Bynum, then in his second year of residency training as a family medicine physician, was wrapping up a long shift when he was called into an emergency delivery. To save the baby’s life, he used a vacuum device, which applies suction to assist with rapid delivery.

The baby emerged unharmed. But the mother suffered a severe vaginal tear that required surgical repair by an obstetrician. Soon afterward, Bynum retreated to an empty hospital room, trying to process his feelings about the unexpected complication.

“I didn’t want to see anybody. I didn’t want anybody to find me,” said Bynum, now an at Duke University School of Medicine in North Carolina. “It was a really primitive response.”

The U.S. political environment presents an additional obstacle. Health and Human Services Secretary Robert F. Kennedy Jr. and other top Trump administration health officials have publicly blamed autism, diabetes, attention-deficit/hyperactivity disorder, and other chronic issues in large part on the lifestyle choices of people with the conditions — or their parents. For instance, FDA Commissioner Marty Makary suggested in a Fox News interview that diabetes could be better treated with cooking classes than “.”

Even before the political shift, that attitude was reflected at doctors’ offices as well. A 2023 study found that when treating patients with Type 2 diabetes. About 44% viewed those patients as lacking motivation to make lifestyle changes, while 39% said they tended to be lazy.

“We don’t like feeling shame. We want to avoid it. It’s very uncomfortable,” said , a nurse at the University of Wisconsin-Madison, who has of related studies, published in 2024. And if the source of shame is from the clinician, the patient may ask, “‘Why would I go back?’ In some cases, that patient may generalize that to the whole health care system.”

Indeed, Christa Reed dropped out of regular medical care for two decades, weary of weight-related lectures. “I was told when I was pregnant that my morning sickness was because I was a plus-size, overweight woman,” she said.

Except for a few urgent medical issues, such as an infected cut, Reed avoided health care providers. “Because going into a doctor for an annual visit would be pointless,” said the now 45-year-old Minneapolis-area wedding photographer. “They would only just tell me to lose weight.”

Then, last year, severe jaw pain drove Reed to seek specialty care. A routine blood pressure check showed a sky-high reading, sending her to the emergency room. “They said, ‘We don’t know how you’re walking around normal,’” she recounted.

Since then, Reed has found supportive physicians with expertise in nutrition. Her blood pressure remains under control with medication. She’s also nearly 100 pounds below her heaviest weight, and she hikes, bikes, and lifts weights to build muscle.

, a California psychiatrist, is among a group of physicians trying to bring attention to the detrimental effects of shame and develop strategies to prevent and mitigate it. While this effort is in the early stages, she co-led a session on the spiral of shame at the American Psychiatric Association’s annual meeting in May.

If physicians don’t acknowledge shame in themselves, they can be at risk of depression, , sleeping difficulties, and other ripple effects that erode patient care, she said.

“We often don’t talk about how important the human connection is in medicine,” Woodward said. “But if your doctor is burned out or feeling like they don’t deserve to be your doctor, patients feel that. They can tell.”

In a survey conducted this year, 37% of graduating students at some point in medical school. And nearly 20% described public humiliation, according to the annual survey by the Association of American Medical Colleges.

Medical students and resident physicians are already prone to perfectionism, along with an almost “masochistic” work ethic, as Woodward described it. Then they’re run through a gantlet of exams and years of training, amid constant scrutiny and with patients’ lives on the line.

During training, physicians work in teams and make presentations to teaching faculty about a patient’s medical issues and their recommended treatment approach. “You trip over your words. You miss things. You get things out of order. You go blank,” Bynum said. And then shame creeps in, he said, leading to other debilitating thoughts, such as “‘I’m no good at this. I’m an idiot. Everyone around me would have done this so much better.’”

Yet shame remains “a crack in your armor that you don’t want to show,” said , a family medicine physician at the University of Utah who has taught medical students about the potential for shame as part of a broader ethics and humanities course.

“You’re taking care of a human life,” she said. “Heaven forbid that you act like you’re not capable or you show fear.”

When students are taught about shame, the goal is to help future physicians recognize the emotion in themselves and others, so they don’t perpetuate the cycle, Pippitt said. “If you felt shamed throughout your medical education, it normalizes that as the experience,” she said.

Above all, physicians-in-training can work to reframe their mindset when they receive a poor grade or struggle to master a new skill, said Woodward, the California psychiatrist. Instead of believing that they’ve failed as a physician, they can focus on what they got wrong and ways to improve.

Last year, Bynum started teaching Duke physicians about shame competence, beginning with roughly 20 OB-GYN residents. This year, he launched a larger initiative with , a research and training partnership between Duke University and the University of Exeter in England that he co-founded, to reach about 300 people across Duke’s Department of Family Medicine and Community Health, including faculty and residents.

This sort of training is rare among Duke OB-GYN resident ’s peers in other programs. Dancel, who completed the training, now strives to support students as they learn skills such as how to suture. She hopes they will pay that approach forward in “a chain reaction of being kind to each other.”

More than a decade after Bynum experienced that stressful emergency delivery, he still regrets that shame kept him from checking on the mother as he usually would following delivery. “I was too scared of how she was going to react to me,” he said.

“It was a little devastating,” he said, when a colleague later told him that the mother wished he had stopped by. “She had passed a message along to thank me for saving her baby’s life. If I had just given myself a chance to hear that, that would have really helped in my recovery, to be forgiven.”

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Agentes del Servicio de Inmigración y Control de Aduanas (ICE) también se han presentado en clínicas comunitarias.

Proveedores de salud dicen que intentaron  donde había una clínica móvil, apuntaron a las caras de médicos que atendían a personas sin hogar y detuvieron a un transeúnte, subiéndolo a un auto sin identificación, frente a un centro comunitario de salud.

En respuesta a estas actividades de control migratorio alrededor de clínicas y hospitales, el gobernador demócrata Gavin Newsom promulgó el mes pasado la ley , que prohíbe a los centros médicos permitir el acceso de agentes federales a áreas privadas, incluidos los lugares donde los pacientes reciben tratamiento o hablan sobre temas de salud, sin una orden judicial o de registro válidas.

Si bien el proyecto de ley recibió un amplio apoyo de grupos médicos, trabajadores de salud y defensores de los derechos de los inmigrantes, expertos legales afirman que California no puede impedir que las autoridades federales realicen sus funciones en lugares públicos, como vestíbulos y salas de espera de hospitales, estacionamientos de centros de salud y vecindarios aledaños: lugares donde las recientes actividades del ICE han generado indignación y temor.

En enero, la administración Trump revocó las restricciones federales previas sobre la aplicación de las leyes de inmigración en o cerca de áreas sensibles, incluidos los establecimientos de salud.

“El problema que enfrentan los estados es la ”, dijo la abogada , profesora en la Facultad de Leyes de Georgetown. Explicó que el gobierno federal tiene derecho a realizar actividades de control migratorio y que existen límites a lo que el estado puede hacer para impedirlas.

La ley de California designa el estatus migratorio y el lugar de nacimiento de un paciente como información protegida, la cual, al igual que los expedientes médicos, no puede divulgarse a las autoridades sin una orden judicial.

Además, requiere que los centros de salud establezcan procedimientos claros para gestionar los pedidos de las autoridades de inmigración, incluyendo la capacitación del personal para notificar de inmediato a un administrador designado o a un asesor legal si los agentes intentan entrar a un área privada o revisar los expedientes de los pacientes.

Otros estados gobernados por demócratas han promulgado leyes para proteger a los pacientes en hospitales y centros de salud.

En mayo, el gobernador de Colorado, Jared Polis, promulgó la  , que penaliza a los hospitales por compartir sin autorización información sobre personas que se encuentran en el país de manera irregular y prohíbe a los agentes del ICE ingresar a áreas privadas de los centros de salud sin una orden judicial.

En junio, entró en vigencia en Maryland que exige al fiscal general crear directrices para mantener al ICE fuera de los centros de salud. Nuevo México ha implementado para los datos de pacientes, y Rhode Island a los establecimientos de salud preguntar a los pacientes sobre su estatus migratorio.

Los estados gobernados por republicanos se han alineado con los esfuerzos federales para evitar que se gaste en atención médica de inmigrantes sin papeles.

Estos inmigrantes no son elegibles para la cobertura integral de Medicaid, pero los estados sí facturan al gobierno federal por la en ciertos casos. Bajo una ley que , Florida exige que los hospitales que aceptan Medicaid pregunten sobre el estatus migratorio del paciente. En Texas, los hospitales ahora deben informar cuánto gastan en la atención de inmigrantes indocumentados.

“Los texanos no deberían tener que asumir el costo de la atención médica de los inmigrantes ilegales”, declaró el gobernador Greg Abbott al emitir su el año pasado.

Los esfuerzos de California por limitar la aplicación de la ley federal se producen en un momento en que el estado, donde más de una cuarta parte de los residentes , se ha convertido en blanco de la represión migratoria del presidente Donald Trump.

Newsom promulgó la SB 81 como parte de que prohíbe a los agentes de inmigración entrar en las escuelas sin una orden judicial, exige que los agentes se identifiquen y prohíbe el uso de máscaras. La SB 81 se aprobó con una votación partidista sin oposición formal.

“No somos Corea del Norte”, expresó Newsom durante una ceremonia de firma de leyes en septiembre. “Estamos rechazando estas tendencias y acciones autoritarias de esta administración”.

Algunos partidarios del proyecto de ley y expertos legales afirmaron que la ley de California puede impedir que el ICE viole los derechos de privacidad de los pacientes ya existentes.

Entre estos derechos se incluye la Cuarta Enmienda, que en lugares donde las personas tienen una expectativa razonable de privacidad. Las deben ser emitidas por un tribunal y firmadas por un juez. Sin embargo, con frecuencia los agentes del ICE utilizan órdenes administrativas para intentar acceder a áreas privadas para las que no tienen autoridad, dijo Genovese.

“La gente no siempre entiende la diferencia entre una orden administrativa, que es un simple documento, y una orden judicial, que es ejecutable”, dijo Genovese. Añadió que las órdenes judiciales rara vez se emiten en casos de inmigración.

El Departamento de Seguridad Nacional (DHS) ha dicho que ni los requisitos de identificación para los agentes del orden público en California, calificándolos de inconstitucionales. El departamento no respondió a la solicitud de comentarios sobre las nuevas normas estatales para centros de salud, que entraron en vigencia de inmediato.

Tanya Broder, asesora principal del National Immigration Law Center, afirmó que las detenciones de inmigrantes en centros de salud parecen ser relativamente raras. Sin embargo, la decisión federal de revocar las protecciones en torno a áreas sensibles, dijo, “ha generado temor e incertidumbre en todo el país”.

Muchos de los informes periodísticos más destacados sobre agentes de inmigración en centros de salud ocurrieron en California, principalmente en relación con pacientes detenidos que habían sido trasladados a un establecimiento de salud para recibir atención médica.

La California Nurses Association, el sindicato de enfermeras más grande del estado, copatrocinó el proyecto de ley y expresó su preocupación por el trato que recibió Milagro Solis-Portillo, una salvadoreña de 36 años que estuvo bajo vigilancia constante del ICE en el Hospital Glendale Memorial durante el verano.

Los líderes sindicales también de agentes en el California Hospital Medical Center, al sur del centro de Los Ángeles. Según Anne Caputo-Pearl, enfermera de parto y representante sindical principal del hospital, los agentes llevaron a una paciente el 21 de octubre y permanecieron en su habitación durante casi una semana. El diario informó que a Carlitos Ricardo Parias, creador de contenido de TikTok, lo llevaron al hospital ese mismo día tras resultar herido durante un operativo de control migratorio en el sur de Los Ángeles.

La presencia del ICE intimidó tanto a enfermeras como a pacientes, aseguró Caputo-Pearl, y motivó restricciones de visitas en el hospital. “Queremos una explicación más clara”, dijo. “¿Por qué se permite que estos agentes estén en la habitación?”.

Sin embargo, representantes de hospitales y clínicas dijeron que ya cumplen con los requisitos de la ley, los cuales refuerzan en gran medida las publicadas por el fiscal general del estado, Rob Bonta, en diciembre.

Las clínicas comunitarias a lo largo del condado de Los Ángeles, que atienden a más de dos millones de pacientes al año, incluyendo una gran proporción de inmigrantes, han estado implementando las directrices del fiscal general durante meses, según dijo Louise McCarthy, presidenta y directora ejecutiva de la Asociación de Clínicas Comunitarias del Condado de Los Ángeles.

Agregó que la ley debería ayudar a garantizar estándares unificados en todos los establecimientos de salud a los que las clínicas derivan pacientes y brindarles la tranquilidad de que hay procedimientos para protegerlos.

Aun así, no se puede evitar que se produzcan redadas migratorias en la comunidad, lo que ha provocado que algunos pacientes e incluso trabajadores de salud teman salir a la calle, señaló McCarthy. Se han producido algunos incidentes cerca de clínicas, incluyendo el arresto de un transeúnte frente a una clínica en el este de Los Ángeles, que un guardia de seguridad grabó en video, contó.

“Hemos escuchado a personal de las clínicas preguntar: ‘¿Es seguro para mí salir?'”, dijo.

En St. John’s Community Health, una red de 24 centros de salud comunitarios y cinco clínicas móviles en el sur de Los Ángeles y el Inland Empire, el director ejecutivo Jim Mangia coincidió en que la nueva ley no puede prevenir toda la actividad de control migratorio, pero afirmó que sí les brinda a las clínicas una herramienta para defenderse si se presentan agentes, algo que su personal ya ha tenido que hacer.

Mangia dijo que el personal de St. John’s tuvo dos encuentros con agentes de inmigración durante el verano. En uno de ellos, impidió que agentes armados ingresaran a un estacionamiento con rejas en un centro de rehabilitación de adicciones donde médicos y enfermeras atendían a pacientes en una clínica móvil.

Otro incidente ocurrió en julio, cuando agentes de inmigración a caballo y en vehículos blindados, en una demostración de fuerza por parte del gobierno de Trump.

Mangia dijo que agentes enmascarados con equipo táctico completo rodearon una carpa de atención médica callejera donde el personal de St. John’s atendía a personas sin hogar, les gritaron que se fueran y les apuntaron con un arma. Según Mangia, los proveedores quedaron tan conmocionados por el incidente que tuvieron que recurrir a profesionales de salud mental para ayudarlos a sentirse seguros al regresar de nuevo a la calle.

Un vocero del DHS declaró a CalMatters que, en raras ocasiones, cuando los agentes entran a ciertos lugares sensibles, los oficiales necesitan de un supervisor secundario.

Desde entonces, St. John’s ha intensificado sus esfuerzos para brindar apoyo y capacitación al personal y ha ofrecido a los pacientes con miedo a salir la opción de visitas médicas a domicilio y entrega de alimentos. Los temores de los pacientes y la actividad del ICE han disminuido desde el verano, afirmó Mangia, pero con el DHS planeando , duda que esta situación se mantenga.

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U.S. Immigration and Customs Enforcement agents have also shown up at community clinics. Health providers say that officers have tried to hosting a mobile clinic, waved a machine gun in the faces of clinicians serving the homeless, and hauled a passerby into an unmarked car outside a community health center.

In response to such immigration enforcement activity in and around clinics and hospitals, Democratic Gov. Gavin Newsom last month signed , which prohibits medical establishments from allowing federal agents without a valid search warrant or court order into private areas, including places where patients receive treatment or discuss health matters.

But while the bill received broad support from medical groups, health care workers, and immigrant rights advocates, legal experts say California can’t stop federal authorities from carrying out duties in public places, which include hospital lobbies and general waiting areas, health facility parking lots, and surrounding neighborhoods — places where recent ICE activities have sparked outrage and fear. Previous federal restrictions on immigration enforcement in or near sensitive areas, including health care establishments, were rescinded by the Trump administration in January.

“The issue that states encounter is the ,” said , a supervising attorney and clinical teaching fellow at Georgetown Law. She said the federal government does have the right to conduct enforcement activities, and there are limits to what the state can do to stop them.

California’s law designates a patient’s immigration status and birthplace as protected information, which like medical records cannot be disclosed to law enforcement without a warrant or court order. And it requires health care facilities to have clear procedures for handling requests from immigration authorities, including training staff to immediately notify a designated administrator or legal counsel if agents ask to enter a private area or review patient records.

Several other Democratic-led states have also taken up legislation to protect patients at hospitals and health centers. In May, Colorado Gov. Jared Polis signed the bill, which penalizes hospitals for unauthorized sharing of information about people in the country illegally and bars ICE agents from entering private areas of health care facilities without a judicial warrant. In Maryland, requiring the attorney general to create guidance on keeping ICE out of health care facilities went into effect in June. New Mexico has instituted , and Rhode Island has from asking patients about their immigration status.

Republican-led states have aligned with federal efforts to prevent health care spending on immigrants without legal authorization. Such immigrants are not eligible for comprehensive Medicaid coverage, but states do bill the federal government for in certain cases. Under a , Florida requires hospitals that accept Medicaid to ask about a patient’s legal status. In Texas, hospitals now have to report how much they spend on care for immigrants without legal authorization.

“Texans should not have to shoulder the burden of financially supporting medical care for illegal immigrants,” Gov. Greg Abbott said in issuing his last year.

California’s efforts to rein in federal enforcement come as the state, where more than a quarter of residents , has become a target of President Donald Trump’s immigration crackdown. Newsom signed SB 81 as part of a prohibiting immigration agents from entering schools without a warrant, requiring law enforcement officers to identify themselves, and banning officers from wearing masks. SB 81 was passed on a party-line vote with no formal opposition.

“We’re not North Korea,” Newsom said during a September bill-signing ceremony. “We’re pushing back against these authoritarian tendencies and actions of this administration.”

Some supporters of the bill and legal experts said California’s law can prevent ICE from violating existing patient privacy rights. Those include the Fourth Amendment, which without a warrant in places where people have a reasonable expectation of privacy. Valid warrants must be . But ICE agents frequently use administrative warrants to try to gain access to private areas they don’t have the authority to enter, Genovese said.

“People don’t always understand the difference between an administrative warrant, which is a meaningless piece of paper, versus a judicial warrant that is enforceable,” Genovese said. Judicial warrants are rarely issued in immigration cases, she added.

The Department of Homeland Security has said or identification requirements for law enforcement officers, slamming them as unconstitutional. The department did not respond to a request for comment on the state’s new rules for health care facilities, which went into immediate effect.

Tanya Broder, a senior counsel with the National Immigration Law Center, said immigration arrests at health care facilities appear to be relatively rare. But the federal decision to rescind protections around sensitive areas, she said, “has generated fear and uncertainty across the country.” Many of the most high-profile news reports of immigration agents at health care facilities have been in California, largely involving detained patients brought in for care.

The California Nurses Association, the state’s largest nurses union, was a co-sponsor of the bill and raised concerns about the treatment of Milagro Solis-Portillo, a 36-year-old Salvadoran woman who was under round-the-clock ICE surveillance at Glendale Memorial Hospital over the summer.

Union leaders also of agents at California Hospital Medical Center south of downtown Los Angeles. According to Anne Caputo-Pearl, a labor and delivery nurse and the chief union representative at the hospital, agents brought in a patient on Oct. 21 and remained in the patient’s room for almost a week. The reported that a TikTok streamer, Carlitos Ricardo Parias, was taken to the hospital that day after he was wounded during an immigration enforcement operation in South Los Angeles.

The presence of ICE was intimidating for nurses and patients, Caputo-Pearl said, and prompted visitor restrictions at the hospital. “We want better clarification,” she said. “Why is it that these agents are allowed to be in the room?”

Hospital and clinic representatives, however, said they are already following the law’s requirements, which largely reinforce put out by state Attorney General Rob Bonta in December.

Community clinics throughout Los Angeles County, which serve over 2 million patients a year, including a large portion of immigrants, have been implementing the attorney general’s guidelines for months, said Louise McCarthy, president and CEO of the Community Clinic Association of Los Angeles County. But she said the law should help ensure uniform standards across health facilities that clinics refer out to and reassure patients that procedures are in place to protect them.

Still, it can’t prevent immigration raids from happening in the broader community, which have made some patients and even health workers afraid to venture outside, McCarthy said. Some incidents have occurred near clinics, including an arrest of a passerby outside a clinic in East Los Angeles, which a security guard caught on video, she said.

“We’ve had clinic staff say, ‘Is it safe for me to go out?’” she said.

At St. John’s Community Health, a network of 24 community health centers and five mobile clinics in South Los Angeles and the Inland Empire, CEO Jim Mangia agreed that the new law can’t prevent all immigration enforcement activity, but he said it does give clinics a tool to push back if agents show up, something his staff has already had to do.

Mangia said St. John’s staff had two encounters with immigration agents over the summer. In one, he said, staff stopped armed officers from entering a gated parking lot at a drug and alcohol recovery center where doctors and nurses were seeing patients at a mobile health clinic.

Another occurred in July, when immigration agents MacArthur Park on horses and in armored vehicles, in a show of force by the Trump administration. Mangia said masked officers in full tactical gear surrounded a street medicine tent where St. John’s providers were tending to homeless patients, screamed at staff to get out, and pointed a gun at them. The providers were so shaken by the episode, Mangia said, that he had to bring in mental health professionals to help them feel safe going back out on the street.

A DHS spokesperson told CalMatters that in the rare instance where agents enter certain sensitive locations, officers would need “.”

Since then, St. John’s has doubled down on providing support and training to staff and has offered patients afraid to go out the option of home medical visits and grocery deliveries. Patient fears and ICE activity have decreased since the summer, Mangia said, but with DHS planning to , he doubts that will last.

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