- Associated Press - Saturday, March 18, 2017

DAVENPORT, Iowa (AP) - Dr. Nazir Kayali settled into his chair, deep in thought.

His hand stroked his chin and a smile grew into a laugh as he considered his circuitous path to the Quad-Cities.

The Syrian-born pediatrician’s first trip outside his native country was to Ohio in 1990, where his cousins were practicing medicine.

Wishing to follow in his cousins’ paths, Kayali asked what he might expect from America.

They halfheartedly told him a joke that went along with the generalization that Americans are egotistical and care only about money.

“A stranger comes to America and finds a booth that says ‘Two questions for $100,’” Kayali began, barely able to get the words past his own laughter. “He asks a woman, ‘Is that a lot of money for two questions?’ She replies ‘Yes. What’s your second question?’”

But the international medical graduate found the opposite to be true in middle America. Here, he said, he found warmth, compassion and acceptance.

Dr. Nazir Kayali has his plate dished up by daughter, Sarah, 17, as they sit down for dinner at their home in Bettendorf. Having lived in Des Moines for his residency and in the Quad-Cities previously, Kayali, a Syrian-born pediatrician, has called Bettendorf home for the past five years.

Having lived in Bettendorf for the past five years, Kayali boasts that the Quad-Cities is his third stint in Iowa, having secured his H-1B visa to complete his residency from 1993-1996 at Iowa Methodist Medical Center in Des Moines. Out of all the hospitals in the nation, his first choice was in Iowa’s capital city.

He then came to the Quad-Cities from 1999 to 2007, returning to Syria so his children could get to know their family in Aleppo.

But his Iowa memories and experiences stayed with Kayali.

When war made Syria too dangerous, the pediatrician with a soft spot for Iowa was relieved to learn of an opportunity in the safe place he had come to know more than 6,200 miles away. And it called his family back.

“I’ve had a very positive experience,” Kayali said. “The acceptance and the people, from residents, staff, colleagues and patients; it was all so incredible.”

The sentiment is the same for many of the international medical graduates who have immersed themselves in the community, including Dr. Sarojini Ratnakar, who joked that she took the easy path to practicing medicine in the United States.

The Indian-born and -trained hospitalist for Genesis Health System did not have to jump over the same hurdles that other international medical graduates did. Her husband already had a visa, so she was able to come as a spouse.

Dr. Sarojini Ratnakar talks with patient Marcia Johnson of Bettendorf in her room at Genesis Medical Center-East Rusholme Street, Davenport.

Ratnakar’s story, however, is similar in that she, too, came to the U.S. to make a better life and has settled into the void created by the country’s physician shortage.

In America’s heartland, where the shortage is more pronounced, the challenge isn’t so much in finding qualified doctors. The real test is in convincing them to stay.

Iowa ranked seventh in medical students per 100,000 population, but the state has one of the lowest physician-to-population ratios in the country. In other words, medical students are graduating in Iowa; they just aren’t practicing here.

Even more alarming is Iowa’s consistently low ranking in retaining physicians who earned their medical degrees in-state.

Since 2006, the retention percentage for in-state graduates has fluctuated between 34 percent and 36 percent for physicians, according to data from the Association of American Medical Colleges, or AAMC.

Hospitalist Dr. Sarojini Ratnakar, who was born in India, reads a chart before going to the patient’s room at Genesis Medical Center-East Rusholme Street, Davenport.

Ratnakar said she struggled when she first came to practice in Iowa in 2004.

“I moved from Atlanta, because my family was here, but at the beginning, I really wanted to go back,” she said.

As she immersed herself in the Quad-Cities, however, something changed.

“It’s the people here,” she said. “I wanted to go back, but now I won’t leave, because this place is just fantastic. I would not trade it for anything.”

Just like Ratnakar, other international medical graduates are starting to form attachments and a sense of place and are not necessarily waiting for a door to open elsewhere.

Community Health Care CEO Tom Bowman has become familiar with the doctor shortage in his 10 years at the Davenport clinic.

Bowman said Community Health Care, or CHC, tries to fill the gaps in medical treatment in the community and, in order to do so, relies heavily on sponsorship of international medical graduates through J-1 or H-1B visas.

Foreign graduates accounted for more than 50 percent of CHC recruits in the past decade, and they haven’t always been keen on staying in the area.

“Some of it, even though we’re not as rural as some parts of country, is that they tend to gravitate to more diverse and urban areas,” Bowman said. “But we’re getting better on that front.”

In the past 15 years, Community Health Care has sponsored and employed 33 international medical graduates, but only 17 have remained here. However, when narrowing the focus to the past decade the percentage of doctors sticking around increases from 50 percent to about 65 percent, the Quad-City Times (https://bit.ly/2mPonTy ) reported.

Hospitalist Dr. Sarojini Ratnakar looks over the patient board for the night at Genesis Medical Center-East Rusholme Street, Davenport.

The same can be said of the percentage of active physicians who are international medical graduates, practicing in Iowa. As of 2014, their numbers increased from 17 percent to 18.6 percent, making foreign doctors second only to Iowa-educated doctors in the recruitment pool.

From 2006-14, foreign doctors accounted for almost one-third of physician growth in Iowa, according to data from AAMC. In fact, foreign graduates have become such a mainstay in American medical care, they now account for about 1 in 4 physicians.

“Foreign graduates are very hard workers, so they really don’t mind going to any place,” Ratnakar said.

The sprawling city of Kingwood, West Virginia, county seat of Preston County, was home to just more than 3,000 people when Kayali practiced there after his three-year residency in Des Moines.

“(It’s) a small town in the mountains where no one else would go,” the Bettendorf pediatrician said.

Except for his family’s social life, Kayali said, the little town produced a positive experience. But it also was the place in which he first experienced the struggles that strike a community that is medically under-served. Some of the most basic conditions were worsened, he said, by the lack of physicians in the area.

“I would see really sick kids, and I wouldn’t imagine seeing such cases in the United States,” Kayali said.

For rural areas in the U.S. like Kingwood, it’s difficult to attract physicians, which is why foreign physicians have become such a vital resource.

A study commissioned by AAMC found that the U.S. will have a shortage of 61,700 to 94,700 physicians by 2025, and rural areas can expect to suffer the most. Those regions of the country typically lack the amenities, diversity and financial incentives available in urban areas, making them less desirable to many incoming physicians.

As an incentive, foreign graduates can prolong their stay in the U.S. by serving in medically under-served areas with modest populations where other health providers are scarce.

With J-1 visas, states can sponsor physicians through the Conrad 30 waiver, which allows 30 international medical graduates to stay in the country as long as they practice their medical specialty in shortage areas for a minimum of three years.

J-1 visas typically require participants to return to their home country for two years to apply the knowledge and training they acquired in the U.S.

Over the past 10 years, more than 10,000 physicians in the U.S. stayed and served in shortage areas under Conrad 30, according to AAMC President Darrell Kirch. In the same decade, the Iowa Department of Public Health sponsored 292 foreign doctors out of the potential maximum of 300, meaning Iowa used 97 percent of its allotment of Conrad 30 doctors. In comparison, the national average is 59 percent.

From 2007 to this year, Scott County ranked eighth in the number of Conrad 30 waivers granted in the state with 18.

But the number of state-sponsored waivers has decreased since 2012, when the Department of Health and Human Services took over applications for Federally Qualified Health Centers such as CHC.

While Scott County did not receive a single Conrad 30 waiver out of the 30 recommended by the state this year, it does not mean the need isn’t there.

___

Information from: Quad-City Times, https://www.qctimes.com

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