Doctors exploited; patients suffer, too

By Marshall Allen

Sunday, Dec. 23, 2007 | 6:53 a.m.

A government program to address a national health care crisis by placing foreign doctors in America's rural towns and inner cities is being undermined by employers - mostly U.S. doctors who profit by exploiting the physicians and diverting them from the patients who need them.

Stories of abuses within the program, which receives little government oversight, are whispered among foreign doctors in hospital corridors, reported online and heard by colleagues in foreign medical schools. And the abuse appears to be a primary reason that fewer of them are participating in the program, the Sun has found in its continuing investigation.

Some of the foreign doctors are cheated financially and worked to dangerous levels of exhaustion, and they can't easily escape the jobs because the employers sponsor their visas. The doctors are sharing their experiences with colleagues back home - in places such as Ghana, Haiti, India and Pakistan - who are now finding other paths to U.S. residency to avoid being bullied and treated as indentured servants.

Government officials are worried about the decline in foreign physicians willing to work in our most needy towns and cities, but have no explanation for the cause. On the rare occasions the government has heard of problems, it has been slow to step in, let alone hold employers accountable for violating federal law.

The result: The physician shortage is getting worse for the 34 million Americans who don't get appropriate health care because there aren't enough doctors where they're needed. And the many employers who abide by the federal law are themselves being undermined by colleagues who soil the program's reputation.

The dire consequences of the program's problems may be no clearer than in the Nevada town of Beatty, population 1,154, "the gateway to Death Valley." The community is about to lose its only doctor, who is from the Philippines. She has fulfilled her commitment under the government program, and the nonprofit organization that runs the clinic, Nevada Health Centers, has had no luck finding a replacement.

Nevada Health Centers by all accounts treats the doctors fairly and as intended under the law. Several years ago, it was receiving about 100 applications a month from foreign physicians for openings at its 27 clinics.

But now it gets no applications and recruiting efforts have been fruitless.

The government program, adopted by Congress, is known both as the J-1 visa waiver program and the Conrad 30 program, for its author, Sen. Kent Conrad, D-N.D. It makes immigration concessions for foreign medical school graduates who are nearing the end of their medical residency training in the United States. The foreign doctors hold J-1 visas, which require them to return home when they finish their residency. If they return home, they must stay there for at least two years, and if they want to return to the United States, they must start the immigration process all over again.

Rather than go home after their medical training, foreign physicians can qualify for J-1 waivers to stay in the United States as long as they commit to at least three years of service in a federally designated physician shortage area - usually a rural or blighted urban area. And at the end of the term, these J-1 doctors can begin the U.S. residency process. About 3,100 foreign doctors participate in the program, a number that is declining year by year.

For years, Nevada Health Centers and, by extension, residents in rural Nevada benefited from the doctors' participation in the program.

But starting Jan. 1, barring a miracle, there will be no doctor based in Beatty.

"Recruiting has become virtually everything we do," said a disheartened Dr. Carl Heard, interim CEO for Nevada Health Centers. "This is just going to get worse. There's going to be communities like these where we're going to have to say, 'We can't do anything for you.' "

Nationally, doctors who come from foreign medical schools say they are forgoing the J-1 visa for what they consider a more attractive option, called the H-1 visa. The H-1 visa takes more steps to acquire and limits where a doctor can do residency training, but it leads more quickly to a "green card." The downside for rural and inner city America is that the H-1 visa, unlike the J-1 visa, does not require foreign doctors to return home for two years after they finish their training. That eliminates any motive for foreign doctors to commit to three years of service in a medically underserved area.

Nationwide, the numbers of J-1 visas and requests for waivers to work in underserved areas are plummeting, according to the statistics available.

According to a 2006 government report, the pool of physicians who do their residency training on J-1 visas dropped more than 45 percent from 1996 to 2005, from about 11,600 physicians to about 6,200.

"The reasons for this decrease are not completely understood," the U.S. Government Accountability Office wrote.

And the number of annual requests from doctors wanting to work in underserved areas on J-1 waivers dropped from 1,374 in 1995 to 1,012 in 2005 - a 26 percent decrease.

While officials struggle to explain the dwindling popularity of the J-1 waiver program, foreign doctors told the Sun one of the primary reasons is simple: the employers who supervise J-1 doctors.

J-1 doctors say that because of the buzz around the program in the international physician community, some medical residents are waiting longer for H-1 visas or, if they can get only a J-1 visa, are returning home for two years instead of taking a waiver to work in an underserved area.

Dr. Wahab Brobbey, a J-1 doctor in Iowa who told the Sun he was exploited by his previous employer in Tennessee, said he advised his cousin and other medical school classmates to avoid the J-1 visa. The cousin is now doing his residency on an H-1 visa.

"And they tell their brothers, and they tell their friends - there are lots of us," said Brobbey, who is from Ghana.

Brobbey said the exploitation has gone on for so long, with no accountability for employers, that the J-1 visa waiver program is "basically dead."

"The boat has sailed already," Brobbey said. "I don't know anyone who will do J-1 now."

In 1994 Conrad sponsored the legislation that allowed states to request up to 30 J-1 waivers a year to help bring foreign doctors to needy areas.

Congress provided no money for oversight. Compliance was generally left to states, which have done little monitoring of the program and even less to enforce its guidelines.

J-1 doctors in several states told the Sun that even after they complained about an employer, documenting abuses, the boss was allowed to hire more foreign doctors.

The U.S. Labor Department, which is responsible for ensuring the foreign doctors are paid as the federal law dictates, and the U.S. Homeland Security Department, which oversees compliance with immigration law, appear equally inattentive in policing the J-1 waiver program.

Multiple immigration attorneys and officials from the Labor and Homeland Security departments could recall few examples of an employer being prosecuted for violating terms of the J-1 program. The failure to prosecute occurs even though authorities are aware of the abuses, and U.S. Citizenship and Immigration Services has allowed many J-1 doctors to transfer because their bosses broke federal law. Government officials say they depend on complaints to open investigations - complaints that the foreign doctors are afraid to file. With no formal complaints and only rumors of abuses, federal authorities have not queried the foreign doctors who spoke to the Sun about the abuses, even though, the Sun found, the doctors will discuss problems privately, if asked.

Given the Internet chatter, the problems with the J-1 waiver are widely known in the medical community, and the jobs carry a stigma. Some of the participating doctors refer to themselves as "J-1 positive" as if they're afflicted with a disease.

It is unknown whether J-1 doctors have been sexually abused, though one doctor told the Sun she had been sexually harassed.

Conrad's staff and Gregory Siskind, chairman of a national coalition of immigration lawyers that works with foreign physicians, say the sharp decline in J-1 visas has been a central topic of discussion.

Many factors could explain why more foreign residents are pushing for H-1 visas over J-1 visas, Siskind said, but it's possible some foreign doctors who know about the "real and perceived problems" are deciding to "vote with their visa" by choosing the H-1.

Officials from the Nevada State Health Division, the Labor and Homeland Security departments, and even Conrad's office said they weren't aware of such problems with the J-1 program until the Sun published its first report in September. In response, Nevada officials are enacting reforms.

But word of the abuses has circulated for several years.

In 2005, the American Medical Association adopted a resolution saying the foreign doctors often find themselves "in abusive and intolerable" employment situations and should be able to transfer to other employers without being forced to restart their three-year commitment in an underserved community.

An AMA official said anecdotal accounts are heard frequently of J-1 doctors working unfair call schedules, suffering pay and salary disparities and having the terms of their contracts switched against their will.

The J-1 doctors are in a "vulnerable position," said the AMA official, who because of association policy was not allowed to be quoted by name. "They know it's a privilege to be in our country. They don't want to make any waves, but they're totally being abused and taken advantage of."

Employers who adhere to the J-1 waiver guidelines say they've heard the reports of other bosses flouting the J-1 laws. Saul Blair, executive director of the Phoenix region of IPC, a company that provides doctors to hospitals, employs 17 J-1 doctors, including several who came to him after being exploited by employers in other states. No one monitors where the doctors work or whether "I'm paying them 10 cents or $100,000," Blair said. It would be easy to audit a company's medical records to confirm that J-1 doctors are treating federally designated underserved patients, Blair said, but the government has not.

With a June deadline for Congress to reauthorize the Conrad 30 program, draft legislation is being examined that would draw more foreign doctors to underserved areas. But abuses of the system are not at the forefront of the discussions. The question being asked by Conrad's staff is whether the abuses can be addressed through stronger enforcement. In response to the Sun investigation, Conrad and Senate Majority Leader Harry Reid, D-Nev., have called for the Homeland Security Department to investigate the program.

"We already have the laws on the books to help prevent some of the abuse that's been reported in the media, but obviously enforcement is an issue," Conrad said. "If the Department of Homeland Security needs more resources, or a fine-tuning of the law, then they need to tell that to the Congress."

Siskind, the immigration attorney, wants congressional reauthorization of the J-1 waiver program to include:

Such changes would remove much of the leverage that employers have over J-1 doctors and could lead to a large reduction in problems, Siskind said.

Currently, J-1 doctors can transfer, but they say it costs at least $15,000 in attorney fees and other expenses and depends on documenting abuses to the satisfaction of U.S. Citizenship and Immigration Services, which must approve the switch.

"Additional protections are needed for the doctors to make it easier to move employers when they are in an unbearable situation," Siskind said.

J-1 doctors across the country say reform is urgently needed or the trend away from the program will continue.

A J-1 doctor in Arizona said he has learned his lesson about the J-1 waiver program, and is warning others that "there's no system to protect the J-1 physician."

"Everyone warned me against it - everyone," the doctor said. "And now I'm the victim of it."

Another J-1 doctor feels conflicted about staying in the United States.

"If I had known about this I would have never done it here," the doctor said. "I advise everyone I know not to come here on J-1. Go to Australia."