Navigating the Public Medical Care System (CAJA) at the San Rafael Hospital

I apologize for the length of this post, but I wanted to give as much detail as possible to help others who find themselves in the same position.

I recently wrote a post about how we joined MediSmart and the specialist I went to see. This was regarding a reddish patch of skin on my lower back which I had been living with for several years - first in Canada, then ongoing in Costa Rica.

In Canada, a doctor I had at the time (before 2011) took a look and basically said that it was just a sign of aging. After about four years in Costa Rica with the patch still there, I decided to have our CAJA doctor (a general practitioner) take a look (then 2015). She thought it might be some kind of fungus and directed skin scrapings to be taken and analyzed. When nothing of particular concern was indicated by the analysis, she prescribed a popular skin cream called "Crema de Rosas" and Betametasona (a steroid medication).  I used both for over two years, but the patch lingered on. However, when a new CAJA doctor arrived on the scene (also a general practitioner), I pointed out to him that the treatment did not seem to be doing anything and expressed maybe I should see a dermatologist. He agreed.

Then, the only question was whether to get an appointment with a dermatologist in CAJA or a dermatologist in the private system. I elected for the private system (in this case MediSmart) because first time appointments with a specialist in CAJA can sometimes be long delayed.

Five days after I saw the MediSmart doctor (October 30), he emailed his diagnosis and lab report to me. It was a non-malignant skin cancer confined to the top layer of the skin. He said that it could be removed with minor day surgery - that he could do it under MediSmart or that I could also have it done through CAJA. I decided to check how long it would take CAJA to move forward given the head start report provided by the MediSmart doctor. Not long.

On November 1st, I had an appointment with my regular CAJA doctor, showed him the Medismart diagnosis, and who then issued me a referral for a dermatologist at the hospital assigned to us when we first joined CAJA - the Hospital San Rafael  in Alajuela.

Here is where the fun begins:

In the CAJA system, a "referral" is not an "appointment". It merely opens the door to get an appointment. On November 3rd, I took the referral to the hospital, the purpose being to have a dermatologist assigned to my case and an appointment with that doctor. At the main door of the hospital, a guard looked at the referral and directed us (Lance and I) to reception on the 4th floor. There, there were three reception windows with three clerks and long line ups at each.

It was by no means clear which window was appropriate. But, a prominent sign in front of the third window (as you walk in) listing "Dermatología" and a number of other specialities suggested that window was the right one. A similar sign listing still more specialities was in front of the first window. No signage was in front of the second window.

Logic dictated that we should be in the third window line up.  But, after dwelling in that line up for a period of time, a really nice lady thinking - and rightly so - that we might not understand the system looked at my referral, determined that I was in the wrong line up, and directed us to the second window line up. So we moved from the middle of the third window line up to the end of the second window line up. Once at the second window, I presented my referral and was quickly assigned to a dermatologist and given an appointment with that doctor for four days later (November 7th).

We subsequently learned that the line up at the first window was a line up for able bodied people to get an appointment; the line up at the second window was a line up for preferred service to get an appointment (pregnant, disabled, mothers with babies, and seniors like myself); and the line up at the third window was a line up for people showing up on the day of their appointment. 

With the appointment in hand, was I all set? Not on your life - there was another line up to come. This was a new case, so the case had to be opened and a file had to be created. With a first appointment in hand, this requires the patient to retreat to the main floor of the hospital and get in the appropriate line up at the "Plataforma de Servicios" (Services Platform). There, a clerk reviews the appointment, checks out information on a computer (e.g. are you up to date with CAJA payments) and enters new information. If everything is in order, he or she opens a file and puts a number of print outs in a file folder. Unfortunately, we did not know any of this on the day I got my first appointment for November 7th. We simply went home with the appointment.

For my first appointment, we were told to be at the 4th floor reception area at 1030 for an 1100 appointment. The hospital is about a 50 to 60 minute bus ride from Atenas so we opted to catch the 0800 bus from Atenas. At the Alajuela bus depot it was a short taxi ride to the hospital. We arrived at reception an hour early. My appointment paperwork was processed quite quickly, BUT I did not have a file! We were sent down to the Plataforma to get a file.

At the Plataforma, I grabbed a number from a ticket machine and we sat and waited. The numbers were not moving very fast. I got the bright idea to get a special number for the preferred service line up. Mistake! It must have been new baby registration day because there were several babies and it took ages to create files for them. I should have stayed in the regular line. The numbers you get for the preferred line are not the same as those from the ticket machine which are flashed out on a wall screen. They are obtained by walking up to one of the clerks and asking for a preferred number card. Apparently, it seems OK to interrupt and do that when the clerk is trying to deal with somebody else. With the card in hand, you then have to listen very carefully for the number to be called (and obviously have to recognize the number when spoken in Spanish). 

By the time my number was called, my 1100 am appointment was long gone. But, my file was eventually created and we headed back up to the 4th floor. The reception clerk saw me, waved me in ahead of others, put the file in order and directed me to a waiting area elsewhere on the 4th floor. It didn’t take long to see the doctor (in Spanish "doctora" as it turned out).

Events may have unfolded differently had I tried to get the file opened on the same day that I got the first appointment. I don't know which, but I expect that the file either would have been handed to me with instructions to deliver it up to 4th floor reception before leaving the hospital or would have been kept and routinely delivered by some internal office procedure.

The doctora set an appointment for the next day for what I thought was going to be a minor procedure to confirm the MediSmart diagnosis. I started to have my doubts about this when I was told to put on a gown, booties and a head covering and directed to an operating room where my doctora and two nurses waited. About an hour and a half later, the reddish patch was gone and I was on my way with stitches and a dressing on my back. I had several prescriptions to fill at the hospital farmacia but was told it would take two hours so we left them there and opted to take a taxi home instead of a bus.

Which meant we had to return the next day to pick them up! In hindsight, I should have tried to have them filled at our Atenas clinic farmacia. Live and learn.

My next appointment was scheduled for five days later. This turned into a bit of a fuster-cluck because my file was placed in the wrong consulting office. After patiently waiting (no pun intended) about five hours, we finally told a reception lady that there was no doctor. She was on the phone immediately, we were given a different room number to go to and I saw the doctora right away.

I have two more appointments the last week of November.

Hospital San Rafael is large and modern. The medical staff are excellent, but the administrative system might be deserving of some scrutiny. Go there with a lot of patience as there are lineups for everything. If you have never been there before, it might be a good idea to bring somebody with you who not only knows Spanish but also knows the CAJA system. Parking is very limited. So, if you are going to drive to Alajuela instead of taking a bus, I suggest parking at the Juan Santamaria International Airport or at the City Mall Shopping Center, and taxing to the hospital - it’s not very far from either place. 

At every visit, Costa Ricans helped us out when we were stuck - wonderful people.

I expect that the system is not much different at other CAJA hospitals.

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the San Rafael Hospital