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(David Villafañe)

In the last three years, six out of 10 general practitioners have left the Island. 8,143 specialists also left during that period, and the trend has slightly increased in 2017.

Puerto Rico lacks certain medical specialties, such as immunopathology, neuropathology and nuclear radiology, which forces patients to go abroad in search of highly specialized medical services.

Doctor shortage also shows in other areas, what implies difficulties with appointments and access for patients.

 "An appointment with a geneticist can take up to two years," acknowledged Dr. Víctor Ramos, president of the College of Physicians and Surgeons of Puerto Rico.

 Data provided by that College warn that, currently, Puerto Rico only has one Sports Medicine specialis, four colonrectal surgeons, two dermapathologists, two head and neck surgeons, three trauma surgeons, three pediatric endocrinologists, three pediatric nephrologists and two pediatric radiologists.

As the island has one of the highest rates of cancer and diabetes, the small number of doctors available to treat these patients is significant.

Puerto Rico has only 21 oncologists, 27 hematologists, eight hematologists pediatric oncologists and 33 endocrinologists.

 In addition, despite the increase in the senior citizens population, there are only 10 geriatricians.

According to the data from the College of Surgeons, most of these physicians are in San Juan and Bayamón, while the medical districts of Aguadilla and Humacao are the ones with the smallest number of physicians.

  "The only two specialties that comply with numerical parameters (to adequately serve the population) are ophthalmologists and psychiatrists. There is a deficit in all the other (branches of medicine), including general practitioners," said Ramos.

Problems with medical plans for delayed or denied payments and difficulties in obtaining approvals for patient procedures appear to be the main reasons why many doctors opt to move their practices out of the island, according to experts.

The difference in salaries due to the issue of matching funds in Medicare and Medicaid programs was also pointed out as part of the problem, among other factors related to the Island's economic crisis.

 A greater crisis ahead

 In Puerto Rico, there are 9,546 registered physicians. Registering is a compulsory local requirement to practice medicine.

However, the number of doctors on the island is lower since the College list includes doctors who want to continue in the registry despite having retired.

 Others, meanwhile, have limited practice, for example, as they do not accept new patients or  perform invasive procedures, nor do they hospitalize or they just  work one or two days a week.

 In addition, studies conducted by the College  and other medical organizations warn that the average age of doctors in Puerto Rico is 60, which is why they anticipate that this will create a major crisis in health services several years from now, since there seems not to be a proportional generational shift on the horizon.

This is due to the doctor exodus increasingly growing, especially newly-graduated doctors that go abroad to complete their specialties and opt to settle mainly in the USA for better salaries and working conditions.

Pending debts 

 During the past six years, 17 of the 24 orthopedic residents who have graduated from the School of Medicine of the Medical Sciences Campus (ECU) of the University of Puerto Rico (UPR) have settled abroad after completing their subspecialties, said Dr. Humberto Guzmán, orthopedist and physician there.

"It is estimated that three out of four residents (medical graduates) stay in the mainland after finishing their specialties and fellowships," said Guzmán.

 According to the orthopedist, one of the main dilemmas faced by doctors occurs at the beginning of their practice, when they try to be hired by medical plans and the process is difficult.

 "It takes them, six, seven, eight months before they can start working as they do not have a provider number, while in the USA they are hired and start working quickly," said Guzmán, who warned that there are doctors who need to work, because they have debts up to $ 250,000 in student loans that are charged to them as soon as they graduate.

 According to Guzmán, the lack of control and oversight over insurers is the main factor behind the island´s doctor exodus.

 "We do not see government oversight on insurers. PRHIA ( Puerto Rico Health Insurance Administration) gives them too many benefits," he said asking for greater supervision.

He mentioned, for example, the number of surgeries and orthopedic equipment that are denied by administrative personnel in health plans that, in many cases, do not have medical knowledge.

"We had to cancel cases, with the patient already changed in the operating room, because the medical plan does not approve the implant," lamented, meanwhile, Dr. Andrés Muñiz, head of the orthopedics residence at RCM.

 Looking for a solution

According to Ramos, the government has fallen short in its attempts to address the doctor exodus with actions such as the Incentives Act for the Retention and Return of Medical (Act 14-2017)

"That only applies to 3,500 of the 9,000 doctors on the island because it does not includegeneral practitioners or the internist of eight regions, in addition to the pediatricians of San Juan, like me," he said.

 He mentioned as an alternative, to cover student loans to university students who commit to stay in Puerto Rico for a certain number of years after graduating.

He warned that "we don’t have to reinvent the wheel," because there are 14 states have been taking action to retain their doctors.

 Among those initiatives, he mentioned the creation of laws that prohibit insurers from canceling contracts without a cause, that prohibit medical plans from having closed suppliers networks that prevent new contracts and that are paid adequately.

 Tied to commitment

For Dr. Angel Rodriguez, an adult oncologist surgeon who completed his specialty in Philadelphia and subspecialty in Canada, despite the fact that the income of a doctor in the mainland doubles that on the island, other factors cause doctors -like him - choose to stay.

 "In addition to a need for my specialty, my family is here, and I studied at the UPR. I feel the commitment to stay," he said. However he acknowledged that it also took months to be hired by the plans and certified by the Puerto Rico Board of Medical Licensure and Discipline.

"My family is here. I left to complete my subspecialty, but I knew I was going to return to serve the Island," said Dr. Sanet Torres, who added that she is one of the six pediatric infectologist on the island, so she works in four hospitals and participates in infectious clinics in several areas.

Guzmán and Muñiz, as well as Dr. Pablo Marrero, orthopedics resident, agreed that they are pleased to serve the Puerto Rican population.

 "I know I want to go back, although it's going to be difficult. I do not understand why there are so many obstacles in a place with so much medical necessity, and where there are so many difficulties for patients," said Muñiz, who this year will complete his subspecialty at Harvard University in Massachusetts.

Marrero will also soon leave for Orlando, Florida, to complete his subspecialty, and he also looks forward to returning.

"When I decided to become a doctor, I decided to be a doctor here, not in the mainland. My family is here, and I love Puerto Ricans. It is a sense of belonging and commitment, but it is unfortunate that one does not feel the support of the government. They ask you to come back, but they do not do anything to help," he said.

 "In the end, patients are the affected ones because they do not have access to (adequate health services). Getting an appointment for certain pediatric specialties can take more than a year. We need more pediatricians and pediatric subspecialists," said Guzmán.


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