Monday, January 30, 2017

Quick Take on Trump Ban, MD Training Edition

I receive daily updates from a discussion board for faculty members involved in residency programs that train internal medicine physicians. Usually it's a sedate series of discussions about how best to achieve throughput from the ER to the floors, or how best to schedule swing shifts in the ICUs, and so on. There's usually two or three such posts each day, and mostly I flick through them just to see the kinds of technical matters that affect residency training.

Today, however, only 48 hours after Donald Trump's travel ban on people from Syria, Sudan, Libya, Somalia, Yemen, Iraq, and Iran, there is practically an explosion of posts about what this means for programs across the country and their International Medical Graduates (or "IMGs"). And there's a fair amount of hand-wringing about what comes next. "All of our alarm bells should be going off," wrote one physician--and it's worth noting that in physicianspeak this comment is the rhetorical equivalent of going bonkers, for while I may tend toward hyperbole in political analysis, my colleagues on the whole do not. Trump's order, along with a host of other actions he has taken in his first week in office, is changing this to a degree heretofore unprecedented for this generally nonpartisan, apolitical profession.

The cause of the alarm is that a lot of resident trainees are going to be affected by this--see here for what may be the first of many examples of much-beloved doctors in the middle of training being put on a plane and sent packing without any warning whatsoever. This not only affects the residents, but will probably include a fair number of licensed physicians currently in practice, as visa waivers are granted to physicians from abroad who are willing to work in underserved areas--including many areas of the rural Midwest, ie the kinds of places that have embraced Trump and may soon feel the impact of this policy. In my home of internal medicine, there are about 7000 positions filled each year, of which half are filled by visa-holding immigrant physicians. Of course, only a small portion come from these seven nations, although I have known many a Syrian and Iranian physician in my time.

But the ban's impact is going to affect much more than the physicians coming just from these countries for training. Any Muslim physician, particularly those from majority Muslim countries, would be wise to consider whether their country will soon be on this list as well. And this order comes just as residency programs across the United States sit down and decide whom to rank for offers of residency training--not just internal medicine programs, but all of them. There are about 28,000 first-year spots open, of which nearly a quarter are filled by IMGs. Again, the ban won't affect all IMG physicians, but a substantial majority of programs devoted to primary care--internal medicine, pediatrics, family medicine, as well as psychiatry--are going to have to decide whether they want to roll the dice on highly-qualified Muslim applicants they may ultimately never be able to train, or take less promising applicants from elsewhere, or simply not fill the positions--which increases the work burden for trainees and faculty alike.

Since we aren't by any means experts on the subject, physicians shouldn't be in the business of wading into policies about immigration, but the thoughtlessness that has thus far characterized the first eight days of the Trump administration has forced this on the profession. We not only have only the faintest notion of what consequences this single action will bring, and there is no reason to suspect that we aren't in store for more policies with even greater impacts. In one week, Trump has shown himself to be utterly incapable of governing in a way that does nothing but wreak havoc, and one doesn't need to be a policy expert to see this. Nevertheless, the vast majority of Republican politicians and Washington insiders, who are the only people who have any shot at restraining this man, have been feckless enablers even as they must surely know deep down that if he is not stopped, genuine ruin awaits.


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