Sunday, Sept. 30, 2007 | 6 a.m.
How Foreign Doctors Qualify:
The J-1 Program Requires Perseverance, Navigating Bureaucracy
By the time J-1 doctors start working in underserved communities, they have already traveled a long road.
They must be among the top prospects from foreign medical residency in the United States.
To participate in the government's J-1 program, which allows the doctors to remain in the United States after their residency rather than return to their homeland, they need to find a job for at least three years in a medically underserved area.
Employers and prospective J-1 doctors connect through recruiters, through employment ads in journals and trade magazines, or by word of mouth. The doctors and employers sign an employment contract that stipulates what each party must do to abide by the program's regulations.
A J-1 doctor's salary must be set at the prevailing wage, an amount determined by the federal government that's supposed to reflect how much a similar American physician would earn. The contracts are setn to the U.S. Labor Department to verify the salary.
The employment package also is sent to the Nevada State Health Division, which reviews the contracts and supporting documents and approves or rejects the employment arrangements.
After the state has approved the deal, U.S. Citizenship and Immigration Services grants the foreign doctor the appropriate visa. The Nevada State Board of Medical Examiners then licenses the J-1 doctor.
After the doctors finish their three years in an underserved area, they are eligible to apply for a "green card" for permanent U.S. residency and begin the formal immigration process, if they can find a sponsor. Those without sponsors can do it themselves, but that may take an additional two years of service in an underserved area.
J-1 doctors say the complex process of finding employment makes them less likely to complain if there's a problem with a boss.
More on Indentured Doctors
- Sponsor cheated her; doctor says (09-30-07)
- Patients in Pahrump shortchanged, ex-clinic workers say (09-30-07)
The sign at the clinic says "walk-ins welcome," but a sick person would have had a hard time finding a doctor here.
It's a weekday at the Health Care Center of Southern Nevada, a cinder block building on a dilapidated stretch of Lake Mead Boulevard. The office is open, the TV is on and magazines are fanned out on a table.
But the place is empty of patients, and for good reason. The receptionist says no doctors are present. The physician who is supposed to work 40 hours a week here in this poor urban area is instead in the office only on Wednesday afternoons.
The rest of the time, the doctor is making rounds in Las Vegas hospitals, caring for patients who bring more revenue to her boss.
This is not the way the clinic - or the doctor - is supposed to operate. The doctor is a foreign national and she and scores like her in Nevada are here specifically to provide care in poor or rural areas where medical care is scarce. Government regulations require them to work full time in such communities for at least three years. At the end of that period, they are allowed to begin the process of immigrating to the United States.
Instead, an investigation by the Sun found , many of these doctors are being misused by the Nevada physicians who sponsor their visas. Those sponsoring physicians pull the foreign doctors away from the clinics and assign them to work in Las Vegas hospitals, where they generate more revenue for their sponsors.
The foreign doctors rarely complain because they fear their sponsors will fire them.
As a result, many Nevadans living in poor and rural areas are not getting better care at their local clinics - and the abuses don't stop there. Many of the foreign doctors are required by the sponsors to work at the hospitals for long hours, often to the point of exhaustion. Some also find that their work contracts have been revised or ignored, without their consent, to divert part of their pay to the sponsors.
These abuses are a dirty secret in the Las Vegas medical community - and the Sun found that they also exist to some extent nationwide. But the federal and state officials who are supposed to oversee the program in Nevada profess they are unaware of the problems.
Quid pro quo for staying
Congress created the Conrad State 30 program in 1994. Under it, the government allows 30 foreign doctors in each state, each year, if the physicians agree to care for patients in blighted urban neighborhoods or rural towns where few physicians want to work, such as North Las Vegas or Pahrump.
The physicians are referred to as "J-1 doctors" because they held J-1 visas when they came to the United States to serve their medical residency. That visa requires them to return home after their training, but they can get a new visa if they agree to perform 40 hours a week of primary care in a medically underserved area for a three- or five-year term, depending on the circumstances. Their wages are required by law to match those of similarly skilled American colleagues. When they complete their obligation they are allowed permanent legal residency and can pursue U.S. citizenship.
The J-1 arrangements are widely praised by state and federal health officials because they bring desperately needed and highly trained doctors into areas where the need for medical care is growing.
About 4,000 J-1 doctors are employed nationally, including 80 in Nevada. About 65 are in the federally designated "underserved" parts of Las Vegas, North Las Vegas and Pahrump. State records show about 250 have served in Nevada since 1998.
Problems and abuses within the J-1 program were uncovered during a lengthy Sun investigation that included interviews with 25 of the foreign doctors, seven of whom are still part of the program. The doctors who finished the program were more free to talk, but most would not allow their names to be published for fear of retribution by their current or former employers.
A dozen of the doctors interviewed made serious charges. Others with complaints about how they were treated professionally shrugged it off. Almost all the doctors said they witnessed employers taking advantage of other foreign doctors. The Sun sought to speak with dozens of additional J-1 doctors, but they refused to discuss their experience or did not call back.
Proof program can work
This is how the J-1 program is supposed to work:
Nevada Health Centers operates 22 clinics and hires foreign doctors because the intent of the federal program - to ensure that people get quality health care - matches that of the nonprofit organization, said CEO Steven Hansen.
Dr. Gerry Lorenzana, who is from the Philippines, recently completed the J-1 program at a Nevada Health Centers clinic. He has heard of other foreign doctors being mistreated, but says he's been treated well and enjoys caring for underserved patients, so he's staying at his job even though he has his "green card."
Lorenzana performs primary care for patients 40 hours a week at the Cambridge Family Health Center. He's not dispatched to hospitals and gets time off to compensate for coming into the clinic for mandatory meetings.
Hansen said the nonprofit organization is not cashing in on the J-1 doctors. On the contrary, he has to seek government funding to keep the charitable clinics running.
Nevada Health Centers' by-the-book approach to hiring J-1 doctors stands in stark contrast to the practices of some other J-1 employers.
An administrator who used to work at North Vista Hospital, the hub for care in underserved North Las Vegas, said she knows of J-1 employers who operated phantom clinics in the city - renting a room or office to give the appearance of a workplace for a foreign doctor - and only rarely sending the doctor there.
The administrator, who still works in health care in Las Vegas and requested that her name remain unpublished, said billings by many J-1 doctors stemmed predominantly from their work at Las Vegas hospitals, suggesting they spent little of their time doing community clinic work.
Some J-1 doctors complain that they, and the government system that allows them to stay in the country, are being frequently exploited. The names of three Las Vegas employers came up most often: Dr. Nutan Parikh, Dr. Rachakonda D. Prabhu and Dr. Abdul Siddiqui.
Prabhu denied any wrongdoing and said he hires foreign doctors because the J-1 program benefits them and the community - even though he loses money by employing them. "You don't get rich by serving the poor," he said.
Parikh and Siddiqui did not return calls for comment.
All three employers are accused of preventing their J-1 physicians from fulfilling their federal mandate to spend at least 40 hours a week in an underserved area. Some J-1 doctors say the government was repeatedly lied to - in sworn affidavits and falsified records - to hide the violations.
Many J-1 doctors also said they were overworked by the employers. Physicians are accustomed to working long hours, but published research says working more than 80 hours a week leads to exhaustion, which puts patients at risk.
Cancer specialist Dr. Hari Deshpande said he worked more than 80 hours a week, driving among hospitals and five clinics, when he worked as a J-1 doctor for Parikh at Las Vegas Cancer Center. Deshpande did not complain about the long hours, accepting it as the cost of staying in the United States.
A J-1 doctor who worked for Siddiqui at the Health Care Center of Southern Nevada said he worked 19 days in the clinic and hospitals - at 12 to 14 hours a day - for every two days off. That's 84 to 98 hours a week. Some doctors employed by Prabhu said they routinely worked from 80 to 100 hours a week, a claim Prabhu denied. Others who worked for Prabhu did not have this complaint.
Dr. Christopher Landrigan, who teaches at Harvard Medical School and directs the Sleep and Patient Safety Program at Brigham and Women's Hospital in Boston, said any person who works more than 80 hours a week - there are 168 hours in a week - suffers from chronic partial sleep deprivation.
He said overworked doctors also deal with sleep inertia, meaning it can take 15 to 30 minutes after waking up before the brain functions properly. A delay in becoming alert is particularly relevant for doctors taking night calls.
Deprived of sleep, doctors may forget to ask for tests or have a hard time analyzing lab results, diagnosing problems or synthesizing information, Landrigan said.
"If you're sleep deprived, there's a host of data that show errors go up," he said.
Said one J-1 doctor: "When you're very tired, you're thinking poorly, and sometimes you can make mistakes when you write hospital orders, or prescriptions, or giving phone orders to the nurses."
Besides long hours, the doctors say, payment disputes are common. Siddiqui, for instance, is accused of violating program guidelines by changing contracts so the foreign doctors go unpaid for months, and failing to pay promised incentive bonuses.
Prabhu pays his doctors in full and on time, his current and former J-1 physicians said, but some of their contracts include restrictive noncompete agreements that violate the spirit of the program by making it difficult for doctors to stay employed in Las Vegas when they finish their term. Prabhu said he doesn't enforce the noncompete language even though it remains in some of his contracts.
Despite their grievances, the foreign doctors worry their visas could be jeopardized if they were to formally complain about their sponsors.
So they bite their lips and buckle under. Some doctors liken their employment to indentured servitude - overworked, underpaid and beholden to, of all people, U.S. doctors turned taskmasters.
Abuses occur nationwide
Employers nationwide violate the terms of the J-1 program.
A Pakistani doctor who was a J-1 physician in rural Utah, and who now lives in Las Vegas, told the Sun that his boss ordered him to work every weekday in a 24-hour clinic, totaling 32 hours for Monday through Thursday, followed by a marathon solo shift from 7 a.m. Friday to 9 p.m. Sunday. He was not allowed to leave the clinic the entire 62-hours of the weekend shift, he said.
Los Angeles lawyer Rita Sostrin said she helped a J-1 doctor in Arizona find another job after he arrived to work in a rural clinic, only to be sent by his employer to offices in more affluent areas. Another Arizona employer did not pay a J-1 doctor for five months, Sostrin said.
In another case, an employer required a physician to perform procedures for which he was not qualified, in emergency rooms and intensive care units, Sostrin said. "He brought it up to this employer and the employer got verbally abusive: 'You're in my control. There's nothing you can do about this.' "
Dr. Wahab Brobbey, a Ghanian-born J-1 physician, was hired in 2003 to work in rural Tennessee, where his employer arranged for him to be paid $134,000 annually through an income guarantee agreement with a local hospital. Under the terms of the one-year arrangement, Brobbey's initial earnings were a loan that would be forgiven after he completed his three-year term. The employer was to pay Brobbey's salary after the first year.
The arrangement might have worked - but Brobbey says his boss dodged paying his salary by firing him without cause after year one.
Brobbey found a job in Iowa - but is now being dogged by the Tennessee hospital to repay $150,000 in salary and benefits.
"It seems to be a widespread thing going on and it seems (employers) get away with it," Brobbey said. "Maybe there's no criminal penalty for this kind of stuff, but I think it's a crime, what they are doing."
In Las Vegas, J-1 doctors have formed the backbone of Prabhu's Red Rock Medical Group, a three-clinic practice headquartered in a two-story concrete warren of hallways and examination rooms on West Charleston Boulevard.
Prabhu, a pulmonary specialist, is a prominent member of the medical community and one of the state's most politically active physicians. Governors have appointed him to advisory committees and he was invited to the White House during a state visit by the Indian prime minister.
Prabhu came to the United States from India more than 30 years ago, and since 1999 he's hired about 30 J-1 doctors - more than any other employer in Nevada. In 2006 Red Rock employed eight J-1 doctors at the El Dorado Medical Center, its site in North Las Vegas, and four more at a clinic in Pahrump.
The Sun spoke to 11 J-1 doctors who worked for Prabhu, two of them current physicians. Of those, about half said Prabhu treated them fairly and the others said they felt overworked - one said they were nicknamed "Prabhu's slaves" in hospitals - or that Prabhu often failed to assign them 40 hours a week at his clinics in North Las Vegas and Pahrump.
There is a financial motive to work the foreign doctors long hours outside the underserved areas: The J-1 doctor makes the most money for his boss by performing higher-paying procedures in hospitals or clinics that serve patients with good insurance coverage. Or, J-1 doctors can be used to rake in revenue through multiple call shifts - 12- or 24-hour hospital assignments during which they admit and treat walk-in patients.
Prabhu and John Hickok, his chief operating officer, said the doctors adhere to the 40 hour-a-week rule, and said the proof was in the number of patients they see. They said the J-1 doctors work a few hospital shifts to build professional contacts and enhance their resumes, and that some of them also make hospital calls to follow up on patients they've encountered at the clinics.
But according to workers at Prabhu's North Las Vegas clinic during a Sun visit in 2006, at least four of the eight J-1 doctors were at the site only 10 to 20 hours a week. When asked for a clinic schedule, Prabhu and Hickok said their lawyer advised against releasing one. The Sun was provided a schedule by another source. If believed, the schedule shows most of the doctors are assigned in an underserved area for three- or four-hour shifts, a few days a week. For example, one J-1 doctor had been scheduled just nine hours a week, plus one Saturday a month; another for 12 hours a week and an occasional Saturday.
Hickok said the schedules are flexible and have little to do with the actual hours the doctors work in the clinic.
Several of Prabhu's current and former foreign doctors said they did not work 40 hours a week in the underserved areas because Prabhu required them to work in hospitals, where they could bring in more revenue.
Prabhu told the Sun he would open his books to an auditor to prove his J-1 doctors were working full time in the underserved areas. But when the Sun offered to pay for the audit, the offer was rescinded. He also promised the Sun a list of patient encounters to substantiate the workload, but when the Sun said it would accept the opportunity to examine them, that offer, too, was taken back.
A loan to work
This is how topsy-turv y the J-1 system can become: One J-1 doctor was pressured by Siddiqui to take out a personal $100,000 loan to open the very clinic where he was to be employed. The Sun reviewed the court record in the case and spoke to Siddiqui's attorney.
Dr. Renante Ignacio, a geriatric specialist, came to Las Vegas in December 2001 on the promise that he would be assigned to work at the Health Care Center of Southern Nevada.
But when he arrived, Ignacio learned the clinic hadn't yet opened. Siddiqui didn't have enough money to open the North Las Vegas office, according to court documents.
Carolyn Ellsworth, a Las Vegas attorney who represented Ignacio at the time, said it was impermissible to require the foreign doctor to take out a loan on his employer's behalf.
Neither Ignacio nor Siddiqui would speak to the Sun.
Siddiqui co-signed the loan, and Ignacio turned the money over to his boss, Ellsworth said.
The North Las Vegas clinic eventually opened, but Ignacio left within a year for a different employer, according to the lawsuit. The loan went unpaid, the bank came after Siddiqui for repayment as the co-signer, and he sued Ignacio for breach of contract, claiming the doctor had deprived him of income. The lawsuit was dismissed.
Ellsworth's experience with J-1 doctors extends to employers other than Siddiqui.
She said she has counseled about 10 foreign doctors on legal issues involving their employers. Among the foreign doctors' complaints: Their bosses reneged on promised salaries and paid them less than required by the government. Or, the employers signed contracts with hospitals and required the J-1 doctors to do rounds for many hours a week.
Nigerian pediatrician Dr. Anselem Oparaugo says he quit working for Siddiqui about a year ago after his compensation agreement was changed against his will, resulting in three straight months with no salary. He said he and four other J-1 doctors were ordered to split their net billing revenue 50-50 with Siddiqui and his business partner - or quit and find work elsewhere.
Oparaugo, worried about his job options, signed the contract. He said that for the next three months, he was told his revenue didn't cover the cost of doing business, and was paid nothing, in violation of federal regulations for foreign workers. Oparaugo said he knows of one other J-1 doctor at the practice who also was unpaid for at least three months.
Another J-1 doctor who worked for Siddiqui at the time said Siddiqui's failure to pay physicians was caused by a combination of inefficiency and the time it takes to ramp up the billing cycle.
"The payment was terrible," the doctor said. "A physician - or a carpenter - would not work at that salary."
Oparaugo survived by moonlighting for Nevada Health Centers, the nonprofit organization that hires J-1 doctors. He eventually landed a job there.
State health officials claim they are unaware of employers exploiting the J-1 program, but Oparaugo says he informed them about his predicament and that they helped him get his new job.
Oparaugo said he's happy now, but he faces lingering problems. He said Siddiqui paid him the first year through an income guarantee arrangement with Sunrise Hospital Medical Center. Siddiqui has not repaid all the money, and now Oparaugo says Sunrise is threatening to sue him.
Officials of the Nevada State Health Division say they are unaware of any complaints by J-1 doctors or allegations that doctors are violating federal law by not working 40 hours a week in an underserved area. The confusion demonstrates the problem when various government agencies share in managing and overseeing a program.
Officials from U.S. Citizenship and Immigration Services and the U.S. Labor Department - the agencies that conduct background checks on the doctors, approve the visas and certify they are employable - say oversight of the program is the state's responsibility. The state says it does not have the resources to directly monitor the program and trusts the sponsors and J-1 doctors to report any problems.
"The J-1 program is an unfunded opportunity to get physicians to the state," said Judith Wright, bureau chief of the Nevada Bureau of Family Health Services, which runs the J-1 program. "We do what we can with the resources we have."
The U.S. Government Accountability Office, the congressional watchdog, noted in a November report that no single federal agency tracks the use of J-1 waivers for doctors in underserved areas. In addition, an investigation of the J-1 program showed that oversight was "somewhat weak," with instances of doctors not fulfilling their service in underserved areas.
Robert Divine, who was chief counsel and acting director of U.S. Citizenship and Immigration Services from 2004 to 2006, acknowledges: "Nobody at the federal level is routinely doing anything to ensure these (employers) are doing what they said."
Until 2006, officials of the Nevada health division made yearly site visits to clinics to verify the doctors were working the 40 hours a week required by law. Today, the state relies on employers signing a sworn affidavit, under penalty of perjury, pledging the J-1 physician will work full time in the underserved areas. And every six months the doctors and employers must submit paperwork verifying their adherence to the rule.
Knowingly submitting false records to the state can be prosecuted as a felony, punishable by one to five years in prison and a $10,000 fine. Still, some foreign doctors - having worked their entire lives to get to this point, and needing to endure three to five years of obeying their employers - will lie to protect their road to legal residency.
The doctors say their bosses lie, too, and that's why officials of the state health division can tout total compliance with the 40-hour-a-week mandate.
Karen Allen of the state's Bureau of Family Health Services said: "I am not aware of any cases in which program guidelines were not being followed."
Utah and California provide even less oversight for J-1 doctors and employers, performing neither site visits nor self-reporting to ensure guidelines are followed. Texas officials, in contrast, said they visit clinics regularly to make sure J-1 doctors are in the underserved areas and perform phone surveys with the physicians every six months to ensure they're not be ing overworked or underpaid.
Retired surgeon Dr. Ikram Khan has served in advisory capacities to Nevada governors and now, along with infectious disease specialist Dr. Amir Qureshi, a J-1 doctor from 1998 to 2001, aims to improve oversight of the J-1 system. The men sit on an advisory committee that makes recommendations about assigning J-1 doctors to employers.
Qureshi said he knows many physicians who have been cheated by employers, including one who didn't receive his first paycheck for four months.
Khan said: "The intent of the law was supposed to be a win-win for both sides . It was not intended for abuse by one side or another."
Prabhu says he hires J-1 doctors to bring more physicians to Las Vegas, where there is a shortage. Althoug h most of the approximately 30 doctors Prabhu has hired are still in the city, the trend might not continue. Some of Prabhu's more recent J-1 contracts include noncompete agreements that make it difficult for the foreign doctors to stay.
Many states forbid noncompete clauses for J-1 doctors because they would defeat the long-term purpose of keeping J-1 doctors in underserved areas after they leave the program. Nevada, however, allows the agreements. Qureshi says Nevada's guidelines must be changed.
"How dare you get a no-compete clause signed when you bring somebody into an underserved area where technically no one wants to go ?" Qureshi said.
As many as six of Prabhu's contracts, according to his chief operating officer, not only forbid his doctors from stealing patients or setting up practices close to his clinics - common noncompete terms - but also stipulate that, for two years after leaving Prabhu, the physician can't work in any Clark County hospital where he previously held privileges.
Such language is in the contracts the Sun obtained for two of Prabhu's current J-1 physicians. One of those doctors has privileges at every Clark County hospital, so after he leaves Prabhu's practice, his contract makes it difficult for him to practice medicine in Las Vegas. Prabhu's current and former J-1 doctors say the clause is unreasonable.
Months before this story was published Prabhu defended the noncompete agreements, saying doctors could sue him if they thought them unreasonable.
Several of Prabhu's former employees invoked the name of Dr. Suresh Khilnani as a warning not to cross Prabhu in court. Prabhu sued Khilnani for violating a different type of noncompete agreement, and in 1998 a jury awarded Prabhu $300,000.
Just before the Sun published this story, Prabhu said in a final interview that he was not familiar with the restrictive noncompete agreements in his contracts with his J-1 doctors, that the language was written by his attorney and that he would not enforce the agreements. Hickok said current J-1 contracts do not include the restriction against working in hospitals, and he and Prabhu said it's possible for doctors to be released from the noncompete agreements.
Prabhu was asked why he does not simply remove the language to be consistent with his philosophy of bringing more doctors to the region. Prabhu then said he would have the noncompete clauses removed from the existing contracts.
Prabhu said his noncompete agreements have not forced any physician to leave Las Vegas, but one doctor said that's not the case . A physician who said he worked 100-hour weeks for Prabhu, including countless call shifts at hospitals, left town in November, saying he didn't want to be beholden to Prabhu by asking to be released from the noncompete agreement.
The foreign doctor blames himself for signing Prabhu's contract in the first place.
"It never crossed my mind that these particular phrases or clauses can create problems down the road," he said.
He recommended that the government reform the J-1 physician program by allowing the state health department to sponsor the foreign doctors.
"Employers should have no say in it," the doctor said.