Colombia offers an interesting lesson on medical education structures. Over 6,300 general physicians graduate from Colombian medical schools each year, and with four new medical programs preparing to graduate their first classes, that annual total is expected to top 6,500 soon.
Securing a spot at a Colombian medical school is highly competitive, with only one in six applicants gaining admission. For instance, in 2022, Colombian medical schools received 62,244 applications while admitting only 10,682 students. That’s a 17% acceptance rate. And in a key feature that North Americans will appreciate, we regularly receive anecdotal evidence that acceptance to Colombian medical schools is largely merit-based rather than based on family wealth. Sliding-scale options are available for tuition so socioeconomic status is not a barrier. Although, we have heard from private Colombian physician accounts that there are some wealthy families that game the system for cheaper tuition costs. This stands out in stark contrast to the U.S. system, where a socioeconomic gap between physicians' family of origins and patients' family of origins is rapidly widening and has been identified as a major issue in U.S. healthcare.
Data from the Asociación Colombiana de Facultades de Medicina (ASCOFAME) shows that, as of 2023, Colombia has roughly 25 physicians for every 10,000 residents.
Beyond these numbers, however, the real insight comes from examining the way these aspiring physicians receive their training.
In Colombia, every physician undergoes a comprehensive generalist medical training program before undergoing any specialization. This is a foundational requirement for all medical school students. Every physician who specializes has first spent years as a general practitioner.
Interdisciplinary integration is fundamental to their clinical reasoning; Colombian doctors rarely view conditions such as thyroid disease in isolation. Instead, they assess such disorders side by side across cardiology, neurology, gastroenterology, dermatology, psychiatry, and nutrition.
In my experience, Colombian general practitioners have a much better understanding of endocrinology and nutrition than U.S. PCPs. They're expected to manage basic thyroid cases rather than automatically referring patients to specialists.
[Related: How US PCPs are Struggling to Manage Thyroid Cases]
Many Colombian physicians describe their training culture in terms of vocación; a calling entered primarily for the intellectual satisfaction of solving complex human problems in service of people, not financial reward.
Unlike the U.S, where completing a residency is necessary to practice medicine, in Colombia, residencies are optional and meant for specializing on top of a generalist foundation.
Doctors in Colombia can begin practicing as general practitioners before deciding to pursue specialized training, such as an endocrinology residency. The U.S. has come under fire for a medical education system that is primarily accessible to the wealthy, with a growing socioeconomic gap between physicians and the average patient, which is frequently noted in the current literature as increasing barriers to care.
Recent U.S. media coverage has brought increased attention to the undisclosed purchase of residency positions. In one documented instance at a Michigan hospital, an informal $400,000 contribution was paid by a family to secure a residency placement for their child.
This case only came to light after the family sued to get the $400,000 back. Behind the scenes, informal accounts also point to nepotism and financial contributions shaping residency acceptance decisions. If there are limited spots available for physicians to become practicing doctors and at least some of these have been proven to be allocated for those who could pay, questions should be asked.
Interestingly, in comparison, Colombia has a very competitive residency system for those physicians who would like to specialize after graduating as a generalist, and typically have higher earning potential, especially in the private healthcare system.
Notably, Colombia has a sliding-scale tuition model for their general physician medical education programs, and there is more socioeconomic diversity among its graduated physician base. We have heard stories from some Colombian medical school graduates that a few wealthy families still game the system. However, we have also received anecdotal insider reports that Colombian residency systems are so merit- and performance-based in competitiveness that wealthy Colombian families may pay for their children who graduated as generalists to study abroad in a residency in a country with less competition for spots to specialize.
While no country is perfect, what has stood out to me regularly in my networking with Colombian physicians is a national tendency for self-awareness and safeguards because of this. Colombia has one of the highest income inequality and wealth gap levels in the world, ranking as the second most unequal country in Latin America and the highest among all OECD nations. In fact, it was a Colombian generalist who first told me this fact. But recognizing this issue, the country established a medical education system that did not largely become dominated by the wealthy seeking power. Likewise, Colombian physicians have told me of healthcare-at-home programs and local thyroid studies being run by the government where physicians are heavily involved in public health compared to the U.S. A heavy amount of data collection was often involved to determine whether outcomes justified government expenditure. In fact, in my experience, this type of data around pilot programs is something that many Colombians are not aware is in high demand in the U.S.
Of course, there is always room to grow. Many Colombian physicians and family members of physicians tell me that being a doctor in the South American country is an underpaid calling and that their salary can affect their morale and feeling of being undervalued. Additionally, as everyone graduates as a generalist, generalists especially are underpaid and access to a residency is extremely difficult and competitive to specialize and have somewhat higher earning potential. Unlike in the U.S., completing a residency in Colombia is not necessary to practice medicine, but it is one of the few paths to advancement in pay in the country with other options being to attempt to enter higher-paying systems such as the U.S. healthcare system where they will have to pass exams, match into a U.S. residency, and complete a 5-7-year residency typically followed by a fellowship.
Colombian dietitians place a strong emphasis on iron research to combat anemia; a focus with far broader implications than it might seem at first glance.
Although the quality of a patient's blood can directly influence outcomes in procedures like epidural blood patches, this connection remains significantly under-researched. Existing studies predominantly examine how pharmaceutical treatments, such as blood thinners, might reduce the effectiveness of blood patches, while largely ignoring the comparable impact of administering a patch to a Vitamin K-deficient patient.
Essential nutrients, including iron, vitamin B12, folate, and vitamin K, are critical for both efficient blood clotting and wound healing. Consequently, malnutrition or iron deficiency can compromise a patient's clotting ability, potentially diminishing the success rate of procedures like epidural blood patching.
In Colombia, integrating nutritional assessment is a natural element of the generalist approach to care–although this does not mean that it always happens at the level of depth that it should. While there are times key points are missed, clinicians in Colombia generally demonstrate a greater receptivity to new ideas. Conversely, U.S. patients frequently state that physicians share nutritional misinformation, such as claiming diet has no impact on their health condition.
Integrating nutritional considerations into patient management is especially critical for those with spinal CSF leaks. Many chronic leak patients have long histories of dietary restriction that’s often caused by food sensitivities, gastrointestinal motility problems, or restrictive eating habits that develop when almost everything a patient consumes seems to worsen symptoms.
That pattern of restriction has predictable hematologic consequences:
Every one of those deficiencies directly affects a patient's ability to form blood clots, which is the very mechanism an epidural blood patch depends on.
This is where Colombia's integration of nutrition into general medical care emerges as a strength. Colombian and Ecuadorian dietitians are comfortable reading and interpreting a complete blood count or a coagulation panel as a routine part of their scope. That integration is precisely the kind of nutrition-literate, lab-literate clinical culture that spinal CSF leak care needs and does not currently have anywhere I have observed.
Yet spinal CSF leak treatment remains rare in Colombia. Because these patients are rarely diagnosed in the first place, Colombia's nutritional expertise remains underutilized for this population.
While the generalist approach offers clear strengths, my work alongside clinicians in Colombia has highlighted significant knowledge and procedural gaps. When discussing epidural blood patches with local general practitioners, many showed little familiarity with the intervention, while a number of them even labeled it “advanced technology."
This viewpoint aligned with a conversation I had with a Venezuelan anesthesiologist, who shared that she had minimal practical experience performing epidural blood patches for CSF leaks, a clinical deficit reinforced by multiple other South American practitioners.
That framing is worth pausing on, because the procedure is not new by any reasonable clinical standard.
Robert Danis first proposed sealing a dural puncture with an epidural injection in 1924, recommending the use of saline. This was the right idea but the wrong solution, and still is a solution incorrectly recommended by U.S. anesthesiologists to me who are not up-to-date on the gold standard for spinal leaks.
Their reported rationale typically is that the pressure of the saline in the epidural space is what heals the spinal leak. This pressure in the epidural space is a known concept, and one I’ve experienced myself. This is commonly termed the tamponade effect. Compression against the dura can push spinal fluid up to the head, as I have experienced, and create an immediate “brain float,” as I have described and other patients have described.
However, this does not seal the leak. The relief lasts only as long as there is compression. A similar effect would be to take a long, thin balloon for making balloon animals and squeeze part of the balloon with your hands.
What happens? Obviously, the other part of the long balloon is going to expand where you’ve pushed the air there. Similarly, a dura where there is compression from fluid in the epidural area can experience more spinal fluid being pushed up to the head with immediate relief until the compression ultimately dissipates as the body deals with the fluid in the epidural area.
The modern technique of using blood was performed and reported by James Gormley in 1960, using two to three milliliters of a patient's own blood. He observed that "bloody taps" during spinal puncture seemed to reduce the incidence of post-dural puncture headache.
Blood patches at larger quantities nowadays often are better understood by patients as providing first a tamponade effect of pushing against the spinal cord and sending spinal fluid up to the head and then the relief lasting only a few hours to days later because of failure to clot or the relief lasting permanently because of a successful clot and rapid healing at the site of the leak.
A procedure first described by a general surgeon over one hundred years ago, using nothing more exotic than a spinal needle and the patient's own blood, is not advanced technology in any technical sense. In parts of South America, the procedure has ultimately been left out of the standard medical curriculum. This points to an issue with training pathways rather than technological scarcity or technical complexity.
The training gap I have observed is really not a training problem; it is an incentive-alignment problem.
Training follows incentives, curriculum reflects what gets tested, and skills are maintained by being performed regularly.
Standard medical instruction in the United States presents the procedure primarily through a limited obstetric framework. It concentrates on post-dural puncture headaches stemming from labor epidurals, which exhibit a clear onset and a predictable clinical path.
In contrast, spontaneous intracranial hypovolemia presents far less obviously and can require targeted thoracic or cervical procedures based on the site of the CSF leak. Conventional obstetric-centered instruction simply leaves clinicians unprepared to handle these more nuanced and intricate cases.
You already have the clinical expertise. What you might be missing is the roadmap to turn your expertise into a cross-border practice that serves U.S. patients and gets paid in USD.
Up next: We bring it all together. What happens when you combine Korea's procedural excellence with Colombia's generalist and nutritional focus? The answer isn't about choosing one system over another; it's about learning across borders. In the final article in the series, we explore what each system can teach the other, and why cross-border collaboration might be the most important trend in healthcare you're not paying attention to.