Travel Ban Confusion Complicates Match Day Decisions

Marcia Frellick

February 15, 2017

UPDATE: The Trump administration announced February 16 that it would discontinue its legal push in appeals court to reinstate their travel ban, but would instead issue a new, revised immigration order next week. No other details were given.

As medical school students look ahead to Match Day on Friday, March 17, some international students have additional anxiety in light of the uncertainty surrounding President Trump's executive order banning travel for people in seven Muslim-majority countries.

Residency programs also have to decide whether they will hold spots for students from the targeted countries who may not be allowed to come to the United States if legal rulings change.

First comes decision day February 22, when preferences must be ranked by both programs and students.

"Some applicants are concerned that the program directors won't rank them and there's concern from programs on whether the students can begin training on time," Mona Signer, president and CEO of the National Resident Matching Program (NRMP), told Medscape Medical News.

Trump's executive order, issued on January 27, aims to prevent citizens of seven majority-Muslim countries — Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen — from entering the United States for 90 days. It suspended entry of all refugees for 120 days and barred refugees from Syria indefinitely. A federal judge has since imposed an emergency stay, halting the key parts of the executive order.

The administration's next step is unclear, but news sources have reported that Trump may take the fight to the Supreme Court or issue a revised order.

According to the Association of American Medical Colleges (AAMC), 260 medical students have applied to US residency programs from the seven countries the ban covers.

Questions include whether the ban will be reinstated, and, if it is reinstated, whether medical students would be exempted. Some worry the ban could spread to other countries. Last year, 3769 non-US citizens who studied medicine abroad matched into a US residency program, according to the American College of Physicians.

Hospital residency programs have had different responses to the executive order.

St Vincent Charity Medical Center in Cleveland, Ohio, with 67 residency spots, said in a statement, "[W]e may be forced to turn away our best candidates for fear that their citizenship will be an obstacle. This is detrimental to both the advancement of medicine and the care of our patients. And it is an affront to our faith."

Keyvan Ravakhah, MD, program director of St Vincent's internal medicine residencies, told Medscape Medical News that questions about whether candidates can get visas or can enter the United States "will impact my rank list."

Orientation there starts in June, and he says he can't take the chance someone might be delayed. "It's so complex to be a resident in the United States.... They can't be late," he said.

This is the first time the program has considered country of origin, Dr Ravakhah said. And he suspects the damage of the order may be long-lasting.

"For many of them this is a dream come true," he said. "This is heartbreaking. I think many of them may pursue other countries." The sacrifice of time and money is great, he explained, and if there's only a small chance of acceptance, they may give up hopes to come to the United States.

A Different View

At Rush University Medical Center in Chicago, Illinois, Richard Abrams, MD, associate dean of graduate medical education, takes a different view.

"This is our family and this is what our family has been for as long as I've been here," he told Medscape Medical News. "We're not going to make ranking decisions based on country of origin. We never have before."

He said that international applicants make up about 15% to 20% of the residency candidates each year and the number from the seven countries comprise a handful of those.

He acknowledges that, depending on the resolution of the executive order, his program could be short-staffed. "It's a risk we're willing to take," Dr Abrams said.

But the fears go beyond the applicants and beyond those from the seven countries, he said.

He said there's even more uncertainty among residents already in the program that the order will extend to other countries.

"The message is the same and that is if you're here, you're in our program, and if something happens, we're standing by our commitment to you," Dr Abrams said.

Uphill Battle for All International Students

International students already face high odds in matching to a first-year program in the Unted States, Signer said.

NRMP statistics show that in 2016 almost 94% of senior students in US allopathic medicine programs matched to a first-year position.

But for non-US citizens in international medical schools, "You're looking at about half of them matching to a first-year position," Signer said.

"Even if they match, they still have to get their visas taken care of, and have to get their consular interviews to get their visas…. Who knows how long those will be backed up depending on what happens with the executive order?" she said.

Effect on Physician Shortage

Atul Grover, MD, PhD, executive vice president of AAMC, told Medscape Medical News that the executive order and pending actions have brought a "mass of uncertainty" into the matching process.

The risk of ranking students in the seven countries will be especially high for programs with a small number of residencies. "There are 614 hospitals in the country that train fewer than 50 residents in any given year," he said.

AAMC has been recommending expanding the number of residencies by a minimum of 3000 to 4000 to accommodate the growth in US graduates and keep spaces for international graduates. "We're going to need all of them," he said.

International students often fill some of the widest gaps, he said.

"Because of policies and choices, they are often more likely to end up serving rural or urban underserved patients," he said, adding that people with a J-1 visa who want to stay in the United States have an obligation to serve at least 3 years in these communities, which helps get care to people who need it the most.

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