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Foreign aid for Texas
Web Posted: 06/27/2004 12:00 AM CDT

******* Ortiz
Express-News Staff Writer

JASPER — When Dr. Saurabh Singh wanted to hire a doctor for a new clinic he was opening in nearby Woodville, he ran advertisements in newspapers and health journals for nearly a year.

They didn't garner a single phone call.

It wasn't until Singh started looking at foreign doctors that he had any luck. He hired a doctor using the same visa waiver program that permitted him to begin his career in the United States.

A native of India, Singh was able to stay here on a special visa waiver that permits foreign doctors to remain if they work at least three years in areas with a doctor shortage.

Health care experts say rural communities have the toughest time recruiting doctors, and as a result, are increasingly dependent on foreign physicians. But if a federal program that allows states to recommend the visa waivers for physicians is not renewed, more small towns could continue to have too few doctors — or none at all.

The State 30 J-1 visa waiver program, as it is called, expired June 1, and its future is still in a congressional committee, although aides to several U.S. House members predict it will be approved in some form this year.

"Everyone wants to go to a big city where there are specialists, movie theaters and a nice house," said Singh, now a permanent resident, who goes by Dr. Steve. "These rural communities need doctors bad."

Nationally, more than 1,000 doctors received J-1 visa waivers last year.

In Texas, more than 4.9 million people live in what the government has designated "health professional shortage areas," places with less than one doctor per 3,500 residents.

The state recommended visa waivers for 71 physicians over the past three fiscal years. Of those, 43 went to work in counties on the Texas-Mexico border.

Among those was Dr. Rogelio Garcia-Cavazos, who had planned to return home to Monterrey, Mexico, after specializing in rheumatology at the University of Texas Health Science Center in San Antonio.

Then he learned a Laredo health center that treats the uninsured was in need of an internist and rheumatologist, a doctor who treats arthritis. The offer was too good to pass up.

Of the 20 patients he sees daily at Gateway Community Health Center, only one doesn't speak Spanish. His bilingual fluency and familiarity with Mexican culture are crucial to the job, said Garcia-Cavazos, noting he is able to joke with his patients more easily in Spanish.

"You can be hard on them without offending them," he said. "If you need patients to stop doing something or take something, there are ways to say that without stepping on their toes."

In Jasper, Singh is one of only a handful of doctors, and the only one who makes house calls. He attended the University of Texas Medical Branch in Galveston, and says he likes rural life for its simplicity and safety. The sticky East Texas heat also reminds him of home.

Singh and Garcia-Cavazos can stay here because of the visa waiver program.

Physicians who attend U.S. medical schools under an "exchange visitor" visa are required to return home for two years before they can apply to work in this country — unless they get a waiver.

Most who get it had help from state governments, which can recommend up to 30 doctors a year. Some communities would not have doctors without the program, experts said.

"If this is not reauthorized, we will not have any (J-1 doctors)," said Connie Berry, manager of the Texas Health Department's Texas Primary Care Office.

A perfect storm


Health care experts point to a perfect storm of factors that discourages doctors from setting up shop in rural communities: lower pay, a smaller patient base, a shortage of specialists and a lack of hospitals and new technologies.

"Doctors like to practice where they can refer their patients to other doctors," said Richard Cooper, the director of the Health Policy Institute at the Medical College of Milwaukee.

A shortage of doctors exacerbates the problem.

The United States needs another 16,000 doctors "just to have a barely adequate level of care," said Michael Berry, a senior program analyst for the National Health Service Corps, an arm of the U.S. Department of Health and Human Services. Private analysts make similar projections.

And the American Medical Association agrees a shortage exists in some regions and specialties.

Cooper, considered a national expert on health care workforce issues, estimates a doctor shortage reaching 150,000 by 2020. The nation's 126 accredited medical schools are fully enrolled and can't produce enough physicians, particularly specialists, to keep up with growing demand caused by scientific advancements, he said.

The shortage "is not going to abate," said David Pearson, vice president of advocacy and communications for the Texas Organization of Rural and Community Hospitals.

"All we can do is sell the rural areas on the quality of life, the relaxed atmosphere," he said.

Singh points to Medicare reimbursement cuts and high malpractice insurance premiums as other factors that may discourage doctors from practicing in rural communities. He said doctors must see more patients or see them more frequently to maintain their income — high-volume medicine is hard to maintain in sparsely populated areas.

Conversely, physicians in rural areas can be overwhelmed by patients whose own doctors left town for larger cities, Singh said. At least three doctors are about to leave Jasper, he said.

Part of the community


The visa waivers are issued first come, first serve, said Texas Primary Care Office's Connie Berry.

"It is hard to say Uvalde is a priority over Maverick County, for example," she said. "People's health is at stake, and we want people to go where there is an opportunity."

About 90 percent of the waivers go to specialists.

"Some of those subspecialists are very critical," Berry said. "You can't perform surgery without an anesthesiologist. You could, but it would be very painful."

Singh is no specialist. He started his Jasper clinic eight years ago because he wanted to practice hands-on medicine. Big-city doctors, Singh said, are too impersonal, spending 15 minutes with their patients before hurrying them out the door to see another doctor.

"I don't want to be a referral center," he said. "I told my wife, 'If I can't practice medicine, I'll be a nurse.'"Garcia-Cavazos briefly considered a job in Mississippi while training in San Antonio last year, but changed his mind after experiencing a severe case of culture shock in the Deep South.

"Everyone was looking down on us," he said. "Even the people in KFC were looking down us."

In South Texas, he feels right at home.

Advocates of the J-1 program say foreign doctors often become part of their communities, refuting fears they'll leave their small towns as soon as their three-year commitment is up.

A Texas Primary Care Office study last year found nearly 61 percent of the 297 doctors recommended by the U.S. Department of Agriculture from 1994 to 2000 stayed at least four years.

The USDA ended its J-1 program in 2002, saying it did not have the resources to check applicants' backgrounds.

Some say program flawed


Other agencies can approve requests. Health and Human Services has recommended 42 this year — 10 of whom went to Texas — and has received only 10 applications since January.

Critics of the HHS program say restrictions are so tight, foreign doctors don't bother applying.

"The federal program right now is pretty worthless," said Pearson, of the Texas rural hospital group.

Other J-1 critics claim the program drives U.S. physicians out of business.

"You do not want to flood the market with so many foreign doctors that people here do not want to start down the path of medical school," said Jessica Vaughan, a senior policy analyst for the Washington-based Center for Immigration Studies, which advocates more restrictive immigration policies.

Vaughan said even if there is a doctor shortage — something she disputes — it should be eased without immigration. She said medical schools can increase enrollment, physicians can postpone retirement and some work can be passed on to doctor's assistants or nurses.

"The answer does not always have to be, 'Let's bring in folks from abroad,'" she said. "We have to ask ourselves if we are causing a brain drain that is hurting their home countries."

Not just a patient


Patients said they like Singh for his thoroughness and attention to detail.

Jimmy Hensarling, 38, said Singh has called him at his home at 9 p.m. just to see if he is OK.

"It's not just like you're a patient, you're a friend," Hensarling said. "He seems to care more."

Singh sees 15 to 18 patients a day, most of whom are seniors. His wife, Geeta, who is a former J-1 doctor, cares for younger patients.

"I give them my fullest," he said. "I tell them what they should expect, what will happen. That is what doctors are made for."

Ken Green, a Korean War veteran, often goes to the VA hospital in Lufkin about 60 miles away to save money. But it's such an inconvenience, he prefers to see doctors in Jasper.

He said Singh is as good, if not better, than any doctor he has seen. He doesn't know offhand where he would go if Singh didn't work there.

"At my age, you don't want to go all over the country to see a doctor," he said.



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