Everyday Erinyes #224

 Posted by at 9:00 am  Politics
Jul 182020
 

Experts in autocracies have pointed out that it is, unfortunately, easy to slip into normalizing the tyrant, hence it is important to hang on to outrage. These incidents which seem to call for the efforts of the Greek Furies (Erinyes) to come and deal with them will, I hope, help with that. As a reminder, though no one really knows how many there were supposed to be, the three names we have are Alecto, Megaera, and Tisiphone. These roughly translate as “unceasing,” “grudging,” and “vengeful destruction.”

I was looking around for what to address this week, and then Nameless kind of made up my mind for me. It’s scary. And there’s not much a single activist can do about it. But at the very least it may help us be more understanding of people working in the medical field – all of whom at this point are people overworking in the medical field. No one who is being served by them, or in contact with them in any way, needs to do or say anything to add to their stress.
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Hospitals Are Suddenly Short of Young Doctors — Because of Trump’s Visa Ban

ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.

As hospitals across the United States brace for a difficult six months — with the first wave of the coronavirus pandemic still raging and concerns about a second wave in the fall — some are acutely short-staffed because of an ill-timed change to immigration policy and its inconsistent implementation.

A proclamation issued by President Donald Trump on June 22, barring the entry of most immigrants on work visas, came right as hospitals were expecting a new class of medical residents. Hundreds of young doctors were unable to start their residencies on time.

Trump’s order included the H1-B visa for highly skilled workers, which is used by some practicing doctors abroad who get U.S. residency slots. The proclamation stated that doctors “involved with the provision of medical care to individuals who have contracted COVID-19 and are currently hospitalized” should be exempt from the ban, but it delegated the issuing of guidance to the departments of State and Homeland Security. That guidance has been slow and inconsistent.

 

Many consulates started approving doctors’ visas on Thursday, after ProPublica asked the State Department about the delay. Others say they’re still awaiting guidance.

At hospitals where many incoming residents are visa holders, even a delay of a few weeks in arriving in the U.S. creates a staffing crisis. Doctors and administrators are afraid that the repercussions will last for the rest of the year — leaving them overworked and ill-prepared even before a second wave of the virus hits.

ProPublica has heard from 10 would-be medical residents stuck abroad because of H1-B visa issues. Six of them had gotten emergency consulate appointments for visa approval, but when they arrived for meetings they were told their visas could not be approved. Three were still waiting on DHS approval for their visas, a necessary step before a visa gets a consulate stamp. One resident had application approval but was denied an emergency consulate interview appointment because of the ban. All were destined for hospital positions treating COVID-19 patients.

The State Department told ProPublica on Tuesday that it, “in conjunction with the Department of Homeland Security and interagency partners, is establishing and implementing procedures” for the visa ban, and that it “has communicated and will continue to communicate implementation procedures” to consulates abroad.

On Thursday, the State Department’swebsite posted guidance, spelling out that doctors treating COVID-19 patients were exempt from the ban. On that day, many of the residents ProPublica spoke to said they had suddenly received visa approvals. “A quite remarkable turnaround, given that I received a rejection email three days ago,” one said. In at least five countries, however, consulates were still not processing doctors’ visas.

The Committee of Interns and Residents, an affiliate of the Service Employees International Union, has heard from over 250 interns stuck abroad. Over 150 of them are on H-1B visas.. (The others are on visas that weren’t covered in Trump’s ban, but can’t get approval because their consulates are still closed due to the pandemic.) Union president Jessica Edwards pointed out to ProPublica that while that number may sound small, each intern is responsible for the care of thousands of patients.

As of 2017, there were 2,532 medical residents on H1-B visas, according to the Journal of the American Medical Association — though the Trump administration’s continued restrictions to legal immigration may have made it less appealing for hospitals to sponsor visas in the last few years. But the impact on hospitals is highly concentrated in the less-prestigious hospitals that tend to rely on residents from overseas.

At one New York City hospital serving low-income residents, nearly half the incoming class is still stuck abroad, multiple sources confirmed to ProPublica. One hospital in a large Midwestern city told ProPublica that “roughly half” of its first-year doctors started on time. In the Deep South, a region now overwhelmed by COVID-19 cases, a doctor who was set to start told ProPublica he was among 10 residents still awaiting visa approval as of early July. All hospitals and doctors spoke to ProPublica on the condition of anonymity because they worried about jeopardizing their visa applications.

ProPublica has also spoken to more-experienced doctors facing the same issue — including an infectious-disease specialist blocked from starting a job in an area of the Western U.S. where COVID-19 cases are rising.

 

When there aren’t enough incoming residents to replace departing third-year residents, staffing crunches result.

At the New York City hospital, a doctor told ProPublica that after only 10 days of short-staffing, one resident had called in sick from exhaustion. The doctor recounted a recent shift in which there had only been two junior residents on call, compared with the typical six. Even by having residents work individually instead of in teams of two, they couldn’t keep up with new patient admissions.

“The patients had to just stay there waiting in the (emergency department) for the residents to finish their first admission, in order to see them,” the doctor said. “When the shift was over, I logged into the computer and I would see notes written at 10 p.m., 11 p.m. And these residents are expected to go home and then come back again at 6:30 a.m.”

Even at hospitals with decreasing COVID-19 caseloads, short-staffing is a bigger problem than it was in pre-pandemic times. Some hospitals are seeing a “surge of non-COVID patients” who were unable to get care for chronic conditions like heart disease during lockdown and are now deteriorating, a doctor at a short-staffed hospital told ProPublica. And because protocols prevent doctors from switching back and forth between COVID-19 and non-COVID-19 patients, the hospital needs to keep more doctors on-call to maintain staffing levels in both wards.

“If someone is getting acutely ill, who will see them?” a hospital administrator told ProPublica. “I’ve got my poor residents running around trying to make sure everyone is seen in a timely manner. And residents are great, but they can only be in one place at one time.”

Some of these problems will be fixed as residents receive delayed visa approvals and are able to come. But it will take weeks, if not months, to successfully onboard them. The Midwestern hospital anticipates that arriving residents may not be able to start until mid-August. In the meantime, they’re understaffing services and using fourth-year medical students in place of residents.

Hospitals are used to a summertime efficiency gap, as new interns learn the ropes. This year, it could persist into fall — when a second wave of coronavirus infections is expected.

“I’m really worried that in three months,” said the medical administrator, “we’re going to have a bunch of residents who are just exhausted and just getting into the worst part of the fall, flu and COVID season.”

These doctors already had to push themselves through the first wave of COVID-19 this spring. Furthermore, at hospitals hardest hit by the visa ban, the residents picking up the slack are often themselves H1-B visa holders whose futures are now uncertain. Trump’s ban didn’t revoke visas for anyone currently in the U.S., but if they leave the country — which they will have to do if they change jobs — their ability to return is unclear. Some of the doctors interviewed by ProPublica were living in the U.S. before the pandemic and returned home partly to get visa approval for their new jobs. One doctor ended up stuck in India while her husband was unable to travel there from the U.S.

 

Another doctor from India, now working in the U.S., told ProPublica: “My parents, they’re (in India) by themselves, and both of them are about 70. At some point, probably, they will catch the infection.” If that happens, the doctor plans to leave the U.S. to care for them — “and if I don’t come back, I don’t come back. At this point, I really don’t care.”

The feeling that the U.S. doesn’t value them is compounded among residents who’ve already lived through the first wave of COVID-19 and who are now facing overwork and visa uncertainty. Some said other countries are making it easier for doctors to immigrate, while the U.S. leaves them in limbo.

“We feel underappreciated for what we’re doing,” the New York City resident said. “And what else can you do, more than sacrificing your life?”

Tightly regimented residency schedules can be tricky for H1-B visa holders even in the best cases. Doctors find out in mid-March if they are “matched” with a U.S. hospital, where they’ll be expected to start at the beginning of July. DHS often takes longer than that to approve H1-B applications. Employers can pay for expedited processing to guarantee a decision within five days — but DHS shut down its expedited processing on March 22 because of COVID-19 and didn’t reopen it until June 8.

Shortly afterward, Trump issued his proclamation banning entries on many visa types, including the H1-B.

Most people coming to the U.S. for residencies arrive on a different kind of visa, the J-1, and aren’t covered by Trump’s ban, though some have had issues getting consulate appointments because of the COVID-19 pandemic. But doctors do identical work regardless of their visa types. If anything, doctors with H1-Bs are more qualified than those with J-1s, since they’re required to have completed all three phases of the taxing U.S. Medical Licensing Exam before starting residencies. Residents with H1-B visas were practicing doctors in their home countries, working alongside new medical-school grads from the U.S.

An earlier immigration ban targeting permanent immigrants, which passed in March, contained a broad medical worker exemption. When rumors of a work-visa ban started swirling in late spring, immigration lawyers and hospitals expected it would include the same language. Instead, the June proclamation mentioned only doctors working with hospitalized COVID-19 patients.

 

Every resident who spoke with ProPublica had provided evidence to the U.S. government that they met that description. Some were told by consular officers that they were probably exempt. But until they received State Department guidance, they had to place their visas in “administrative processing” — an indefinite holding pattern.

ProPublica saw an image of a form given to one visa applicant informing them of a hold. The form is typically used to request more information from the applicant. In this case, though, a consular officer had modified the form to say that processing would not begin until “implementation procedures” for the visa-ban exemption had been provided.

Doctors in limbo have formed WhatsApp groups to share information and support, but the dialogue has shown inconsistencies in the ban’s implementation. Some consulates, such as those in Serbia, Russia and the United Arab Emirates, have approved doctors’ H1-B visas as exempt. Asked about the discrepancy, the State Department told ProPublica: “Applicants who believe they qualify for an exemption from Presidential Proclamation 10052 should check the website of the closest U.S. Embassy or Consulate regarding the current status of services. How appointment systems are managed can vary depending on the consular section.”

One applicant who reached out to the State Department for assistance received an email reply from an employee on July 10. The employee said that as far as they knew, the Office for Consular Affairs had given guidance to consulates and embassies to process visas that were exempt from the ban. (The agency declined to comment on that email.)

On Thursday, that applicant received a second email from the same employee. Guidance had been slow in coming, the employee admitted, but it had finally come through.

But some countries still haven’t changed their practices. One doctor stuck abroad told ProPublica they’d sent a follow-up email to the consulate on Thursday morning. “He gave me the same reply,” the doctor said, “that they are still waiting for guidance from Department of State.”

 

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 Alecto, Megaera, and Tisiphone, as hard as it is to get people who really don’t care to do the right thing. I hope you can light soe fires at the State Department.  A shortage of doctors is never good, but at a time like now, it is unthinkable.

And it’s it’s easy to be thoughtlessly exasperated.  It happened to me just yesterday morning.  I had four calls withing a half hour from the same clinic in Pueblo (about 30-35 miles to the south).  The last one I picked up, and it was a fax tone (I can’t get faxes on the line I use for voice calls but have a separate fax number.)  I went to their website and used a contact form to tell them this, and added “I want it to stop.  Now.”  After reading Nameless’s article, I realized I could have been gentler.  Even just leaving off the “Now.” would have been better.  Please put on your Eumenides hats and help us all to think just a lttle more before we speak – or even email.  Thanks.

The Furies and I will be back.
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  11 Responses to “Everyday Erinyes #224”

  1. This is no time for us to have a shortage of doctors! The numbskulls that are crowing about restrictions on visas don’t realize we still have a need for foreign workers. Not only is our educational system a joke, but many of those doctors are seeking a better life here, so it’s a win-win.

  2. I feel for all these caring people starting the normally stressful transition to have all this added to their burdens.  And, because we have a for-profit health care system owning hospitals which in turn are owned by hedge funds, many staff were laid off to enhance profits as the crisis was growing with no reports of any kind of rehiring to be sufficiently staffed for their state’s surge.  Here in CA most urban hospitals have had to call in visiting nurses, etc. from other states in better shape to help cope with the patient loads…and that doesn’t count staff needed for the added bed capacity the State prepared for earlier this year as we got hit.
    Thanks Joanne–the furies need to visit all the laggardly consulates.

  3. I have to agree with Freya’s wise comment.
    So, I did not spend much time breathing, quietly, after responding too Nameless’ post, but came here.
    Joanne, this is another impressive posting, thanks.  It is so sad, and aggravating, that Trump has the power to, apparently, just throw off an idea from his vast store of xenophobic bile, and create soooo much more difficulty for people!  
    The posting mentions fears of a second wave, in the fall.  I take unprofessional exception that idea.  We re already into the 3rd week of July, summer will be 1/3 over in 2 days, and the first wave is only gaining momentum in so many places.  Fools like Gov. (Let me steal an election, it’s so much fun) Kemp, and DeSantis, are appeasing Trump, and the “Live free or die” people who see wearing a mask as an affront to their insensible sensibilities, (If only they could just die, without affecting/infecting others), are blithely ignoring “inconvenient” facts, and this 1st wave will only go on, and on.  

  4. WoW! I didn’t know about this. Typical dt move in complicating the norms of young doctors getting a head start in medicine, and helping the sick, by issuing his visa ban. Gawd, how cruel. 

    We are in dire need of doctors to help with the COVID pandemic, and of them learning the ropes, and now this hurdle of immigration. ugh! 
    Leaving these newly minted residents in limbo is so depressing, and so unneccessary, especially during this time. imho. What a shame!! 
    Thanks, Joanne for post. 

  5. One of the ER doctors who saved my life when my organs were shutting down from septic shock due to chemo was a foreign resident.  I guess criminal Fuhrer Trump* wants to drive up the death count from his plague! 13

    Great job, JD!

  6. thank you…..*#t*&%$# and his sycophants have no clue how dependent we in the US depend on others in so many ways….medical care, home care workers, nursing home workers, food production, etc…..in this 21st century world, we are all parts to a puzzle and not individual nations doing what we do in a vacuum….

  7. I was reading yesterday about physician assistants who are being laid off.  One PA said she was told in March that she was being furloughed until mid June.  In mid June she received her pink slip so is totally unemployed during a pandemic.  Her hospital/clinic is cutting costs to keep profits up.  Her hospital/clinic said the lay offs were due to reduced foot traffic.

    Talk about myopic thinking on the part of hospitals/clinics!

    I also remember reading some time ago that the numbers of suicides of doctors and other medical workers is going up because coping with surging COVID-19 rates and working 18 hour days takes its toll.

    With all these problems, the US is screwed.  Thanks Trump!  May a camel walk up your nose backwards and fart the big one!!!

  8. Remember in the days when Chaos Theory was a fad, it always started with the example of the butterfly moving its wings in the Brazilian jungle causing a storm somewhere else on this globe? If that is true, how could we expect a moronic elephant trampling through laws and procedures, carefully build-up up over time, not to have tremendous consequences for ALL of those these laws and procedures touch upon directly or indirectly?

    As always, Trump acted on impulse, wouldn’t listen to advise if any had been forthcoming from the advisors he surrounds himself with who are as incompetent as he is. The coronavirus couldn’t have picked a better time to go rampant, could it.

  9. Most likely there will be record-breaking burnout among all healthcare workers.

    The country simply cannot endure having four more years of *Rump – who is willing to sacrifice anyone and anything if it advances HIS interests.

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