UCLA Family Medicine Program: Addressing Healthcare Disparities and Fostering Diversity

The University of California, Los Angeles (UCLA) Family Medicine Program stands as a vital initiative to cultivate bilingual and bicultural Latino family physicians, addressing the critical need within California's diverse healthcare landscape. Latinos represent the largest racial/ethnic minority group in California, with a significant portion of the population speaking Spanish. This article delves into the program, its objectives, curriculum, outcomes, and overall impact on healthcare equity.

Background and Objectives

The UCLA International Medical Graduate (IMG) program was established to tackle the shortage of bilingual and bicultural Latino family physicians in California. Latinos constitute a substantial portion of the state's population, and a significant number speak Spanish. The program aims to equip IMGs with the necessary skills and knowledge to effectively serve these communities.

Latinos in the United States have grown to 63.7 million, representing 18.9% of the total population and making up the nation’s second largest racial/ethnic group after non-Latino White individuals. By 2050, one in four Americans will be Latino. More than two-thirds of Latinos report speaking a language other than English at home, highlighting the diverse language needs of this group. Latinos with limited English proficiency face barriers to receiving high-quality medical care and report lower satisfaction with provider communication than English-speaking patients. Patients who are matched with language-concordant physicians are more satisfied with their medical care, bond with their physician, and receive a higher quality of care. Despite efforts to increase diversity in the physician workforce, only 6% of practicing physicians in the United States and 6.8% of board certified family physicians identify as Latino. A shortage of Latino resident physicians also exists. Efforts to address this need have focused on early exposure programs, pathway programs, advocacy for increased primary care residencies, and expansion of international medical graduate (IMG) placements in workforce shortage areas. IMGs are physicians who completed medical education outside the United States and includes both US-born individuals who choose to attend medical schools abroad and individuals who are foreign-born and educated. Research shows that IMGs born in Latin American countries are likely to choose their practice locations based on ethnic matching. Among board certified family physicians, 23% are IMGs, and this percentage mirrors the national estimates of IMGs among all physicians. IMGs play a critical role in addressing health care shortages and maldistributions, and also the need for bilingual physicians. In fact, many states have implemented novel IMG programs to address areas with physician shortages. Nine states have approved IMG legislation, and 19 states have pending legislation that would facilitate full licensure practice pathways without postgraduate training for IMGs. Additionally, three states enacted limited licensure pathways. Some include provisions or requirements for practice in underserved areas. However, pathways are limited that offer the necessary support and opportunities for completing postgraduate residency training and American Board of Medical Specialties (ABMS) certification for family physicians. The Federation of State Medical Boards tracks states with enacted and proposed additional full or limited licensure pathways without accredited North American postgraduate training.

To increase the number of bilingual, bicultural Latino/a family physicians in California, the University of California, Los Angeles (UCLA) Department of Family Medicine developed a novel program in 2006 for physicians who had emigrated from Latin America but were not licensed to practice medicine in the United States. The objective of the study was to assess participant characteristics and describe family medicine residency match, board certification, and initial practice outcomes of the UCLA IMG program. Developed in 2006, the preresidency training IMG program is designed to prepare more family physicians to practice in medically underserved California communities. The program, cofounded by P.T.D. and M.B., aims to accomplish this goal by recruiting international medical graduates and providing them with a rigorous professional education and hands-on clinical experiences to compete and match in a California family medicine residency program. A graduate of the program (B.S.C.) is now the program director.

Program Structure and Curriculum

The UCLA IMG program requires full-time participation, residence in Los Angeles County, no outside employment, English and Spanish language fluency, and US citizenship or permanent resident legal status. The program is currently free of tuition or fees, covers educational expenses, and includes a small stipend. Prior to passage of Assembly Bill 1533, state law prevented IMG trainees from participating in supervised clinical contact with patients because they weren’t recognized as residents or medical students enrolled in a school of medicine. As a result, initially the curriculum also focused on how to best prepare participating IMGs to successfully pass the United States Medical Licensing Examinations (USMLE) and improve professional-level English oral and writing skills.

Through passage of California legislation in 2012, the California Medical Board authorized the following program requirements to allow participants to receive hands-on clinical instruction: (a) graduation from a medical school recognized by the California Medical Board (recognition by the World Federation for Medical Education and the Foundation for Advancement of International Medical Education and Research); (b) Educational Commission for Foreign Medical Graduates (ECFMG) certification; (c) passing score for the USMLE Step 1 and 2; and (d) permanent legal US residency status. The state medical board also requires clinical instruction to take place at health care facilities operated by UCLA or other approved UCLA-designated teaching sites with a formal affiliation agreement. Finally, faculty at UCLA or faculty affiliated with UCLA are required to provide the clinical instruction and supervision.

Upon completing family medicine residency training, graduates are contractually required to practice family medicine for a minimum of 2 years in a medically underserved community in California. The curriculum was developed to support participating IMGs to successfully prepare an application to a California family medicine residency training program by providing a clinical hands-on experience in underserved clinical settings and opportunities to learn the language and culture of US medicine. During their training, participants perform patient interviews, conduct assessments, develop treatment plans, draft clinical notes, and present cases to licensed supervising UCLA faculty physicians. This hands-on experience is like that of a medical student involved in patient care while adhering to the medical board supervision and training standards. The curriculum includes a required medical English course. In 2009, the clinical curriculum increased from 8 weeks to 12 weeks (6 weeks hospital and 6 weeks primary care); and in 2010, the outpatient curriculum expanded to include the core concepts of the patient-centered medical home. Participants also are required to complete a course and obtain HIV specialist (American Academy of HIV Medicine) certification. Within the program, clinical training does not exceed 16 weeks of clinical instruction, and all clinical experiences are in underserved settings at UCLA affiliates.

Upon completion of the program, UCLA program directors provide a letter of recommendation for family medicine residency match applications.

Methodology

A cross-sectional study of program graduates (N=204) from 2007 to 2024 was conducted. Data were abstracted from program administrative files and the California Medical Board. Primary outcomes were match rate into California family medicine residency programs, completion of a residency, board certification, and initial training practice location. Residency practice training location was stratified by health professional shortage area (HPSA) designations. Residents who were not yet eligible for board certification or medical licensure were identified and excluded from calculations of graduates who are board certified and/or holding an active medical license. Descriptive statistics were computed for participant characteristics and outcomes. The study was an institutional review board exempt by UCLA. R version 4.4.1 (R Project) was used for all data analysis.

Data abstracted from the program application include age, gender, language spoken, race/ethnicity, immigration status, country of origin, and international medical school.

Key Findings and Outcomes

From 2006 to 2024, a total of 177/204 (87%) participants completed the UCLA IMG program and entered the match. Enrollment has ranged from 4 to 21 physicians. Between 2006 and 2012, 27 participants did not advance (n=25) or withdrew (n=2) due to not passing USMLE Step 1 or 2. Program attrition was observed only among those accepted without passing USMLE Step 1 and/or 2 and was 27/88 (31%). Starting in 2012, a passing score for USMLE was required for acceptance, and no attrition has taken place since then.

All program participants were fluent in Spanish and were US permanent residents or citizens. The program has placed 177 graduates into US family medicine residency programs. All graduates 177/177 (100.0%) that have applied and entered the National Resident Matching Program matched in a family medicine residency program. Of these, 172 (97%) matched in California residency programs and 5 (2.8%) matched in out of state programs. Among program graduates that matched, 157/177 (89%) completed residency training and 18/177 (10%) were in training. The majority of those eligible for medical licensure had a verified medical license (98.8%). ABFM board certification was verified for 152/159 (95.6%) of those eligible. Less than 10% of those that completed residency also completed an ABMS sponsored fellowship. A significant number of graduates matched with UCLA, followed by Riverside and Clinica Sierra Vista in Kern County.

Addressing Health Disparities and Workforce Diversity

In this study of IMG physicians, we found that the UCLA IMG program was effective at preparing IMG program graduates that were fluent in Spanish and bicultural to match in a California family medicine residency program and subsequently practice family medicine in underserved geographic areas. Like other medical specialties, family medicine falls short in racial/ethnic diversity and does not reflect the diversity of the US or California population. The UCLA IMG program addresses the need for more bilingual and bicultural Latino family physicians in California where Latinos are the largest racial/ethnic minority group and where a large percentage of the population speaks Spanish. Building a diverse family physician workforce should include IMG pathway programs with postgraduate training that address health disparities in diverse disadvantaged communities. Without IMG pathways to practice and other medical education innovations, research has estimated that 92 years of a doubling of matriculating Latino medical students would be required to correct the deficit of Latino physicians. All program graduates successfully matched into family medicine residency programs, with the vast majority (97.2%) training within California. Nearly half (45%) of these graduates are serving in the rural San Joaquin/Central Valley agricultural regions of California, addressing a critical shortage of primary care physicians in these underserved communities.

Policy Implications and Model Pathway

Our study has health equity, workforce, graduate medical education, and primary care policy implications. The UCLA IMG program represents a model pathway program for IMG physicians to seek residency training, ABFM certification, and help mitigating health disparities that arise from the lack of primary care access in underserved areas. While many US states currently are debating legislation authorizing new pathways for IMGs toward licensure and clinical practice in underserved rural and urban areas, the UCLA IMG program is a case study that illustrates how US medical schools and departments of family medicine can develop and innovate programs that provide pathways for IMGs toward board certification and family medicine practice for communities in most need of diverse physicians. States with enacted or proposed legislation creating licensure pathways for primary care practice lack academic family medicine input. Another policy consideration is the brain drain that occurs when IMG physicians from low-income countries migrate to higher-income nations like the United States, worsening health care shortages in their home countries. The UCLA IMG program recruits and trains IMGs already residing in the United States-citizens and permanent residents.

Limitations and Future Directions

This study had limitations. Our study was descriptive, and we acknowledge selection bias among program participants. We did not have a comparison group. The UCLA IMG program requires that graduates practice 2 to 3 years in an underserved California area, and future studies will evaluate long-term practice choices, patient population characteristics, and predictors of success or challenges. Future studies also will include qualitative methods to capture participant perspectives and areas of program improvement. More than half of family physicians practice within 100 miles of their residency program location and within the same state, while California retains 75%. Research has shown that IMGs tend to practice in the same state where they do their graduate medical education training and where they have networks, and that IMGs born in Latin America choose practice locations based on ethnic matching.

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A major barrier for IMGs to obtain medical licensure and board certification is the limited understanding of the process required to enter a US residency training program. Other barriers include limited English proficiency and limited understanding of the US health care system and graduate medical education, meeting ECFMG requirements, passing the USMLEs, and obtaining an authorized immigration status. The UCLA IMG program…

UCLA Family Medicine Residency Program

The UCLA Family Medicine Residency Program is dedicated to diversity and depth of quality experience: Critical to acute to outpatient continuity care: Our residents receive ACLS, BCLS, Neonatal and PALS training/certification during orientation, sponsored by the UCLA Medical Center. Our residents comprise the rapid response team of Santa Monica Hospital, and senior residents oversee rapid responses and codes. Our residents work alongside UCLA residents from the pediatric, surgical, emergency medicine, and internal medicine programs. Our residents develop robust continuity patient panels at UCLA Family Health Center (UFHC) and MidValley Clinic. Academic lecture series to informal talks to medical student mentorship Education Half Day Curriculum every Wednesday morning devoted to a combination of didactics, small group discussions, and Journal Club presentations. This Wednesday morning experience uses a rotating 18 month curriculum covering the core topics in Family Medicine. Scholarly projects are required and presentations on clinical topics for various conferences throughout the Medical Center and Residency are encouraged. ○ Culture of real-time teaching whether in clinic or while rounding that transcends across all training sites, led by UCLA attending physicians. Dedication to UCLA medical student mentorship, beginning as PGY2 where students work closely with residents for patient care, presentations, and note collaboration.

Training Sites and Patient Diversity

Our residents spend approximately half of their training at either Mid-Valley County Clinic and Olive View/UCLA County Medical Center for adult outpatient and inpatient medicine, urgent care, pediatric, and emergency medicine experiences. Santa Monica: Our UCLA Family Health Center serves a racially and ethnically diverse population, including many university employees as well as families from the local community. Most patients have public or private insurance; some are medically indigent. Mid Valley: Our Mid Valley site is based in a new county comprehensive care clinic located in the federally designated underserved community of Van Nuys, in the heart of San Fernando Valley. It serves a diverse, medically indigent population that is predominately Latino and immigrant.

Mission and Opportunities

The mission of the UCLA Family Medicine Residency Program is to train exemplary clinician leaders and educators who are able to provide care for patients in both inpatient and outpatient settings, with particular emphasis on the care of medically underserved patients and their communities. Our program is an integral part of the Department of Family Medicine at UCLA and benefits from UCLA Health's broad geographic network of hospitals, clinics, and other facilities that stretches across the social, and economic breadth of one of the nation’s largest cities. We offer our residents: A broad-based curriculum that includes rich inpatient and ambulatory care experiences, and reflects state-of-the-art community and evidence-based medicine and clinical care. In-depth and immediate exposure to UCLA's renowned abundant research and medical education resources for those inspired to pursue academic medicine. An expansive choice of community outreach opportunities, including mentorship programs in communities of greatest need, community health fairs, and global health opportunities. A multitude of diverse experiences and the flexibililty to find and pursue their personal passions in medicine throughout all three years of training. Unparalleled leadership and teaching opportunities.

Harbor-UCLA Family Medicine Residency Program

Harbor-UCLA Medical Center offers a dynamic Family Medicine Residency Program designed to train residents as versatile and resourceful family physicians equipped to address the health needs of diverse and underserved populations. The program emphasizes not only clinical excellence but also a commitment to health equity and social justice, underlining the belief that healthcare is a fundamental human right.

Program Overview and Curriculum

The Family Medicine Residency Program is a three-year training program providing residents with comprehensive training in a wide range of family medicine practices. This training includes exposure to chronic disease management, acute care, procedural skills, and community health engagement. The program takes pride in its culturally diverse and socially engaged community, enabling residents to work directly with patients from various backgrounds and address the social determinants of health that affect access to care. The curriculum has been updated in alignment with the latest ACGME requirements, ensuring that residents acquire essential competencies throughout their training. The program includes a longitudinal Community Medicine curriculum, where residents explore epidemiology, cultural sensitivity, and intervention strategies tailored to the community's needs. Throughout the three years, residents develop leadership skills and participate in community advocacy, reinforcing the program's commitment to social change and health equity.

Key Rotations and Training Sites

During the residency, residents rotate through various training sites characterized by multicultural populations. Each rotation is designed to provide hands-on training experiences, emphasizing the delivery of care in medically underserved areas. Residents receive mentorship from experienced faculty who are passionate about community health and primary care advocacy. The residency program has training sites that serve as a living classroom for residents, where they learn the practical skills necessary for patient care. These sites include county clinics and community hospitals where residents are exposed to real-world challenges faced by underserved populations. The program values experiential learning, allowing residents to address and navigate the barriers that impact health access.

Fellowship Opportunities

In addition to the comprehensive residency training, the program offers fellowship opportunities, including:

Sports Medicine Fellowship: This is a fully-accredited fourth-year position that trains residents in the management of sports injuries and team physician responsibilities.
Community Health Fellowship: Focused on preparing residents for advocacy and service work in partnership with underserved communities.
Faculty Development Fellowship: Tailored for residents who aspire to academic medicine, focusing on curriculum development and leadership.

Application Process and Visa Sponsorship

Applicants to the Harbor-UCLA Family Medicine Residency Program must submit their applications through the NRMP and ERAS, following which a completed application must include various essential documents such as a Dean's letter, medical school transcripts, and three letters of recommendation, one of which should be from a primary care physician. Additional requirements apply for international medical graduates, including ECFMG certification and a valid California medical license. The program is friendly to international medical graduates (IMGs) and is able to sponsor visa types necessary for residency. Generally, the program supports J-1 and H-1B visa sponsorship for qualified applicants.

Resident Life and Community Engagement

Harbor-UCLA Family Medicine Residency Program is integrated into a supportive community that values wellness and resilience among residents. The program offers advocacy training, personal mentoring, and numerous extracurricular activities to enhance camaraderie and professional development. There are also numerous opportunities to engage in global health initiatives, allowing residents to work in international settings during their vacation time. The program not only focuses on training excellent clinicians but also prepares residents to be advocates for social justice. The longitudinal Community Medicine curriculum engages residents in real-world scenarios where they tackle health disparities within their local communities. Activities include participating in free clinics, school-based health services, and community health fairs that bring healthcare directly to underserved populations.

Salary and Benefits

Residents receive a competitive salary commensurate with other programs in the region. As of October 2024, the salary for a first-year resident (PGY-1) is approximately $72,301, with benefits that include health insurance, paid vacation, liability insurance, and additional support for professional development activities. Additional information regarding bonuses for primary care practices and other incentives can also be found through the program's resources.

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