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Conversations in Pulmonary, Critical Care and Sleep Medicine by the American Thoracic Society
Patti: [00:00:00] America has long relied on foreign-born physicians. Now is it turning its back on them? I'm Patti Tripathy, and we will be talking to two experts in this area, Dr. Eram Alam, who's. History of, uh, area research's, history of medicine, and she's a professor at Harvard and Dr. Lynn Schnapp, who has, uh, worked all over the country.
She's a pulmonologist and she is particularly interested in mentorship or has mentored all along and created labs for the best and the brightest. Quite often they are foreign born physicians. Dr. Ira alum, uh, let me ask you, what inspired you to write a book, your first book, care of Foreigners, how Immigrant Physicians Changed the US Healthcare System?
And it's right behind you as well.
Eram: Yeah. Thank you so much for the invitation and to, you know, I'm excited to be in conversation with all of you and yeah, [00:01:00] so this, this question came about 'cause I. Studied history of medicine as when I was working on my PhD and I was really interested in healthcare disparities and so much of the research out there says, yes, there are these kinds of racial disparities that exist.
Then I just started to ask this question, well, who's actually working in these communities? Who's taking care of the people that are there? And that led me into this research that showed me that in fact, immigrant physicians are the ones that were on the front lines of under-resourced communities and working in those areas all across the United States.
And so I wanted to dig a little deeper and figure out how is it that this entanglement between immigration and the US healthcare system began and has endured for the last 60 years?
Patti: And Dr. Schnapp, uh, do you anticipate, uh, that uh, with some policy changes that uh, there will be less people? You say quite a number [00:02:00] are from, uh, south Asia, uh, that you are, that are in your program and mentorship and, uh, do you expect things to change and that gonna create some, uh, you know, shortage of doctors?
Lynn: Yes. So as chair of the Department of Medicine, we are, I oversee the internal medicine residency program as well as the fellowships across all the different specialties. And we have actively recruited the best and brightest from around the world to fill our slots. And many of those traditionally have come from foreign trained physicians.
In particular some of the areas of medicine that have fallen out of favor in the United States. For example. Nephrology, um, endocrinology infectious disease, really critical parts of medicine have increasingly been filled by those who have trained overseas who are, uh, are, [00:03:00] are foreign citizens.
And they fill a critical niche in, in the care of our patients, across our communities.
Patti: And are they usually going to rural communities area? We have port.
Lynn: Yeah, so often they're going to rural communities, particularly for us, we have residents and fellows who are on J one Visas, um, and for their, um, waiver for they are required to provide care in underserved regions.
So they are often in those areas where others haven't, haven't wanted to go and provide critical services for rural America.
Patti: And, uh, both of you can answer the next question. What do you anticipate could happen, uh, come July when H one B visa changes, uh, go into effect?
Lynn: for us, we have we are stopping, um, accepting H one B applications [00:04:00] for positions.
And In a number of our specialties that is going to hurt us, um, in terms of being able to fill, fill the need of patient care
Patti: and Dr. Elam.
Eram: Yeah, I mean we see this as Dr. Schnapp has just talked about, you know, the out that it's gonna. Be detrimental, I think for patients who no longer will have access to the providers that they need, and especially in rural communities and where these physicians are going, these hospitals are already operating on razor thin margins and they just won't be able to absorb the cost of a hundred thousand dollars Visa fee per person coming in every single year.
And so this is gonna. Result in a situation where maybe a hospital could have had 10 immigrant physicians coming in and now they'll have six. And so the consequences of that are gonna be suffering and premature death for the population that is going to not be served as a result. [00:05:00]
Patti: And a quarter, uh, more of the US physician labor force for the last 60 years has been, uh, immigrant physicians.
Am I correct? And a MA expects 87,000 job losses. Am I correct?
Eram: Yeah, so it is true. Historically since 1965, at least a quarter of the US physician Labor force has been comprised of immigrant physicians, and especially in the first 10 years after this piece of legislation, that was really crucial in allowing immigrant physicians to enter the country passed, which is called the Heart Seller Immigration and Nationality Act.
So between 65 and 75, sometimes there were even. 46%, 50% of the US physician labor force that were actually immigrant physicians. And since then it has been just a standard 25%, if not more, um, in certain communities. So that has been a consistent number throughout, for sure.
Patti: Dr. Schamp, uh, what, what [00:06:00] are you doing proactively to prepare for a shortage of telemedicine?
what steps are you taking?
Lynn: Well, it. I would say a multi-prong approach. Some of it is a little bit of a wait and see, um, as policy changes are coming to us constantly and sometimes Ping ponging back and forth of, of what, the current interpretations of laws are.
So we are trying to be as nimble as possible. We are trying to, extensively increase our re outreach across the country to ensure that we can fill, um, the slots that we have, um, with others. and then for rural care which is. Bigger than just immigrant physicians. I mean, the, it, I think it requires us to really think outside the box in terms of partnering with other [00:07:00] allied health professionals to provide care of expanding our use of digital medicine, telemedicine technologies.
and being and
Patti: training physician assistant assistants and nurse practitioners as well. Yes.
Lynn: Yep.
Patti: And other care workers.
Lynn: Yeah. one example. Um, many programs have a hospital at home program where we're incorporating EMT providers to help, um, with care at home. And so needing to rethink which I think will be helpful regardless of where we are in the long term.
Patti: Is this a dire situation for, uh, medicine right now?
Lynn: You know, I just think there's so much uncertainty of what the future holds. The other challenge in addition to the H one B fees for us is the increased scrutiny of [00:08:00] our other, of our green card holders of our J one visas. The amount of time it takes to process visas, we don't know whether people will be able to.
Start on time. And so we have, we have to have backup to fill positions. We're telling many of our, our immigrant physicians who are here to really think hard about whether they need to go visit their family at home because of concerns of whether they're gonna be able to come back to the country.
So there's a lot of stress on everyone right now.
Patti: Yeah.
Eram: and I think it's coming from all sides, so we have the immigration attacks that are happening. We have the cuts to Medicare that are happening. We have, so it's, it's not just one singular route that's causing all.
These issues to really emerge and, you know, even caps on US trained physicians and their, how much they can take out in terms of loans. All of these things coming [00:09:00] together, they're going to really, really affect the labor force. So that 86,000 a MC figure that you quoted that's the consequence of all of this stuff.
Patti: And some people don't even realize that these physicians who are being trained, maybe in third world country, actually go through another or rigorous exam exams and training in the us. They just don't come from their degrees from another country and start practicing here.
Lynn: That is correct. And ironically, there's actually a pilot program now from the American Board of Internal Medicine.
To expedite some of the training and, and, and acknowledging the expertise of some of our immigrant physicians who come over. So for, a number of physicians who come for a fellowship for subspecialty training if they demonstrate outstanding performance as a [00:10:00] fellow, they will not have to repeat their internal medicine residency in order to get licensed and certified, which is a, you know, actually that's a step forward for us.
Patti: And what you were mentioning earlier, you know, I, we are from India too. My, I. Was 12 when my family arrived. My dad's a physicist and his mother happened to die, uh, in India, and he, uh, couldn't go back as, as if he hadn't seen her for 15 years because he didn't know how or if he was gonna be able to come back.
and there's a lot of fear amongst, uh, doctors. There was a doctor who was supposed to appear today who didn't apparently want to be targeted for talking about this issue. So is there a lot of fear amongst, uh foreign born physicians? They don't know what can happen to them.
Eram: people are.
Really, um, they're gonna make other [00:11:00] choices. You know, the, just recently there was an article that came out in the New York Times about the xenophobia that South Asian, the South Asian community in general is experiencing and people making different choices about where they wanna go. So Canada, the uk, while imperfect Australia, they have maybe slightly more predictable.
Kinds of routes for immigration so that people aren't caught in between these really, really precarious, erratic, xenophobic policies that they can't quite make sense of. And I think this is going to, you know, this is ultimately gonna have a really, again, negative effect on people's choices.
Patti: Yeah. And people talk about the American dream and soon it could be like the European dream when everybody is heading somewhere else.
Right.
Lynn: I absolutely agree. I mean, I think the, what this threatens is this pipeline of intellectual powerhouses who have [00:12:00] traditionally come to America, the, been to America a degree. And that pipeline is being disrupted and it's very, gonna be very hard, I think, to recreate that over time.
Patti: And it's just not physicians, but scientists as well.
Correct.
Lynn: Yes, absolutely. Many of our outstanding postdoctoral fellows come from different countries all around the world. and they have their choice of where they want to go. I, I think the United States is becoming less and less attractive for them as sites because of this. The barriers and the, the biases and prejudice that is, is apparent.
Patti: Is there something I didn't ask you that, uh, you would like to comment on regarding this issue?
Lynn: still have hope that common sense will win out. And you know, we are, [00:13:00] we are working hard to support all of our teams across the school of medicine across our health system to make sure that they feel supported, that our patients feel supported. We will get through this.
Eram: I just want to emphasize what you started off by saying, which was how important these physicians are in places and in specialties that often US trained physicians don't want to go. So I think part of, you know, my. Important message is to say that. This is a foundational structure of the US healthcare system.
This isn't just some kind of gift that the United States is giving an immigrant. This is in fact something that is absolutely essential and necessary to the workings of the everyday in the United States. And I think that's an issue writ large with immigrants, not just in. The medical specialties or, or scientists.
And so we need to be reminded of how important, [00:14:00] how integral and how foundational immigrants are to the functioning of all of the society. And not just medicine, but that, you know, this is, this happens to be where our specialties lie. And so we can speak to that, but you know, I just really wanna underscore that.
Patti: Well, let me just talk to you about a comment that was made because of a post that I had on, on, um, social media. And, uh, someone said, you know, why don't they just stay back in India? Doesn't India need the doctors too? So it's kind of a xenophobic comment and it could happen that, uh, people won't be going and the brain drain that happened for so long.
You know, countries will be retaining their own, uh, you know, experts.
Lynn: I think we're gonna see more of that. Um, I think it also. Will threaten the ability to share, advances in medicine across the world. Uh, medicine is global. I mean, the COVID Pandemic I think [00:15:00] is a great demonstration of that. And we need to elevate the care, not just in our country, but across the world and share the best, and share the latest innovations.
We often have people coming from. Around the world to train to gain some skills to bring back to their country, and that is at risk as well. so the healthcare in the United States is not simply at risk. It's healthcare across the world, I
Patti: would say. Yeah. Dr. Alam anything else you'd like to add, uh, based on your research for the book that you've written?
Eram: Well I can just start off with the numbers, which is that disproportionately immigrant physicians work in what's called. Health profession shortage areas across the United States. So these are urban and rural areas where the ratio of physician to patient is one to 3,500. Um, and over 80 million US citizens [00:16:00] live in these shortage areas, which are serviced by these physicians.
And this has been the case for the last 60 years. So just that sheer volume is. Over this, the, the course of such a huge period of time I think is something really important to point out. You know, another very concrete example, Dr. Schnap talked about COVID and how it was so illustrative of the interconnectedness of our world.
And it also was really, really showed how vital these physicians are to. All of our communities, so New York and New Jersey were the original epicenters of the disease in the United States. And just very soon after that, there was this emergency temporary licensing measure that was put in place. So for immigrant positions who hadn't.
Done all of their paperwork, or hadn't passed all of their exams yet. They were allowed to get a temporary license to go and work in special [00:17:00] COVID facilities in nursing homes, in public hospitals in order to provide what was called mission critical care. And they showed up and unfortunately, this program lasted for about 18 months and then they were stripped of their license.
But just the fact of its existence, the fact that. So quickly these immigrant physicians could be recruited to provide this vital and necessary care in the United States. Tells you how important they are and how necessary they are, especially these moments of emergency and crisis. They really show us the value of these practitioners.
Patti: how can, uh, people, what can they do to ease the fear and, um, what, what do Americans need to know?
Lynn: I think one thing that we can do is. Is acknowledge the challenges and the stress, um, and fear that our immigrant physician colleagues are feeling and do everything that we [00:18:00] can to support them.
It's challenging time and as, it's very hard for us to really understand the stresses that they're under. Um, but. To acknowledge it and to provide them space and support as much as we can.
Patti: Do they think that every day that they might get deported.
Lynn: So it's funny, I just had a conversation with, um, one of my faculty who is whose daughter was going off to college and he's actually Canadian, um, but Indian heritage, and he was telling me he is sending his daughter with a copy of her passport in her wallet. Because while she is a US citizen you know, there is, there's fear. We just had our debriefing on, on what our, how are we going to handle if ICE agents come into the health system and what are we, how are we gonna [00:19:00] manage it?
And what are the what steps do we take? Mm-hmm. For, these are very real conversations that I never thought I would be having as as a physician in the us
Patti: That's such a tragedy. and, uh, Dr. Schnapp, thank you so much. Um, it's been a pleasure to talk to you about this topic and also wanted to mention that 30% of the participants or attendees of the, uh, national conference that's coming up in Orlando, American Thoracic Society Conference are from, uh, other countries. And you spoke about, uh, globalization.
So we'll see it right here coming up. And, uh, that's it. Hope to see you again.