Dr. Dave Campbell, Chief Medical Correspondent, Morning Joe/MSNBC
Dr. Daniel Howell, Pulmonary and Critical Care Medicine, currently working on the Covid-19 ICU’s in New York City
In a Task Force press briefing April 21st, President Trump spoke of the executive order he will sign suspending immigration for sixty days as the novel coronavirus pandemic sweeps the United States. He said the immigration policy will preserve medical resources for American citizens. He also indicated it will protect the solvency of our healthcare system and provide relief to jobless Americans. While the order is reported by Business Insider to include exceptions for migrant farmworkers and healthcare workers, grave concerns exist for the status of immigrant physicians and healthcare workers who have already or will be able to bring the fight to the coronavirus pandemic, on the frontlines.
Immigrating to the United States of America is the dream of many across the world who understand it to be a place of aspiration, where one can make their very own American dream. Immigrants aspire to realize the opportunity and liberty afforded to those that make the U.S. their home. There is nothing novel about a twenty-something Irishman choosing to re-locate here, it is an experience that is embedded in our culture. One of us, Daniel Howell, is a foreign-born doctor, termed an International Medical Graduate (IMG), who knows first-hand there were many twists and turns to navigate in order to make that move a reality.
Dan graduated from Newcastle Medical School, England and soon began the process of obtaining a spot in a U.S. Residency Program. This took him three years and involved spending over $15,000 on various exams and last-minute flights, studying eight hours a day while working full-time in the ER, and countless emails that were ignored to various institutions trying to get the required “U.S. clinical experience”.
Yet again, there is nothing novel or unique about that endeavor and Dan believes there are many physicians that have a more challenging path. This year, according to the National Residency Matching Program, 4222 non-U.S. citizen IMGs are due to start their U.S. Residency Training on July 1, 2020. These doctors will be tasked with taking care of patients across the country and are fundamental parts of the team needed to deliver safe care. This is especially true at leading academic institutions where residents make up a large proportion of the workforce. These doctors, many of whom are waiting for their visas to be processed right now, need to be admitted in order to maintain the level of service that Americans so desperately need at this time.
“Implementing a change in the U.S. immigration policy should be for the common good of the nation,” said William Wallace, a third-year medical student from Florida studying medicine abroad. “However, limiting the entrance of foreign doctors into the U.S. does the opposite.”
A similar number of IMGs will be completing their specialty training and are due to become fully qualified attending doctors in their chosen field, including critical care medicine. The supply of critical care physicians, who are the specialists with the expertise to manage COVID-19 patients in the ICU are in even shorter supply than ventilators, personal protective equipment, and testing in the U.S. However, most of these doctors are currently permitted to work in the United States on J1 and H1b visas which are due to expire when their training ends on June 30th. These skilled physicians all depend on processing of visa extensions, employment authorizations or green cards in order to remain in the U.S.
There is huge gap in the supply of doctors between population-dense large metropolitan and more dispersed rural areas. Even in good times, it can be difficult, if not impossible, to secure an appointment with a specialist in many parts of rural America. A key part of the rural physician workforce is comprised of foreign-born doctors who are fulfilling the requirements of their J1 waiver. Those qualified, competent and highly trained physicians working on a J1 visa are required to return to their home country for two years. These physicians may have that requirement waived if they choose to work in areas deemed to have a severe shortage of doctors. Without continuing to process these waivers many parts of rural America may see further physician shortages.
The importance of processing doctors is not just limited to those in training or who have just completed their training. Over twenty-five percent of all doctors in the U.S. are foreign-born. The U.S. healthcare system is heavily reliant on these immigrants to maintain the safe, quality, compassionate healthcare service. Many remain on visas in a temporary holding pattern, in some cases for many years, after completing their training as they await green card processing.
The reality most in the U.S. have come to terms with is the COVID-19 pandemic is a national crisis of historic proportion. The highly contagious new coronavirus, SARS-CoV-2 will continue to create clusters and outbreaks of disease in hot-spots across the country, even as the warm months of summer lazily drift along. As board-shorts and T-shirts replace long pants and long-sleeves, the virus will search for at-risk populations squeezed into tight living quarters to gain a deadly foothold.
It would seem that all paths to medicine are extreme for an immigrant. Dan’s younger brother Jon Clarke immigrated from Ireland when he was eighteen years old and enlisted as a navy Corpsman. He served his new country five years of active duty service to gain citizenship in the United States of America. Jon pursued his dream to become a physician while always looking up to his older brother as a role model. With hard work, he was accepted into medical school this spring.
“It was by no means the easy road,” Jon said. “But I am in a much more comfortable place today than the international medical graduate as I have the security of remaining in the United States upon graduation from medical school in four years. The five years spent as a corpsman tending to Marines at Naval medical facilities and another four years to earn a bachelor’s degree, was well worth it.”
For doctors working on H1-B visas there are very strict restrictions on the location and job role especially since the publication of a 2015 memo “Matter of Simelo Solutions”. These restrictions block H1-B doctors from work wherever there is need across the country. Lifting these restrictions would lead to a more dynamic and responsive workforce. Likewise, H1-B holders should be able to practice in another state if there is need due to a Covid-19 outbreak.
The need to prevent Covid-19 transmission within and across borders is clear. However, any change in U.S. immigration policy should understand the need to not only continue but to speed up visa and green card processing for foreign doctors. Indeed, there is action that the Trump Administration could take to unleash the non-U.S. citizen doctors to care for the nation. Whether from Ireland, Jordan, Ghana or Brazil, there are doctors across the world hoping to realize their own personal ambitions, but also come to the United States to provide critical medical care to a desperate American population during this difficult time. Anxious immigrant doctors are eager for the United States to keep its door open to them. They are willing to practice in big cities and rural farmland, inner cities and remote underserved outposts. The health of American will be better preserved by embracing rather than shutting out immigrant physicians and other healthcare workers.