Five months after the Department of Health (DS, in Spanish) was supposed to start providing financial incentives for the 186 specialist and subspecialist doctors in training to remain in Puerto Rico, none of them received a single payment.
For outgoing Health Secretary Carlos Mellado, this “Incentive Scholarship” is one of the major achievements of his administration and his most significant measure to address Puerto Rico’s severe shortage of specialist doctors. However, as of Wednesday, December 18, he acknowledged in written statements to the Centro de Periodismo Investigativo (CPI) that the incentive’s “implementation process” was still in development and that the agency had not issued a single check.
Miguel Rosa is one of the specialists in training, or residents (as they are known in medical jargon), who applied for the incentive, which amounts to up to $12,000 annually. For months, the doctor — training as an emergency physician at the Episcopal Medical Center San Lucas in Ponce — received no response from the DS regarding his application.
A few days ago, the DS finally began sending contracts for the scholarship to some applicants, just after the CPI requested information from Mellado.
The Puerto Rican government’s failure to meet its commitments to doctors in training extends beyond the special incentive that Mellado created. Rosa said that the stipend, which ranges from $37,116 to $43,322.42 annually, is not consistently paid on time. Rosa also noted that the DS pays with delay to other 530 resident doctors, subspecialists, and interns this amount that use this money to cover their basic living expenses. For him, this situation is “unacceptable.”
“If they at least had stability [with the checks], one could organize,” Rosa said, referring to the students’ financial commitments.
Mellado has publicly stated that this scholarship and the increase in medical residency positions have been two of the major achievements in retaining doctors during his administration, which ends this month. However, just days before leaving office, neither has occurred as announced, and the outlook for the shortage of specialist doctors in Puerto Rico has not significantly improved, according to at least four experts consulted.
Concerning the new medical residency positions in Puerto Rico, Mellado has refrained from disclosing the exact number and specialties. As a result, it is unclear what, if any, growth in new entry positions by medical specialty has occurred on the island compared to 2021, the year he took office as Secretary.
Medical residencies are training programs lasting between three and five years, offered by universities, hospitals, or consortia of both, working in a hospital or clinical institution and treating patients under the supervision of a doctor in the selected specialty. They are highly competitive because there are few entry slots in most specialties.
Since April 2024, when Mellado announced the measure, the numbers for new specialist doctor positions supported by the DS have changed several times. Additionally, these figures mix positions for residents, fellows, researchers, and participants in the so-called “state internship” (a requirement for general practitioners, not specialists). This raises doubts about the extent to which the number of specialists in Puerto Rico has truly increased, in which years of residency they are in, and whether it was in the most needed specialties.
In the medical field, residents are doctors who train in a specific specialty, while fellows are specialist doctors who undergo a form of advanced residency to become subspecialists.
In April, Mellado said there would be 135 new positions. Then, between August and November, he publicly implied in interviews that he had achieved about 530 new positions. However, it turned out that these 530 “new positions” were not new. About 37.5% of them, or 199 positions, were not for specialists or subspecialists but instead, internships for general practitioners.
On December 2, Mellado told the newly elected governor, Jenniffer González’s Incoming Transition Committee that there were 528 new positions. However, he retracted when questioned by committee member, attorney Verónica Ferraiuoli Hornedo.
“The other thing I wanted is a clarification, and it’s something that no one has been able to explain to me adequately, are the medical residency positions. In your presentation, you state that from 200 medical residency positions in 2021, we increased to 528 positions today. Someone told me that it’s not that we have 528 resident doctors in hospitals overnight; but that this is staggered,” Ferraiuoli Hornedo questioned Mellado.
Mellado responded that there were around 300, but the CPI found this figure to be incorrect.
Photo provided
An analysis by Dr. Ibrahim Pérez, former director of Health of San Juan, using data from the Accreditation Council for Graduate Medical Education (ACGME), indicates that between 2022 and 2024, there was an increase of 41 first-year positions — or new entry — for all of Puerto Rico, not just those subsidized by Health for specialists, subspecialists, and transitional interns (a program that serves as a bridge to enter a specialty). The DS only subsidizes about 32% of the 1,029 accredited residency and fellowship positions in Puerto Rico, according to the ACGME.
This means that, at present, the net increase in new specialist doctors subsidized by Health, thanks to Mellado’s efforts, is much less than represented in all public instances by the official.
As of press time, the DS has not responded to the question of how many of these positions are for new specialists.
Internships are a requirement for doctors to practice medicine in Puerto Rico as general practitioners. Health also said that starting in January 2025, another 56 residencies will begin, but they will be state internships for general practitioners. State internships are a one-year rotation that doctors must complete in a hospital in Puerto Rico to apply for a medical license. This rotation includes areas such as pediatrics, emergency room, and gynecology and obstetrics, explained Dr. Víctor Ramos, former president of the College of Surgeons.
Dr. Olga Rodríguez de Arzola, vice president for Medical Affairs and Dean of the School of Medicine at Ponce Health Sciences University, explained that after completing four years of traditional medicine, one cannot practice medicine until completing a year of internship or a residency program, which allows doctors to have a specialty. The residency time depends on the specialty, as, for example, primary care specialties like internal medicine, pediatrics, and family medicine are three years, while surgery is five years.
In response to the CPI’s questions about why state internships are included in residency statistics, Health indicated that although “internships are not new medical specialty positions, they fulfill a critical function in the professional development of doctors and in strengthening the local health system.”
In Puerto Rico, the Ponce School of Medicine, the Medical Sciences Campus (RCM) of the University of Puerto Rico (UPR), and the Central University of the Caribbean (UCC, in Spanish) have residency programs, mostly in hospitals. The only medical school that does not have one is the San Juan Bautista School of Medicine in Caguas, according to Yaidy Cruz, director of student programs at the institution. Their students are accommodated in residency programs of other universities or hospitals in the United States and Puerto Rico.
The world of long and demanding medical careers is complex. It involves first studying for four years in medical school after completing a bachelor’s degree at a university. After graduating, the graduate can become a specialist by attempting to enter a residency program or be a general practitioner by completing a year of state internship. Most fellowships are programs similar to residencies but lasting up to three additional years, allowing specialists to complete a subspecialty. The term is also used in the medical world for specialists or subspecialists who are granted a research grant.
The RCM is the institution with the largest number of residency programs in Puerto Rico, and according to Dr. Arelis Febles, Interim Associate Dean of Graduate Medical Education at the institution, they did not have an increase in positions this academic year.
Photo Claudia S. Ortega | Centro de Periodismo Investigativo
The UCC indicated that they did not request more resident positions from the ACGME this year because 12 positions had already been added after the DS, in this four-year period, said it had identified funds to activate them and pay the stipend to residents. However, this year, the accrediting council approved seven new entry positions for July 2025 for an Internal Medicine Residency Program for the Pavía Hospital in Arecibo, which was done in conjunction with the UCC. That program has DS funding for the three years that the residency lasts for each doctor, so it has a total of 21 positions.
Health pays the stipends of residents from private universities and hospitals. In the case of the RCM, resident doctors receive their stipends from the UPR, which is funded by legislative funds. These residents’ payments are higher and are made on time.
Residents will have to keep waiting for their scholarship
Dr. Sebastián Castañer, president of the Association of Resident Doctors of San Lucas Hospital, said the residents of this institution did not receive the contract they had to sign to receive this scholarship until last Friday. According to DS data, 61 of the 186 resident doctors and fellows who applied for this incentive scholarship are from this hospital, making it the institution with the highest number of applications.
“To date, no resident has received a check under this concept, as the implementation process is still in development to meet the established administrative and legal requirements,” Mellado said. In a written statement to the CPI, he also indicated that payments are projected to begin in January and, from then on, will be made monthly.
In early December, he had declared at the transition hearing that this incentive scholarship “is being paid every three months.”
A condition of the scholarship is that if they decide to leave Puerto Rico, they must return the scholarship money. Mellado assured the Incoming Government Transition Committee that resident doctors were granted a payment of $2,650 in addition to this scholarship.
Although the supposed incentive was announced in April, Dr. Rosa said they did not receive official information until September.
That month, attorney Yasarel Pesante, Assistant Secretary of Medical and Nursing Services of the Department of Health of Puerto Rico, called an informational meeting and indicated that they would get an email with a regulation and a letter of intent to apply for the incentive scholarship within 24 to 48 hours. The official also told a media outlet that the money would begin to be paid in October.
Rosa mentioned they just got an email from the DS on October 30. The email contained a letter informing them of their commitment to remain in Puerto Rico if they accepted the scholarship.
On November 15, several residents who submitted the required documents received another email in which the agency requested other documents to process the disbursement, but these were the same documents they submit every year to renew their contracts and had already been sent in the summer of 2024.
To justify the constant delays in paying residents’ stipends, Mellado detailed the DS’s bureaucratic billing process, which “includes several stages of review and usually takes up to 15 business days from the submission of the invoice for the payment to be issued.” However, residents sometimes report delays of up to two months.
The crisis of specialists in Puerto Rico is severe
Puerto Rico has a shortage of specialists, which has consequences for patients waiting months for appointments. A CPI investigation revealed that mortality from heart diseases increased by 12% in 2022; however, according to the American College of Cardiology, there are currently only 95 cardiologists on the island, representing one per 17,500 adults, the lowest of all U.S. jurisdictions.
Additionally, due to the lack of psychiatrists, cardiologists have to prescribe anxiety medications to their patients, said cardiologists Luis Molinary Fernández and Luis Rosado Carrillo.
Photo Gabriel López Albarrán | Centro de Periodismo Investigativo
A recent study by Puerto Rico Medical Defense Insurance Co. indicates that the number of practicing doctors increased in the last five years, but not in medical specialties, where a drop was reported. In 2023, there were 5,082 professionals in general practice in Puerto Rico, while there were 4,727 specialists.
According to the study, general medicine — which includes general medicine, family medicine, internal medicine, hospitalists, and emergency physicians for the purposes of this study — has the highest percentage of available professionals, with 30.5%. Internal medicine is next at 11.6%, followed by pediatricians at 9.1%.
However, cardiologists, endocrinologists, infectious disease specialists, rheumatologists, dermatologists, otolaryngologists, and psychiatrists, among other specialties and subspecialties, are less available.
“This could explain the lack of availability of appointments for patients and the long waits in medical offices in certain specialties,” the study says.
It also emerges that the aging of doctors, many of whom are nearing retirement age, is a concern, especially if the trend of reducing the number of specialists continues.
“Several important specialties such as anesthesiology, cardiology, gastroenterology, and surgery, among others, have doctors with average ages over 60 years. This represents a future challenge if the number of residencies cannot be increased and/or younger doctors cannot be retained by incentivizing them to maintain their practice in Puerto Rico,” the document states.
It is also indicated that more than 40% of doctors actively practicing in specialties such as cardiology, dermatology, gynecology, pediatrics, rheumatology, surgery, and urology are over 65 years old or will be over 65 in the next three years.
Mellado acknowledges measures fall short
“Increasing positions will help reinforce some residencies and increase specialists in training, but it will not guarantee that they will stay in Puerto Rico after completing their residency. Retaining them to establish themselves permanently in Puerto Rico is the biggest challenge we face,” Dr. Pérez indicates in his analysis. “It is imperative that each sponsoring institution collects and reports where the doctors who completed their training have established themselves to identify reasons and patterns and take the correct measures to stop the exodus.”
His analysis reveals that since the late 1970s, the University of Puerto Rico School of Medicine is the only institution that has consistently maintained over 50% of its graduates in postgraduate training within Puerto Rico. Furthermore, the percentage of graduates moving to the United States has dropped from 56% in 2022 to 43% in 2024, with the majority coming from the Central University of the Caribbean and the University of Puerto Rico.
The president of the College of Surgeons, Carlos Díaz, opined that measures such as bonuses for residents and increasing resident positions are not enough to stop the exodus of doctors but only improve pre-exodus conditions.
“After I train in Puerto Rico, with whatever positions there are, what incentives do I have to stay here? There is no incentive because the incentive was to give doctors a 4% income tax [rate]. But if that incentive is no longer there, doctors have no incentive to stay. You can open as many positions as you want, but they won’t stay,” Díaz said.
Therefore, he said that one of the measures the College requests is a tax incentive of at least a 10% tax exemption.
“We recognize that affirmative steps still need to be integrated more broadly among different government agencies to effectively address the retention of specialist doctors in Puerto Rico. However, this public policy represents a step forward in the right direction, laying the groundwork to solidify Graduate Medical Education on the island and fostering an environment that can motivate more doctors to continue their professional careers in Puerto Rico,” Mellado said in written statements to the CPI.
Dr. Juan Medina, a surgical resident at San Lucas, stated that although residencies are invested in, funds must also be allocated to hospital infrastructure, such as better equipment, to provide better medical services in Puerto Rico.
Dr. Ramos, who participated in the 1999 strike to increase resident doctors’ pay, recalls that the loss of residencies began after implementing the Health Reform, which privatized most of the health system.
