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February 11, 2019

Long-term Potential Implications of Immigration Barriers for Medical Education

Author Affiliations
  • 1Council on Medical Education, Medical Education Programs, American Medical Association, Chicago, Illinois
  • 2Medical Education Programs, American Medical Association, Chicago, Illinois
JAMA. 2019;321(8):741-742. doi:10.1001/jama.2019.0231

Presidential proclamation 9645 (Enhancing Vetting Capabilities and Processes for Detecting Attempted Entry Into the United States by Terrorists or other Public-Safety Threats), upheld by the US Supreme Court in June 2018, has received substantial attention in the medical community. This proclamation introduced uncertainty into the lives of some physicians in training, physician-scientists, physician-teachers, and patients, including concerns about access to care, the diversity of the physician workforce, and physician shortages in some specialties.

The proclamation applies only to a small percentage of international medical graduates (IMGs). In its final iteration, the proclamation generally bans travelers from Iran, Libya, North Korea, Somalia, Syria, and Yemen, and all Venezuelan government officials. The health care community was concerned enough to express unease regarding its immediate potential effects such as the possibility of residency training programs not being able to rank the most qualified candidates due to visa restrictions and predicted physician shortages (related to an aging population and the increasing number of patients with multiple chronic conditions).

The effect of IMGs who are not US citizens (non-US IMGs) on clinical teaching, research, and provision of patient care in the United States is important. Compared with US medical school graduates, non-US IMGs provide care to a disproportionate number of socioeconomically disadvantaged patients, and certain states and specialties disproportionately depend on foreign-born physicians.1

According to data from the Association of American Medical Colleges, the percentage of IMGs in the active physician workforce in 9 states (Connecticut, Delaware, Maryland, Michigan, Nevada, North Dakota, Ohio, Texas, and West Virginia) was 25% or greater in 2016 (46 164 of 172 928); in 4 other states (Florida, Illinois, New Jersey, and New York), the percentage of IMGs was 30% or greater (67 425 of 188 072).2 Although data from some states suggest that some IMGs with J-1 visas continue to practice in underserved areas for only short periods after their service obligations end, other states report continued practice by physicians in these areas for up to 10 years.1

In addition, data from the 2018 National Resident Matching Program indicate that of 7542 positions offered in internal medicine, 2076 were filled by non-US IMGs; of 552 positions offered in neurology, 144 were filled by non-US IMGs; and of 601 positions offered in pathology, 185 were filled by non-US IMGs.3 Pediatrics and family medicine also depend on IMGs to fill their positions.

Certain subspecialties are disproportionately reliant on foreign-born graduates of international medical schools. National Resident Matching Program data indicate that in 2018, these individuals filled 23.4% of pediatric endocrinology positions, 27.4% of vascular neurology positions, 34.1% of geriatric medicine positions, 53.7% of abdominal transplant surgery positions, and 60% of internal medicine oncology positions.4

Recent data further establish the significant contributions of all IMGs (both US citizens and non-US) to clinical teaching, mentorship, and research. As of 2015, almost 20% of academic physicians in the United States were IMGs (15 075 of 82 737), and just more than 15% of full professors (2808 of 18 653) completed their undergraduate medical training overseas.5 In addition, collaboration (such as the ability to attend conferences) between US-based physician-scientists and researchers and their global colleagues contributes to innovations that directly benefit patients in the United States.

To date, data indicate that the overall number of individuals blocked from entering residency training in the United States because of the proclamation has been quite small. As of August 15, 2017, 97.8% of the 2766 physicians initially sponsored by the Educational Commission for Foreign Medical Graduates for J-1 visa status for the 2017-2018 academic year had successfully secured this status and arrived at their US training programs. Of the 57 initially sponsored J-1 physicians who were nationals of the countries identified in executive order 13 780 (precursor to the implemented proclamation, which was in effect as of August 2017), 50 (87.7%) had successfully secured J-1 status and reported to their training programs.6

In the short-term, it is a concern that some otherwise fully qualified and vetted physicians are being prevented from entering and practicing in the United States based solely on their country of origin. However, the actual number of affected physicians remains quite small, particularly in comparison with the size of residency training in the United States. The longer-term effects of this policy have not been thoroughly considered and must be addressed if the US health care system continues to rely on IMGs for the provision of care and instruction of the next generation of physicians.

Furthermore, the unintended consequences of the tone set by the proclamation should raise potential concern about the implications for the US health care system. The specter of immigration limitations likely has an effect on individuals seeking to enter the United States, and qualified non-US citizen IMGs may choose instead to pursue training and employment in other countries. This ripple effect was observed in the 2017 National Resident Matching Program main residency match that took place during the proclamation rollout and judicial review of the various iterations of the proclamation. Even though the overall match rate of non-US citizen IMGs increased slightly, 176 fewer IMGs (compared with 2016) participated in the match process.7

A recent American Medical Association Council on Medical Education report6 also noted that the number of J-1 visa applications the Educational Commission for Foreign Medical Graduates received for the 2017-2018 declined 33% from Iran (from 33 to 22) and 60% from Syria (from 30 to 12), countries that have provided thousands of physicians who provide care for patients in the United States.

The possible long-term effects of the proclamation on foreign students seeking to apply to US medical schools also remain unclear. The 2001 terrorist attacks may provide some context. Although the number of F-1 student visas issued by the US Department of State increased continuously from 241 003 in 1996 to 293 357 in 2001, that trend reversed to 234 322 in 2002. Numbers declined further (to 215 695 in 2003), and did not surpass 2001 levels again until 2007 (when they reached 298 393).8 Data collected after the implementation of the proclamation are suggestive of a repeating pattern: the number of new international undergraduate students enrolled at US institutions declined by 6.3% from the 2016-2017 academic year to the 2017-2018 academic year (115 841 to 108 539).9

Multiple mitigating factors likely contributed to the decline in international student application visas and enrollment during these periods. However, the long-term effects of the proclamation on medical school enrollment bear ongoing monitoring because a diverse body of medical students is critical to the creation and retention of a diverse physician workforce, especially in underserved areas with undersupplied specialties.

It is important to acknowledge that some global health policy experts oppose US reliance on IMGs to complete the US physician workforce. Those opposed note that physician-exporting countries may lose important human capital and may be left unprepared to respond to both crises and basic health needs. However, unless the medical community and physician workforce planners in the United States are prepared and willing to implement changes in how physicians are taught and distributed across the country, the United States may be unlikely to meet the medical needs of an aging population, especially in areas where care is usually provided by non-US IMGs.

Although the number of physicians affected by presidential proclamation 9645 is quite small, particularly in relationship to the 25 000 first-year residency positions that are available, the more fundamental question is what type of society does the United States want to be. International scientific and educational collaboration has become more common, and restricting access to individuals simply because they come from a particular country may have a chilling effect on the United States as the leading biomedical, clinical, research, and education country in the world.

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Article Information

Corresponding Author: Carrie L. Radabaugh, MPP, Medical Education Programs, American Medical Association, 330 N Wabash, Ste 39300, Chicago, IL 60611 (carrie.radabaugh@ama-assn.org).

Published Online: February 11, 2019. doi:10.1001/jama.2019.0231

Conflict of Interest Disclosures: None reported.

Disclaimer: The views expressed in this article reflect the views of the authors and do not necessarily represent the views of the American Medical Association.

Additional Contributions: We thank Annalynn Skipper, PhD, RD (Chief Health and Science Office, American Medical Association), for her review of the manuscript. Dr Skipper was not compensated.

WWAMI Rural Health Research Center. Conrad 30 waivers for physicians on J-1 visas: state policies, practices, and perspectives. http://depts.washington.edu/fammed/rhrc/wp-content/uploads/sites/4/2016/03/RHRC_FR157_Patterson.pdf. Accessed January 24, 2019.
Association of American Medical Colleges. 2017 state physician workforce data report. https://www.aamc.org/data/workforce/reports/484392/2017-state-physician-workforce-data-report.html. Accessed January 24, 2019.
National Resident Matching Program. Results and data: 2018 main residency match. https://mk0nrmpcikgb8jxyd19h.kinstacdn.com/wp-content/uploads/2018/04/Main-Match-Result-and-Data-2018.pdf. Accessed January 24, 2019.
National Resident Matching Program. Results and data: specialties matching service, 2018 appointment year. https://mk0nrmpcikgb8jxyd19h.kinstacdn.com/wp-content/uploads/2018/02/Results-and-Data-SMS-2018.pdf. Accessed January 24, 2019.
Khullar  D, Blumenthal  DM, Olenski  AR, Jena  AB.  US immigration policy and American medical research: the scientific contributions of foreign medical graduates.  Ann Intern Med. 2017;167(8):584-586. doi:10.7326/M17-1304PubMedGoogle ScholarCrossref
American Medical Association Council on Medical Education.  Impact of Immigration Barriers on the Nation’s Health. Chicago, IL: American Medical Association; 2017.
National Resident Matching Program. Results and data: 2017 main residency match. https://mk0nrmpcikgb8jxyd19h.kinstacdn.com/wp-content/uploads/2017/06/Main-Match-Results-and-Data-2017.pdf. Accessed January 24, 2019.
US Department of State, Bureau of Consular Affairs. Visa statistics. https://travel.state.gov/content/travel/en/legal/visa-law0/visa-statistics.html. Accessed January 24, 2019.
Institute of International Education. New international student enrollment. https://www.iie.org/Research-and-Insights/Open-Doors/Data/International-Students/Enrollment. Accessed January 24, 2019.
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    2 Comments for this article
    Robt Peinert, MD | Recently Retired Orthopedic Surgeon
    Regarding the article by Radabaugh et al, a very simple solution exists and that is to educate more of our sons and daughters in the field of medicine. It will require making a medical education something that is affordable for the average family. Perhaps a kind of internal national medical service directed mainly at primary caregivers whose med school costs would be eliminated after 4 years of service following completion of training!
    The Need
    Rod Lovett, MD | Grace Medical Home
    I have served repeatedly overseas in Africa, Asia, and Central America. The need of those suffering medically and surgically in developing countries is tremendous. The average American has no idea how great the need there is. How selfish of us, how self-centered we in American medicine are when we do not do more to meet these needs. I would propose that every physician graduating from medical school be required to serve in one of these developing countries at least a couple of months during the first 3 years of their practice. And I would propose that every medical school in America require and fund their professors to spend a month in teaching and training in these developing countries every 3 years. This would make a tremendous difference. Training qualified nationals in their own countries facing indigenous medical and surgical problems is far better than bringing them to the States to train them. Physicians trained here never return to their own countries.

    There are a number of very experienced organizations American physicians can serve under in these medically poor countries. The AMA should be in the business of publishing opportunities for physicians to serve and teach in these countries and American hospitals should be in the business of adopting sister hospitals in developing countries to aid in training and service.