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Tuesday, February 07, 2017

Medical community unifies in opposition to Trump travel ban- Medscape

As a registered nurse, I'm impressed by how quickly the medical providers and the health care communities have unified in opposition to the travel ban from Muslim countries, a cruel directive put in place by Donald Trump. It's rare to see medical professionals across the gamut, from provider to health systems, unify so rapidly against anything. But this horrible travel ban is bad for everyone, especially for patients seeking care in the US and providers who are doing international public health work to protect humanity from the next pandemic. List of medical groups officially opposed to the illegal Muslim travel immigration ban are found at the end of this blog.*

Image result for immigrant passport picture
This is a chilling image- regardless of a person's nationality or religion. Americans must beware of unintended consequences.  

(UPDATED February 6, 2017 – Editor's note: This story was updated to reflect recent restraining orders that block enforcement of some or all of the ban's provisions.)

Medical societies often part ways on government policy, but Donald Trump's temporary ban on travelers from seven Muslim-majority countries united most of organized medicine, including the American Medical Association (AMA), in voicing confusion, worry, and in some cases, outright opposition.

The outcry goes beyond dramatic stories of individual physicians or patients denied entry or reentry into the United States. 
Medical societies fear that the travel ban — temporarily put on hold by a federal judge — inadvertently inflicts systemic damage on medical education, research, and patient care. These groups decry discrimination, affirm the need for global collaboration, and express solidarity with foreign-born Muslim members who practice here and abroad.

"Discrimination in any form is wrong," said John Miegs Jr, MD, president of the American Academy of Family Physicians (AAFP), in an interview with Medscape Medical News. "This country has always been welcoming. We're all immigrants in the broadest sense of the word."

Dr Miegs said he appreciated the responsibility of the Trump administration to keep Americans safe. "We would just like them to look at some of the unintended consequences of the travel ban."

Nitin Damle, MD, president of the American College of Physicians (ACP), said that his group "values the significant contributions of Muslim physicians to the health and well-being of our nation.

"If the executive order is not permanently rescinded, blocked by the courts, or reversed by Congress," Dr Damle said in a news release, "it will hinder the free exchange of information and travel among doctors around the world."
Gerald Williams Jr, MD, president of the American Academy of Orthopaedic Surgeons, told Medscape Medical News that his group, while advocating for global collaboration, is taking a watch-and-wait approach. 
"The entire effect of the travel ban is unknown," Dr Williams said. "We're hopeful that people in the Trump administration will mitigate the bad effects."
On January 27, Trump signed an executive order that he said would help keep foreign terrorists from infiltrating the United States. 
For 90 days, the order bars anyone coming here from Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen. In addition, it suspends the admission of refugees from any nation for 120 days and indefinitely suspends admission for Syrian refugees in particular. The White House says the pause will give agencies such as the Department of Homeland Security time to tighten up their vetting process. (In other words, time to write regulatory language to prevent all immigration!)
At least 33 national medical societies have taken public positions in response, mostly by issuing news releases, although one group tweeted its position and issued some signed letters of concern. They include three major primary-care societies: the ACP, the AAFP, and the American Academy of Pediatrics.
Echoing the sentiments of other groups that went on the record, AMA CEO James Madara, MD, said in a letter to the Department of Homeland Security that the executive order should not "impact patient access to timely medical treatment or restrict physicians and international medical graduates (IMGs) who have been granted visas, to train, practice or attend medical conferences in the United States." Dr Madara noted that one in four practicing physicians in this country are IMGs, who are more likely to work in underserved areas, especially in primary care.
According to the Accreditation Council for Graduate Medical Education (ACGME), 10,000 IMGs licensed in the United States graduated from medical schools in the seven Muslim-majority countries.
The travel ban does more than prevent certain medical students and physicians from entering the United States for the first time. It has the effect of trapping others inside the United States. The Infectious Diseases Society of America (IDSA), for one, reports that some of its members from the seven named countries who work here are afraid to visit relatives back home for fear they won't be able to return, "despite having valid visas."

The validity and application of the executive order now are up in the legal air. Federal judges in five states have blocked enforcement of some or all of the ban's provisions with temporary restraining orders, although one issued by a federal judge in Boston already has expired. The most sweeping of these orders, coming from US District Judge James Robart in Seattle, Washington, could escalate into a court battle royale. On February 4, a federal appellate court in San Francisco, California, denied a request by the Trump administration to delay Robart's temporary restraining order — for the time being, at least — but said it would hear more arguments from both sides before ruling on the government's motion. The Trump administration has indicated it also intends to formally appeal Robart's decision, a stepping stone to a possible Supreme Court case.

On February 1, the White House clarified that the ban does not apply to lawful permanent residents, also known as green card holders. That still leaves visa holders and approved refugees for the courts to rule on.  (IMO the "green card" protected immigrants are still at risk for discrimination, and deportation, because the methodology imposed by the Trump administration and the decrees issued without promulgated process can be imposed again, at any time.)

"Science Doesn't Happen in a Vacuum"

A number of medical societies worry that the travel ban will prevent some of their international members from attending annual conferences in the United States. The Endocrine Society already is receiving cancellation calls for its annual meeting — ENDO 2017 — in Orlando, Florida, in early April, said Gary Hammer, MD, PhD, the society's meeting chair, in an interview with Medscape Medical News.
"Meetings such as this are the core of collaborative scientific discovery and clinical advancement," said Dr Hammer, director of the endocrine oncology program at the University of Michigan in Ann Arbor. "We all publish about discoveries, but it is the human contact of physicians and scientists where the most sharing occurs. The travel ban severs that."

Of the 18,000 members of the Endocrine Society, roughly 40% live outside the United States. For the Gerontological Society of America, it's 18%. Such a high percentage of international members, these groups contend, underscores the need for unhindered travel.

Some scientific collaboration requires face time, not just email time, adds Dr Hammer. For example, researchers from different countries are more likely to share tissue samples if they personally know and trust one another.

"Science doesn't happen in a vacuum," he said. "It's human beings shaking hands and looking each other in the eye and agreeing to pursue a common goal."

Will Residency Programs Write Off Some IMG Applicants?

Organized medicine also fears that the travel ban, if not fine-tuned, could prevent IMGs from the seven Muslim-majority countries from landing a residency-training slot in the United States. Match Day, when medical school seniors and graduates find out what residency programs have accepted them, is around the corner on March 17.


In his letter to Homeland Security, the AMA's Dr Madara said White House guidance is urgently needed "to ensure that the upcoming residency matching program...does not leave training slots vacant and that qualified IMG applicants can participate."

The ACGME is concerned as well, noting that medical schools in the seven named countries account for some 1800 physicians already in residency and fellowship programs here. "They too are a valued and welcomed group of colleagues," said ACGME CEO Thomas Nasca, MD, in a statement.

Yet another group on red alert is the National Resident Matching Program (NRMP). It warns that residency programs may write off IMGs from the seven countries. "It seems likely that residency program directors will be reluctant to rank J-1 visa applicants because they may not be able to enter the country to begin training," NRMP President and CEO Mona Signer, MPH, said in a news release.

Dr Nasca asks residency programs to not give up on IMG applicants.

"Our colleagues from other countries have cared for America and Americans for generations," Dr Nasca wrote. "We must not abandon them now, as they search for the American dream we often have taken for granted."
*On record in opposition to the Donald Trump immigration travel ban:
American Academy of Dermatology (AAD)
American Academy of Family Physicians (AAFP)
American Academy of Neurology (AAN)
American Academy of Orthopedic Surgeons (AAOS)
American Academy of Pediatrics (AAP)
American College of Cardiology (ACC)
American College of Chest Surgeons (CHEST)
American College of Physicians (ACP)
American Congress of Obstetricians and Gynecologists (ACOG)
American Gastroenterological Association (AGA)
American Medical Association (AMA)
American Medical Student Association (AMSA)
American Osteopathic Association (AOA)
American Psychiatric Association (APA)
American Society of Clinical Oncology (ASCO)
American Society for Clinical Pathology (ASCP)
American Society of Hematology (ASH)
American Society of Nephrology (ASN)
American Society of Pediatric Hematology/Oncology (ASPHO)
American Society for Radiation Oncology (ASTRO)
American Society of Transplant Surgeons (ASTS)
American Urological Association (AUA)
College of American Pathologists (CAP)
Endocrine Society (ES)
The Gerontological Society of America (GSA)
HIV Medicine Association (HIVMA)
Infectious Diseases Society of America (IDSA)
North American Society of Cardiovascular Imaging (NASCI)
Renal Physicians Association (RPA)
Society for Gynecologic Oncology (SGO)
Society of General Internal Medicine (SGIM)
Society for Maternal-Fetal Medicine (SMFM)
Society of Nuclear Medicine and Molecular Imaging (SNMMI)
*Statements, letters, tweets expressing concern or opposition
Follow Robert Lowes on Twitter @LowesRobert

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