Prescription From Abroad
These stories originally appeared as a two-part series:
They were passing through East Tennessee on their way from New Jersey to Texas, where Dr. Mohammad Razaur Rahman had a job interview.
"What is this place? It is beautiful," Afshan Rahman asked her husband in Urdu, their native dialect.
"Tennessee," he replied.
It was 1981. Rahman was fresh from completing an internship and residency in New Jersey. He'd also completed requirements for immigration from Pakistan to the United States, a journey he'd been planning since he was a child. He and Afshan had been married nearly two years and had a baby son.
He was looking for a place to practice his passion: internal medicine.
The Rahmans didn't stay in Texas long. Back in New Jersey later that year, Rahman saw in an issue of Journal of the American Medical Association an ad for an internist in rural East Tennessee.
"This place looked beautiful, and I told my wife, 'This is the same place you wanted to come,' " Rahman said.
Loudon had mountains, a waterfront, lush green fields and forests. It had a small-town feel, people with strong family values and a sense of community.
What it didn't have was enough doctors.
Or anyone from Pakistan. Or anyone, even, from India.
Rahman was at the forefront of a national trend: foreign-born physicians who complete medical school overseas and come to the United States for internships and residencies, then settle in areas where few primary-care physicians want to work.
Now, foreign-born doctors commonly fill the gaps in poor, rural communities, especially in Appalachia and the South; in poor neighborhoods of large cities; and in Veterans Administration hospitals, where the hours and comparably lower pay are unlikely to entice many American-born doctors.
Some come with work visas that originally were designed to draw physician researchers doing work deemed to be in the United States' "public interest." The requirements for those visas were amended in 2002 to include practicing physicians, an attempt to replace a discontinued government visa program and stem what public health officials feared would be a shortage of primary-care physicians.
Others come on J-1 "exchange visitor" visas that once required foreign-born doctors who had completed their education to return to their home countries for two years before applying for U.S. immigration. Now a waiver to the J-1 visa lets primary care doctors instead choose to serve three years in an area the government designates as needy. Afterward, they can apply for U.S. citizenship and practice anywhere they want.
Some doctors view these stations as a sort of indentured servitude. They do their time and move to bigger cities, often with higher ethnic populations.
Others grow to love the areas in which they're working and stay longer. In some cases, the scenery or even the people may remind them of their native countries. Or they find deep fulfillment caring for the neediest communities.
What the Rahmans found in Loudon was, simply, home.
"When we came here for the interview, we started looking at the (phone book) to see if there were any Pakistani" or anyone else with a foreign-sounding name, Rahman said. "We did find someone in Knoxville, and we called him from the hotel, and we said, 'We are thinking of moving to this area. How is the ethnic population from India, from Pakistan in this area?' "
It was Knoxville nephrologist Naseemul Siddiqi, from India, who took that call and introduced the Rahmans to other South Asians in the area.
But in Loudon, the Rahmans were the only ones.
"People had told us, 'Don't go to the South; it is strange,' and things like that," Rahman said, "but our experience was completely different. We found people very friendly in the South."
That was true from the first night the family came to Loudon – "Oct. 24: I can remember the date," Rahman said.
It was unseasonably cold for October in East Tennessee, and the Rahmans arrived at their rented house in a Loudon County subdivision to find that their water pipe had frozen and burst. Their mover had gotten stuck in a snowstorm, so they had none of their furniture or other belongings.
"At nighttime, my neighbor knocked on the door just to welcome us, and he found out we didn't have water," Rahman said. "And the whole neighborhood came. They fixed the pipe … and brought food and mattresses for us to sleep on."
That neighbor became a close friend. His entire family became Rahman's patients.
Rahman had patients right away, and if they were bothered by his brown skin or lilting accent or Muslim religion, they didn't show it. The town needed an internist, and its people seemed thankful to get one.
"It looked like everybody knew before we came that we were moving to this area," Afshan Rahman said. "That is something we were not expecting. (Trenton) New Jersey is a big city. You don't even know the people next door."
One of the virtues of big cities is the ability to find most anything you need. The Rahmans were somewhat concerned: In a small community, would there be a mosque? And where would they get food – not only the spices to make traditional Pakistani dishes, but also meat? Islamic law dictates a religious ritual, called Zabihah, for slaughtering animals that will be eaten.
They soon learned that they could worship in Knoxville. For more than 25 years now, they have made the 45-minute drive to mosque every Friday and on various holy days for prayers.
Rahman slaughters his own meat for the family's use. Initially, the administrator of Loudon's small community hospital arranged for him to slaughter animals at Wampler's in Loudon County. Wampler's would then dress the animal for Rahman. When Wampler's ceased slaughtering a few years ago, the husband of one of Rahman's nurses offered his butcher shop in Monroe County.
"I asked my husband, I said, 'Dr. Rahman's wanting to get a beef, and with his culture, they do certain things, you know,' "
said Mary Ann Morgan, Rahman's office nurse of 11 years. "He said, 'Well, sure,' because he loves Dr. Rahman just like I do."
Rahman experienced near-universal tolerance of his differences, but that didn't mean they went unnoticed.
"In the beginning, people used to look and ask us questions: 'Where are you from? How did you come to Tennessee?' " Rahman said. "They were just curious. They just wanted to find out.
"The way things are now, patients have known me for so long, they don't think about differences. In the last 10 years, no one has asked me where I'm from. If I eat a different kind of food, or if I dress differently, or if I go to a different place to worship, they have accepted, because I talk to them."
Rahman also had to familiarize himself with the culture of his patients. In the beginning, communication was sometimes a problem. He tried to be sensitive to those who might have difficulty understanding his accent, having a nurse present in the exam room to interpret as necessary. As his accent has lessened and his patients know him better, it's rarely a problem now.
Morgan, Rahman's nurse, also remembers that there were Southern or Appalachian expressions that initially puzzled Rahman, "but he picked up on them real quick," she said. "His brain clicks fast. … Once he hears something, it's with him forever."
Expressions like "too many irons in the fire" might have given him pause, Morgan said. Or people saying they couldn't "cern" something (an Appalachian term, from "discern," that means to see or understand).
"They just cut it short," Morgan said. "That's what we do here in the South is cut the words off. We know proper English."
What Rahman understood from the start were his patients' medical problems.
Loudon County's five leading causes of death are heart disease, cancers, hypertension, chronic lower respiratory diseases and diabetes. More than 20 percent of county residents have high blood pressure; about 30 percent smoke.
Linda Bowden of Loudon credits Rahman for catching and controlling her high blood pressure and that of her 87-year-old father. Rahman also watches closely for cancer in her family, she said; he caught her sister's cancer as well as their late mother's. Her whole family, including her husband, parents, adult children, 19-year-old grandson, sister's family and husband's brother's family have been loyal patients of Rahman for more than 20 years.
"If there's something that needs to be doctored, he's going to doctor it," Bowden said. "He's not going to worry too much about whether insurance is going to cover it. It's not about the money. It's about taking care of the patient."
Rahman's practice, in downtown Loudon, is in a low, 1970s-era office. Rahman shares it with another internist, from India, but initially shared it with an OB/GYN – the town's second South Asian resident, who came six months after Rahman.
For years, the community hospital was right down the street, and Rahman made rounds there every day and was on call many nights. Now, the county hospital, Covenant Health-owned Fort Loudoun Medical Center, is in a new, modern building in nearby Lenoir City and able to attract specialists of every type.
But back then, when his patients came to him with the ills that these days would immediately result in referral to a specialist, Rahman couldn't do it. There were none in Loudon County, and many of his patients couldn't feasibly travel to Knoxville. So Rahman availed himself of continuing education as he learned his patients' needs.
"I was the first physician to start doing stress testing and giving some cardiac services, because we did not have a cardiologist," Rahman said. "We did not have a gastroenterologist, so I got trained to do endoscopies, and I started doing endoscopies here. We did not have a pulmonary physician here, so I started managing people on respirators."
And, as his patients aged, Rahman became specialized in geriatrics, or elder care.
Rahman no longer does the specialized procedures now that there are specialists in Lenoir City, and he visits the new hospital only for meetings and, Morgan said, to volunteer with nursing home or hospice patients. He can even look at X-rays on the computer without leaving his office.
His approximately 3,000 patients are drawn not only from Loudon County, but also from outlying areas including Vonore, Madisonville and Sweetwater. Many are poor and know he will treat them.
Rahman has accepted state Medicaid, or TennCare, since it first existed. Physicians in more affluent areas often opt not to take on the headache that is TennCare because of low reimbursements and mounds of paperwork. In rural communities, the need for doctors to accept TennCare is great. In 1999, about 15 percent of Loudon County patients were on TennCare rolls, and more than half had Medicare, the federal government's insurance program for senior citizens.
But Gov. Phil Bredesen's cuts to the TennCare program have caused other problems for Rahman's patients: Many of them now have no insurance at all.
"Many times, they will not come anymore" when they have medical needs, he said. "But I tell them, 'Money is not a problem. If you can't pay, just tell me.' And we will see them for free. Once they find out, they come. But sometimes it takes awhile … they are very independent.
"We have open access – anybody can come, even people with no insurance. If they can't pay, that's not a problem. That's the way a physician should be."
By now, Morgan said, Rahman has treated three or four generations of many families. He inspires fierce loyalty among his patients, some of whom panicked when the hospital moved to Lenoir City, thinking Rahman would follow. (He never considered it.)
Bowden, who works in a Loudon pediatrician's office, said her office often refers patients to Rahman when they age out of pediatrics. The atmosphere in his office, similar to that in her own office, helps ease the transition to an "adult doctor," she said.
"We get a relationship with our patients, you know, and (Rahman's employees) are kind of like we are," Bowden said. In fact, when her son, now 24, turned 19, "there was no question who he would go to. I felt like Dr. Rahman would take care of him just like the doctor I worked for did."
Above Rahman's office door is a wooden carving from Pakistan, Arabic letters calling the names of his God.
Most of his patients "had never seen a Muslim before," Rahman said. "They'd always hear from people or from the media what kind of people (Muslims) are, so when they do see us, they get confused. They don't know who to believe."
Loudon County's primary newspaper runs a full-page listing of local churches, six columns of tiny print. Five and a half columns list Baptist churches. No Islamic places of worship are listed.
Morgan, like most of Rahman's office staff and patients, is Baptist.
"We bring up religion," she said. "We can talk about anything."
"The ministers and pastors, they're my friends," Rahman said. "I have their Bible, and they have my Quran." And the friends often have discussions.
Rahman said some of his patients and friends pay attention when Pakistan is in the news and ask him questions.
And the question has to be asked: Being Muslim, was his family treated differently after 9/11?
Rahman paused, then smiled. "Better," he said.
Patients, neighbors and fellow physicians called to offer support. Local law enforcement personnel, many of whom also are patients, called to offer protection if needed. Rahman didn't need it. He couldn't name a single derogatory event, before or after the 2001 attacks on the World Trade Center and Pentagon.
"We just take care of each other in this community," he said.
Rahman's caricature is one of hundreds featuring locals on the wall of the downtown diner. His family's name often is in the local newspaper. A picture of his children is on the wall of the local ice cream parlor. He and Afshan have sat in the stands, cheering their neighbors' children along with their own, in various sporting events throughout the years.
But if the Rahmans are part of Loudon, that means part of Pakistan is in this small town, too.
Four years after moving to Loudon, the Rahmans built a home, a grand Tudor-style house on Fort Loudoun Lake. That's where they used furnishings, food and tradition to bring their homeland to their friends, neighbors and three children, now all young adults.
The Rahmans' older son, Ayaz, in medical school, was born in New Jersey but remembers no other home besides Loudon. Their daughter, Aisha, who just graduated from law school, was born in East Tennessee, as was their younger son, Haseeb, a college student in Missouri. They've been to Pakistan to visit only a few times; though the Rahmans still have friends and extended family there, their immediate families all have immigrated to the United States.
"My parents brought Pakistan to Loudon for us," Aisha Rahman said. "Our story is so steeped in Pakistani. They were there for the independence (of East Pakistan, now Bangladesh) and the breakoff from India. They lived through a (civil) war (the Indo-Pakistani War of 1971). It's very hard not to talk about that when your kids are growing up."
Rahman planned the house with a room designated for daily prayers, which family members who are home in Loudon do together. In the house, they speak only Urdu.
"In our house, me and Raza always want to have whatever we do like a tradition," Afshan Rahman said. So they surround themselves with relics from their home country and traditions like drinking hot tea in the mornings.
In the beginning, they might have clung to tradition to help stave off homesickness. Both Rahmans were the first in their families to immigrate. Afshan, especially, missed her mother and her younger siblings. She was just 19 when the couple, who had grown up in the same neighborhood, married. She was pregnant with their first child, in a strange country, by the next year. Telephone calls from the U.S. to Pakistan, Rahman remembered, were outrageous: You had to make a reservation, then pay more than $5 a minute.
But now, their traditions are a celebration of who they are, of how their own culture combines with the place that is home: Loudon. Loudon is where the Rahmans eat traditional Pakistani food at home – and serve it to friends who visit – but also fry okra and eat fried fish or pasta at local restaurants.
Loudon is where they wear traditional clothing to mosque and on special days, but wear Western clothing to the office or Wal-Mart.
Loudon is where they appreciate that this country's liberties afford the ability to hold on to their heritage while still becoming an integral part of the small-town community they love.
"Obviously, we're very American, and we're living the American dream, too," Aisha Rahman said. "This country was built on immigrants. It was built upon this idea of wanting something better but never forgetting where you're from. I hope that I can talk to my kids in our language, and I hope that they will learn that religion is very important to me. …
"But Loudon is home."
"This is home now," Afshan Rahman said. "God made us to end up in this place.
"Interested in a medical career in the beautiful mountains of East Tennessee?" asks the Web site of Claiborne County Hospital and Nursing Home in Tazewell.
Then it goes on to extol the "lifestyle advantages" of small-town living near Cumberland Gap. A county steeped in tradition, with numerous historic sites and activities. A moderate climate, with "four distinct and lovely seasons." Hiking, fishing and golf. Low cost of living.
And, though it's not explicit on the Web page, a desperate need for doctors, who will have all the work they need, all the challenges they want and near-celebrity status when they go to town.
Claiborne, like other rural counties in East Tennessee and the rest of the country, has faced an ongoing physician shortage. Countywide, there are only 20 doctors. Fifteen of them provide primary care, amounting to about one doctor for every 2,000 or so residents. There is one obstetrician/gynecologist. There are three pediatricians. The county hospital has three general surgeons on active staff.
In some ways, those numbers are an improvement, said Betsy Maples, the hospital's director of development. Ten years ago, the county had only one pediatrician and no ob/gyn.
But recruiting and retaining doctors to practice in the isolated county, 40 miles and about an hour from Knoxville, continues to be a challenge, said Maples, who was once director of economic and community development for Claiborne County.
"A couple of our physicians are nearing or already past retirement age," she said. "That will exacerbate the shortage."
Among the many hats Maples wears now is figuring out how to attract physicians. The Web site is one tool. Maples also applies for grants, runs advertisements in publications that medical students read and promises doctors who come to Claiborne County that they'll get small-town Southern hospitality: an appreciative patient base, a place on the hospital's medical staff, help finding housing or schooling for their children.
But it also made a big difference when the government declared Claiborne County a Health Professions Shortage Area. That allowed foreign-born doctors who were completing post-graduate education in the United States to choose to serve at least three years in Claiborne County instead of returning to their home countries for two years as per normal J-1 "exchange visitor" visa requirements. After those three years, they could practice anywhere in the U.S.
Today, about half of the physicians living and practicing in Claiborne County originally came from other countries.
In seven years at Multi-Specialty Medical PC, licensed practical nurse Debbie Sparks has seen doctors come and go.
There was Dr. Aurelia Radulescu, from Romania, who stayed about three years. Dr. Junaid Sultan, from Pakistan, stayed about a year. Dr. Mahmoud Farkhondeh, from Iran, stayed about a year before starting a pediatrics practice in adjacent Union County. Internist Dr. Cristian Speil, also from Romania, stayed about five years.
And then there's Dr. Brent Neal, born about 200 miles away in Covington, Ky., who went to medical school at East Tennessee State University's James H. Quillen College of Medicine in Johnson City. He practices with two doctors from Romania and two from the Philippines in Multi-Specialty Medical's unassuming brick building minutes from downtown Tazewell.
Sparks said Multi-Specialty Medical's patients like all of the doctors. At least one other Claiborne County practice has several foreign-born physicians, and some doctors who are originally from other countries have individual practices. If the people of Claiborne County, which is more than 98 percent Caucasian, have a problem with seeing foreign-educated doctors, they don't express it.
Moriah Honchell, 24, drives from Morristown to Multi-Specialty Medical, where her mother, grandmother and 5-year-old daughter also are patients. She switched several years ago from another practice in town because she was impressed with Speil's treatment of her grandmother. Speil also diagnosed her mother with diabetes, she said. She's just as happy with the current doctors.
"They've all been really good – very thorough," she said.
"The biggest concern (patients have) is whether they'll be able to understand what (the doctors) are saying, but we've not had any problem with that," said Sparks. No one questions their qualifications: "If you're a doctor, you're a doctor. And we need doctors."
It helps, she said, that Multi-Specialty Medical's physicians are "very friendly, and they seem to be well-educated. They're smart. … They're kind of like celebrities, in a way, because they go out, and everybody wants to speak to them."
When husband and wife Drs. Ryan Guanzon and Mariel Castillo-Guanzon moved to Claiborne County from Brooklyn, N.Y., in the spring of 2007, they knew they would turn heads. The Filipino couple practice internal medicine and pediatrics, respectively, at Multi-Specialty Medical.
"The people were pretty polite about it," Guanzon said. "It's just that, you see someone (who looks) different. It's not as though we felt that we were not welcome."
The Guanzons met after both had completed medical school in the Philippines and come to New York on J-1 visas for their internships and residencies. They married in 2005 after completing their education. Both knew they wanted to stay in America, so they began looking for an underserved community where they could practice together, waiving the J-1 requirement to return to the Philippines for two years.
They'd narrowed it down to Alaska; rural Louisiana; and Tazewell. Alaska was too isolated, and in Louisiana, they'd be practicing in different places about a half-hour apart. Tazewell needed both an internist and a pediatrician.
The Guanzons found Tazewell friendlier, with a "slower pace of life" than the "rat race" of New York City, Guanzon said. Their son, now 10 months old, was born in East Tennessee; Guanzon's parents also live with them. (Castillo-Guanzon's family is still in Manila.) They've found a small number of Filipinos in surrounding areas, including some who travel to be the Guanzons' patients, and several Catholic churches they can attend.
"It's quiet and laid-back here," Castillo-Guanzon said.
"I love the fishing," her husband said.
Best of all, both feel they're practicing medicine in a place where they can really have an impact – unlike their native country, where doctors aren't given the resources or respect they have here.
"I knew I would be a better doctor if I came over here," said Guanzon, who decided by the end of elementary school that he would be a doctor. His wife chose her career in high school.
But if she were practicing in the Philippines, Castillo-Guanzon said, she'd most likely depend on her family financially. Doctors' salaries are low there compared to other professions, she said. Post-graduate education is trying, she said; older doctors look down on the younger ones and treat them as "work horses." Furthermore, American medical knowledge doesn't translate very well to the Philippines, where preventive medicine is almost nonexistent and resources are limited.
"Here, I can actually make my patients better," Guanzon said.
Guanzon estimated about 70 percent of the doctors he graduated with in Manila are now in the U.S. on J-1 visas, either in rural areas or completing their medical education.
"I know I'm part of the 'brain drain' that plagues my country, but I don't know how my government can expect me to stay, because after all of the sacrifices you make, after all of the training that you've been through, you cannot even feed your family with the salary they want to give us," he said. "I am not someone who's unpatriotic. I love my country. If I had the choice, I would live there. … They mock the doctors who come over here. They say we're unpatriotic, that we've left the poor people to suffer back home. But … I'm married. I have a family. Unfortunately, they come first."
And his classmates? "They want to stay, too," he said. "They want to practice the exceptional medicine we have here (in the U.S.) as long as they can."
Claiborne County provides a wealth of opportunity to practice medicine. A 1998 state Department of Health study indicated that almost half of residents had been diagnosed with diabetes. About 35 percent smoke; about 28 percent have high blood pressure. Heart disease and cancers are the top causes of death. Lung cancer and heart disease rates are much higher than the statewide average. And influenza/pneumonia is the fifth highest cause of death among all ages, implying patients have underlying health problems.
"They have a lot of problems," Guanzon said, "both health-wise, and their (personal) situations. Sometimes I have to get into both."
In Claiborne County, where the median household income was $25,782 at the last census, about a quarter of people live below the poverty level. It jumps to 30 percent among the elderly and families with children younger than 18.
Often, poverty breeds depression. Claiborne County's suicide rate was almost double that of the rest of the state when the 1998 study was done. Suicide is the second leading cause of death among county residents ages 25-44 and the fifth among those 15-24. Yet, just as there are shortages of other medical specialties, there aren't enough psychiatrists. Behavioral health services come mainly from surrounding counties, or from primary-care physicians.
"I believe in listening to patients," Guanzon said. "I try to empathize with their problems. The situation in a person's life changes how their perceive their health and how they tend to approach it."
But, as a matter of culture, some patients aren't receptive to a therapeutic approach to depression, he said. Their desire for a "quick fix" often leads them to use drugs to numb their psychological pain. There also exists a stigma against admitting to mental health problems.
"I always tell them, 'This is something common that I deal with every day, nothing to be ashamed of. And you can tell me everything, because this is a safe place to be. It's a doctor's office. I won't tell anyone about your problems,' " Guanzon said.
He won't turn his back on his patients who abuse drugs, a "very big problem in small-town America," he said. The only patients he's rejected are the few who displayed racism or disrespect.
"I don't fight with them, but I tell them I don't like what they're saying," he said. "And once I tell them, I can't see them again. My attitude toward them would be tainted."
As a pediatrician, Castillo-Guanzon hasn't experienced any negative reactions from patients.
"Maybe it's because the kids like me," she said, laughing. And then, more seriously, "If not (for me), (parents) would have to travel an hour just to see a pediatrician. They find it very easy and convenient to come here."
Claiborne County residents still travel to Knoxville or Morristown to see specialists, Maples said, though the county has had some success in finding solutions. For example, Knoxville's Vista Radiology and East Tennessee Heart Consultants both provide services to the hospital. And several physicians from University Health System and Mercy Health Partners in Knoxville have part-time offices in Claiborne County where they see patients a couple of days a week. Among them are a gastroenterologist, an ear-nose-and-throat specialist, and a neurologist. The county also has an oncologist now, she said.
"We have a real need for orthopedic surgeons in this area," Maples said. Though a local general surgeon does some orthopedic surgeries, younger doctors "tend to specialize," she said.
Maples and others are pinning hopes on Lincoln Memorial University's new Debusk College of Osteopathic Medicine, which will graduate its first class of 150 doctors in 2011. Osteopathic doctors – D.O.s – receive similar training and are licensed to do the same things as M.D.s but focus on preventive care and manipulation, using the hands to try to diagnose or heal the body.
Between 60 to 70 percent of D.O.s opt to practice primary care, and studies have shown they are most likely to practice within 75 miles of where they went to medical school. Claiborne County Hospital, in the same county as LMU's Harrogate campus, is one of several area facilities to work with students at the medical school.
The college's namesake, O.V. "Pete" DeBusk, has said it will attempt to recruit specifically students who intend to practice in this region. DeBusk is founder and CEO of Powell-based DeRoyal, an international manufacturer of medical products and supplies with a large plant in New Tazewell.
"There's a tremendous need in the Appalachian area for medical care," DeBusk said last year. "It is an area that has been underserved for decades. There's a big void, and we've got a doctor population that's aging."
A consultant who did a medical staff development plan for the hospital last month said there will be continue to be a need to recruit both primary-care and specialty physicians to the county, Maples said.
"You just have to find the right person," she said. "If people are looking for a big city, this probably isn't where they want to be. But if you find people who have families and want to raise their children up in a small-town environment and like the outdoors, we have the national park 15 minutes from here, and we have tons of lakes."
Some, such as India-born Dr. Jaykrisna Patel, who has been in Claiborne County about 30 years and mentors J-1 physicians, like it enough to make a life there. Others fill the county's health care needs for at least some period of time. Maples said the community is thankful for both.
"Everyone in this community recognizes the need for physicians," she said.
The Guanzons aren't yet sure whether, when their J-1 visa waiver obligation is up, they'll stay in Tazewell or move on. They really aren't thinking about it yet.
"I'm very satisfied with practicing here," Guanzon said. "I try to bring the best medicine that I know to the people here, because I think they deserve it. I think everyone deserves the best from their doctors."
Health writer Kristi L. Nelson may be reached at 865-342-6434.