Powerful Lessons from Cuban Medical Education Programs: Fostering the Social Contract in Athletic Training Programs

Creativity and Innovation in the Face of Limited Resources

Despite the embargo, which created relative isolation for Cuban health care educators and service providers, the Cuban health care education program has experienced success creating positive health outcomes with limited resources.^14,15 Blocked off from the rest of the world by trade restrictions, Cuban health care educators and providers used innovative strategies to maximize their resources. These innovations often resulted in creative, nontraditional approaches to resolving health care issues, including alternative therapies and interventions. Further, creativity and innovation were facilitated through interprofessional practice settings where a plethora of health care specialties work together to create solutions to health care problems.

Not unlike the situation in Cuba, athletic training professional programs are expensive to operate, often resulting in limited resources. Using teamwork and collaborations, athletic training can continue to do more with less by working collectively through innovative educational programming and practice initiatives. Interprofessional education has been integrated into the new CAATE standards,¹¹ further endorsing creative and innovation application of skills and knowledge. In an increasingly complex health care environment, the ability to work collaboratively with other health care professionals is a necessity for athletic trainers. Athletic trainers should consider the need to “think differently” about education and clinical practice. In a forward-thinking model, Gardner¹⁶ contends that there are 5 minds for the future: cognitive, synthesizing, creative, respectful, and ethical. Athletic trainers should integrate each of the 5 minds rather than simply relying on cognitive knowledge to carve our niche in the health care professions. As a means of fulfilling the social contract, athletic trainers embracing this broader perspective on education and health care can expand and defend their role as health care professionals. This will sustain the profession well into the future and is integral during educational reform.

Preventative Medicine and Treating the Whole Patient

As a nation, Cuba's medical education program centers on the health of the patient, not just the treatment of disease or injury.¹⁷ Preventative care is emphasized across the lifespan, and alternative interventions, including but not limited to tai chi, healthy eating, and art as medicine,^15,17 are widely used. In the case of poor health, the health care provider is engaged at the most fundamental level through family physicians or consultorios. Structurally, Cuban health care begins with family medicine, where a “barrio” doctor ensures comprehensive care of those in the neighborhood. At this level of care, all aspects of care are evaluated as potential influences on health. The family doctor treats generations of families and has a strong understanding of the whole person and the person's environment, considering biopsychosocial elements as determinants of health. With a focus on wellness in the context of social, mental, and physical health, trends are identified early and can be prevented before they become problematic.¹⁷ Should an individual need more advanced care in the Cuban system, polyclinics provide more advanced health care services through specialists. The third tier of medical care in the Cuban system is the hospital or specialty clinic. This inverted health care model beginning at the most basic level of care through rigorous evaluation of all factors influencing health reflects the tenets of the evolving disablement model approaches in the athletic training literature.^18,19 Further, the role of educating patients for self-responsibility adds to the effectiveness of the preventative model.

Disablement models emphasize multiple levels of health determinants similar to those practiced in Cuba. Several authors^20–23 have identified the role of disablement models in athletic training as an integral link to clinical outcomes measures. Conceptually, disablement models focus on a patient-centered, whole-person approach, integrating physical, psychological, social, environmental, and cultural elements. According to the Institute of Medicine, patient-centered care necessitates that the practitioner “identify, respect, and care about patients' differences, values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care; listen to, clearly inform, communicate with and educate patients.”²⁴ Athletic trainers are actively engaged with patients in a variety of settings. Athletic trainers are in unique situations to implement the whole-patient approach because of the trusting relationships established with patients, not unlike the family physicians in Cuba. As a profession, adopting this model anchored in whole-person care can guide athletic training clinical practice, education, research, and policy, facilitating compliance with the contract with society.

Community Outreach

Cuba is well known for providing health care for all. Despite political perspectives regarding the equity of health care, it cannot be denied that Cuban health care systems provide health care services to community and outreach areas that would not normally be provided care. With an emphasis on rural medicine, Cuban health care providers are trained to value serving even the most remote patients. Further, Cuba actively engages in educating underrepresented physicians from low-income communities in the United States, Asia, and Africa.¹⁷ At the completion of their educational training, these individuals commit to serving local communities where medical need is extreme. This commitment to serve is instrumental in providing a return on investment for the country by placing well-trained professionals in areas of dire need and fulfilling the most fundamental construct of health care—patient first.

Athletic training services in remote areas in the United States are dismal at best. Although most colleges and universities have athletic training services, high schools, youth leagues, and other organizations are still grossly underserved. As a profession, athletic training has launched several initiatives to facilitate the placement of athletic trainers in these underserved areas, but most have been met with little change in health care services. Athletic training needs to continue to develop strategies and legislation to provide underserved clients appropriate medical coverage by athletic trainers. As advocates for the profession, educational programs should establish leadership programs that engage students to emerge committed to advocating for critical initiatives for the profession. As a profession, working in silos defined by employment venues prevents the creation of sound approaches to address this disparity in services collectively. As did the Cubans, perhaps athletic trainers need to consider a “different” approach to serving others. Designing outreach programs within the community rather than placing an athletic trainer in traditional settings could alleviate the problem. Alternative outreach initiatives and clinical experiences could posit athletic trainers in the community working collaboratively with physicians to address the overall health needs of a community.

Training and Distribution of Health Care Providers

Cuban medical education systems focus on training physicians efficiently and effectively to develop competent health care providers to fulfill the contract with society. Health care directives affect educational and service approaches and access to health services for all.²⁵ Anchored in training family practice physicians, Cuban health care professionals are well qualified to address a wide range of health care issues in a broad population. Training physicians to focus on the fundamental levels of health rather than specialize early provides a strong foundation for understanding the interconnected elements of health inherent in the disablement model. For example, Cuban doctors are very well respected across the world and serve in a “global brigade” for the world. This outreach medical initiative is feasible because health care professionals are trained to appreciate the whole patient and the medical influences that affect their health across the globe. This training makes them versatile, integrated health care providers able to work in a plethora of settings without compromising the integrity of the social contract.

Athletic trainers are also embracing a generalized approach to health care through educational reform by emerging in new settings to expand the scope of practice to meet the needs of society. New standards and competencies address the changing context of health care for athletic trainers. Further, changes in the competencies¹¹ and emerging specialty certificates and residencies align with the direction of the Cuban medical system. With the goal of training all professionals to address the comprehensive patient with sound clinical skills and comprehensive interventions, athletic trainers can expand professionally in health care settings. Strong foundational knowledge and skills anchored in disablement models will enhance the professional status of athletic trainers.

To implement this approach, education programs must carefully construct educational opportunities to facilitate the development of broad, widely applicable skills that can be used on a range of patients. Not only will this promote whole-patient approaches, it will provide a framework for generating meaningful clinical outcome measures. Gone are the days where athletic training programs place students in convenient locations for clinical experiences. Athletic training programs must place students in clinical venues where they will be exposed to a rigorous, meaningful, diverse experience to practice and understand the implications of their actions on patient outcomes. Academic programs should be designed to prepare students to meet the health care needs of all rather than provide services to the few to fully affect professional and organizational benefits.²³

Like Cuba, athletic training is already beginning to reap the benefits of integrating some of these approaches into educational programming. Athletic trainers are currently fulfilling professional roles in a wide range of settings in the United States and abroad. New and exciting opportunities for employment, such as in the military, performing arts, industry, and emergency departments, are emerging regularly. When athletic trainers are educated with a broad perspective of skills and knowledge, these professionals will be employable in a variety of settings while meeting the emerging needs of our society and world overall.

Research Initiatives

Cuba is well known for its innovative research initiatives. Limited for decades by the embargo with the United States, Cuban health care researchers have developed innovations with little support from or collaboration with other countries. In spite of limited resources, Cuba health care researchers eliminated polio, diphtheria, rubella and mumps; produced the world's first meningitis B vaccine; produced antiviral drugs; and created a national biomedical Internet.²⁶ Additionally, Cuba was the first country to produce an antidiabetic foot medication through its biotech network that significantly reduced the number of diabetes-related amputations. Within this small country, collaboration among researchers provided opportunities to expand the effect and reach of the research.²⁷ Cuba has been resilient in producing outstanding medical research that is respected worldwide, and has established a research network that disseminates Cuban scholarly research nationwide in MEDICC Review and other reputable journals.

Athletic training has suffered similar strife throughout its professional evolution. As scholars, athletic trainers are working diligently to create research networks despite early limitations in athletic training–specific publications. With the emergence of athletic training journals such as the Journal of Athletic Training and Athletic Training Education Journal, scholars found a professional voice and have built a reputation of producing meaningful, scholarly work. Athletic trainers have also long suffered from limited access, generally speaking, to funding resources for research. Although several outside agencies fund athletic trainers, the Research and Education Foundation is the only funding agency directly related to the profession. Athletic trainers, not unlike Cubans, have endured and branched out to seek the recognition of other agencies. Despite funding challenges, athletic training educators, clinicians, and researchers continue to work diligently to find funding and to publish sound research. It is imperative to have a professional presence by producing research to guide practice within our own profession, and educational programs must emphasize this role in the preparation of future professionals.

The creation and implementation of practice-based research networks is instrumental in creating translational research that can be used in clinical practice.^20–23,28 As a profession, these networks provide athletic trainers reach beyond the scope of their limited clinical setting to generate outcomes to move the profession forward. As in Cuba, working in isolation can create positive outcomes, but expanding the reach of the research to a broader application contributes to profound changes within the profession. Knowledge and research help position athletic trainers in the medical community as respected contributors to science. With continued evolution of research initiatives and collaborations, athletic training professionals are emerging as respected scholars and practitioners, both of which contribute to fulfilling our obligation to society to advance knowledge.

Internationalization, Global Outreach, and Cultural Competence

Cuba has extended its borders by facilitating global outreach from the beginning of educational training. As part of the training, Cuban physicians commit to serve global health care needs when activated. This “global brigade” is engaged across the world, with Cuba providing relief services without hesitation. With proper international integration and global medicine training, these physicians are prepared to address the needs of the world. A strong program anchored in global health and cultural competence posits them well to be successful, effective leaders in world health interventions.

The 2020 Standards¹¹ created core competencies to guide educational and clinical preparation of athletic trainers. Anchored in the ACGME core competencies, these fundamental behaviors transcend all aspects of professional care and enhance cultural competence in a variety of ways. Embracing these constructs through innovative experiences, athletic training students will emerge competitive in the increasingly global health care market. Although athletic training education is substantively different, international initiatives in athletic training provide students the opportunity to become exposed to global health care issues. Service learning projects in diverse areas or clinical rotations in free clinics in diverse areas provide athletic trainers with international exposure while staying within the United States. Whether one is traveling abroad or serving locally, understanding the unique differences in health care across cultures facilitates not only expansion of reach as health care professionals but also provides valuable knowledge and skills beyond traditional interventions. Internationalization and outreach to culturally diverse patients create a community of resources where collaborations and exchanges can reach beyond physical borders to facilitate broader health care goals. Equally important, athletic trainers with international exposures also develop a stronger sense of cultural competence, which is integral to the social contract and whole-patient health care.

Rapidly changing demographics require health care professionals to be culturally aware, sensitive, knowledgeable, and self-confident in providing culturally competent care. Cultural competence is proposed as an effective solution to reduce health disparities that exist within and beyond the United States.²⁹ There is strong evidence that health professionals do not automatically have the attitudes or skills necessary to be effective in culturally diverse settings.³⁰ Athletic trainers should become aware of the limitations of their cultural values, beliefs, and practices; obtain cultural knowledge; become open to cultural differences; and develop cultural skill. They must be willing to engage in cultural encounters and want to (rather than have to) provide culturally competent care.³¹ Through these experiences, athletic trainers are afforded an authentic chance to confront ethical, cultural, personal, and societal challenges that demand professional decisions in new and culturally challenging environments.³² In these interprofessional initiatives, athletic trainers become powerful advocates for change at the personal, local, and global levels,³³ which affects social responsibility and intellectual maturity.³⁴ It is the responsibility of the athletic training profession to facilitate internationalization and global health care training to fulfill the contract with society to expand the reach of professional services across the globe.