BY KELLIE SCHMITT Californian staff writer firstname.lastname@example.org
As a 3-year old boy in India, Dr. Brijesh Bhambi watched his father maneuver an ox-driven plough on the family farm, and imagined digging a hole to the other side of the world.
His father told him a smarter way to get there would be to study hard and become a physician.
ABOUT THIS SERIES
This is the first part of a three-part series examining Kern County's high number of foreign-trained doctors and the impact on patient care.
TODAY: More than half of Kern doctors graduated from a foreign medical school. Why? And is that good or bad?
SUNDAY: A Caribbean medical school recently agreed to pay Kern Medical Center $35 million to have its students train at the cash-strapped county hospital. It's happening elsewhere, too, and has its critics.
MONDAY: Kern's physicians come from many far-flung corners of the globe. We take a look at several compelling personal journeys.
HOW WE CRUNCHED THE NUMBERS
To estimate the percentage of foreign-educated doctors practicing in Kern County and throughout California, The Californian merged the state Medical Board's most recent databases of total doctors by county and total foreign-educated doctors by county. Some of the individual data points from each database could be from slightly different time periods, but the Medical Board said this was the best, most recent data available.
To calculate board certification rates, we typed hundreds of local doctors' names into the American Board of Medical Specialties website to see if they were board certified. We also looked at rates for the local doctors educated at the 10 foreign and 10 U.S. medical schools supplying the most physicians to Kern County.
We obtained a list of recent residents and graduates from Kern Medical Center, the county's only teaching hospital, and excluded them from the analysis since they may not have had time to complete board certification.
- IMPORTING DOCTORS: Pace of foreign-physician influx may slow
- IMPORTING DOCTORS: Are we creating a foreign brain-drain?
- IMPORTING DOCTORS: KMC's multimillion dollar deal with Caribbean school marks part of controversial trend
- IMPORTING DOCTORS: Concerns about the quality of Caribbean schools persist
- IMPORTING DOCTORS: Many American students turn to Caribbean medical schools
- IMPORTING DOCTORS: Foreign physicians in Kern share their stories
"It was the only way out of poverty," Bhambi said. "There was no plan B."
So Bhambi did focus on his studies, entering Indian medical school at age 16, passing the U.S. post-medical school exams and securing a training, or residency, spot in the South Bronx. Eventually he landed in Kern County, where he now works as an interventional cardiologist at the Bakersfield Heart Hospital.
Many local physicians have experienced a similar journey here. In fact, 57 percent of Kern County's doctors attended medical school overseas, according to a Californian analysis of state Medical Board data. That's consistent with other Central Valley counties but more than twice the national average of about 25 percent, and four to five times the amount in other California counties with similar total numbers of doctors such as Sonoma and Marin counties.
The high number of international medical graduates (IMGs) has played an instrumental role in providing much-needed physicians to Kern County. Many IMGs also end up in primary care medicine, an important field that American-trained doctors often bypass in favor of more lucrative specialties.
"They have helped us fill a void, bringing care to thousands of people who would have been without care had they not been there," said Stephen Schilling, CEO of local health clinic chain Clinica Sierra Vista.
But importing a physician workforce isn't without challenges.
Culture clashes can arise between physicians and patients, especially in a place like Kern County where the top countries of doctor origination -- India and the Philippines -- don't reflect a population nearly 50 percent Latino.
And while large national studies have demonstrated the high quality of international medical graduates, a Californian analysis of specialty certification rates reveals much larger disparities among Kern's foreign graduates than their U.S. counterparts.
Recruiting and hiring international physicians can be difficult without a clear system for determining which schools are the best.
"Some schools abroad are fabulous, and their students have high board passage rates and great scores," said Callie Langton, associate director of the Health Care Workforce Policy for the California Academy of Family Physicians. "Then there are others that aren't held up to the same standards as schools in the U.S."
QUESTIONS OF QUALITY
Even as international doctors increasingly fill U.S. healthcare needs, doubts about their quality of care have persisted. In 2010, a study released by the peer-reviewed journal Health Affairs attempted to clarify the competency question.
The study evaluated the outcomes of more than 240,000 patients hospitalized for heart problems. Foreign-born physicians who trained abroad fared even better than their American-trained counterparts when it came to death rates. (The study differentiated between foreign doctors who trained overseas and American doctors who attended medical school abroad, a group that had the worst patient outcomes, according to the report).
That success rate among foreign-born doctors may come as no surprise to many of Kern's, who detail a highly competitive, lengthy path to becoming a U.S. doctor.
The Health Affairs report also looked at whether a physician is board certified in his or her specialty. After physicians attend medical school, they must complete at least three years of training in a specialty, or residency. Following that, the physician can take a test in that specialty to become board certified.
While this is voluntary, 80 to 85 percent of American doctors become board certified in an American Board of Medical Specialties (ABMS) member board, according to the organization. Among newer graduates, that number jumps to more than 87 percent, according to a 2011 study published in the Journal of the American Medical Association.
"Thus ABMS member board certification is emerging as a de facto requirement for the full participation of physicians in the U.S. health care system, and non-board certified physicians compose an increasingly marginalized group," the study authors said.
In Kern County, only about 70 percent of the 634 foreign-trained physicians have ever received board certification, according to an exhaustive Californian review of ABMS physician records. That percentage, though, doesn't tell the whole story. Certification rates varied dramatically depending on which foreign medical school Kern's doctors attended.
Take the most common 10 foreign medical schools graduating Kern County doctors. The certification rate among those schools' local physicians ranges from 33 to 93 percent, with an average of 64 percent.
Kern's most prevalent U.S. medical school graduates' board certification rates range from 69 to 100 percent, with an average of 80 percent -- about the national average.
And while the foreign graduates' rates vary wildly by facility, those of Kern's U.S. school alums are more consistently high. Numbers for eight of the 10 most common American schools that have educated local doctors fall above the national average, compared to just two of the foreign schools.
Among foreign schools, the Autonomous University of Guadalajara Faculty of Medicine has the lowest rate while Grant Medical College and University of Bombay in India and the University of the Philippines College of Medicine have the highest.
Dr. Roy Daug, a graduate of that Philippine school, said his competitive university instilled the importance of getting the highest certification available.
"Coming from my medical school, it was a badge of honor to be board certified," he said.
Despite its poor showing in The Californian analysis, The Autonomous University of Guadalajara Faculty of Medicine also tries to impart the importance of board certification, said Ricardo Del Castillo, dean of the school's international office. The university markets itself to U.S. students who can't get into stateside medical schools.
"We tell them that they have to go for the highest level that is being certified by the board by each state and their specialty," he said. "We put all the options in their hands, and it's up to them."
Even as board certification is becoming increasingly vital for job seekers, Schilling, the Clinica Sierra Vista leader, pointed out that wasn't always the case. Some doctors may not be board certified today simply because there was less emphasis on that step decades ago -- for all doctors.
That was true for Dr. Carlo Amazona, who studied at Far Eastern University, Dr. Nicanor Reyes Medical Foundation in the Philippines, a school where just 38 percent of its graduates are board certified in Kern. For Amazona, who works in Clinica Sierra Vista's McFarland site, the certification wasn't required at the time he was hired decades ago. He had always planned to get it one day, but now, in his mid-60s, it will probably never happen.
'HOW DO YOU KNOW?'
The Medical Board of California has a list of approved foreign medical schools, which means that facility's medical curriculum meets certain criteria, such as having studies in alcoholism and spousal abuse. Since the Medical Board can't travel to all schools, it also relies on international accreditation agencies to determine if "it's a real school," said spokesman Dan Wood Dan Wood .
"Just like here in this country, certain schools have better reputations, and others aren't as well known," Wood said.
The board plans to do a comprehensive review of international medical schools, though how it will accomplish that hasn't been determined.
All this variance among foreign schools challenges local recruiters and others who hire overseas alum.
"In no way do we want to disparage foreign medical graduates, but the issue is: How do you know?" said Dr. Eric vanSonnenberg, chief medical officer at Kern Medical Center. "If we could choose the super stars, we would, but we don't know how."
Over at Kaiser Permanente, which has "a big portion" of doctors who received medical training overseas, the key is examining residency data. Since foreign doctors must do a U.S. residency, there is plentiful information to scrutinize, said Dr. Julia Bae, the medical director for Kaiser in Kern County.
"We only hire those at the top of their programs," she said.
Over time, she's come to rely on other international medical graduates to help her recruit doctors who graduated from the "Harvards of all the different countries out here."
Bae has found the foreign doctors she hires have an incredibly strong work ethic. In order to even get to the U.S. for residency, they had to be the best of rigorous programs in their home country.
"They also seem to have a lot of compassion for patients because of the challenges they went through," she said. "I don't look at hiring from other countries as a weakness, but as a very positive thing. It makes us stronger."
Patients might be initially hesitant when they see a foreign doctor with a difficult-to-pronounce name, she said. But by the end of their visits, she sees high patients satisfaction scores with no correlation to accents.
Local patients interviewed throughout Kern County said language and cultural proficiency does influence their patient experience.
Sandra Price, who was leaving Kaiser's downtown Bakersfield offices, said she must accompany her 71-year-old mother to every doctor's appointment to help interpret the doctor's English. The thick accent is exacerbated by her mom's hearing troubles.
Doctors tend to be really accommodating, she added, slowing down and allowing her time to repeat their words to her mom.
Mayette Kennedy also struggles to understand her Bakersfield physicians.
"It's so hard to follow instructions if there's a language barrier," she said as she left the Kaiser offices with her 11-year-old son, William. "Just the way they pronounce the words is so different that I have to stay focused."
Language isn't the only issue. Kennedy, who is a Philippine American, said she's also struggled with a Philippine-trained doctor whose style was too timid, and whose medical advice was not aggressive enough.
Ultimately, she said she would like to have a doctor -- of any cultural background -- whose English she can understand and whose advice is medically sound.
A CHANGING POPULATION
Language issues can take on a new level of complexity when the doctor speaks his or her non-native language to a patient who also isn't a native English speaker, or who doesn't speak English at all.
While Kern County is nearly 50 percent Latino, just 53 of 1,108 doctors -- or less than 5 percent of physicians -- report having a Hispanic cultural background to the California Medical Board.
The top countries supplying foreign doctors to Kern are India and the Philippines, which experts say is because their medical schools typically use U.S. textbooks, easing not only language skills but also exam proficiency. Mexico comes in a distant third but that's a result of the large influx of doctors from University of Guadalajara, which attracts U.S. students.
The lack of Latin American doctors isn't only true in Kern but in the U.S. overall, said Dr. Patrick Dowling, chairman of the family medicine department at the David Geffen School of Medicine at UCLA. That's ironic, especially since Hispanics make up such a large portion of the new immigrants to the United States, Dowling added.
A lack of culturally competent care can have serious health implications.
When Fausto Sanchez's wife got pregnant in the United States, she was terrified to go to the doctor. As an immigrant from a Mexican region known as La Mixteca, language wasn't her only concern. Culturally, women aren't accustomed to seeing male doctors, and being forced to see one spurs much anxiety.
Because of that fear, she did not see a doctor until she was eight months pregnant, Sanchez said.
"She was afraid to see the doctor because of language," he said. "She said, 'Why should I go? I feel afraid and embarrassed."
The delay in care didn't pose a problem for Sanchez's family -- other than an angry lecture from the doctor, who said she should have been taking prenatal vitamins -- but Arvin-resident Sanchez sees the same storyline play out again and again for other recent immigrants in the local Latino community.
"It's a big problem," added Maria Yepez, a Spanish-speaking community organizer for the Dolores Huerta Foundation in South Kern. "Language is important and different cultures sometimes don't understand each other."
Dr. Jorge Enriquez, a Bakersfield general surgeon who attended medical school in Mexico, said that's why a vast majority of his patients are Latino. They are drawn to him not only because he speaks Spanish but because he understands cultural nuances in care.
For one, the family is more involved in the medical process.
"If grandmom has surgery, there will be 40 people in the waiting room," he said. "With Americans, they're not all going to stop their jobs for her surgery."
Enriquez giving grandmom a big hug might not only be acceptable but appreciated. And little language cues such as saying "Wait here for just five little minutes" versus simply "Wait here" can affect a patient's psyche.
Language, too, is an issue -- even if interpreters are present.
"From doctor to patient, the story changes, which is unfortunate," Enriquez said. "It's not personal anymore."
That can be frustrating on both ends.
Dr. Kyaw Tun, a Kaiser doctor from Burma, said working with his 200-some Hispanic patients is difficult since translations can double the length of a patient visit. Often, information doesn't seem to be translated directly.
"You ask one question and they keep telling them other things," he said. "What is she saying? I said a yes or no question. It takes a long time to get to the point."
Ultimately, the solution to these cultural and linguistic issues is to find a way for more Latino doctors to come practice in the United States, said Chad Silva, policy director for Latino Coalition for a Healthy California. That plan also entails creating better career pipelines for Latinos within the United States to attend medical school.
In the meantime, his organization would like to see more cultural and linguistic training courses for physicians.
"It's not enough if you have someone who just speaks Spanish," he said. "You have to understand what the cultural understanding and attitudes are toward health. Not everyone is the same, even among Latinos."
CALLING KERN HOME
For Bhambi, the doctor who once dreamed of digging a hole to the United States, Kern County has been a welcoming home for foreign-trained doctors, perhaps because people are so accustomed to diversity.
When asked about his patients' response to him over the years, Bhambi's face lit up and his already fast speech quickened with enthusiasm. He spoke of the warm compliments patients pay him and pointed to the wagon in the lobby filled with wooden hearts that a Tehachapi resident crafted for him.
As time goes on, he expects to see openness toward foreign-trained physicians grow, even in coastal areas of California that tend to recruit fewer international graduates.
"Younger people don't have the same baggage," he said. "Foreign physicians have earned respect from the mainstream. We're no longer second-class doctors."
Californian staff writer Kellie Schmitt is also a fellow with The California Endowment Health Journalism Fellowships, a program of the University of Southern California's Annenberg School for Communication & Journalism.