SIDE EFFECTS
With a Quirk in Visa Law,
Small Towns Lose Doctors

Like their American counterparts, foreign doctors say working in rural areas often means few chances to hone their specialties or work with cutting-edge technology. Working in an underserved area can also mean long and lonely hours. "It's like serving jail time," says Minoo Kavarana, a Mumbai native working in Appalachia as a heart surgeon on a J-1 waiver. While Dr. Kavarana calls his work rewarding, he says he will leave London, Ky., after his required three years unless the hospital builds a new heart-surgery facility.

The number of foreign doctors in the U.S. on a J-1 visa has plummeted, falling about 45% to almost 6,000 in 2005-06, compared to nearly 11,000 in 1995-96. Connie Berry, a senior health official in Texas, says the total number of foreign doctors hasn't changed -- it's just that many have defected to the H1-B.

'Life-and-Death Situation'

The effect is profound in small towns and rural areas, where the dearth of doctors is already acute. About 25% of all physicians in practice or in training across the U.S. are foreign, but in rural areas the percentage is often much higher.

Without J-1 physicians, some rural residents might have to travel more than 100 miles to reach a hospital. "It's a life-and-death situation," says Rep. Jerry Moran, who represents a rural constituency in Kansas where several hospitals haven't successfully recruited an American physician in more than a decade.

Back in 2001, Crosby, N.D., a remote farming community, received 150 applications for two physician slots at its 25-bed hospital. This year, the sole doctor, from the nation of Georgia, is on call around the clock. Six recruiting firms and numerous ads in medical journals have failed to draw qualified applicants for the second opening.

In Gilmer, Texas, population 3,000, a Sri Lankan doctor on a J-1 waiver reopened the 20-bed hospital three years ago. He hasn't taken a vacation in two years, having just found an Indian doctor to join him. In North Carolina's tobacco-growing region, Pender Memorial Hospital lost three of six physicians last year and is scrambling to replace them.

The situation is so bad that when war was raging in Lebanon last summer, Sen. Kent Conrad of North Dakota mobilized the State Department, the Department of Homeland Security and the embassies of Norway and Canada to ensure that a Lebanese oncologist visiting Beirut could return to his job in Fargo.

Sweeping Changes

Signed into law in 1990, the H1-B visa was created to address the shortage of experts in such fields as high technology and the sciences. Later that decade, amid a worker shortage created by the dot-com boom, leaders of Silicon Valley companies such as Intel Corp. lobbied Congress heavily, arguing that the visa's limits were making corporate America less competitive globally. In October 2000, Congress passed sweeping changes to H1-B regulations.

In order to boost the number of H1-B workers that corporate America could hire, Congress exempted research institutions and universities from a ceiling on the number of workers they could bring on the H1-B. That meant teaching hospitals were suddenly free to use the H-1B visa as much as they wanted.

"The 2000 act opened the gates for universities to use the H-1B for physician training," says Jan Pederson, an immigration attorney in Washington, D.C., who specializes in visas for foreign physicians.

The J-1 Exchange Visitor program has a very different provenance, harking back to the days when American doctors were still in ample supply in rural areas. From 1977, it let foreign medical graduates come to the U.S. to learn new skills that they could then use back home.

By law, foreign physicians on the J-1 visa are required to return to their countries of origin for at least two years to use their skills there. After that, they can then attempt to re-enter the U.S. to seek work and permanent residency.

By the 1990s, the number of U.S. doctors willing to work in rural areas was dwindling. While some federal agencies had sent foreign doctors to certain needy areas in the past, a national system wasn't formalized until 1994. That year, Sen. Conrad created a provision allowing each state to enlist up to 20 J-1 foreign medical graduates annually to work in their underserved communities. The new law waived the requirement that doctors return to their home countries for two years and let them become eligible for a green card after spending three years in an underserved area.

The arrangement has its detractors, who worry it drains skilled doctors away from countries that need them. Last year, the World Health Organization urged developed countries to reduce their reliance on foreign physicians. In the Feb. 1 issue of the New England Journal of Medicine, Fitzhugh Mullan, a professor of health policy at George Washington University, writes that the huge U.S. market for foreign physicians is "inadvertently destabilizing the medical systems of countries that are battling poverty and epidemic disease."

The J-1 waiver program has provided more than 1,000 doctors annually to underserved areas, outperforming scholarship and loan programs designed to attract young U.S. doctors to these same places. The program's success in its early years prompted Congress to expand it in 2002. Late last year, Congress extended the J-1 waiver program until 2008.

But those efforts have been undermined by the changes to the H1-B. It allows foreign physicians to remain in the U.S. after their training, instead of returning home for two years. It also lets them apply immediately for a green card without having to work in a rural community.

Teaching hospitals in big cities like New York now use the H1-B to lure foreign medical graduates to their facilities. Despite the fact that obtaining an H1-B visa for a doctor can cost more than $1,000, hospitals at universities are increasingly turning to the visa, particularly to court promising international medical graduates to their programs. The J-1 costs employers almost nothing.

Fixing the Problem

Some state health officials have started to mobilize to fix the problem. Ms. Berry, the Texas health official, says that one idea is to require all foreign medical graduates to spend time in an underserved area, regardless of which visa they use to enter the U.S. for training.

Situated in a valley at the foot of the Cascade Mountains, Yakima is typical of U.S. towns that had come to rely on J-1 waiver doctors. "Just like we can't get American kids to pick our apples, we can't get American doctors to treat patients in needy areas," says Michael Maples, chief executive of Community Health of Central Washington, a nonprofit agency that operates community health centers in the area.

In recent years, a significant reduction in timber harvesting on federal lands and a program to protect endangered species eroded one of Yakima Valley's main economic activities. When the lumber mills disappeared, many residents lost their jobs and health insurance. Meanwhile, field workers rarely get any health benefits. The average family income in Yakima is $28,000 a year, and 42% of Yakima County residents are on some form of public assistance.

Yakima Neighborhood Health, a nonprofit facility in the city's downtown, opened in 1975 with a small all-American staff that treated about 12 patients a day. But as demand for low-cost care surged, it added a medical clinic. Today, the sprawling clinic's internists, family doctors and pediatricians see 600 patients a day. About 80% of the facility's $12 million annual budget is covered by federal or state reimbursements.

Ms. Monoian, the chief executive, set out to hire the clinic's first J-1 waiver physician in 1995. Jocelyn Pedrosa, a pediatrician on a J-1 visa from the Philippines, was completing her residency at the University of Illinois, Chicago. Aware that Ms. Pedrosa was also considering positions in South Carolina and Texas, Ms. Monoian sent her a brochure about Yakima that featured white-water rafting on the cover and touted its outdoor life. She also informed the young physician that the town boasted the only Nordstrom department store outside a major city.

"I broke out a map and saw pine trees and Yakima in big letters," recalls Dr. Pedrosa, who interpreted this to mean the area was green and the town not too tiny. After completing her three-year assignment, Dr. Pedrosa decided to stay in Yakima. The Nordstrom is gone, but she is the medical director of the clinic.

Under her watch, the facility has more than doubled in size. Foreign doctors on J-1 waivers have formed the backbone of this growth. "I don't know how we would have bridged the 1990s to the present without" foreign physicians, says Ms. Monoian.

Currently, seven of 12 full-time physicians at the clinic are foreign. But the facility is short three physicians. Two foreign doctors left two months ago after doing their time. Another is due to leave in a month.

Like other facilities, Yakima Health advertises in medical publications, such as the New England Journal of Medicine. It also receives referrals from Washington state's health department, whose officials attend job fairs to meet potential J-1 waiver physicians.

But the entire state is suffering. Between October 2006 and January 2007, the state health department received only two applications from J-1 waiver doctors. The previous year, the health department had received seven applications by Jan. 31. And, two years ago, the state had received 13 inquiries by that date. "It's simply alarming," says Jennell Prentice, program manager for the state.

Among the patients in the packed waiting room at Yakima Health one recent Wednesday were gas-station attendant Colin Cunningham, his wife, Amanda and their 1-year-old, Braden, who came to see James Jabile, a pediatrician from the Philippines.

Dr. Jabile, who completed his J-1 residency in a New York City hospital, says he hasn't decided whether he will stay or leave once he completes his three-year stint later this year. The clinic's primary-care administrator Rhonda Hauff, who has been trying to fill the existing vacancies, says: "We're praying he'll buy a house and stay."

Another patient in the waiting area was Bill Nedeff, 71, who says he lost his job after suffering back injuries at an apple-packing plant. He came for a consultation with Vivek Shah, an Indian internist who moved to Yakima five years ago on a J-1 waiver. Dr. Shah stayed because his wife, a dentist, also has work, he says. Still, he says, "Everyone I know on a J-1 missed the boat for an H-1B. They didn't know they had that alternative."

Write to Miriam Jordan at miriam.jordan@wsj.com¹