Texas sees shortage of Spanish-speaking nurses, doctors post-COVID

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Two here, the interaction was strange and impersonal. She later said she wanted to say more but thought she needed to keep questions simple.

“I get so desperate,” Jiménez said. “I would love to speak and communicate just the same as (English speakers) without depending on other things. Sometimes I go places where no one speaks Spanish, and I have to try my best to communicate.”

Language barriers have long been an important factor in the persistent inequities in health care. The COVID-19 pandemic, and a worsening physician and nursing shortage, has highlighted the urgent need for medical professionals who can communicate with the roughly 7 million Texans who prefer or speak only Spanish.

Hispanics, who comprise about 40 percent of the state’s population, account for only 8 percent of licensed physicians in Texas and about 6 percent of registered nurses, according to state licensing board data. There are no exact figures on how many of those providers speak Spanish. One study published last year in American Family Physician identified 222 counties nationwide, concentrated mostly in Texas and New Mexico, that lacked a Spanish-speaking family physician, despite at least 20 percent of those populations speaking Spanish.

Many Texas medical schools recognize the problem and emphasize recruiting efforts for young Hispanics who may believe medical education is out of reach.

“It has to be a concerted effort,” said Dr. Leonel Vela, senior associate dean for educational resources at the University of Texas Rio Grande Valley School of Medicine. “It has to start from the top as a vision and a goal to increase enrollment. A wait-and-see attitude won’t do it.”

Limits of translation

Jiménez did see a Spanish-speaking medical assistant at the start of her Jan. 23 appointments.

“Respira profundo,” said the assistant, Carmelita Ramirez, as she eased Jiménez into a chair. Take a deep breath. The assistant took her blood pressure and listed off her medications in Spanish before leading Jiménez to an examination room.

Many Houston primary care clinics that treat a high percentage of Hispanic patients try to employ a robust bilingual support staff, to help take vitals or perform administrative duties. Those workers need additional training to convert complex medical terminology into Spanish. Many hospitals and clinics pay a fee for third-party translation services, which provide live, certified translators by phone or video.

The emergence of on-demand video translation has been extremely helpful, especially at COVID vaccine clinics, said Dr. Kim Alleman, director of nursing and patient care services at UT Physicians. It is not always feasible to have an in-person translator, she said, and patients are more comfortable when they can see the person on the other end.

Still, the services have their limits.

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Alleman acknowledged that online translation is no substitute for Spanish-speaking nurses, who can have free-flowing conversations that put patients at ease.

Dr. Andrea Caracostis, CEO of Hope Clinic, a federally qualified health center that serves underinsured and uninsured patients, said video services use more data than the audio-only option and can be prone to connection interruptions. Also, she said, a provider may not know when details become lost in the translation.

Past studies show that “language concordance,” in which the doctor and patient speak the same language, is significantly associated with a lower likelihood of confusion, frustration and language-related poor quality ratings, and positively associated with patient satisfaction.

Elda Ramirez, a Houston emergency room nurse and assistant dean of diversity, equity and inclusion at UTHealth Houston’s Cizik School of Nursing hears the sigh of relief when a Spanish-speaking patient realizes they speak the same language. Ramirez grew up translating for her parents and relates to their struggle.

“You have a whole different understanding of where they’re coming from,” she said. “How are you going to get that kind of rapport when you have a translator?”

Struggling with demand

The UH clinic, located on the main Third Ward campus, absorbed an influx of uninsured, Spanish-only patients after the university closed its primary care clinic in southwest Houston last year.

Carmelita Ramirez (no relation to Elda Ramirez), meanwhile, is one of only two medical assistants there who can speak the language. The clinic staggers their shifts or shuffles appointments so they can accommodate those patients, she said.

“It’s a lot more responsibility,” she said.

Other Houston outpatient clinics have to contend with growing demand for health care with a limited number of Spanish-speaking workers.

San José Clinic, a safety-net provider that relies on volunteers, last year tallied about 2,300 more doctor visits at its Midtown location compared to 2020, according to data from the clinic. Its second location in Rosenberg, which opened in August 2020, saw annual doctor visits nearly double over the last two years, from 1,298 in 2021, to 2,472 last year.

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The clinic’s volunteer model makes it difficult to find and retain nurses and doctors, especially with so much competition in the medical center, said chief clinical officer Adlia Ebeid. Recently, the clinic has relied more on contract labour, but the cost makes that unsustainable, she said.

Providing adequate translation has been part of the struggle. San José lost its core group of certified volunteer translators during the pandemic, Ebeid said. Right now, its front office workers train to serve in dual roles as medical translators, but shifting between a family’s trusted resource and a doctor’s voice can become complicated.

“We ask our medical assistants who have developed this bond with the patient, and have this network of trust, we ask them to pause for a second and dictate word for word from a physician who has a different level of authority,” she said. “We find that it’s compromising the relationship.”

The clinic is looking for dedicated medical translators to address the problem. Online translation services are too expensive, Ebeid said, costing anywhere between $5,000 and $10,000 a month.

“It baffles me that we’re minutes away from the medical center and we struggle so much for something so simple,” she said.

Houston’s large population of immigrants who are in the country illegally also needs special attention, because “they literally try to disappear into the paint of the wall,” said Rennie Rogers, the director of Latino health at St. Joseph’s Medical Center. That dynamic is part of what prompted the downtown hospital in 2021 to open the Latino Health Center of Excellence, a 29-bed, Spanish-language unit on the 8th floor. All of the personnel speak Spanish. The unit also offers Hispanic- or Latino-centered food menus and TV programming.

Staffing the unit was like looking for “the needle in the haystack,” Rogers said. Not only did nurses need to have a strong grasp of Spanish, the hospital also required them to pass a proficiency test for medical terms.

“It’s a different set of skills to truly be able to speak enough Spanish to the patients so you can take care of them in Spanish,” Rogers said.

Bright spots

Despite the ongoing challenge in clinics and hospitals, medical schools offer signs of hope.

The 2021-22 academic year saw a historically high number of medical school applicants and enrollees nationwide, mostly among underrepresented minorities, according to the Association of American Medical Colleges.

Applicants rose by 17.8 percent from the year before, totaling more than 62,000, the AAMC found. Of the roughly 22,000 students who started medical school that fall, those who identified as Black or African American rose by 21 percent from the previous year. The number of Asian students saw an 8.3 percent increase, followed by a 7.1 percent increase among those of Hispanic, Latino, or Spanish origin.

School officials say the pandemic’s disproportionate toll on people of color, and the widespread use of remote learning, played some role in the surge in applicants. In Texas, however, the numbers are still not enough, said Vela, the senior associate dean at the UTRGV medical school.

His school implemented a program called Vaqueros MD, in which high school juniors and seniors in the overwhelmingly Hispanic region can earn conditional acceptance to the medical school. The university also offers scholarships that cover both undergraduate and medical education, and hosts an annual competition that encourages area high school students to develop creative solutions to health care barriers.

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The University of Houston’s Tilman J. Fertitta Family College of Medicine, which enrolled its first students in 2020 on full scholarships, similarly focuses on improving representation in primary care. Nearly one-third of its inaugural class is Black or Hispanic, almost double the national rate for medical school acceptance among those groups.

The college participates in a national program that pairs high school students with medical student mentors who teach them the basics of medicine. The program is underway at Jack Yates High School. The college hopes to expand those partnerships to Austin High School in East End and the mostly Hispanic student body at Cristo Rey Jesuit College Preparatory School of Houston, said Dr. Stephen Spann, the medical school’s founding dean.

For now, Spanish-speakers like Jiménez will have to get by with translators and bits of English picked up from YouTube and Duolingo.

Language is only one part of her life that makes health care challenging. She has epilepsy, she said, and cannot drive herself anywhere. The bus ride from her southwest Houston home to the UH clinic takes more than an hour and a half.

She also is uninsured, making the UH clinic one of her few viable options.

“Finding a place that is accessible but that I can also afford, it’s very difficult,” Jiménez said.

julian.gill@chron.com

jhair.romero@chron.com