The US immigration ban: implications for medical education and the physician workforce

Abstract

On Jan 27, 2017, a presidential executive order, which was later suspended, halted entry to the USA for 90 days for immigrant and non-immigrant persons from seven Muslim-majority countries (Iraq, Syria, Iran, Sudan, Libya, Somalia, and Yemen). New replacement orders seem to be in the making to, more or less, achieve the same goals. Although the media has covered the legal, political, and humanitarian impact of the order, we would like to describe the effect on medical education and the physician workforce in the USA. International medical graduates (IMGs) comprised 25% of all active residents and fellows in in the USA, with approximately 1200 currently training in internal medicine residencies or fellowships from the seven banned countries.1Accreditation Council for Graduate Medical EducationForging ahead: annual report 2015–2016.http://www.acgme.org/Portals/0/PDFs/2015-2016-ACGMEAnnualReport.pdfGoogle Scholar, 2American Board of Internal MedicineABIM statement: travel ban threatens to disrupt patient care.http://www.abim.org/news/abim-statement-travel-ban-threatens-to-disrupt-patient-care.aspxDate: Jan 31, 2017Google Scholar Approximately 23% of US physicians with active licences are IMGs.3Young A Humayun J Chaudhry DO et al.A census of actively licensed physicians in the United States, 2014.J Med Regul. 2014; 101: 8-23Google Scholar Syria in particular, one of the seven countries with a 90-day visa ban and an indefinite refugee ban, is home to the University of Damascus, which trained a high number of physicians with an active licence in the USA in 2014 (2632).3Young A Humayun J Chaudhry DO et al.A census of actively licensed physicians in the United States, 2014.J Med Regul. 2014; 101: 8-23Google Scholar A notion that foreigners are taking positions from Americans has been used in defense of the executive order. We argue that, for the physician workforce, this is certainly not true. IMGs have been filling an abundant number of residency positions that cannot be filled by US graduates. In 2014–15, there were 21·7% more open residency positions than there were US graduates.4Mullan F Salsberg E Weider K Why a GME squeeze is unlikely.New Engl J Med. 2015; 373: 2397-2399Crossref PubMed Scopus (32) Google Scholar Moreover for IMGs to secure residency positions in the USA, they have always had to meet higher standards than US graduates. For instance, 2013–16 residency match data show that IMGs had higher examination scores, more research experience and peer-reviewed publications, and were more likely to have graduate degrees or completed residency training than their US graduate counterparts.5National Resident Matching Program (NRMP) and Educational Commission for Foreign Medical Graduates (ECFMG)NRMP historical reports 2007-2016.http://www.nrmp.org/match-data/nrmp-historical-reports/Google Scholar Such hurdles ensure that those who successfully make it into the USA are usually highly selected people with extraordinary capabilities who provide high quality of care.6Tsugawa Y Jena AB Newhouse RL et al.Quality of care delivered by general internists in US hospitals who graduated from foreign versus US medical schools: observational study.BMJ. 2017; 356: j273Crossref PubMed Scopus (63) Google Scholar Physicians who are legally admitted to the USA under immigrant and non-immigrant visas have been through comprehensive vetting (including primary source verification for birth, civil status, biometrics, and educational background) and are highly unlikely to pose a threat to national security.7Nowrasteh A Terrorism and immigration: a risk analysis. Cato Institute policy analysis number 798.https://object.cato.org/sites/cato.org/files/pubs/pdf/pa798_1_1.pdfDate: Sept 13, 2016Google Scholar A large number of IMGs practise in rural and underserved areas (as a part of the “J-1 waiver” programme) and provide care to patients in areas where there are critical shortages of physicians. Abrupt reduction of IMG physicians will reduce access to care in such areas, particularly in specialties with high proportions of IMGs such as internists (38·6%), cardiologists (43·6%), nephrologists (47·2%), and geriatricians (50·7%).1Accreditation Council for Graduate Medical EducationForging ahead: annual report 2015–2016.http://www.acgme.org/Portals/0/PDFs/2015-2016-ACGMEAnnualReport.pdfGoogle Scholar We urge the US Government to consider the impact of this order, and any future immigration restrictions, on the health-care workforce. The views presented in this Correspondence are solely those of the authors’ and not of Mayo Clinic. We declare no competing interests.