As the U.S. population becomes increasingly diverse, foreign-born doctors, nurses and associated care givers are essential to address the needs of growing immigrant communities. Michelle Anne Bholat, MD (RES ’95, FEL ’96), MPH, and her colleagues in UCLA’s International Medical Graduate Program are working at the intersection of immigration and health care to train the next generation of providers.
Immigration is changing the face of American health care. This is especially true in California, where more than a quarter of residents were born outside the United States. While public attention tends to focus on the challenges of such demographic change, Michelle Anne Bholat, MD (RES ’95, FEL ’96), MPH, executive vice chair of the Department of Family Medicine, prefers to talk about “solutions and contributions — ways in which immigrants are strengthening the health care system.” “International providers — including physicians, nurses and home health aides — are a great resource for this nation,” says Dr. Bholat, who also is executive director and cofounder of UCLA’s International Medical Graduate (IMG) Program, which has the goal of helping doctors from Spanish-speaking countries to obtain their medical license to practice in California and provide care in medically underserved communities. “They bring language and cultural diversity, as well as different perspectives that lead to better treatment, not just for immigrant patients, but also for all patients” in often overlooked areas of the state. Dr. Bholat spoke with U Magazine contributor Karen Stevens about “immigration’s beneficial impact on health care” and “keys to serving a diverse community.”
Dr. Michelle Anne Bholat: They are filling a great need that will keep growing as the population ages. Nationwide, they make up about one-sixth of medical professionals. The numbers are even higher in California. In 2017, they made up 36 percent of physicians, 35 percent of registered nurses and 42 percent of nursing, psychiatric and home health aides. Even with such a strong presence, we have to raise representation in certain areas. One reason we started the IMG program is that we realized 38-to-39 percent of California’s population is Hispanic, but the percentage of Hispanic physicians in California is small; it is now about 6 percent.
Dr. Bholat: It improves outcomes and helps reduce errors of communication and misdiagnoses. It also helps patients feel more at ease and may encourage them to give more information and to follow their treatment plan. One thing we have come to emphasize in the relationship between the patient and the health care provider is health literacy, which means giving context, not just terminology. We want patients to understand what is going on. It really is about communication, and that involves more than just language. We can hire health care providers who speak Spanish, or we can teach them to speak Spanish, but that’s not everything. We also must find the best method to communicate with each patient. It has to go in both directions — we don’t want anyone to feel confused or degraded. Often, for instance, a patient will try to respond in English, but it is difficult for them, and that won’t provide us, as physicians and health care providers, with the best information to assess their needs and provide the right help.
Of course, with so many different languages spoken in Los Angeles, and throughout California, we may not always have the right fit in terms of someone who can translate. We may have a Spanish-speaking patient or one who speaks Tagalog or Russian. So, we have to try to be aware of how people are feeling. I remember a Chinese couple for whom we had a Mandarin translator, but both the patient and his wife were looking quite quizzical, and I could tell something was wrong. We switched to a Cantonese translator, and the couple’s expressions immediately changed to relief.
Dr. Bholat: Knowing a patient’s culture helps us increase compliance and decrease emergency room visits. It also gives us the opportunity to provide the patient better quality of care and for them to have a better quality of life. I recall one woman who came in with a horrible infection. She was undocumented and had undiagnosed diabetes — she had no idea she had it. Every time the nurse was going to give her insulin, the family said, “No, it’s very dangerous.”
Fortunately, I know that in Mexico there are certain cultural beliefs about insulin, so we were able to address those and make her comfortable enough to take it. Sometimes, families have many decision-makers and there’s a pecking order. A study of cultural anthropology must take place at the bedside. Who is going to speak on behalf of the patient if he or she can’t speak for themselves? As a physician, I always have to be aware of not only what the patient is doing, but also what I am doing. For example, if I am seeing someone from Cambodia, do I smile? Do I look stern? How does the family expect me to behave? These are things we have to be cognizant of, so people will participate in their treatment.
Dr. Bholat: At UCLA, we are a melting pot, and you can see the strength of our diversity at work throughout our system, from physicians to residents and fellows to nurses and staff. Being able to meet the language and cultural needs of our patients has been wonderful. I recently was on inpatient service, and one of the doctors said she could speak Spanish but not well enough to communicate with a patient, so she had the chief resident, who is a native Spanish speaker, join her. They were able to get a better differential diagnosis and better treatment.
Dr. Bholat: Since its inception in 2007, the IMG program has graduated 140 family physicians, and those physicians have increased access to care by more than 1.5 million encounters. Dr. Patrick T. Dowling, the chair of family medicine, and I started the program because we wanted to increase the number of bilingual and bicultural physicians who could serve the Hispanic community. We also wanted to stop “brain waste.” Many medical school graduates from Latin America find it difficult to make the transition to practice here. They may experience financial difficulties or have trouble learning our system. We help physicians who trained in Latin America who are legal residents pass U.S. medical exams and obtain family medicine residencies. In return, they promise to practice in underserved areas in California for at least two years. These are smart, motivated people. There is some bias that foreign-trained doctors are not as good as those trained in the U.S., but that is changing. The physicians who come through our program are sought after.
Dr. Bholat: I’m a Latina from Los Angeles. My grandparents came from the Aguascalientes region of Mexico. From a very early age, I wanted to be a doctor. I figured I could do it in spite of the fact that no one in my family had even been to college. When I was about 16, I wrote to UCLA and said I would like to apply to medical school. They sent a brochure and told me what I had to do. I thought maybe I could cobble together my education and do it.
I say “cobble” because I was a teen mom, and in my family, education was valued, but hard work and getting a paycheck were probably more important. There were times when it was difficult, but my husband, who is an immigrant from Myanmar, told me I should keep going, and he helped by taking care of our family. I went to Cal State Long Beach and then to medical school at UC Irvine. When I got to medical school, I realized that I was very different from my classmates because of my age and experiences. All that I went through to get to this place has led me to value diversity in ways that are personal.
Dr. Bholat: The contributions that immigrants make in medicine, science and technology are vast. But current immigration policies create an environment in which people don’t feel welcomed and don’t want to come. I fear that will set us back an untold number of years in regard to health care delivery in this country. I am proud to be a member of the UCLA Advisory Council on Immigration Policy. We celebrate our DACA (Deferred Action for Childhood Arrivals) students. I am fortunate to have in my own department a former DACA student, who now is a faculty member. Current national policies also affect patients — those who are here legally and those who are not. People may forgo care out of fear about what may happen to them or their relatives. By not seeking treatment, they may end up with more serious conditions that could cost lives or more money to the health care system.
We have to make sure everyone has access to things like preventive care, including something as simple as a vaccine. In terms of what do I wish for in the future, the International Medical Graduate Program is a prototype of a solution that could be replicated elsewhere. It also would be great for our medical school students to exchange ideas with students in, say, Mexico. I am very proud of our ambulatory care nursing program, where we have helped a diverse group of individuals become medical assistants at UCLA Health. I would like to see us develop a program for home health aides, many of whom are immigrants.
There are people who complain that immigrants take up resources. But it likely will be immigrants who will be taking care of them when they are aging or hurt or will be taking care of their mothers and fathers as they grow older. Immigrants are primary care doctors, specialists, nurses, aides and other providers who fill very important roles in our health care system. They also are doing tremendous research. One study shows that more than 40 percent of researchers at our top cancer centers come from other countries. We should remember that we do better with diversity. We can learn from one another. We are all in this together.