LACK OF LATINO DOCS IS BAD MEDICINE
Shortage could prove dire to health of fastest-growing U.S. demographic
SAN ANTONIO — As she walked into a medical school retreat in Bandera, one of Brianna Bal’s first thoughts was that she “didn’t really look like everybody else.”
Many of the UT Health San Antonio students were white, and she learned during the orientation that many were following in their parents’ footsteps by going into medicine.
Not Bal. She was the first in her family to graduate from college — the University of Texas at San Antonio.
Her mother is Mexican American, her father is from Turkey, and she grew up on the city’s West Side.
Chatting with her future classmates, she was hit by self-doubt.
She recognizes it now as what is sometimes called impostor syndrome — a phenomenon in which a person has feelings of inadequacy or failure despite experiencing success.
Yet the Spanish she learned as a child, she believes, has made her a better doctor. Her understanding of the language, she said, gives her an advantage in a physician workforce that is still mostly white and non-Spanishspeaking.
The third-year medical student said she has treated Spanish-speaking patients throughout her early training. Speaking the language goes a long way toward establishing trust and, many times, led them to share a more complete medical history, which can result in better treatments.
Cultural connections between doctors and patients matter. African Americans and other minority groups in the U.S. experience more illness, worse outcomes and premature death compared with white patients, according to the Centers for Disease Control and Prevention.
The majority of physicians practicing in the U.S. — 56.2 percent— are white, and 17 percent are Asian, according to the Association of American Medical Colleges.
Currently, less than 6 percent of U.S. doctors identify as Hispanic or Latino, 5 percent are African American and one-third of 1 percent are Native American.
Minorities have historically been underrepresented in medicine, but the shortage is less dire in the San Antonio area.
In Bexar County, 66.2 percent of doctors are white, 22.5 percent Hispanic, 6.1 percent Asian and 3.1 percent black, according to the Bexar County Medical Society.
Nearly 64 percent of the county’s residents are Hispanic.
The U.S. Census Bureau projects that by 2044, more than half of Americans will belong to a minority group, which would make non-Hispanic whites the minority. In the next 40 years, the Hispanic population will grow from 18 percent to nearly one-third of the U.S. population.
David Hayes-Bautista, director of the Center for the Study of Latino Health and Culture at the University of California, Los Angeles, found the number of Latino physicians as a percentage of the population has declined.
Hayes-Bautista and his colleagues reviewed census data since 1980 and published a study in 2015 on the shrinking Latino physician workforce.
In 1980, there were 9.2 Latino medical residents per 100,000 Latinos in Texas. In 2017, the rate dipped to 8.2.
California has a worse shortage. Its medical schools admit and graduate so few Latinos that researchers say it would take 500 years to train enough Latino physicians to meet the needs of Latino patients.
Hayes-Bautista blamed policy decisions in the 1980s and 1990s that reduced the number of residency slots because of a once-predicted physician surplus. The result was that California essentially squeezed out international medical school graduates from its physician workforce, he said.
“We’re living now in the aftermath of that disastrous decision,” Hayes-Bautista said.
Every state has its own story. In Texas, he said, the Latino physician shortage isn’t as bad partly because segregation was more overt and the thinking decades ago was that Mexican Americans need their own doctors.
“There was more of an investment in training Latino physicians and pharmacists,” he said.
Despite that history, Dr. Laura Dominguez, an otolaryngology professor at UT Health San Antonio, can easily count the number of Hispanic faculty members in her department.
Three of 24 faculty members identify as Latinas. Half of her department colleagues are women, but she said that’s unusual for the subspecialty of surgeons who treat ear, neck and throat conditions.
She is one of few Latinas in this highly competitive medical field, one that requires a minimum five years of residency training after four years of medical school.
Disconnects and disparity
During a rotation at University Hospital, Bal recalled trying to explain a cultural nuance to her classmates.
The students were treating a pregnant patient, but they were confused about why her mother and grandmother were in the exam room, making it crowded.
Bal explained it’s not unusual in Latino communities for multiple generations of a family to take part in raising a child. That’s what she saw growing up in a close-knit family.
She doesn’t mind helping her classmates, she said, but sometimes she feels sapped.
Other medical students often try to pass Spanish-speaking patients to her, as she is one of the few students who speaks fluent Spanish. They want to avoid using a translator service, which can give way to miscommunication.
“It’s not that they don’t want to take the patient or that they’re lazy,” she said. “They just know that the patient will probably have a better experience.”
If physicians are unable to speak a patient’s primary language or navigate through cultural and social nuances, Hayes-Bautista said, they won’t be able to communicate effectively with patients.
He believes the shortage of Latino physicians will have dire consequences for the overall health of Latinos. His research shows that white doctors are also less likely to practice in areas where the need is the greatest.
Unconscious bias also affects the way doctors treat patients, according to a 2016 study by University of Virginia researchers. They found that among white medical trainees, half believed in myths, such as that black people have thicker skin or can tolerate more pain than white people. These misconceptions resulted in worse care for black patients.
Look at the soaring maternal mortality rate in the U.S., where, according to the CDC, the risk of pregnancy-related deaths for black women is three to four times higher than that of white women.
Or consider that U.S. Latinos face a staggering 142 percent projected rise in cancer cases by 2030, according to a new book, “Advancing the Science of Cancer in Latinos,” published in conjunction with an international conference held in San Antonio.
The researchers say this disparity stems from cultural barriers to care, low screening rates, underrepresentation in clinical studies and data that fail to reflect the population’s diversity.
Moving mountains
A breakdown of applicants to medical schools nationally in 2018 shows that 49.8 percent were white, 22.5 percent Asian, 7.3 percent black and 6.5 percent Hispanic, according to the Association of American Medical Colleges.
Chiquita A. Collins, UT Health San Antonio’s chief diversity officer, said the reasons for the lack of diversity in medicine are complex, requiring the students who make it to medical school to be resilient. Academic institutions should strive to make every student feel valued on campus, she said.
The Joe R. and Teresa Lozano Long School of Medicine at UT Health San Antonio is actually doing well. Hispanic students here make up 20.4 percent of the enrollment.
In Austin, at the new Dell Medical School at the University of Texas, enrollment data show 11 percent identify as Hispanic and 6 percent as black. At the University of Texas Medical Branch at Galveston School of Medicine, 18 percent of students are Hispanic. That number is 14.9 percent at the McGovern Medical School at the University of Texas Health Science Center at Houston.
The Long School of Medicine’s student body also differs significantly from other medical schools in the country, including Johns Hopkins in Baltimore, where only 8 percent of medical students are Hispanic.
Collins said medical schools need to put in the work to attract more diverse applicants.
“We can’t move mountains in a day — I know that,” she said.
She believes early exposure to science, technology, engineering and math will lead to more minority applicants to medical school.
The academic institution recently partnered with San Antonio ISD to open CAST Med High School, a charter school. It helps students from lower-income families and minority communities get an early start in the medical, biomedical research or public health fields.
“We need to expose kids to these kind of paths earlier. Third grade is really the tipping point,” Collins said.
Collins recalled being one of only two black students in the sociology graduate program at the University of Michigan. Before she found a mentor, she nearly quit to pursue a career as a flight attendant.
“Adversity doesn’t have to stop you. Sometimes it makes you stronger,” she said. “There’s truth to that.”
The right place
Bal was in the first class of an accelerated bachelor’s degree/medical doctorate program offered jointly by UTSA and UT Health San Antonio.
The pilot program aimed to reduce training from eight to seven years in an effort to increase the number of physicians in South Texas. But the program is under review and could be discontinued.
It was a good opportunity for Bal, who spent her summers during high school in the lab. She was one of hundreds of students who participated in UT Health’s college prep program, called Voelcker Biomedical Research Academy. She discovered during those summers that she’d rather work directly with patients than in a lab.
After UTSA, Bal started to get hands-on experience as a medical student working with patients. But she soon developed a serious illness, losing 30 pounds and vomiting as many as 15 times a day. She started to have difficulty walking.
The sudden sickness forced her to move back in with her parents and derailed her progress in school. She was devastated.
She was also lucky.
For six weeks, she was told her symptoms stemmed from stress. Finally, her primary care doctor did a spinal tap and found she had viral meningitis, a rare infection among healthy adults. By that point, her brain was swelling.
She recovered, but her vision, hearing and memory were damaged. But for an aspiring physician, she also had the valuable experience of being a patient facing a lifethreatening condition.
She returned to medical school, and one of her first patients was diagnosed with meningitis. “I thought, ‘I’m in the right place.’ ”
Bal, 24, is now working a rotation at University Hospital in the neonatal intensive care unit and will graduate in spring 2021, a year after she initially planned.
She learned her mother had turned down a full scholarship to a Northern college after receiving a letter saying she would be one of the few Hispanic students on campus. This was meant to encourage her. Instead, her mother stayed in San Antonio and went to community college.
“My parents always wanted me to have success,” Bal said. “My mother tells everybody, because she’s so proud, that I’m going to be a doctor. These are the things that keep me going when I’m up at 3 a.m. and it feels like everything’s working against me.”
Phillip Acosta, a second-year medical student from San Antonio, said joining the Latino Medical Association chapter on campus helped him find support.
“We try to help the first-year students balance their time so they don’t make the same mistakes we made,” he said.
A pile of debt
The affiliation has also saved him money. Medical students in the group study together and share academic resources, such as subscription access to medical journals that can cost up to $200 each.
The average debt incurred over four years of medical school is nearly $200,000, although tuition at UT Health San Antonio is considered affordable compared with most U.S. medical schools.
After they cross the stage, new physicians typically apply for a spot in a residency program, which is the next step toward working in the field and which takes three to five years, depending on the specialty.
Collins said pursuing medicine is an investment that few can afford without going into debt.
“Being a medical student is a fulltime job, so the cost of living is largely paid by loans,” she said.
A recent article in the New York Times highlighted that while preparing for a career in medicine is expensive for all students, hidden costs can be prohibitive for low-income students. Its conclusion: While U.S. medical schools are the training grounds for a white-collar, high-income industry, they select students from predominantly highincome, and typically white, households.
A recent study found that threequarters of U.S. medical students come from an affluent households, a rate that hasn’t budged since 1988.
There’s a lot of pressure not to fail, said Jaime Cruz, a second-year medical student from Dallas and a member of the Latino Medical Association at UT Health’s medical school.
“My family’s counting on me,” he said. “You don’t want to be seen as struggling.”