Approximately a quarter of the country's physicians are international medical graduates. This diverse physician community, many of whom obtained their medical degrees abroad before taking up positions in the United States, play a significant but often overlooked role in U.S. healthcare.
According to the American Association of Medical College (AAMC), more than 6,000 international medical graduates (IMGs) come to the U.S. each year to participate in medical residency programs, under what are known as J-1 non-immigrant visas.
Once they complete their residency, these physicians have two options, should they wish to practice in the U.S. They can return to their home country for at least 2 years, then apply to re-enter the U.S. following a different immigration pathway, such as an H1-B worker visa.
Alternatively, they can apply for what is known as a Conrad 30 J-1 Visa Waiver. This allows IMGs to stay in the U.S. providing they commit to serving in underserved, often rural, areas for 3 years.
In the past 15 years, the AAMC say that this waiver has funneled 15,000 foreign-trained doctors into otherwise underserved communities.
This includes doctors such as Dr. Muhammad Tauseef, who was interviewed for a National Public Radio broadcast last January.
Born and educated in Pakistan, Dr. Tauseef remained in the U.S. under the J-1 Visa Waiver and began working with mostly uninsured children at a pediatric practice in Louisiana.
"That was a challenge," he said. "But it was rewarding as well because you are taking care of people who there aren't many to take care for."
Following a move to Texas 2 years ago, Dr. Tauseef now cares for low-income patients at Los Barrios Unidos Community Clinic in Dallas. Six of the 30 physicians who work there are from other countries.
More hostile environment for IMGs
Today, IMGs seem far more reluctant to talk about their vital contribution, perhaps given the anti-immigrant rhetoric swirling around the U.S.
One eminent surgeon approached recently by Medical News Today, for example, suddenly backtracked on an initial promise to talk about his personal experience of moving to the U.S. from Iran, citing concerns that sounded similar to those made by someone in a combat zone.
"The racist climate in the U.S. is [...] destructive. [The media] want me to answer questions [but] they will not take the bullets," he said. "The current admin has caused a lot of damage. You should talk about medicine without employing country of origin. Otherwise, you will see people commenting about 'why is he not going back to where he belongs'."
With his travel ban, President Trump is targeting citizens from predominantly Muslim countries, including Iran, Libya, Somalia, Sudan, Syria, and Yemen.
Yet in addition to legal, political, and moral concerns, these orders also threaten his own country's healthcare.
In a report published in HealthAffairsBlog, economists Matthew Basilico, of Harvard University in Cambridge, MA, and Michael Stepner, at the Massachusetts Institute of Technology in Cambridge, found that around 14 million doctors' appointments were provided each year by physicians trained in the six countries listed above.
Ironically, a large proportion of those doctors work in states that helped to put Trump into the White House - such as Indiana, Kentucky, Michigan, Ohio, and West Virginia, according to the report.
"They provide 1.2 million doctors' appointments per year in Michigan; 880,000 in Ohio; 700,000 in Pennsylvania; and 210,000 in West Virginia," the study authors wrote.
"International medical graduates have been a resource to provide medical care to areas that don't otherwise have access to physicians," said Andrew Gurman, chairman of the American Medical Association, when speaking to National Public Radio earlier this year.
"They don't all have permanent visas, and so a lot of them are concerned about what their status is going to be, whether they can stay, whether they can go home to visit family and still come back. And the communities they serve have similar questions," he commented.
The care provided by IMGs from the countries targeted by the Trump administration fills glaring gaps in U.S. health provision.
"Rural and underserved communities in the United States have long struggled to attract high-quality physicians in sufficient quantities. Incentive programs have attempted to bridge this gap, but shortages remain. Our analysis suggests that physicians entering from these countries [...] are situated on the front lines of medical need."
Basilico and Stepner also pointed out that many IMGs on the rural "front line" work in specialties that are particularly important in remote areas, where a single cardiologist or neurologist can be responsible for managing life-threatening conditions for hundreds of local people.
The challenges of being an IMG
The current uncertainties and air of threat engendered by the Trump administration swirl around foreign-trained doctors who have already had to overcome significant challenges to bring their skills to U.S. healthcare.
As well as the social and cultural implications of moving to a new country, they also face financial hurdles. For example, foreign medical licenses often don't transfer to the U.S., meaning that physicians are sometimes required to spend up to $15,000 over a 3-to-5-year period for often duplicative training.
Resource constraints can also force some foreign-trained physicians to lower their personal bar and become nurses or physician assistants in the U.S.
A study by Michelle Denise Ferreol explored the personal experiences of a range of IMGs from the Philippines, many of whom have since carved out successful careers at various levels of the U.S. healthcare system.
Having come to the U.S. in 1997, Rowena Punzalan, M.D., now practices in pediatrics and hematology in Wisconsin. But she initially had not planned to stay. "I fully intended to do my residency and go back to the Philippines," she said in the study.
But greater opportunities in the U.S. changed her mind. "I thought I could spend more time with my family here and less time working, for the same amount of earnings," explained Dr. Punzalan. "I wanted to do research, which wasn't really possible in the Philippines. I like the opportunity it affords me here to interact with leaders in the field."
Several interviewees highlighted the fact that IMGs did not always have the same access to the tools and techniques available to those who learned their trade in the U.S.
"By the time I got here, I was way behind already," said Ed Ferreol, M.D., who is now a Virginia-based neuropathologist. "When you take a residency, you get exposed to [...] techniques and practices that aren't available in the Philippines."
Racial hurdles also rear their heads. Heidi Zafra, M.D., came to the U.S. in 1992 and now practices pediatrics in Wisconsin. "Wisconsin is purely white [...] So there's a challenge making [locals] believe it's okay to have an Asian doctor. You really have to show that you're competent, but that you would really take care of them."
IMGs also face location challenges, often taking up positions in isolated rural communities. For instance, working as a psychiatrist in Alabama, Tina Zafra, M.D., spoke of having to "learn what Southern culture is all about. The food, the people, the conservatives - they're mostly conservative Republicans."
She is echoed by Benjamin Gozon, M.D., who is now a physical medicine and rehabilitation doctor in Wisconsin. "With the cultural differences, it's not that easy to make friends," he said. "You don't necessarily have a lot in common with many people around here."
Yet despite coping with "outsider" challenges, IMGs continue to plug the gap in healthcare provision that many U.S.-trained physicians seem reluctant to fill.
The Atlantic has covered issues that put U.S.-trained doctors off rural practices, and one heartfelt response came to a feature by Olga Khazan last January.
"Most doctors don't want to live in areas with no amenities. They don't want to send their kids to schools where creationism is taught in biology class," railed Zeeky34. "Who are they going to hang out with in rural areas [where] there aren't many educated people? Lots of doctors are non-white - they sure don't want to live in those places. What does rural America have to offer American doctors?"
Long-term contribution by IMGs
Embracing immigrant physicians is vital for U.S. healthcare in terms of long-term demographics of an aging population, as much as to address current shortages in rural provision.
The number of adults aged 65 years or older is expected to increase by nearly 20 million by 2030, matched by a growing need for physicians in health professional shortage areas that threatens to create a significant dearth of physicians in the coming decades.
The Trump administration's efforts to block immigrants from countries that provide many IMGs are therefore particularly ill-conceived.
"There could very well be a patient in a rural area who had an appointment with their doctor this week and the doctor was not allowed back into the country," said Matthew Shick, director of government relations and regulatory counsel with the AAMC, speaking to CNN.
He went on, "At a time when the United States is facing a serious shortage of physicians, international medical students are helping to fill an essential need."
In June 2017, the AAMC joined 21 other health-related organizations to highlight the short-sightedness of the Trump administration's anti-immigrant stance.
In a statement, they said, "International researchers and scientists strengthen the laboratories at medical schools and teaching hospitals that develop cures for life-threatening and chronic conditions, providing hope for millions of Americans."