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The Revista Panamericana de Salud Pública/Pan American Journal of Public Health publishes letters from readers for the purpose of stimulating dialogue on various aspects of public health in the Americas and of constructively clarifying, discussing, and critiquing the ideas expressed throughout its pages. Letters should be signed by the author and include his or her professional affiliation and mailing address. If a commentary on a given article requires a reply from the author, an effort will be made to obtain the reply and to publish both letters. The editorial team reserves the right to edit all letters received and to condense them so as to improve their clarity.
PUERTO RICO'S PHYSICIAN MIGRATION
Physician immigration is largely understudied, although there are some reports that describe various reasons why doctors leave their country for another. A major factor appears to be increased financial remuneration; other factors may be research or educational opportunities (1). In the continental United States (CONUS), most immigrating physicians are from India (31%), followed by the Middle East (15%) (2).
However, we did not find any mention in the medical literature of physician migration within states or territories of the United States.
Recent anecdotal reports describe an increasing trend among physicians from Puerto Rico to migrate to the CONUS, with up to 10% of physicians registered with the Puerto Rico College of Physicians and Surgeons (approximately 900) having moved to the CONUS in the last few years (3). A large number leave right after they graduate from local medical schools. In 1990, 70%75% of medical school graduates completed their residency in Puerto Rico, now only about 50% do so (4). Another report, from Ponce School of Medicine, notes that up to 70% of its graduates move to the CONUS for residency or specialty training and do not return to the Commonwealth of Puerto Rico (5).
Reimbursement, malpractice claims, and quality of life play a role in doctors moving from one state to another. Whether these factors play a role in the case of Puerto Rico is unclear. There are no reliable reports in the medical literature to account for this trend, but an increasingly stagnant economy and steadily deteriorating school systems (both public and private) seem largely responsible for the migration of physicians and other health professionals such as nurses and dentists (3, 6). Another factor could be a decrease in the number of residency slots accredited by the Accreditation Council for Graduate Medical Education (ACGME), which was brought about by an unfinished health reform that began in 1994 with the intention of privatizing the public health system. The ACGME website lists 521 accredited residencies in Puerto Rico for academic year 20052006 and only 9 institutional sponsors, concentrated mostly in the cities of Ponce and San Juan.
Several factors facilitate physician migration from Puerto Rico to the CONUS. Puerto Ricans are U.S. citizens and are able to migrate to the CONUS and participate in the national matching system. They do not need special visas such as the J-1B visas that non-U.S. citizens need. Medical education is largely conducted in English and Puerto Ricans are knowledgeable in colloquial as well as medical English and Spanish. As Puerto Rico is a U.S. territory, it has many of the same cultural iconsfrom politics, to television, to food and retail such as Jay Leno, Wendy's, and The Gap. These similarities allow for a smoother transition than for Spanish speakers from other countries. Another factor that may play a role is the existence of a large professional Puerto Rican community already present in the CONUS, which may contribute to the recruitment and mentoring of promising young physicians. Finally, the overall growth in the Hispanic population has increased the demand for Spanish-speaking physicians across the country, especially in those states with a large Hispanic population such as Florida, Texas, and California.
The impact of this migration may have consequences in Puerto Rico. It could lead to decreasing availability of physicians in subspecialties, which could lead to a decrease in local standards of care and force Puerto Ricans to come to the CONUS for specialty care. Medical and other health care educational programs may also suffer. As more trained physicians and researchers migrate, the critical mass necessary to develop and conduct research protocols may diminish, leaving junior staff to fill the vacuum. Another consequence for Puerto Rico is the loss of educational investment. Training medical students and residents requires a large capital investment, and when they leave that investment is lost. The loss of skilled workers such as physicians to the economy at large and to the tax base also has an impact.
Conversely, an increase in physicians from Puerto Rico in the CONUS would augment the chances of networking and research collaboration. The standard of care and educational opportunities can be maintained by offering continuous medical education through videoconferencing, which could improve benefits to trainees and may not entice others to migrate. Some possible videoconferencing solutions have already been explored to make training and specialized care available remotely by the Southern Governors Association (SGA), of which Puerto Rico is a member. The SGA has conducted public health drills in which simulated patients move across state lines, and physicians and medical centers from various states connect to diagnose and treat them (7). This situation would allow physicians in Puerto Rico to continue to provide care for their patients if a disaster forced migration to a predominantly English-speaking area.
This apparent physician migration should be systematically examined to clearly determine the origins and potential impact on the health care system of Puerto Rico and the recipient states. This evaluation should propose possible corrective interventions that may avert a physician shortage for Puerto Rico in the future. It is also possible that this migration could be sustained and that recruitment of Puerto Rican physicians could help address the growing need for Spanish-speaking providers in parts of the CONUS that are now experiencing this need, such as Georgia and the Carolinas. Only rigorous and comprehensive examination of the issue can provide the needed information to plan for a stable health care system in Puerto Rico.
J. Edwin Nieves and Kathleen M. Stack
Veterans Affairs Medical CenterPsychiatry
116A Department of Psychiatry
100 Emancipation Drive
Hampton, Virginia 23667,
United States of America
1. Aluwihare APR. Physician migration: donor country impact. J Contin Educ Health Prof. 2005;25(1):1521.
2. Cooper RA. Physician migration: a challenge for America, a challenge for the world. J Contin Educ Health Prof. 2005;25(1): 814.
3. Leitsinger M. Necesidad de trabajadores bilingües atrae a puertorriqueños. October 30, 2006. Available from: http://www.cienciapr.org/news. Accessed May 2008.
4. Santana Ortiz M. Más médicos se quedan en EE.UU. Ponce School of Medicine Alumni News. May 29, 2007. Available from: www.psm.edu/Alumni/News.htm. Accessed May 30 2008.
5. Fernández Colón J. Atraídos por Estados Unidos futuros médicos specialistas. Ponce School of Medicine Alumni News. May 29, 2007. Available from: www.psm.edu/Alumni/News.htm. Accessed May 30 2008.
6. Roldan-Soto C. Deterioro en la educación, cuesta abajo los colegios privados. El Nuevo Dia 2007. October 15, 2007. P. 6.
7. Cweik MA, Rafiq A, Qamar A, Tobey C, Merrell RC. Telemedicine licensure in the United States: the need for a cooperative regional approach. Telemed J E Health. 2007;13(2):1417.