Puerto Rican medical students face challenges when applying for residency

Andrea Vélez Figueroa, MD, left, a graduate of the Universidad Central del Caribe (UCC), poses with Alexandra Conde Toro, right, a fourth-year medical student at UCC.

Courtesy of Andrea Vélez Figueroa, MD

Brenda Marín Rodríguez, MD, PhD, completed her medical degree at the University of Puerto Rico School of Medicine in San Juan in December 2024, and despite holding a doctorate from Harvard University in neuroscience and graduating from an accredited medical school, she worries residency programs won't take her seriously. To increase her chances of matching, she has applied to about 100 programs.

She decided to cast such a wide net, even taking out thousands of dollars in additional loans, because of the difficulties she's seen other Puerto Rican medical students face when applying for residency - or even away rotations - at institutions on the mainland United States.

The commonwealth of Puerto Rico, which became a territory of the United States in 1917, thus making its residents U.S. citizens, is home to four medical schools that are fully accredited by the Liaison Committee on Medical Education (LCME): the University of Puerto Rico School of Medicine (UPR), Ponce Health Sciences University School of Medicine (PHSU), San Juan Bautista School of Medicine (SJB), and Universidad Central del Caribe School of Medicine (UCC).

The medical schools in Puerto Rico stand apart from the dozens of medical schools in other parts of the Caribbean that are not LCME-accredited. Many are for-profit institutions that have a reputation for taking students who were not accepted to the more competitive medical schools in the United States. Graduates of these schools who apply for residency positions in the United States are considered international medical graduates (IMGs). In 2024, U.S.-citizen IMGs matched at a rate of 67% and non-U.S.-citizen IMGs matched at a rate of 58.5%, compared with U.S. MD graduates, who matched at a rate of 93.5%, according to the National Resident Matching Program, which runs the Match®.

"A lot of program directors are not aware that the four medical schools in Puerto Rico are LCME-accredited," Marín Rodríguez says. "A lot of people don't even know that Puerto Rico is a territory of the U.S. I've applied [for residency] based on statistics for international schools, since we're often incorrectly categorized."

John Paul "JP" Sánchez, MD, MPH, dean of the Universidad Central del Caribe School of Medicine (UCC) and executive director of the Latino Medical Student Association (LMSA), has seen this over and over.

"This has been a chronic problem for decades," he says.

After receiving feedback from Puerto Rican students that they'd faced discrimination when applying for away rotations and residency on the U.S. mainland, LMSA conducted a survey in 2022 to document the hurdles.

Of the 113 Puerto Rican medical students who responded to the survey, 51.4% said they'd received a notification of application denial because they were considered an international student, 43.1% said they were asked to provide documentation or proof of U.S. citizenship, and 61.3% said they'd received offensive questions or comments based on the medical school they'd attended.

"Students are often asked if they actually speak English. They are also often asked if they are U.S. citizens [and] if they can work in the United States. That ties to the misconception that they are international [students]," Sánchez says. "I think some may view this as blatant discrimination. Some might view it as mistreatment."

"The four LCME-accredited medical schools in Puerto Rico graduate nearly 20% of Latina/Latino physicians, and it's dismaying to hear that these students face unfair barriers in their application to residency," says Norma Poll-Hunter, PhD, senior director of equity, diversity, and inclusion at the Association of American Medical Colleges (AAMC). "Latino and Latina physicians, and Spanish-speaking physicians in particular, are grossly underrepresented in the United States, and we on the mainland must do our best to remove any additional burden to those with the skills and drive to serve our patients."

Models of bilingual medical education

With a population of 3.2 million people and about 3,500 square miles in land area, Puerto Rico is more populous than 20 U.S. states and the District of Columbia, and is about twice the size of Rhode Island.

The four medical schools in Puerto Rico collectively graduate about 400 physicians each year, most of whom were born on or have family from the island. The students must meet the same requirements as those on the mainland - including passing the United States Medical Licensing Examination Step 1 and Step 2 in English - while attending school bilingually.

"We do everything in Spanish and English," says Andrea Vélez Figueroa, MD, who graduated from UCC in 2024 and is now doing a preliminary residency year in internal medicine at the Dr. Ramón Ruiz Arnau University Hospital in Bayamón, Puerto Rico. "Progress notes on patients are in English, but we're talking with patients and attendings in Spanish. Puerto Rican students are bilingual - from birth, basically."

Vélez Figueroa says that Sánchez encouraged her to leverage her Spanish-speaking skills while interviewing for residency. She adds that Sánchez developed a medical Spanish certificate program for students at UCC, which has been valuable in quantifying the students' language expertise.

Sánchez adds that he encourages residency selection panels to consider Puerto Rican students' Spanish skills as an asset, particularly since the United States is facing a shortage of Spanish-speaking physicians in relation to the growing number of primarily Spanish-speaking people in the nation.

Hispanic or Latino/Latina people make up about 19% of the total U.S. population, and nearly 70% of them - 42 million people - favor speaking Spanish in their home, according to the U.S. Census Bureau. Yet less than 6% of physicians identify as Hispanic or Latino/Latina.

As of 2019, Puerto Ricans accounted for about 20% of all Hispanic or Latino/Latina applicants to medical school, the second-largest Hispanic subgroup after Mexicans and Mexican Americans. This is despite accounting for only 9% of the Hispanic or Latino/Latina population in the United States.

And according to Sánchez, Puerto Rico's medical schools are the largest producers of English-Spanish bilingual physicians in the country.

"I think that the four medical schools in Puerto Rico can uniquely inform medical schools in the States on how to provide quality bilingual education," he says.

Medically underserved

While the United States is facing a physician shortage, particularly of primary care providers (PCPs), Puerto Rico is facing an even more severe shortage.

A 2022 article published in Family Medicine notes that the island has 120.7 PCPs per 100,000 people, compared with 156.7 per 100,000 on the mainland. The article also states that there has been a "massive exodus" of physicians due to Puerto Rico's economic crisis, with an estimated 5,000 physicians moving their practices off the island from 2006 to 2016.

Compounding the challenges, Puerto Rico's health care system has struggled in the aftermath of Hurricane Maria in 2017 and has experienced significant funding and infrastructure issues, according to various news reports.

And while many Puerto Rican students may be drawn to staying to serve in their island communities (Puerto Rico has the second-highest retention rate of physicians staying to practice where they pursued their residency -75.6%), some would like to train on the mainland but face multiple barriers to doing so.

A key hurdle is that it can be geographically and economically more challenging to complete an away rotation on the mainland, says Vélez Figueroa.

"Students here have to be very selective when doing away rotations," she says. "[Opting for this depends on] how much money I have to spend to travel over there."

Furthermore, they may face pressure from their local administration and advisors, who hope to retain medical talent.

"They prefer that none of us leaves the island, even though there are only residency positions for less than half of local students and graduates applying," says Marín Rodríguez.

Overcoming bias

In recent years, Sánchez and other LMSA leaders have worked to raise awareness of the challenges Puerto Rican students face throughout the academic medicine journey - for example, by giving presentations to graduate medical education offices across the country and disseminating fact sheets to institutions.

And over the past decade, the AAMC has worked to communicate with its member institutions about the role of medical schools in Puerto Rico and remind them of their LCME accreditation.

Still, the continued barriers that Puerto Rican students face have been wearying.

Sánchez has recommended implementing more safeguards to ensure that Puerto Rican medical students are given a fair chance, like providing a computer alert from the Electronic Residency Application Service® (ERAS) that would automatically remind users of the Puerto Rican schools' accreditation.

"We at the AAMC want to ensure all students are treated equitably when applying for residency and will continue to work to dispel misinformation about the medical schools in Puerto Rico," Poll-Hunter says.

Sánchez encourages Puerto Rican students who experience any form of discrimination to report it directly to AAMC ERAS investigations at [email protected].