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Foreign Aid

A novel program helps doctors trained in Latin American countries to become licensed in the U.S. and work with underserved communities.

By Lyndon Stambler
Photography by Mark Berndt

Dr. Carmen Morales, from Mexico, in the clinical-science phases of the International Medical Graduate program. With her are (from left) Dr. Joaquin Velarde (Columbia), Dr. Edna Biddy (Mexico), and UCLA faculty member and cardiologist Dr. Ravi Dave.

Nidia Payan and her husband, Oscar Hernandez, came to the United States in 2003, after earning their M.D. degrees in Mexico. Their dream was to continue their medical training in the states, but they soon ran up against some harsh realities.

Their tourist visas prohibited them from working. Their English was poor. Life in the U.S. was expensive. And they didn't know how to earn their medical licenses. "It was complicated," Dr. Payan says.

To get by, they sold tamales. Studying English at night, they volunteered during the day in a Los Angeles medical clinic, where 90 percent of the patients spoke Spanish. A Korean doctor there relied on a translator, and "communication was short," Dr. Payan recalls.

Indeed, the shortage of bilingual and bicultural doctors in California, where the state's 13-million Latinos comprise one-third of the population but just 5.5 percent of the physicians, is a significant problem. It often contributes to misunderstandings that put Spanish-speaking patients at risk, leading to misdiagnoses, errors and often unnecessary testing. To address that issue, UCLA, through its International Medical Graduate (IMG) program, is helping immigrant physicians trained in Latin America, like Drs. Payan and Hernandez, to receive their U.S. licenses and serve the state's Latino community.

This unique program, the only one of its kind in the U.S., was created in 2006 by Patrick T. Dowling, M.D., M.P.H., chair of the Department of Family Medicine, and Michelle Anne Bholat, M.D., M.P.H., vice chair of family medicine and executive director of the IMG program.

Each year, the privately funded program, with an annual budget of about $750,000, admits a dozen foreign-trained doctors, who live in the United States legally but face obstacles to passing the U.S. Medical Licensing Examinations (USMLE). The program provides stipends and guides them through the three steps of the USMLE - basic science, clinical knowledge and skills, and their ability to manage patients. In April 2012, the State Assembly approved a bill, sponsored by Assemblywoman Holly Mitchell (D-Los Angeles), to give international medica

Dr. Ravi Dave (center), a UCLA cardiologist and IMG faculty mentor, works with program participants Drs. Joaquin Velarde (Columbia), Carmen Morales (Mexico) and Edna Biddy (Mexico) in the simulations lab.
l graduates the opportunity for up to four months of hands-on training, under the aegis of the UCLA program. It is pending before the State Senate.

It costs between $52,000 and $54,000 to put a graduate through all phases of the program, with more than 40 percent going for stipends. Upon their successful completion of the program and passing of the USMLE, students are matched with a three-year residency in family medicine in California. Following the residency, the doctors must spend at least two years working in one of California's 510 federally designated underserved communities for primary care. (Almost 35 percent of California's Hispanic population lives within so-called medically underserved areas, compared to 20 percent of the total population.) Depending on their previous training, the graduates take from nine-to-21 months to complete the steps prior to residency. To date, 54 students have completed the program at UCLA; 20 have finished their residency and are practicing in underserved communities, and 34 are in residency training.

One recent graduate is Jose Chavez, M.D. Dr. Chavez was born in El Salvador. His father left when Dr. Chavez was age 4. Two years later, his mother moved to the U.S., leaving him behind to be raised by his extended family.

At an early age, he decided to become a doctor. It took 12 difficult years, during which he would come to the U.S. to work construction jobs and purchase old pickup trucks to sell back home to earn money for tuition. He was supposed to graduate from the National University of El Salvador in 2001, but he came down with typhoid fever after volunteering to help victims of two earthquakes that struck the country that year. He survived his illness but ran out of money.

He came back to the U.S., but work opportunities were scarce. He found a job in an Iowa slaughterhouse. "I couldn't eat pork for a while after working there," he says. He finally earned enough money to complete his M.D. degree in El Salvador, in 2005, and then worked for two years in a rural town. But he could not find a place in a residency program, so he again came to the U.S. and worked in construction. He tried to study for the USMLE, "but working during the day and studying at night was tough," he says.

Dr. Michelle Anne Bholat, M.D., M.P.H.
Michelle Ann Bholat, M.D., M.P.H.
Co-founder and executive director of the IMG program and vice chair of Family Medicine
Patrick Dowling, M.D., M.P.H.
Patrick Dowling, M.D., M.P.H.
Co-founder of the International Medical Graduate (IMG) program and chair of the Department of Medicine

Dr. Chavez found his way to the IMG program, which he began in 2009 and completed in 15 months. "Thanks to the IMG program, I could stop working for 15 months and dedicate 12-to-15 hours a day to studying," he says. In July, Dr. Chavez begins his residency at Riverside County Regional Medical Center.

Throughout their careers, Drs. Bholat and Dowling have devoted themselves to addressing healthcare imbalances. Dr. Bholat, who grew up in a poor family, was a teenage mother who took an equivalency test to complete high school. Although she had no mentors, she earned a degree at Cal State Long Beach, her M.D. degree at UC Irvine and her master's degree in public health at UCLA. "I just stayed focused on medicine. I never wanted to do anything else," she says.

Dr. Dowling, whose office is decorated with pictures of the slain Kennedy brothers, JFK and RFK, was moved to serve the community following the assassinations in 1968 of Martin Luther King, Jr. and Bobby Kennedy. He trained in family medicine at Chicago's Cook County Hospital, where he worked in large, overcrowded wards that lacked privacy. "That really opened my eyes," he says. He also worked as medical director of the United Farm Workers clinics in the Coachella and Imperial valleys.

Dr. Dowling arrived at UCLA in 1998 as the first chair of UCLA's Department of Family Medicine, and he, in turn, recruited Dr. Bholat as the first Latina vice chair of the department. They had worked together at Harbor-UCLA Medical Center and established the Wilmington Family Health Center, which grew from 5,000 to 24,000 annual visits. "We've been a really effective team all these years," Dr. Bholat says.

In 2004, Dr. Dowling began to focus his attention on the lack of Spanish-speaking doctors. The solution he and Dr. Bholat developed became the IMG program. "There was such a disparity there," recalls Gerald S. Levey, M.D., who was dean of the UCLA medical school at that time. "I immediately thought if anything was going to work, we should try it."

Drs. Bholat and Dowling identified several candidates for their new program through Welcome Back, which prepares foreign-trained health workers for careers in the U.S. The doctors were working in construction, bookbinding, as lab techs, aids and counselors. "We discovered there were all of these doctors in Southern California who had emigrated here legally from Latin America," Dr. Dowling says. "Probably 400 or 500 at least, trying to study to take the test and get into residencies. They didn't have a clue of how the system worked."

Dr. Bholat, who runs the IMG's day-to-day operations, developed everything from applications to the curriculum. She and Dr. Dowling carefully assess each applicant's medical knowledge and English skills, interviewing all finalists, making gut decisions, which "is the way we learned to practice medicine," Dr. Bholat says.

"I've been in medical education for 30 years, and this is the most significant thing I've been involved with," Dr. Dowling says. "We now have 54 doctors, who will be practicing in underserved areas of this state, and who speak the language of those communities. They'll see hundreds of thousands of patients who will understand them. They will be role models for Latino kids. They will have an enormous ripple effect that is more than any single doctor can have."

Two years after she and her husband came to the U.S., Dr. Payan learned about the IMG program. But in order to enroll, she needed a student visa and a Social Security card. She began working as a janitor for a school where she took English classes, making $8 an hour. "I was making more selling tamales," she says. "But I needed to apply for a job to get my Social Security number."

Within six months, Dr. Payan received her student visa, applied for California residency and received a Social Security card. And she began the IMG program. (Her husband followed two years later.)

But she almost didn't make it through. Drs. Bholat and Dowling warn their students not to take the USMLE before they are adequately prepared. Dr. Payan, however, fell short by two points on the basic-medical-sciences test. That score jeopardized her chances of landing a residency, and Drs. Bholat and Dowling considered dropping her from the program. "If I had known how hard it was going to be, I would have stayed in my country," Dr. Payan says.

But Dr. Bholat, who had overcome setbacks in her own life, and Dr. Dowling agreed to let Dr. Payan continue. "This girl was just too good. I knew that," Dr. Bholat says.

Dr. Payan proved Dr. Bholat right. After passing the exam, she went on to a residency in family medicine at the UC San Francisco Fresno Family and Community Medicine Program - her team won the California Academy of Family Physicians' 2010 Battle of the Residents competition, and in June, she will begin her two-year commitment to work with the underserved community at Clinica Sierra Vista in Fresno. Meanwhile, her husband, Dr. Hernandez, is completing his first year at the UCSF Fresno program. "I'm his boss now," Dr. Payan jokes.

With a 1-year old daughter, Valentina, and two careers in family medicine, Drs. Payan and Hernandez see a bright future for their family. "Everything for the last few years was on standby," Dr. Payan says. "Now we see our future the way it should be, with a family and working in our field, helping our people, even though we are in a different country."

Lyndon Stambler is a freelance writer and teaches journalism at Santa Monica College.

 





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