A Lawyer in the Examination Room
By Chay Sengkhounmany and Stephen C. Dorner
This article was first published in Clearinghouse Review: Journal of Poverty Law and Policy, Nov.-Dec. 2013. © 2013 Sargent Shriver National Center on Poverty Law.
Faris Al-Jashami, 41, sits on the examination table at the Shade Tree Clinic and waits to be seen by the medical team. The door opens and two medical students in short white coats and a third person pile into the eight-foot-square examination room. The room was not made to accommodate four people, but Al-Jashami was not bothered by the close quarters. A patient of Shade Tree Clinic since 2010, he was used to the number of people who saw him at each visit.
“I have a pain in my chest,” Al-Jashami tells the team. “It started a week ago with a sharp stabbing pain on my left side when I walk. Yesterday morning I woke up from a frightening dream with the pain in my chest. I had the same pain again this morning, but it was not as strong.”
“Do you feel any numbness?” a fourth-year medical student asks. “Do you get nausea or have shortness of breath?” Al-Jashami shakes his head “No” in response. The students conduct a physical examination of Al-Jashami. As they do so, they continue to ask him questions.
“Mr. Al-Jashami, are you currently experiencing any significant stresses in your life?” the fourth-year student asks as she listens to his heart through a stethoscope. “Your chart says that you are separated from your wife. Will you tell us about that?”
“My wife and son have been in Mexico since May,” Al-Jashami explained. “They went to go get my wife’s visa. When she went to the interview, they told her that she needed to get more information or she would not be able to come back to the U.S. for ten years. My son is a U.S. citizen, but he went with his mom because I cannot take care of him by myself.
“I have no one here. I left all of my family when I left Iraq, and now my wife and son are in Mexico. I don’t know when they will come home. I have terrible dreams of people I know who are dead. I think about the things that happened in Iraq. I need my wife with me. She takes care of me and helps me get through the bad memories. I miss my boy.”
The third member of the team, who is not wearing a white coat, speaks up and reaches to shake Al-Jashami’s hand. “Mr. Al-Jashami, I am Chay Sengkhounmany. I am a lawyer with Legal Aid Society, and I am here to help the patients of Shade Tree. Would you like to come to the social work office after your medical visit and talk with me about your family being in Mexico?”
Legal Care in the Health Care Setting
Shade Tree Clinic is the Vanderbilt University School of Medicine’s student-run primary care clinic that serves as the free, comprehensive medical home for more than 400 uninsured and underinsured patients in Nashville, Tennessee. These individuals face tremendous barriers to care, and the mission is to meet these needs—medical and beyond. Shade Tree’s mission is made possible through a combination of grants, fund-raisers, generous donors, and the Vanderbilt University Medical Center. The clinic is managed by medical students and has only one paid employee—a licensed medical social worker, underscoring the importance of the clinic’s social mission. Additional clinic volunteers come from other institutions in the area, including Meharry Medical College, Lipscomb University College of Pharmacy, and the Vanderbilt University Law School. The result is a diverse interdisciplinary team joining together to meet the patients’ medical needs.
Legal Aid Society of Middle Tennessee and the Cumberlands is a private, nonprofit organization that gives free legal services to people with low income. It receives funding from various sources including the Legal Services Corporation; federal, state, and local governments; and private foundations. Legal Aid Society has 30 attorneys in eight offices pursuing its mission to advance, defend, and enforce the legal rights of low-income and vulnerable people to secure for them the basic necessities of life. Its holistic approach to the issues faced by its clients makes it a logical home for a medical-legal partnership.
Shade Tree Clinic and Legal Aid Society partnered under the umbrella of Middle Tennessee Medical-Legal Partnership in 2012 to offer legal assistance to the patients of the clinic. In doing so, Shade Tree Clinic joined a few hundred other health care organizations that now include legal services as part of their treatment regimen. Every day unmet legal needs keep vulnerable Tennesseans from being and staying healthy: families live in flood-damaged homes; the elderly cannot get their prescription drugs because they are wrongly denied coverage; parents cannot take their children to their medical appointments because they cannot take time off work. The Middle Tennessee Medical-Legal Partnership tackles these social determinants of health and seeks to eliminate barriers to health care in three ways:
1. Direct Legal Service: Offering legal services to low-income families within a clinical setting where medical personnel are viewed with credibility and trust. Early legal intervention can often help prevent health problems due to environmental hazards or lack of resources. Ongoing advocacy for basic needs can ensure long-term health improvements.
2. Training and Education: Training health care professionals to help them identify nonbiological sources of illness in their patients and assist in creating a culture of advocacy.
3. Systematic Advocacy: Working to influence all levels of the governmental system, programs, and policies so that the number of people who benefit may grow.
Since January 2012, roughly 100 of Shade Tree’s 400 patients have received legal assistance from the medical-legal partnership. The model is unique among national medical-legal partnerships because of its home within a student-run medical clinic. This environment presents an unparalleled opportunity for interdisciplinary education that enhances medical students’ ability to examine a patient’s social history as it relates to the patient’s medical care. Health issues often require a social rather than a biomedical solution, yet social solutions have been neglected by traditional medical education. Education, nutrition, poverty, immigration, and employment affect patient well-being but exceed a doctor’s training. The Shade Tree Clinic closes this gap by incorporating a legal services attorney into clinic operations. Students are trained to identify social issues and resolve them in partnership with the attorney. The result is a new model of both health care delivery and education for the training of the next generation of physicians, thereby strengthening the future of medical care.
The Medical Student Perspective (Stephen C. Dorner)
For doctors, meeting a patient for the first time can be daunting. Before the doctor is someone in need and looking for a solution but unable to identify the problem. The patient can describe the problem in vague terms, point to areas of concern, and maybe even act the problem out. But, despite the doctor’s best efforts, the doctor cannot experience what has brought the patient to the clinic. The physician’s challenge is to assess the constellation of history, signs, and symptoms to identify the problem, diagnose it, and offer a solution. The physician-in-training’s challenge is to develop skills to manage the vast library of medical information required for this task.
The medical-student team faced such a challenge when Al-Jashami presented himself at the clinic. The differential diagnosis for chest pain is long. Cardiovascular issues are the most concerning, and so the team quickly sought to rule them out. Pulmonary issues are second since respiratory compromise can lead to a quick deterioration in patient vital signs requiring rapid response and protection of the airway. After eliminating the most obvious concerns, health care providers must consider the possibility of an atypical presentation such as gallbladder inflammation, small bowel obstruction, or hernia. If you were to ask a medical student meeting Al-Jashami for the first time to diagnose him, social issues may not make the top five diagnoses on the differential. Students are traditionally trained to identify and treat biomedical issues, stunting their perspective of what “medical” means, but Shade Tree strives to teach students, through continuity of care and our interdisciplinary team, that health care is about much more than medicine.
I first met Al-Jashami about six months before his chest pains began. One night he told his medical team at the clinic that he was hearing voices and having bad dreams, and so his team sent him to the social work office, where I was working that night, for a referral. At Shade Tree Clinic, referrals for mental health services are made through the social work department after a thorough discussion with the patient about the patient’s mental state. I extended my hand to greet him and was met with a firm grasp and a smile. Before me sat a man who looked very tired, wearing a ball cap and an oversized coat. I began speaking with him as if we had met for coffee, asking where he was from, if he had any kids, how he met his wife, and what he did for work. Our conversation was pleasant and easy. He seemed eager to speak with someone.
Al-Jashami was a Kurdish refugee from Iraq and came to the United States by way of Saudi Arabia after fleeing the persecution of Saddam Hussein’s regime. Under the Republican Guard, his family had been tortured and murdered. Alone, he arrived in Nashville and found work in a warehouse; there he learned English and Spanish and met a Mexican woman, an immigrant, whom he eventually married and with whom he has a son, now 13.
“I don’t have many friends,” he told me at one point. “I like to sit and watch my boy play soccer with his friends, but I don’t like to talk to people. I feel so angry very quickly.” We then segued into a conversation about his mental health.
I soon realized that he needed additional treatment beyond the resources Shade Tree Clinic could offer. Al-Jashami had signs of major depressive disorder with psychotic features and components of possible posttraumatic stress disorder. He was depressed and experienced auditory hallucinations and flashbacks to his time in Iraq. He needed regular counseling, antidepressants, and the consultation of a psychiatrist for the consideration of antipsychotics—resources Shade Tree is not equipped to supply. I took on Al-Jashami’s case and worked for months to create a treatment plan. However, mental health resources in Nashville are scarce, especially for the uninsured. Most facilities are either capped or have price ranges in excess of $100 per visit.
The best solution I could devise was a piecemeal approach where he met with a counselor at an outside, sliding-scale clinic for $10 per visit; Shade Tree supplied his antidepressants; and once a month he met with the on-call psychiatrist to assess his mental state. As the clinic team worked to develop a treatment plan, Al-Jashami and I spoke several times a month. He was the most compliant and gracious patient with whom I have ever worked. We came to know each other so well that I felt more like I was helping a friend than working to make a referral.
When Al-Jashami presented himself with chest pain, he had been undergoing counseling and taking antidepressants for three months. The clinic team was aware that this regimen was not substantial enough to control his symptoms. The regimen was also incapable of responding to the toll his wife’s immigration status was taking on him. Fortunately his health care was being managed by both a doctor and an attorney.
Treating Chest Pains Through Legal Care (Chay Sengkhounmany)
As I sat with Al-Jashami and asked him about his family’s separation, I began sorting through the likely solutions to this family’s dilemma. Al-Jashami’s wife, Claudia Cruz, entered the United States without documentation or inspection and had accrued over one year of unlawful presence in the United States. The problem is that once a person leaves the United States after having accrued over one year of unlawful presence, the person triggers a 10-year bar from returning to the United States.
Cruz had left for Mexico to get her legal permanent residence, or “green card.” Because she entered the United States without inspection, she could not apply for her green card within the United States. She had to interview and have her application processed at a U.S. Consulate in her country of origin. When she crossed the border into Mexico, she was then barred from returning to the United States for 10 years.
A hardship waiver is available for the 10-year bar. For the consular officer at her interview, Cruz had the hardship waiver form and a statement from her husband. But the statement was not enough to meet the requirements for the waiver. She was granted time to get more documentation, but she and her family did not know how much longer she and her son would have to wait for another interview or if any additional documentation would be enough for approval to return to the United States. By the time I met Al-Jashami in the examination room, his family had been in Mexico for over five months.
The standard for the hardship waiver of the 10-year bar is extreme hardship to a U.S. citizen spouse or parents should they remain in the United States without the immigrant applicant and also extreme hardship should they be forced to relocate to the applicant’s country to be with the applicant. Cruz needed to show that her husband would suffer extreme hardship from being separated from his wife if she were not allowed to return to the United States and that he would suffer extreme hardship if he relocated to Mexico.
The family did not have an attorney to help prepare the hardship waiver. Family members got the assistance of an immigration consultant, or notario, who was not licensed to practice law. The consultant helped them fill out the form and had Al-Jashami write a personal statement. Cruz’s waiver case is fairly straightforward, and if the application had been well documented, she would have received approval of her visa to return home on the day of the interview. But the application was not well prepared.
Cruz’s waiver case was straightforward and approvable because of Al-Jashami’s significant medical history. I asked Al-Jashami to write another personal statement that specifically described how he would fare without his family with him and how he would do if he moved to Veracruz, a Mexican state riddled with gang violence. I asked Stephen Dorner to draft, on behalf of Shade Tree Clinic with the approval of the faculty medical director, a letter that outlined Al-Jashami’s medical conditions, his treatment at Shade Tree Clinic, and how detrimental to his health and well-being his relocating and not being able to receive comparable care in Mexico would be.
I submitted the additional evidence in November 2012, and Cruz’s waiver application was approved the next month. She and her son returned home in February 2013. Vanderbilt University Media captured the family reunion on film from the moment the bus rolled into the parking lot. Seeing the smiling, tear-stained faces of the family brought tears of joy to my own eyes.
Although Al-Jashami continues to come to Shade Tree Clinic for treatment, he has not returned with complaints of chest pain. The team has no scientific proof that the legal care Al-Jashami received made the pain go away, but every time we see the family together smiling, we are inclined to believe that legal care had something to do with it.
“At first, I did not believe my husband when he first told me he met a lawyer at his doctor appointment,” Cruz said with a smile when I met her for the first time. “But I am so glad he did.”