Will Trump's ban cause foreign-born doctors to look elsewhere?

The US has long depended on foreign-born physicians to shore up its ranks

Get sick in Toledo, Ohio, and chances are good you'll be treated by a doctor born in another country. If you have allergies, stomach issues or neurological problems, the chances are even better. At least half of those doctors are foreign-born, Ohio Medical Board data shows 2014 some from the seven countries listed on President Trump's travel ban.

Allergist Syed Rehman, for instance, was born in Iraq, attended medical school in Pakistan and came to the United States for his speciality training in 1984. Neurologist Mouhammad Jumaa was born in Syria, went to medical school in Damascus, then did eight years of training in Pittsburgh. And Dr Imran Ali, a professor of neurology at the University of Toledo Medical School, left Pakistan to complete his training in North Carolina.

For decades, foreign-born doctors like Rehman, Jumaa and Ali have played a vital role in shoring up American's health care system. The doctors come to the United States for residency, drawn by cutting edge medical training and American ideals, then stay to fill the country's growing need for doctors. But Trump's executive order this week 2014 and worries it may expand to other countries, such as Pakistan 2014 has touched off a wave of anxiety, anger and dire predictions that immigrant doctors, faced with hostility or uncertainty, may go somewhere else. The news made the front pages of media outlets across Pakistan and India.

"Overall the thing that attracts people to America is the society, the people, the freedom to pursue your dreams," said Ali, who has raised three kids in Toledo. "If that paradigm changes then what's the reason to come?"

And that, Ali and other physicians said, should worry everyone.

Foreign-born doctors often are willing to work in the isolated rural areas, small towns and blighted urban centres that many American-born doctors shun. It's estimated that about 10,000 foreign-born doctors have served such stints. There are about 926,000 active doctors in the United States, according to the Kaiser Family Foundation. As of 2013, about 45,000 of them came from India, 11,000 from Pakistan and 10,000 from the Philippines, according to data gathered by the American Medical Association. Another 3,800 came from Syria and 3,900 from Iran, which are included in Trump's ban, the data showed.

The need for foreign doctors is likely to grow. A 2016 report by the Association of American Medical Colleges projected a shortage of between 62,000 and 95,000 primary care and speciality physicians over the next decade as the population grows and ages. Monday, the association, which represents medical schools and teaching hospitals, said Trump's 90-day ban on visitors from seven predominantly Muslim countries could cause long-term damage to patients and health care in the United States.

The significant role of foreign-born doctors in many communities can be seen in Toledo, a Rust Belt city of about 285,000 residents. Some foreign-born doctors there estimate that as many as 40 per cent of their peers were born outside the U.S., although there's been no official count. Eight of the 14 specialists in the University of Toledo neurology department come from other countries. "I can't even imagine what medicine would look like without foreign-born doctors," said Dr Gretchen Tietjen, an American-born neurologist who is chair of the department.

Trump's temporary ban is limited to Iran, Iraq, Libya, Somalia, Sudan, Syria and Yemen. It's unknown whether it will be extended or applied to other countries, though such possibilities have been mentioned. Its chaotic implementation caused high-profile examples of doctors being stranded or detained en route to the US.

Doctors say the ban has sown widespread fear, even among practitioners from countries it doesn't include. The Medical Colleges Association estimates that about 18,000 current medical residents are not US citizens. Other foreign doctors are practicing on non-immigrant visas. As a result, in Toledo some doctors say colleagues have decided not to go home to Pakistan, or bring loved ones from abroad, because they're afraid of getting caught up in a travel ban. 

The ban could also create bias in the process of matching residents to programs in teaching hospitals throughout the country. The Medical Colleges Association estimates that about 1,000 foreign medical school graduates from the seven banned countries have applied for American residency and fellowship programs this year. Many other applicants could be affected if the ban is expanded to other countries.

On Tuesday, the American Medical Association sent a letter to the Department of Homeland Security voicing concern that residencies may go unfilled and urging it to "provide details and mitigate any negative impact on our nation's health care system," the letter said.

It's resulted in an uncomfortable quandary for Tietjen, who is currently deciding how to rank applicants for four coveted neurology residency positions. Residents are a crucial part of the workforce, she said, helping staff about 1,000 beds at multiple hospitals. Of the 40 applicants who made it to the interview phase, five come from countries under the ban, she said. Now, for the first time, she can't simply judge their skills and potential, she must also look at their nationality and their chances of getting through immigration. Five of the 16 current residents are from Pakistan, and one is from Iran. 

"It just feels morally wrong not to look at people by their qualifications rather than where they came from," she said. "I feel empathy for people who don't get a spot because of this ban."

The White House press office did not respond to an email and phone call.  

In interviews, Toledo doctors from countries such as Syria and Iraq said Trump's ban is likely to discourage others like them from coming to the United States for residency. The physicians are taking a risk and cannot afford to have their time wasted, said Rehman, the allergy specialist, who's affiliated with multiple hospitals in Toledo. "It will hurt us in the near future," he said.

Egyptian radiologist Haitham Elsamaloty came to the United States in 1994 and is the interim chairman of the radiology department at the University of Toledo. He worries his home country may soon be added to Trump's ban and wonders whether others may choose not to follow his path.

"This ban is going to limit students who are very good and have all the drive and motivation to be the scientists of the future," Elsamaloty said. "They will look to Canada. Canada has open arms. Or Germany, France or the UK. They are all open societies and don't have a ban." 

Jumaa, the stroke specialist from Syria, said the US will always be attractive to foreign doctors because it has the best medical education in the world. But it's a high-risk, once-in-a-lifetime investment to apply for residency in the US, he said. Will potential residents from the seven countries still want to come if their families can't visit, or their travel might be restricted?

"I would tell them not to go through the uncertainty and to pursue medical education in another country," he said. 

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