CRISFIELD -- Two years ago, doctors from India, the Philippines and Nigeria started coming to this sleepy crabbing capital to set up practices. They made little Edward J. McCready Memorial Hospital the most ethnically diverse place in town -- and probably saved it from financial ruin.
McCready's new chief executive had realized that American doctors weren't interested in a place that could offer hospitality but not a lot of money, prestige or excitement. So he tapped the foreign market, finding 10 of 16 new physicians from overseas.
"It was a question of whether this hospital was going to survive," said J. Allan Bickling, who also recruited doctors from Switzerland and Scotland. Within a year, patient admissions and revenues jumped more than 60 percent.
Increasingly, the nation's less glamorous hospitals and clinics are relying on foreign doctors who are willing to practice in places like the Eastern Shore or inner-city Baltimore, Appalachia or the Dakotas.
But the trend has sparked a backlash. Led by the American Medical Association, several organizations have proposed laws that would greatly reduce the number of foreign doctors entering or staying in the United States. Health economists say the newcomers are contributing to an oversupply of doctors, driving up the nation's health care bill and making it hard for U.S. physicians to compete.
"Many physicians are having trouble finding a place to work when they get through their many years of training," said Dr. Michael Scotti, the AMA's vice president for medical education.
Tougher requirements
Already, the requirements for foreign doctors are getting tougher. Starting this month, those trained overseas must take a competency test designed to test clinical and language skills. In the test, physicians are required to interview and take medical histories from "patients" who are actually examiners.
Today, 22,000 -- almost a fifth -- of the 104,000 medical residents training in U.S. hospitals come from other countries. Most come here on visas that require them to leave at the end of their training, presumably to apply their medical knowledge back home.
But more than 1,000 each year obtain waivers that allow them to stay if they spend three years working in places shunned by American doctors. This is giving the medical profession an increasingly international flavor. This year, a quarter of the 600,000 physicians in practice come from other lands, with large contingents from India, Pakistan and the Philippines.
Many of the arrivals acknowledge that they occupy a second tier of American medicine. For instance, internists starting at McCready can expect to make about $70,000, said Bickling, about half of what could be earned in more cosmopolitan practices.
Despite this, foreign doctors say they enjoy salaries and technological advantages they could only dream of back home.
"The United States is the mecca of medicine," says Dr. Kumar Rajagopalan, 34, who trained in New York and Cleveland before becoming McCready's first cancer specialist. "Back in India, the schools all followed textbooks done in the United States. Here, it's nice to practice what you read."
He says he has every amenity he needs -- "a big house, a big yard, peace and quiet. And the air is clean. Life here is a lot less stressful."
Rajagopalan says he has been accepted warmly by the townspeople who "truly admire and respect what a doctor does." Patients stumble over his last name, so he is known simply as "Dr. Kumar." Some of Crisfield's other foreign doctors encourage the practice.
Raised in southern India, Rajagopalan learned English as a child while attending British-style schools. In high school and medical school, he was reading textbooks written in English. And though he speaks with a lilting accent, he chooses his words confidently and with few missteps.
Helen Seifert, who was diagnosed recently with lung cancer, says she doesn't care about her doctor's nationality. "He's one of the best isn't he?" said Seifert, 67. "He's aware of everything you need."
Seifert sees Rajagopalan every other week for three days of outpatient chemotherapy. "If I had to go to Salisbury, that would be a hardship," she said, explaining that she couldn't drive herself. "My son and daughter, they both work. It would be hard for them to get off work."
'Glamour' of United States
Near the hospital, in a rickety house next to a laundromat, Dr. Eshwara P. Kanchana practices internal medicine with two doctors from Nigeria. Kanchana, who moonlights in the hospital emergency room, moved to Crisfield last year after finishing his residency at Nassau County Medical Center on Long Island.
A native of southwestern India, Kanchana is the first doctor in his family but by no means the first professional. His father is a lawyer; other family members work with computers. After graduating from an Indian medical school and spending a year in an ophthalmology residency, he looked toward the United States.
"I'd probably say it was the glamour of the United States," he said, taking a break from emergency room duties. "When you're a child, you hear all the good things about the U.S. Also, I wanted to see what was the state of the art in medicine."
But the road to the United States can be a bureaucratic minefield.
Kanchana went to Singapore to take two standardized exams measuring knowledge of basic science and clinical medicine. The tests, the same ones given to American applicants, are given around the world -- but not in India.
Kanchana passed.
Next, he had to apply for a position at a U.S. teaching hospital. Many doctors apply to scores of hospitals and make costly trips for interviews. But Kanchana heard about a doctor from Nassau County who was interviewing residency candidates while attending a conference in New Delhi. To his delight, he was accepted.
To enter the United States, foreign doctors need visas that are issued stingily -- and without any apparent pattern -- by U.S. embassies and consulates.
"It's very arbitrary," said Kanchana, who received his on the first try. "Your visa could be rejected very easily. Only 30 percent who pass the exams get visas. I had friends who were rejected three or four times. Then, they gave up."
Kanchana received a visa, then a waiver that allowed him to stay after his residency by agreeing to commit at least three years to Crisfield.
The waivers are precious, and foreign doctors hire American immigration lawyers to navigate Byzantine immigration procedures and fill out paperwork correctly. "The paperwork is scary," said Rajagopalan, who paid a lawyer $10,000 to help him through the process. "It's hard to figure out what they want."
Dr. Ritchie C. Shoemaker, who heads the Somerset County Medical Society, said Crisfield's new doctors have blended in well.
"I feel fortunate that the people McCready hospital is recruiting are very good, and I haven't heard any complaints about the quality of work," Shoemaker said.
Bickling said a few patients have objected to seeing the new doctors with the exotic names and accents, but he chalks that up to the occasional prejudices that run through any community.
The new competency exam, given in Philadelphia by the Educational Commission for Foreign Medical Graduates, should make it easier for hospital residency programs to eliminate applicants who struggle with the language.
"In a way, the test is good for us," said Dr. Tah-Hsiung Hsu, chief of medicine at Harbor Hospital in South Baltimore.
Overwhelmingly, it is the community hospitals like Harbor that look to the foreign market for residents. Elite programs affiliated with academic medical centers -- such as Johns Hopkins and the University of Maryland -- draw many of the best domestic applicants.
Each year, Harbor considers 5,000 applications for 10 residencies that open each year in internal medicine, according to Hsu. More than 90 percent of the job-seekers are from other countries -- and the slots overwhelmingly go to foreigners.
"Now, maybe I'll screen 1,000 in a well-selected group," Hsu said.
Last year, Union Memorial Hospital received 3,000 applications for 10 slots in its residency program in internal medicine. Ninety percent of the applicants were foreign medical graduates, according to Dr. Robert Ferguson, chief of medicine. About half the slots are awarded to foreigners.
The overseas candidates who make the cut are "exemplary," Ferguson said. "The low-level foreign graduates never apply. They know they'll never get a position."
Dr. J. Ramsay Farrah, a Hagerstown pediatrician who heads the state medical society's new International Medical Graduate Section, said it is hard for foreign graduates to get into elite programs. "But any hospital that you can start with is a start, an opportunity."
Dr. Navin C. Shah, a Lanham urologist who once headed a national association for Indian-born doctors, said foreign physicians have generally prospered in America but do fight prejudice. Some have been overlooked for promotions, he said, and some have encountered want ads that exclude foreign graduates.
"All we're saying," said Shah, is that if a person has "trained here and passed all the exams under the American system, treat him as such."
Restrictions requested
Hoping to restrict the flow of foreign doctors, the American Medical Association has proposed federal legislation that would greatly reduce the number of residency slots opening each year -- thus making it much harder for foreign doctors to compete. The proposal is now before a Congressional study group.
Michael Scotti, AMA vice president, said there is no evidence that foreign doctors are less skilled or knowledgeable than those educated in the United States. But he said taxpayers, who subsidize residencies through the Medicare program, shouldn't have to support foreign doctors who are trying to gain a foothold in America.
Another organization, the Council on Graduate Medical Education, has proposed to phase out the visa waivers.
"Many doctors see foreign physicians as the boogie man," said Michael Maggio, a Washington immigration lawyer who helps many foreign doctors get waivers. "They feel they are being pushed out of a 500-series Mercedes into a 200-class Mercedes. When you look at what the average person makes, I think even the underpaid doctor is doing very well."
In Crisfield, Kanchana said he understands why some American doctors are fearful.
"They see foreign doctors as a threat," he said. "We're contributing to the communities and keeping the hospitals running. But it's their battle to preserve their previous lifestyle. They see this pinch, a shrinking pie.
"I can't say if I were in their shoes, I would act any different."
Pub Date: 8/04/98