Primary care in the US and Cuba: Some preliminary thoughts

1.

Doctors can be of all kinds, but the most basic division is between a generalist and a specialist. A generalist is someone who understands the body as a whole while the specialist knows more about a specific part of the body -- the heart, say.

For the most basic kind of care -- primary care -- you need a generalist physician. If a population has good access to generalists, then it is likely that its health will be strong. Put another way: if you regularly see and trust a family doctor, you are less likely to have serious health problems in the long run. If a problem does happen, your personal doctor can advise you best because she has a holistic view of your health. She emphasizes preventive care and can influence your lifestyle choices. This long term patient-physician relationship is at the heart of primary care.

In the US, however, there aren’t enough generalists to satisfy the population’s needs. Primary care does not pay as much as specialty care; incentives are in favor of high end, sophisticated medical procedures and technology rather than basic preventive care. A surgeon or colonoscopist will earn significantly more than a primary care physician. This imbalance prompts medical students to prefer the lucrative specialties. Family physicians I’ve talked to have a hard time keeping their businesses afloat. To increase revenues, they see more patients; that gives them less time to spend with each individual patient; and there’s also the frustrating billing and reimbursement process which involves much haggling with insurance firms.

Partly due to the shortage, patients in United States experience care in a fragmented and uncoordinated way. This is the system’s bane. Many don’t have a personal doctor. Those who do are unable to secure an appointment. They instead see an unfamiliar physician or visit the emergency room. I called a clinic today, expressing my wish to join and seek an appointment, and was told the next available appointment is in September. In Western Massachusetts, where I live, the doctor shortage problem is especially acute.

2.

Other countries, even resource poor ones, have placed their bets on primary care. Cuba is a good example. Michael Moore in his typically emotional and unrigorous way endorsed the country’s healthcare in Sicko, but gave little sense of why the system was good.

Cuba’s family doctors are the pivot around which its nationalized health system revolves; they provide and mediate the majority of the population’s care. The country's medical education mandates family medicine residencies for all prospective doctors. The strong emphasis on primary care is probably the reason for the country’s generally good health indicators. Every neighborhood has a family doctor who works in a consultario. The consultario might just be a room in the doctor’s home or a formal clinic.

Geography is important: the neighborhoods of a city are sectioned. Each doctor is responsible for about 125-150 families, which totals to about 800-1000 residents.

There are no appointments as in the American system. The morning is for walk-ins; in the afternoon, the doctor does home visits (hence the strictly geographic design). She knocks on the doors of the disabled, those who haven’t visited in a long time, and those who might have returned from the hospital the previous day or week. Sometimes the doctor takes the patient to a polyclinic (larger secondary care centers) to consult with specialists.

Thus, the family doctor’s holistic assessment of the patient, developed over years, permeates through the system. Statistics about each family are maintained in a basic folder – a physical paper folder. But they are eventually entered into an electronic system. Cuba’s Ministry of Health, thus, has epidemiological data at the level of the each neighborhood and community (see image towards the end).

As with any system, there are shortcomings. And the shortcomings are the very reasons why the US will never move towards a similar design. First, patient choice is restricted. If you live in a certain neighborhood, you will likely have to visit the doctor assigned to that neighborhood; and you may not like that doctor. The idea that government will dictate whom you should see is simply untenable in the US.

Second, while American doctors, specialists especially, have exorbitant salaries (even after adjusting for medical school debt and malpractice insurance), in Cuba you find the other extreme. Doctors are severely underpaid. It is not uncommon to find doctors working as waiters in the evening. Which prompts the question: does the lack of adequate reward alter how a doctor practices or is the humanitarian impulse behind the medical profession motivation enough?

But the US-Cuba comparison -- a sensitive debate that often disintegrates into ideological rabble rousing -- may not be appropriate. There is something to be said about a nation’s political culture and what its citizens are comfortable with. The United States too has its safety nets (even if they are not always easily accessible) in the form of community clinics in economically depressed regions; they provide care irrespective of the patient's insurance status or ability to pay.

The more pertinent point is the relevance Cuban primary care has for the developing countries of the world, where the pressing issues are not patient choice or sophisticated technology – typically concerns of the rich world – but how large numbers of the poor can be provided access to basic care. If Cuba, a country that has faced economic crisis ever since the Soviet Union collapsed, can use its meager resources to design an excellent family doctor system, then that model – whether controlled by government or private enterprise or by both working together – offers hope to dozens of other nations.

3.

To finish, here is an illustrative picture of a board – mural consultario – displaying demographics inside the lobby of a family doctor clinic in Havana. The picture was taken in June 2010. The language is Spanish, but what is being described can be inferred pretty easily. Please click the image for a better view (and to use zoom).




The marked portion of map at the top shows the streets of Havana covered by this clinic. There are 3398 residents who live in these streets, 1749 male and 1641 female. The four Roman number categories (I, II, II and IV) indicate “Apparently healthy, “With risk”, “Sick”, “With post disease complications” respectively.

This is followed by a two sets of classifications. The first indicates the number of women not of child bearing age, smokers, the obese, people with sedentary jobs, alcoholics, and people living in difficult social conditions. The second breaks the neighborhood by non-transmittable chronic conditions such as hypertension, asthma, and diabetes. The numbers corresponding to each characteristic are updated constantly as the family doctors who work at this clinic (there are three of them) obtain more information.

What is impressive is how well the clinic knows its population. Presumably, there is such a board – created and maintained by the Cuban Ministry of Health with help from the local clinicians – for every consultario in the country.

Hari Balasubramanian is an assistant professor of Industrial Engineering at the University of Massachusetts, Amherst. His principal research focus is operations research applied to healthcare delivery (see academic webpage here). He also writes a humanities focused blog, Thirty Letters In My name.