Over the past six years, independent Bristol Hospital has doubled down on recruiting medical providers — literally — growing the size of its core physician group to 63 doctors and 40 other licensed practitioners.
That hiring fits squarely into an industry-wide trend of medical providers shifting to hospital system-affiliated employment, either in hospitals themselves or in their ever-growing networks of off-site outpatient practices.
An estimated one-third of U.S. doctors are independent, down approximately 50 percent since the turn of the century, according to consulting giant Accenture.
For recruiters, it's a competitive market, particularly for primary care doctors and in-demand specialists, such as geriatric psychiatrists.
“You're forced to compete with a gazillion organizations,” said Bristol Hospital CEO Kurt Barwis, who added it can take years to fill a position with nearby competitors like Starling Physicians, Hartford Hospital and St. Francis Hospital and Medical Center — along with out-of-state providers — all wooing the same talent.
In addition to touting its community environment and the level of control group-practice physicians have over clinical activities, Bristol Multispecialty Group — the hospital's core group of employed doctors — has tried to gain a competitive edge by recruiting foreign-born physicians, despite complex immigration rules that make it difficult for immigrant doctors to work long term in the U.S.
Of the Multispeciality Group's current doc crop, a dozen are here on J-1 visas: A temporary visa that's common among foreign medical graduates who do their residencies in the U.S. and hope to make a career here.
Among those visa holders is Dr. Nandini Menon, a Canadian primary care physician who Bristol Multispecialty Group hired last year after she finished her post-grad medical training at St. Barnabas Hospital in The Bronx, following medical school on the Caribbean island of Dominica.
Menon said she was drawn to Bristol because it was able to secure crucial waivers for a number of J-1 doctors that allow them to remain in the U.S. longer, with a potential path toward permanent residency.
“Places say 'yes we can do J-1 waivers,' but the paperwork that goes into that and the knowledge required in getting that to actually happen are two very different things,” Menon said.
The so-called “Conrad 30” waivers — named for a former Congressman who pushed to create them in 1994 — allow foreign doctors to skip a requirement that they leave the U.S. for two years when their J-1 expires. In exchange, they agree to work for three years in a federally designated provider shortage area, after which point they can pursue a green card.
J-1 waivers have helped fuel Connecticut's relatively high number of foreign doctors. The state has the seventh-highest percentage of international medical school graduates (28.1 percent), according to 2014 data from the Association of American Medical Colleges. That's compared to a national median of 18.6 percent.
Barwis said trust plays a big role in the process, and the more experience a hospital has, the better chance it can land a recruit. J-1 visas are complicated and plenty can go wrong, so if a physician accepts a job offer from a hospital inexperienced with the program, their ability to remain in the United States is at stake, he said.
He also said he's been impressed with the caliber of foreign recruits.
Dr. Vanessa Malit, a surgeon who joined Bristol Multispecialty Group in 2014, agrees. She works closely with two Lebanese doctors at Bristol who took the J-1 immigration route. She said they have “extremely good skill sets.”
“Honestly I think the J-1 opportunities here have expanded our ability to recruit higher-quality physicians,” Malit said.
Supply and demand
The problem for hospitals trying to recruit foreign doctors is that Conrad 30, as its name implies, only allows 30 applications per year for the state.
The Department of Public Health, which facilitates the program for Connecticut, accepts applications on a first-come, first-serve basis, and like a rabid music fan sleeping outside to get concert tickets the next morning, Bristol Hospital has learned to have someone at or near the front of that line often.
Its legal team has also become well-versed with the intricacies of immigration rules, paperwork and deadlines.
Their strategy, however, may be in jeopardy. According to DPH, waiver applications have recently begun to exceed the cap for the first time since the state joined the Conrad 30 program in 2002.
It happened in 2015, when there were 34 applicants. In 2016, there were 36. And last year, 45 applied.
DPH says it's weighing whether to switch to a lottery system.
“The department recognizes the important role that all J-1 waiver visa holders play since they are required to provide services in medically underserved areas,” DPH spokeswoman Maura Downes said. “Unfortunately, there are only 30 slots allocated to Connecticut for this program.”
Karen Buckley, vice president of advocacy for the Connecticut Hospital Association, said the association has taken an interest in the topic.
“We are currently investigating how other states handle the J-1 visa issue and exploring options with staff from the Department of Public Health to potentially modify the system so that we can continue to recruit high-quality physicians for positions in Connecticut hospitals,” she said.
Barwis said he hopes the situation leads to Connecticut finding a way to get more foreign doctors hired in the state.
Doing so may take an act of Congress, according to DPH.
The timing is a bit precarious, given the political gridlock in Washington, D.C. on immigration reform.
It's unclear how the Trump administration might respond to a state wanting to import more physicians from other countries.
While Trump's “travel ban” last year (which appears headed to the Supreme Court) caused uncertainty for foreign doctors from Muslim-majority countries — and even stranded some overseas — Bristol Hospital did not see any major impacts, said Ed Henry, executive director of the Multispeciality Group.
Connecticut may need to convince a federal agency to sponsor additional spots, Barwis said. Some other states have found creative ways to bring in more foreign medical talent, such as Tennessee, he added.
Henry said the future growth of the group depends in part on the immigration situation.
“Certainly, being in an underserved area, the ability to recruit J-1 visa candidates is a help for us and a critical need and that should continue moving forward,” Henry said.