Trump Immigration Order Causing Chaos for Medical Centers: NEJM

Alicia Ault

February 02, 2017

President Donald Trump's executive order temporarily barring immigration from seven countries with largely Muslim populations has created chaos, fear, and uncertainty — and may ultimately threaten medical progress and patient care, according to clinicians from several large academic institutions who voiced their concerns in three items published online February 1 in the New England Journal of Medicine (NEJM).

In addition, talk of banning Muslims has not only caused personal fear for some clinicians but has also led to deep concerns among their patients, two Muslim physicians write in a letter to the journal. "At a personal level, I feel really supported by my colleagues and by my institution," said one of those physicians, Fahad Saeed, MD, a nephrologist and palliative care physician. He told Medscape Medical News that he also feels a deep connection with his patients, some of whom are now worried that he will not be around to provide their care.

But "there is fear of what's going to happen to my immigration status in the future." said Dr Saeed, who is an assistant professor at the University of Rochester, New York. Dr Saeed's coauthor is Muhammad H. Majeed, MD, a specialist in child and adolescent psychiatry at Natchaug Hospital, Mansfield Center, in Connecticut.

The order, signed on January 27, suspended the Refugee Admissions Program for 120 days, suspended indefinitely the Visa Interview Waiver Program, and barred admissions for 90 days of anyone coming from Iraq, Iran, Libya, Somalia, Sudan, Syria, and Yemen.

"Since President Trump signed the order, there has been pandemonium among residents, fellows, and GME [graduate medical education] offices throughout the country," write Ahmad Masri, MD, and Mourad Senussi, MD, both fellows at the University of Pittsburgh Medical Center Heart and Vascular Institute in Pennsylvania, in a perspective article published in NEJM at the same time.

The order threatens what has become essentially a bedrock of American medicine — "the free exchange of ideas, experience, and perspectives," an exchange that also involves people, and "now extends far beyond U.S. borders," write Katrina Armstrong, MD, physician-in-chief of the Department of Medicine at Massachusetts General Hospital in Boston, and colleagues in a separate perspective article.

Dr Armstrong, joined by colleagues from Johns Hopkins Medicine, the University of Michigan Health System, the University of Pennsylvania Perelman School of Medicine, and the University of California, San Francisco, said international medical graduates are crucial in internal medicine, making up more than 50% of the residency slots in 2016, filling gaps in caring for the underserved and veterans, and serving as faculty in top internal medicine programs across the United States.

"Although the scope of the current executive order is limited to seven countries, the numbers of individuals touched in academic medicine are not small," write Dr Armstrong and colleagues. At Partners Healthcare, which encompasses Mass General and Brigham and Women's Hospital, more than 100 personnel are affected by the Trump immigration order. Twenty were applying for a visa at a US consulate overseas or getting ready to travel to the United States when the order was issued, and two were not allowed to board flights, they explain.

Muslim Countries Dominate IMGs

Dr Masri and Dr Senussi said data show Muslim-majority countries provide a large number of residents and trainees for US medicine. Thus, barring immigration of graduates from Muslim-majority countries could have a wide-ranging impact.

"In 2015, the Educational Commission for Foreign Medical Graduates…reported that 24% of practicing physicians in the United States are international medical graduates (IMGs)," they write. More specifically, "[i]n 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."

In 2014-2015, 1879 physicians training in the United States on a J-1 visa were from 10 countries with a Muslim-majority population. Syria alone accounted for 165 of those doctors. The J-1 visa requires that clinicians return home for 2 years after completing their training or seek waivers by taking certain clinical jobs — usually in underserved areas, Dr Masri and Dr Senussi note.

And, the graduates also fill slots in training positions "that would otherwise remain unfilled," the physicians write. Now, the order "may well lead selection committees to reconsider their choices of applicants on the basis of country of origin," they write. Some training programs are already looking into ranking physicians from the seven countries covered by the order, and from all countries with a Muslim majority.

"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," Dr Masri and Dr Senussi said.

Feeling the Fear Personally

Meanwhile, Dr Saeed of the University of Rochester said he and Dr Majeed felt they had to speak out against the potential for widespread antipathy toward Muslims, and the possibility that international medical graduates might lose their jobs, which would disrupt patient care.

But it is also personal: A patient with terminal kidney disease asked Dr Saeed if he was going to be leaving the country as a result of the president's order. "I told him 'I'm not going anywhere,'" Dr Saeed said, but he added, "I think he was afraid of abandonment."

Dr Saeed and Dr Majeed figured other patients might be feeling the same way — fearful and worried about their care — so they decided to contribute to the letter, he told Medscape Medical News.

They wrote their letter on Christmas Day, Dr Majeed told Medscape Medical News. Before and after the election, they listened with concern as Trump talked of the potential for an immigration ban that would target Muslims.

Both are from Pakistan, and both were able to train through the H-1b visa program, which Trump also had suggested might need to be restricted or eliminated. Dr Saeed now has a Green Card granting him residency; Dr Majeed told Medscape Medical News he is still in the United States on a visa.

Pakistan is not covered by the order, "but there's a concern that Pakistan will be on the list in the near or distant future," said Dr Saeed, which gives many pause, including Dr Majeed.

"Will the renewal of our visas be denied? Will we be required to leave the country, even though we are residing here legally?" they ask in their letter.

"We ask the medical community to stand in support of physicians who require visas, and we ask the government to continue to allow qualified international medical graduates to enter the United States," they write.

Dr Saeed, Dr Majeed, Dr Senussi, and Dr Masri have disclosed no relevant financial relationships. Dr Armstrong reports serving on an advisory board for GlaxoSmithKline; one coauthor reports serving on an advisory board or receipt of grant, personal fees, or stock options from CareWeb, Lippincott, Williams & Wilkins, McGraw-Hill, John Wiley & Sons, The Doctor's Company, IPC Healthcare, Accuity, PatientSafe Solutions, EarlySense, QPID, and The other coauthors have disclosed no relevant financial relationships.

N Engl J Med. Published online February 1, 2017. Majeed and Saeed letter, Masri and Senussi perspective, Armstrong et al perspective

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