A few years ago, while loading discarded construction materials onto a truck, Jesus Antonio Lara Cuellar fell and hit his head. He injured his back too, but it was his fractured wrist that landed him in a Houston emergency room. Lara, from El Salvador, couldn’t string together enough English words to explain what had happened. The attending physician’s command of Spanish was no better, and there were no interpreters available to help the conversation along.

“He asked me some questions. I said ‘yes, yes, yes,’ and ‘no’ to some things, but I didn’t know what he was asking me,” Lara told me recently, in Spanish. The doctor administered several injections, and then, without warning—or at least none Lara had understood—proceeded to yank at his arm, causing him intense pain. “I shouted ‘stop,’ but he didn’t listen,” Lara said. “It was horrible.”

He now knows that the doctor was preparing his arm for a cast. The shots had been for the pain, to relax his muscles, and to prevent tetanus. “There was a barrier between us,” Lara said. It would be years before he felt comfortable going to the doctor again.

There aren’t nearly enough physicians in Texas capable of communicating effectively with the more than 7.5 million Texans who solely or primarily speak Spanish. And that’s on top of the fact that Texas has a shortage of physicians of any language abilities—more than 6,000 too few—and a shortfall of 29,000 registered nurses that is expected to nearly double by 2032.

Because there’s no reliable count of how many Texas physicians speak Spanish, most experts point to the need for more doctors from among the 40 percent of the state’s population who are Latino to help address the shortfall. Only about 10 percent of physicians, and 17 percent of medical students, identify as Latino or Hispanic. Yet most of the state’s medical schools and residency programs aren’t training enough primary care physicians, much less Spanish speakers, to make up the difference any time soon.  

Still, there are efforts to change that. The Texas Tech University Health Sciences Center in El Paso operates the only medical school in the country that has incorporated mandatory Spanish-language instruction into its curriculum. Almost two-thirds of its roughly eight hundred graduates since its founding, in 2009, identify as Hispanic. Before new students dive into the intricacies of biochemistry or pathology, they are immersed in the social, financial, and psychological complexities of border communities. They begin with a three-week language-immersion exercise in one of a dozen impoverished El Paso neighborhoods, where they interact with Spanish-speaking patients and learn to recognize when their own ability to speak the language is a significant limitation. Further language instruction continues throughout the first year, and the second year incorporates more Spanish medical terminology. For the remaining two years of the program, the school offers further courses in medical Spanish, language labs, and other opportunities in the community for students to practice their language skills, though none of these are required.

As the founding dean, Jose Manuel de la Rosa was closely involved in determining the type of medical school Texas Tech created in El Paso, a city whose population is 82 percent Hispanic and largely Spanish-speaking. He recalls the chair of the psychiatry department raising an important question amid the discussion. “He said, ‘If our doctors can’t speak Spanish, how are they going to know when a patient says the television is telling them to jump out the window?’ ” De la Rosa told me of his colleague’s comments. “And then the rest of the group joined in, because if you can’t talk to half your patients in pediatrics or internal medicine, how can you practice medicine in El Paso?”

Initially the school considered making prior instruction in the language a prerequisite for entrance, but there was concern that such a requirement might be interpreted as an unfair advantage for Latinos. Rather than demanding language proficiency, the school settled on a more practical solution. It designed a Spanish course adaptable both to students who have never spoken the language and to native speakers. But all students, regardless of their skills with the language, must improve to a higher level of competency in Spanish in order to graduate.

Considering the variability of language proficiency among incoming students, fluency isn’t the goal. The focus is on training physicians who, at a minimum, are able to engage with patients in Spanish. “We want students to be able to start the conversation (in Spanish), but also to understand their own limitations, and to know when to enlist an interpreter,” said Salma M. Elwazeer, a clinical assistant professor at the medical school, and assistant professor in the Texas Tech University Health Sciences Center El Paso dental school.

At the opposite end of Texas’s border with Mexico, the University of Texas Rio Grande Valley School of Medicine makes a concerted effort to admit students from the Valley, many of whom speak Spanish. But expanding the local pool of medical school applicants has been a challenge, according to Leonel Vela, senior associate dean for educational resources at UTRGV. “We’re behind the eight ball,” he said. “But it is achievable.”

Despite efforts to close the education gap in Texas, structural and historical barriers continue to disproportionately and negatively affect the Latino population, which in turn depresses the number of Spanish-speaking doctors. The COVID-19 pandemic, in which Latinos had a mortality rate more than twice that of non-Latino whites, laid bare this disparity,  as well as the urgency to increase representation in medicine, argued three doctors from UT Health Science Center at San Antonio, in the Journal of the American Medical Association in 2021.

“Enhancing educational opportunities and attainment is the key to admitting diverse medical students into medical school,” wrote the authors, among them transplant surgeon Francisco G. Cigarroa. While serving as chancellor of the UT system, Cigarroa spearheaded the effort to create the UTRGV medical school in 2014. Even as direct state appropriations for medical education for the 2022–2023 biennium will top $3.446 billion, there is more to be done, the authors argue. “The debt burden to all undergraduate and medical students should be alleviated so that pursuing an academic career in medicine and science is achievable,” Cigarroa and his fellow authors concluded.

Physicians will, of course, work across cultures and languages, but in the view of Stephen J. Spann, who was raised in Uruguay and is now dean of the University of Houston’s medical school, any healthcare workforce should ideally match the population it serves. As things stand now, health care institutions that receive federal funding, such as Medicare or Medicaid payments, must provide interpreters. Even so, Spanish-speaking patients and their families often look to Latino health care workers, regardless of whether they’re proficient in medical Spanish. “When a patient who sees a physician with a similar cultural background, they’re much more willing to follow recommendations,” Spann said. “At the end of the day, we need to admit more Latino students.”

The UH medical school, established in 2019, gives preference to students who demonstrate an interest in primary care for underserved populations, and as a result, its student body is the most diverse in the state. Sixty-six percent hail from Black, Latino, and immigrant communities, and a majority of them speak Spanish. “If applicants say they are bilingual, that is a little bit of an advantage,” Spann said. He emphasized that while language is certainly important, cultural humility is essential.

A first-year medical student at UH, Anna Franklin has witnessed the positive effects of language and culture in Spann’s clinic. She has also seen how the lack of these points of connection failed her mother, an experience that informed Franklin’s decision to study medicine. Her mother, who is Peruvian, speaks English but is more comfortable communicating in her native tongue. Yet when she was diagnosed with Parkinson’s disease, she was referred to a non-Spanish-speaking neurologist with a different cultural background in Houston. “She felt like her concerns were easily dismissed, but because she is very shy, she didn’t feel like she had the right to question her doctor,” Franklin said.

Her mother became increasingly reclusive, which exacerbated her condition. Franklin persuaded her mother to switch to a Spanish-speaking doctor from Colombia. “Eliminating the language and cultural barriers was absolutely crucial,” Franklin said. “The neurologist she has now can explain things in a way that makes sense to her, and the improvements she has made over the past year have been phenomenal.”

A year ago, Lara saw a news report on Telemundo about Spann’s clinic, which serves low-income and uninsured patients. Assuming that language would again be an obstacle, he was reluctant about going in for a checkup. But when Lara finally did, Spann greeted him in fluent Spanish. “I got up and hugged him, like you’d hug a family member that you haven’t seen in a long time,” Lara said. “Since then, I look forward to my doctor’s appointments.”