Family Medicine in Cuba

Lee T. Dresang, MDAssistant Professor, University of Wisconsin Medical School

Faculty, St. Luke’s Family Practice ResidencyMilwaukee, WI

Laurie Brebrick, FNPSixteenth Street Community Health Center

Milwaukee, WI

Danielle Murray, MDFellow, Meharry Obstetrical Fellowship

Nashville, TN

Ann Shallue, DOResident, St. Luke’s Family Practice Residency

Milwaukee, WI

Lisa Sullivan-Vedder, MDAssistant Professor, University of Wisconsin Medical School

Faculty, St. Luke’s Family Practice ResidencyMilwaukee, WI

Corresponding Author:Lee T. Dresang, MD

3289 S. Illinois AvenueMilwaukee, WI 53207Phone: 414-294-0588Fax: 414-384-5578

Email: ldresang@fammed.wisc.edu

Date of submission: February 22, 2004

Word count (excluding abstract, table and references): 2708

Key words: CUBA, FAMILY PRACTICE, PUBLIC HEALTH, COMPLEMENTARY THERAPIES

ABSTRACT

Despite a poor economy, Cuba has achieved health outcomes similar to those of the United States. Family medicine is a foundation of the health system in both countries. The authors of this paper traveled to Cuba to explore differences between family medicine in the two countries. In this paper, we analyze differences in the proportion and distribution of family physicians, their involvement in public health and their use of complementary medicine. These differences may provide US family physicians with ideas for change or further research.

INTRODUCTION

In March of 2003, the authors of this paper traveled to Cuba through the Medical Education Cooperation with Cuba (MEDICC) organization to gain firsthand insight into the role of family physicians in Cuba. As a family physician, three family practice residents and a family nurse practitioner, we were interested in comparing and contrasting family medicine in Cuba and the US.

We chose to focus on Cuba because of the excellent health outcomes which it achieves.Cuba spends much less on health care than the US but has similar health outcomes. Cuba spends just 7.4% of its Gross National Product on health care, compared with the 13.6% spent in the US.1 Cuba’s GNP per capita is one of the lowest in the Western hemisphere (Table 1). Nonetheless, Cuba, unlike most Latin American countries, has achieved health outcomes at levels almost equal with the US (Table 1).

Table 1: Comparison of Health Statistics and Gross National ProductCuba vs. US and other Latin American Countries2

Country Life Expectancyat Birth

Maternal Mortality(per 100,000 live births)

Infant Mortality(per 1,000 live births)

Gross National Product per Capita (US$)

Cuba 76.3 34.1 7.2 11703

US 77.2 7.1 7.2 31,910Haiti 54.6 523.0 80.3 1470Guatemala 65.3 111.1 49.0 3630Source: Pan American Health Organization Year: 2001

With our trip to Cuba, we saw a unique opportunity to visit a developing country with the purpose of learning rather than teaching.

METHODS

We traveled legally to Cuba through MEDICC, an organization which administers medical rotations in Cuba. Information on how to participate in pre-planned MEDICC electives and how to organize “short course” rotations can be found at www.medicc.org.

We prepared for our trip with a literature search, reading and discussions. In Cuba, we met with family physicians, nurses, public health officials, medical educators, and complementary medicine providers as we toured seventeen health care facilities in Camaguey, Nuevitas and Havana.

RESULTS/DISCUSSION

While we wish to highlight differences between family practice in the US and Cuba, it is worth briefly summarizing similarities.

Similarities between family medicine in Cuba and the US

The philosophy and practice of family medicine is similar in the US and Cuba. Family physicians in both countries provide preventive care, continuity of care, diagnosis and treatment of acute and chronic health conditions, and care for entire families and the communities where they live.

In both countries, family physicians are responsible for the majority of health care in rural and other traditionally underserved areas. In Cuba, physicians serve two years in clinics, often located in rural and other traditionally underserved areas, as part of their family medicine residency. After their training, family physicians are strategically located to be accessible to all.

Similarly, family physicians are responsible for most of the care in rural and underserved areas of the US. The US government defines a Primary Care Health Personnel Shortage Areas (PCHPSAs) as one with a patient per primary care physician ratio of less than 1 per 3,500. In 1995, 784 of the 3,082 counties in the US were designated as PCHPSAs. Of the 2298 non-PCHPSAs, 1132 would become PCHPSAs without family physicians. This contrasts with only 45 of 2298 non-PCHPSAs which would become PCHPSAs without internists, 11 without pediatricians and 9 without obstetricians.4

Selected differences between family medicine in Cuba and the US

While similarities abound between family medicine in Cuba and the US, three striking differences are the proportion and distribution of family physicians, their involvement in public health and their use of complementary medicine.

The proportion and distribution of family physicians

Whereas Cuba has the highest family physician to population ratio in Latin America5 and family physicians are evenly distributed around the country, the US has a shortage of family physicians in many areas and is currently dealing with a decline in residency applicants.

Cuba’s health care system is family practice dominated; in contrast, the US health system is specialist dominated. In Cuba, every physician must complete a three-year family practice residency after their six years of medical school. Only thirty percent specialize further.6 In the United States, only about one third of physicians are primary care physicians – family practice, internal medicine and pediatric physicians.7 Cuba has a family physician per patient ratio of approximately 1:600 or about 1 per 150 families.6 In

the US, the average family physician per population ratio is approximately 1:3200.8 Two studies suggest that the ideal ratio is 1:1500.9,10 The growth of managed care, which emphasizes the role of the generalist, has led to recommendations that “50% of all US physicians and residency positions should be in the primary care disciplines.” 7

Despite recommendations for more family physicians in the US, applications to family practice residencies have been dropping in recent years. The number of family practice residency slots filled in the match has dropped steadily from a maximum of 2,905 in 1997 to 2,239 in 2003.11 This has been attributed to: “student perceptions of the demands, rewards, and prestige of the specialty; market changes; lifestyle priorities; and the influence of faculty and resident role models.”11

Cuba differs from the US not only in the proportion, but also in the distribution of family physicians. The US is the only developed country in the world without a national health system. The lack of a centrally organized health system is one reason for a maldistribution of health services, with shortages in some areas and duplication of services in other areas. Cuba, in contrast, has a national health system with a clinic (consultorio) (Figures 1 and 2) in each community and specialty clinics (policlinicos), hospitals and institutions strategically located for referrals.

In Cuba, the location of consultorios -- clinics with adjoining housing units for a family physician and a nurse – is centrally planned to achieve an even population-based distribution. Each family physician and nurse team is responsible for approximately 600 individuals or 150 families in a designated geographic area surrounding their consultorio.12 Family physicians typically spend half of their day in their consultorio and the other half making home visits. Notably, family physicians often have a half-day per week to join their patients visiting specialists in policlinicos. This provides continuity for patients, builds collegial relationships between family physicians and specialists, and offers education for all parties involved.

The system of consultorios evolved in response to challenges similar to those faced in the US today: an emphasis on curative rather than preventive services, a lack of collaboration between the levels of health care resulting in fragmented care, patient discontent related to the inconsistent quality of care, and an excessive use of emergency rooms.13 When Cuban physicians finish their family medicine residency, they choose from a list of clinics with openings. This system helps maintain an even distribution of family physicians.

In contrast, the US has evident health shortages, especially in rural areas. The greatest shortage of health care providers is in rural communities of fewer than 10,000 people that are not adjacent to metropolitan areas.14 More than 20 million people in the US live in non-metropolitan areas with a shortage of primary care physicians. People living in non-metropolitan areas are approximately four times more likely to live in an HPSA than people in metropolitan areas.15

The US already has programs such as the National Health Service Corps that recruit family physicians to HPSAs. However, the US could improve the distribution of family physicians by training more family physicians. According to the Counsel on Graduate Medical Education (CGME), “specialty choice is the most powerful predictor of rural practice location; family physicians are much more likely than any other specialty to settle in rural areas and comprise almost half of the entire physician population in rural areas. The relatively small number of family physicians educated has contributed to the shortage of rural physicians.”14

The abundant supply of family physicians in Cuba allows for family physicians to take on roles outside of the consultorios within Cuba and in developing countries throughout the world. In 1999, in addition to the 17,335 family physicians working in consultorios, 1454 worked in schools, 799 in daycares, 1347 in workplaces, 2124 in management and 670 in teaching.12 In addition, Cuba is able to send as many as 1500 family physicians to work in other countries.16 Funding for family physicians in Cuba is from the government; funding abroad is by host countries in exchange for their services. Cuba demonstrates that there is little risk of training too many family physicians. In addition to working in current HPSAs, family physicians in the US can play increasing roles in daycare, workplaces and abroad.

Epidemiologic surveillance by family physicians

In Cuba, family physicians “regularly assess the health situation of their communities in epidemiological terms, using this information to help them ferret out health problems and the individuals that might be at risk.”12 Epidemiologists meet with family physicians on a regular basis to monitor for trends and aberrations (Figure 3). “Data concerning acute and chronic illnesses pass sequentially from family physicians to the municipal, provincial and national levels of the Ministry of Public Health.”16 Computerized surveillance of chronic problems like diabetes as well as acute illnesses like influenza has been implemented at all provincial levels and is being extended to municipalities and rural health centers.16 Using uniform forms and collecting data on a national level give power to epidemiological studies.

Coordinated efforts of Cuban family physicians and public health officials have impacted not only individual practices, but also the country as a whole. For example, a 1981 outbreak of dengue fever which resulted in 344,203 reported cases and 158 deaths, was quickly identified and the disease was eliminated within four months through spraying of insecticide and an intense public education campaign to eliminate mosquito breeding grounds.17 Similarly, an epidemic of peripheral and optic neuropathy which resulted in 50,862 reported cases between 1991 and 1994 was identified, researched and eliminated through vitamin distribution.17

Family physicians in the US also assess the needs of their patients and communities and make individual and larger scale interventions, but the infrastructure for doing so differs from the centrally organized Cuban system. Community-oriented primary care (COPC) is a “systematic approach to health care based on principles derived from epidemiology,

primary care, preventive medicine, and health promotion that has been shown to have positive health benefits for communities in the United States and worldwide.”18 In the United States, “because of lack of predictable reimbursement for COPC services and difficulties encountered incorporating COPC in medical and residency curricula, widespread application of COPC has not occurred.”18 Care Management is promoted within many health systems as a method for monitoring and improving how certain health problems are addressed, but only within that proprietary system. The lack of a national system means that certain organizations actively participate in health surveillance while others are less active.

Unlike Cuba, the US does not have an all-encompassing national databank for family physicians to access. A few national databanks exist in the US. For example, the Center for Disease Control (CDC) monitors certain health conditions, such as STDs. The CDC and local health departments are available for voluntary reporting of public health concerns. However, often data is collected by individual health systems or researchers and is not available at a national level or the method of data collection is not compatible with the methods used by others who are researching the same problem. Having a national databank would be helpful for analyzing regional practice differences such as variations in use of epidurals in labor or opiod use for chronic pain. Regional differences in infectious disease rates detected through a national databank would allow family physicians to adjust their preventive and curative strategies accordingly.

Critics of a national databank raise concerns of privacy protection and misuse of patient information. Health data would need to be protected as it is currently protected within individual health systems.

Epidemiologic surveillance strategies employed in Cuba “may prove instructive for countries, including the US, that lack efficient data gathering and reporting systems for preventive services and efforts in community-oriented primary care.”16 Recommendations from the Association of Family Practice Residency Directors and others are available for family medicine educators wanting to teach COPC to medical students and family practice residents.18 In addition, the US has the technology to standardize data collection at a national level. This would prove useful for research and timely given current concerns of bioterrorism.19

Complementary and alternative medicine (CAM) by family physicians

Family medicine has achieved “integrative medicine” to a greater extent in Cuba than in the US. “Complementary medicine” is non-allopathic medicine used alongside conventional allopathic medicine. “Alternative medicine” is non-allopathic medicine used instead of conventional medicine. “‘Integrative medicine’ results from the thoughtful incorporation of concepts, values and practices from alternative, complementary and conventional medicines.”20

In Cuba, family physicians learn the science of CAM in medical school. Students spend two hundred hours in the first two years of medical school on CAM rotations (Figure 4).

In addition, it is integrated into physiology, anatomy and clinical courses. Examples of CAM taught to Cuban physicians include acupuncture, herbal medicine, trigger point injections (Figure 5), massage, heat therapy, TENS, magnetic therapy, pyramid therapy, moxycombustion, fangotherapy (mud), cupping, laser/photo therapy, floral/essence therapy, homeopathy, yoga, meditation exercise training and music and art therapy. Most family physicians in Cuba practice at least herbal medicine, also known as “green medicine.” A national formulary and educational materials on green medicine are distributed to all practitioners by the Cuban Ministry of Public Health.16 One example of herbal medicine used in the western part of Cuba, the bark of sassafras tree macerated in alcohol is applied topically to treat arthralgias.21 A family physician we met practiced his own acupuncture. For therapies which they do not perform themselves, family physicians refer to natural medicine clinics.

In contrast, in the United States, CAM is “not taught extensively at US medical schools or generally provided at US hospitals.”22 In a survey of family medicine department chairs and residency directors, 29 percent indicated they are currently teaching, 6 percent starting to teach, and 6 percent considering teaching some form of CAM. Seventy-two percent of this teaching is elective.23 An increasing number of US medical schools are teaching CAM. From 1996 to 2000, the number of medical schools reporting CAM as part of a required course increased from 46 to 82 of the 125 US medical scools.24

Although most family physicians in the US are not being trained in CAM, CAM is widely used by those living in the US. In 1997, the total out-of-pocket expenditures for CAM in the US was conservatively estimated to be $27.0 billion.25 CAM use is more common in recent years: “approximately 3 of every 10 respondents in the pre-baby boom cohort, 5 of 10 in the baby boom cohort, and 7 of 10 in the post-baby boom cohort reported using some type of CAM therapy by age 33.”26 In the US, “patients say that physicians whom they have ordinarily found to be caring, thoughtful and understanding become angry, defensive and dismissive when the possibility of using alternative medicine is mentioned.”27 Perhaps because of this, less than 40 percent of patients discuss their use of CAM with their primary care physician.25

The extensive use of CAM by family physicians in Cuba may be due, in part, to the current embargo and paucity of allopathic medicines. However, even in the US with its abundance of allopathic medicines, a need for greater familiarity with CAM by family physicians in the US may be indicated if for no other reason than to integrate what their patients are already doing outside the health care system into their current traditional care. A step in this direction, the Society for the Teachers of Family Medicine (STFM) has developed curriculum guidelines for “programs wishing to include formal training in complementary and alternative medicine in residency training.”28 Although more studies will be useful, there no longer is a need to wait for better studies before teaching CAM: the Cochrane database already includes over 5,000 randomized, controlled trails involving CAM.24

CONCLUSIONS

Despite political differences, Cuba and the United States share a passion for baseball, the use of the US dollar as an official national currency, and family medicine as a foundation of their health system. Cuba, however, trains every physician as a family physicians with only thirty percent specializing further, distributes them more evenly, integrates them more into the public health system and better trains and supports their use of complementary medicine. The excellent health outcomes which Cuba achieves with so few resources attest to the effectiveness of their health care model. Family physicians in the US may want to draw from the experience of family physicians in Cuba as family medicine enters the 21st century.

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Figure 1: Consultorio

Figure 2: Consultorio

Figure 3: Epidemiologic data on wall of consultorio

Figure 4: Instruments used for complementary medicine techniques at

Carlos Finley Institute in Camaguey

Figure 5: Trigger point injection