In 1991, Carlos Domínguez, a family doctor in one of Havana’s poorest neighborhoods, bought a boat for 12,000 pesos — the equivalent of saving his entire paycheck for three years — to escape the government that had trained him to be an international doctor.

The boat was old and needed to be outfitted with the transmission from a 1952 Ford, one of the many American cars that still cruise the streets of Havana. The mechanic warned him there was no reverse gear. The boat could only go forward.

“Perfect,” Dr. Domínguez, now 46, said he replied. “I don’t plan on coming back. From now on, I’m just going forward.”

And so, armed with his grandfather’s World War II compass, he left Cuba and made his way to Miami, rowing the last seven hours after the gasoline ran out. He was 28 years old and ready to resume his life as a doctor.

But first he needed to pass four exams given only in English, and then put in several years of training as a hospital resident.

Dr. Domínguez, who had been taught Russian in his military school in Cuba, knew no English. Still, he passed one exam before failing the second by a few points. Already married and saddled with family responsibilities, he put away his medical school books, and signed up for a program to become a nurse in one year. Since 2001 he has worked as a hospice admissions nurse, a job that allows him to work with patients while avoiding the hurdles that doctors have to overcome to practice medicine in the United States.

Cuban doctors have been fleeing to South Florida since Fidel Castro seized power in 1959, but the pace intensified after 2006, when the Department of Homeland Security began a program that allowed Cuban medical personnel “who study or work in a third country under the direction of the Cuban government” to travel to the United States legally. The program has effectively turned a crowning achievement of Cuba’s foreign policy on its head.

In the 50 years since the revolution, Cuba has sent more than 185,000 health professionals on medical missions to at least 103 countries. About 31,000, most of them doctors, are in Venezuela, where they work in exchange for cheap oil and other trade benefits for the Cuban government.

And more are in the pipeline. Cuba’s official news agency reported that more than 25,000 health professionals graduated this year, “the largest graduation ever.”

But many doctors on the island are now vying to be tapped for an international mission, in part because they know that no matter where they are sent, they will be one step closer to a visa to the United States.

The missions have earned Cuba much recognition, goodwill and bargaining power. President Obama told reporters at the end of a recent hemispheric meeting in Trinidad that he found it “interesting” to learn from Latin American leaders “about the thousands of doctors from Cuba that are dispersed all throughout the region, and upon which many of these countries heavily depend.”

Yet for many Cuban doctors, who earn the equivalent of $25 a month, the lure of a life of freedom and opportunities in the United States is too strong to resist. And so these children of the revolution, educated by a Communist regime to reject capitalism and embrace socialism, have ended up in Miami, often tending to elderly Cubans who fled the island before the doctors were born.

Ana Carbonell, chief of staff for Representative Lincoln Diaz-Balart, Republican of Florida, said more than 2,000 Cubans had already settled in the United States under the parole program.

“It brings to our community highly qualified professionals at a time of great need,” Ms. Carbonell said. “They work alongside U.S.-trained doctors, and they enhance any practice or wherever they work.”

Many have been able to obtain licenses and practice medicine. Others have chosen to settle for careers in the medical field but not as physicians, and some work in fields that have nothing to do with medicine.

“I know neurosurgeons who are working in warehouses or factories or as gas attendants,” said Julio César Alfonso, 40, who graduated from medical school in Cuba in 1992 and works as a clinic manager in Miami. “But I know many more who are working as nurses, medical assistants and technicians.”

Lianete Pérez, 37, works as a medical assistant in the office of a pediatrician in Miami. A former anesthesiologist, Dr. Pérez longed to leave Cuba, arrived in 2002 and is studying to take the medical exams later this year. Unlike other doctors who resent having their skills tested years after medical school, she said she welcomed the chance to go back to the books.

“There are enormous differences between medicine in Cuba and in the United States,” she said. “I can’t tell you that Cuban doctors are not well trained, but I can tell you that the books we used were edited in 1962, and for me, coming here was like starting all over again.”

Aside from old books, Cuban medical students and doctors must contend with a lack of modern equipment and, often, of drugs and diagnostic tools taken for granted in developed countries. But many expatriate doctors say their dealings with patients in Cuba were more humane and less rushed than they are in the United States.

Foreign doctors trained in languages other than English face immense challenges getting a license to practice in the United States. Not only must they relearn their profession in English, but many, like Dr. Domínguez, must also work to support themselves and their families. Cuban doctors, in particular, tend to be older by the time they arrive in the United States, sometimes too old to dedicate years to studying for exams and finding and completing a residency program.

Finding a residency program is almost impossible, they say, in part because most hospitals seek young doctors who can work long hours for little pay. A 40-year-old doctor is often deemed too old to be accepted in a residency program. Dr. J. Donald Temple, an associate professor of medicine at the University of Miami, said foreign-trained doctors faced the widespread perception that medical schools abroad are not as rigorous as medical schools in this country.

“They are not going to be accepted as readily as American-trained doctors are for some of the more competitive residency programs,” said Dr. Temple, who runs a training program for Latin American and Caribbean doctors to become leaders in the medical field in their own countries. “Many programs would not even consider them.”

Their loss is Miami’s gain. Just about any hospital in Miami can boast of having highly trained Cuban doctors working as nurses or medical assistants or even lab technicians.

Carlos Pérez-Sedano, 40, is one of them. He said he was sent to Ghana in September 2005. A year later, just two months after the parole program was announced, he applied for a United States visa. By December 2006, he was in Miami.

He now works as a case manager at Kendall Regional Hospital and is studying to take the exams for his Florida medical license. He says that half of the case managers in his department are Cuban doctors, and that at least 50 Cuban doctors work in other areas of the hospital, not all of them as physicians. Hospital officials at Kendall Regional say they keep no record of the nationality of their employees.

One out of every four doctors in the United States was trained overseas, said an American Medical Association official who deals with international doctors, but who is not authorized to speak to reporters and declined to give her name.

“We feel that international medical graduates are an integral part of our work force, and we don’t see that changing any time soon,” she said. “We rely very heavily on them because they take positions that are in underserved areas and go into primary care. Without them our country would be in dire straits, especially minority populations and the poor.”

This is the path that Dr. Juan A. Bereao took when he came from Cuba 11 years ago. A surgeon in Cuba, he now works as a house doctor in several South Florida hospitals, including Kendall. For three years before that, he was a resident in internal medical at Bronx-Lebanon Hospital in New York City, where most of his patients were poor and from ethnic or racial minorities.

Dr. Domínguez, the hospice nurse, said he was mostly at peace with the fact that no one calls him “Doctor” anymore, except some old patients from Cuba he sometimes run into in Miami. He earns more than $100,000 a year, sends his two children to private schools and vacations with his family in France and Spain. But he said a part of him would always pine for the profession — and the title.

“I’ve had to get used to think as a nurse, but it’s difficult,” he said. “Deep down, I’m still a doctor.”

Source: New York Times