Interviews
U.S. Physicians at the ELAM:
An Interview with Drs. Flora Cox, M.D., Jean Smith, M.D.,
& Maxine Orris, M.D.

By Michele Frank, M.D.

MEDICC Review interviewed three U.S. physicians and professors of medicine working with the Medical Committee of the Interreligious Foundation for Community Organization’s (IFCO; http://www.ifconews.org) , that brings young people from underserved U.S. communities to study medicine at Cuba’s Latin American School of Medicine
(ELAM, according to its Spanish acronym; http://www.elacm.sld.cu).

IFCO is the principal organization recruiting, preparing and supporting U.S. students enrolled at ELAM. The three physicians interviewed by MR are currently involved in professional research, including specific research projects related to medical education in Cuba, which was the main purpose of their recent trip to Cuba. MEDICC Review caught up with the three physicians as they helped the U.S. students matriculating at ELAM prepare for “Step 1” of the United States Medical Licensing Examinations.

Dr. Flora Cox, M.D. is a board-certified Psychiatrist who has been in clinical practice for 27 years. She teaches, supervises trainees and does research, in addition to her clinical practice.

Dr. Jean Smith, M.D. is a specialist in Internal Medicine with a decades-long background as a physician in clinical practice, administration and medical education. She is an Associate Professor of Medicine at Columbia University and is currently pursuing a research project related to genetics and comparative genetics education.

Dr. Maxine Orris, M.D . is an attending physician in Internal Medicine at the Long Island College Hospital and runs a community-based clinical practice in Brooklyn, NY. She trained first as a doctor in Havana, Cuba where she graduated from the “ Calixto Garcia Hospital” Medical School and also completed a residency in Internal Medicine and Tropical Medicine.

MR: Dr. Cox, what are your thoughts and impressions with regard to the students? Is it your perception that this experience is particularly difficult for the U.S. students as compared to other nationalities?

FC: I imagine that there are factors that are quite universal, issues that are equally difficult or challenging for most of the students, irrespective of their national origins. [For the perspective of students from other countries, see MR Feature Profiles in Commitment: Conversations with ELAM Students]. At the same time, there are clearly certain issues that are more problematic – like the language issue. The U.S. students, and I think students from perhaps two or three other countries, are English-speakers, not native Spanish speakers...I think that in a way this will turn into an advantage for the U.S. students in the long run. We very much need bi-lingual, truly bi-lingual, physicians in the U.S., particularly in the underserved areas where these students come from, for the most part, and where they have committed to working in the future. We need culturally competent, bi-lingual health professionals. So it’s not just about language: not over there in the States, or here either. It’s about culture, too, and the huge cultural differences…But they are working hard and doing well.

They will be required to pass the United States Medical Licensing Exams (USMLE). I believe that the Cuban medical education system is preparing our students well…but there are some cultural and social issues in terms of the study of medicine that require U.S.-trained physicians to help address. So we are trying to assist in this regard.

MR: Could you elaborate?

FC: We are assisting them in studying for these boards, these exams. In addition to the full Cuban medical curriculum, the U.S. students must also study for the boards. There are some significant differences, so they need additional academic content – in the behavioral sciences, for example…So the U.S. students need to put in extra study time. Also, remember that they are studying medicine in Spanish, taking exams in Spanish, interacting with patients in Spanish, but they will also have to be fully competent and able to take exams and then work and practice in English as well! A big challenge, don’t you think?

MR: Yes, but as you said, in the end they will be better doctors for it. Now to you, Dr. Smith: how are things going in terms of the assistance to the students for studying for the boards, preparing for the exams? Do you have a sense of how they’re doing? How they themselves feel it’s going?

JS: I think it’s still a little too early to tell. We’ve had some feedback, but we really have not had a lot. I mean I think only two or three students have taken step one of the boards…So it’s still a little early in terms of being able to evaluate from a programmatic standpoint.

MR: How does this differ from other educational experiences for U.S. medical students? Do any of you know of any other medical education program that is similar to the Latin American Medical School Program?

JS: I don’t think there’s anything like this…This is an unusual project. I don’t think anybody else is doing what Cuba’s doing.

MR: There’s nothing like this in the U.S.?

JS: Clearly, if they were doing anything like this in the U.S. then our kids wouldn’t have to be here (laughing). Maybe I’m not being nice, but it’s true!

MR: With regards to that, I’ve heard in various places that U.S. medical education leaders – deans, professors, administrators – have been skeptical about this whole program. ‘Why are these students going to Cuba to study medicine?’ they’re asking. ‘It must be that they couldn’t or wouldn’t make it in the U.S. After all, we’re working very hard to recruit students of color, we spend a great deal of time and energy and resources on recruiting qualified minority students and we never meet our goals. So why do they need to go to Cuba?’

JS: Two reasons: first, yes, virtually every medical school in the United States now has some minority students and scholarship programs. But even those who are on scholarships are running up considerable debt. Remember, it’s almost always a “financial package” that’s offered, not just a scholarship. They have to take out loans. Some of these kids are coming out with debts upwards of $200,000. The other thing is that most of the schools are running at 3-5% minority enrollment. These are relatively small numbers.

Reason #2 is medical school is inordinately competitive in the United States. One of the criteria – and this has come up legally, actually – is that you have to be pretty darn close to being a straight A student to get into medical school. This happens to be utter nonsense. Being a straight A student has nothing to do with whether or not you’re going to be able to practice medicine, be a good doctor, pass your boards, or even discover DNA! It’s irrelevant – the grades thing is irrelevant, but it is a reality. And that shuts out a lot of people. You have some highly talented, competent people who just didn’t manage to make straight As. Maybe they were working while they were in school, maybe they had to work – whatever reasons.

So when you’re talking about minority students, there are at least two reasons for the low numbers. And both these reasons also reduce the numbers who actually even apply to medical school, because they know they’re not going to be able to afford it. And they know their chances of getting in, unless they’re straight A students, is not very high.

MR: What is your sense of what the thinking is about the program in the U.S. medical community?

JS: You know, the medical community in the United States recognizes that Cuba has an excellent health care system and an excellent educational system...There are any number of physicians in the U.S. who are working together with Cuba on different projects in health. It’s also a very well known fact – albeit one that’s not publicized like some other issues – that there are all these Cubans who left Cuba, went to the United States and took the USMLE. And passed it!...In terms of major health indices, Cuba has some of the best statistics in the world.

MR: Yes Dr. Cox? Did you want to add something?

FC: Yes. I think there is a growing awareness in the United States of the medical school program here in Cuba for the American students. There are a number of professional organizations that have visited the program here and have brought back positive reports about the medical school. The National Medical Association has visited the school several times, as have both the National Medical Student Association and the American Medical Student Association. The American Public Health Association; some specialty professional associations like the Black Psychiatrists of America, the American Academy of Child and Adolescent Psychiatry, The American Academy of Neurology, representatives of the American Pediatric Association among others – many others, in fact. Also a number of political organizations, congress-people and other elected officials have visited the school as well. So there is a growing awareness. However, I don’t feel that the level of awareness is where it should be. I understand that there are still many spaces available for students and we really need to make a significant effort to spread the news about this fantastic program and wonderful opportunity for North American students. It makes no sense not to fill all of the spaces that have been offered. [Cuba currently offers 500 scholarships to students from the United States, though fewer than 100 students have taken advantage of them, eds.]

MR: Yes, Dr. Orris?

MO: I think that what Dr. Cox is saying is very important and I agree with you totally. I think that although there’s a certain amount of awareness in the medical community, we really need to figure out how to get the information about this into the universities in the U.S., to the undergraduate college and university population. We need to go to the universities, approach the minority student programs, for example, and present this to students who might possibly want to take advantage of this opportunity.

MR: Dr. Orris, you are in a somewhat unique position, as you studied medicine in Cuba, did a residency in Cuba and then had to take and pass the USMLEs. You are in a position to see both sides from a number of different angles, to make comparisons, and of course, to be quite helpful to the students. Can you talk about your involvement with IFCO and ELAM?

Four of the nearly 100 US Students studying at ELAM

MO: After I came back to the States and after passing my boards I then had to do another residency to be able to practice medicine in the U.S...

Then, I heard that Cuba had offered an amazing amount of scholarships for U.S. minority students to come and study in Cuba. And I said, 'well, this is familiar, I’ve done that!' So I figured I should start helping this project. Since, as you said, I know both sides and have had the particular experience I’ve had, I felt I ought to support this, I ought to get involved. I guess you could say that I was in a position to really understand, to know, just what an amazing gift Cuba was offering, and also I knew or know what the students would need to do to be able to then come back and utilize that gift – or share it, really – with the underserved populations, the communities where these young people come from. So I got involved with IFCO because of the Medical School project...specifically as a member of their medical committee.

MR: What does this committee do?

MO: Well, it’s a national medical committee and it oversees the activities related to the medical school scholarship program. This includes publicity, to get out the word on the availability of these scholarship opportunities. We want the information about this program to get to the minority students who have been shut out, effectively, for many different reasons, from getting a medical school education. We do not select the students; The Cuban medical school handles the selection process...there are a number of different criteria or pre-requisites that we are looking for to ensure that students are really able to make the best of this amazing gift that the Cubans are giving. For example, in the case of the U.S. students, it’s required that there’s some good pre-med course work under their belts before coming to Cuba, at least two years of college, and they need to have done decently. We’re not expecting all As because we know that most of the kinds of students we’re looking for don’t go to college easily - they need to work usually, not only in college but probably they worked in high school, too, to help support their families. We’re reaching out to young people who are coming from underserved populations, minority students: blacks, Puerto Ricans, Chicanos, etc. and especially Native Americans. As I said, we’re not looking for high grade point averages, but we are looking for people who are, well, desperate to become doctors, people who have that kind of burning desire and soul of a doctor.

MR : So then you and Dr. Cox and Dr. Smith are members of this medical committee? Are there others?

MO: Yes, there are other physicians, community leaders, other health professionals. We all have different roles, different kinds of membership. For example, we have a whole bunch of other doctors who...offer our students externships and involve them in research projects, during the summers for example....We have students who have spent the summer in Alaska working in a hospital there under the mentorship of physicians who have stepped forward to help in this way.

MR: So this gives them the possibility to experience and function within a medical environment in the United States?

MO: Yes, absolutely, and it’s important. It also gives them the possibility of being involved in research projects, getting publications with their name on it which will help them when they’re looking for residencies later.

And then there’s another part of the committee’s work which has to do with working together with the Cubans, with the School, and with the students to ensure that they are adequately prepared for the Boards.

MR: There’s a lot of talk about attrition, about students dropping out or flunking out and I’ve heard a number of different opinions on this so-called attrition rate. Could you comment on that?

MO: We found, when we first started this project, that the door was way wide open – just about anyone who wanted to study medicine who had graduated from high school could apply…but that’s not what medical school’s about. So at the very beginning, with the first medical students we had, there was a higher attrition rate. But those students that continued – from the first group of students – are now in their 4 th year. And they are very, very committed. Very solid. The students that are in 3rd year, 2nd year and 1st year – that’s where you begin to see how the pre-requisites that I talked about before have helped. The attrition rate is going down, I believe. I don’t think there was even one student from 1st year who left, not even with that scare around the legal situation. [Legal restrictions relating to travel and study in Cuba by US citizens enacted by President Bush in May 2004 prohibited US students from attending ELAM; that stipulation was subsequently rescinded, though the travel restrictions remain. See U.S.Medical Students Back in Cuba, Despite Restrictions.]

MR: Given the current political situation I imagine it must be more difficult to recruit students, to get the word out.

MO: Yes, it really is harder now. Because even though this is one of the most amazing offers – there really is not a similar offer anywhere, nothing like this anywhere else in the world - it’s more difficult now. But we’re just going to keep at it! The Cubans are prepared to receive five times the number of students as are here now…

MR: What about the externships and the docs from the U.S. who have been down here and had the chance to see this project, to interact with the students?

MO: Oh it’s so interesting! They just LOVE our students, [who] are clearly being very well prepared and they’re interesting, dynamic, bilingual, very strong clinically – both in terms of hands-on practice and also in terms of clinical thinking. It has long been recognized that Cuba has a good medical education system. After all, there are a lot of Cuban doctors who have left the island who are now practicing in the U.S. And the program, the education – whether your pro-Cuba politically or not - is seen has being on a very, very high level...Again, as I have said already, this is an amazing gift. And the students who are here and moving on through the educational system are coming to realize this fully. I have no doubts that they will succeed. More importantly, I know they will be good doctors – in every sense of the word.

For more information:

www.ifconews.org

www.elacm.sld.cu