A Quarter of the Work Force: International Medical Graduates and the Lives They Save

By Wendy S. Salkin

On Monday, May 1, 2017, International Workers’ Day, thousands took to the streets across the United States to demonstrate in support of immigrants’ rights in the United States and against immigration policies recently rolled out by President Trump.

Among the Presidential Actions taken by President Trump during his first hundred days in office has been the issuance of his “Buy American and Hire American” Executive Order, issued just two weeks ago on April 18, 2017, in which the President states that “[i]t shall be the policy of the executive branch to buy American and hire American.” What is meant by “hire American” is detailed in section 2(b) of the Executive Order:

Hire American. In order to create higher wages and employment rates for workers in the United States, and to protect their economic interests, it shall be the policy of the executive branch to rigorously enforce and administer the laws governing entry into the United States of workers from abroad, including section 212(a)(5) of the Immigration and Nationality Act (8 U.S.C. 1182(a)(5)).

Among the laws governing entry to the United States of workers from abroad are those that regulate the H-1B visa program, which “allows companies in the United States to temporarily employ foreign workers in occupations that require the theoretical and practical application of a body of highly specialized knowledge and a bachelor’s degree or higher in the specific specialty, or its equivalent.” As of April 3, 2017 of this year, premium processing of H-1B visa petitions was suspended for up to six months. Premium processing is a 15-day process whereby the H-1B visa is “issued to highly skilled foreign workers.” But, during the premium processing suspension period, “applicants will likely have to wait six months or more for their visa to be approved.”

Physicians, researchers, and media outlets alike have voiced concern over the effects that the President’s new immigration policies are anticipated to have on the distribution of H-1B visas to international medical graduates, on which numerous American hospitals throughout the United States rely for staffing.

As Kahn & Gardin reported in their April 17 Research Letter in JAMA, “Distribution of Physicians With H-1B Visas By State and Sponsoring Employer”:

A total of 10 491 labor condition applications [LCAs] were certified for use in physician H-1B positions by 2156 sponsoring employers in 2016. Nationwide, applications to the H-1B program represented 1.4% of the active physician workforce. New York state had the largest number of applicants (n = 1467; 14.0%), followed by Michigan and Illinois. North Dakota had the highest percentage of the physician workforce comprised of H-1B applicants (n = 1602; 4.7%)…

Kahn & Gardin also reported that, “[i]n 2015, 24.2% of active physicians across the [United States] were international medical graduates [IMGs].” As Miriam Jordan of The New York Times reported in her March 18 article, “Rural Areas Brace for a Shortage of Doctors Due to Visa Policy”:

There were 211,460 international medical graduates practicing in the United States in December 2015, according to the latest data available from the Educational Commission for Foreign Medical Graduates.

Uncertainty over how the proposed overhaul of the H-1B visa program will affect international medical graduates who serve as physicians in the United States has led to expressions of insecurity among hospitals, physicians, and patients alike.

For instance, the Maine Hospital Association has expressed “worr[y] that 20 out of Maine’s 36 hospitals are now vulnerable to a potential doctor shortage.”

And Dr. Muhammad H. Majeed and Dr. Fahad Saeed’s letter to the editor, “Denying Visas to Doctors in the United States,” was published in The New England Journal of Medicine on March 2 of this year.[1] There, they give voice to the insecurity of IMG physicians who are concerned that the new administration’s immigration policy changes will make it difficult or impossible for them to renew their visas:

The possibility of these administrative changes has made us and many IMG physicians who require a visa feel insecure about our future here in the United States. Muslim IMGs are particularly concerned because of President Trump’s statements suggesting that Muslim immigrants may be temporarily banned from the United States. Will the renewal of our visas be denied? Will we be required to leave the country, even though we are residing here legally? This uncertainty undermines confidence in the health care system and potentially erodes the trust that physicians have established with their patients.

This widespread insecurity among IMG physicians finds its complement in the insecurity experienced by their patients. Dr. Majeed and Dr. Saeed make their patients’ concerns salient by opening the letter with the following scene:

In an embarrassed tone, an 87-year-old patient with end-stage chronic renal disease who is now receiving palliative care asked one of us, “Will you be able to stay in the United States for a few more months? I don’t want to change my physician during the last few months of my life.” He was expressing concern about the impact of statements made by President Donald Trump about immigration and immigrants. Since the November election, both of us have received similar expressions of concern from other patients as well.

While the full impact of the administration’s new immigration policies remains to be seen, we already have ample evidence of the indispensability of IMGs to the American healthcare system. As Vox reported on February 3 of this year: “[c]ompared with US-trained physicians, foreign doctors are…more likely to practice in areas where there are doctor shortages—in particular, in rural areas….They’re also more likely to serve poor patients on Medicaid….” What’s more: IMGs “make up more than 50 percent of geriatric medicine doctors, almost half of nephrologists (or kidney doctors), nearly 40 percent of internal medicine doctors, and nearly a quarter of family medicine physicians, according to data from the Association of American Medical Colleges.” And then, there is the BMJ study published on February 3 of this year that, as Vox explained, shows “patients treated by foreign-trained doctors had better mortality outcomes than those treated by doctors who went through American medical schools.”

This, then, is a reminder that among the international workers we recognize on May Day are those who have chosen to move to the United States to provide indispensable healthcare to patients throughout the country, which patients may well go underserved or completely unserved but for these physicians.

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