Pediatric Emergency Medicine in Costa Rica
Marlow Macht describes his experiences in pediatric emergency medicine in Costa Rica.
After finishing my tropical medicine coursework at Tulane, I left forSan Jose, Costa Rica to do two weeks of pediatric emergency medicine at the national children’s hospital. Having done a rotation in Ecuador and having traveled elsewhere inLatin America, I was eager to see how health care worked in “the Switzerland of Central America.” This entry is about what I learned.
- Socialized medicine.
The most striking think about the Costa Rican health care system, for someone from the States, is the socialized health care system. Health care is divided into three levels: the EBAIS (Equipos Básicos de Atención Integral en Salud), which provides primary care with a non-residency-trained physician and a nurse, but have no laboratory or x-rays; clinics, which include some specialists and have basic labs and x-rays; and hospitals, which have the full range of health care services. Working in the emergency department of the Hospital Nacíonal de Niños, I almost exclusively seeing patients who had already been evaluated an an EBAIS or clinic, and had been referred. The accessibility of basic health care had tremendous advantages. There was a much greater emphasis on preventive care than exists in the US. For example, each Costa Rican parent (without exception) brought their child’s librito azul, which documented not only growth curves, but details of the birth such as Apgar scores and whether resuscitation was needed. This low-cost intervention served to educate parents and to make it much easier for patients to go from EBAIS to hospital with complete health care records.Although some patients did come to this tertiary referral center because they felt they would get better care for common illnesses, patients were largely happy with the basic care they received and very trusting of the system.
The availability of primary care meant that wait times in the emergency department were much shorter than for similar facilities in the U.S. (In my limited experience, wait times of longer than 1 hour were rare. I don’t know if the same holds true in adult EDs.)
The end result of this system is that Costa Ricans, although they have a per capita GDP roughly 1/4 of that in the U.S and per capita health care expenditures about 1/10 of that of the U.S., have a life expectancy two years longer than that of citizens of the U.S.. (There are other health indicators in which Costa Rica lags behind the U.S.) From my experience, I believe that this is a result of spending to ensure access to preventive care for all Costa Ricans, coupled with decreased spending on diagnostic technologies. Most notably, there is considerably less use of CT scanning in Costa Rica.
2. Medical culture
In part because of the socialized medical care system in Costa Rica, as well as differences in Latin and North American cultures, the culture of medicine differs. Although many Costa Rican physicians (particularly in tertiary care centers such as the Hospital Nacíonal de Niños) have done residency or fellowship training in the U.S., and there may be more similarities than differences, patients (and parents) seem less inclined to challenge their doctors than in the U.S. The power differential between patients and physicians is great.
With exceptions, there seemed to be less emphasis on explaining the diagnosis to the patient and gaining the patients buy-in for the treatment plan. There was also less emphasis on defensive medicine in Costa Rica than in the U.S. My impression, from speaking to numerous medical students, was that there was somewhat less systematic emphasis in medical school on the humanistic aspects of medicine. In general, medical students were younger than in the U.S. Costa Rican physicians enter a six-year training program after high school. The last year of this training is the intern year, after which all physicians participate in a national lottery and then choose general practitioner slots for at least one year after graduation.
3. Care for vulnerable populations
Because of the rapidly rising wages and living standards in Costa Rica, the country hosts a significant number of migrant workers. Most come from Nicaragua, with some from Panama and other Latin American countries. Immigrants from these countries are guaranteed access to health care regardless of documentation status.
Costa Rica also has a small indigenous population. Because of language and cultural barriers, this population can have greater difficulty accessing care.
Marlow Macht, MD, MPH
Incoming Intern
Denver Health Residency in Emergency Medicine,
Colorado
marlow.macht@gmail.com
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