The Emergency Medicine era "After Hurricane Maria"
Maria Uzcategui-Santos, MD
In Puerto Rico our emergency medicine healthcare system continues to have room for improvement and poses a lot of challenges. The hurricane that has divided our eras into the time “Before Maria” and “After María” showed us the worst devastation we could ever imagine but at the same time has given us force to re-organize and promote the specialty.
According to the US Census Bureau, approximately 375K people left the island since 2017. Most of the migration was done by younger-educated generations. We are living a global healthcare crisis that has directly affected our network of emergency services including low numbers of paramedics, nurses, respiratory therapists and most importantly, emergency medicine trained doctors. The cause mainly comes down to suboptimal monetary compensation, high volume patient workload, absence of mid-level providers, poor primary medical care and a collapsing healthcare system in which the private medical insurance companies have taken over due to the lack of legislature from the local government to regulate them. On top of all that “Before María” the government of Puerto Rico went bankrupt owing the United States more than $72 Billion. The healthcare system in the island was collapsing even before the hurricane. Since the amount of emergency medicine trained doctors is limited, most of the coverage in the emergency rooms is done by doctors in general medicine that gain experience through years of clinical work but with no formal specialty training. Not all hospitals provide with all the sub-specialty services and the patients need to be constantly transferred to other institutions. Sometimes we experience huge delays in transports between hospitals mostly due to poor communication networks, few ambulance services, emergency room overcrowding in the accepting hospital that causes them to go into diversion, and as it may seem sad, inability for patients to privately pay for the ambulance services. All these directly affect patient outcomes.
There are few emergency rooms in the island with full time EM trained physician coverage. The training programs are extremely competitive and produce superb emergency medicine doctors but unfortunately, a lot of the graduates migrate to the US to continue training and/or to work. A big challenge for us has been to encourage and convince EM doctors to stay and work in PR. Between the two emergency medicine programs in the island since 2017 they have graduated approximately 50 doctors. Half or less have stayed to work as full time ER physicians in the island.
Ok, so who do we fix this? How do we make insurance companies pay the same rates as in the rest of the US? How do we fix a broken infrastructure of this magnitude without money? In the immediate future, we don’t. We need to re-organize and work with what we’ve got. The ACEP Puerto Rico Chapter is organizing a social media campaign to emphasize in the importance to have emergency medicine trained doctors covering the ERs. They are also organizing educational talks across the different underserved areas to reinforce the medical knowledge in those areas to improve patient outcomes. As for the trainees that migrate, it can be completely understandable if they want to go to the US seeking different job conditions and other ways of life. There is no right or wrong answer regarding deciding to stay or leave.
A big factor in the decision-making process is family, either staying to be close to family of leaving to provide better for family. Most of the doctors that decide to leave, go heartbroken. There are many Puerto Rican doctors that live in the mainland and would love to return but, many of the previously mentioned factors make it very difficult. Basically, an emergency medicine trained physician gets paid less in PR compared to what he would get paid in the US. The Government of Puerto Rico, to retain specialists from leaving, has implemented an income tax relief of 4% for 15 years that has been favorable and has encouraged many people to return to the island. For the EM trained doctors that have decided to stay and fight the fight, it has been tough but not impossible. Resilience has united us. Hurricane Maria humbled all of us. We have gone through adaptative processes to adjust so we can find ways to treat our patients up to the standards of care with substandard conditions and that has made us very proud.
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