Original illustration: @ArtOfGonzalez

It came out of the blue, on a lazy Saturday morning.

Marica, did you get the call? They’re calling everyone, well not everyone, Juan told me they called him. What about you, have they called you yet?”

This happened over a year ago, but I still remember it like it was yesterday: my phone kept ringing like mad.

“No, marica, they haven’t called me yet.”

One could only be so innocent to think life as a general practitioner begins when some rector signs your diploma. Ojalá.

I was freaking out, my heart was racing, I was shitting my reciengraduada pants. It had only been a week since my fabulous walk down the Aula Magna’s bazillion year-old staircase, the ink on my diploma was still fresh. I certainly didn’t feel ready to get The Call.

Soon enough, my phone started ringing. Caller ID showed a Movilnet cellphone: “Que pirata!” I thought to myself. But  I picked it up immediately.

“Is this Dra. Cantor? We are calling from CORPOSALUD.”

And so it began, the first day of any physician’s career in Venezuela. One could only be so innocent to think life as a general practitioner begins when some rector signs your diploma. Ojalá. It begins and ends (like pretty much everything else in this country) by the will and the power of a secretary sitting comfortably in her government office while juggling her social media feeds.

“Yes, this is her speaking,” I said. “What can I do for you?”

This was future calling, for better or for worse. Someone had already decided how, when and where my first job would be and there was nothing I could do about it. I, as the rest of my class, had waited for this call for over two months and it had just now stormed in, so inconvenient and almost unwanted.

The first day of any physician’s career in VenezuelaIt begins and ends by the will and the power of a secretary sitting comfortably in her government office.

“You’ve earned a position as rural physician for the state,” the voice said. “You are expected at CORPOSALUD’S offices first thing on Monday morning, the institution’s director will provide you with further detail.”

Our fates were sealed, we had an appointment with none other than our own regional health minister office’s head honcho. El chivo que más mea.

That day, we sat in old dusty chairs, about 80 of us. The mood was tense, El Comandante’s eyes were everywhere, even that infamous picture of him holding a stethoscope.

You are privileged wealthy people, all of you with your fancy cars and cellphones. You don’t care for the patients’ needs, you don’t know what it’s like to be hungry or sick

In came the big boss, the regional head of the Sistema Nacional Público de Salud. He had some things to say and a desperately attentive audience. Every worker in the building was there: he held the next several years of our lives in his hands. Himself an Universidad de Los Andres (ULA) graduate and therefore our colleague, he nonetheless launched into a hypocritical attack on the quality of our education. He almost had the nerve to call us dumb and say that M.I.C’s were (Médicos integrales comunitarios, our Cuban-style quickie “doctors” from Universidad Bolivariana) better.

“I know most of you want to stay close to your homes, you want the papitapelada”.

“You are privileged wealthy people, all of you with your fancy cars and cellphones. You don’t care for the patients’ needs, you don’t know what it’s like to be hungry or sick…”

We just needed to fulfill our Artículo 8 to move on from this.

That’s why we’re here, really. Article 8 of the Law on Medical Practice, el bendito artículo 8, put our whole future in his greasy, communist hands.

Artículo 8. Para ejercer la profesión de médico en forma privada o en cargos públicos de índole asistencial, médico-administrativa, médico-docente, técnico-sanitaria o de investigación, en poblaciones mayores de cinco mil (5.000) habitantes es requisito indispensable haber desempeñado por lo menos, durante un (1) año, el cargo de médico rural o haber efectuado internado rotatorio de postgrado durante dos (2) años, que incluya pasantía no menor de seis (6) meses en el medio rural, de preferencia al final del internado.

There’s no point translating word for word, what it means is clear enough: for the first one or two years of our careers, the state owns us. It gets to tell us where to go and what to do, and we have no say in the matter. It’s a monopsony buyer of our services. Logically, it pays us a pittance.

Just another chavistic nightmare, then? Not at all. Various forms of Rural Service for new doctors had been around since the 1940s, and Article 8 as such has been written into the Law on the Medical Profession since 1982.* Friggin’ Luis Herrera. I mean, they have changed so many other aspects of the way our health system is organized, but this particular article survives. It suits them for it to survive.

As with everything else that was screwed up before, the revolution’s main role has been to make it worse. Once upon a time a young person could live comfortably with what you got paid doing La Rural. Most health centers were equipped with a residence for the rural physician and even provided food.  

These days? You’re on your own, under a labor contract that has not been discussed since 2003, and with a basic salary that has been at times embarrassingly close or even actually less than the minimum wage.

Back in the room of dusty chairs, it was finally time to be awarded la asignación. The “sorting hat” moment. Slowly, they called each of us by last name. Some people already knew what hospital they had been assigned to, la rosca, you know. They called my name and I felt a punch in my stomach.

You’re on your own, under a labor contract that has not been discussed since 2003, and with a basic salary that has been at times less than the minimum wage.

Normally, one would have a chance to decline a bad job offer. Not here. If you decline your assigned position you get blacklisted and God knows how long until you got another offer from the state. The system was known to be anything but fair or meritocratic. It was yet another case of my enchufado is better than yours. If you’re with el proceso, the definition of “rural” becomes conveniently flexible. A modern outpatient clinic with easy hours, located less than a couple of miles from your home in an urban setting might be your spot…if you have the right friends.

Some of my classmates had already purchased an airplane ticket before graduation, so they could leave the country with their diplomas even though, for most of them, practicing abroad wasn’t in the cards. They’d rather be extravagantly over-qualified waitresses or babysitters in Miami than hungry doctors in La Azulita.

The moment I realized there was nothing right about this process, I felt at ease. I gave them their letter back and, today, I work at a hospital where I never in a million years though I would, and I’m as pelabola pero feliz as anyone in Maduro’s reign. I could work in the private health sector, illegally of course, as the requirement for private practice is La Rural. Since it is impossible for a physician with a single state job to provide for herself, let alone for a family, breaking the law is my only alternative to straight-up hunger.

Nowadays, staying on as a general practitioner is rare. We’ll all get our Artículo 8 and then move on to grad school to become pediatricians or surgeons.  Private clinics still need general practitioners to treat and triage ambulatory patients so they’ll play it to their favor.

My classmates would rather be extravagantly over-qualified waitresses or babysitters in Miami than hungry doctors in La Azulita.

And even if you do get a job illegally, it won’t pay well. You’ll be hawked off as a consultant or a substitute and, for the most part, it will be impossible to establish a stable working relationship. The clinic is watching its back, you will have to watch yours. That’s scary, especially if you make a mistake in your practice, which,  let’s face it, is likely given that you just graduated like, five seconds ago.

Between all of this and the health crisis with even the milicia stealing the drugs that patients have to buy for themselves but can’t really afford, praying before my shift feels like the most helpful thing I do.

I pray I don’t make any mistakes.

I pray I treat my patients to the best of my abilities.

I pray nobody dies on my watch.

______
*Correction: An earlier version of this story had La Rural being born in 1982. In fact, it’s Art. 8 specifically that dates from 1982.

Previous articleTinedo’s Choice
Next articleENCOVI 2016: A Tragedy in Numbers

Head of the Church of Martha Stewart: I bake therefore I am. Táchirense: Almojabana and quesadilla lover, “toche” and “juemadre” user. Pastelitos de queso con bocadillo fanatic and overall gochadas supporter. Also doctor —as in proper MD— and pobresora universitaria too.

31 COMMENTS

  1. I am currently doing my rural too (in fact, I’ve just returned from my ambulatorio). To anyone else, this article is 100% correct. We’re basically slaves, because the infamous article 8 is required to advance your career. And, since it’s required by law, there really is no incentive for the state to treat you any better. After all, who would want to work in a town in the middle of nowhere or a dangerous barrio if the pay isn’t good enough? Oh, but the point isn’t what you want: It is what you’re given.

    But the article misses one point: The condition the medical centers are in. My ambulatorio is in a pretty deplorable condition. The infrastructure is decades old and in dire need of a makeover, several air conditioners need repairing, and we just spent 3 WEEKS without water service. But the absolute worst part: There are no medical supplies and even less medication. Are you in pain? Well, please buy whatever you need because there isn’t a damn thing here. Dehydrated? Well, you better bring the saline solution, because we sure as hell don’t have any to spare. Your child is having a seizure? We have to watch until the seizure stops because we don’t have any anti-seizure medication. And so on.

    It really is depressing.

  2. “I pray nobody dies on my watch.”

    But, they will. People die all the time. Sometimes it is preventable, sometimes not. You will strive to do your job perfectly, but sooner or later, you will fail. And, what you do with that will define you. Good luck.

    • The problem is when someone dies on your watch because you didn’t have the proper tools to treat them. That’s one of the underlying issues here.

  3. Great first post, Astrid! I just came back from visiting my cousin who’s also doing the rural. I’m glad it’ll be over soon!

    This paragraph seemed a bit misleading to me:
    > Some of my classmates had already purchased an airplane ticket before graduation, so they could leave the country with their diplomas even though, for most of them, practicing abroad wasn’t in the cards. They’d rather be extravagantly over-qualified waitresses or babysitters in Miami than hungry doctors in La Azulita.

    Just for clarification, doctors *can* practice abroad without having gone through La Rural, can’t they? Artículo 8 just seems to imply they can’t practice in big cities in Venezuela until they’ve done it.

    And what about getting a graduate education abroad and coming back to practice medicine? Is that possible, or would one have to do La Rural upon comeback?

    • In some countries (like USA, Spain) you’ll have to take certain tests (STEPS or MIR) in order to enter graduate school. Some of my classmates who left are going trough this process, they didn’t do art 8. (Really, really expensive process) You can’t practice as a general physician unless you take a revalida (Spain), but in USA you can’t practice at all until you take the STEPS.

      In Venezuela, to enter ANY graduate school, the requirement is art 8. In some cases a year or two of residencia asistencial.

      It’s not possible to get your graduate’s degree and come back to practice, you’ll have to do your art 8 first, in any case.

    • In Canada there was a TV documentary about a Venezuelan doctor who still can’t practice after 9 years. He works as an emergency department nurse.

    • Seriously, Maduro’s raises have been so many and crazy I don’t know for sure. Around 80 plus cestatriste. I think.

  4. My brother ended up in Nirgua for La Rural, he did not get paid a dime while he was there. His money was “lost” and were threaten with jail if they leave or say anything. I think that is the legal definition of slavery.
    He finished his rural with my father’s support, started working private and then applied to the psychiatry school at UCV. He got accepted and after 7 months of not getting paid, left the program and consequently the country.
    Some people judged him that because “he got the MD degree for free” and should stay in Venezuela “paying back”. One thing is paying back and the other is not having money to buy food for himself.
    He moved to the US, after 3 years studying for the STEPS and working to survive he was able to get into the psychiatry program. He is kicking ass today,
    Looking to his friends that didn’t leave, I think it was the best decision he could have ever made. I know it wasn’t easy, he suffered a lot.
    I’m really proud of him, I never say it but I am.

  5. Please let me summarize, if I understand right:

    – You received free tuition from the State for your very expensive medical studies.

    – In exchange of this free education, you are under the legal obligation to serve during one year in the countryside to validate you diploma.

    – After this term, you are free to work everywhere you want.

    – This legal framework exists long before you started you medicine studies, and probably before your birth, so you knew the game rules from the beginning

    – Now you are working illegally.

    I sympathize with your griefs about favoritism and corruption, about the ridiculous salaries and awful conditions, and the political bias. Nevertheless, describing the rural service as some sort of slavery is very unfair and misleading. Have you ever think that the rural service could be useful to complete your education, giving you skills otherwise difficult to obtain?

    • Note that experience gained by practicing medicine without adequate medicines or proper instruments does not always help you become a better doctor!

    • Not to mention it’s not like those communities served by the Rural have their pick of graduated doctors. Most of them depend on newbie graduates for medical attention because they are extremely unattractive areas to most doctors (rural, deprived, dangerous, etc where people still need care).

      To me this read like misguided whinging, I also sympathise with gripes about corruption and the absurd wages they receive (which by the way also goes to some adjunct physicians with 20+ years of experience, being paid barely above minimum), but decrying the assignment in general like its existence (and not merely its conditions) is unfair seems petty and childish to me.

      • As a medical student myself I must say that I think you missed the point of this article.

        Rural service has been there for quite long, and it might even be a lovely experience; but when you are forced to work in a God-forgotten town in the middle of nowhere, earning 50 cents of a dollar daily, without any resource to work except your brain; well, you just don’t focus on the bright side of things.

        Besides being exploited by the system that has emphatically trying to destroy your career (and autonomous unuversities as a whole) and that constantly portraits you as an enemy to the people, with the current economical crisis, rural service is pretty much slavery.

        Also, even when no one charges you for your medical training, we could hardly say it’s free. In the context of economical disaster we are facing and the constant cuts to universities’ budgets, hundreds of students have been forced to drop out for not being able to cover all the expenses related to even living in a city with a proper med school. Not to say that you risk yourself to being mugged or even killed as you simply ride a bus to your campus.

        Rural service might be an amazing initiative. But its true potential has been absolutely destroyed by a system that only see doctors as an enemy to beat and humilliate.

        Calling this denounce “misguided whining” makes no sense

  6. Thanks for this article. It`s very important to know this information, not just for the doctor but for the general population that need to know how hard it is to work in this country. I wish you the best of luck on your Rural, as a medical student myself.

  7. If I recall, if you pledge to work as a doctor in outback Australia for two year, you get citizenship. Unlike your VZ hardship service, you will at least get paid in AU, and get resources.

    You will be in the middle of nowhere for a while. But you will meet amazing people. And have interesting stories to tell your kids someday.

  8. I didn’t know that you got a state sponsored medical degree. So yes, they want their payment.

    What if you enter the military as a medic? Wouldn’t you have an officer’s commission? Would military service satisfy your service requirements?

  9. “You received free tuition from the State for your very expensive medical studies.

    – In exchange of this free education, you are under the legal obligation to serve during one year in the countryside to validate you diploma.”

    Are you seriously talking about Venezuela? Ever been there lately?

    – What “State”?? Narco-Dictatorship. Kleptocracy- get it right.

    Quality of that “free” education? Serve? Serve who? Cabello and Maduro and Tarek? Or “el pueblo”? Get real..

    “Validate your diploma”? Just to survive and make it n 1 piece, honestly in Kleptozuela, the “State” should give medals of honor.

    Our country is really screwed up. Deeply messed up. Now the “State”‘s rules are in the discussion.. Cubazuela 2, get ready, Go.

  10. Great post! So many memories… I ended up in Petare. Jose Vicente Rangel junior was the major at that time. Got paid roughly 1,000.00$ Monthly ( yep, a thousand dollars) and was able to pay for the STEPS, three Kaplan courses ( one for each step) and two trips to Los Roques with my mom. Survived sexual harrasment and the “choros” with a “I’m more arrecha than you”/malandra attitude. Didn’t really add up to my medical knowledge much but absolutely love the people that work closely with me ( nurse, janitor, etc…) and my patients. Some of the most emotional experiences I’ve had as a doctor were there. One when a homeless recognized me as the med student who helped him when the Vargas tragedy happened two years before and came back with a bag full of “chucherias” and teary eyes. The other one, when Silvestre came for his two year old check up and her mother realized the annoying med student that had just delivered her baby in “la maternidad” and didn’t agree with her name choice was me. I left “just for residency” and never ever thought I’d never practiced in Vzla again. Astrid, keep posting and good luck!

  11. Good post colega. But the “Rural” has been going on since 1946, by order of the Junta Revolucionaria de Gobierno. The first medical promotion to ever do it was the UCV’s “Jose Maria Vargas” of 1946, my grandfather was part of it. I did mine with Corposalud Miranda, when Diosdado Godgiven was governor. They jumped me all around La Urbina, Petare, Pueblo de Baruta, El Hatillo y Zona Rural del Hatillo. Great memories. At the time, the payment was quite Ok.

  12. The idea that recently graduated physicians be asked to work for a limited period where they are most needed is in itself impecable , specially as its one way they compensate the state for giving them a cost free education and a chance of honing their recently acquired medical skills .

    The practice however , at least in Venezuela, is fraught with problems for three reasons :
    1. because of the very poor living conditions they must endure where they are sent to work , the state cannot give them living conditions which are minimally acceptable …
    2. the wages are very poor , so poor that they must use their own resources or those of their families just to survive.and worse of all ,
    3. the working conditions are so deficient , that they cannot do the job they are sent to do for want of those basic means which any physician needs to have available to properly treat their patients health problems . I think is the one that bothers young physicians the most . Their vocation is to treat and cure diseases and if they are recruited fo the job the least the govt can do is give them the tools to do so , not giving them these essential tools is to condem them to lives of deep distress and frustration …..

    • Exactly. I mean, as always, not that bad of an idea in principle and was running for decades, but put it in the hands of Chavismo and in the country of Chavismo and of course people see is at slavery.

      “Hey, go to work in some very remote and/or dangerous place, for a pitiful pay or no pay at all, without tools and resources to actually do your job, and under the supervision of cretins that consider you ideologically suspect by default” is not precisely paying back the country for the help you got to be a doctor. Is just being used by the Government to say they care for the health of the people that you are going to have to treat with the no medicines and no instruments they generously not provide…

      • The conflict between the theory behind La Rural and the practice is what plagues all programs of this sort everywhere. The conditions to treat patients are usually sub-par so even if you accounted for the remoteness or rurality that makes these postings undesirable, no provider is going to go or stay of their own free will. Retention is an intractable, hard-to-solve problem from specialists to recent graduates to nurses all the way down to part-time community health workers. No one wants to work where the health system hampers whatever efforts they do put in.

  13. The people defending the slavery conditions of exploitation and the clear bias against actual doctors favoring the knockoff imposters are the same as the bastard cited in the article that barked idiocy like:

    “…M.I.C’s were (Médicos integrales comunitarios, our Cuban-style quickie “doctors” from Universidad Bolivariana) better.”

    And:

    “You are privileged wealthy people, all of you with your fancy cars and cellphones. You don’t care for the patients’ needs, you don’t know what it’s like to be hungry or sick…”

    Yes, the education was “state-sponsored”, but it wasn’t free, people pays outrageous taxes in Venezuela for something anyway, but what the hell, it’s better to call them “selective whiners”

    Disgusting.

    • No, the education is free. People pay (more) taxes in other countries but in almost all they still have to pay for their own medical studies (and in most of those, it’s very expensive).

      The state is a disaster, obviously, and its corrupt and full of incompetent chavista commisars and lackeys and its run by narco thugs. Doesn’t change the fact that the medical education is free.

      • Nothing is free, Citoyen, the students might not pay the whole scholarship, true, but that doesn’t mean it’s free, the money to pay all the expenses comes from somewhere, and in Venezuela’s case, it comes from taxes and in some extent from oil rent.

        The education was state-sponsored with social mobility in mind, it was ruined due to the corrupt and the thug lackeys.

        You might use a million examples, but in the end, nothing is free, bashing on the newly graduate and blame them fits in the same disgusting slum mentality that always blames the victim because it considers the aggressors as “sacred social avengers”

Leave a Reply to Pepe Trueno Cancel reply