PUERTO RICO HERALD: Bruce Bowen Takes Over As Scotiabank Chief

February 26, 2004
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The downfall of medical residencies: Since 1992, the number of residency programs available in Puerto Rico has been cut by half. As a result, hundreds of medical school graduates have no place to practice.

Since the Rossello administration sold most of the island’s public hospitals, the number of residency programs for medical school graduates has dropped to an alarming level.

To make matters worse, most local hospitals are too small and can’t afford to establish residency programs, making it difficult to find qualified staff in Puerto Rico. Island hospital executives believe the government could help remedy the situation by providing incentives or other financial assistance and by coming up with a legal solution to the crisis in malpractice insurance.

The situation on the U.S. mainland is vastly different from Puerto Rico’s. Statistics show that in the States, there is an ever-growing availability of residency programs, thanks in great part to much larger private hospitals and medical schools.

Becoming a physician in Puerto Rico

Students who finish medical school must spend one year, known as an internship, rotating through various specialties or through areas within one specialty. These areas include emergency room, general surgery, internal medicine, intensive care, orthopedics, pediatrics, and obstetrics / gynecology (OB / GYN).

In the past, the word intern was used principally to describe individuals in their first year of graduate medical education; less commonly, it designated individuals in their first year of a residency program. The Accreditation Council for Graduate Medical Education (ACGME) hasn’t used the term since 1975, instead referring to individuals in their first year of graduate medical education as residents. Nevertheless, first-year residents are still sometimes called interns.

In Puerto Rico, the term internship also refers to one-year programs that aren’t accredited by ACGME and are offered by private hospitals. Auxilio Mutuo Hospital and Inter American Hospital of Advanced Medicine (HIMA by its Spanish acronym) offer these programs, known as criollo internships.

After the first year, residents in ACGME-accredited programs spend two years or more training in a medical specialty or subspecialty. Only after having completed their residency can they become full-fledged physicians.

"To practice medicine in Puerto Rico, the law requires you to participate in a residency program and pass a test [revalida]," said HIMA Medical Director Jaime Rivera. There are, however, alternative ways to become a physician in Puerto Rico.

According to Rivera, some 260 students graduate from local medical schools every year, but Rivera said the only way HIMA residents can make money is by working as medical screeners in the emergency room during their time off from the residency. "We just don’t have any money to pay them. In fact, we don’t have money to pay the physicians who are training the residents," he said. That’s pretty tough, considering that residents usually work 80 hours a week in shifts of up to 24 hours straight.

Why would residents, who used to get stipends averaging $18,000 to $24,000 a year before the privatization of public hospitals, accept such harsh conditions? "Since there isn’t enough space locally, they have no other choice if they don’t want to go stateside," said Rivera. "Also, some of these residents have studied in places such as Mexico and the Dominican Republic and aren’t [necessarily eligible] to participate in residency programs in the States.

"It costs too much to have an internship program in a private hospital," added Rivera. "For instance, an intern must go through all the stages of a patient examination to learn about a particular health condition. This requires using medical materials, which entails a lot of expense. Also, we offer residents free food, free medical care, parking, and even malpractice insurance, and this doesn’t come cheap."

Carlo said it takes about three to five years to establish a residency program. "A hospital must have board-certified attending physicians and must be ready to make a large investment," he said.

According to Rosa Toledo, setting up a residency program in neurosurgery for one resident could cost up to $700,000. This includes associated expenses for attending physicians’ salaries, equipment, and an on-call system for the resident.

He added that the financial assistance Medicare can offer is minimal. "Medicare will only reimburse 1% more to hospitals with residency programs than it reimburses to hospitals without such programs," said Rosa Toledo.

Pavia Hospital in Santurce has residents rotating through the hospital, but not nearly as many as it once had. "We had a residency program specializing in urology, but we shut it down because of the pressures created by malpractice insurance," said Executive Vice President Alfredo Volckers. "The residents themselves prefer to practice at Centro Medico because there is a cap on malpractice lawsuits against public hospitals, whereas someone who sues a private hospital for malpractice can ask for any amount."

Nevertheless, Pavia still allows one resident in urology and a few in family medicine to practice each year, all from the UPR School of Medicine.

Malpractice insurance a major obstacle

Insurance Commissioner Dorelisse Juarbe explained that a plaintiff in a malpractice lawsuit against a public hospital can claim up to $75,000. If there is more than one victim from a single act of malpractice, the claim is capped at $150,000 for the whole group. There is no limit on claims against private hospitals.

Another benefit for public hospitals, she said, is that they get legal representation from the Department of Justice. Private hospitals must obtain their own legal representation.

Sources in private hospitals noted that malpractice insurance costs more for hospitals with residency programs than for those without them. However, none could say exactly how much more.

"We need the government to do something about this immediately. More than 30 states have already passed laws to solve the crisis spurred by malpractice insurance, and here we are, still waiting," said Volckers.

According to Juarbe, Puerto Rico’s Legislature has tried to set limits on malpractice awards. "However, those efforts were met with strong opposition from malpractice victims and the bill was tabled. We don’t know if this will be discussed again," she said.

"If the government would straighten out the problems with malpractice, private hospitals would be in a better position to offer residency programs," said HIMA’s Rivera. Rosa Toledo said, "Hospitals with residency programs do incur higher insurance costs because insurers understand there is a higher risk involved."

Local hospital executives say this shouldn’t be so. "All resident physicians are closely supervised by an attending physician. In reality, the risk is minimal," said Dr. Pila Hospital’s Diaz.

Juarbe said it really depends on the insurance company. "Insurers could believe covering a hospital with a residency program is riskier than covering one that doesn’t have a program. Still, they will make their decisions based on experience. If they have seen many cases involving residency programs, they will charge more for coverage," she said.

Malpractice considerations also affect the number of residency positions at a hospital. Carlo said ACGME determines the number of positions according to a hospital’s patient mix, among other factors. Now that many private hospitals are referring high-risk cases to public hospitals for fear of being sued, the patient mix at both kinds of hospital is changing. Whereas residents in public hospitals are being exposed to too many trauma cases, those at private hospitals probably aren’t seeing enough.

How it’s done in the States

In Puerto Rico, there are thousands of physicians who are unable to practice because they can’t get into a residency program. Meanwhile, the Washington-based National Resident Matching Program (NRMP) said it offered a record number of residency positions last year.

Another benefit to stateside residencies is that the stipends are higher. According to some residents in the States, stipends start at $30,000 to $40,000 a year. In Puerto Rico, they rarely exceed $25,000 a year.

Although there were 17 fewer residency programs participating in last year’s NRMP, the number of positions in those programs increased by 450, of which 300 were in first-year residency programs. Nearly 24,000 active applicants on the U.S. mainland participated in the match last year, up 506 from 2002 and reversing a three-year downward trend. Some 79% of the applicants were matched with a record-high number of first-year residency programs. Last year also set an all-time record for the total number of applicants successfully matched.

Overall, the number of matches for specialty programs on the mainland increased in 2003. Internal medicine and pediatrics placed residents for 95.1% and 93.8%, respectively, in the available positions. Other specialties that saw higher fill rates for their first-year residency programs were general surgery (up 4.6% to 99%), diagnostic radiology (up 3.1% to 97.8%), and pathology (up 6.4% to 90.1%). Family practice, however, saw a slight decline in the percentage of positions filled, down to 76.3%.

In Puerto Rico, the number of residency programs and residency positions is dropping precipitously, to the point that programs in some specialties are about to disappear. Since 1992, the number of local positions has been cut in half, and some programs, such as neurosurgery, are graduating only one physician per year.

For years, Puerto Rico’s hospitals have been offering more medical specialties and subspecialties, hoping to keep patients from traveling stateside for treatment. With the number of physicians practicing these specialties declining, however, it seems more patients will have to travel abroad for medical care.

How many hours should residents work?

Many veteran physicians remember that when they were residents, they sometimes had to work 120-hour weeks and shifts of more than 24 hours straight. Today, the law says residents shouldn’t work over 80 hours a week or shifts longer than 24 consecutive hours. Some believe the new law will ensure quality care, while others say it diminishes residents’ learning opportunities.

Frances Garcia of Central Caribbean University said that about two years ago, the Association of American Medical Colleges decided it wasn’t in the best interest of patients or residents to have the residents work more than 80 hours a week. "Since then, all U.S. states and Puerto Rico have enacted laws to ensure residents don’t work more than that a week, and these laws are followed rigorously."

The local law, known as Law 47 of Jan. 4, 2003, requires residents to have eight hours off between shifts, on-call duty scheduled no more than every third night, and at least one day off per week.

Civil penalties are imposed on programs and residents that violate the law. Programs are subject to a maximum fine of $5,000 per violation, while residents can expect a maximum fine of $200 for each offense, according to the Accreditation Council for Graduate Medical Education (ACGME).

"Now, residents have too much time off and are losing out on learning new things," said Jaime Rivera, medical director of the Inter American Hospital of Advanced Medicine (HIMA by its Spanish acronym). "For example, if residents leave at 8 a.m. and there is a tumor board at 10 a.m., they will miss it. They could stay for the board, but the law says they must leave." A tumor board, explained Rivera, is a meeting where specialists discuss progress on a specific case.

Luis Rosa Toledo, director of the residency program at the Alejandro Otero Lopez Hospital in Manati, said the reduction in hours could actually cause residents to have to work longer. "While it is a good thing to give residents time to rest, we must consider that now they have less time to comply with the requirements established by ACGME. I estimate that what takes residents a year to learn will now take an additional two months."

Defenders of the law say it improves the quality of life for patients and residents alike. "One day I worked 36 hours straight and had a car accident because I fell asleep [at the wheel]," said psychiatry resident Iris Rodriguez in an interview for Hours Watch, a website hosted by the Interns & Residents Committee in the U.S. "Nobody can tell me that after working for 24 hours you can perform your job well. You’re putting patient care at risk when you’re deprived of rest."

According to Alex Agostini of the Interns and Residents’ Committee, the reduction in hours will also result in their spending less time doing grunt work and focusing more on practicing medicine.

Rosa Toledo believes Puerto Rico law should consider allowing residents to remain at the hospital after finishing their 24-hour shifts so they can participate in educational activities that don’t require patient contact. "In New York, residents can stay for up to six more hours [during which they don’t attend patients] after finishing their 24-hour shifts, but the local law requires residents to leave after 24 hours, which limits the time they can spend engaged in educational activities," he said.

The road to becoming a physician

Generally speaking, when students graduate from medical school, they undertake a residency program at a hospital, where they put their knowledge into practice and gain new skills by interacting with patients while under the supervision of an attending physician.

This is true for those graduating from fully accredited medical schools in Puerto Rico and on the U.S. mainland. Graduates of schools elsewhere, however, may have to take a longer road to become licensed practicing physicians.

M.D.s from accredited universities

To graduate from a school in Puerto Rico or the mainland U.S. that is accredited by the Association of American Medical Colleges, students must take Step 1 of the U.S. Medical Licensing Examination (USMLE) during their second year of medical school. They must take Step 2 before graduating.

Newly graduated doctors of medicine (M.D.s) can enter a residency program in Puerto Rico or the mainland U.S. Once they finish their residency, they must take Step 3 of the USMLE. If they wish to practice a medical specialty, they must take the appropriate board.

M.D.s from foreign or nonaccredited universities

Since the USMLE accredited universities, graduates must first enter what is known in Puerto Rico as a criollo internship, which lasts one year. After completing the internship, M.D.s obtain a license to practice medicine in Puerto Rico only.

If these M.D.s want to enter a residency program after finishing their criollo internship, they must take the USMLE. They can only do so, however, if the school from which they graduated is eligible for examination by the Educational Commission for Foreign Medical Graduates (ECFMG).

M.D.s may be eligible for certification by the ECFMG if the school they attended is in the International Medical Education Directory. Only after being certified can they take the USMLE, enter a residency program, and follow the procedure for M.D.s from accredited medical schools.

Shortage of nurses still hurting local hospitals

Although local hospitals have been increasing the financial incentives they offer nurses, the brain drain of nursing professionals to the States continues.

Puerto Rico Hospital Association Vice President Juan Rivera said the organization has been brainstorming in hopes of stemming the tide of nurses seeking better opportunities, including better pay. One of the ideas is to import nurses from other Latin American countries such as Costa Rica or Venezuela. The federal government, noted Rivera, allowed stateside hospitals to hire nurses from the Philippines.

Jorge Torres, the Association’s President, said this is just an idea. Another proposal is to have government offer tax exemptions to nurses and to help universities finance nursing programs.

"Someone also recommended we bring in physicians from the Dominican Republic and have them work as nurses or physician’s assistants," added Rivera. He acknowledged, however, that this idea might not work because the Dominican physicians probably would obtain the license to practice medicine here and would leave their jobs as nurses. "Then we would be back to square one, struggling to find nurses," he said.

Local hospitals, meanwhile, are doing everything they can to attract nurses. Ponce’s Dr. Pila Hospital, for instance, was able to recruit 20 nurses over the past six months by sweetening the incentive package. "We offered a recruitment bonus if they came to work with us," said Reinaldo Diaz, the hospital’s owner and president of the Fundacion Dr. Manuel de la Pila Iglesias.

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