Court's Travel Ban Ups Rigors, Reluctance for Foreign Clinicians

Kerry Dooley Young

July 02, 2018

The US Supreme Court decision in favor of President Donald Trump's authority to restrict immigration from certain countries may dissuade physicians and medical students in many more nations from seeking permission to work and train in the United States, leaders within medical groups said.

"We are seeing a chilling effect from the travel ban not just in the Muslim countries but a number of other countries where people used to travel to the United States, not only to study and practice medicine but also other math and science careers," Janis Orlowski, MD, chief healthcare officer for the Association of American Medical Colleges (AAMC), told Medscape Medical News. "The intolerance to immigrants has raised concerns for many people who would normally come to the United States and study."

Barbara L. McAneny, MD, president of the American Medical Association (AMA), said in a statement to Medscape Medical News that "the president's so-called travel ban exacerbates the growing physician shortage, widens workforce gaps in underserved areas, disrupts US physician-training programs, and impedes the collaboration of scientists and health professionals seeking to prevent, prepare for, and manage public health threats."

In a 5-4 decision on June 26, the US Supreme Court justices said the Trump administration had set forth "a sufficient national security justification" for its Proclamation No. 9645, the so-called travel ban. The measure, which was modified in April, imposes various travel restrictions on citizens of North Korea and Venezuela as well as five predominantly Muslim nations: Iran, Libya, Somalia, Syria, and Yemen. The Supreme Court's majority noted that three Muslim-majority countries — Iraq, Sudan, and Chad — had been removed from the list of targeted nations since Trump introduced entry restrictions in January 2017.

In a dissenting opinion, Justice Sonia Sotomayor included the arguments made in an amicus brief from the AAMC and other medical groups. In March, more than 30 organizations, including the AAMC, the AMA, the American Nurses Association, and the American Academy of Family Physicians, asked the Supreme Court to reinstate an injunction against the proclamation.

The Trump immigration policy would have harmful effects on the nation's healthcare system, as well as on education and national security, Sotomayor wrote in her dissent, in which Justice Ruth Bader Ginsburg joined.

"What the unrebutted evidence actually shows is that a reasonable observer would conclude, quite easily, that the primary purpose and function of the Proclamation is to disfavor Islam by banning Muslims from entering our country," Sotomayor wrote.

"Unintended Consequences"

Both the AAMC and the American Society of Hematology (ASH), another party to the amicus brief, issued statements calling the Supreme Court decision disappointing. The AAMC and the ASH also said the next step will be to appeal to Congress to change the law.

"As we expressed in our amicus briefs challenging the various executive actions over the past year and a half, nationality-based exclusions will worsen the nation's health professions shortage and impair our ability to advance medicine and protect public health," said Darrell G. Kirch, MD, chief executive officer of the AAMC, in the statement.

The travel restrictions already are impeding the exchange of ideas in medicine, said William W. Pinsky, MD, chief executive officer of the Educational Commission for Foreign Medical Graduates (ECFMG). In an interview with Medscape Medical News, Pinsky recalled a recent dinner in Geneva where he met with "a great group of bright young doctors, some of whom were still in training in various countries around the world." One was a Syrian-born emergency department physician who lives in Italy. She'd been invited to give a presentation at a meeting in Chicago but could not get a visa to attend, he said.

The tone of the Trump administration's travel restrictions may reduce the size of the future pool of applicants for US training spots, even in countries where the rules might not, Pinsky said. Young physicians in India and Pakistan, for example, might have more qualms about training in a nation with these kinds of restrictions in place, he said.

In time, the Trump administration's approach could worsen the challenges in finding physicians for underserved areas, including rural parts of the country and major cities, he said.

Pinsky said these are "unintended consequences" of the White House's immigration policy. The president has said his policies seeking to curb immigration from certain countries stem from concerns about terrorism.

"While all of us are very interested in security and want us to do everything we can do to protect everybody here, we also have to realize that access to quality healthcare is a security issue as well," Pinsky said. "We don't want to inadvertently keep out individuals that can help us."

Rigors and Reluctance

In its decision in the Trump v. Hawaii case, the majority of the Supreme Court cited existing waiver programs and other paths for people from the targeted countries to enter the United States as a reason to uphold the president's proclamation.

ECFMG officials are keeping an eye on this year's applications from young physicians to see whether the Trump orders have made people reluctant to travel to the United States. The current presidential proclamation includes many of the same countries as a previous executive order.

The number of applications for ECFMG certification from Yemeni applicants in 2017 was consistent with the number from 2016. But the organization reports a combined 17.9% decrease in applications for ECFMG certification in 2017 compared to 2016 from nationals of the other five countries targeted in the executive order issued in March 2017: Iran, Libya, Somalia, Sudan, and Syria.

To date, the ECFMG has received approximately 35% fewer J-1 visa sponsorship applications from nationals of these six countries for the 2018-2019 academic year.

Although the restrictions upheld by the Supreme Court do create barriers for people seeking to enter the United States from Iran, Libya, North Korea, Somalia, Syria, Venezuela, and Yemen, in most cases, the visa classifications that are used most commonly for US training programs remain available to applicants from all countries except North Korea and Syria.

But foreign physicians and medical students must devote years of "careful planning and considerable investment" toward winning spots to train and work in the United States, wrote Ahmad Masri, MD, and Mourad H. Senussi, MD, in an article published last year in the New England Journal of Medicine. The rigors of the process mean that "only the cream of the crop" of students and physicians from foreign medical schools match into US residency programs, they wrote.

In an email exchange with Medscape Medical News, Masri said the Supreme Court's decision on the Trump immigration policy was disappointing, but expected. The court focuses only on legal issues, not on "the ethics or the practicality of the travel ban," he said.

"Restricting immigration or visa issuance should be based on the individual, not on the country of origin," Masri said. "Making the visa application process longer through requesting paperwork and social media accounts that are not proven to improve the vetting process will likely harm the healthcare system in the US."

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