Medical school graduates recently learned if they had been accepted into a residency program in their desired specialty and at their hospital of choice. Students that did not match with a program then go through a sort of weeklong dating game to determine where they will continue their medical training. For international medical graduates, this process has an added layer of tension this year: President Trump’s executive order suspending travel from six predominantly Muslim nations and ratcheting up visa reviews for all foreign nationals could prevent them from doing a residency in the U.S. at all.
The result would not only disrupt plans of IMGs to work and study in the U.S., it would hurt U.S. healthcare by adding to the current physician workforce shortage.
“One of the unfortunate consequences when you’re looking at suspending travel or impacting immigration of physicians is that those physicians — those medical graduates — are often likely to practice in underserved areas where the shortage might be felt first and perhaps the hardest,” Matthew Shick, director of government relations and regulatory counsel at the American Association of Medical Colleges, tells Healthcare Dive.
Strict vetting procedures
Under the president’s revised immigration order, issued Mar. 6, foreign nationals from Iran, Libya, Somalia, Sudan, Syria and Yemen would be barred for entering the U.S. for 90 days. Those holding valid visas or green cards would not be affected, and no visas would be revoked solely as a result of the executive order.
The order also establishes uniform screening and vetting procedures for all immigrants, regardless of their country of origin. According to Sec. 5, “This program shall include … in-person interview; a database of identify documents proffered by applicants to ensure that duplicate documents are not used by multiple applicants; amended application forms that include questions aimed at identifying fraudulent answers and malicious intent; a mechanism to ensure that applicants are who they claim to be; a mechanism to assess whether applicants may commit, aid, or support any kind of violent, criminal, or terrorist acts after entering the United States; and any other appropriate means for ensuring the proper collection of all information necessary for a rigorous evaluation of all grounds of inadmissibility or grounds for the denial of other immigration benefits.”
The heightened scrutiny has teaching hospitals across the U.S. concerned about IMGs whom they’ve matched and are expected to start residency programs July 1. In a statement, the American Hospital Association said the order “could have a negative impact on international medical school graduates in our nation’s teaching hospitals in the upcoming academic year.” The group called for an immediate case-by-case waiver review for matched residents from the six affected countries.
A federal judge in Hawaii and one in Maryland have temporarily blocked the amended executive order, which was to take effect Mar. 16, but the White House has vowed to appeal those decisions.
Small window of time
The AAMC has identified about 500 residents in the current residency application process who are from the six suspended countries. The new screening procedures could impact up to 10,000 IMGs, according to Shick. “It’s a very short timeframe to get everybody through the process from Mar. 17 to July 1,” he said.
Those who aren’t cleared in time would have to defer for an entire year, putting their medical career on hold until the 2018 match. The deadline is difficult not just because of the short timeframe. Residents who are rotating out of programs will leave patients that need to be seen and treated by the incoming crop of residents, and if they’re not able to start on time, it creates a significant hardship on the hospital and their patients, Shick says.
While all states would be affected, some rely heavily on foreign doctors to fill residencies. According to AAMC statistics, about 40% of residents in Michigan, West Virginia and Connecticut are international medical graduates, 45% in New York and Nevada, 55% in New Jersey and more than 60% in North Dakota and Wyoming.
Southeast Michigan could be especially hard hit if Trump’s immigration ban takes effect. “Southeast Michigan has the highest concentration of Middle Eastern population outside of the Middle East,” David Pieper, executive director of the Southeast Michigan Center for Medical Education, told Healthcare Dive via email. “I don’t have statistics, but a huge percent of our physicians and residents are from the six banned countries.”
Pieper says residency program directors and other officials within SEMCME’s constellation of 10 teaching hospitals have expressed a great deal of concern about the effect of the immigration ban on their programs.
Detroit Medical Center is one of the hospitals that have matched medical graduates from the Muslim-dominant countries Trump wants to ban. In 2015, eight out of 32 first-year internal medical residents — or 25% — were from Syria, Iraq and Sudan.
While the immigration ban threatens to leave teaching hospitals shorthanded this coming year, it could have an even broader impact on the physician shortage facing U.S. hospitals.
Serving the underserved
Current U.S. immigration programs provide opportunities for individuals who want to enter public service. Under the Conrad 30 program, physicians on a J1 visa who are coming out of residency can remain in the U.S. if they practice in a medically underserved area for at least three years. The program allows for 30 waivers per state and averages about 1,030 waivers a year — sending more than 13,000 physicians to underserved areas over the past 15 years, according to Shick.
“The program flies under the radar, but it’s scope is quite large, on a par with the National Health Service Corps,” he says, referring to the loan repayment program for U.S. citizens who choose to practice in underserved areas.
Certain types of care could also be harder hit by the executive order. For example, IMGs tend more often to match to primary care and family medicine, areas with some of the greatest physician shortages.
Shick says the AAMC was disappointed the order did not specifically address the value of immigrating physicians to national health security. The group has developed an FAQ guidance — in partnership with the Education Commission for Foreign Medical Graduates and American Council on Graduate Medical Education — to help institutions expedite the screening process for international residents hoping to start July 1.