Travel Ban Is Revealing—but Does Not Threaten American Medicine

Travel Ban Is Revealing—but Does Not Threaten American Medicine

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A 90-day ban on travel from seven countries has sparked tremendous outpourings of worry or outright opposition by some 33 medical organizations.

“The community is reeling over the order, fearing that it will have devastating repercussions for research and advances in science and medicine,” states an article in Modern Healthcare.

Certainly the order is disrupting the lives of individual physicians who have won coveted positions in American medical institutions and were not already in the U.S. when the order was issued. Also their employers have a gap in the work schedule to fill. War tears people’s lives apart, however innocent they may be. And countries that sponsor terrorism have effectively declared war on the U.S.

But is American medicine so fragile that it can’t survive a 90-day delay in the arrival of physicians, most of them trainees, from Iran, Iraq, Libya, Syria, Yemen, Somalia, and Sudan? After all, every year more than a thousand seniors in U.S. medical schools do not land a position in a post-graduate training program through the annual computerized “Match” of graduates with internships.

After another chance through the Supplemental Offer and Acceptance Program, or SOAP, hundreds of seniors are still without a job. This means that they cannot get a license to practice in the U.S., however desperate rural communities or inner-city hospitals are to find a physician, and their four years of rigorous, costly post-college education are wasted. Yet James Madara, CEO of the American Medical Association (AMA), is worried about vacant residency slots, according to a Feb 3 article in MedScape by Robert Lowes.

Entry to medical school is highly competitive, so presumably all the students are well-qualified. Can it be that graduates from Sudan are better trained? Does the U.S. have so few young people capable of and interested in a medical career that we have to depend on a brain drain from countries that are themselves desperately short of physicians?

For all the emphasis on “cultural competence” in American medical schools, and onerous regulations regarding interpreters for non-English speakers, what about familiarity with American culture and ability to communicate effectively with American English speakers? Some foreign-born graduates are doubtless excellent, but many American patients do complain about a communication gap. So why do some big institutions seem to prefer foreigners? Could it be that they want cheap, and above all compliant labor? Physicians here on an employment-related visa dare not object to hospital policy.

Whatever the reasons for them, here are some facts about the American medical work force:

One-fourth of practicing physicians in this country are international medical graduates (IMGs), who are more likely to work in underserved areas, especially in primary care, according to Madara. According to the Accreditation Council for Graduate Medical Education (ACGME), 10,000 IMGs licensed in the United States graduated from medical schools in the seven countries affected by the ban.Immigrants account for 28% of U.S. physicians and surgeons, 40% of medical scientists in manufacturing research and development, and 15% of registered nurses, according to the Institute for Immigration Research at George Mason University. More than 60,000 of the 14 million workers in health-related fields were from the seven countries affected by the ban.

Is medicine, like agriculture, now filled with “jobs that Americans won’t do”? Actually, we have more than enough Americans who love medical work. But some of best doctors are being driven out by endless bureaucratic requirements, including costly “Maintenance of Certification™” programs that line the pockets of self-accredited “experts” but contribute nothing to patient care. They are being replaced (substituted for) by “mid-levels” with far less training. Then there are thousands of independent physicians having to retire or become employees because they can’t afford the regulatory requirements—soon to be greatly worsened by MACRA, the new Medicare payment system. Physician “burnout” is becoming so bad that we lose up to 400 physicians—the equivalent of a large medical school class—to suicide every year.

The U.S. should be a beacon to attract the best and brightest, and it should welcome those who want to become Americans. Unfortunately, the lives of Americans, as well as the opportunities of aspiring foreign-born doctors, are threatened by those who desire to kill Americans and destroy our culture. These must be screened out.

Meanwhile, the reaction of organized medical groups to the travel ban is spotlighting serious problems in American medicine.

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38 Comments on "Travel Ban Is Revealing—but Does Not Threaten American Medicine"


Member
Feb 20, 2017

Many comments below take large exception to this blog post. My take it that it raises some interesting issues…..for example the hundreds of medical students who don’t “match”…..and comparing them to the international students who take slots. I don’t know the answer, but it seems a worthy discussion point…..and the exodus of talent from third world countries (vs. a more libertarian argument that people should be free to migrate) is a topic also worthy of discussion and debate. Thank you THCB for publishing.

Member
Feb 14, 2017

Basic Health Access recovery requires spurious studies and statements to be challenged.

The following indicate distributions and primary care contributions of different medical school origin graduates. Only Allopathic private US medical schools have worse distribution than International graduates when considering locations over decades rather than a few years after graduation. Only origins in certain nations contribute to distribution and to primary care.

If the AMA and others really focused on health access, why did they allow the 5th Pathway to be terminated – one of the best routes to Spanish speaking physicians and graduates among the most likely to distribute.

Note that the AMA and other databases do not track about 20% of IMGs who leave the US after training and are found in other nation.

Medical School Grads 1987 to 1998 as found in the AMA Masterfile 2013 in practice zip codes with over 75 physicians (Super Centers and Major Centers)

77.3% Allopathic Private Most exclusive origins, training, specialties, locations
77.0% Other Distant International
75.4% MS in India
71.7% National Average
70.3% Allopathic Public
68.2% Central American
61.4% Caribbean
57.9% Osteopathic Private
54.1% Osteopathic Public Least exclusive origins, highest choice of FM, and best distribution
50.1% Canadian Over 30% found in Canada

Most concentrated results in the least distribution and is a result of exclusive origins, scores, selections, training choices, careers, and top concentrations of health care dollars.

Most concentrated, particularly when not choosing family medicine, translates to least care where needed. Choice of family medicine is least in the most concentrated and are most in those distributing above average.

Here are the estimated standard primary care years over a career based on the half way point after graduation

Standard Primary Care Years (Active in US x % Office Primary Care x Career Years)
13.49 Osteopathic Lower MCAT Higher proportions active in US, FM dominant
12.48 Osteopathic Higher MCAT
12.04 Caribbean US and international origin medical school graduates
11.80 Historically Black
11.53 Allo MCAT 8.5 – 9.25 Lower MCAT results in higher primary care contributions
11.50 West Distribution U of Washington and U of California Schools were doing better at the time
11.38 The Philippines
10.61 Nigeria
10.39 Allo MCAT 9.25 – 9.5
9.97 Early Admission Schools
9.88 Allo MCAT 9.5 – 10
9.60 Allo MCAT 10 – 10.5
9.54 Central America Now lower due to loss of 5th pathway
8.88 Pakistan
8.73 National Average 1987 – 1998 Grads All Sources
8.05 Allo MCAT 10.5 – 12
7.36 Puerto Rico
7.22 India Origins
5.68 Other Distant
5.37 Canadian
4.04 China Lowest proportion active in US and in office primary care

Note the inverse relationship with MCAT and other standardized test scores.

A greater range of tracking of graduates reveals limited contributions of international graduates due to losses out of the US after training, exclusive origins among concentrations, exclusive locations for US training, low choice of family medicine, and poor retention in primary care for those taking primary care training due to predominant choice of internal medicine.

Only 13% of the internal medicine geriatricians (about half are IMG) are found in 2621 lowest physician concentration counties where 43% of the elderly are found and even higher proportions of the complex elderly.

Yes there are contributions. No, the contributions of IMGs are not stellar. Most importantly no MD DO NP or PA solution for health access can work without entirely different financial designs for generalists and general specialties – 90% of the services for the 2621 lowest physician concentration counties where access is still delayed, denied, and compromised by design.

Member
Feb 14, 2017

Dr. Orient – I have watched the AAPS for a long time as I tend to agree on their stances regarding over-regulation in medicine and the burden placed on physicians like me — who loves my patients, works hard to make their lives better, and yet still could have an insolvent business despite my best efforts. I am with you for the second half of your piece as you echo my sentiment well.

However, the first half of your piece has nothing to do with the second. I am well aware of the difficulty American medical students have matching and this is a tragedy on its own, however this is not the fault of FMG’s. FMG’s are very well trained in their respective countries and do this country quite a service regarding caring for underserved populations.

From the October 12th blog post on AAPS… “The Association of American Physicians and Surgeons stands for the preservation of the sanctity of the patient-physician relationship, and for safeguarding the individual rights and independence of patients and physicians…
As physicians we are obligated to protect our patients and our healing mission. We must continue to guide, educate, and support our patients through these confusing and turbulent political times.”

Physicians must at our core agree on one thing: we should ALWAYS fight injustice and come down on the side of humanity. The discrimination of specific individuals has been done throughout history everywhere in the world. When we begin to endorse it in ANY form, human beings suffer. I am disappointed by the first half of your post. This should not the mission of a practicing physician.

My hope is for the AAPS to get back to doing what needs to be done. Stop getting distracted by political issues that do not forward the agenda of independent physicians everywhere. Focus, please, for we have our work cut out for us. Do it for patients across this great nation who depend on us. Do it for the forgotten children who have no one to fight for their health and wellness. Do it for the elderly patients who need a physician advocate.

Member
Feb 14, 2017

This post and the prior asking our President to apologize are difficult to respond to given that both reflect moralistic outrage of varying degrees–always a challenge to reply to. I can, hazily, recall 1968-71, when I served in the military and in Viet Nam. When I came back home, I was vilified as were the people I served with. The rhetoric and its overwhelming moralistic bludgeoning were similar to what we are hearing today. I can recall how I cringed when people asked “were you in Viet Nam,” or in a group asked if there were Viet Nam vets amongst us. It just wasn’t worth raising your hand. I neither wanted the pat on the back nor to try to persuade anyone about anything to do with Viet Nam. It was undeniably FUBAR.

Regarding this current FUBAR, one might ask whether such posts further considered thought and dialogue on the subjects at hand. If so, good. But if they only advance full blown outrage (from both pros and cons) and nothing further, then I start to turn off my hearing aids. Writers here should be doing more than criticize; we owe it to ourselves to further the debate with consideration of the “other side” and reasoned suggestions on what to do.

Was the order poorly thought out? For sure. There were so many better ways to do this; but it seems that our President is more interested in making an emphatic point and then walking it back than taking 12 months or so to craft a more balanced approach and then try to walk it through a Congress that would find ways to delay and fight it tooth and nail. Even so, it shouldn’t have happened.

I can recall my son in his late 20’s telling me about how much he hated where he was working. My reaction was to “fix” that, and I immediately started talking to him about where he might send his resume and some contacts I had. He got angry with me, and said words that I’ll remember for a long time: “Dad, I wasn’t asking you to fix this for me. I’ll do that. I just wanted you to listen to me and share my frustrations.” Our posts should be about more than sharing indignant frustrations.

Oh, and the connection between the ban and healthcare is a tad tenuous, as Margalit pointed out.

Member
rosskoppel
Feb 14, 2017

There is so much wrong with this article. Doctors are not killing themselves because of the need to re-certify their skills., I agree the professional associations rake in the money for this…but this is not the government….this reflects rules by fellow physicians.

Most of this piece is just blind rage against any regulation (except against abortion). Doctors are unhappy because of the terrible EHR software they struggle with daily, because they must fight with insurance companies, and because of the insane payment system we have here absent a rational payment system. Similarly, if foreign doctors are taking the worst jobs in the worst places, why would this upset American physicians?

The author did not speak out against the high cost of medical training, but that certainly is a major source of tension for younger doctor; much more so than that a fellow doctor in the poorer hospital across the state has a funny accent.

PS: Doctors familiar with Big Macs are probably not advising their patients wisely about nutrition.

Member
Feb 14, 2017

Everybody sitting down? Good. A glass of water could help too…. Here we go…

Why do articles like this one come into existence? Why did it take a coin toss to decide whether to publish or not to publish? Oh, sure, you can take issue with pretty much every sentence, but something in the whole is infuriating precisely because it cannot easily be dismissed: the travel ban has nothing to do with medicine in America. It just doesn’t.

You may think that the travel ban is ill-conceived, idiotic, evil, discriminatory, unconstitutional, fascist, whatever floats your boat….. but that does not change the simple fact that it has nothing to do with medicine.

Yes, a few doctors were caught in the ban (probably some engineers, teachers, waiters, drivers, etc. as well). Yes, the human stories of the physicians were unfortunate, but were they worse than the stories of waiters, drivers or full-time moms? Or are we implying that physician misfortunes are somehow more important than, say, a taxi driver’s travails? See where I can take this? I won’t though.

At some point some hot-the-trot “reporter” decided to make a connection that doesn’t exist (that’s how the press works now) and state that the travel ban will hurt medicine in the US, will hurt poor and rural people, will hurt science and research and we’re all going to die as a result of the travel ban, maybe not this travel ban, but future ones, bigger and meaner ones, certain to come, etc. etc. etc. And “we” went along with that, because it supports our beliefs, because the end justifies the means, because when they go low, we don’t go high. We go straight down into the sewer, head first, and we know it, and it’s terribly frustrating, and it makes us feel guilty inside, and insanely raw and angry on the outside.

Articles much, much worse than this one were written all over the place all the time. Why do we blow a gasket now? Why are we unable to patiently debate anything anymore, let alone concede that a tiny random grain of truth may even exist on the “other” side, god forbid the heresy?

And here is the saddest part. Outside our ever shrinking echo-chambers, we’re losing the big argument. We’re losing it because a perpetual stream of uncontrolled outrage is not very persuasive to anyone but those already outraged, and eventually even they will grow tired….

Member
Peter
Feb 15, 2017

“Why do we blow a gasket now?”

You’re right, more voters should have recognized a despot before they voted.

Gaskets are being blown because because this act is the insidious tip of what this administration is capable of. This act gives license to the acts that will follow. This weekend two muslim Canadian women were questioned at the border about their religion and if they liked Trump. They were detained for 5 hours and had their cell phones investigated. The agents found several harmless religious videos that I doubt they understood and ultimately the women were denied entry to visit their relatives.

THAT’S WHY WE ARE BLOWING A GASKET.

Member
Feb 15, 2017

Peter, the travel ban was stupid. The implementation of the travel ban was a master class in incompetence. The courts struck it down. There is no tip and no iceberg. It’s how government was set up to work, and it worked. People got caught at the borders before the travel ban, and will get caught after the travel ban, for all sorts of idiotic reasons (I missed a flight from Canada a few years ago because I was traveling with a colleague who had a green card and they detained him and humiliated him for hours).
That’s not why we are blowing a gasket….

Member
Peter
Feb 15, 2017

“There is no tip and no iceberg.”

Wait for it, it’s only been 25 days.

“It’s how government was set up to work,”

No, it’s how this government is set up to work.

Member
Peter
Feb 15, 2017

“Yes, a few doctors were caught in the ban (probably some engineers, teachers, waiters, drivers, etc. as well). Yes, the human stories of the physicians were unfortunate, but were they worse than the stories of waiters, drivers or full-time moms? Or are we implying that physician misfortunes are somehow more important than, say, a taxi driver’s travails? See where I can take this? I won’t though.”

This is a health care blog, if you want to discuss the other careers affected then go to the taxi blog, or engineer blog, etc. By extension this ban affects the whole country.

No, I don’t see where you take this.

Member
Feb 15, 2017

It’s not about this blog. It’s about national headlines. I have not seen any national headlines running story after story with breathless updates about individual cabbies or about the ruin of the taxi industry, complete with charts, and color graphics..

Member
Allan
Feb 14, 2017

Margalit, once again I enjoyed the thrust of your argument and have much agreement. Who you voted for doesn’t change the excellent points you make. You were a strong supporter of Sanders who was beaten by Clinton. I think Sanders had at least as much support as Clinton in the Democratic party, but apparently many in the Democratic leadership didn’t recognize how important some of his issues were. If they did I believe Clinton would be President today. Outrage Trumped Clinton and Trump Trumped outrage.

Member

Many comments below take large exception to this blog post. My take it that it raises some interesting issues…..for example the hundreds of medical students who don’t “match”…..and comparing them to the international students who take slots. I don’t know the answer, but it seems a worthy discussion point…..and the exodus of talent from third world countries (vs. a more libertarian argument that people should be free to migrate) is a topic also worthy of discussion and debate. Thank you THCB for publishing.

Member
Feb 14, 2017

This extremist, politicized post is riddled with spin and comes from the leader of a fringe physician group with deeply objectionable positions. It has no place on this website.

“The AAPS statement of principles declares that it is “evil” and “immoral” for physicians to participate in Medicare and Medicaid, and its journal is a repository for quackery. Its website features claims that tobacco taxes harm public health and electronic medical records are a form of “data control” like that employed by the East German secret police. An article on the AAPS website speculated that Barack Obama may have won the presidency by hypnotizing voters, especially cohorts known to be susceptible to “neurolinguistic programming”—that is, according to the writer, young people, educated people, and possibly Jews. […]

“[…] promotion of dangerous medical quackery, such as antivaccine pseudoscience blaming vaccines for autism, including a view that is extreme even among antivaccine activists, namely that the “shaken baby syndrome” is a “misdiagnosis” for vaccine injury; its HIV/AIDS denialism; its blaming immigrants for crime and disease; its promotion of the pseudoscience claiming that abortion causes breast cancer using some of the most execrable “science” ever; its rejection of evidence-based guidelines as an unacceptable affront on the godlike autonomy of physicians; or the way the AAPS rejects even the concept of a scientific consensus about anything. Let’s just put it this way. The AAPS has featured publications by antivaccine mercury militia “scientists” Mark and David Geier.”

Source: http://nymag.com/scienceofus/2016/12/tom-price-belongs-to-a-really-scary-medical-organization.html

Member
Peter
Feb 14, 2017

“every year more than a thousand seniors in U.S. medical schools do not land a position in a post-graduate training program”

“But 8,640 did not — a number that includes international applicants”

“we lose up to 400 physicians—the equivalent of a large medical school class—to suicide every year.”

“Although it is impossible to estimate with accuracy because of inaccurate cause of death reporting and coding”

“the lives of Americans, as well as the opportunities of aspiring foreign-born doctors, are threatened by those who desire to kill Americans and destroy our culture. These must be screened out.”

Yes, screened out in an intelligent, organized and effective way – not through a mindless tweet thought designed to appease the political base while fear mongering an entire religion.

And by the way, there is already an extensive screening process in constant review for its effectiveness.

You’ve got a credibility problem doc.

Member
Steve2
Feb 14, 2017

“are threatened by those who desire to kill Americans and destroy our culture. These must be screened out.”

Agreed. So let’s ban people from the countries where killers really come from, like KSA, Egypt and Pakistan.

Member
Allan
Feb 14, 2017

Steve, That may or may not be a good idea even if sarcasm was involved. I can’t say since apparently the seven countries were on the temporary ban list because there is no way at the present to check the history of immigrants from those seven nations.

However, thinking about things in a completely different fashion, the US has first world healthcare and these countries under discussion don’t. Why are we so satisfied to brain drain trained physicians from these nations where trained medical personal are in short supply and the needs for these doctors are so much greater?

Member
Peter
Feb 14, 2017

“because there is no way at the present to check the history of immigrants from those seven nations.”

So the U.S. was just flipping a coin?

Wrong as usual Allan.

http://www.vox.com/policy-and-politics/2017/2/2/14452090/refugee-vetting-difficult

Member
Allan
Feb 14, 2017

There has been so much infrastructure destruction that the normal ability of governments to communicate with one another prevents our government from verifying needed information in those 7 countries where false passports are used by many.

Peter, there was no flip of a coin by Trump or Obama in recognizing that problem. It appears that your responses are based upon what wall you are presently banging your head against. All I seem to hear from you is insult after insult with accusations all lacking fact or any understanding of what you are talking about.

Member
Steve2
Feb 14, 2017

“Why are we so satisfied to brain drain trained physicians from these nations where trained medical personal are in short supply and the needs for these doctors are so much greater?”

I think it is a good question. I dont know if we are morally correct to be doing this. As a physician I think I almost have too many conflicting interests to have a valid opinion (and I am pretty opinionated). It would likely benefit me financially to keep these people out of our country. OTOH, it would also benefit, probably those people in those other countries. Weigh that against basic life, liberty and pursuit of happiness beliefs and I don’t know the correct answer. As a first pass answer, I think we should have more domestic production of physicians, meaning we need more residencies and a few more med schools.

Steve

Member
Allan
Feb 14, 2017

Steve, I liked your answer. Honest and willing to question both sides of the equation. I always think about this question much like you do and consider the morality. People are dying all over the world and we have so much yet we complain and are terribly self centered. I soothe my feelings knowing that our capitalist system here has helped to bring so many lives out of dismal poverty all over the world.