Editorial Type:
Article Category: Article Commentary
 | 
Online Publication Date: 01 Oct 2019

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

EdD, ATC, FNATA and
MS, AT
Page Range: 275 – 282
DOI: 10.4085/1404275
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Context

The Cuban medical education and health care systems provide powerful lessons to athletic training educators, clinicians, and researchers to guide educational reform initiatives and professional growth.

Objective

The purpose of this paper is to provide a brief overview of the Cuban medical education system to create parallels for comparison and growth strategies to implement within athletic training in the United States.

Background

Cubans have experienced tremendous limitations in resources for decades yet have substantive success in medical education and health care programs. As a guiding practice, Cubans focus on whole-patient care and have established far-reaching research networks to help substantiate their work.

Synthesis

Cuban medical education programs emphasize prevention, whole-patient care, and public health in a unique approach that reflects disablement models recently promoted in athletic training in the United States. Comprehensive access and data collection provide meaningful information for quality improvement of education and health care processes. Active community engagement, education, and interventions are tailored to meet the biopsychosocial needs of individuals and communities.

Results

Cuban medical education and health care systems provide valuable lessons for athletic training programs to consider in light of current educational reform initiatives. Strong collaborations and rich integration of disablement models in educational programs and clinical practice may provide meaningful outcomes for athletic training programs. Educational reform should be considered an opportunity to expand the athletic training profession by embracing the evolving role of the athletic trainer in the competitive health care arena.

Recommendation(s)

Through careful consideration of Cuban medical education and health care initiatives, athletic training programs can better meet the contract with society as health care professionals by integrating the Accreditation Council for Graduate Medical Education's core competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice now promoted in the Commission on Accreditation of Athletic Training Education's 2020 Standards for Accreditation of Professional Athletic Training Programs.

Conclusion(s)

Educational and health care outcomes drive change. Quality improvement efforts transcend both education and health care. Athletic training can learn valuable lessons from the Cubans about innovation, preventative medicine, patient-centered community outreach, underserved populations, research initiatives, and globalization. Not unlike Cuba, athletic training has a unique opportunity to embrace the challenges associated with change to create a better future for athletic training students and professionals.

KEY POINTS

  • Athletic training should integrate the Accreditation Council for Graduate Medical Education's Core Competencies into educational programs to facilitate patient-centered care.

  • Cuban medical education programs provide insight into how innovative programming can create opportunities for athletic training programs.

  • Athletic trainers are obligated to fulfill the social contract with society as health care providers.

INTRODUCTION

The Cubans didn't discover the importance of multi-sector action, good clinical practice or sound public health. What they did was find ways to meld them together—a profound strategy shift that has brought outstanding results even in the toughest of times.1

Not unlike Cuba, athletic trainers are working hard to create a niche as health care professionals. During the evolutionary process of the profession, significant educational reform challenged athletic training professionals to embrace change, with the recent major reform initiative being that of the transition to the entry-level master's degree. Many powerful lessons about resiliency and commitment to change in spite of hardships can be learned from the Cuban medical education system. Change has a way of disorienting even the most competent professionals. Athletic training is facing a “disorienting dilemma”2(p8) not unlike what Cuba faced regarding providing quality medical education, services, research, and outreach in a challenging environment. In a small nation with nominal resources and extreme political influence, the Cuban health care professionals have become competitive in providing quality medical education and effective health care services at home and abroad. In light of educational reform and the changing health care landscape, athletic trainers strive to design educational programs that best prepare students to be competitive in a variety of interprofessional settings. As a construct, perspective transformation during change guides professionals toward critical, dynamic relationships promoting inclusive, integrative processes.3,4 As individuals shift through transformative processes, social consolidation and reinterpretation of new biographies emerge.5 The athletic training profession is undergoing transformation in many ways, and educational programs change to meet the ever-changing health care climate.

Professionalism and quality care are fundamental constructs of educational reform.6,7 The social contract in health care is expressly defined as the dynamic relationship between medicine and society in response to contemporary changes within a profession.8,9 The purpose of this commentary is to present an overview of the values-based Cuban medical education and health care systems to draw parallels for integration into training US health care providers, specifically athletic trainers. Next, an analysis of Cuba's comprehensive approach to health care and how it aligns with athletic training educational initiatives in the context of the Accreditation of Graduate Medical Education (ACGME) Core Competencies and the Commission on Accreditation of Athletic Training Education's (CAATE's) 2020 Standards for Accreditation of Professional Athletic Training Programs will be provided.10,11 Practical suggestions for integrating elements of altruistic, values-based health care curricula and professional practice into athletic training education programs as a platform for fulfilling the social contract for students and practicing professionals in athletic training will conclude the commentary.

As a practical model, the Cuban medical education focuses on preventative health care and the patient-provider relationship.12,13 This model embraces the role of an interdisciplinary team working collaboratively to provide prompt, preventative care through strong, caring relationships anchored in primary care services. With a focus on the primacy of the patient as a means for intervention, it is strongly anchored in the ethics of care. Embracing the ACGME core competencies in theory despite political, financial, and self-interest influences, Cuban medical education provides useful lessons to athletic trainers facing educational reform. Athletic trainers and other health care professionals in clinical practice and academia can benefit from a broader understanding of how the Cuban model of medical education and practice can be implemented across the curriculum in professional training. This model provides a strong framework of reflective practice on educational programming and initiatives for integration into American health care education models to reinforce the social contract inherent in medicine (Figure).9

Figure. Parallels between athletic training education and Cuban medical education programs.10,11 Abbreviations: ACGME, Accreditation of Graduate Medical Education; CAATE, Commission on Accreditation of Athletic Training Education.Figure. Parallels between athletic training education and Cuban medical education programs.10,11 Abbreviations: ACGME, Accreditation of Graduate Medical Education; CAATE, Commission on Accreditation of Athletic Training Education.Figure. Parallels between athletic training education and Cuban medical education programs.10,11 Abbreviations: ACGME, Accreditation of Graduate Medical Education; CAATE, Commission on Accreditation of Athletic Training Education.
Figure Parallels between athletic training education and Cuban medical education programs.10,11 Abbreviations: ACGME, Accreditation of Graduate Medical Education; CAATE, Commission on Accreditation of Athletic Training Education.

Citation: Athletic Training Education Journal 14, 4; 10.4085/1404275

As introduced earlier, the social contract in medicine is defined as the ever-changing, reciprocal relationship between medical professions and society.8,9 Anchored in expectations, this tacit contract exemplifies the powerful role and deep responsibilities held by today's health care professionals.3 Although professional boards and organizational codes of ethics guide behaviors, the human resource, financial, and emotional demands in health care have the potential to threaten and degrade the trust established through the social contract. Education, leadership, relationships, contemporary discussions, and moral boundaries in the health care setting are all affected by these changing demands.9 Health care professionals, including athletic trainers, should educate young professionals on how to fulfill the deep responsibilities entrusted them by constantly considering improvement initiatives.

HISTORICAL RELATIONSHIPS WITH CUBA: EDUCATION AND HEALTH CARE

As a point of reference, it is important to discuss the evolution of Cuban medical education programs to understand how persistence and response to change actually strengthened their systems, which may help guide athletic training during educational reform. Although American educators have been collaborating with Cubans for 2 decades through Medical Education Cooperation With Cuba (MEDICC), the powerful lessons have not been formally embraced by many Americans because of the political dynamics between the countries.14 The goal of MEDICC is to have the “US and Cuban health communities working together to improve health, health living [sic], and health equity in both countries.”15(p1) With more Americans traveling to Cuba since the 2016 accord between the US Department of Health and Human Services and Cuba's Ministry of Public Health, wider acknowledgment of Cuba's contributions to these collaborations are forging a new era of cooperation among health care providers, researchers, educators, and administrators across nations.14 Educational and health care collaborations shed light on potential innovative strategies for athletic training programs in an effort to fulfill the contract with society as health care professionals.

LESSONS FROM CUBA

Anchored in core professional competencies similar to ACGME and driven to fulfill the social contract, Cuban medical education programs strive to create health care providers who are willing and able to fulfill the deep responsibility inherent in providing quality care for all similar to initiatives emerging in athletic training education reform. First, Cuba embraces creativity and innovation to significantly affect health advances when faced with hardships. Athletic training has faced significant challenges and encourages creativity and innovation in carving a niche within an ever-changing health care system. Second, preventative medicine is the foundational component to overall health care in Cuba. Athletic trainers have always focused on preventative health care as a fundamental professional domain, and recently adopted the disablement model to comprehensively embrace this construct. Third, community-based programs contribute to significant positive health outcomes in Cuba. Athletic trainers have broadened their scope to focus on a variety of nontraditional settings for employment, including, but not limited to, community outreach. Fourth, the training and distribution of health care providers in Cuba meets the needs of the population rather than the needs of the health care providers. Athletic trainers are emerging as health care providers in settings unique to the profession, reflecting versatility as health care providers. New educational standards integrate innovative competencies once thought beyond the professional scope of the athletic trainer to prepare students to serve emerging population needs. Next, developing research initiatives to widely address global health issues brings together health care providers and serves patients in Cuba. Research collaboratives extend well beyond the reach of the individual laboratory and affect the health of many constituents, expanding the possibilities of each individual setting to generate a larger, more profound outcome. As athletic training research, especially educational research, expands, more research collaboratives are emerging to best serve the profession. Last, athletic trainers can potentially fill the expanding global need for unique health care providers if trained to do so. Cuban medical education programs embrace diversity and demonstrate a strong sense of cultural competence while mandating international service. Integrating cultural sensitivity, intercultural education, and internationalization into athletic training education programs will prepare culturally competent athletic training professionals who can succeed in global health care settings (Table).

Table Lessons for Athletic Training Programs Anchored in Cuban Health Care Educational Cornerstones
Table

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 authors2023 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.2023,28 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.

CONCLUSIONS

Without a significant shift in perspective on how to best meet the needs of society as health care providers, athletic trainers are at risk of falling short of becoming the competitive, qualified health care providers of the future. Athletic trainers have modeled and can continue to model the resiliency of Cuba in many ways. Athletic trainers can thrive despite limited resources to create innovative health care solutions and opportunities across the globe and at home. Athletic trainers can compete with other health care providers who are highly specialized by embracing the whole-patient approach to health care endorsed in disablement models and through interprofessional training and practice. Athletic trainers can investigate and fulfill voids in community health care by training diverse, competent health care providers. Athletic trainers can produce quality research despite limited research collaborations and dollars for professional effect and respect. Lastly, athletic trainers can integrate and embrace global outreach as an imperative in educational programming to expand the boundaries of the expert services they provide.

This paper sought to highlight initiatives generated through collaborative efforts in Cuba and does not promote the adoption of universal health care designed like the Cuban system. However, it does promote an alternative perspective on designing educational programs that emphasize key successes in Cuba's current educational system to create an academic culture focusing on the whole person. Athletic trainers are branching out into multiple venues where a wide range of clinical skills will be used in interprofessional environments. As athletic training programs move to advanced degree levels, it is imperative to evaluate potential opportunities leading to unique, collaborative initiatives to meet the needs of those served. Athletic trainers are working diligently to become competitive in the health care market and to maintain a unique niche in this aggressive health care landscape. Identifying areas where interprofessional collaborations are anchored in a broad, widely applicable context could shed some light on maintaining a foothold as health care providers.

Now is the time to stand back and look broadly at educational opportunities in athletic training. According to Frank's35 perspective on “the painter and the cameraman” in clinical education, education reform and professional growth occur when a profession can focus on the fine details, as does the cameraman, while integrating bold brushstrokes on the overall canvas, as does the painter. Through this perspective transformation, athletic trainers can strive to meet the needs of the public while fulfilling the contract with society as valuable health care professionals.36 Paul Geisler37 wrote an editorial on the culture surrounding athletic training education and the perceptions associated with “athletic training school.” With innovative, creative educational and clinical practices paralleling the Cuban system, athletic trainers can reverse this perception and enlist generations of athletic trainers to fulfill the professional contract with society as health care professionals.

Copyright: © National Athletic Trainers' Association
Figure
Figure

Parallels between athletic training education and Cuban medical education programs.10,11 Abbreviations: ACGME, Accreditation of Graduate Medical Education; CAATE, Commission on Accreditation of Athletic Training Education.


Contributor Notes

Dr Peer is currently Professor and Athletic Training Program Coordinator in the Department of Athletic Training, School of Health Sciences at Kent State University. Please address correspondence to Kimberly S. Peer, EdD, ATC, FNATA, Department of Athletic Training, School of Health Sciences, Kent State University, 350 Midway Drive, 266B MACC Annex, Kent, OH 44242. kpeer@kent.edu.
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