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Vital visas: ND has nation's highest reliance on foreign doctors with work visas

Dr. Fadel Nammour, originally of Lebanon, stands Monday, May 8, 2017, in his south Fargo clinic. He made a three-year commitment in 2002 to work in North Dakota and is now a U.S. citizen. Michael Vosburg / Forum News Service

FARGO—Dr. Fadel Nammour was warned against coming to North Dakota to begin his career as a gastroenterologist.

After attending medical school in his native Lebanon, Nammour came to the United States, where he received six years of training in Baltimore and Camden, N.J.

On the East Coast, he encountered bleak stereotypes about what life in North Dakota would be like.

"They don't have roads," he was warned. "It's gravel. They have the Badlands there. What are you getting yourself into?"

But Nammour quickly discovered modern, state-of-the-art medicine at Fargo's Essentia Health, where he pledged to work for three years under a work visa program to help areas experiencing physician shortages. Nammour ended up staying at Essentia for 11 years.

"I felt very welcome when I started here," he said Monday, May 8. His colleagues, the staff and patients all made him feel appreciated.

Then, four years ago, Nammour struck out on his own to start an independent practice here, Dakota Gastroenterology Clinic. Nammour, who is now a U.S. citizen and vice president of the North Dakota Medical Association, estimates he's one of about 400 foreign-educated doctors practicing in North Dakota.

In fact, North Dakota tops all states in its reliance upon foreign physicians who are in the United States under a work visa program that is under scrutiny in the debate about immigration policy.

In North Dakota, 75 physicians among 1,602 active state physicians were in the U.S. under a visa sponsored by their employer in 2016, according to figures from the U.S. Department of Labor compiled by the Journal of the American Medical Association.

Foreign physicians under the visa program comprised 4.68 percent of North Dakota's active patient care physicians, the highest rate in the nation, according to a ranking by the medical journal, which analyzed figures from the Office of Foreign Labor Certification.

In Minnesota, 202 physicians comprising 1.47 percent of all physicians were visa holders under the program. South Dakota had 37 physicians in the visa program, or 2 percent of active physicians.

Nationwide last year, 10,491 physicians from foreign countries who represented 1.4 percent of the active physician workforce were certified to work under the H-1B visa program, a temporary work program that allows foreigners to take positions employers say they couldn't otherwise fill. Nammour was able to work at Essentia under the program.

A 'vital part' of system

The program's critics contend that some employers have used the visa program to displace American workers, especially in the information technology field. But health providers, especially in underserved areas, have come to rely on foreign physicians because of the shortage of American doctors.

For instance, when Nammour arrived at Essentia in 2002, a colleague from India comprised the other half of a two-physician gastroenterology department, although an American-born physician had recently left.

"We were the only two for years," he said. A third physician from India later joined the department.

The authors of the JAMA article concluded that "the elimination, restriction, or modification of the H-1B program may affect hospitals and states that employ large numbers of visa holders."

"I share those concerns," said Courtney Koebele, executive director of the North Dakota Medical Association, which represents physicians. "They're a vital part of our health care system."

It wasn't a surprise to learn that North Dakota ranks high in its dependence on foreign doctors, she said, in a state that is heavily rural, where there is a chronic shortage of physicians.

"We have physician-recruitment issues in our state," Koebele said. "Undercutting this would really hurt our efforts."

Dr. James Volk, a senior executive vice president at Sanford Health, said more than 15 foreign physicians work at Sanford under the visa program. "It's probably 6 percent of our medical staff here in Fargo," he said. "It's a significant percentage."

Sanford relies on foreign physicians when it is otherwise unable to fill a position. "Recruiting in primary care is more difficult," Volk said.

Because of the shortage of physicians, Sanford's reliance on foreign physicians has been "fairly stable in recent years," he said.

"It is predicted to get worse, especially in primary care," Volk said.

At Essentia Health, foreign doctors have helped to fill specialty positions as well as primary care slots, said Kris Olson, vice president of physician and professional services.

Because of the paperwork involved, Essential hires foreign physicians under the work visa program sparingly, she said. "We feel we have a very conservative vetting process," Olson said.

Still, she added, "We do feel it's an important program." In some cases, without the program, "We wouldn't have a doc."

Between six and eight Essentia physicians in Fargo are visa holders, Olson said. For the entire Essentia system, which includes 17 hospitals and 69 clinics, 43 physicians are visa holders.

"If we didn't have these folks," Olson said, "we'd have gaps in care."

Besides becoming a U.S. citizen, Nammour married a native of Moorhead, and they have three sons. Originally he never expected to stay beyond his initial three-year commitment under the work visa program.

Patrick Springer

Patrick Springer first joined the reporting staff of The Forum in 1985. He can be reached by calling 701-241-5522. Have a comment to share about a story? Letters to the editor should include author’s name, address and phone number. Generally, letters should be no longer than 250 words. All letters are subject to editing. Send to

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