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Academic Medicine:
doi: 10.1097/ACM.0b013e3181d2ad1d
Workforce

Retention of J-1 Visa Waiver Program Physicians in Washington State's Health Professional Shortage Areas

Kahn, Talia R.; Hagopian, Amy PhD, MHA, MPH; Johnson, Karin PhD, MPH

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Author Information

Ms. Kahn is a medical student, University of Washington, Seattle, Washington.

Dr. Hagopian is assistant professor, Department of Global Health, University of Washington, Seattle, Washington.

Dr. Johnson is research review analyst, Group Health, Seattle, Washington; when this research began, she was a research scientist, University of Washington, Seattle, Washington.

Correspondence should be addressed to Ms. Kahn, c/o HAI at the Department of Global Health, University of Washington, Box 354809, Seattle, WA 98105; telephone: (425) 444-5818; fax: (206) 685-4184; e-mail: kahnt@u.washington.edu.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text and PDF of this article on the journal's Web site www.academicmedicine.org.

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Abstract

Purpose: To determine whether the Conrad Program, which allows states to recruit 30 foreign-trained physicians per year to work in underserved settings, is meeting its goal of increasing the number of physicians in Washington State's underserved areas. Participating physicians have completed their residency training in, and want to continue residing in, the United States.

Method: The authors identified all J-1 visa waiver physicians assigned to employers in Washington between 1995 and 2003, tracked them (whenever possible) through public databases to their current locations, and surveyed them about their experiences in, and subsequent to, the program.

Results: The authors tracked 141 of 155 physicians (91%). Of those 141, 77 (55%) responded to the survey. These respondents reported that they remained with their J-1 waiver employers a median of 23 (range: 0–120) months longer than their required commitment periods and that they remained in practices serving primarily underserved populations for, on average, 34 (0–120) consecutive months after fulfilling their commitments. After leaving J-1 waiver employers, 35 of 47 physicians (74%) who served in rural areas moved toward more urban areas, and 57% (80/141) still live in the state. Whereas most expressed satisfaction with the program, 29/77 (38%) felt employers should have shown them more respect.

Conclusions: In Washington State, the Conrad Program has increased the number of physicians in underserved areas who frequently stay beyond their obligations. The significant movement away from rural areas for postobligation employment, however, highlights the long-term need to continue state efforts to recruit physicians to these areas.

After years of debate over whether the United States can expect a physician shortage or surplus, the current consensus is that the United States must expand its domestic production of medical graduates by up to 100,000 new doctors if there is any hope of keeping up with demand for care.1–5 Although U.S. medical schools have recently expanded their capacity to train a modestly larger number of new physicians, this number is not likely to keep pace with demand (especially if the much-anticipated political initiative to expand access to care for America's 50 million uninsured is successful6). Therefore, the United States will likely continue to maintain its long-standing reliance on physicians trained abroad who, according to estimates, now compose about 25% of the U.S. physician workforce.7

The unequal physician distribution pattern in the United States is also a long-standing phenomenon. Many rural and inner-city areas struggle to attract sufficient numbers of health care workers despite the abundance of specialists in suburban and more affluent locales.8

U.S. policy toward foreign-trained physicians, most of whom are from lower-income countries,7 has been quite friendly as some evidence suggests that international medical graduates (IMGs) fill gaps in the U.S. physician workforce, and may marginally improve care for underserved populations.9,10 One expression of the friendliness of U.S. policy toward physicians from abroad is the high number of residency training positions, which is deliberately far greater than the number of U.S. medical school graduates (one recent estimate is that residency slots exceed medical school slots by 30%).11 Not only is this number unlikely to decline, but several members of Congress have made calls to increase the number extensively.12,13

To enroll in a U.S. residency training program, IMGs must obtain a work or training visa. In general, IMGs secure either an H-1B (work) or J-1 (training) visa. With the H-1B visa, physicians have the ability to pursue permanent immigration status immediately after completing their training. Despite being more costly, requiring more processing time, and leaving physicians' dependents ineligible to work, this visa is becoming increasingly popular.11,14 In contrast, the J-1 visa is cheaper, quicker to obtain, and allows dependents to pursue work in the United States, but it does entail a “return-home” clause that requires holders to return to their home countries on completion of training and remain away from the United States for at least two years before returning to pursue more permanent immigration status.15 J-1 visa holders are in good standing as long as they are duly enrolled in their training programs, typically three to five years.

One way around the two-year return-home requirement is for IMGs to agree to serve in an officially designated rural or urban underserved area in exchange for a “J-1 visa waiver.” The federal government has developed a system to identify areas of greatest need; these are called Medically Underserved Areas and Health Professional Shortage Areas (HPSAs). The definitions of these are based on a combination of factors such as physician density, health outcome indicators, population poverty levels, and proportion of the population over age 65.16 Notably, but not surprisingly, living in HPSAs is associated with poorer health status.17

Under the 1994 Conrad J-1 Visa Waiver Program (updated and expanded in 2002; hereafter referred to as simply the Conrad Program), each participating state is allocated 30 visa waiver slots annually to administer through its state health department.7 After states recommend (to the U.S. State Department) physicians for visa waivers, these doctors are obligated to work for an approved J-1 waiver employer for the duration of their commitment period, which in Washington State is three years for primary care physicians and five years for specialists.

The Conrad Program is one of a number of state and federal programs designed to recruit and retain physicians to rural and inner-city urban practices. Others include scholarships, loan repayment, bonuses, tax incentives, and housing subsidies.18 In 2006, 24% of urban and 45% of rural community health center physicians in the United States were participating in one of these incentive programs.19

Numerous studies have examined retention of U.S. medical graduates in underserved practice recruitment programs,18,20–27 yet few have assessed the longevity of IMGs practicing in underserved areas via the Conrad Program.28 Crouse and Munson28 examined the retention of J-1 waiver physicians in rural Wisconsin, using a survey administered to the leaders of institutions where these physicians had worked. They found a correlation between the retention of J-1 waiver physicians and their effectiveness at integrating into these communities. However, because researchers were unable to contact the J-1 waiver physicians directly, they could not ascertain the physicians' own reasons for leaving their communities or the midrange and long-term effects of this program on retention in rural areas.

Retention of J-1 waiver physicians is difficult to study because no single federal agency is responsible for managing the Conrad Program, and because monitoring is not required of the states or of the three federal agencies that may also request waivers (i.e., Appalachian Regional Commission, Delta Regional Authority, Department of Health and Human Services). Despite this, 41 (85%) of the participating states and two of the federal agencies reported tracking J-1 waiver physicians between 2003 and 2005.15 Many require physicians and/or employers to submit at least annual written reports regarding the number of hours their J-1 waiver physicians work. Some states also monitor these physicians through phone calls and site visits; however, many report that funding and staffing constraints limit their ability to carry out sufficient monitoring of J-1 waiver physicians.15

One result of the lack of monitoring is concern about the integrity of the program. In 2003, a University of Washington study found that state health program administrators knew of J-1 waiver physicians who had experienced unfair working conditions and switches in job assignments, causing some of the physicians to leave their commitments early.2 In response to numerous reports in 2007 by the Las Vegas Sun citing similar abuses, Majority Leader Harry Reid of Nevada and Senator Kent Conrad of North Dakota called for a federal investigation of the program.29–34

The Washington State Department of Health administers a questionnaire to its J-1 waiver employers one year postobligation to assess physician retention. However, until this time no information existed about the long-term geographic and career trajectories of participants in Washington State's Conrad Program, some of whom have been working in the United States since 1995.

The purpose of our study was to locate the Washington State J-1 waiver physicians who were assigned to employers in the state between 1995 and 2003 and, where possible, to survey them about their experiences in the program and their geographic and career trajectories, with the aim of determining whether the program is meeting its goals.

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Method

With the assistance of the Washington State Department of Health Office of Community and Rural Health, we obtained data on 155 physicians who, sponsored by this department, began J-1 waiver assignments in Washington between 1995 and 2003. We chose this time period because it includes the initial year J-1 waiver physicians worked in Washington and because most participants who enrolled during this time period had completed their commitments by the time of our study (with the exception of four who had five-year commitments that began in late 2003). The data set included the J-1 waiver physicians' specialties, their medical school and residency training information, their J-1 waiver employers' names, and the terms of their employment contracts. We used online public physician databases to identify current U.S. work addresses for physicians who began J-1 visa waivers in Washington State between 1995 and 2003.

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Physician survey

The Washington State Institutional Review Board approved our survey, which consisted of 29 questions about physicians' experiences in the Conrad Program, their history of employment since completing J-1 waiver commitments, and the specifics of their current employment (See supplemental digital file, http://links.lww.com/ACADMED/A13). We asked physicians to rate their experiences as excellent, good, fair, or poor and to describe ways in which either the Washington State Department of Health or their J-1 waiver employers could have improved their experiences. The Department of Health sent a letter to all eligible physicians prior to our mailing the survey, announcing the study and allowing them to opt out. Nine asked to be excluded. Thereafter, we mailed a paper copy of the survey directly to the J-1 waiver physicians and provided them with the choice to respond via regular mail, electronically, or by telephone.

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Rural–urban analysis

Rural–Urban Commuting Area Codes (RUCAs) are a subcounty measure of rural/urban status, often used by health services researchers and employed to determine eligibility for federal programs.35 This taxonomy uses smaller census areas (rather than counties) and assesses interdependence based on commuting flows, thereby providing a more sensitive way of assessing rural/urban status than using larger county units.36

RUCAs classify the population density of settlements and towns, delineate the functional relationships between them, and assign them codes between 1.0 and 10.6 (higher numbers indicating increasing rurality). The RUCA scheme has 33 categories designed to be aggregated in various ways.35 For our purposes, we aggregated the codes into four groups: urban, large rural city/town, small rural town, and isolated small rural town.

Thus far, two versions of the code exist. We used ZIP code Version 1.11 of the RUCA Codes (based on 1998 Census commuting data and 1988 ZIP codes) to classify the addresses of all 155 J-1 waiver employers. We used the newer ZIP code Version 2.0 (based on 2000 Census commuting data and 2004 ZIP codes) to classify, with regard to urban and rural status, the current work addresses of the 127 physicians we located (we were unable to find current U.S. addresses for 14 J-1 waiver physicians and could not assign RUCA categories based on another 14 ZIP codes).

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Data analysis

We employed two separate data sets for our analysis. First, we used a data file from the Washington State Department of Health on all physicians who began J-1 waivers in Washington State between 1995 and 2003 (N = 155). To these data, we appended variables related to physicians' current locations, as determined from our online search. Secondarily, we collected data from physicians who responded to our survey, although, of course, this data set represented only a subset of the total physicians in the study (n = 77). We averaged the RUCA scores to compare the average pre- and postobligation period rural status of the 127 J-1 waiver physicians on whom we had complete data, and we made comparisons using t tests and chi-square analyses. We used linear and logistic regression to identify independent variables from both the original data set as well as the survey data that correlated with retention. We used Kaplan–Meier survival analysis to portray physician retention over time. We conducted statistical analyses using SPSS Version 16.0 (SPSS, Chicago, Illinois). We present data as means or medians along with range. We considered a P value ≤.05 to be significant.

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Results

The Washington State Department of Health maintained data on all 155 physicians who began J-1 waivers in Washington State between 1995 and 2003. Of these, we located current U.S. work addresses for 141 physicians and mailed surveys to them. Of 141 physicians, 77 (55%) physicians responded, which is fairly typical for surveys of this nature.37,38 Table 1 compares their characteristics and those of the 78 nonresponding physicians who had participated in the state's Conrad Program. We presumed nonrespondents either did not receive our request to participate (perhaps because they were not in the country) or declined to participate because they were uninterested or felt no urgent need to report their experiences.

Table 1
Table 1
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Physicians in the state data set (N = 155) were primarily male (n = 126, 81%) and of Asian descent (n = 89, 57%), and about two-thirds (n = 105, 68%) practiced primary care. We found very few differences between respondents and nonrespondents on the variables we could compare; however, respondents to our survey (n = 77) were more likely to be from Latin America and to be currently working for their J-1 waiver employers (P < .05) than were nonrespondents.

Notably, a full quarter (n = 21; 27%) of our survey respondents began their J-1 waiver period in 2003 (Table 1), but only eight survey respondents (10%) who began waivers that year had five-year commitments, and only four survey respondents (5%) were still completing their obligations at the time they received the survey. We excluded these four survey respondents from the analysis of retention and migration; however, we did include their responses in the analysis of physician satisfaction and the overall state of Washington's Conrad Program.

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Retention in underserved areas

About half of survey respondents (39/77; 51%) characterized their current practice as serving primarily low-income populations. Respondents remained in underserved areas for a median of 26 and a mean of 34 months (range: 0–120 months) after completing their obligations. More than two-thirds of respondents (n = 54; 70%) said they had spent more than half of their time since completing their obligations working with primarily underserved populations. Logistic regression failed to identify factors other than retention in Washington State that correlated with whether physicians would spend at least half of their time, after completing their obligations, serving primarily underserved populations. The other factors we included in this analysis were the physicians' ratings of their experiences in the program, their salaries, their generalist versus specialist status, their nationality, and their age.

Figure 1 illustrates the “survival time” for serving underserved populations and compares J-1 waiver physicians currently working in Washington State (n = 46) with those working elsewhere in the United States (n = 26). Physicians who remained in Washington after completing their commitment seemed to be more likely than those who left Washington to continue working in practices that served primarily underserved populations.

Figure 1
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Chi-square analysis showed that respondents who remained in Washington State were more likely to have spent at least half of their time since completing their J-1 waiver obligations serving primarily underserved populations, compared with physicians who left Washington (P < .05).

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Retention with J-1 waiver employers

Of the 141 Washington J-1 waiver physicians we tracked, 32 (23%) are still working for their assigned J-1 waiver employers. Of the 77 survey respondents who had completed their commitments, 65 (84%) remained with their waiver employers longer than their commitments required. These physicians stayed for a median of 23 and a mean of 25 months (range: 0–120) longer than their obligation periods. Linear regression did not identify any of our measured factors as being correlated with how long physicians would stay with their waiver employers after completing their obligations. Other factors we studied in this analysis comprised physician salary, generalist versus specialist status, nationality, and age.

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Retention in Washington State

Of the 1995–2003 Washington State J-1 waiver physicians we tracked, 80 of 141 (57%) were still living in the state at the time of our study. However, only 37% of Latin American physicians (10 of 27) were still in the state, significantly fewer than those of other origins (P < .05). To illustrate, 73% and 57% of European and Asian physicians (19 of 26 and 51 of 89), respectively, were still living in Washington State. Logistic regression analysis failed to identify any factors, other than being from Latin America or Europe, that correlated with whether a J-1 physician was still practicing in Washington State. The other factors we included in this analysis were the physicians' ratings of their experiences in the program, and their salaries, generalist versus specialist status, nationality, and age.

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Rural–urban analysis

During the J-1 waiver period, approximately two-thirds of physicians (80/127; 63%) were based in urban communities. Of the remaining 47 physicians who completed their obligations in rural areas, 22 (47%) practiced in large rural cities/towns, 15 (32%) practiced in small rural towns, and 10 (21%) practiced in isolated small rural towns. After completion of the obligation period, however, 115 (91%) of the 127 J-1 physicians we tracked practiced in urban areas.

The average 10-point scale RUCA rating for original J-1 waiver locations was 3.02 (where higher numbers indicate more rurality), whereas the average current employment RUCA category was 1.51. We conclude, therefore, that physicians have moved toward more urban areas (P < .001). Of the 80 physicians who began their waivers in urban areas, none moved to rural areas, and of the 47 physicians who undertook their periods of service in rural areas, 35 (74%) moved to urban areas (Figure 2).

Figure 2
Figure 2
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Satisfaction with J-1 waiver employment

Of the 77 survey respondents, 56 (73%) rated their waiver experiences as good or excellent, and the remainder (21, 27%) rated them as either fair or poor. Logistic regression analysis failed to identify any factors, other than being a primary care physician, that correlated with whether a physician was satisfied with his or her experience. Other factors we analyzed were the length of physicians' J-1 waiver commitments, salary, current practice location, nationality, and whether on-call hours were required by contract.

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Physician concerns about the Conrad Program

In response to an open-ended question on why respondents may have left or changed J-1 waiver employers before the completion of the statutory obligation period, 8 of the 13 (62%) respondents who changed employers pointed to exploitive or disreputable employers; the remainder were making adjustments to better fit family or professional goals.

In response to another open-ended question, physicians provided their reasons for staying at their current jobs. Of 70 respondents, 15 (21%) named professional reasons and 8 (11%) cited some preference for the size or nature of the community, although 12 (17%) also specifically said they liked their current employer or coworkers for a variety of reasons. Twelve respondents (17%) cited issues related to family as their reason for staying in their current job. Only four (6%) said they liked serving an underserved population.

In an open-ended question regarding what J-1 waiver employers could have done to improve the physicians' experiences, 23 of 60 respondents (38%) said they felt employers could have shown more respect (e.g., treating them in the same manner that they treated their nonwaiver employees), offered specific supports (such as legal help with visa applications), or offered more appropriate compensation (e.g., more competitive salaries based on the going market rate).

In an open-ended question, respondents provided several suggestions for ways in which Washington State could improve its management of the Conrad Program. The most prevalent was to more vigilantly monitor exploitive employers for practices such as low pay, long call hours, and unfair contracts (e.g., postobligation, noncompete clauses, which restrict physicians' rights to open practices in the same underserved area upon completion of their obligations). Related to this, respondents suggested the establishment of a more formal grievance process. Other suggestions included streamlining paperwork, offering to help physicians who pursue Green Cards (for permanent resident status) while simultaneously completing visa-waiver service, reducing specialty commitments to three years (from the current five), allowing the opportunity to change employers more easily when situations are poor, and conducting interviews with physicians when they complete their commitments. That said, there were 18 specific references to Washington State's Department of Health staff as helpful and responsive.

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Discussion and Conclusions

The objectives of Washington State's Conrad Program are threefold: (1) to increase the availability of physician services in designated underserved areas, (2) to increase access to primary care physicians, and (3) to serve Washington State communities who have stated a preference for a J-1 visa physician candidate.39 Our study found that Washington State's Conrad Program is meeting its objectives both in the short and long term, although the significant migration of postobligation physicians away from rural areas is worrisome. J-1 waiver physicians are remaining with their waiver employers, on average, 25 months longer than their commitment periods. Further, as self-reported in our study, they are remaining in practices that serve primarily underserved populations for an average of 34 consecutive months after fulfilling their commitment periods.

J-1 waiver physicians committed to serve in HPSAs are in ideal positions to expedite their progress toward permanent residence in the United States by meeting the U.S. Department of Labor's labor certification requirements for Green Card applications. After working in an HPSA for an aggregate of five years, applicants may demonstrate that it is a matter of public interest that they be granted permanent residence on what is called a “National Interest Waiver Green Card.”40 Although we did not specifically ask physicians to provide their reasons for remaining in underserved practices past their obligation periods, the fact that the average number of months physicians stayed with their J-1 waiver employers or in underserved areas after completing their obligations was approximately two years could indicate that many physicians may have remained in these areas to meet the Green Card requirements for permanent immigration status. The open-ended comments from some respondents who specifically referenced the expedited Green Card further support this theory, but more qualitative research is needed to fully understand the extent to which permanent residency is an incentive.

Although 57% of Washington State J-1 waiver physicians who began their commitments between 1995 and 2003 are still living in the state, only 37% of the Latin American physicians who were granted waivers are still working there. Almost half (48%) of Latin American physicians (n = 18) originally assigned to Washington State have relocated to Texas or Florida, and many who responded to the survey stated their reason for doing so was to be closer to their home countries. Waiver programs are limited to 30 physicians per year per state, and some large states, like Texas, fill their slots more quickly. It is, therefore, possible that some physicians who would prefer assignment to a large state with more Hispanic residents unwillingly end up in Washington (Jennell Prentice, Conrad Program Manager, Office of Community and Rural Health, Washington State Department of Health, Interview, July 23, 2008). Allotting larger states more physicians to fill their greater need and providing physicians more choice about initial state assignments could improve retention, although not without other consequences (e.g., hindering the less desirable states from filling their J-1 waiver positions).

Significant numbers of J-1 waiver physicians moved closer to more urban areas after completing their obligations. We presume the reasons for the migration of these physicians are similar to those of physicians generally: limited opportunities for professional and educational growth, frustration with the lack of cooperation among major health care providers, long hours, frequent on-call shifts, and insufficient time off work.41–44 However, this immigrant population may also have religious or cultural needs that rural communities are less able to meet.28

Our survey did not include specific questions about community-related factors that influence retention. However, open-ended responses to our survey indicate that preference for the size or nature of the community causes some physicians to stay in rural and underserved areas. As with any successful rural/underserved recruiting strategy, employee recruitment should target individuals who are likely to be happy in a particular geographic area.

More than half the physicians who did not remain with their first waiver employers cited, as the main reason they left, problems with those employers including unequal treatment and financial troubles. These physicians recommended that the Washington State Department of Health monitor exploitive employers and/or administer exit interviews of physicians to improve satisfaction and reduce turnover. Physician satisfaction with their employment situations could also improve patient care.45 Respondents expressed the importance of establishing the Washington State Department of Health as a physician ally, since many physicians may be fearful of reporting maltreatment, particularly as immigration policy has become more restrictive since 2001.7

There are some limitations to our study. The survey data represent only a subset of the physicians who began J-1 visa waivers in Washington State between 1995 and 2003. Further, survey respondents were more likely than nonrespondents to be currently working for their J-1 waiver employers. Therefore, data on retention with J-1 waiver employers in underserved areas may be artificially inflated. In addition, we were able to track only 91% of physicians to addresses within the United States, and we are, therefore, unable to provide information or draw conclusions about the 14 remaining physicians, some of whom may have returned to their home countries after completing their obligations. Further, we provided our respondents with no definition of “underserved populations,” so survey data on retention in practices serving primarily underserved populations are based on respondents' own definitions, which are unlikely to be consistent across survey respondents. Although this study did indirectly obtain information regarding physicians' reasons for staying with or leaving their J-1 waiver employers, future studies may seek to more definitively characterize the factors that determine these patterns. Moreover, direct interviews with physicians may yield richer data. Finally, as this study is limited to physicians who began waivers only in Washington State, generalizability to other states may be limited.

The results of this study suggest that Washington State's Conrad Program is generally meeting its goals. The significant movement away from rural areas for postobligation employment, however, requires the state to continually refill rural physician practices. Additionally, although the Washington State Department of Health does track physician location throughout their commitment periods, it does not monitor physician satisfaction during their employment situations. Based on the results of this study, we conclude that annual satisfaction surveys and exit interviews may be useful in reducing employer misconduct. However, immigrants can be expected to be reluctant to report abuses unless the Department of Health can guarantee immigration status protections. Our findings, combined with reports by others,7,29–34 suggest that the Conrad Program should consider ways to protect IMGs in the program from exploitation by unscrupulous employers.

While the Conrad Program is, for the moment, helping to fill the need in HPSAs, the growing trend toward temporary IMG employment visas (the H series) may portend a reduction in J-1 visa holders. Because fewer H-visa holders (than J-1 visa holders) are required to work in HPSAs,46 an increase in the number of rural counties becoming underserved or becoming more underserved is likely as more IMGs migrate toward urban areas and fewer IMGs apply for waivers to fill their vacancies. The Washington State Department of Health should be aware of, and prepare for, this probability.

Finally, in 2007, Senator Edward Kennedy of Massachusetts and Senator Arlen Specter of Pennsylvania proposed a program to expand the Conrad Program by allowing states that had granted all 30 waivers in that fiscal year, and yet filled fewer than 20% of their needed HPSA positions, to increase their waivers from 30 to 50.47 Before committing to expand this program, however, we caution policy makers to consider the global impact of draining an already limited physician workforce from poor countries.2,4 Expansion of other physician relocation incentive programs aimed at creating incentives for U.S. medical graduates to locate their practices in high-need areas, such as the National Health Service Corps, may be an excellent alternative to an expansion of the Conrad Program.

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Acknowledgments:

The authors would like to thank Gary Hart who was the original principal investigator on this project, and Emily Kaltenbach, who helped with early data collection from the Washington State Department of Health. They would also like to recognize Mark Doescher and the support of the University of Washington Rural Health Research Center, as well as the staff and leadership at Health Alliance International. Finally, the authors would like to thank Jennell Prentice and Juno Whittaker at the Washington State Department of Health Office of Community and Rural Health without whom this research would not have been possible.

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Funding/Support:

This study was made possible by a grant from the University of Washington Medical Student Research Training Program and the support of Peter House at the University of Washington Family Medicine Research Section.

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Other disclosures:

This study began in the University of Washington Center for Health Workforce Studies, funded by the U.S. Health Resources and Services Administration's Bureau of Health Professions, Center for Health Workforce Analysis, grant #6 U79 HP 00003-04.

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Ethical approval:

The Washington State institutional review board approved this study.

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Previous presentations:

The results of this study were presented on January 30, 2009, at the Western Regional Meeting of the American Federation for Medical Research, Carmel, California.

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