Hospital systems throughout the United States are lining up lawyers to fight President Donald Trump’s restrictions on legal immigration, fearful the White House could limit the number of foreign-born doctors who work in America and cripple their ability to provide necessary care.

Trump’s initial immigration order has been rolled back in parts, but the White House aims to replace it with a new order next week. And the U.S. medical system is now worried that Trump’s stated objective — to restrict even legal immigration to create more jobs for American citizens — could create gaps in the health care nationwide.

”The number of physicians trained in this country is not substantial enough to meet all the needs of healthcare, especially in large urban centers with lots of underserved,” said Dr. Kim Baker-Genaw, the director of medical education at Henry Ford Hospital, a major teaching hospital in Detroit.

Almost a quarter of physicians working in the United States are international medical graduates who have come to the country on an H-1B visa for highly skilled workers to train and work in a range of fields and specializations.

Without them, thousands of medical jobs would go unfilled — particularly in urban areas with high poverty rates, rural areas where medical facilities are few and far between, and Department of Veterans Affairs facilities. Indeed, the number of medical residency positions available each year outnumbers U.S. medical school graduates.

That trend is set to continue: According to the New England Journal of Medicine, by the 2023 academic year, the number of positions available “will continue to substantially exceed the number of U.S. medical graduates seeking them.” The Association of American Medical Colleges predicts that by 2025, there will be a shortfall of between 61,700 and 94,700 physicians in the U.S.

Already, foreign-born doctors with valid visas have been affected. Doctor recruitment group The Medicus Firm reports that about 15,000 doctors are from the seven Muslim-majority countries from which Trump signed an executive order banning travel. Before last week’s appellate court ruling allowed travel to resume, there were reports that doctors who were outside the country when the order was signed were stopped from returning home.

Medical systems now are gearing up to help protect their access to doctors in the country on the H-1B visa, which allows highly-skilled workers to work in the country, and the J-1 visa, which allows people to travel to the U.S. for work and study exchanges.

Henry Ford Hospital serves a low-income, often uninsured population in Detroit that relies on the hospital system for primary care. The hospital provided $299 million in uncompensated services last year, and said it needs foreign-born doctors to ensure patients continue to get the care they need.

“As physicians, we take care of everybody,” Baker-Genaw said. Henry Ford’s staff has doctors from more than 60 countries, helping the hospital better serve its patients including many Arab and Hispanic immigrants.

Henry Ford fears changes to immigration law could upend its recruitment strategy, Baker-Genaw said. The hospital has a lawyer working with doctors impacted by Trump’s executive order and those concerned future action is coming.

"We’ve had an attorney on retainer from a law firm that works on immigration who has been down here meeting with all the involved trainees and faculty,” Baker-Genaw said, noting that the attorney has been on call 24/7 working to provide doctors with the most up-to-date information as possible.

The lawyer is available “whenever we need them related to any immigration changes or questions from those concerned that if they leave the country they won’t be able to come back,” Baker-Genaw said. “If everybody had to leave in one month, it would cause chaos.”

Care of patients — particularly those who are low-income and without insurance —could be compromised were their doctor have to leave the country abruptly.

“I have a lot of long-term patients who take medication that treats heroin addiction,” said Dr. Muhammad H. Majeed, a doctor at Natchaug Hospital in Mansfield Center, Connecticut. “When I see them, I worry about myself and them.”

He went to medical school in Pakistan but came to the U.S. for his residency in 2010. His visa expires in 2018 and he is hesitant to leave the country for any reason until then.

“I’m so used to living here, having an international lifestyle. I feel myself more Americanized socially. I just relate with this place so much than I do with Pakistan,” Majeed said. “When you live in a country for a decade and you work there, you’re not politically a citizen but socially and mentally you live there, you transition over time with the lifestyle.”

Foreign-born doctors who are legal permanent residents also fear they could lose their status if Trump makes additional changes to immigration and visa programs.

“Despite having a green card, I’m insecure,” said Dr. Farhad Saeed, a nephrology specialist from Pakistan who works at the University of Rochester Medical Center in Rochester, New York.

Woodhull Hospital, part of the NYC Health + Hospitals system, is concerned potential changes could impact its ability to attract top talent to care for its Brooklyn population. Thirty-six percent of Woodhull’s patients are uninsured, and NYC Health + Hospitals provides care across the system regardless of ability to pay.

Dr. Susan Grossman, director of the internal medicine program at Woodhull, said about 80 percent of her residents are international medical graduates. Current hospital residents have been advised not to leave the country, said Grossman, who currently has two residents from among the seven countries included in the executive order. They have access to legal assistance through the NYC Health + Hospitals system, which said it would possibly also refer doctors to other legal organizations if appropriate.

She just finished interviewing applicants for next year last week, and they aren’t the only ones who are rattled.

“Both residents who are currently in the program and several of the people I interviewed expressed concern about the impact of the executive order and possible future decisions,” Grossman said.

Although she interviewed potential residents from some of the seven countries, she said she wouldn’t be using nationality as a factor in her decision making process. Some of the interviewees feared being from one of the countries could mean they are not ranked by any hospitals as a part of the medical residency program.

“We’re trying to select the best qualified candidates and we’re not looking at where the doctors are coming from,” Grossman said. “We have a tremendous amount of out-patients and in-patients and we want to provide them with doctors that are able to meet their needs.”

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