Imagine going to a doctor who doesn't understand your language. You have to speak through an interpreter to describe your problems, give your medical history, and figure out what you're being told by the doctor. That's what 3 to 6 million working poor Latinos in California have to contend with — if they are lucky. Most don't have access to medical services; in impoverished rural areas, there is a dwindling supply of physicians, while in urban areas, few doctors accept MediCal, the state's Medicaid program, because of low payments.

According to the California Medical Association, the number of practicing physicians in California is shrinking. Citing Economedix figures based on 2000 census data, the CMA says California has only 38,900 full-time physicians engaged in patient care. That gives the state 110 physicians per 100,000 residents — 47th of the 50 states in physician supply.

Bram Briggance, associate director of the California Workforce Initiative at the University of California-San Francisco, disagrees with the CMA's numbers. A CWI report pegs the number of practicing physicians in California at 89,000, but Briggance agrees that there are areas with physician shortages. The real issue, he says, isn't aggregate numbers, but whether the right kinds of doctors are practicing where they're needed.

Culturally competent

Language isn't the only barrier to care for California's Spanish-speaking population. If a physician doesn't understand one's culture, even the best care is likely to miss the mark. For example, health problems are the province of the grandmother in the extended Latino family. A culturally competent physician includes the grandmother or the senior family member in the care plan.

Because they can't find linguistically and culturally competent physicians, some Latinos turn to illegal clinics where providers speak Spanish. Some patients have died after being treated by unlicensed and untrained providers.

During the 1999–2000 legislative session, Assembly Democrat Marco Antonio Firebaugh, who represents predominantly Latino central Los Angeles, introduced a bill that passed both houses and was signed by Gov. Gray Davis. The law created the Task Force on Culturally and Linguistically Competent Physicians and Dentists, whose members include the CMA, the California Dental Association (CDA), the California Medical Board, and the California Hispanic Health Care Association. The group will develop CME standards for cultural and linguistic competency.

A task force subcommittee studied the feasibility of a three-year project to bring 50 Mexican physicians and 20 dentists to underserved areas of California, to practice in not-for-profit community clinics. The proposal was introduced last February as AB 1045 by Firebaugh.

AB 1045 passed the Assembly in May and was referred to the Senate Business and Professions Committee, whose chairperson scheduled interim hearings in Mexico City this month and in Los Angeles next month. The CMA, the CDA, foreign dentists and physicians, and international medical graduates will testify.

The California Hispanic Health Care Association is AB 1045's sponsor. Executive Director Arnold Torres wants to help the medical establishment to determine how California physicians can do a better job of serving the 31 percent of California's population whose mother tongue is Spanish. "You're talking about a major redirection of medical schools, which should have been done long ago. That takes a phenomenal amount of resources that haven't been there for a long time."

Meanwhile, the frustrated Torres sees the unmet health needs of working poor Latinos. In Monterey County, the association's six clinics can't recruit enough primary care doctors, so they've had to hire locum tenens physicians, who cost much more but aren't so productive as staffers. Farm workers don't go to the clinics because the temporary physicians don't speak Spanish.

Practice requirements

To participate in AB 1045's program, Mexican physicians would have to be board-certified in Mexico in family practice, pediatrics, Ob/Gyn, or internal medicine; pass Parts 2 and 3 of the United States Medical Licensing Examination (USMLE); participate in a CME program after arriving; take English-language classes; and practice under a three-year temporary license.

Proponents see a viable short-term solution here, but opponents — including the CMA, the CDA, and the state medical board, say it could undermine quality of care. "We would be very concerned about establishing a limited license for a select few on a short-term basis for only the poorest of the poor," says Bob McElderry, the CMA's associate director of government relations. "That establishes a bad precedent and a two-tiered health care system that says, 'Because you're poor, you don't get a fully credentialed, licensed doctor.'"

Instead, the CMA recommended that the state medical board streamline the licensure process for Mexican physicians in the program; that they take the same exams as other medical graduates, though Part 1 of the USMLE could be taken in Spanish if the applicant passes an English proficiency exam; that physicians in the project fulfill the same residency requirements as other international graduates; and that California medical schools be encouraged to establish a supervised residency training program in the clinics.

The CMA's long-term recommendations include residency programs in underserved areas and a loan forgiveness program for service in underserved areas. McElderry agrees that California medical schools need to produce more physicians who reflect the state's diversity.

"The contours of this measure are still in flux," says Firebaugh. "We may set up a sister association with particular medical schools. Or we may do something in our own medical schools, which would not be a bad outcome."

--Bob Carlson

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