On January 27, 2017, U.S. President Donald Trump signed an executive order banning nationals of seven countries — Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen — from entering the United States for at least 90 days, with the possibility of a wider “Muslim ban” in the works. Setting the broader ethical and political ramifications aside, this order will have a detrimental effect on graduate medical education (GME) and the U.S. health care system as a whole.
In 2015, the Educational Commission for Foreign Medical Graduates (ECFMG) reported that 24% of practicing physicians in the United States are international medical graduates (IMGs). In the 2016 Main Residency Match, there were 7460 IMGs who were not U.S. citizens (21% of all applicants). Although there are no current published statistics on the countries of origin of physicians in the United States, the ECFMG and the National Resident Matching Program (NRMP) published a report in 2014 detailing the outcomes for IMGs of the 2013 Main Residency Match. It indicated the number of applicants according to country of citizenship at birth and country of medical school attended (detailed for countries with at least 50 applicants). In 2013, there were 753 applicants whose country of citizenship at birth was Iran, Iraq, Libya, Sudan, or Syria; 299 of these (40%) were matched into a U.S.-based residency program. If the ordered ban expands to include other countries with a Muslim majority population, the number of potentially affected applicants will increase significantly. In 2013, there were 2101 applicants from 11 different countries with Muslim majority, of which 40% were matched into a U.S.-based residency program.
Furthermore, IMGs who train on a J-1 visa (a nonimmigrant visa sponsored through the ECFMG Exchange Visitor Sponsorship Program [EVSP]) are required to return to their home country for 2 years or obtain a “J-1 waiver” clinical job in order to stay in the United States. J-1 waiver positions are usually obtained through the Conrad 30 Waiver Program, which is intended to recruit physicians to serve in underserved rural and inner-city areas of the United States.5According to an ECFMG ESVP report, in 2014–2015 there were 9206 sponsored J-1 physicians from 130 countries, and 6 of the top 10 countries of origin — accounting for a total of 1879 J-1 physicians — have Muslim majority populations (Syria, currently 1 of the top 10 countries of origin and on the executive-order ban list, had 165 J-1 physicians in 2014–2015). Physicians with J-1 waivers are filling clinical jobs in areas of need. An executive order that has not taken into account the widespread ramifications may lead to further shortages of physicians in areas that are already in dire need.
For international medical students and graduates, pursuing medical training in the United States requires careful planning and considerable investment. Aside from meeting the requirements of one’s own medical school and home country, one has to sit for the U.S. Medical Licensing Examination Step 1, Step 2 Clinical Knowledge, Step 2 Clinical Skills, and possibly Step 3. After passing these exams, one applies through the Main Residency Match, which requires applying for a visitor visa (unless one is exempt), applying to a number of programs through the Electronic Residency Application Service, and traveling to the United States for in-person interviews. After this emotionally and financially draining process, one submits a Rank Order List and awaits the Match results.
This process usually requires at least 2 years of preparation, and only the cream of the crop of medical students and physicians from foreign medical schools match into U.S. residency programs — trainees who have shown aptitude and dedication, have worked hard, and have made a considerable financial investment in order to reach the pinnacle of graduate medical training.This grueling process represents “extreme vetting” at its best.
The executive order is thus detrimental to GME, a well-designed process that funnels hard-working IMGs into training positions that would otherwise remain unfilled. Since President Trump signed the order, there has been pandemonium among residents, fellows, and GME offices throughout the country. It has created much uncertainty and may well lead selection committees to reconsider their choices of applicants on the basis of country of origin. Currently, training programs are seeking advice from their GME departments and lawyers about ranking physicians from the seven banned countries and from all countries with a Muslim majority, as well as all applicants who require visas. Though hospitals and training program directors may be well intentioned and want to ensure that their matched physicians arrive by July 1 to begin their training in a timely manner, the ban is leading to inadvertent religious and racial discrimination.
The pathway to becoming a competent, well-trained physician is full of challenges, ranging from long hours and years, to life and job stresses, to financial debt. Physicians do not need further obstacles and worries imposed on them by orders that are not well thought out. Immigrants have made a long list of contributions to the U.S. health care system and to science in general — achievements that transcend country of origin, as well as religion, race, color, ethnic background, gender, and sexual orientation.
In the face of the executive order, we have seen an outpouring of support from patients, colleagues, program directors, faculty, and hospital staff — all of whom honor the diversity that helps to make this country great. As one of our patients put it, “I voted for Trump, but there is no way I’m going to let him take you away, doctor!”
The views expressed in this article are those of the authors and do not necessarily reflect the positions of the University of Pittsburgh Medical Center.
This article was published on February 1, 2017, at NEJM.org.
