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Old town, nuevos patients: Small-town doctors treating influx of Hispanic immigrants

New populations are changing the face of rural communities and changing the way physicians practice.

By Bob Cook, AMNews staff. Oct. 1, 2001. Additional information


Ligonier, Ind. -- Kim Waterfall, MD, is like a lot of small-town doctors. He sees patients with a wide variety of conditions. He's one of the few physicians in his area. And he struggles to communicate with his vast number of Spanish-speaking patients.

Dr. Waterfall, a Ligonier, Ind., family physician, and other small-town physicians nationwide are just beginning to absorb a massive wave of immigration, mostly from Mexico, that hit some of America's smallest towns over the last five years.

A bilingual physician could increase his income an extra 5% to 7% a year in locum tenens.

The lure, same as it ever was for America's immigrants, is jobs. Jobs in meatpacking, manufacturing, carpet-making. Jobs in areas with not nearly enough people to fill them, like Ligonier, with 4,357 residents and about 2,500 industrial jobs. And two physicians.

Dr. Waterfall likes that his Spanish-speaking patients tend to smoke less, listen to their doctor more and tend to be better about paying at the time of service than his other patients.

"I had preconceived notions of Mexican people, " Dr. Waterfall said. "I felt most weren't the kind of people I wanted as patients.

"I was expecting that if I said something wrong, they'd flip a switchblade out and be some sort of Pancho Villa-type. I didn't expect them to be as nice as they were. I grew up in Columbia City, Ind., and my exposure to Mexicans was next to nil."

But the language barrier, despite the hiring of a Spanish-speaking office helper to double as an interpreter, makes for long days. Not good when your hospital employer -- in Dr. Waterfall's case, Parkview Health System of Fort Wayne, Ind. -- is paying you in part based on productivity.

"I still feel there is some type of a cultural barrier that makes it harder to give them service," Dr. Waterfall said. "It takes longer. So it does impact you economically."

But not too much, said Keith McManus, MD, a family physician in Siler City, N.C., 30 miles from the University of North Carolina in Chapel Hill. Certainly not to the effect of cuts in Medicare, Medicaid, or managed care reimbursements. "We just stay late," Dr. McManus said.

The nation's Hispanic population increased 57.2% between 1990 and 2000, according to the U.S. Census Bureau, more than any other ethnic or racial group tracked in the decennial survey.

More than half of the nation's 30 million Hispanics are either in California or Texas, but their population is spreading. Thirty-four states saw their Hispanic population growth beat the national average, and 22 states saw their Hispanic populations at least double, led by North Carolina at a 393.9% increase.

Hispanics first moved to Ligonier in the 1960s, attracted by migrant tomato picking but staying for the manufacturing jobs. In 1990, Hispanics accounted for 9% of its 3,443 residents.

But in 1993, the Chamber of Commerce in nearby Elkhart County placed ads along the Texas-Mexico border saying the region needed industrial workers, and from there word spread about Ligonier, said the chamber president, Glenn Longardner. The jobs, mostly in auto manufacturing but also supporting the region's recreational vehicle and manufactured-housing industries, pay about $11 a hour, or about the same wage as a Mexican laborer might make in a day back home.

The result: Ligonier's Hispanic population zoomed up 352%, to 1,451 from 321. With 33% of the northeast Indiana town's residents Hispanic, the once-empty Cavin Street strip downtown now has three Mexican restaurants, one Mexican supermarket, a Mexican ice cream shop, two Spanish-language video and music stores, a Spanish-speaking real estate agent's office and a Mexican Western-wear shop.

Crossing through the Mexican-dominated downtown are families of Southern whites who settled here in the 1950s and 1960s, horse and buggies ridden by Amish families living outside of town, and the most recent immigrants, Yemenis, some dressed in traditional Muslim garb.

Making adjustments

Like Ligonier, many of the towns that attracted Spanish-speaking immigrants had little or declining population growth in recent years, but doctors were still busy because of the chronic problem of attracting physicians to small communities.

The office of Robert Stone, MD, sits in a chipping-white-paint, two-story columned building at the south end of the Cavin Street strip. Dr. Stone, a family physician, has practiced in Ligonier for 42 years. Ten of those years, he was the only physician in town. Now, he and Dr. Waterfall are the only doctors in Ligonier -- another family physician left last year. The nearest hospital is 18 miles away -- northwest to Goshen, Ind., or east to Kendallville, Ind.

The combination of few doctors and no nearby hospital makes it no problem to attract Spanish-speaking patients, even though Dr. Stone, like Dr. Waterfall, doesn't speak the language, and, unlike Dr. Waterfall, doesn't have a Spanish speaker on staff.

Dr. Stone said his income hasn't changed with the ethnicity of his patient base. Doctors in Ligonier and elsewhere say the mix of insured, Medicare and Medicaid patients is virtually the same as it was before Spanish speakers emigrated to their town.

But Dr. Stone has adjusted his schedule. He said he had so many walk-in patients, many of them new to the United States, that he stopped maintaining an all-appointment schedule.

"It's been a year since I stopped doing hospital rounds. It's in direct response to the fact I've been so dadgone busy. It makes more sense to send [patients] to a hospitalist or internist. That allows me to spend more time in the community."

Dr. Waterfall, employed by a hospital, hasn't dropped his rounds at the Parkview Noble Hospital in Kendallville, nor has he stopped taking appointments at his clinic, on the south edge of town on U.S. 33, between a furniture store and a bank.

But after having absorbed a state-run, sliding-scale fee-for-service clinic whose funding got pulled last year, he's hired on that clinic's nurse practitioner, Barb Chivers, who sees new patients. Officially, Dr. Waterfall is not accepting new patients, "but I don't turn anybody down."

Among the other adjustments Dr. Waterfall has made:

  • Hiring Spanish-speaking office staff to serve as interpreters. "If [women] came in, they might bring a 7-year-old child to do the interpretation. That impacts on care in a big way. If a woman has feminine difficulties, and you're working through her 7-year-old son, that doesn't work."
  • Finding a pharmacist to help figure out Mexican prescriptions. "Seven out of 10 [patients] get to Mexico once a year. And they bring back medicines. So I call Lutheran Hospital in Fort Wayne, Ind., and its has a computer that matches the Mexican drug to the U.S. equivalent."
  • Spending extra time going through charts. After taking in the state clinic, Dr. Waterfall and Chivers tossed out 1,000 charts of patients believed to have moved back to Mexico or Texas. Because translation requires longer patient visits, Dr. Waterfall and Chivers spend an extra two to three hours a night going over charts.

One adjustment Dr. Waterfall would like to make is to get another physician, but that's not likely to happen soon. Goshen Health System, which runs the Goshen General Hospital, has been trying for six months without success to find a full-time doctor for Ligonier.

Finding someone qualified for a multicultural small town is difficult, said Jim Hamilton, vice president and executive director of Parkview Medical Group, the arm of the Parkview system that runs Dr. Waterfall's office and others in northeast Indiana.

"Rural Indiana, Ligonier, good quality care, speaks Spanish -- you can see how the algorithm goes," Hamilton said. "You've almost narrowed yourself to a population that's pretty small."

For a model on how to recruit such a physician, many states dealing with large Hispanic growth are looking to North Carolina. The North Carolina Medical Society Foundation and the state's Office of Rural Health for 25 years have worked together to provide a package of medical education loans, moving expenses and other perks in exchange for doctors agreeing to work in rural areas.

Burnie Patterson, assistant director at the Office of Rural Health, said "people are very interested in bilingual [physicians]. They are more in demand, so they have more options than most physicians coming out."

Looking for Spanish speakers

A bilingual physician could make an extra 5% to 7% a year, at least in locum tenens, said Dustin Koger, vice president of operations at Staff Care, the temporary placement office for Irving, Texas-based physician recruiter Merritt Hawkins.

Some medical students are already learning Spanish in anticipation of this need. Patricia Keener, MD, an assistant professor of pediatrics at the Indiana University School of Medicine in Indianapolis, said her school had set up a medical Spanish class because of the unexpected growth of the Hispanic population in her state -- up 117.2% since 1990.

In Ligonier's Noble County, the only Spanish-speaking doctor is psychiatrist Domingo Cruz-Diez, MD, a Puerto Rico native who runs the Kendallville-based Northeastern Center, a nonprofit mental health group. Dr. Cruz-Diez practices in Ligonier for a few hours every Monday.

Some of Ligonier's Spanish speakers prefer to travel elsewhere to find a doctor who speaks the language, said Jose Gutierrez, pastor at Templo Betel, a Spanish-language Assembly of God church. The closest is a doctor in Topeka, Ind., five miles away. But most stay in town, he said.

So that means physicians like Dr. Waterfall and Dr. Stone will need to find a way to communicate with Spanish speakers -- or pick up a little Spanish themselves.

"I understand Spanish -- some of the medical-ese, whether or not they have colds, diarrhea, vomiting," Dr. Stone said. "Because I had four years of Latin and three years of French -- they're all romance languages -- if you have the same base and any kind of ear, you can pick it up quickly."

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Tips on using an interpreter

  • Speak to the patient, not to the interpreter.
  • Face the patient.
  • Use courtesy greetings in the patient's language.
  • Learn key words pertaining to medicine to keep up with the interpreter.
  • Allow sufficient time for the interpretation.
  • Do not expect the interpreter's timing to match yours. It might take more or less time to explain what you said.
  • Do not interrupt the interpreter. Let the interpreter finish a point before adding more or asking for clarification.
  • Speak slowly, clearly and in short sentences.
  • Use lay terms as much as possible.
  • Help the interpreter prepare by providing appropriate information in advance.
  • End the session diplomatically if it's not going well. Seek help elsewhere and understand that knowing the language does not necessarily mean skillful interpreting.

Source: Indiana State Medical Assn., as provided to the organization by Jos´┐Ż Lusende, multicultural coordinator at St. Vincent Hospital, Indianapolis

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Profile of Ligonier, Ind.


1990 population: 3,443
2000 population: 4,357

1990 Hispanic population: 321
2000 Hispanic population: 1,451

10-year population growth

Overall: 914 (up 26.5%)
Hispanic population: 1,130 (up 352%)
Non-Hispanic population: -216

City's state rank

Overall population: 134
Number of Hispanic residents: 22
Percentage of Hispanic residents: 2 (33.3%, behind East Chicago, Ind., at 51%)

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Hispanic population on the rise

The national growth rate of the Hispanic population over the last 10 years is 57.2%. But many states outstripped that percentage, mostly states that had a small Hispanic population in 1990. Twenty-two states at least doubled their Hispanic population between 1990 and 2000. The growth ranking (parentheses indicates rank in total number of Hispanics) is as follows:

Top states, Hispanic growth:

1. North Carolina: 393.9% (15)
2. Arkansas: 337% (36)
3. Georgia: 316.1% (10)
4. Tennessee: 278.2% (28)
5. Nevada: 216.6% (14)
6. South Carolina: 211.2% (32)
7. Alabama: 207.9% (38)
8. Kentucky: 172.6% (39)
9. Minnesota: 166.1% (27)
10. Nebraska: 155.4% (33)
11. Iowa: 152.6% (37)
12. Mississippi: 148.4% (41)
13. Oregon: 144.2% (19)
14. Utah: 138.3% (23)
15. Delaware: 135.6% (42)
16. Indiana: 117.2% (22)
17. Oklahoma: 108.1% (26)
18. South Dakota: 107.6% (48)
19. Wisconsin: 107.0% (24)
20. Washington: 105.8% (11)
21. Virginia: 105.6% (16)
22. Kansas: 101.0% (25)

Rank by total number of Hispanics:

1. California: 10,966,566
2. Texas: 6,669,666
3. New York: 2,867,583
4. Florida: 2,682,715
5. Illinois: 1,530,262
6. Arizona: 1,295,617
7. New Jersey: 1,117,191
8. New Mexico: 765,386
9. Colorado: 735,601
10. Georgia: 453,227
11. Washington: 441,509
12. Massachusetts: 428,729
13. Pennsylvania: 394,088
14. Nevada: 393,970
15. North Carolina: 378,963
16. Virginia: 329,540
17. Michigan: 323,877
18. Connecticut: 320,323
19. Oregon: 275,314
20. Maryland: 227,916
21. Ohio: 217,123
22. Indiana: 214,536
23. Utah: 201,559
24. Wisconsin: 192,921
25. Kansas: 188,252
26. Oklahoma: 179,304
27. Minnesota: 143,382
28. Tennessee: 123,838
29. Missouri: 118,592
30. Louisiana: 107,738
31. Idaho: 101,690
32. South Carolina: 95,076
33. Nebraska: 94,425
34. Rhode Island: 90,820
35. Hawaii: 87,699
36. Arkansas: 86,866
37. Iowa: 82,473
38. Alabama: 75,830
39. Kentucky: 59,939
40. District of Columbia: 44,953
41. Mississippi: 39,569
42. Delaware: 37,277
43. Wyoming: 31,669
44. Alaska: 25,852
45. New Hampshire: 20,489
46. Montana: 18,081
47. West Virginia: 12,279
48. South Dakota: 10,903
49. Maine: 9,360
50. North Dakota: 7,786
51. Vermont: 5,504

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