Trump’s travel ban could spark crisis in state’s doctor shortage, healthcare leaders say


Michigan’s reliance on foreign doctors

Michigan ranks fifth in the nation in share of international medical graduates in its physician workforce. The national average is 24.2 percent

New Jersey: 38.4%

New York: 37.1%

Florida: 35.3%

Illinois: 31.2%

Michigan: 29.3%

Source: Association of American Medical Colleges

Uncertainty surrounding President Trump’s immigration order targeting seven Muslim-majority nations is causing anxiety among healthcare leaders in Michigan, a state where international medical graduates comprise 30 percent of the physician workforce.

A steady influx of foreign-born doctors is critical to poor, rural and heavily minority parts of the state, where a physician shortage is already acute. Indeed, the government offers visa waivers to international students in exchange for their promise to spend time in underserved areas. Now, healthcare leaders say, these physicians, residents and students are rethinking careers in Michigan.  

“They are a critical component of access to care in rural Michigan,” said John Barnas, executive director of the Michigan Center for Rural Health. The center, part of Michigan State University, advocates for rural health collaborations and recruitment and retention of rural health care providers.

Barnas said Michigan has accepted 30 international medical graduates a year under the J-1 waiver program for about the past 15 years, and 20 annually for years before that. That has meant approximately 600 physicians agreeing to serve at least three years in rural and urban settings where there is medical need, in practices ranging from primary care to anesthesiology.

John Barnas

John Barnas, executive director of the Michigan Center for Rural Health, said international medical graduates are a “critical component” of Michigan's health care system. (Courtesy photo)

“If you had to do without them,” Barnas said, “it would be devastating.”

Trump’s executive order on immigration, now on hold in the federal courts, applies to seven Middle-Eastern nations. But several doctors interviewed by Bridge Magazine say physicians from other parts of the globe have also expressed fear about their futures, and whether they can safely travel abroad or visit their families.

“It's not only Muslims,” said Detroit Henry Ford Hospital heart specialist Khaldoon Alaswad, a U.S. citizen from Syria who runs the cardiac catheterization laboratory at the Edith and Benson Ford Heart and Vascular Institute. “I have friends from India that are Hindu, Sikh. They canceled their trips. They are afraid to leave the country.”

Alaswad said he fears confusion surrounding the immigration order could diminish the number of future foreign graduates who apply for residency and practice in America.

“The United States is now seen as hostile,” he said. “As a U.S. citizen myself, now I feel like a second-class citizen.”

Henry Ford Health Systems has an immigration lawyer on retainer who has been busy in recent days answering a flurry of questions from upset international residents and doctors.

“There is lots of concern,” said Dr. Kim Baker-Genaw, vice chair of internal medicine at Henry Ford Hospital.  “They contribute a great deal to our ability to provide care.”

Baker-Genaw said the worry is particularly acute for those from the seven countries named in the ban – Iraq, Syria, Iran, Sudan, Libya, Somalia and Yemen – but also those from other Middle East countries and beyond. Henry Ford officials say they have doctors and residents from 60 countries.

Bob Wheaton, spokesman for Michigan’s Department of Health and Human Services, said international medical graduates “are an important part of Michigan’s health care workforce. So it’s important for Michigan to be able to recruit and retrain physicians to successfully meet the needs of Michiganders in underserved communities. We will be watching the developments at the federal level closely.”

Ari Adler, spokesman for Gov. Rick Snyder, said the governor is concerned “any time people talk about making it tougher for people to immigrate to Michigan.”

He added: “He is most interested in finding a way to have all sides on the immigration issue have a constructive dialogue about protecting our borders while still making immigrants feel welcome to come here, regardless of their profession.”

Finding hospital residents  

Three days after the travel ban was announced, immigration attorney Marc Topoleski presided over a hastily-arranged meeting at Henry Ford Hospital.

“We had more than a hundred people with all kinds of questions and concerns,” he said.

Topoleski said he's also heard from Michigan automotive and technology firms with similar concerns about their employees.

Marc Topoleski

Michigan immigration attorney Marc Topoleski said he has heard concerns from automotive and technology firms – as well as hospitals – about the travel ban. (Courtesy photo)

Adding to the potential confusion, Topoleski said, thousands of graduates at U.S. medical schools and schools abroad are to find out on March 17 – in what is known as “Match Day” – if they have been selected for a residency program and where they are to begin their training. Trump's order, he said, has thrust that into disarray.

Physicians abroad are worried they won't be allowed into the United States to start their programs. And U.S. hospitals are weighing the risk of offering slots to students from the seven banned countries, given the prospect they could be turned back.

“Hospitals are not sure how to process these candidates. If a resident would not be able to come, that would leave that spot unfilled,” Topoleski said.

A three-judge panel of the U.S. Court of Appeals for the 9th Circuit ruled unanimously on Feb. 9 that Trump’s temporary travel ban should remain suspended, allowing people previously barred to continue entering the United States. Trump has both signaled his intent to appeal or submit a rewritten executive order that could have a better chance of withstanding legal scrutiny.

Leaving aside the merits of the president’s immigration policies, an official of the Association of American Medical Colleges said neither Michigan nor the nation can afford to lose a large segment of the medical workforce.

“Right now, we are facing as a nation a problem of physician shortages. We expect those shortages to grow,” said Matthew Shick, director of government relations for AAMC.

A plea for more doctors  

Indeed, a 2016 analysis by AAMC projects a U.S. shortage of up to 95,000 physicians by by 2025. It issued a statement on Jan. 30 that it was “deeply concerned” the travel ban will “disrupt education and research and have a damaging long-term impact on patients and health care.”

It added that 10,000 foreign graduates in the past decade have gone on to practice in underserved areas across the country. The J-1 visa waiver program allows immigrant residents and fellows to remain in the United States to practice if they commit to a federally designated underserved area for at least three years.

Michigan itself faces a projected shortage of 4,000 physicians by 2025, while rural pockets around the state are already well short of recommended ratios of primary care physicians to patients.

A 2015 report by the nonprofit Lansing-based Citizens Research Council  found four rural counties in Michigan -- Cass, Keweenaw, Lake and Oscoda -- consistently fall below recommended ratios of primary care physicians. Seven other rural counties -- most in the northern half of the Lower Peninsula -- fall below suggested ratios in every primary care field it examined except family practice.

In the bottom 10 counties in Michigan, all rural, the availability of primary care doctors ranged from one doctor for every 3,100 residents in Arenac County, north of Bay City, to nearly 7,500 residents for every doctor in Cass County in southwest Michigan. Those rates, based on 2010 data, far exceed the 1,200-to-1 ratio recommended by the American Academy of Family Physicians.

International medical graduates are one part of the solution in rural and urban areas where doctors are harder to find. Legislation signed into law in January should help as well. It gives advanced practice nurses – who are more highly trained than registered nurses – more authority to diagnose, treat and prescribe medications for patients independent of a physician. Advocates say that be especially helpful in rural Michigan.

Health practitioners, including those from the U.S. Veterans Administration, are also increasingly turning to telemedicine -- using technology to diagnose and treat patients who may be a hundred miles away -- as another piece to the health care puzzle.

See related: The doctor will see you now – remotely

According to the AAMC, there were nearly 8,000 international medical graduates in active practice in Michigan in 2014, 29.3 percent of the total physician workforce of about 27,000. That was fifth highest percentage in nation and well above the national average of 24.2  percent.

A more detailed analysis of 2010 data posted by the U.S. National Library of Medicine found a significant number of foreign doctors in Michigan from three nations named in Trump’s travel order: 151 from Iran, 259 from Iraq and 511 from Syria. Another 251 were from Egypt, 687 from Pakistan and nearly 3,000 from India.

Where most doctors come from

Physicians from countries in the Middle East and beyond are an important piece of Michigan's health care system. Here are the number of foreign-born doctors working in Michigan as of 2010. (Syria, Iraq and Iran were among the seven countries blocked in President Trump’s contested travel order)  

India: 2,916

Pakistan: 687

Syria: 511

Iraq: 259

Egypt: 151

Iran: 151

Source: U.S. National Library of Medicine

Personal stories

The role of foreign graduates has grown dramatically in recent decades, as U.S. medical schools failed to produce enough graduates to meet the need for medical care. According to one analysis, international graduates comprised just 10 percent  of physician work force in 1965, rising to 21 percent in 1981 to where it is today.

At the same time, medical studies indicate that the care provided by foreign medical graduates is as good – or better – than that given by graduates of U.S. medical schools.

A study published earlier this month in the BMJ – previously the British Medical Journal – found that Medicare patients treated by international medical graduates had a 5 percent lower mortality rate within 30 days than patients by U.S. medical graduates. Patients had a slightly higher cost of care with international graduates.

Lebanese native Dr. Adnan Munkarah of Henry Ford Hospital said he's also concerned the travel ban will chip away at the number of foreign graduates who apply for U.S medical training. He said he even heard from a Canadian resident in training afraid to cross the border into Canada.

“She said, 'I am terrified.  You don't know what is going to happen.' There is such a fear that even someone from Canada is afraid about this,” said Munkarah, 54, an obstetrician-gynecologist and chair of the Board of Governors for the Henry Ford Medical Group.

“I think that people (foreign medical graduates) who were very excited to come here are going to give it second thoughts,” he said.

Despite those concerns, Munkarah, 54, stressed that he recognizes the need for strong and reasonable border security.

“I am all for making sure the United States is secure. This is why I am living here. I have seen what terrorism can do and I don't wish that on anyone,” he said, referring to the brutal Lebanese civil war which claimed an estimated 250,000 lives.

Still, he said, any reduction in the international medical workforce would come at a price.

“In order for us to provide the best care, we need to have a diverse healthcare workforce,” he said. “I don't think U.S. medical schools are going to be able to fill that gap in the short term. The problem is not that easy to solve.”

Alaswad, the heart specialist, said he has a very personal stake in this issue.

Alaswad and his mother

Henry Ford Hospital cardiologist and Syrian native Khaldoon Alaswad and his mother, Aisheh Alaswad. Her plans to visit him from Syria were put on hold by the travel ban. (Courtesy photo)

After months of persuasion on his part, his 77-year-old mother – who has heart problems and high blood pressure - had agreed to travel to Michigan this year for a visit with her son and grandchildren. He wanted to make sure they had that personal contact before her possible death. An outspoken critic of the regime of Syrian President Bashar Hafez al-Assad, Alaswad said he fears he would be imprisoned or worse if he traveled to Syria.

He recalled that on his last visit to Syria, in 2009, he was interrogated for six straight days by Assad regime security officials.

“My name is on a list of wanted people,” he said.

He said his mother, Aisheh Alaswad, had an interview scheduled for March at the U.S. Consulate in Beirut about her visa application. Then, the day after the executive order, Khaldoon  Alaswad opened an email with the subject line: “Notice on Executive Order.”

The message: “Your visa appointment has been canceled.”

Alaswad said another interview has been scheduled for her in April, so he remains hopeful she will be able to come and see him.

In the meantime, he said he believes America will somehow figure this out.

“I trust the people to do the right thing in the end,” he said. “I know how America is destined. I think this country has a funny way of taking two steps forward and one step back. This is a step back, but we are going to go forward again."

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Thu, 02/16/2017 - 10:10am

For decades now, the education system has systematically reduced the number of medical students to permit more doctoral candidates from foreign countries. Now we're told that might have created a shortage due to politics? What is needed is for this country to increase education of its own students/ doctors and let the rest of the world educate theirs. We can not succeed in our country if we put and pay for the rest of the world first. The reality is that the system set up to help the rest of the world, just isn't working for America as advertised by the political class.

Thu, 02/16/2017 - 10:30am

I noticed the vast majority of the foreign doctors come from India. Having dealt with this situation, between the elitism and the language barrier, I would like to see the medical schools that my tax dollars are subsidizing make more effort at recruiting americans.

David Waymire
Thu, 02/16/2017 - 12:10pm

Then open your wallet. The cost of educating a doctor today is quite high...and many students don't want to take on the loans. We've slashed state support for higher education in our state by billions of dollars (in 2000, we invested about $1.9 billion...17 years later, we are at $1.6 billion). That has forced universities to raise tuition or provide sub-standard educations. You can't get Cadillac services (and everyone wants the best when it comes to THEIR health) on Yugo budgets.

Fri, 02/17/2017 - 3:12pm

Doesn't the federal government still offer to forgive federal student loans for serving areas with high needs listed in the article for both teachers and doctors (possibly also nurses), in addition, to enlisting in military? No one promoted the loan forgiveness for high need areas and what is considered a high need area in eligible fields and what fields are eligible when I was going to college. Schools should promote the loan forgiveness to students who test good for the eligible fields.

Thu, 02/16/2017 - 11:54am

So, your telling us, that a 90 day travel ban is going to spark a crisis? Sorry, I have to call BS on this article.

David Waymire
Thu, 02/16/2017 - 12:07pm

If you think this will be lifted in 90 days, I have a nice used car to sell you...The whole thing is for show, and the show will last until Trump is gone.

Thu, 02/16/2017 - 1:01pm

This article is garbage and an over generalization of the topic.

Thu, 02/16/2017 - 1:13pm

I come from India, although a similar background and definitely sympathize with my fellow applicants from the 7 countries on the executive order. However, all these articles stating there is a shortage and a crisis are so insulting. This is my second year applying for Internal Medicine residency and none of the programs in Michigan have invited me for an interview. I am a resident of Michigan, a GC holder, have 8 points above the median scores and relevant clinical experience. The rejection emails state there are over 3500 qualified applications for 10 positions. Could some one please enlighten me what this crisis is all about? I hate to blame my misery on someone else but, it hurts when I see some programs filled with residents from the same ethnic region. I will keep trying and keep up with the competition.

Kevin Grand
Thu, 02/16/2017 - 7:56pm

Hmmmmmm, the story above and the comment above cannot BOTH be correct.

Would Mr. Roelofs be so kind as to explain this "discrepancy"?

Thu, 02/16/2017 - 3:33pm

Much to due about nothing. Another liberal Trump hater trying to scare the public into opposing our president. Where were you when Obamacare was adding 40 million new patient service demands on our existing medical industry and cutting compensation to providers? Sorry no credibility from your pen. We just can't trust what you say anymore.

chuck g
Thu, 02/16/2017 - 11:43pm

Several of the above comment abound with misinformation. The physicians discussed in the article are not American medical school graduates. They graduated from overseas schools and are seeking post graduate training in the US. So no US tax dollars or American medical school positions were used to educate them. In Michigan, within the past five years or so there have three new medical schools opened so there has been no effort to limit the number of American students educated in Michigan. The number of medical students who can be educated is limited by the amount of clinical experience available for teaching each student and resident in training. Not every hospital is suitable for teaching purposes so not all patients are available for teaching purposes. . For example there is a finite number of deliveries available in teaching hospitals for teaching medical students and obstetrical residents. There is a minimal number of deliveries each obstetrical resident must do to be considered competent to be a specialist which in turn limits the number of deliveries available for medical student training. This same problem exists for teaching all areas of medicine. If it were not for international medical graduates training in the US there would be an enormous deficit of physicians available to staff American hospitals and subsequently practice in the US.

Fri, 02/17/2017 - 9:24am

To all our friends on the bleeding heart left, what is the morality of the US sucking up all the doctors from these already desperately underserved countries just so they can make more money helping a bunch entitled Americans?

Mark Whelan
Sun, 02/19/2017 - 6:19pm

So much BS. If they have a legal visa, have been here for 20 years have a valid license what is the problem. Trump's Executive Order is for undocumented illegals and those "refugees" who have not been thoroughly vetted. This has nothing to do with anybody here legally. Why is Bridge speculating on circumstances that do not exist AND DO NOT APPLY TO THE SITUATION. Foreign doctors are not vital to anybody. If there were no foreign born doctors in the US willing to work so cheaply then there would be better pay offered for other doctors. How is bringing cheap foreign based labor is any way advantageous to the American worker. It is not. It drives down wages and keeps American workers from filling the jobs. These are not "jobs Americans are not willing to do" these are jobs American business has been able to import cheap labor for.

Mon, 02/20/2017 - 11:08pm

If you have ever been in a war zone, been awaken by the sound and percussion of high explosives, that reality wouldn't allow you to disregard what you've heard for a lifetime and built your dreams on simply because of some 'newspaper' headlines over a couple of months.