Politics and the wellness of our foreign-born colleagues

Travel bans and visa-law changes in a volatile political arena can affect the morale of a large number of physicians, in training and established in practice, as well as international students enrolled in medical schools in the United States.

An internal medicine resident is saddened that his parents, who live in Syria, could not attend his graduation ceremony. An Iranian nephrology fellow is heartbroken that she cannot plan her wedding back home. An attending physician from Jordan wonders if her country will be next.

Numerous reports in medical literature and the popular press have described the role played by foreign-born physicians in the U.S. health care system and the detrimental effect of a travel ban, such as the compromise to health care in medically underserved communities. Many individuals face consequences as well, from limited liberty to travel to their home countries, to fear of being unable to return to the U.S. to complete education or training, to the inability of family members and loved ones to visit.

Stressful personal life events coupled with an uncertainty of the future are proven contributors to physician burnout (11. Shanafelt TD, Hasan O, Dyrbye LN, Sinsky C, Satele D, Sloan J, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600-13. [PMID: 26653297] doi:10.1016/j.mayocp.2015.08.023, 22. Dyrbye L, Shanafelt T. A narrative review on burnout experienced by medical students and residents. Med Educ. 2016;50:132-49. [PMID: 26695473] doi:10.1111/medu.12927). Travel bans and visa-law changes in a volatile political arena can affect the morale of a large number of physicians, in training and established in practice, as well as international students enrolled in medical schools in the United States. While this is also true for nonmedical professionals from international backgrounds, the effect on physicians and medical students is of particular concern, especially given the ample evidence of burnout in a profession known to have higher rates of suicide and depression than the general working population (33. West CP. Physician well-being: expanding the triple aim [Editorial]. J Gen Intern Med. 2016;31:458-9. [PMID: 26921157] doi:10.1007/s11606-016-3641-2). Moreover, international medical graduates have historically reported discrimination in the workplace (44. Chen PG, Nunez-Smith M, Bernheim SM, Berg D, Gozu A, Curry LA. Professional experiences of international medical graduates practicing primary care in the United States. J Gen Intern Med. 2010;25:947-53. [PMID: 20502974] doi:10.1007/s11606-010-1401-2). This could be exacerbated by the recent wave of xenophobia and decreased sensitivity toward differing cultural and religious identities in the political arena.

International pre-med students and medical graduates undergo an extensive selection process before arriving in the United States. Following their migration, they experience additional challenges compared to their American peers. They experience a dual learning curve, acquiring knowledge and skills like other trainees and at the same time becoming new members in a culture likely very different from their own. They can also experience personal costs of migration and visa-related hardships.

While the travel ban was being challenged in court, in April 2017, the United States Citizenship and Immigration Services froze expedited processing of H1-B visas, one of the programs that grant work visas to foreigners. As a result, renewing an H1-B visa can take up to eight months. The end of May brought extensive questionnaires for all U.S. visa applicants, including J1 visas, the visa most commonly acquired by foreign physicians. The added vetting process includes social media information going back five years and financial, employment, and travel histories going back 15 years. It can potentially take weeks to months to get a visa. Foreign workers traveling abroad need to have a valid visa to return, and given the time constraints of clinical duties, these visa reforms are prohibiting physicians from leaving the country.

It is difficult to predict whether changes in the political climate will affect any given international physician's decision to apply for training in the United States. If fewer physicians do choose to come, this could result in unfilled residency and fellowship positions. According to the National Resident Matching Program (NRMP) data report for 2017, U.S. medical school graduates only filled 60% of the first-year residency positions, while the remaining positions were filled by international medical graduates, most of whom are not U.S. citizens. Some residency programs may be more affected, such as internal medicine, family medicine, and pediatrics; international medical graduates filled 54.9%, 55.1%, and 32.5% of these positions, respectively (55. National Resident Matching Program. Charting Outcomes in the Match for International Medical Graduates. 2nd ed. September 2016. Washington, D.C.: National Resident Matching Program; 2016.).

Decreases in international graduates coming to the U.S. may become more pronounced with time given that a minimum of two years of planning is needed on the applicant's part to meet the requirements to participate in the NRMP. This includes completing all certification exams to obtain the Education Commission for Foreign Medical Graduates certification, as well as traveling to the U.S for residency and fellowship interviews.

Primary care may be more affected than other specialties if foreign-born physicians stop applying, and underserved communities will be particularly affected when their physicians' wellness is at stake. The U.S. physician workforce is not diversifying at the same pace as the nation's demographics, but this may be alleviated by the continued participation of international medical students and physicians, who could potentially improve minority health and health care access for the underserved (66. Talamantes E, Moreno G. Immigration policies and the U.S. medical education system: a diverse physician workforce to reduce health disparities [Editorial]. J Gen Intern Med. 2015;30:1058-9. [PMID: 25794539] doi:10.1007/s11606-015-3281-y). Foreign-born physicians also add diversity to the educational environment of our institutions and provide cultural bridges that enrich the experiences of their peers.

The wellness of international medical students and physicians is a key component in the system in which they learn, train, and practice, with major implications not only for the individual but also for the patients they serve. Their wellness is affected by their environment and is particularly affected by the president's recent executive orders and visa changes.

These students and physicians need and deserve more support. In addition to civic engagement to influence national policies, medical institutions should ensure diversity in leadership positions, train their personnel in cultural competence and empathy to ensure effective work in cross-cultural situations, and promote wellness and social events that foster diversity and inclusion.

Institutions should also provide legal counseling and offer supporting documents that facilitate the visa processing not only of their international students and employees but also of their loved ones. Moreover, the training of students, physicians, and ancillary medical staff should include advice and counseling to handle those heart-wrenching moments when caregivers are met by cultural insensitivity from their patients.

It is evident that continued participation of international physicians is imperative to the current U.S. health care system. We ought to recognize how the present political chaos is affecting our colleagues and learners, offer them our emotional support, and voice their hardships to governing groups in both academic and nonacademic medical institutions.

For now, the Syrian resident's parents attended his graduation via social media, the Iranian fellow put her wedding plans on hold, and we both hope that the future will be safer for diversity.