People often ask why I spend so much time discussing clinicians from South America. The answer is that I am not studying countries to decide which one has the "best" healthcare. I am studying healthcare systems to understand why different countries consistently develop different strengths. My goal is not to argue that one nation provides better care than another, but rather to understand how educational systems, professional culture, healthcare financing, regulation, and clinical incentives shape the care that patients ultimately receive. Every country has blind spots, and every country has areas of excellence. The challenge, and the work I find most interesting, is learning from both at once rather than picking a winner.
Although I frequently discuss South America because of what I have observed regarding metabolic health, thyroid disease, nutrition, patient interviewing, and the psychological aspects of chronic illness, I look at every country for what it contributes. Instead of asking which country has the best doctors, I ask different questions. How are physicians trained? How are psychologists and dietitians trained? Who is able to enter these professions in the first place, and do the admission systems that gate entry primarily reward academic performance, or do they unintentionally reward wealth? How much socioeconomic distance exists between clinicians and the patients they are meant to serve? These questions matter because a clinician's background inevitably shapes their perspective, their assumptions, and the way they listen to a patient's story.
Educational Systems and Clinical Culture
What Educational Traditions Teach Clinicians to Notice
I have seen excellent psychological approaches throughout Europe, many of which have historically influenced psychology training across South America. Psychologists in many of these countries often receive extensive education in psychological theory itself, and many clinicians emphasize understanding a patient's story, emotional experience, and social environment alongside their symptoms. Whether one agrees with every theoretical framework underlying that training is less important than recognizing that these traditions have shaped how many clinicians approach patient care. That does not mean psychologists elsewhere cannot provide equally excellent care; it illustrates how educational traditions influence clinical thinking long before a clinician ever sits down with a patient. Many Spanish-speaking clinicians I have spoken with describe an approach built around acompañamiento (accompaniment, or walking alongside patients throughout illness rather than focusing exclusively on isolated symptoms). That philosophy resonates strongly with my own experience as both a patient and a researcher, because so much of what patients report is dismissed for lack of a framework to receive it, not for lack of clinical relevance.
Who Gets to Become a Physician
This broader question about educational access fascinates me most in the United States, where the population of people who can become physicians has narrowed in ways that are well documented but rarely discussed with patients directly. Researchers have found that medical students disproportionately come from high-income households, and the trend has been moving in one direction for years. An AAMC analysis found that more than three-quarters of medical students came from families in the top two quintiles of household income, and a 2023 study published in JAMA using deidentified AMCAS data found that between 2014 and 2019 the share of medical school applicants from households earning $200,000 or more increased while the share from households earning under $75,000 declined by roughly the same amount, with applicants from the lowest income bracket accepted at about half the rate of applicants from the highest.
That socioeconomic gap between physicians and their patients has itself become an area of medical education research as a major concern in the U.S., because lived experience shapes communication, assumptions, and understanding of a patient's circumstances. That observation does not suggest physicians from affluent backgrounds cannot provide excellent care; many certainly do, but it raises reasonable questions about whether important perspectives are becoming underrepresented within medicine. Heavy reliance on entrance-exam scores compounds the problem, since test performance increasingly reflects access to expensive preparation rather than raw ability or clinical promise, and it has long been questioned within education research more broadly as a proxy for who will become a capable practitioner.
Colombia offers an instructive contrast. Colombian medical graduates train as generalists, and specialization is optional rather than mandatory, which means there is no unmatched population comparable to what exists in the US system. Generalist practice is a complete and respected clinical outcome rather than a consolation prize for those who did not secure a competitive residency. Colombian physicians I have spoken with describe their training culture in terms of vocación, a calling entered not primarily for financial reward but for the intellectual satisfaction of solving complex human problems in service of people. When physicians from that system describe socioeconomic diversity as the primary axis of diversity their schools optimize for, and describe their admissions goal as getting everyone who qualifies by merit in and graduating everyone who qualifies by merit out, they are describing a system built on a different value judgment about what medical education is for.
The US system also produces a large population of fully credentialed physicians who never get to practice. Thousands of US and international medical graduates each year pass USMLE Step 1 and Step 2 CK, have their credentials verified through Intealth (formerly the Educational Commission for Foreign Medical Graduates), and graduate from schools accredited within frameworks aligned to the World Federation for Medical Education, and still cannot participate in patient care because there are not enough residency positions to match them, independent of their competence. Some of these are US citizens who attended medical school in the Caribbean because of lower tuition and less test-score-driven admissions, which is not on its own a red flag about the quality of the physician it produces. An unmatched graduate who passed the licensing exams and chose medicine without family wealth to fall back on is not primarily a patient-safety problem. That person is evidence of what a scarcity-driven system excludes, and what that exclusion costs everyone.
Patient Narrative as Clinical Data
My own work has increasingly centered on thyroid disease, nutrition, and treating a patient's narrative as clinical data rather than anecdote. Patients frequently recognize meaningful physiological patterns long before laboratory values become diagnostic, and their observations often contain clues that deserve investigation rather than dismissal. This is where the accompaniment model and the narrower, more transactional model of patient interviewing diverge most visibly. A clinician trained to listen for the whole story is more likely to catch the pattern that a fifteen-minute, symptom-checklist visit will miss.
A Case Study in Diagnostic Lag: Spinal CSF Leaks Across Borders
Studying healthcare internationally has repeatedly reminded me that every system has limitations, and nowhere has that been clearer to me than in the international variation I have observed in the recognition and treatment of spinal cerebrospinal fluid (CSF) leaks and intracranial hypovolemia. When I spoke with a Venezuelan anesthesiologist about CSF leaks, she explained that she had relatively little experience performing epidural blood patches, simply because she claimed that there was a low need to provide spinal CSF leak care in her practice. Several Colombian general practitioners told me something similar, that they had little familiarity with epidural blood patches, with some describing them as advanced technology. That surprised me, because the epidural blood patch is not new. Robert Danis first proposed sealing a dural puncture with an epidural injection in 1924, and the modern procedure was first performed and reported by James Gormley, a general surgeon, in 1960, using two to three milliliters of a patient's own blood after observing that "bloody taps" seemed to reduce the incidence of post-dural puncture headache. Since then it has become the standard, gold-line treatment for post-dural puncture headache and is now used far more broadly to treat intracranial hypovolemia from spontaneous and procedural CSF leaks alike.
The training gap I have observed is not really a training problem on its own. It is an incentive-alignment problem. Training follows incentives, curriculum reflects what gets tested, and skills are maintained by being performed regularly. Most U.S. physicians who learn the epidural blood patch learn it in the narrow context of obstetric anesthesia, managing post-spinal headache after a labor epidural, a relatively standardized presentation. Spontaneous intracranial hypovolemia don’t have the clear onset associated with a needle placed in the spine, may require thoracic or cervical approaches depending on the leak's location, and training confined to the obstetric context does not prepare physicians for that complexity. When competency in recognizing and treating these leaks is not an explicit requirement across neurology, anesthesiology, pain management, and family medicine residencies, the skill stays concentrated in a small number of academic centers, and the vast majority of patients with a leak never make it to a setting equipped to recognize what is happening to them.
Listening for Patterns That Patients Already Know
While researching Spanish-language patient discussions, I intentionally searched for symptom descriptions rather than diagnoses. Instead of searching for "spinal leak," I searched for phrases describing headaches that improved after lying down, or symptoms that required patients to stay horizontal for relief. Across multiple forums I found numerous women describing patterns remarkably similar to those eventually diagnosed as spinal CSF leaks. Forum discussions cannot establish a diagnosis on their own, but they can reveal symptom patterns worthy of further clinical study, and I think that kind of pattern-listening across language and geography is undervalued in how research questions typically get formed.
One conversation especially stayed with me. After being interviewed in a podcast in which I discussed my own spinal leak experience, an Argentine friend contacted me. Years earlier he had undergone spinal anesthesia after a devastating knee injury sustained while playing soccer, and he remembered almost nothing from after the surgery except overwhelming pain, though he could never determine whether it originated from his knee or his head. The anesthesiologist had not advised him on the risk of a spinal CSF leak based on what he remembered, and my podcast was the first time he had heard of this years later. Watching my interview, he found that the automatically generated Spanish subtitles by YouTube triggered vertigo because they continuously moved across the screen, and he had to watch the interview in short segments to get through it. His experience does not establish causation; many conditions cause vertigo. And one of those conditions includes a spinal CSF leak. But hearing stories like his reinforces why it matters to ask thoughtful, open-ended questions rather than assuming every patient experiences a complete recovery after spinal anesthesia.
What a Regulated Private Market Gets Right: Lessons from South Korea
My thinking about international healthcare has also been deeply shaped by my own experience living in South Korea, where I used the public system for mandatory work-visa medical examinations and the private system for specialist care. One dermatology clinic in particular stood out. When I called to make an appointment, the staff apologized repeatedly that the earliest opening was a full week away, and their customer service throughout was exceptional. An English-speaking clinical assistant spent considerable time asking about my lifestyle, work environment, daily routine, and skincare habits, and asked me to bring in every product I used so she could walk through exactly how I applied each one before any recommendation was made. That kind of extensive interviewing reminded me of the accompaniment-style conversations I have since had with South American clinicians. The dermatologist himself, communicating through the assistant as interpreter, likewise focused heavily on lifestyle and goals before recommending treatment, which combined scar-directed procedures using electrical energy devices, facial treatments, anti-inflammatory injections, and oral doxycycline.
South Korea's healthcare economics are part of what makes this kind of care possible at that price point and pace. Unlike systems like in Australia where private procedural care can command sharply higher reimbursement the more advanced the intervention with certain specialists monopolizing areas of the private market, South Korea tightly regulates healthcare pricing while still maintaining an active, competitive private sector. Providers compete within a regulated price structure rather than around it. That creates a meaningfully different set of incentives than a system where reimbursement scales aggressively with procedural complexity, and it is one reason I now ask, in every country I study, whether a strong private-pay sector exists, whether it is price-regulated or open, and whether professional accountability operates alongside government regulation. Several clinicians from Colombia and Ecuador have independently described confronting colleagues they believed were harming patients, which suggests that professional self-policing can matter as much as regulation on paper.
Where the Korean Model Fell Short
During my dermatology treatment in Korea, oral doxycycline caused significant dizziness for me in Korea, just as it would again years later when it was re-prescribed in the United States. Later, back in the U.S., a dermatologist eventually prescribed ampicillin instead, an older antibiotic, and for me it worked extremely well. The large inflammatory cysts across my face and jawline improved dramatically without the dizziness. That reinforced an important lesson that medicine should remain individualized, and an older treatment sometimes proves to be the better choice for a particular patient, regardless of how sophisticated the newer options look.
Looking back, I also recognize a real limitation in the Korean care I received. Despite the excellent interviewing process on skincare habits, no one evaluated my nutritional status. No one checked vitamin B12, iron, or thyroid function, and today I know all three substantially affect my skin. When my B12 falls, I develop dryness around my mouth, peeling lips, irritation under and around my nose, and heightened skin sensitivity. Iron deficiency produces a similar picture.
At the time, in Korea, I ate a seafood-rich diet that likely supplied adequate B12 but may also have resulted in a relatively high iodine intake. Additionally, I rarely ate red meat on a young teacher's budget. Because I was on a young teacher's budget, I rarely ate red meat, which is comparatively expensive in Korea compared to the U.S., reducing one of the richest dietary sources of highly bioavailable iron. Looking back, I have also observed that fish has not appeared to maintain my vitamin B12 stores as effectively as certain non-fortified dairy products, particularly aged cheeses, which consistently seem to have a much greater impact on my serum B12 levels. Although the mechanism is unclear, I have wondered whether differences in the food matrix or other aspects of digestion and absorption could contribute to this effect. My iron status, however, has remained difficult to maintain without red meat or liver.
I was also dealing with significant gastrointestinal motility problems that may have affected absorption regardless of what I was eating, and my menstrual cycle became irregular for the first time in my life around the same period, something my coworkers and I jokingly attributed to "cycle syncing," an idea now generally regarded as unsupported, but which in hindsight was far more plausibly an endocrine or nutritional signal. I had also recently aggravated an existing spinal CSF leak while moving internationally and lifting heavy luggage, so in retrospect, numerous physiological systems were shifting at once, and without lab testing there was no way to disentangle which factor was driving what.
Excellent interviewing and outstanding procedural care cannot fully compensate when important nutritional or endocrine contributors go unidentified, just as nutrition alone cannot replace a procedure when a procedure is genuinely needed. The most effective healthcare integrates both, and the Korean dermatology experience is one of the clearest examples I have of a system that excelled at one half of that equation and quietly missed the other.
Anesthesiology, Literature, and the Value of Cross-Specialty Review
One area where South Korea's system may be particularly relevant is intracranial hypovolemia care. Internationally, management of these leaks has increasingly shifted toward more advanced procedural approaches in some regions, and while those interventions unquestionably have a role for carefully selected patients, the epidural blood patch remains the established first-line treatment for many symptomatic spinal CSF leaks. There have also been documented historical cases in which patients with intracranial hypovolemia underwent procedures, including CSF shunt placement, that later proved inappropriate once the underlying diagnosis was fully understood, which raises real questions about diagnostic pathways, procedure selection, and the incentives that shape them.
What strikes me is that South Korea has maintained a strong private-practice pain management anesthesiology presence within this area of care specifically where the U.S. and other English-speaking nations have allowed neuroradiology to claim expertise and lead the helm on chronic leaks despite not having the same background in epidural procedures and flow dynamics as anesthesiology, crucial components when planning how to target a location with an epidural needle and a viscous substance for treatment (blood). In my opinion, the proper place for a neuroradiologist is continuing to develop more accurate non-invasive diagnostic approaches for spinal CSF leaks, including working with AI to enhance this, so as not to disable patients further through brutal invasive diagnostic practices as is common practice when patients fall into the hands of neuroradiology.
Many Korean publications on epidural blood patches have been written by anesthesiologists rather than other specialties, and a widely referenced English-language review article by U.S. anesthesiologists was a 2022 paper authored by a Korean anesthesiologist that synthesized evidence across specialties. Several American anesthesiologists have independently recommended that review to me in conversations about spinal leaks, which struck me because U.S. anesthesiologists often rely most heavily on literature produced within their own specialty. A comprehensive cross-specialty review written by one of their own may have done more to reconnect anesthesiology with developments in neurosurgery and pain medicine than a review from outside the field could have.
By contrast, an informal survey that colleagues and I conducted among more than 3,000 US pain physicians suggested that many respondents who described their own experience had not personally performed an epidural blood patch since residency. The survey was not designed to estimate national practice patterns and should not be read as representative of all US physicians, but it nonetheless raised real questions about how procedural experience is maintained, or lost, over the course of a career.
That leads me to a broader systems question I keep returning to: if private healthcare prices are regulated, as they are in South Korea, does that encourage clinicians to preserve expertise in highly effective, lower-cost procedures like the epidural blood patch, which is the known gold standard per research, before escalating to substantially more expensive interventions? Conversely, do systems that reward advanced procedures more generously create an unintentional pull toward more complex interventions earlier in the treatment pathway than clinically necessary? These are empirical questions that deserve careful research rather than assumptions in either direction.
Integrating Rather Than Ranking
Ultimately, this is why I study healthcare internationally rather than ranking it. When I look at Colombia, I see enormous strength in foundational clinical reasoning, patient interviewing, nutrition, lifestyle medicine, psychological understanding, and the ability to integrate a patient's lived experience into clinical decision-making, strengths that deserve broader recognition and discussion. When I look at South Korea, I see different strengths: sophisticated procedural medicine, strong health technology, excellent customer service, efficient access, and a tightly regulated private market that encourages competition while limiting price inflation, alongside a robust pain management anesthesiology tradition that appears to have preserved procedural expertise in the epidural blood patch specifically. Neither country represents a complete model. Each fills gaps the other leaves open.
Rather than asking which country has the best healthcare, I ask a different question: where the United States has a particular weakness, who, inside or outside the country, is solving that problem well, and what can we learn from them? Likewise, where does the United States genuinely excel, and how might other countries benefit from those strengths? That systems-level perspective is what interests me most, because progress rarely comes from assuming any one country has all the answers. It comes from recognizing that different healthcare systems solve different problems well, and then thoughtfully integrating those lessons into better care for everyone.