Doctors from Mexico Treat Farmworkers in Rural California

Marta Monteya, 39, sat nervously in a corner of the exam room at the Circle Drive Clinic of the Clinica de Salud del Valle de Salinas, waiting for her first visit with Dr. Armando Moreno.

Her appointment at the nonprofit health clinic in Salinas, an agricultural city in Monterey County, was to receive a contraceptive injection. But Monteya had an additional concern. Since suffering a miscarriage three months earlier, she’d been overwhelmed with feelings of sadness. Would she feel comfortable telling this new doctor about it? Would he understand her if she did? A native of El Salvador, Monteya only speaks Spanish. She has struggled to communicate with American medical providers in the past because they spoke only English.

The door opened, and a young, bespectacled man strode into the room, beaming at her.

“Martita, how are you?” Moreno exclaimed, greeting Monteya in fluent Spanish and using the diminutive form of her name, an expression of warmth and affection common in Latin America. “My dear Martita,” he continued as if he’d known her for years, and then he launched into questions about her health and the reason for her visit.

Monteya’s tense face melted into a smile.

A medical doctor and practicing ob/gyn in Mexico City for 11 years, Moreno arrived in Salinas last summer as part of a unique program that brings Mexican doctors to work at Federally Qualified Health Centers in California. The Licensed Physicians from Mexico Pilot Program (PDF) was approved by former California Governor Gray Davis in 2002, but the program’s champions had to work tirelessly for 19 years to overcome administrative and political obstacles before the first doctors came to work in California.

24 Physicians So Far

The CEO of the Clinica de Salud del Valle de Salinas system, Maximiliano Cuevas, MD, and longtime policy Latino/x consultant, journalist, and civil rights activist Arnoldo Torres, invested years of work to create the program in collaboration with the National Autonomous University of Mexico (UNAM) in Mexico City. Their goal is to help alleviate a dire shortage of Spanish-speaking and culturally responsive primary care physicians in California, particularly in agricultural areas like Salinas, where large populations of Mexican and Central American immigrants reside.

Currently 24 Mexican doctors serve majority Latino/x and farmworker populations at clinics in Monterey, San Benito, Tulare, and Los Angeles Counties. Each doctor is licensed by the Medical Board of California (PDF) to work in the state for three years. Specialties included in the project are family medicine, internal medicine, pediatrics, and obstetrics and gynecology. The first Mexican doctors began arriving in mid-2021, and six more are due soon. As of last December, the doctors had treated tens of thousands of Californians. In Salinas alone, they’d conducted 24,000 medical visits for routine screenings, diabetes care, urinary tract infections, and a broad array of other matters.

Latino/x people comprise the largest racial and ethnic group in California, making up 39% of the population in 2020. Yet, only 12% of the state’s medical school graduates and 6.9% of licensed physicians were Latinos/x by 2019 (PDF), according to the Fitzhugh Mullan Institute for Health Workforce Equity at George Washington University.

This disparity in representation of Spanish-speaking Latino/x doctors detracts from patient satisfaction and can harm the quality of care, said Cuevas, whose organization operates 13 clinics across the Salinas Valley and the Greater Monterey Bay Area. Research from UCLA (PDF) backs up Cuevas’s years of personal experience.

“It’s important for physicians to be able to speak the language of the population [they serve]. That way you’re able to communicate and get the little nuances of what people are saying,” Cuevas said. “Another part is an emotional aspect, where the patient has to feel that they can trust their doctor, and I think first and foremost to trust anybody you have to be able to communicate with them, preferably in a language that they understand.”

Each consultation becomes a small tribute to those who have risked everything for a better life, progress, and the well-being of their loved ones.

—Armando Moreno, ob/gyn from Mexico

Researchers at UC Davis are evaluating the impact of the program, and results are expected this year. Anecdotally, since the doctors from Mexico began arriving at health centers operated by Clinica de Salud del Valle de Salinas, patient satisfaction has increased, said Hina Sheth, the organization’s director of compliance and quality. Patients used to complain to her about not feeling understood by their providers, Sheth said. Now they tell her how much they love the Spanish-speaking physicians. Appointments with the doctors fill up fast, with many patients asking for them by name. Moreno said at least one patient a day tells him how glad they are that he’s there.

Jon Yoshiyama, MD, Clinica de Salud’s associate medical director and a practicing physician at the Circle Drive location, said some of his patients have switched to seeing one of the four Mexican doctors now working at his site. Although he and other English-speaking doctors there can call in an interpreter to translate for Spanish speakers, many patients prefer a more direct option, Yoshiyama said.

“I try not to take it personally,” he said. “Having someone who’s fluent makes all the difference. The communication is faster. Patients are more willing to open up. There are fewer misunderstandings.”

Circle Drive patient Mari Zepeda, who was born in Mexico, knows just how uncomfortable it feels not to be able to communicate directly with the doctor. She saw an English-speaking ob/gyn for all three of her pregnancies even though she speaks only Spanish. When her niece, Leticia Rubio, 26, became pregnant earlier this year, Zepeda was determined to help her find a Spanish-speaking provider. She scoured the web for reviews and asked friends for advice on where to find one. On a recent afternoon, she and Rubio sat smiling in the exam room after an appointment with Moreno.

“He was very nice; he answered all my questions,” Rubio said. The fact that he spoke Spanish “was very important,” she added.

Down the hall, Jose Arias, a 43-year-old farmworker from El Salvador, was waiting for a physical with another doctor from Mexico, Juana Lucio, MD. It was Arias’s first visit to a doctor in over 20 years, and lately he’d been experiencing chest pains and backache. He, too, sought out the clinic because he had heard that the doctors there speak his language.

“I said, ‘Great, we’re going to understand each other,’” Arias said.

Cultural Familiarity

The advantages of having Mexican doctors on staff go beyond their facility with the Spanish language, providers and administrators said. The doctors offer cultural familiarity and understanding that allow them to connect more easily with patients from Latin America and engage them effectively in treatment.

Moreno puts his patients at ease by using linguistic flourishes, slang, and lighthearted jokes that his patients recognize from their home countries. He and other Mexican doctors in Salinas also work with patients who wish to incorporate traditional healing practices into conventional medical treatment plans if they don’t pose risks. This might include drinking herbal tea, making a special soup, or performing a small ritual by brushing the body with plants and saying a prayer. Even if this doesn’t heal them physically, Moreno said, the process helps “heal their minds” and makes them feel respected.

“We don’t have to fight with their beliefs,” said Moreno, who is fluent in English like the other doctors in the program. “We have to listen and understand what they believe, and we have to treat them according to their beliefs. . . . Then they don’t feel like you’re over them, like you are bossing them. They feel like you are equal.”

Because the doctors have lived in and practiced medicine in Mexico, some in indigenous communities, they understand culturally specific words and beliefs about illness that might confuse an American physician or interpreter, Cuevas said. These include terms like empacho, or indigestion, which patients typically attribute to particular food choices, but which may signal issues such as irritable bowel syndrome or back problems. Patients also might believe that they are sick because a jealous person gave them mal de ojo — the evil eye. Or that they’re experiencing back pain or muscle spasms from exposure to cold temperatures or “bad air.” The doctors use these terms as clues to ask further questions or order tests to figure out what’s really ailing the patient.

Treatment is another area that benefits from the Mexican doctors’ cultural awareness, particularly when it comes to lifestyle changes, said the clinic’s patient services manager, Terry Gomez. In the past, Latino/x patients have balked at some doctors’ suggestions to switch to unfamiliar or expensive foods such as tofu, quinoa, or olive oil, or to eliminate staples such as tortillas from their diet, she said. The doctors know to offer recommendations that align with patients’ dietary norms and economic reality, she said. They might advise simply cutting back on tortillas, for example, or tell them to boil their beans and flavor them with cilantro and onion instead of frying them in lard.

Preparing to Practice in California

Practicing medicine in America has required the Mexican doctors to adapt, too. As part of their licensing requirements for the program, each physician must complete a six-month orientation course, approved by the Medical Board of California, that teaches about California’s medical delivery system and protocols. It has taken time to get used to computerized medical records, America’s complex insurance and billing code system, and short appointment times, some doctors said.

Internist Eva María Perusquía Frías, MD, said that in Mexico she sometimes would spend over an hour with each patient, listening and asking questions to uncover underlying problems driving their health complaints. In Salinas her appointments last only 15 minutes. Nonetheless, she still tries to offer a deep level of attention, staying late if necessary. She recounted how one patient complained of headaches and dizziness. After careful questioning, Perusquía Frías learned the patient had recently lost two siblings and was having trouble parenting a teenage son. The woman’s real problem was stress and depression, the doctor said. She prescribed an antidepressant and referred her to a therapist.

“You must work with patients, hear the patients, read between the lines,” said Perusquía Frías. “Otherwise, you only get the surface of the problem and don’t find out what’s really going on.”

That requires fluency in the patient’s language and culture, she noted. Perusquía Frías said she applied to participate in the project for the satisfaction of serving a population with whom other providers did not want to work. She also wanted “to prove to myself that my academic and personal skills were good enough to work not only in my own country and language, but also in a foreign place following the highest international standards to protect the health and safety of the patients.”

Past Struggles and Future Plans

Board members at Clinica de Salud del Valle de Salinas first proposed bringing Mexican doctors to the US in 1998 after hearing complaints from patients about the lack of Spanish-speaking providers. The clinic was having a hard time finding enough physicians to work in Salinas, let alone doctors who spoke Spanish and understood the culture, Cuevas said. Many US physicians don’t want to work in rural areas, he said.

Cuevas and Torres had to get buy-in from the Mexican government, the Medical Board of California, and the California legislature; navigate immigration obstacles; and obtain $1.7 million in philanthropic support to fund the administration of the program and evaluations by UNAM and UC Davis. The doctors’ salaries are similar to compensation for American physicians, which is higher than in Mexico, and are paid and funded by the community clinics themselves.

The project met with pushback from some California medical school officials, physicians, and the California Medical Association, which argued that the program would create a “two-tier” health care system in which doctors treating Latino/x patients don’t have to meet the same licensing requirements as American doctors. Cuevas argued that the Mexican doctors are just as qualified as their American counterparts. UNAM’s medical school is internationally recognized, and physicians in the pilot program must pass a medical board review course commensurate with American standards.

At the end of their three-year license terms, the doctors are required to return home — a rule designed to prevent a “brain drain” of medical talent from Mexico.

“I think people saw the program as a form of competition against US-trained physicians,” Cuevas said. “We told them it’s not competition. Doctors are not taking care of this population to begin with in adequate numbers.”

The program isn’t intended to resolve California’s shortage of Latino/x physicians, Cuevas and Torres said. Rather, it’s a stopgap measure to provide relief to underserved Latino/x patients while the state works on reducing the shortage. Efforts such as the University of California Programs in Medical Education (UC PRIME) and California Medicine Scholars Program are recruiting more people of color, including Latinos/x, to study medicine. But reshaping the medical workforce involves a considerable time lag, Torres said. Training a doctor takes a decade or more.

A Tribute to Those Who Risked All

Cuevas and Torres have been dogged in their efforts to get this program off the ground, and they plan to advocate next year for the program to be extended for another 15 years so 150 Mexican doctors at a time can practice for three-year cycles in California clinics. Talks with institutions in Mexico have begun, Torres said. Cuevas hopes the next cohorts will include psychiatrists and doctors who not only speak Spanish but indigenous languages as well.

The program “is a reasonable Band-Aid, but this is not a solution,” Torres said. “California should not be dependent on Mexico for its doctors. California is not doing enough to educate and train doctors and to recruit candidates for medical school. So, our proposal will be an attempt to make a substantial contribution.”

Back at the Circle Drive clinic, Monteya’s visit with Moreno was coming to an end. Comfortable in his presence, she told him how sad she had been feeling. He promised to connect her with an emotional support group through a contract agency. The help would be free to her, even though she doesn’t have insurance, he reassured her.

After he left, Monteya marveled at how well the doctor spoke Spanish and how different the visit was compared to seeing an English-speaking physician.

“It felt great,” she said, noticeably relieved. “I felt like he’s going to support me better.”

“Practicing medicine in California has been a powerful experience –a challenging yet unforgettable adventure,” Moreno said. “Leaving home, family, and friends was not easy, and adapting to a new environment presented its own challenges.

“Beyond the ability to provide medical attention in Spanish and understand their cultural background, fears, and expectations, each consultation becomes a small tribute to those who have risked everything for a better life, progress, and the well-being of their loved ones.”

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