As I mentioned a few weeks ago, I spent a few weeks studying in another country. It was actually my last two official weeks of medical school, and I went and spent time at the Hospital Nacional de Niños in San José, Costa Rica. My first day on the rotation, we sat down with our supervising physician and talked about the similarities and differences in health care in Costa Rica and in the US. He had experienced both systems, having done his fellowship training in the US before returning to Costa Rica to practice. Since I was privy to this discussion (and since I'm graduating today and have a lot of other things on my mind), I thought I might share some of the points with you.
First and foremost, medical education. I told you all about the system in the US back in my first post. So, how does it differ? As in most foreign countries (many European countries included), students enter medical school right after high school. Depending on whether they go to a public or private school, the schooling lasts for 5-6 years. The first two are spent in the classroom, and they spend the next four doing various clinical activities. The final year is referred to as their internship, and is similar to our first year of residency, except they aren't specializing. They spend 3 months each in Internal Medicine (Adults), Surgery, OB-GYN, and Pediatrics. After this schooling, they can choose to work as a general practitioner, or they can elect to do a residency. The residency could be in either Costa Rica or the states, though it is more difficult for them to get into residency in the states due to the licensing requirements. Competition for the residency slots is tough, and really the best and brightest are the ones who end up doing residency.
So, similar, but different.
Where things get really interesting is how the health system is set up. They have health care for every citizen. It's funded by a 10% tax on the citizen's paycheck--the employee pays 5% and the employer pays another 5%. The government matches this 5% contribution, so, in essence, 15% of each citizen's paycheck, regardless of what they make, goes into the Seguro Social. These public hospitals are set up all over the country. Primary care offices are the first line to the citizens, and in theory, the Primary Care offices know everything about the patients in their neighborhood. Then, there are the hospitals: primary, secondary for more advanced or specialty care, and tertiary. The Hospital Nacional de Niños is the only tertiary children's hospital in the country; the secondary hospitals have pediatric floors and some specialists, but the complex kids all get referred.
Under this system, everyone gets the healthcare they need. They may have to wait for it if there are more urgent cases to be seen, but everyone eventually gets what they need. A truly social system. Of course, they've also developed a private system on top of the public system, where you can go and get things done faster if you have the money for it. And, because they increased the government funding to healthcare, they elected to abolish their military, relying on international courts to resolve disputes with neighbors.
It was a little amusing to talk about the health systems to the students and residents, because everyone seems to be so astounded that the US, a first world country with a better standard of living than Costa Rica, doesn't provide healthcare to everyone. We are, of course, in the process of changing that now, but it's still in infancy.
A few more interesting tidbits more specific to pediatrics. First, which astounded me, particularly after last week's post, was that parental refusal of vaccines is a justifiable reason to call social services. In other words, they've deemed vaccines so important that they will overrule parents in whether or not their child gets the vaccine. If we did that in the US, we wouldn't be seeing these outbreaks.
Second, their age range for pediatrics is very different. In the US, Pediatricians care for children from infancy up through college-aged, sometimes well into their 20s depending on their overall health. When I was working in our Pediatric Emergency Department (I am not currently in a stand-alone children's hospital, so our Peds ED was attached to the adult ED), we'd see patients all the way up to 26 or 28, depending on who was working. In the PICU, they took a harder cut-off at age 18.
But in Costa Rica, they start transitioning over to the adult physicians at age 13. Which does make some sense--adolescents are more like adults than they are like infants--but they still aren't small adults. I'm not sure where this age came from--whether it was due to a lack of pediatricians or a universally decided on age, but it's interesting none-the-less.
Then, of course, the mix of diseases is very different there. I spent a week working in the Pediatric Endocrine clinic, and saw a grand total of 2 kids with diabetes while I was there. Contrast to my month on Pediatric Endocrine here, where 2 full clinic days per week were dedicated to kids with diabetes (only one full day was dedicated to other endocrine disorders). And I saw a couple patients with Bartter syndrome, which is apparently most frequent in Costa Rica.
They also have stricter laws on abortions, though I didn't delve too much into that discussion, so I'm not entirely sure what those laws are. But I do know that it is not legal to have an abortion due to a prenatal diagnosis of Down Syndrome.
Overall, they seem to have a well run health system. They do most all the same things we do, with some minor differences in tests (hypoglycemic growth hormone stimulation test instead of arginine). They do not have the same number of nurses (1 nurse per 4-5 patients in the NICU), so their NICU was much louder than I was accustomed to. They have slightly different instrumentation and ways of sterilizing, but still maintain aseptic technique and clean religiously. Based on my perception, I wouldn't deem them a third-world country. Maybe a second-world country, because they aren't quite up to the first world yet. But they're getting there, and seem to have made great strides.
Plus, it's an absolutely beautiful country.
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