A Bicultural Community–Academic Partnership to Improve the Latina/o Physician Workforce in Washington State (2019–2021)

Abstract

From July 2019 through April 2021, the Latino Center for Health, a bicultural population health research center at the University of Washington, partnered with community stakeholders to generate evidence to inform elected officials about the need to increase the diversity of the state’s physician workforce and ultimately improve Latina/o health in Washington state. Legislative efforts resulted in legislation creating goals for the state’s medical schools to admit students representative of the state’s population diversity and the creation of a new residency pathway for international medical graduates. (Am J Public Health. 2024;114(S6):S467–S471. https://doi.org/10.2105/AJPH.2024.307627)

Latinas/os are the largest ethnic minority group (13%) and the fastest-growing segment of Washington state’s population¹; 32% are immigrants (23% non-US citizens) and 65% speak Spanish at home.² They are more likely to live in rural counties where access to bilingual health care services is scarce.³ Until recently, Latinas/os were not reflected in the electoral power structures at the local and state levels, thus lacking political representation and power to advocate for community needs.⁴

For years, community and health care leaders have indicated the need to increase the number of bilingual and bicultural Latinas/os in the health workforce to meet the needs of the rapidly growing and underserved Latina/o patient population in Washington state. Within this context, and aware of physician workforce study results⁵ released by the Latino Policy and Politics Institute in California, the executive director of the largest federally qualified health center system serving Latinas/os in western Washington state asked the Latino Center for Health to replicate this work in our state. The Latino Center for Health at the University of Washington is the only research center in the state with a singular focus on promoting Latina/o health and well-being (Figure 1). The Latino Center for Health’s team is composed of multicultural, multinational, and multilingual researchers and staff informed by our lived experiences, ties to Latina/o communities, and training in population and health policy research. In response to the community-identified health workforce issue and building upon the existing partnerships (Figure 1) between the largest Latina/o-serving community health center systems in Washington state and the Latino Center for Health, we developed the Latino Physician Workforce Study, a policy-action community-engaged participatory effort to study the current Latina/o physician supply in the state.

FIGURE 1—

Ecosystem of the Latino Center for Health in Washington State

Note. CBO = community-based organization. The Latino Center for Health is led by a multicultural, multilingual group of researchers and staff with ties to Latina/o communities across Washington state. It was created by a Latina/o community-led advocacy effort in partnership with University of Washington researchers, and supported by elected officials who secured funding by the state legislature.

INTERVENTION AND IMPLEMENTATION

The Latino Center for Health made the proposal in 2019 to the state legislature to analyze the current Latina/o physician workforce using state medical licensing data. This proposal included the engagement of an advisory committee to (1) inform interpretation of the data, (2) guide the formulation of policy recommendations, (3) develop the communication and dissemination strategies, and (4) promote the policy recommendations to legislators.

The primary aims of the analysis included estimating the number of practicing Latina/o physicians in the state; describing their demographic, training, and practice characteristics; and determining their geographic distribution relative to the state’s Latina/o population (Figure 2). In addition, we provided Latina/o physician workforce modeling projections from 2020 to 2040. Our analyses indicated that there are approximately 45 Latina/o physicians per 100 000 Latina/o population, compared with 277 non-Hispanic White physicians per 100 000 non-Hispanic White population in the state. Furthermore, 12 of Washington state’s 39 counties do not have any Latina/o physicians and an additional nine counties meet the Health Resources and Services Administration’s designation for a Health Professional Shortage Area (defined as 28 physicians or fewer per 100 000 population); nearly all of these Health Professional Shortage counties have a high proportion of Latinas/os (19%–66%), agricultural workers (11%–31%),⁶ and Spanish-speaking households (16%–51%). Unless there is a significant increase in the number of Latina/o physicians practicing in our state (15%–20% over a 5-year period), the growing Latina/o population (13% to 17% between 2020–2040) will result in an increasing disparity in the ratios of the White and Latina/o physicians relative to the White and Latina/o populations (https://bit.ly/3PnrrDt).

FIGURE 2—

Sample Graphic Used to Summarize Physician Locations, Hours of Service, and Ratio of Latina/o Physicians to 100 000 Latinas/os in Washington Legislative Districts 1–49

Note. FTE = full-time equivalent. We use 160 hours per month as our parameter representing 100% FTE and applied interquartile cut-points for “Full-time” > 80% FTE (i.e., > 127 hrs/month), “Part-time” 10%–80% FTE (i.e., 16–127 hours/month), “Less than part-time” < 10% FTE (1–15 hours/month), and “Unknown” hours, where an address was provided but not the number of hours worked at the address. Ratio cut-points were established using HRSA thresholds of designated health professional shortage area, applies a 1:3500 ratio, or approximately 28 physicians to 100,000 population. Additional maps provided in the full report, “Today’s changes for serving tomorrow’s diverse communities: Increasing the Latino Physician Workforce Now”: https://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?fileName=LPWS-FINAL-REPORT_20201031_single_aaed8f7a-b9bb-4746-8fe1-0978bbce0c74.pdf

Source. Washington State Medical Commission and the US Census, American Community Survey 5-Year Estimates (2014–18).

We assembled the study’s 20-member statewide advisory committee so that it was geographically representative of Washington state and included diverse political and multisectoral perspectives from industry, medical education, health care delivery, policy, health workforce development, international medical graduate advocates, and bipartisan elected officials. We convened advisory committee members four times over nine months (2019–2020).

The communication rollout of the study report included strategic distribution to stakeholders, a press release to Latina/o community and mainstream media partners, and a virtual two-day symposium with 70 participants from academia, health care, community-based organizations, representatives of key legislative districts across Washington state, and community advocates.⁷ The report and symposium briefed relevant policymakers, community leaders, and advocates from across the state on evidence-based physician workforce trends and emerging needs utilizing Geographic Information System (GIS) maps (data-driven visual tools) and bilingual digital testimonials by Latinas/os (patients, a provider, a physician recruiter, and a state legislator) to personalize the issue.

Our research-to-policy efforts took place in the context of the COVID-19 pandemic and the Black Lives Matter movement following George Floyd’s murder, which served to heighten awareness of pervasive and enduring racial and ethnic inequities in health, health care access, treatment, and outcomes.⁸ Public officials at all levels in Washington state declared racism a public health crisis.⁹ The state legislature placed issues of health equity front and center for the 2021 legislative session. These new legislative priorities presented a window of opportunity for policy efforts addressing the shortage of Latina/o physicians in the Washington state workforce.

PLACE, TIME, AND PERSONS

The Latino Physician Workforce Study, conducted from 2019 to 2021, is a policy-action community-engaged participatory effort to study the current Latina/o physician supply in Washington state.

PURPOSE

The purpose of this study was twofold: to characterize the Latina/o physician supply in the state’s medical workforce—including its geographic distribution relative to the state’s Latina/o population—and to inform legislators and medical education and health care delivery leadership of this dynamic’s impact on access to culturally responsive and linguistically appropriate care for Washingtonians. Additionally, through communicating our policy recommendations to the state legislature, we aspired to influence legislation aimed at the institutional level to eventually increase the Latina/o physician supply in Washington state.

EVALUATION AND ADVERSE EFFECTS

The research-to-policymaking process set forth by the Latino Physician Workforce study resulted in three budget-neutral legislative priorities in anticipation of a statewide budget shortfall attributable to the COVID-19 pandemic. The first two policy recommendations were for public medical schools and residency training programs to establish goals to achieve representativeness in admissions by 2025, and for these schools and programs to be required to publicly report progress annually toward these goals. The legislative request regarding acceptance goals for medical schools was included in Senate Bill (SB) 5228 in the 2021 legislative session.¹⁰ The third policy recommendation was to create a pathway to residency for international medical graduates, and it was included in House Bill (HB) 1129¹¹ for the establishment of temporary licensure of international medical graduates. Our efforts to engage policymakers throughout the process (as study funders, advisory committee members, and symposium participants) resulted in their championing the policy recommendations.

SUSTAINABILITY

Community-engaged participatory efforts toward policy change have significant challenges. Sustaining meaningful and trusted relationships with the community, policymakers, and industry leaders takes ongoing attention and open communication, which are challenged by organizational instability with leadership and staffing transitions. The Latino Center for Health collaborates with Latina/o-serving organizations, communications and media outlets, and advocacy groups that reach both urban and rural jurisdictions across Washington state. Standing advisory committee meetings of representatives from Latina/o-serving entities help guide programmatic decisions for the Latino Center for Health and foster a research-community collaborative environment. Bicultural and bilingual faculty and staff are scarce, and building a strong research group that is not dependent on grant funding to provide long-term sustainability is difficult. Working with a larger advisory group with possibly competing needs and slow processes may create difficult dynamics between partners. Our project was aided by a skilled and trusted facilitator that helped the group navigate through difficult dynamics toward decision-making.

The California physician workforce study indicates that this problem is not unique to our state.⁵ Regional sustainability of these workforce policies may be achievable with aligned and reinforcing efforts by a critical mass of nearby states.

PUBLIC HEALTH SIGNIFICANCE

The goal of achieving parity of Latina/o physicians in the state’s workforce to expand access to culturally responsive and linguistically appropriate care is fundamental to improving the health of Latina/o communities. Furthermore, health-related outcomes improve with patient–physician cultural and linguistic concordance,¹² and Latina/o physicians and other physicians from groups underrepresented in medicine are more likely to practice in underserved communities.

Our study also highlights the importance of trusting partnerships and aligned values (e.g., centering equity and promoting health justice for vulnerable populations) across interested parties. When public health researchers and practitioners invest in and maintain trusting and meaningful partnerships with community, industry, and other potential allies, we create the possibility of achieving culturally relevant and positive health outcomes in a timely manner.