Nyapati R. Rao

Indian Medical Students’ Views on Immigration for Training and Practice

Purpose To assess the attitudes of medical students in India about participating in graduate medical education in the United States and other countries and in subsequent clinical practice in those countries. Method A total of 240 students who were attending their final year at two medical schools in Bangalore, India, were surveyed during 2004. Surveys were completed by 166 (69%) of the students. Results Among the responding students, 98 (59%) thought of leaving India for further training abroad. Of those who wished to leave, 41 (42%) preferred the United States, 42 (43%) preferred the United Kingdom, and 9 (9%) preferred Canada, Australia or New Zealand. Only two students preferred the Middle East. Most who favored training in the United States indicated that they intended to remain after training, whereas fewer than 20% of those who favored training in the United Kingdom had such intentions. While more than 60% perceived greater professional opportunities in the United States than in India, approximately 75% were concerned that the United States had become less welcoming after the terrorist attacks of 9/11, and similar numbers were concerned about the examination administered by the Educational Commission on Foreign Medical Graduates. Conversely, the majority of respondents felt that opportunities for physicians in India were improving. Conclusions While optimism about future medical careers in India is increasing, the interest of Indian medical students in training and subsequently practicing in the United States remains high.

A Roadmap for Observership Programs in Psychiatry for International Medical Graduates

ObjectiveInternational medical graduates (IMGs) constitute a significant proportion of the psychiatric workforce in the United States. Observership programs serve an important role in preparing IMGs for U.S. residency positions; yet there are limited resources with information available on establishing these observerships, and none specific to psychiatry. In this article, authors present a roadmap for observership programs in psychiatry for IMGs.MethodThis article draws on the experience of the IMG committee of the Group for Advancement of Psychiatry in establishing observership programs.ResultsAuthors highlight the benefits of observership programs to IMGs, psychiatry departments, and the U.S. medical system as a whole. The different components of an observership program are presented, along with core competencies that need to be acquired. The authors discuss challenges that observership programs may encounter as well as recommendations for overcoming them.ConclusionObservership programs provide a unique opportunity to integrate IMGs into the U.S. medical system. This article provides a framework for establishing such programs in a way that will optimize their benefits and avoid potential pitfalls. Drs. Hamoda and Sacks contributed equally to this article and are hence co-1st authors.

Psychodynamic Psychotherapy Training as Acculturative Experience for International Medical Graduates: A Commentary.

“Preparing International Medical Graduates (IMGs) for Psychiatry Residency: AMulti-Site NeedsAssessment” (1) addresses the needs of IMGs entering psychiatry residency training in Canada. On the basis of a survey of five psychiatric residency training programs, the authors report that respondents ranked (in order of importance) understanding the Canadian healthcare system, learning medical documentation, practicing evidence-based medicine, and providing mental health care among the greatest challenges they face in successfully adapting to postgraduate medical training. Language barriers and social isolation were particularly difficult for those residents who did not speak English as their first language. Furthermore, residents who had lived in Canada for 12 months or less reported greater perceived knowledge gaps in psychotherapy. This commentary will focus on acculturation issues that underlie the survey’s findings, including language difficulties causing social isolation that may affect the psychotherapeutic competence of IMGs. Among the cultural challenges, we will examine how differences between the collectivistic cultures of origin (for the majority of IMGs originating in non-Western countries) and the host country’s individualistic culture (2) can affect an IMG’s performance in psychiatry. After assessing various approaches to acculturation of IMGs, we will explore how training in psychodynamic psychotherapy can serve as an acculturation tool, offering IMGs unique opportunities for letting go of their old cultures and adapting to the new culture in a phase-appropriate manner. In this commentary, we use the term psychotherapy to refer to psychodynamic psychotherapy.

Psychiatric Residents’ Attitudes Toward and Experiences With the Clinical-Skills Verification Process: A Pilot Study on U.S. and International Medical Graduates

ObjectiveThe authors report on a pilot study of the experiences and perceptions of foreign international medical graduate (F-IMG), United States international medical graduate (US-IMG), and United States medical graduate (USMG) psychiatric residents with the newly mandated Clinical Skills Verification (CSV) process. The goal was to identify and suggest remedies to any problems with the implementation of CSV in order to facilitate its success as an evaluation tool with all the three groups of residents.MethodThe authors designed a 51-item survey questionnaire to gather demographic data and information about three principal content areas: 1) views on the effectiveness of the program; 2) the assessment experience; and 3) evaluation and feedback. A link to the survey was e-mailed to the directors of nine general-psychiatry residency programs in the United States with a request to forward it to the residents. The data were collected from February 2010 through March 2010.ResultsSixty-three general-psychiatry residents (51.2% of 123 eligible residents) from nine selected programs completed the entire survey. Both IMG and USMG residents felt that the CSV was helpful in improving their clinical skills. Both groups of IMG residents, in contrast to their USMG counterparts, wanted more supervised interviews and were more likely to experience feedback as excessively negative and critical. In comparison to USMGs and US-IMGs, F-IMGs were less comfortable conducting an observed interview. They also had had less exposure to and experience with the CSV processes before their residency.ConclusionsMost residents reported positive experiences with the CSV. The survey also revealed notable commonalities and differences between IMG and USMG residents in their experiences and perceptions of the CSV process, mostly related to their cultural and medical school backgrounds. Authors recommend that residency programs take definitive steps toward addressing the unique needs of these groups of residents.

A little more than kin, and less than kind: U.S. immigration policy on international medical graduates.

High-performing doctors willing to work to alleviate the shortage of medical care in the United States should be encouraged to do so, not prevented because of their countries of origin.

Acculturation, education, training, and workforce issues of IMGs: current status and future directions.

In assembling the International Medical Graduate (IMG)focused articles for this special issue of Academic Psychiatry, our goal has been to “reexamine the role of IMGs in American psychiatry so that we can advocate for rational public policies and develop training models that successfully address IMGs’ sociocultural and educational needs” (1). We invited papers on themes that “include but are not limited to psychiatric workforce dilemmas in the context of healthcare reform, educational and training strategies, acculturation and linguistic challenges, issues in evaluation and feedback, and effective psychotherapy and clinical research training models pertinent to IMGs” (1). We believe this special issue takes an important step in meeting our goal. IMGs constitute 33% of all U.S. psychiatry residents (2); they are composed of two groups: USIMGs and foreign IMGs. USIMGs, who comprise 20% of all IMGs, are U.S. citizens who obtained their medical education abroad (i.e., in foreign countries outside of the U.S. or Canada), whereas foreign IMGs (FIMGs), are citizens of foreign nations whose medical education also took place in their native countries or elsewhere abroad. FIMGs are an extremely diverse group. In 2010, 9,399 ECFMG-certified FIMGs graduated from 1,074 medical schools located in 138 countries or territories (3). They spoke more than 130 native languages, with English being the most common (34.1%), followed by Arabic (9.7%), Spanish (7.1%), Urdu (5.3%), and Hindi (5.1%) (3). USIMGs, U.S.or Canadian-born or naturalized citizen physicians, tend to be younger than FIMGs. Most members of this group receive their medical education at one of four foreign medical schools: Ross, St. Georges, and American University of the Caribbean (all located in the Caribbean), and Guadalajara University School of Medicine, located in Mexico. Although USIMGs have cultural and linguistic advantages over FIMGs, their overall performance on the qualifying examinations and board examinations is not as robust as that of FIMGs. The considerable heterogeneity that exists in cultural, ethnic, language, and medical-educational backgrounds has resulted in lack of a cohesive identity among IMGs regarding just what is implied by being an IMG. Some IMGs, both USIMGs and FIMGs, see the continued use of the initials “IMG” as insulting, gratuitous, and discriminatory, and ask that this practice be abandoned (4). However, others experience no such degradation in being referred to as IMGs, but recognize that some IMGs have specific additional educational requirements and want their needs to be appropriately addressed. In ourview, the latter perspective hasmerit because the educational, cultural, and linguistic challenges that confront IMGs are quite real (5), and psychiatric educators owe it to the American public, the field at large, and the IMGs themselves to address them appropriately during their training. As compared with psychiatric scholars, educators in general medicine have done a better job at systematically examining the needs of their IMG residents and fellows. Lacking a formal, published “evidence base” pertaining to IMGs’ training in psychiatry, we must first turn to the generalmedical literature for perspectives on IMG education.

The History of International Medical Graduate Physicians in Psychiatry and Medicine in the United States: A Perspective

International medical graduate (IMG) physicians are vital to the physician workforce in the United States, and over the past few decades have become especially important in the provision of psychiatric care in this country. IMG physicians have assumed crucial roles in caring for the underserved, and they have had greater opportunities in public psychiatry than in other areas of the field. In this chapter, key historical patterns in medical training in the United States are outlined. Medical training in India is described to illustrate issues experienced by medical graduates not born in the United States. It is suggested that IMG physicians are collaborators who bring wisdom, expertise, effort, and valuable traditions, and yet IMG physicians have often faced prejudice and obstacles to their professional advancement. It is hoped that IMG physicians in the future will be more respectfully embraced and will have robust professional opportunities in the health system of the United States and other economically established countries.

Identity Development for International Medical Graduate Physicians: A Perspective

Unlike their peers who were born in the USA, international medical graduate physicians face the challenge of having to develop a professional identity as a physician in a new and unfamiliar culture. Successfully developing a strong, bicultural identity can provide the IMG physician with a sense of belonging and heightened self-esteem while allowing for the maintenance of a valuable connection with the culture in which he or she was raised. As IMG physicians comprise 30 % of the United States’ physician work force, it is crucial for them to establish a physician identity that is professionally and personally gratifying, congruent with the clinical services they provide, and authentic to those they teach and train. This chapter provides an overview of the myriad of ways in which a physician’s identity impacts his or her daily life, and offers practical strategies to encourage international graduates to actively develop their own identities in ways which will benefit themselves both personally and professionally, allowing them to provide the best care possible to their patients.

Training Needs of International Medical Graduate Physicians in Psychiatry: A Perspective

The heterogeneity in the cultural, linguistic, and medical educational background of international medical graduate (IMG) physicians in psychiatry poses significant challenges in assessing their training needs. This chapter addresses the complex determination of training needs and their recommended solutions. To that end, inter-group differences within the IMG physician spectrum are discussed, with an emphasis on the imperatives within each culture. The recent literature on training needs for IMG physicians was reviewed and the following needs were identified as most relevant (in descending order): communication and language skills, medical/pharmacologic knowledge, dealing with social isolation, other acculturation issues, adequacy of supervision, psychosocial/patient management focus, cultural diversity training, understanding the health care systems, understanding the hospital culture, and medical documentation. This chapter highlights the role of psychotherapy training as an acculturative experience, along with the importance of a program development paradigm for needs evaluation and training implementation. Specific recommendations will be listed to assist training directors and IMG physicians in this crucial training area.