Interviews

Clarivel Presno, MD
President, Cuban Society of Family Medicine

Cuba's Society of Family Medicine is the youngest medical society in the country, representing the youngest field of specialization and the youngest membership in age. Perhaps this triple character of youth at least partially accounts for other remarkable activity it has generated since its founding in 1994-barely a decade after the family medicine duo of doctor-and-nurse was adopted as a nationwide model.

Today, the Society, recognized as a non-governmental organization in Cuba, has some 16,000 members. The membership is unique in one respect, including not only physicians specializing in family medicine, but also nurses, pediatricians, psychologists, and ob/gyn whose practice is based at the primary care level.

President of the Society, elected by the membership, is Dr. Clarivel Presno, a woman whose dynamic leadership, scientific rigor and dedication to the professionals she represents have earned her respect throughout Cuba's medical community.

To begin with, a personal question: why did you decide to become a family doctor? What attracted you to this specialty?

Vocation, I imagine. In junior high school, I was already attracted to medicine. But the actual decision to join the profession was of course more complex. Now, the decision to become a family doctor was a question of timing. I was entering medical school right when the first family doctors were being trained as specialists. It was a tremendous challenge-and something of a mystery. We had no prior notions of the specialty. And we all had one question: would the family doctor program really work, would people accept us? Would we have sustainable results?

We had the initial answers sooner than we expected: ten family doctors began the program, out of the Lawton Polyclinic in Havana. A few more of us joined them within months. We were spread out in the community, serving specific neighborhoods, much as the family doctors do now. The level of satisfaction we achieved among the population, and our own professional satisfaction at becoming family doctors, were the catalyst for extending the program all over the country. And as you know, now over 98% of Cubans are served by family doctors and nurses.

I know you then spent 13 years in Lawton, working with your patients in the community. What was your most difficult moment?

I'd say there were two kinds of difficult moments. The first one was prolonged and the result of a general concern: were we, as family doctors, going to be professionally capable of attending successfully to such a wide variety of health problems, along the whole gamut of the population? When you looked into the waiting room, you could see a mother with a baby in her arms or an elderly man; you could find people who wanted attention to their biological problems, but also to psychological and social problems. So, the question over time was: would we be up to the challenge?

And you have to remember that at that time, our training was still very much biologically focused. Yet, we were being called on to fulfill a social responsibility for which we weren't fully prepared. We were more prepared to treat the individual, but not necessarily to see that person in the context of their family and community.

On a personal level, my most difficult moment came one December. It was December 3rd, the day we celebrate Latin American Physicians' Day, so I remember my office was full of people who had come in to wish me well, and the whole atmosphere was very festive.

Then suddenly, I looked up and saw a young woman, one of my patients, who was outside on the sidewalk. She didn't say a word. Just pointed to her abdomen with such a look of pain and anguish on her face that I immediately ran to her. And I was already fairly certain that I was seeing the symptoms of an ectopic pregnancy. She had had a menstrual extraction a few weeks earlier, and had shown no sign of infection since, and so I decided then and there to rush her to the hospital myself.

I was so sure of my diagnosis that I took her right to surgery, and found the surgeon on duty. He asked me why I was so certain it was an ectopic pregnancy; and I explained the reasons. But I also told him: I need you to trust my diagnosis, because this young woman's life may depend on it. But he didn't. He sent us down the hall for more tests, and I went with her. She already looked terrible. And then apparently he had second thoughts and came after us. "Let's get her to surgery", he told me.

When he went to drain the abdomen, the pressure was so great that it shot the syringe out of his hand. She had already suffered a tubal rupture.

The procedure saved her life, and I had the joy of telling her parents she would pull through. Afterwards the surgical team apologized for ever doubting my diagnosis. But most important, I felt I had not only "graduated" as a family physician, but I also felt that the role and capabilities of family physicians had also been vindicated. Our specialty had gained in credibility, in scientific respect.

Of course, we still have detractors. But over the last 15 years, family doctors have earned a place in Cuba's medical and scientific community. And there are many Cuban specialists in other fields who we can now say are fervent believers in family medicine-top medical school professors, the most prestigious in the country, who are convinced of the important role family physicians play, and who can see beyond the hospital walls to recognize a universe in which only the family doctor is capable of serving. Human biology, after all, only determines 8% of the health situation: the environment, family, community and other factors determine the rest.

What then are the major challenges facing curriculum development and medical education for family physicians, so that they can practice most effectively in this context?

Since 1984, when the family doctor program began, we have been slowly incorporating more social medicine into the curriculum. When I graduated, I had only spent time in the community during periods in two years of medical school. Right now, students spend some time in the community during periods in five of their six years of training-20% of their education takes place in the community.

Today, I think we don't need more time in the community, but rather to shift focus wherever the students are. That is, even with hospitalized patients, the focus can't be only clinical. The professor making rounds with students has the obligation to explain the clinical aspects of an infarcted patient, or one whose hypertension suddenly shot up, but also to speak to the social influences that unleashed the process that landed that patient in the hospital.

The Society of Family Medicine was created in 1994, just one year after Cuba's economy hit bottom. What implications did this have for the Society?

Of course, our work was infinitely harder than it would have been in good times. But it was also more necessary. Because it was precisely at that point when we had to prove that, despite everything, we were committed to the continuing scientific development of our human resources. We weren't willing to give that up. And it was time family practitioners were organized into a scientific society, just as the other medical specialties.

The economic situation has affected us, of course. For example, we would like to do more for the 2,000 of our family doctors and nurses in the mountains, who serve 100% of the population there. We are constantly trying to do more, prioritizing their subscriptions to our journal and other publications, but although most have electricity, of course they don't have computers, so it's difficult to guarantee daily contact. And this is the main challenge we have: to serve them better, because they are the ones working in the toughest
conditions.