Born in India Transforming Rural Maryland

Born in India, Transforming Rural Md.

Extended Family of Medical Specialists Helps St. Mary’s Thrive
By Jenna Johnson
Washington Post Staff Writer
Friday, December 7, 2007

St. Mary’s County was once a place where no doctor wanted to settle. In the 1970s, the county hospital used decades-old equipment, struggled to make payroll and had no full-time specialists — not even an obstetrician, although more than 600 babies were born there each year.

Then came Vinod K. and Ila Shah, Bombay-educated and D.C.-trained husband-and-wife doctors who were eager to open a practice in the rural area. They had heard about St. Mary’s from Vinod’s younger brother and were enticed by the potential impact that even a small practice could have there.

“It was just like miracle workers walked in,” said Richard Martin, 92, who was then head of the hospital. “I told them, ‘You are the answer to my prayers.’ “

The couple was soon joined by Vinod’s younger brother, Umed K. Shah, a gastroenterologist. Next came two family friends. A few years later, another brother arrived, cardiologist Anil K. Shah, with his wife, Beena Shah, a neurologist.

In time, Vinod and Ila Shah recruited more friends and family, including the rest of Vinod’s eight siblings, each of whom is a doctor or is married to one. They built the largest private specialty practice in Southern Maryland, Shah Associates, which has treated about 90,000 of St. Mary’s 110,000 residents.

For many years, foreign-born doctors have been the unlikely medical backbone of rural America. In the 1970s, the United States actively recruited them, promoting the opportunities available in remote areas avoided by many U.S.-born physicians. Then, starting in the 1990s, a visa waiver program promised to fast-track doctors to a green card if they worked in a rural area for at least three years.

Today, at least 23 percent of practicing doctors in the United States attended a foreign medical school, and almost all of those practitioners were born overseas. But recent changes in visa policy have had the unintended consequence of slowing the flow of foreign-born doctors to rural areas, a trend that Shah is, in small ways, resisting.

Two generations of Shah doctors see patients who span several generations of Southern Maryland families. “We come here for everything,” Navy retiree Paul Hailor said at their main office in Hollywood, Md. “My fiancee is down the hall waiting for a pulmonary appointment. Kids come here for MRIs, CAT scans.”

Nurses and patients have a system for keeping all of the Shahs straight. They use initials for the four Shah brothers: Dr. V.K. the cardiologist; Dr. U.K. the gastroenterologist; Dr. D.K. the child psychiatrist; and Dr. A.K., another cardiologist. The other Shahs, especially the four with names beginning with ‘A,’ often go by their first name: Dr. Amish the cardiologist, also V.K.’s son; his wife, Dr. Arpana the dermatologist; Dr. Beena the neurologist; Dr. Jyoti the sleep specialist.

“Every once in a while, we get someone calling in wanting to talk to ‘Dr. Shah,’ ” said Betsy Warren, a registered nurse who has worked for Shah Associates for 16 years. “You ask them, ‘Which Dr. Shah?’ And they say, ‘The one with dark hair.’ “

To Southern Maryland, the Shah family has imported distinctive aspects of Indian culture: colorful saris, lavish parties for hundreds stocked with huge trays of vegetarian Indian food and recitals featuring classical Indian dances.

Family members say it took years to earn the trust of the community, but once they did, the practice quickly grew. Some local doctors who once viewed the Shahs as competition eventually joined the practice.

Each time the nearby Patuxent River Naval Base added employees, the practice received a wave of patients. The practice’s offices, where employees had once been asked to park in front so business would appear brisk, were soon overflowing.

In 1995, V.K. Shah found an empty lot on Route 235 in Hollywood. Two years later, he opened the Philip J. Bean Medical Center, dedicating it to a late local physician who he said “delivered half the county.”

“We said, ‘Let’s name it after someone who means something to this community,’ ” Shah said. “I think people should feel good about this place — it should mean something to them.”

But the facility that felt like a palace then is already too small, and the practice, with 65 physicians in 10 locations, is scrambling to recruit more doctors. “Demand is so high across the board,” said Shah, 66. “I can’t retire.”

Plans were announced last week for a 32,000-square-foot addition to the medical center. The extra space will allow specialists from Georgetown University Hospital and Washington Hospital Center to practice there as part of a new partnership.

Because Shah Associates provides so much of the medical care in the region, the partnership will allow the universities to study health patterns over generations, said Leslie Miller, head of the cardiac program at both hospitals.

Shah Associates has compiled its patients’ medical records into a database that allows it to track the medical histories of families and look for early warning signs in younger generations. Such locally comprehensive databases might one day help researchers better understand such hereditary conditions as heart problems, he said.

“They are a model of the health care of the future,” Miller said. “These guys, on their own, using their own money, have put together this extraordinary system. . . . We want to extend what they have done.”

But in many areas that are more rural than Southern Maryland, as in many inner cities, the gap between medical needs and resources remains great, despite government efforts.

In 1994, Congress made foreign doctors who train in the United States while holding a so-called J-1 visa eligible to apply for a green card if they practiced for at least three years in underserved areas. The program, which exempts J-1 holders from a required return home for two years after their training is complete, has placed thousands of doctors in inner-city and rural communities, as well as in prisons.

They continue to flood the United States with residency applications, but each year the program receives fewer applications and fills fewer spots. Last year, only 900 of the 1,620 available waivers were issued.

Rural health experts attribute much of that drop to the popularity of another visa, the H-1B, which allows U.S. companies to temporarily sponsor highly skilled foreign workers in such fields as medicine, architecture and science.

In 2000, to make more H-1B visas available for technology companies, Congress exempted research institutions and universities, including their hospitals, from a cap on the hard-to-get visas. The popularity of the J-1 waiver program plummeted, and the pipeline that once channeled doctors to underserved areas narrowed.

Today, no medical facilities in Southern Maryland are eligible to sponsor physicians under the J-1 waiver program. A majority of the nearly 30 Maryland primary medical care centers designated as having a specialist shortage are in Baltimore. The District has 13 sites, including the D.C. jail. Virginia has nearly 120, two of which are in the Washington area.

With baby boomers beginning to retire, the American Medical Association says, the country could be short as many as 200,000 doctors before 2020 — a shortage that is expected to hurt already-underserved areas the most.

V.K. Shah, who is also vice president of the American Association of Physicians of Indian Origin, said a shortage could be prevented by drastically increasing the number of medical schools in the United States, relying more on nurses and nurse practitioners or by allowing more qualified international medical graduates to practice in the United States.

But to practice, foreign doctors must first complete training in a U.S. residency program, for which spots are scarce. Last year, 46 percent of foreign applicants received residencies, compared with 93 percent of American graduates, according to the National Resident Match Program, which facilitates the application process for more than 1,000 U.S. institutions.

Each year, Shah Associates hosts a handful of graduates from foreign medical schools, encouraging them to seek opportunities beyond big cities. This summer, four recent graduates of Mumbai medical schools traveled to Southern Maryland on tourist visas for an unpaid crash course in American medicine.

The graduates watched as the Shahs cracked jokes with their patients, reassured them about upcoming operations and gently recommended diet changes. Mitesh Lotia, 24, one of the graduates, said that the one-on-one interaction held great appeal.

“In India, we would see 100, 150 patients a day,” he said. “There was no time to get to know patients. I want to practice here. I’ll go anywhere.”