Podcast – No es fácil: clinical electives in Cuba - NASGP | The art of GP locuming

NASGP

Few things in Cuba are easy. Most countries faced with what Cuba has lived with for more than half a century would be failed states. Cuba keeps going, with hardship and sacrifice, but a shared vision. The reputation of Cuba’s health service – providing rich-country outcomes on a poor-country budget – attracts interest from politically aware medical students. But arranging an elective there, well, no es fácil. Fidel Castro’s Escuela Latinoamericana de Medicina provides medical training for poor students from other countries, but few people in Cuba’s health service are aware that medical training worldwide often includes an elective. Only the occasional foreign student managed to penetrate the indifference, the bureaucracy, the lack of information and the limitations of Cuba’s IT, and arrange an elective. I was fortunate to meet a Cuban doctor with the imagination to think outside the restrictive Cuban box. He had welcomed one such applicant. We discussed the practicalities of an elective programme, and in 2010 I started Cuba Medical Link, a UK registered charity with a website to help students arrange electives in Cuba. Eight years, 400 students from 20 countries later, I have closed this programme. No es fácil, an elective in Cuba. Foreign students are in Cuba on Cuba’s terms. They pay substantial fees for their tuition. They have to speak Spanish. They learn alongside Cuban medical students, they live as paying guests with Cuban families. Being Cuban no es fácil, and students gain an insight into the difficulties of everyday life under the USA’s economic blockade. They acquire a first-hand experience of the Cuban health system and of the social sacrifices and restrictions of political freedom which underpin it. Once they have surmounted the hurdles of registering in Cuba and donned a bata blanca (white coat) elective students enter a world of shared knowledge of the human body and its infirmities. Cuban doctors are generally welcoming and keen to teach. But practising in Cuba no es fácil. Buildings may be in need of basic repairs, and doctors may have only a thin, shabby towel to dry their hands. But the commitment to patients is the same. Cuban ingenuity keeps antiquated CT scanners working 24/7 and every stroke patient is scanned in A&E – an objective few British hospitals achieve. Back home, students probably don’t think much about the patient’s diagnosis till they have the results of a battery of investigations. Cuban students have to learn to make a diagnosis without technology, and elective students have to try to do the same. As one British student said, “I felt like an amateur compared to their seemingly vast clinical skills!” Some differences can be startling. Interactions with patients can sometimes be uncomfortably brusque. And in a country in which people live in each others’ pockets, confidentiality isn’t a consideration. It can be a shock to find two doctors consulting in the same small room and all available space crammed with patients’ relatives and friends, nurses, medical students and even the next patient who has wandered in through the open door. In many countries preventative health care is given only lip service, or responsibility is devolved to public health departments. Visiting students see how in Cuba it is everyone’s responsibility, and they make the connection with Cuba’s impressive health statistics. They may even take part: a Japanese student was proud to give a talk about reducing their risk of heart disease to a group of abuelos (elderly) at their exercise class. As another student observed “The primary care doctor in Cuba is part shaman, part confessor and this demonstrates both their medical and social roles and how it is difficult, and probably inappropriate, to try to see one without the other.” Students go to the beach, play football, go dancing with their fellow Cuban students.