Rexrode (M4), Dr. Michael Englesbe (Department of Transplantation Surgery) and all of our community partners who none of this work would be possible without.
*Name and details have been changed.
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Devon is a fourth-year medical student at University of Michigan. She is passionate about health policy and access to transplantation. She can be followed on Twitter at @Devon__Cassidy.