DOCTOR'S ORDERS

Foreign medical students learn today how much America wants them

Obsession
"America First"
Obsession
"America First"

Like most physicians, Irene (who requested her last name be withheld) is an overachiever. She’s a trained obstetrician-gynecologist, a reproductive health researcher at an Ivy League university, and even served as a volunteer surgeon in war-torn Iraq.

She’s also from Iran, one of the six predominantly Muslim countries whose citizens are banned from entering the US under an executive order by US president Donald Trump. At 1pm eastern time today (March 17) Irene and hundreds of other international medical students will find out how that ban affects their future.

Each year, thousands of anxious fourth and final year medical students around the world participate in the National Residency Match Program (NRMP)—affectionately known as “The Match”—when they learn where they will be placed to train to become US licensed physicians in one of 21 specialities. This year, more than 42,000 medical students—a record—applied to be matched with 32,000 spots in 5,000 programs, according to the NRMP. Of last year’s 35,000-plus applicants, 7,460 were international medical graduates with citizenship from a country other than the US or Canada.

Trump’s travel ban is only temporary, and has been blocked while facing challenges in court. But students from the affected countries are worried that the ban will hinder their ability to secure clinical training visas. That obstacle, or even the perception of an obstacle, could be enough to make programs less likely to take them on as a match. According to 2016 NRMP survey data (pdf), 42% of program directors consider visa status—that is, obtaining the appropriate visa for clinical training—as an important criterion for a residency application interview. Post-interview, 26% consider it significantly during the ranking process.

 Students from the affected countries are worried that the ban will hinder their ability to get visas. Students aren’t alone in their fears. Organizations that include the American Association of Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), and the Educational Commission for Foreign Medical Graduates (ECFMG) have voiced concerns about the ban’s potential impact. Match Day anxieties are emblematic of the ripple effect Trump’s ban could have on US healthcare, which depends heavily on immigrant doctors.

Irene, who was informed along with other applicants on Monday of her match with an American clinical program, learns the details of that match today. She worries the ban might have affected her chances of being offered a position in her top-choice obstetrics/gynaecology programs, and that her training location preferences will be compromised because of her Iranian citizenship. Even if she is able to secure a clinical training visa, Irene worries that she will be unable to re-enter the US if she has to leave for any reason. The US “is always referred to as a land of opportunity,” she says. “Now I realize that they are closing the door for people like me.”

The AAMC estimates that the current group of Match applicants includes more than 500 from the six countries banned by Trump’s most recent order. That figure was obtained by looking at applicants born in, currently living in, or who have recently graduated from medical school in one of those countries. The NRMP would not confirm the AAMC figure, noting that they do not collect data on applicants’ country of origin.The ECFMG did not respond to a request for comment, but told ABC News it estimated 850 applicants would be affected.

On Wednesday, two federal judges blocked Trump’s order, which was a revised version of an earlier ban on immigrants from seven predominantly Muslim countries. (That ban is also tied up in court, after being struck down by a federal judge last month.) But applicants from Iran, Libya, Somalia, Sudan, Yemen, and Syria may already have been affected, as program directors ranked their choices weeks ago. Applicants from those countries may be at higher risk than in the past of not matching at all, or may have to settle for locations that are less preferable—all because of the fears many programs have around ranking applicants who may not obtain a clinical training visa in time to start this summer.

 “Some program directors say…‘‘I just can’t take the risk of ranking someone who can’t start on July 1.’” “We are deeply disappointed that the revised executive order [does not] explicitly recognize the importance of international medical graduates, physicians, and medical researchers to the nation’s health security,” the AAMC said in a statement last week. It urged the Trump administration to “at the very least” apply waivers to health professionals affected by the ban.

Some program directors “are ranking people best suited for their programs and others say, ‘I just can’t take the risk of ranking someone who can’t start on July 1,’” says AAMC’s executive vice president, Dr. Atul Grover.

Keyvan Ravakhah, the internal medicine program director at St Vincent Charity Medical Center in Cleveland, falls in the latter category. He says that the hospital took the ban into consideration when compiling their Match list, adding that in the future the program might only interview candidates whose visas are secure.

“We want to have [competitive doctors] in our residency. At the same time, we want to make sure we have enough people who don’t have visa issues,” Ravakhah says.

America depends heavily on immigrant doctors. As of 2015, more than a quarter of physicians and surgeons in the US were born outside the country. An estimated 7,000 international medical graduate physicians—which includes current medical residents—hail from the six countries affected by Trump’s ban, according to the Immigrant Doctors Project out of Harvard University. Altogether, those doctors provide Americans with 14 million medical appointments a year.

Grover points out that international medical graduates typically have about a 50% match rate to US residency programs; last year’s was 46.8%. The 2017 match rate will be released by NRMP today, but since it doesn’t separate graduates by country of origin, it will be difficult to determine the ban’s impact right away.

For now, most organizations that assist foreign students are in a wait-and-see mode, though vocal in their opposition to the travel orders. After the original executive order, the Accreditation Council for Graduate Medical Education released two statements—the most recent (pdf) pointing out that 10,000 licensed physicians in the US hail from one of the original seven countries included. Many of those doctors participated in the “Conrad 30 Waiver Program,” which permits new doctors to work in specific underserved areas in the US after residency. The Council also found that 1,800 doctors from the original seven countries were currently in residencies and fellowship programs—serving close to 1 million patients annually.

“We are fairly specific in the expectations that physicians care for patients regardless of social status and ethnic background, and that’s the culture we build into our residency programs as well,” says the Council’s chief executive, Dr. Thomas J. Nasca.

The NRMP, a private nonprofit organization which has run the Match since 1952, released a statement (pdf) in February acknowledging the concerns raised by the ban. But the organization is optimistic that program directors will choose residents without considering visa requirements (even though last year’s survey illustrated it as an important factor).

CEO Mona Signer said via email that the organization had not been contacted by program directors with concerns about the ban. And the organization’s chair, Dr. Maria Savoia, is optimistic the Match process won’t be impacted.

“We believe that the Match process will be fair this year and we have encouraged the programs to pick the best matches irrespective of country of origin,” said Savoia.

 “It’s often the most exceptional students from these countries who apply to train.” All the uncertainty means that some program directors are bracing for a potential excess of unfilled spots, particularly in underserved areas, such as the rural midwest and rural south, where physicians trained outside the US often serve.

“Over 90% of Americans have at least one doctor—a resident or independently practicing physician—from a country [affected by the ban] in their commuting zone, and these doctors disproportionately work in rural midwestern states, known as the Rust Belt,” says Heather Sarsons, an economist with the Immigrant Doctors Project. She believes the ban could ultimately dissuade international medical students from even applying for programs in the US.

Matthew Basilico, a researcher with the Immigrant Doctors Project and a Harvard medical student and economics PhD student, worries about what a low match rate among doctors from the affected countries could mean for the quality of healthcare in the US more broadly. One recent study in BMJ found that patients of foreign medical graduates have lower mortality rates.

“It’s often the most exceptional students from these countries who apply to train,” Basilico says. Without them, “we know that quality of care could suffer.”

Correction: An earlier version of this article named Keyvan Ravakhah’s place of work as the St. Vincent’s Charities Hospital, instead of the St. Vincent Charity Medical Center. This story has also been updated to reflect information from the Educational Commission for Foreign Medical Graduates.

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