When Spanish-speaking patients see Dr. Victor Salazar, their demeanor often changes.
"Patients see my face, realize I'm Latino, and they're so happy," said Salazar, 35, a Kern Medical Center resident.
Salazar says that's because language and cultural differences can present barriers to medical care. Even if patients can articulate their concerns in English, important nuances can get lost in translation.
Yet as the number of Latin American immigrants climbs, California is facing a growing shortage of doctors who reflect their patient populations in this way. In Kern County, Latinos make up about half the population but just 55 out of about 1,100 local doctors recently reported having a Hispanic cultural background to the California Medical Board.
Salazar is part of a new KMC program that is making a small dent in that gap by bringing two Latin American-trained medical students into the family medical residency program. Their placement is part of a larger UCLA effort to bring native Spanish-speaking students to California's underserved communities -- in the hopes they'll stick around.
"There's no question that physicians that can speak patients' language as native speakers are only going to be good for healthcare," said Dr. Eric Vansonnenberg, KMC's chief academic officer. "I think there's a good chance they're going to stay in Kern County and this will start a pipeline."
ABSENCE OF LATINO DOCTORS
The United States relies heavily on foreign-trained doctors, with those graduates making up about 25 percent of its physician workforce. But not a single Latin American nation makes the list of the top 10 countries sending doctors here, said Dr. Patrick Dowling, chairman of UCLA's department of family medicine.
"That's ironic because Hispanics represent almost half of the 38 million immigrants," Dowling said. "I always wondered, 'Why that absence?'" he said.
To practice in the United States, foreign-trained doctors must apply to an American residency program, which involves a competitive placement process. About five years ago, Dowling set up a program through UCLA to train students from Latin American medical schools, ensure their skills were to U.S. standards, and place them in family medicine residencies in the state's underserved communities.
"We found these gems, these diamonds," he said. "They have a woman in Fresno who was cleaning elementary school restrooms at night."
The program has placed 43 students statewide, 42 of whom still practice in California.
KMC can use the influx. CEO Paul Hensler estimates 60 percent of patients are Latino, and about a third of its total patient population are Spanish speakers who require a translator.
But last year, just one of its 18 family medicine residents was Latino, even though nearly 90 percent of that program's participants trained in foreign or "off-shore" medical schools.
Next year, Hensler said he's interested in expanding the effort to place more of UCLA's Latin American-trained residents.
SIMILAR CULTURAL BACKGROUNDS
The immigrant journeys of KMC's two new residents reflect those of many of their patients -- something they say adds to their understanding as doctors.
Dr. Miguel Dorantes, 51, grew up in Mexico and worked construction in Southern California in his 20s. He was so busy raising a family that he didn't consider other career options. Eventually, his wife, who trains the blind, persuaded him to go back to school.
"She said, 'You're a smart person," he recalled. "You should have a career."
When his wife went into labor -- just as the midwife took a break -- Dorantes delivered his daughter. Medicine seemed an appropriate choice.
In 1999, he enrolled in a Mexican medical school, crossing the border from Calexico to Mexicali for the seven-year program. After he graduated, a friend told him about the UCLA International Medical Graduates Program.
"It's tough for international medical graduates," he said. "This was a clear path to land a residency."
For Salazar, the path to Kern County was also a long one.
He grew up in Quetzeltenango, Guatemala, a mountainous city named after the county's national bird. His grandparents raised him while his single mother moved to Los Angeles to support them.
Whenever he traveled to east L.A. to visit relatives, he was struck by their sense of hopelessness, especially when it came to obtaining high-performing jobs.
"In the environment where they lived, it was impossible to be a doctor," Salazar said. "I wanted to show my family it was possible to achieve our dream."
In 2007, after he had completed medical school in Guatemala, he joined his mother in Los Angeles and enrolled in an English class. Being accepted into the UCLA program isn't just a success for Salazar, but for his entire family.
"Now they see me, and think they could get a spot at UCLA," he said.
SHARING CUSTOMS AND CULTURE
Eustolia Gonzalez of Arvin says she appreciates seeing a doctor who can understand her roots and background.
"When you're from the same nationality, maybe they went through the same problems as you and share the same customs," she said.
Gonzalez speaks English, but is more comfortable communicating medical concerns in her native Spanish: "In English, it's a lot of different words and meanings, but in Spanish you can say, 'Me duele la cabeza' ('My head hurts') or something, and they understand," she said.
For Dr. Luis Lopez, an obstetrics and gynecology doctor at Clinica Sierra Vista's east Bakersfield location, those patient experiences are the norm. Lopez, who grew up in Colombia, says he understands the deep Catholic roots of Latin America and how faith and belief influence patients' decisions.
He's also aware of the submissive tendencies in some Latin American cultures. Occasionally he'll have female patients reluctant to talk about their medical needs, deferring to their husbands -- an approach that could be frustrating if a doctor wasn't aware of the cultural context.
And he understands food choices, and how to coach patients about obesity.
"I say that there's nothing wrong with tortillas, but you just have to decrease the amount and add more fruits and vegetables," he said.
When doctors reflect the community, it improves communication on many levels, said Dr. Ivan Gomez, the program director for the University of California San Francisco Fresno Family Medicine Residency Program. Gomez recruits Latino doctors to Fresno, including several from the same UCLA program.
Latin American residents are more familiar with the way medicine works in their home countries -- which can clash culturally with mainstream U.S. approaches.
Gomez offers the basic example of a doctor asking patients why they came in. Typically, American doctors ask open-ended questions such as "What's the problem?" But in some Latin American countries, there's a more paternalistic approach to medicine where the doctor does more of the talking and diagnosing.
"It's very common to see the patients, exchange a few words, the patient says OK, and leaves," he said. "A patient who is used to being taken care of that way isn't used to giving a lot of information."
The impact of having doctors who reflect the community extends beyond the waiting room, too. These physicians often end up having a broader local impact, serving on the school board, attending town hall meetings or simply taking their kids to the neighbor's quinceanera.
"You don't have to be Latino to take care of Latino patients, but there should be a distribution of physicians that reflect the community," he said.
BUT WILL THEY STAY?
Attracting enough Latino doctors to the Central Valley is an ongoing challenge, said Steve Schilling, CEO of Clinica Sierra Vista. The vast majority of Clinica's patients are Latino, and Schilling actively tries to recruit doctors who mirror that population.
"The competition for culturally and linguistically competent providers is extremely intense," he said.
At KMC, Hensler hopes the new program will help keep doctors like Dorantes and Salazar in the community.
But despite studies that show residents are likely to stay in the areas where they practice, only about 27 percent of KMC's residency graduates over the past five years have stayed in Kern County at least one year after finishing. That low percentage could be affected by having doctors in disciplines such as internal medicine who often leave to do a fellowship -- but can return afterward, Hensler said.
KMC's family practice figures are higher. About half of its 30 family medicine residents that went through the program in the past five years stayed in the county afterward.
At Fresno's UCSF family medicine residency, about 70 percent of residents find work nearby after graduating. Out of last year's class of 11 family medicine graduates, 10 stayed in the area.
As for Dorantes and Salazar, both said they like Bakersfield so far.
Salazar says the people are nice and, if he were offered a good local job, he'd be open to staying.
Dorantes also said he likes living in a mid-sized city and -- unlike Salazar -- the hot weather "suits me very well." But his wife is still working near Calexico, so he said he's not sure what will happen when he finishes residency.
"Who knows?" he said. "Maybe I'll like the Central Valley."