Costa Rica rejects high number of medical graduates from Cuba

Graduates of Cuba’s Escuela Latinoamericana de Medicina, or ELAM, are “gravely deficient” in their preparation to practise medicine, the head of Costa Rica’s most celebrated medical school told journalists last month.

Of the 138 graduates who failed the medical licensing exams in Costa Rica, 59 were graduates of ELAM, said Ricardo Boza Cordero, director of the medical programme at the University of Costa Rica.

According to Boza, the students were largely behind in fundamental areas including paediatrics and gynaecology-obstetrics, and failed to achieve passing scores in the 11 exams administered.

“Taking into account that some who will practise as doctors in Costa Rica come from foreign universities, we have to make sure they understand the particulars of our national medicine,” he told news sources.

“We made the decision to institute a general exam that evaluates their knowledge of basic subject matters in the curriculum and clinical experience.”

The fact that 43% of those who failed the licensing exam studied in Cuba comes as a surprise to those familiar with the health system there. Doctors from Cuba, a country that has long been known as an epicentre of medicine in Latin America, have been sent all over the world to aid in health missions in disaster zones.

The country boasts one of the highest life expectancies in the hemisphere and excellent healthcare coverage rates, according to the World Health Organization (WHO). Venezuelan President Hugo Chavez sought medical care on the Caribbean island when he was diagnosed with cancer in June 2011.

Lack of congruence in curriculum?

But the issue may not be one of quality of education, but the lack of congruence in curriculum. While Costa Rica may be putting emphasis on some subject matters, Cuba could be preparing students for other areas of focus.

The majority of the medical students who failed the test are graduates of ELAM, a university established in 1999 to provide medical care to the world’s poor.

The university accepts economically disadvantaged students from all over the world and, through a six-year, free programme run by the Cuban government, prepares them to practise medicine in their home country.

Boza did admit that the ELAM and Costa Rican curricula were not aligned in at least 80% of the subject matters. The students were tested on the 20% in which the curriculum diverged under a new examination system introduced this summer.

Many of the students who took the exam have since protested, claiming they should have been grandfathered into the old testing methods – that it, they should not be disadvantaged by the new exam rule, because they were part of the rule that came before it.

ELAM graduates face hurdles elsewhere

Costa Rica is not the only country in which ELAM graduates are facing hurdles in licensing exams.

According to a 2010 WHO article: “Their degrees must be validated by sometimes reluctant medical societies and, even once they receive validation, there may be no jobs waiting for them in the public sector where they are most needed.”

According to André-Jacques Neusy, executive director of the Belgium-based non-profit Training for Health Network, who has studied innovative medical schools throughout the world and is familiar with ELAM, the Cuban medical school is well aware of the challenges of integrating graduates into the health systems of other countries.

“ELAM has many graduates in many countries,” he said, “and in many parts of the world, they are not accepted.

“Part of it is Cuba being Cuba,” he added, referring to the political hurdles. “Another issue is that the receiving countries may not have the capacity to absorb additional doctors. There may not be enough jobs.”

In Honduras, graduates from ELAM were excluded from a residency programme because the government simply did not have enough funds to extend to them.

By contrast, in Uruguay last month, 90 graduates of ELAM were accepted into medical practice, news sources there reported.

Referring to the situation in Costa Rica, Neusy said: “I find it hard to believe that the students were rejected on aptitude alone.”

Rachel True, who has been collaborating with ELAM through a US-based non-profit known as MEDICC, which focuses on enhancing health cooperation between the two countries, said the issue of accreditation is very possibly political.

“With anything having to do with Cuba, there are politics involved,” she said.

Prepared to practise in under-served areas

In True’s experience, graduates are uniquely prepared to practise medicine in under-served areas. Because there is such a strong emphasis on community engagement and social accountability, the students who graduate from ELAM have a strong desire and a thorough training to improve health among impoverished populations.

“ELAM does a better job than we do in the United States of preparing doctors to enter social service,” True said.

“Studies have shown that students enter medical school in the United States with a very high level of altruism. They want to do good. But that drops off significantly as they approach graduation because they have to find ways to repay their debt.

“In the ELAM programme, students don’t have debt.”

True, who tracks the 200 students-graduates of ELAM who have returned to the US, said the students are very well prepared. “Many of them have entered residency and have been successful.”

Costa Rica saturated with doctors

The students returning to Costa Rica faced the unfortunate situation of a health system saturated with doctors.

The ELAM graduates are competing with doctors not only from the country’s prestigious public schools, but also from a number of private universities that have surfaced in recent years.

The country is also trying to position itself as a medical tourism destination for North Americans and Europeans looking for more affordable medical care. For that reason, quality control is of high importance, not only for the Costa Rican government but also for the country’s medical schools.

Boza brings that point home: “The University of Costa Rica needs to guarantee the preparation and high standards of all the professionals that come to the country with a degree in medicine and surgery obtained from a foreign university, with the goal of guaranteeing the welfare and health of all the inhabitants of the country as well as maintaining the high standards of quality in the medical sector.”

For the ELAM graduates who didn’t pass the new examinations? The university is considering letting them take the exams retroactively.