One Last Chance to Be a Doctor

The letter from the USC medical school sat atop the brown, polished upright piano in the Villarreals’ San Joaquin Valley home, unopened. Would it be a rejection like the others? Another crushing blow to Cristina Villarreal’s childhood dream?

Until she applied to medical school, Villarreal’s academic career was nothing but a string of victories: high school valedictorian with a perfect 4.0 grade-point average. Senior class president. The dutiful daughter of farm workers, a student who went off to MIT to earn a degree in chemical engineering but came home summers to help pick grapes.

And then the disappointments began to mount.

“I’m sorry to inform you,” the letter from UC Irvine’s medical school began. UCLA’s letter tried to cushion the pain, citing “the exceptionally competitive applicant pool.” So did UC San Francisco: “This adverse decision does not mean we believe that you are unqualified to enter this medical school. . . . “

Getting into medical school is supposed to be tough. Only the smartest should be allowed to make life-or-death decisions.

But what does “smart” mean for a young woman like her who didn’t have the luxury of wealth or the best schools, but still made it through one of the most demanding majors at one of the nation’s toughest universities? Isn’t that smart enough?

Isn’t Cristina Villarreal precisely what the medical profession needs to solve its historical shortage of minority physicians--especially those, like her, who want to practice in poor, minority communities that have a desperate shortage of doctors?

Those are the kinds of questions that medical schools in California are struggling to answer. For months, medical school deans have been meeting to figure out why the already small number of minority students at their schools has been shrinking for the past seven years. And why they cannot train enough doctors for underserved communities. Communities like Villarreal’s.

Her dream of becoming a doctor was born of watching her family physician, a folksy country doc who wouldn’t charge her father when money was tight. The dream was nurtured when she got to the Massachusetts Institute of Technology and saw for the first time that Latinas could become doctors.

Now she faced the letter from USC. One more chance.

Father’s Commitment to Education

The only reason Cristina had a chance was that her father broke with family tradition.

Unlike others in a clan who emigrated from a village outside Monterrey, Mexico, Carlos Villarreal made a commitment to his children’s education. He would not pull them out of school to help in the fields. Ever.

It was a sacrifice. Extra hands, even if small, have always been part of the economic equation in the grape fields. A good day’s wages meant at least two rows, a thousand trays of grapes.

Parents picked steadily, shaking off the spiders, the bees and the fatigue induced by the scorching sun. The children laid out the paper and spread the grapes evenly so they would dry, not rot.

Cristina and her brothers, Carlos Jr. and Isauro, helped on weekends, sometimes before school, sometimes after. They would not follow their father, who dropped out of school after the eighth grade, or their mother, Adriana, who completed only the third grade.

The words from an uncle echoed in Carlos Villarreal’s head: You can give your children money, but they can lose it. Education, that can never be taken away.

Some relatives thought he was crazy. Others thought him lucky; he had a wife who could pick grapes as fast as a man, giving the family a luxury unavailable to others.

The sacrifice of the parents gave power to their demands: Go to school. Pay attention. Do your homework. The kids knew what they’d hear if they faltered: Don’t worry, you can always come to work with us in the fields.

School came easier for Cristina than her older brother. Carlos Jr. spoke almost no English when he entered kindergarten. Cristina learned English from him and was better prepared when she followed him two years later. The youngest brother, Isauro, had it easier still. He has just completed his sophomore year at Harvard.

When their father sat on the family room floor teaching Carlos Jr. the words for different colors, Cristina danced around them in her little dress, giggling and shouting out the colors before her brother could answer. The father, gifted at arithmetic, drilled his kids on the multiplication tables.

The closeness of the family was reinforced in the fields. As Cristina grew taller and stronger, she no longer was assigned the lighter duty of laying out the paper, spreading the grapes to dry. Her parents bought her a bright red plastic tray for hauling grapes. This bandeja colorada, or red tray, stood out from the others, which were uniformly gun-metal gray.

Cristina juggled picking grapes with her studies and other activities through high school. She played varsity basketball and softball. She scooped ice cream at Thrifty part time. She was senior class president and active in various clubs.

Still, she managed to breeze through school with a straight-A average. She and five of her friends took the single Advanced Placement class available at Orosi High--in calculus.

All this came easily, but it was not sufficiently rigorous to prepare her for one of the toughest colleges in the nation. The first years at MIT were a struggle. Compared to classmates from expensive prep schools, she felt totally unprepared for the trilogy of courses that crush so many freshmen: physics, chemistry and calculus.

She worked long into the night and swallowed her pride, asking friends to help. She stuck to her chemical engineering major, maintaining nearly a B average. She never resorted to the trick used by some MIT students: Stroll down the road and take a less demanding class at Harvard to boost the GPA.

All this time, she continued her juggling act. She worked part time. She played varsity softball. She tutored high school students in math for the SAT. She also was chapter president of the Society of Hispanic Professional Engineers, and founded the MIT chapter of Mexican Americans in Engineering and Sciences. She arranged the pachanga, or bash, for the hundreds of Latino students at northeastern universities who could not make it home for Thanksgiving.

And every summer, after her internships, she would come home to help her parents during the grape harvest. Everybody in town did. About 90% of the 5,600 Orosi residents are farm workers. Three out of four live below the poverty line. Twenty-three percent are unemployed.

Mary Balakian, whose family owned one of the local farms, was startled to learn of an MIT student among her pickers. Balakian, a retired Pentagon budget analyst, ventured into the field and approached the figure of a young woman bent over, swaddled in hat, scarf and long sleeves to protect against the sun.

Is it true that you are going to MIT? Cristina straightened up. Yes, she said. There was a long pause. Do you tell your friends at school that you come here summers and pick grapes? No, Cristina said.

Her closest friends at MIT knew of her background as a farm laborer. No need to dwell on it. That’s just the way it was.

Once, an MIT girlfriend approached her, chatting excitedly about the upcoming rally for the United Farm Workers. Although both Cristina and her friend were members of a campus support group, La Union Chicana por Aztlan, only the girlfriend rallied to the cause of boycotting strawberries.

“You never worked a day in the fields in your life and you are so active,” Cristina said, teasing her friend. “I’m the one who should be doing this.”

But Cristina didn’t. She was always studying.

In her senior year at MIT, Cristina took the Medical College Admission Test, or MCAT, without any of the preparation most students undergo. She applied to every medical school in California. The rejection letters came swiftly, and she felt herself succumbing to self-doubt. Why had she worked so hard? What was the point of all the sacrifice? Why continue the struggle?

During the regular Sunday night phone call home, Cristina tried to mask her frustration. Adriana Villarreal knew better. She gently teased her daughter to snap her back to reality.

“No te preoccupes. Aqui te esta esperanda tu bandeja colorada.”

Don’t worry. Your red tray is waiting here for you.

Not Giving Up on Medical School

Take the job.

That’s what her parents said. So did her colleagues at MIT. She got what many coveted, an offer at a prestigious pharmaceutical company: $45,000 a year as a beginning chemical engineer. Management track. It would mean clothes, a nice place to live. More important, it was a way to start chipping away at $15,000 accumulated in student loans.

But Cristina was torn. She felt she hadn’t given medical school her best shot. “They rejected me, but they didn’t really know me,” she said. “I knew I was better than that. I wanted to prove to myself that I was.”

So with the blessing of her parents, she declined the job, moved back to California and enrolled in a master’s program in public health at Cal State Fresno. It was close to home and comparatively cheap.

This was a time to prepare to retake the medical school admission test, show that she could handle graduate work and broaden her experience in medicine.

From her public health professors, she learned about the misalignment of doctors in the state. California has no shortage of physicians, but doctors are mostly clustered along the coast and in wealthier cities.

Places like Orosi have fewer than one-tenth the percentage of doctors to residents as wealthier coastal cities, which means they carry the federal designation of “primary care health professional shortage” areas.

In an effort to compensate, the National Health Service Corps coaxes newly minted doctors into poor rural communities every year by paying for their medical education. Even then, the young doctors usually move on shortly after fulfilling their minimum commitment of two to four years.

But Orosi was the kind of place where Cristina wanted to practice. Someplace in the Central Valley. A small town close to her family, she’d tell her parents, where she could become “a poor country doctor” like Dr. Gary Shannon, their physician.

Shannon, fluent in Spanish from his years in a Guadalajara medical school, rarely charged the Villarreals, who lacked money and medical insurance.

He has a waiting room that’s so packed, he must turn away 10 patients a day.

He remembers Cristina as a curious 8-year-old always peppering him with medical questions. “Can I work for you? I won’t even ask for money.” He called her his “little Hispanic Albert Schweitzer.”

“There isn’t a schoolchild in Cutler-Orosi who doesn’t know about Crissy,” Shannon said. “She’s a flower in the midst of a desert.”

At Cal State Fresno, Cristina became certified as an emergency medical technician. On her first call, her team of paramedics found a shrieking 5-year-old girl. Her arm was fractured, a bone poking through her skin. The senior paramedic tried in vain to communicate with the terrified parents. But they spoke no English.

Cristina cradled the little girl’s head and whispered to her in Spanish: “Don’t worry. We’ll take care of you.” The screaming stopped. The girl looked up calmly with big brown eyes. The parents let out a breath.

“At that instant, I knew I had made the right choice,” Cristina wrote in her essay to medical schools. “The need for bicultural physicians is obvious. I knew I had to strive . . . to become one of the few.”

Cristina worked nearly full time as a secretary at Cal State Fresno’s faculty mentoring program, but her meager salary had to cover tuition, books, rent on her tiny apartment and other living expenses.

She directed the American Medical College Application Service to send her common application to 23 schools, including all nine in California. Soon, most of the schools sent her secondary applications, each asking her to write introspective essays and demanding a separate application fee.

It doesn’t sound like much--a $40 fee for each of five UC schools. But that, added with $95 for Tufts, $100 for New York Medical College and similar fees for other schools, became prohibitive for a poor grad student without financial aid.

Her older brother, Carlos Jr., chipped in to cover some fees. Cristina stretched her own budget to pay the rest or sent letters to the schools begging them to waive their fees. All but Harvard did.

One of her Cal State professors was so moved by her determination that he dipped into his own pocket to pay $800 for a Medical College Admission Test prep course.

Cristina put together an elaborate chart with a grid of boxes to keep track of the progress of applications. She borrowed an old dining room table to furnish her Fresno apartment. It was covered with neatly stacked piles.

Her mother prayed the rosary every day. At first, it was for Cristina to land some interviews. Later, it was for her to be accepted by at least one school. Adriana, a devout Catholic, wore nothing but white--from blouse to shoes--for weeks, believing such penance would hasten an answer. Each day she would come home from work, her white clothes filthy from her job cleaning portable toilets used by farm workers in the fields. Cristina and her mother had a running joke: It was a season of much bleach.

Some of her mother’s prayers were answered. Cristina started getting requests for interviews at schools around California and beyond. She shelled out $400 to fly back east to interview at George Washington University, but landed just as Washington, D.C., was shut down under a blanket of snow. All interviews were canceled for that Tuesday in January.

Could she stick around until Friday? the admissions office asked. She agreed to stay, but ended up interviewing only with medical students involved in the screening process. No faculty members were available that Friday.

Shortly after she returned home, she received a letter from George Washington. It chastised her for missing her scheduled Tuesday interview, informing her that her name was being removed from the list of eligible candidates.

The application season was a roller coaster of exhilarating highs--”Stanford agreed to interview me!”--and depressing lows in her mailbox: “I am extremely sorry to give you this disappointing news after you have invested so much energy, not to mention money, in your application to Stanford.”

UC San Diego told her she would not be granted an interview, then changed its mind when the problem turned out to be a paperwork snafu. Even UC Davis, the Central Valley’s own medical school, with a commitment to its underserved areas, would eventually reject her after a long spell on its waiting list. Cristina’s admission test scores were 20% to 30% below the average of the students Davis admitted; her undergraduate GPA was lower, too.

Cal State Fresno professor Luz Gonzalez, who employed Cristina as a secretary, became enraged as a pattern emerged.

“The interviewers would have tears in their eyes when they heard Cristina’s story,” she said. “Then the rejection letter would come.”

Few Applicants Are Accepted

The vast majority of people who apply to California’s medical schools get turned down. Last year more than 12,000 people applied for about 1,050 available seats for first-year students at the nine schools. Among Californians, only about a quarter of those who applied were accepted.

The problem is supply and demand. California hasn’t built a medical school since the 1960s, but the state’s population has doubled in the intervening years. As a result, the state exports most of its medical students: Last year, 1,040 Californians began medical school out of state and only 828 started medical school within the state. So, California must import doctors.

In this competitive environment, black and Latino students, whose grade-point averages and test scores tend to be lower, and whose generally lower family incomes make travel to other states harder, often lose out. This exacerbates the medical profession’s racial imbalance.

Latinos, for instance, make up about 30% of the state’s population, but only about 4.8% of the state’s licensed physicians.

It’s not that white doctors cannot be trained to be bilingual and culturally sensitive. Many are. But they haven’t made major inroads into minority communities short on physicians. By contrast, studies show that three out of four Latino and black physicians practice in medically underserved communities.

Against that backdrop, the UC medical schools are struggling to reverse a 46% drop in the number of black and Latino students since 1993--a downward slide that began a couple of years before the UC Board of Regents banned affirmative action.

Subsequently, California voters approved Proposition 209, the statewide affirmative action ban, a move that sharpened the drop in black and Latino medical students.

Last year, UC’s five medical schools--in Los Angeles, San Francisco, San Diego, Irvine and Davis--tried to boost the ranks of those underrepresented minorities, making nearly 30% more offers. But they had few takers.

To figure out why, UC brought Dr. Cornelius Hopper, its former vice president for health affairs, out of retirement. Hopper set up a task force of admissions directors. When he discovered that California’s private medical schools--Stanford, USC and Loma Linda--also saw declines in minority students, he invited them to join.

Hopper, who is still studying the matter, believes that the University of California has been losing minority applicants to prestigious and wealthy private medical schools out of state. The minority students that UC accepts tend to be academic superstars who are then lured away by the prestige and scholarships offered by Harvard, Columbia and the University of Pennsylvania.

The solution, Hopper believes, is to increase the size of the pipeline to get more academically competitive black and Latino students interested in medical careers.

Hopper also noticed that one California medical school defied the trend last year: USC raised the number of its black and Latino students.

Not coincidentally, the associate dean of USC’s medical school admissions, Erin Quinn, wrote her doctoral dissertation on how Latinos can succeed in medical school despite middling admission test scores.

Quinn concluded that other traits such as leadership, life and communication skills and self-confidence play a large role in surviving medical school, passing board exams and becoming a successful physician. Medical schools need to recognize that learning doesn’t end the moment applicants take the admission test, Quinn said. Students continue to grow.

Her findings were confirmed a couple of years ago by two UC Davis physicians who studied how minority students admitted under affirmative action with lower grades and test scores fared. The students had to play catch-up during the first two years of medical school, the research found. But then the rate at which they passed board examinations and become physicians became the same as for others.

Under Quinn’s direction, USC has revamped its admissions process, using a much more personal approach. Grades and test scores are balanced against other, less tangible attributes.

Applicants with lower grades and test scores are not sorted out by computer for quick rejection, as they are at some schools. Instead, each applicant’s file is read thoroughly at least twice. It’s a labor-intensive sifting process, forcing faculty members to take files home nights and weekends.

In the end, Quinn hopes to sprinkle in the class what she calls “diamonds in the rough”--students who perhaps don’t have the very best test scores, but who show other attributes and have the drive and mental horsepower to succeed.

USC can do this more easily than public medical schools, which are subject to the state’s ban on affirmative action. Unlike its public counterparts, USC doesn’t fear a potential lawsuit from every rejected 4.0 white student.

Nor is USC as obsessed as some medical schools with high test scores and GPAs to boost the school’s rankings. UC San Francisco, UCLA and Stanford are usually ranked among the nation’s top 10 medical schools. These schools focus more intently on keeping up their numbers, hoping to move up, or at least not lose ground.

The fact that USC is not as highly ranked gives Quinn more latitude--a tad less pressure from administrators. As a result of her admissions protocol, Quinn says, “we have better students who can communicate well with patients, who are interested in serving low-income people at [Los Angeles] County Hospital,” which USC staffs with doctors.

Under Quinn’s direction, USC has nearly doubled the number of black and Latino students admitted to its medical school in the last two years. The number was low to begin with, only 13 out of 160, but last year it rose to 25.

The decision on whether Cristina Villarreal would occupy one of this year’s 160 slots would be made in a conference room long past dinner time by a bunch of bleary-eyed USC medical professors and medical students.

Deciding Applicants’ Career Possibilities

Of the 5,476 applicants to USC’s medical school this year, a mere 500 were invited to be interviewed.

After the interview was written up, the candidates’ files were parceled out to five-member groups drawn from USC’s admissions committee. Getting one of the 160 slots required unanimous approval.

Seated around a table in the admissions office, four professors and one medical student passed around files as if they were playing a card game, openly sharing their hands, pointing out applicants’ Medical College Admission Test scores and GPAs and heart-wrenching essays and letters of recommendation. Finally, they began to debate the merits of each applicant.

First up was a promising Latina who grew up right around the corner from the medical school in East Los Angeles. She attended a prestigious university and was flagged by an interviewer as “exactly what USC needs. She is committed to return to her community all that she has received from it.”

But her MCAT scores were low, too low for some members of the admissions committee--an average of 7 on a scale of 1 to 15.

“I’m not too worried with a 2.6 GPA from an elite school,” said Alejandro Sanchez, a third-year medical student on the committee. “I’m worried about the MCATs. When I look at these files, I wonder, are we doing anyone a favor? ‘Come here for a year and flounder and leave with $40,000 in debt.’ ”

“Is this one too much risk or not?” asked Dr. Raquel Arias. She looked at the test scores and shook her head.

The voting began. “Defer,” said one professor--killing her prospects for the year. “Defer,” said another. “Defer.” “Defer.” “Defer.”

Then the group began to deliberate the fate of Cristina Villarreal.

Her grades had been steadily improving. “Almost a B at MIT, in chemical engineering. But a 3.7 [GPA] for her master’s in public health,” one professor said. They talked about how she’d worked in the fields since age 5. And they talked about her MCAT scores, which were higher than the previous candidate’s, but not by much.

Arias, who had been quiet, jumped into the discussion.

“I like this one,” she said. She pounded her fist on the table. “Anybody from Orosi who made it through MIT must have a lot of raw talent. This is a jewel.” She saw herself in Cristina. Both are daughters of farm workers. Both grew up in tiny San Joaquin Valley towns.

Arias reminded her colleagues that Cristina wants to return to her roots and treat farm laborers in one of California’s poorest regions.

“It’s so hard to get anybody to go to the [San Joaquin] Valley,” said Arias, a surgeon and the medical school’s dean of women. “I’ll take her under my wing and give her personal attention.”

Unspoken was the final question: the MCAT. All eyes turned to admissions Dean Quinn.

“With those MCATs, it’ll be hard,” Quinn said, “but she’ll be OK.”

All five voted to admit. Quinn wrote the word “RECRUIT” in red ink on Cristina’s file. A few weeks later, the school’s financial aid committee decided to offer her a four-year full-tuition scholarship. It’s worth $33,000 a year, out of the total estimated cost (including room and board) of $50,000 a year.

Fate Resting in an Envelope

When Cristina came home from work, her mother pointed to the letter from USC. It sat atop the piano, just beneath her framed diploma from MIT, which was next to her older brother’s diploma from Cal State Fresno and her younger brother’s acceptance letter from Harvard.

It was a big envelope, not the slender ones that bear cruel news. But it was too early for an acceptance letter. She had only interviewed a couple of weeks earlier.

It must be an invitation to some conference, she concluded. Delicately, she opened it. The first word of the letter from Erin Quinn was enough to cause both Cristina and her mother to cry:

“Congratulations!”

“Gracias por todos los rosarios,” Cristina said as the two women embraced. Thank you for praying the rosary.

The red grape pan stayed in the garage, wedged among other stuff in the rafters.

A few days later, Cristina’s father was visiting Shannon, the family physician, and passed along the good news. “Tell her to hurry up,” Shannon shot back. “I’m ready to retire.”

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Minority Medical Students

California’s nine medical schools are struggling to increase the number of black, Latino and other underrepresented minority students. These minorities have dropped from a peak of 19% of all first-year medical students in 1993 to 12% last fall. The steepest drops came after the UC Board of Regents banned affirmative action in 1995, and California voters broadened the ban by approving Proposition 209 in 1996.

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Source: Assn. of American Medical Colleges, 1999 data *

LYNN MEERSMAN / Los Angeles Times

Doctor Shortages

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Blue-shaded areas are federally designated as having shortages of primary health care professionals, or one doctor for 3,500 or more residents. By comparison, most wealthy urban areas have one doctor for every 300 residents. *

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Source: Office of Statewide Health Planning and Development *

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