Physician, Remake Thyself

Dr. Jose Pineda spent nine years training to be an obstetrician in the Philippines.

But at age 41, he went back to school -- to be a nurse.

Pineda shut down his medical practice last February and moved to the United States. Now he works as a nurse at St. Mary Medical Center in Long Beach, trading his spot atop the medical hierarchy for money and the promise of a better future for his family.

“I am not planning for myself anymore,” said Pineda, who makes $50,000 a year -- four times what his physician’s salary was in the Philippines. “I am planning for my kids.”

Thousands of Philippine doctors are making the same career switch with the intention of making a country switch too. They are willing to take orders instead of give them and to provide care instead of cures, all to live in the United States.

Nurses are in such short supply here that hospitals are looking abroad to fill the gap -- offering record salaries and signing bonuses. And in the Philippines, economic malaise and political instability have many professionals planning to leave.

To become nurses in the U.S., Philippine doctors must pass the U.S. nursing exam. They tend to ace it.

First, however, they must earn nursing degrees. So several nursing schools in the Philippines have recently started fast-track degree programs for physicians. Pineda attended one with 109 other doctors, including his mentor, the man who had taught him how to do caesarean sections.

In this country, Pineda doesn’t deliver babies. He works on a telemetry ward, helping monitor seriously ill patients. On a recent day, he loaded intravenous fluids and typed patient data into a computer.

Dr. Alex Leung, a first-year resident, is one of the few people at St. Mary who knows his history.

“When I talk to Jose, I talk to him like he’s a doctor,” Leung said. “I tell him, ‘Don’t call me doctor.’ Because he knows more than I do.”

But Pineda has no illusions about his new role. At one point he turned to a psychiatrist hunched over a patient file.

“My name is Jose,” he said, introducing himself. “I am the nurse.”

Shortage of Doctors

The Philippines, which produces many more nurses than can be employed at home, has long been the biggest supplier of foreign-born nurses to the United States.

There is no such surplus of doctors, which raises concerns that the country could eventually face a shortage, especially in rural areas.

The exodus is likely to grow. So many doctors have taken up nursing that Philippine nursing students without MDs have complained that the curve is being driven up on the national exam, which they must pass to graduate.

Estimates of the numbers of physicians currently enrolled in nursing school there range from 2,000 to 4,000.

One study surveyed 113 of them last year. Only 6% considered nursing an interesting career, and 59% said it was degrading to become a nurse. More than three-fourths said money had driven their decisions.

The RN-MDs, as some call themselves, face a double culture shock. There is the adjustment of moving to the United States. But more difficult for most is the loss of professional stature.

More than a dozen Philippine nurse-doctors contacted for this story declined to be interviewed. Many have not even told their employers that they have medical degrees.

“We feel a lot of shame,” said 29-year-old Alberto del Pilar, who works the night shift at Western Medical Center in Anaheim for $26.22 an hour.

He remembers being ordered to wash the patients on his first day, in September.

“I never imagined myself ... changing someone’s diapers,” he said. “It is a real adjustment ... draining the urine from the urine bags, scratching their backs. Lots of patients like to be scratched.”

He wishes he could tell them, “Excuse me, sir. I didn’t go to school for 10 years to scratch a back.”

At home, he said, nurses tell complainers to quiet down; here, “the patient is boss.”

Del Pilar, in fact, started out in nursing school in the Philippines. But upon graduating, he went straight to medical school.

As he prepared to start a surgical residency, he noticed more and more advertisements seeking nurses in the United States. Suddenly he found himself pondering the possibility, and wondering if a career in his own country would ever afford him a house or a luxury car.

“Which am I going to choose: to be an RN in America or a surgeon in my own country?” Del Pilar asked his father, an engineer.

“He said, ‘Son, the opportunity is in America, not here in the Philippines.’ ”

Del Pilar has never told his American bosses that he is also a doctor. But a colleague, a friend from nursing school back home, spread the news.

In Del Pilar’s view, U.S. physicians rely too much on machines and lab tests rather than physical examination and intuition. He traces that tendency to doctors’ efforts to protect themselves from lawsuits and mistrustful insurers.

“It removes the art of medicine, the beauty of medicine,” he said. Compatriots express a similar concern: that physicians here don’t spend enough time with patients.

Del Pilar does not want to be a nurse forever. Most afternoons he can be found at Starbucks, keeping himself awake with double espressos while he studies for the U.S. medical boards in the hope of eventually practicing medicine in his new country.

Many new arrivals come with the same dream, though nursing has proved so lucrative -- and the path back to medicine so arduous -- that few are trying to realize that ambition.

Daunting Requirements

There are visas that allow foreign physicians to enroll in U.S. medical residency programs, a prerequisite to becoming full-fledged doctors here. But the obstacles to getting the necessary visas are many.

Seeking to keep salaries high, U.S. physicians have lobbied to keep foreign doctors out. Because the most desirable residencies are snatched up by graduates of U.S. medical schools, foreign-trained doctors often must accept assignments in the urban core. After completing their U.S. training, they are required to return to their home countries for at least two years, or to work in underserved areas, often far from most immigrant communities.

Dr. Aries Bajoyo, who attended medical school in the Philippines and did a residency in Elk City, Okla., in the mid-1990s, beat the odds. He practices medicine and remains in the United States on a temporary visa while he awaits a green card.

His advice to countrymen: “Come as a nurse.”

A nursing degree has long been the fastest way out of the Philippines.

Part of the U.S. colonial legacy is a medical system that mirrors that of the United States. Nurses are trained in English rather than Tagalog and use many of the same textbooks as U.S. schools.

Only 4% of the 2.2 million nurses in the United States are foreign-trained; Filipinos account for 43% of them.

As more nurses retire and fewer enter the field, the U.S. is on track to be 800,000 nurses short of its needs by 2020, according to a recent federal study. Recruitment of nurses abroad has become big business, particularly in California, where nearly a fourth of nurses have received their training overseas. And a state law that took effect this month mandates higher staffing levels, increasing the demand.

Newspaper advertisements in the Philippines tout high salaries and promise sponsorship for visas, flights to Guam to take the U.S. nursing boards and moving expenses. The process -- from nursing-school graduate in the Philippines to gainfully employed green-card holder in the United States -- takes one to two years.

U.S. hospitals pay recruiters as much as $10,000 per nurse. Doctors, once recruited, frequently save hospitals in training costs.

For example, preparing a nurse for the operating room normally takes three months.

“But if you get a surgeon ... training is shorter,” said Manuel Atienza, a Philippine doctor who runs a nurse recruiting business in Las Vegas and who estimates that he has placed 40 Philippine MDs in U.S. nursing jobs in the last three years.

But a good doctor does not always make a good nurse. Nurses may not be assigned to the specialties they mastered as doctors. And even if they are, their expertise is not always appreciated.

Over the last two years, Virginia Alinsao, director of international nursing recruitment at Johns Hopkins Hospital in Baltimore, has rejected all 50 or so applications from RN-MDs.

She worries that they would have trouble giving up their old authority and obeying orders.

“They passed a test and said, ‘Now I am a nurse. Sponsor me,’ ” said Alinsao, who makes frequent recruiting trips to the Philippines, where she was born. “Our answer is ‘no.’ ”

A Larger Crisis Feared

In the Philippines, the doctors most likely to turn to nursing are those in the shortest supply: government physicians in underserved areas.

The supply countrywide is already low. Some public health officials fear that the current flight presages a larger crisis.

In Negros Oriental Province, population 1.2 million, 10 doctors recently completed nursing school and left the country. They included the heads of pediatrics and internal medicine at the main government hospital.

Ely Villapando, the 62-year-old provincial health officer, has had trouble finding replacements for both, as well as for three others who recently retired.

About 230 doctors -- public and private -- remain in the province. But eight of them have already completed their nursing degrees. More worrisome to Villapando are the 36 MDs scheduled to graduate from nursing school in March, followed by 15 more in October.

Villapando is helping draft a proposal to increase salaries to stop doctors from leaving. He understands the draw of the United States, however. Two of his children are nurses here, though they are not MDs.

Recently he was traveling to the province by ferry when a few doctors he knew approached him with their good news: They had just passed the U.S. nursing exam, making them eligible to seek work in the United States.

“They were so happy,” Villapando said with resignation.

It is not that doctors in the Philippines lack prestige. People “look up to you. You are No. 1 after the parish priest,” said Larry Madarang, 48, a Philippine MD-RN. He has given up being a doctor for good and moved to Los Angeles, where he is working as an administrator for a nursing agency and preparing for the U.S. nursing boards.

But for many Filipinos who entered medical school with dreams of fruitful careers, practicing medicine never lived up to its promise. Government insurance workers and court clerks sometimes earn more.

Like many of his counterparts in the U.S., Madarang disparages the Philippines as increasingly impoverished and unstable. Many mention recent terrorist bombings by Islamic militants. But just as important in the decision to leave is a deeply entrenched belief that the surest way to improve your social status is to move to the United States.

“Sending home an appliance or cosmetics or food -- that is a form of prestige,” said Catherine Ceniza Choy, a history professor at the University of Minnesota who has chronicled the 20th century migration of Philippine nurses to the United States.

Pineda, the obstetrician-turned-nurse in Long Beach, admits that his standard of living was good in the Philippines. He owned two modest homes, one of which he rented out. He and his wife, who worked in a bank, employed a full-time housekeeper and a nanny for their three children.

But as the economy soured in the late 1990s, many patients switched to government hospitals offering free care. In an attempt to increase his income, Pineda opened two drug-testing labs, but he left the business, he said, when corrupt government officials demanded a share of his profits.

Pineda worried: “How was I going to put my kids through college?”

So he enrolled in a program that allowed MDs to get nursing degrees by taking night and weekend classes for 18 months.

By the time Pineda arrived in California, several doctors in his nursing class -- among them an anesthesiologist, a pediatrician, an ophthalmologist and an orthopedic surgeon -- had already been hired as nurses at St. Mary.

After he passed the U.S. nursing boards, a requirement for all nurses, the hospital sponsored him for a work visa and signed him on. Soon afterward he bought a three-bedroom house with a yard in Norwalk. His family arrived in October.

Still, there are problems. His 15-year-old daughter finds her public school too easy. Pineda and his wife feel lonely and miss their old neighborhood.

And nursing, for all the material advantages it brings, does not match the thrill of delivering babies.

“Seeing somebody coming to life as a new member of the human species -- it makes you feel you achieved something.”