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Health care: A study in diversity

Most of the doctors practicing here came from outside the United States. Without that diversity, the quality and availability of health care would suffer.

By COLLINS CONNER, Times Staff Writer
© St. Petersburg Times
published February 9, 2003

In a sense, the grateful patients of Dr. Sadras Shanmugham have Clint Eastwood to thank.

Eastwood's Dirty Harry movies gave Shanmugham his first glimpse of U.S. cities, which helped pull him from India in the early 1980s.

There were other draws: America's technological superiority and the U.S. government's push to get practitioners into rural communities.

The result: Shanmugham (pronounced SHAH-moo-gahm) became part of a medical migration that catapulted Hernando and Pasco counties into the age of high-tech health care.

The migration brought these counties increasingly sophisticated hospitals, one of the nation's top-rated heart centers, a wide range of diagnostic treatment facilities and a full roster of specialists.

Imagine what would have happened if the foreign-trained doctors had not moved here.

Hernando residents would have to get by on a third of the current number of physicians. In Pasco, the doctor count would plummet 60 percent.

Instead, for 20 years, the medical communities grew faster than the population. Doctors' offices line up like medical corridors near hospitals in both counties, rapidly expanding the range of medical services.

That growth is directly attributable to the willingness of foreign-trained doctors to set up shop in communities that lack the educational, social and cultural resources sought by most U.S.-trained doctors.

Indeed, in both counties, the officers of the medical societies and the staffs of the hospitals read like a Who's Who in the United Nations. Hernando has physicians from Peru, Lebanon, Italy, Granada, Romania, Argentina and England. Pasco doctors were schooled in Puerto Rico, the Philippines, Bangladesh, Zambia, Haiti and Thailand.

Twice as many Hernando doctors got their training from the University of Damascus than from the University of South Florida. Three times as many Pasco physicians attended medical schools in India than in Florida.

Stephen Goldman, a longtime Pasco physician, said the mix has worked well:

"Nothing is perfect, but we have been able to accommodate so many different people and work together (in) a regular old American, blue-collar community."

* * *

Pariksith Singh left India to do his postgraduate work in New York, then moved to Spring Hill when HMOs were expanding their physician base here. Now Singh and his wife, who is also a doctor, operate two offices and a walk-in clinic. Singh has admitting privileges in four hospitals in Pasco and Hernando.

Just 20 years ago -- around the time Singh started medical school -- the two counties' health care systems were smaller and much more basic.

Spring Hill Regional Hospital didn't exist.

Regional Medical Center Bayonet Point was six years away from opening its Heart Center, now one of the nation's best.

Pasco's medical roster was a third of its present size.

In 1986, when Shanmugham hung his shingle, the medical staff at Spring Hill's Oak Hill Hospital numbered about two dozen -- one fifth its current size.

"There was only one pulmonologist in Hernando County," Shanmugham said. "I was so overwhelmed with work. I would leave the hospital at 12 (midnight) and come back at 6."

Shanmugham believes doctors were a key to the area's phenomenal growth. Retirees wanted available medical care, first and foremost. Without that, he said, older citizens would have bought their retirement homes elsewhere.

"I would say we built the area," Shanmugham said.

Certainly the medical community exploded in both counties.

From 1969 to 1979, while Pasco's population grew 155 percent, its physician base grew 469 percent. In Hernando, from 1980 to 2000, the population nearly tripled and the number of physicians more than quadrupled.

The bulk of the growth came from overseas.

Compare that to Hillsborough, Pinellas and Citrus, where the majority of physicians are U.S. trained -- 63, 65, and 53 percent respectively.

U.S.-trained doctors "didn't want to come to small towns," said former Hernando physician Frank M. Johnston Sr. "The big city is attracting and the opportunity to practice a specialty is attracting. Nobody wanted to do a small town practice."

Urban areas also offer cultural, educational and recreation activities, which are important to a lot of physicians, said Dennis Taylor, who has managed hospitals in Pasco and Hernando counties.

"Very frankly, the urban areas usually have first dibs on American physicians coming out of school," Taylor said.

As medical care became more sophisticated and demand for doctors grew, U.S. schools couldn't produce enough physicians to keep up. Rural areas were left with significant shortages. They were "medically underserved" in the parlance of the U.S. government, which lobbied new graduates of foreign medical schools to come to America for their postgraduate work.

Goldman, the Pasco physician, calls it "the classic immigration story" of the U.S. filling unwanted jobs by importing laborers.

* * *

In the 1970s, when the demand for doctors soared, some overseas schools vied for American students whose grades were too low for admission to U.S. medical schools. Some Mexican and European universities started conducting classes in English.

New schools popped open in the Caribbean that provided, limited laboratories, at best, meager texts, intermittent electrical power and no cadavers. One school rushed its students off Montserrat barely ahead of an erupting volcano. Several schools were shut down as diploma mills.

To ensure U.S. residents would get comparable care, the government required that foreign-trained doctors pass the United States Medical Licensing Exam. Most serve internships, residencies or fellowships at U.S. medical facilities.

"It's clear that American medical schools are the best in the world," said Goldman, who studied at the University of Texas and did his postgraduate work in New York.

"But where you go to medical school is not as important as where you serve your internship, residency or fellowship."

Graduates of the Caribbean schools shouldn't be discounted either, Goldman said. "What's more important is the motivation of the individual," he said. "A lot of those who go to the Caribbean or Europe want to be physicians so badly, they take the rejection (from U.S. schools) and turn it into something good. It makes many of them stronger doctors and they work very hard."

According to records kept by the state, there's no difference between U.S.-trained and internationally trained doctors in the percentage of criminal charges, disciplinary problems and/or insurance claim payouts.

Indeed, the diversity in Pasco's medical staff has helped the county, Goldman said. "The quality of medical care here is far superior than it was before."

M.P.R. Nathan said he studied medicine in India and England, practiced several years in India and then, "like everybody else, came here primarily for the training.

"America is the place where you can get the best medical training."

After serving on the faculty of a New Jersey college of medicine, he decided to open a private practice. "I wanted to start in an area where the opportunities are very good and I don't have to compete with other cardiologists," he said.

Nathan, like hundreds of other international medical graduates who did their postgraduate work in New York, Chicago, Pittsburgh and Detroit, moved south.

Those who came to Pasco and Hernando Counties to establish their practices were, physically, just an hour from Tampa.

Culturally, they were light years away.

* * *

A dozen years ago, several Pasco doctors opened a free clinic for people without insurance. They got donated office space and equipment; they rounded up volunteers to work the desk.

They named their project the Judeo-Christian Health Clinic, which stopped Krishna Ravi at the door. Ravi objected to the name, not just because he is Hindu, but because it fostered exclusivity.

He wanted unity, not division, in his adopted country.

In 1978, when Ravi arrived in Pasco, he saw both sides of being only the third or fourth Indian physician in the area.

On the down side, he was refused a $17,000 loan by the local bank. "I wonder why?" he asks rhetorically.

On the up side, Ravi introduced himself to Ross Olson and asked the longtime doctor for advice. "So he ... spent three hours with me. He showed me how to practice, what he does, why he does it. This guy, fantastic. Why would he do that?"

Still, Ravi and the other international physicians had stepped into a cultural vacuum. Hernando and Pasco had no mosque, no temple, no specialty grocer, no ethnic neighborhoods.

Outside the medical community, there was virtually no diversity in either county.

"You don't see an Indian cop," said Shanmugham. "You don't see an Indian mechanic."

Now, though the two counties are far from multicultural, there are incremental changes taking place. The doctors encouraged relatives and former classmates from their home countries to move here. Hernando now has a mosque. There are Hindu temples in Citrus and Hillsborough Counties, an Indian cultural center in Tampa and, in Brandon, the International Institute of Islamic Medicine.

The 2000 census showed a jump of 192 percent in Pasco's Asian population in the previous 10 years, from 1,404 to 4,096. In Hernando, the number of Filipino residents, admittedly small to begin with, grew 196 percent in 10 years, from 82 to 243.

Shanmugham and Nathan said the doctors didn't want to distinguish themselves other than through their work. They wanted to assimilate.

"We want to be part of," Shanmugham said. "We don't want to be known as the Indian community."

In Pasco, the Judeo-Christian Clinic merged with a free clinic started by Ravi and the county's medical society. The new effort has a nonsectarian name: the Good Samaritan Clinic.

The foreign-born doctors say they became U.S. citizens; their children were born in this country and attend local schools. Dr. Nathan's children studied medicine; his son now practices interventional cardiology in Chicago, his daughter is in residency training in neurology in Miami. Some doctors opened ancillary businesses, some performed charity work in their native countries or their adopted one.

"The greatness of America continues to be the influx of new blood, new cultures," said Ravi, the Pasco physician, "but the greatness is, we get Americanized.

"All these cultures contribute their positive attributes and we get Americanized."

* * *

In the months after the U.S. was attacked by terrorists, Spring Hill erupted over a remark by a foreign-born doctor that seemed to suggest the United States had invited the attack.

An Islamic charity in Chicago was raided by federal investigators, who alleged its donations financed terrorism. Among the big donors: a cluster of Hernando physicians.

"This was a battleground county when we had 9/11," said Singh. "People drew lines, but people also erased lines."

Because the medical community is a mix of so many nationalities, it can mirror worldwide political tensions, Singh said. "I can see where there is so much anger in Israel and Palestine," he said. "You can see a percentage of that anger right here. There's probably a cross section of the situation in the world right now in this county.

"It's complex."

Now, 18 months after the attack, Dr. Nathan has a U.S. flag in his office window. Dr. Singh's office has at least four small posters commemorating those who died on Sept. 11 and he wears a flag pin in his lapel. Stuck in a potted plant at Dr. Ravi's office are two American flags.

Singh said those patriotic displays come from gratitude.

"Think about it, so many people coming with all their idiosyncrasies and their weird accents and they're coming here and this community is letting them thrive -- helping them thrive," he said.

"People can say bad things: "Oh, the country's going down.' I tell them: Guys, you just don't realize how good you have it. I have never seen a country in which there is so much freedom.

"It's an undeniable fact: blessings are not being counted."

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