On Friday evening, President Donald Trump signed an executive order halting immigration from Syria, Iran, Iraq, Libya, Somalia, Sudan, and Yemen. It’s a reckless order that has sweeping implications for the medical community and its future generations.

In March, medical students and graduates of foreign medical schools will learn if they matched with a residency program and can pursue their medical careers. With Trump’s executive order come concerns that applicants from those seven countries will be disregarded because of questions over whether they’ll be able to enter and stay in the United States. The order could easily end medical careers in America before they begin.

I’m a first-year resident at Cambridge Health Alliance, so I remember distinctly the difficulties and anxieties of applying for a residency. For a woman I know here in the Boston area, the executive order has added an extra layer of stress to an already stressful situation.

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She is a young doctor from Iran who has had several interviews all over the US. She is worried that her application will be disregarded if a program director thinks that she won’t be able to get back into the US if she goes home. She’s just applied for a visa renewal and worries that a hospital won’t take a chance on her, even though she is well-qualified.

A program in Ohio has already made such decisions.

“It’s very unfair,” she said. The woman asked not to be named out of fear for her placement. “We may not have a chance to get into residency because of this law.”

After finishing medical school in Iran, she moved to the United States in 2014 to train in neurology. She landed eight interviews this season, which is a testament to how well her skills are regarded. Because of the order, it’s unclear which programs are still considering her and which have decided not to.

This makes my heart sink. I come from a family of immigrant doctors, and I’m intimately familiar with the extra hoops foreign medical graduates need to jump through in order to train and practice in the United States. From securing research opportunities to doing additional rotations and observerships, international medical graduates often need to do more than the average American medical student just to get a foot in the door for a residency spot.

We need doctors — there are shortages in nearly every specialty. For decades, the US has relied on foreign medical graduates to fill unmet need.

Trump’s “extreme vetting” of Muslim immigrants may turn her dream into a nightmare. She’s convinced her nationality will affect decision-making.

“It feels like you are suffocating because you cannot do anything ” she said.

Another doctor I spoke to from Sudan has been preparing for three years to apply for a competitive spot in vascular surgery. He also asked for anonymity for fear of visa problems.

Between taking his medical licensing exams and securing rotations with different surgeons, he has been forced to travel back and forth between the US and Sudan because his visas have allowed him to be here only three months at a time. Despite these obstacles, he was also able to secure eight residency interviews.

“What I’m worried about is how this can affect the rank order lists, because this news, when it came, it came at a critical time for us,” he said. “It’s really a big blow for doctors who want to do residency in the US. We spend a lot of money and we spend a lot of physical time since our graduation to come here.”

He could have gone to the UK or Saudi Arabia, but he told me that he came to the US because there is no limit to achievement here. He plans to call program directors to plead his case.

“I’m shocked … I’m really overwhelmed about what is going on,” the man said.

For residents already in training here, the ban has implications too.

Last week, hours before Trump signed the order, I received a letter from the Committee of Interns and Residents, warning our members not to travel outside of the US.

“If you are from a Muslim majority country, we recommend seeking legal advice from an immigration attorney before exiting the U.S,” the advisory warned.

The CIR’s website even advises all foreign nationals legally working in this country to take precautions. “At this juncture, nationals of all countries may want to consider postponing all non-essential travel until the implications of this order become more apparent.”

With all that has happened since Friday afternoon, I have realized that the executive order applies to me in a way that could affect my family — and my career. I’m married to a green card holder, and that means for the time being, we can’t travel together to visit family abroad any time soon. It’s a decision we made out of fear and uncertainty. Nothing seems more un-American than that.

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  • Medical graduates from US medical schools have priority in residency, and those who are American citizens should have second priority. Foreign medical graduates should be given third priority. If ANY US med grads are not placed, they get first priority. The US taxpayer funds residency programs. We should NOT be funding the ability of foreign medical personnel to work in the US. They should work in their home countries, which need them. During the Ebola crisis, there was a shortage of doctors in those countries. 2/3 were working in the US, some as orderlies or other lower-tier positions.

    • In practice, US medical graduates are given priority in residency, often because they are the most qualified. If a US IMG or a foreign medical graduate is placed, its because they were the most qualified candidate. The US taxpayer funds residency programs for the most qualified applicants, whether US medical graduates or not; don’t we want the best doctors paid by our tax dollars?

      I can find no evidence of your claim that “2/3 were working in the US”- could you please clarify what you meant by that, and tell me where you found it?

    • From a talk by E. Fuller Torrey:
      Another question is why there are so few doctors and health workers in these African countries. Dr. E. Fuller Torrey wrote in the Wall Street Journal recently that for years the U.S. has been part of the brain-drain of African physicians (and other health care professionals) because of an entirely preventable doctor shortage in our own country. He wrote, “The loss of these men and women is now reflected in reports about severe medical-manpower shortages in these countries, an absence of local medical leadership so critical for responding to the crisis, and a collapse or near-collapse of their health-care systems.”

      He estimated that Liberia, a country of four million people, has only 120 Liberian physicians, while there were 56 Liberian-trained physicians practicing in the U.S in 2010.

      My 2/3 is from somewhere else. The point is that a huge number of the physicians trained in Africa at public expense come to the US to do lower-eschelon jobs, robbing their country of needed expertise. That’s arrogance, and wrong.

    • I appreciate the reference. However, our job for our patients is not to ensure Liberia has enough doctors, but to have the best possible applicants for our residencies. International graduates often serve in areas that US graduates just aren’t interested in going, particularly poor rural white areas, and so provide otherwise unprovided medical services for our underserved. These places are starving for applicants; there is no evidence that they are turning away more qualified American medical school graduates in favor of IMGs.

      Also, it’s unfair to say “My 2/3 is from somewhere else” and then not say where that “somewhere else” is. I could say “2/3 of Trump’s proposed cabinet are pedophiles,” and then say “oh the data is from somewhere else.” Would anyone take me seriously?

    • The function of the residency training system is to train doctors for the US market, and these should be US graduates only. Period. No foreign doctors should be accepted. The US system is overrun by foreign doctors at this point, which is intellectually arrogant, and unfair to US kids who want to be physicians. We owe nothing to foreign doctors. As to the “quality” of them, I have huge doubts in many cases. I work with residents and fellows, doing research training for them. The ones with wretched English are NOT adequate. They struggle every day trying to follow complex thoughts. I just reviewed a paper from a very clever person who is of foreign extraction, and found hundreds of errors of English composition in the paper. Communication with patients is a key for the physician, and foreign graduates do not measure up in many many cases.

    • As a medical resident myself, I agree with your assertion that communication with patients is key. I also agree that in several cases- but not “many many,” foreign graduates do not measure up from a communications standpoint. However, that is not a unique problem for foreign residents. Many US-born, US-trained medical school graduates have significant difficulty communicating with patients or maintaining relationships with them; that’s the #1 root cause of malpractice.

      I strongly disagree with the idea that foreign doctors have “overrun” the US medical system. The overall number of matched residents foreign-trained, as well as match rates for foreign medical graduates, is far below that of US graduates. The ones that match, match because they are better applicants than others. We should be more concerned about making our applicants better, rather than trying to stifle healthy competition and reduce the overall quality of our medical trainees because of anecdotal evidence.

  • Every single person has an story but the bottomline is we are all here to become a physician and serve the great people of USA. Being a single mother and trying to adjust my studies with one kid working hard to achieve for 2 years, it is really hard to see such a rule will change all my future. I am waiting for match result as well like many other applicants!!!!

  • Thought in some aspects it is unfair to people who have done their exams and took the time and money to try to secure a residency program in the US , there is another aspect , We and I mean doctors who are US citizens or those who have a permanent residency permit ( Green Card ) and who have graduated from universities outside the US , we can not secure residency spots because of all the competition from international medical graduates.They can work in their respective countries and support their families , while we can’t and have to apply year after year to secure a spot.You can check the NRMP.org for the stats and you will see that we have 50 % chance of getting a spot as they do , does that look fair to us ? They can continue working in their respective countries if they don’t get a match , while If we don’t , then its either poor research jobs , interpretation jobs or UBER .In the UK , they help their nationals to get a job first and then the international doctors , that’s fair , we live here and they live abroad , I do understand that they have spent time , money and effort to get a spot , but we also did that .

    • Dear Dr. Unemployed,

      Just to clarify, I believe you’re referring to US citizen IMGs- that is, US citizens/permanent residents who then did medical school abroad, for example the Caribbean, and are trying to apply back to US residencies? Yes, your match rate was 53.9%, slightly above that of non-citizen IMGs (49.4%), but well below that of US MD graduates (93.8%) and US DO graduates (80.3%).

      This blows. Especially if you’re originally from the US, have US undergraduate debt (which is much worse than most other countries), and spent probably as much or more than US medical school graduates. I don’t know if it’s “fair” or not, but I think there’s many factors at play:

      1) Prejudice against US IMG graduates by US residency programs- I think there might be an intrinsic bias against US IMGs, similar to the unfortunate (unspoken) bias against DO graduates and international IMGs.

      2) It can be difficult for US international medical students- esp from Caribbean- to get clinical training sites in the US mainland for administrative/logistical reasons, thus the quality and diversity of clinical training may suffer.

      3) It could be harder to get strong recommendation letters from clinical faculty for residency applications, given 1 and 2.

      I don’t think it’s fair to solely blame international medical graduates for this, however; there’s simply more of US IMGs, yet the match rate for y’all is higher. You guys have a cultural and language advantage of having grown up in the US (so your Step II CS score will likely be higher).

      As you suggest, I think there could be more done on a national policy level to help US citizens get US residency positions. I think a better use of our advocacy, however, is not to be protectionist, but rather to advocate for greater increases in residency spots. I would love to hear your thoughts on the below article:

      http://thehill.com/blogs/congress-blog/healthcare/266610-shortage-of-residency-slots-may-have-chilling-effect-on-next

  • These visa restrictions are a long time coming! We have many thousands of doctors here who need residencies but cannot get them because of all these foreign medical students are taking them. Nearly one thousand U.S. medical school graduates do not receive a residency each year. How are they going to pay off their student loans? Then there are many thousands of experienced immigrant doctors already here who can’t get into residency for the same reason. It is high time we take care of our own people first.

    • Dear Gary,

      There are not “many thousands.” The number of unmatched US medical graduates, both MD and DO, number under 2,000 in the 2016 match. But around 20,000 DID match. The match rates for US medical graduates is at the same rate, or higher than it has been historically (particularly for DO students). That’s small comfort for those who didn’t match last year (several of whom were my friends and classmates). But it’s important to give credit where credit is due; the Match helps ensure the highest number of matches possible, vs a traditional application process like for medical school.

      The bigger issue is “how are they going to pay off their student loans?” This is a HUGE issue, especially for those who don’t match but even for those who did. Not matching would not be as huge a financial burden if the cost of medical school wasn’t so DAMN high. We need to keep lobbying for this- under the Bush administration, they did away with interest-free federal loans for medical school, which ridiculously screws us over. Even as a resident, I can barely pay the interest on my medical school loans. Can we all agree, this is ridiculous?

      We should also be lobbying for more residency spots, not just to “take care of our own people first.” There’s enough medical need in this country for more residency spots, but Congress refuses to expand Medicare funding to cover it. We should be working together, and not against each other.

  • John Tilden’s comments are all you need to know. My wife is in medical, I’m a programmer and I can speak to the influx in my arena if need be but that is not what this conversation is about, it’s medical. That said, America first. IF and when we need anybody it will be those that integrate, not the insufferable ingrates.

  • Boo Fakkin hoo. Geez lamestream, trade that kleenex in for a beach towel to dry those tears. Our borders will no longer be porous like a sieve…or your heads.

  • Talk to ME Chandan! I am one of those US citizen medical graduates and I know a lot about the residency process! What right does a foreign medical graduate (albeit “excellently” qualified-i.e. studied 24/7 for American boards) have in displacing even an “average” American grad? I have over $400,000 in educational debt and passed step 1 and 2, yet I was told that “there were many qualified applicants” and did not match!!!!!!!!! In fact I have spoken to many foreign medical graduates like you (if you are one, since you claim to know much -I’m assuming you are) who are completely ignorant of the fact that many American graduate go UNMATCHED -EVERY YEAR. You are totally oblivious to the fact that their presence in a US residency funded by American tax payers,places thousands of American graduates (many of whom have been quiet about the issue so far) from a career-from a future!!! This is NOT 1990. I’m talking about 2015, 2016 etc. No I didn’t apply to plastic surgery or neurosurgery like YOU probably did (after spending 16 hours a day in our libraries on your J1 visa)-I applied to internal medicine and family medicine! And no -not at Yale medical center and Mayo Clinic-but at many community programs. Consider the internal medicine program at Detroit Medical Center for example -about 20 out of the 30 first year resident are from India! Ridiculous! These guys have ZERO DEBT, and spend a year studying all day to “kill the boards” and impress program directors.

    Unfortunately, because of my situation, I DON’T CARE about the foreign graduate that can’t come back due to visas when I don’t have a residency!!! Let her finish her medical training in her home country and serve people there. The physician shortage issue is a another problem altogether so don’t even go there. Fact: there are barely enough residency spot available even for Americans (and don’t cite me match data without considering many people withdraw from the match etc. Charting the match is NOT the whole story!)-and those that are available should go to American -with debt and family responsibilities in the USA first!!! Where are the freaking family medicine spots that go unfilled-show them to me!!! You are greedy people who spend all your time studying for step1, 2 and 3 so you can “show up” American grads then come and steal their job leaving them with a half million in debt! This injustice WILL come to an end-don’t worry. We cannot go abroad to complete our training. Chandan are you from India? Why didn’t you complete your residency there?! Greed? The “American” dream? My children’s financial future is in jeopardy because a residency program has probably chose YOU over me and the American public is ANGRY about YOU stealing my job!

    Read below Chandan and get out of your ignorance-and if you have any decency and morals :would you consider giving up your residency position and give it to an American grad you have displaced! These grads are half a million in debt (HALF A MILLION US DOLLARS!!!) and many with children to feed and school! You likely have no debt and no children (you went to medical school at 18 in your country). You can very get well trained in India!

    http://notadoctorjustamd.blogspot.com/2015/03/not-doctor-just-m.html

    • Well said, well written. I have no patience anymore to give such retorts to liberals, I prefer to bludgeon them to death with cruel words as I have found that well meant conversations bounce off their craniums. I live to defeat them, not understand them or talk to them.

    • I urge you to read my initial response below- but again, I’m a US citizen, and US medical graduate. The reason I can discuss the foreign medical graduate process is because I have several friends and resident colleagues; what I’m discussing is fairly common knowledge. I’d ask you to actually get to know some of them, before dismissing their lives and journeys out of hand.

      Again, I’m sorry you didn’t match. I don’t know why; did you get any specific feedback on why you didn’t match? But in any case, claiming that “thousands” of US MD graduates didn’t match is flawed. A little over a thousand didn’t, but 93.8% of allopathic graduates did, a record HIGH. That in no way takes away from the pain of you not matching; several of my classmates didn’t match as well, and it sucks. Hard. But you not matching cannot be blamed on foreign medical graduates. The doctor’s plight above in no way affects your process, nor you hers.

      Re: unfilled family medicine spots, there were about 200 last year. Again, this is publically available data.

      I’m sorry, but I’m not going to give up my residency spot to an American grad, and get trained in India, because I am an American grad. I also have a huge amount of debt; which is another HUGE issue (medical school debt burden) that needs to be lobbied for by all of us.

      http://www.nrmp.org/press-release-results-of-2016-nrmp-main-residency-match-largest-on-record-as-match-continues-to-grow/

    • Jess Sain: “I prefer to bludgeon them to death with cruel words as I have found that well meant conversations bounce off their craniums. I live to defeat them”

      That seems like kind of a bitter, empty life, to live only to hurt others. I’m sorry for whatever happened to you, that makes you feel that rational conversation is no longer an option.

      To John Tilden: Reading over my initial reply, it WAS quite condescending. I apologize for that. I strongly disagreed with what you said, and am trying to provide the facts of the situation, but obviously the Match is very personal to you. But I need to do better about being more understanding, and not let my anger get control of me. Obviously this issue has inflamed passions on both sides of the political divide. But we should be working together, not against each other, to find solutions that help both you and the doctors mentioned in this article. I refuse to believe that things can’t get better for all of us, that this is a zero sum game as Trump would like us to believe.

    • I totally agree with John. There are many of the FMG who come here and after training they can’t stay or choose/forced to leave the country. That not only cost US tax payer lot $$$ and a trained doctor, but on top of a residency slot that could have gone to US citizen. That’s why US citizens & grads first must be first priority, then US citizen (the 2nd pri FMG)) and green card holder etc. After that we can offer the rest to foreigners. AMERICA FIRST!!!!

  • The worst that can happen for these foreign medical graduates is a delay by a semester or two. This is a common occurrence at this level in medical education. Secondly, foreign medical graduates do not have to match residency in the formal match. They can match independently. That is also an advantage for them. Don’t forget that Trump’s ban is only a temporary measure. So the idea that medical careers will end is just hysteria.

    • None of what you say is true. If they are not allowed into the country, then they won’t be allowed to match. No residency director can just “reserve” a residency spot for a trainee physician, and thus leave it empty; this isn’t like deferring law school. This is not a “common occurrence.” They would have to re-apply, and wait a full year; and if the ban still holds (and we have no evidence Trump won’t continue it), they can’t even get into the country to interview. So yes, careers and lives- American lives- are at stake. Foreign medical graduates have to participate in the Match to match into residency in the US; that’s why it’s called a match. That’s why the Match exists. There is a “scramble,” or SOAP for people who didn’t initially match, but that’s open to all residency applicants, not just foreign trained ones. I don’t know where you’re getting your information. Match Day happens in March; programs decide who they decide to rank (and thus accept if matched) next month. So this “temporary” ban will definitely derail the careers of these individuals. Where are you getting your alternative facts?

  • Have you considered that these excellent and eager medical students from these are displacing American citizen medical from a promising medical career! If you went to school in Syria or many other countries you probably have zero educational loans. Yet it you do not think twice about displacing American graduates from a residency …they cannot pay their loans as they are effectively out of a job (many with families) and could be shut of a clinical career!

    • Have you considered maybe actually looking at the Match data? Do you even know how the Match works, for medical residency? There are not enough physicians, especially in primary care, to meet the country’s needs. Foreign-trained physicians fill many vital roles in medical residency, particularly in underserved areas and underserved parts of the country. It is MUCH, MUCH harder for them to match here than US medical school graduates- so the ones that actually match are usually as good, if not better than US medical school graduates. They often have to switch fields entirely- ex. neurosurgery to family medicine- to even match in this country. And that family medicine position is in a nonglamorous location, that US medical school graduates aren’t even applying for. Many positions in residency each year get UNFILLED- and yet you claim that these valued immigrants are “displacing” American graduates. Your wild claim is completely unwarranted, and is an insult to everyone who has actually been through the residency Match process, foreign-trained and US-trained. If you don’t know what you’re talking about, at least ask and be educated- your ignorance diminishes us all. Shame on you.

    • Chandan: This is what I can’t stand about [some of] you foreign medical graduates. You come to this country and ASSUME that everyone is “ignorant” You didn’t think about the fact that I may be an MD!Shame on you! YOUR ignorance diminishes YOUR ilk! And… I apologize to them on your behalf. I can bet that I am way more educated than you are: I have undergraduate and advanced degrees in science before going to medical school and have much more experience with life issues. Most of the people that speak like you that I have encountered are barely even adults and don’t have the maturity to deal with with many medical issues in this country-not in your intern year! I have had to help many medical resident’s with socio-cultural misunderstandings during my rotation. Many were book worms with little previous exposure to adult experiences. I can clearly remember a dying patient with a brain tumor -telling me -in front of the foreign schooled resident-that she would much rather that I would be her physician. I was ashamed for the guy and had to come to his defense, but I definitely sympathized with the patient. Why?He was uncouth but probably had excellent board scores. So Chandan, before you try making assumptions next time, try talking to people respectfully. Your know it all attitude stinks! I cringe to think that this same condescension is borne out in your bedside manner!!! It is the exact thing the patients of this country feel-your condescending attitude-that you think you need to be imported and are better than Americans. That’s the reason the patient in my anecdote above-even though dying-expressed to me in front of the attending that she was not satisfied with her resident’s attitude and poor manner. Want to talk about his board score now?

    • Wow, that was extremely angry. Obviously, this topic is very personal to you. I’m sorry you didn’t match, especially with such a heavy loan burden. Are you in the Match this year? If so, best wishes.

      It’s a little troubling that you are a US medical graduate, and still have some misconceptions about the residency Match process. You also don’t know me at all, yet make a lot of assumptions about me. I’m Indian, yes; but I’m a US citizen, raised here. Went to public school, college, Master’s program, and medical school here. Currently a resident in primary care, not in plastic surgery (don’t know why your mind went there…) I don’t know your educational background, but that would be awesome if you’re “way more educated” than I am. Good for you. I’m sure you also have a lot of “life experience.” So do I. But when you’re so vitriolic (on a public forum, no less), it diminishes any qualifications you have or arguments you make.

      I can speak about the Match process, especially re: foreign medical graduates, because several are friends and colleagues I work with. It is extremely difficult and complicated for foreign medical graduates to apply for US residency- many US programs don’t even give interviews to foreign graduates. So, if they matched here, it’s because they deserved it, and were more qualified than other applicants; they are not “stealing” jobs from American graduates.

      The point you make about maturity is a fair one, but applies to more than just foreign medical graduates. The average age of medical school matriculants has gone down over the past few decades; many more people are coming straight out of undergraduate than before, which cuts down on their real-life experience prior to clinical training- “bookworms”, as you state.

      That’s really sad, that the terminal patient you were observing with a foreign-trained resident felt so despairing that she would rather not see that trainee. That trainee should be disciplined, and dismissed if that’s a recurring pattern. But it’s very short-sighted to assume that this represents all foreign medical graduates, or doesn’t apply to US medical graduates. I have personally seen many cases where patients would prefer foreign-trained graduates, or where US medical graduates have been unprofessional towards our patients. We all need to continuously work to provide more empathic care. That’s very kind of you, to help residents with cultural competency. Although, if you were “ashamed for the guy,” it’s kind of insincere to then deride him publically afterwards. Also, why do you want to talk about his board score? I never mentioned this. Where is this coming from?

      Instead of sniping online, we should be working together- medical students, residents, full attendings- and lobbying Congress for more Medicare funding to fund more residency spots. We simply don’t have enough residency spots to meet the needs of our populace. But trying to undercut other physicians because of your personal experience, and displacing that into protectionism and hatred, is disturbing and unwarranted.

    • In the past two years there were approximately 50 US medical school graduates who only listed pediatric residency programs in the Match who did not match. Research into these 100 or so students discovered that nearly all of them had at least one red flag (failed a class, had to repeat a clerkship, failed either Step I or II, had a serious psychological issue, et cetera) with many having more than one. The profession of medicine is not an entitlement program, it is based on merit. Because we do not have enough positions in our medical schools to meet the demand for physicians, we import physicians. Program directors, clinics, and hospitals want to hire the best physicians possible and given a shortage of slots in American medical schools, many of these positions will taken by physicians who are foreign trained. Focus on what you can do to make your application stronger than condemning a system based on merit.

      I also hope you did not use your real name. If you did, program directors at program you have applied to will have access to your unfortunate rant. After reading it, your rank listing will likely change, if you get listed at all.

    • Petite hit it on the head. If you didn’t match it might be because you weren’t a good candidate or applied too late.

      The majority of US med students actually don’t want to go to the programs that IMG’s go to, and they don’t bother applying to them either. IMG’s apply to many more programs and get fewer interviews.

      Another fact, if you’re not from a US school, you need your scores to be 15-20 points higher to be competitive.
      Another fact, the US has a doctor shortage.

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