International Medical Graduates
Preparedness for Training
Tanveer P. Mir MD, FACP
Senior Medical Director
Hospice Care Network
North Shore Long Island Jewish Health Care System
Woodbury, New York
Former ACP Governor
Q. How will you prepare yourself for training in the United States?
A. By demonstrating a good attitude.
A resident starting training on July 1st can encounter significant problems if he or she has not undergone a formal period of orientation. With demonstration of good planning and self-organizational skills, an International Medical Graduate can start training in July with confidence. The basic ingredient of any success story in medicine is a good attitude. A physician may demonstrate superior clinical skills and possess encyclopedic medical knowledge, but a poor attitude will prevent him or her from being successful. Attitude is a frequently discussed topic in resident evaluation forums. This personality trait combined with compassion and superior humanistic skills will lead to a better acceptance by the patients of a physician who is not born or brought up in this country. A good attitude will lead to letters of commendation and superior evaluations from faculty that make their way to the personal folder of the resident.
A. By demonstrating superior communication skills.
Communication is by far the most important component of a physician-patient relationship. Verbal and non-verbal communication, discussion with patients, families, faculty, and seniors is very important for a resident in training and is perfected by practice alone. Some training programs provide formal role-playing sessions but observation of faculty and senior residents with experience is the best teaching tool.
A. By demonstrating a superior fund of medical knowledge.
A good fund of medical knowledge is important for patient care. All residents are expected to read on a daily basis, and during each rotation, they may be asked to present a topic or two. Access to Medline and the Internet is universally available, and all residents are expected to be well versed with these issues. Regularly scheduled tests and annual in-service examinations prepare residents for taking the Boards after completion of training.
A. Please say "I don't know" and ask seniors when in doubt.
Residents are not expected to know everything in medicine. Familiarization with institutional policies and procedures is important. It is acceptable to say "I don't know" at any stage of training and seek help from senior residents and faculty. A resident who follows these basic guidelines will be successful in a training program. There is no prescription to being a good resident, but a good person always makes a good physician.
Orientation and Acculturation
- An International Medical Graduate (IMG) joining a residency program in the U.S. is expected to perform in the same fashion as a U.S.-born physician. Most International Medical Graduates meet the requirements for U.S. training, when accepted in a program. The United States Medical Licensure Examination parts I & II certify the medical knowledge of a candidate. The Clinical Skills Assessment (CSA) formally assesses spoken English skills, diagnostic and management skills, identification and interpretation of laboratory data, and performance in clinical encounters with standardized patients. Hence the ECFMG certificate of today provides the basic clinical skills to an International Medical Graduate for residency training in the U.S.
- Program Directors, faculty and peers expect residents to adapt to the system as soon as possible. Issues related to patient-physician relationship, verbal and non-verbal communication are as important as medical knowledge and clinical skills. Today's physician workforce in the U.S. represents diverse cultural, ethnic and language backgrounds. It is expected that these factors not interfere in the training and education of residents. Issues related to difficult patients may present a challenge to a physician who is starting training in a new environment. Patient care issues at the end-of-life and death and dying are strongly determined by the patients' belief system and values. A physician from a different background may not be able to comprehend these cultural nuances. Hence provision of care at the end-of-life may be a difficulty that an IMG has to encounter in a new environment.
- Several training programs in the U.S. and Canada offer orientation and acculturation programs to IMGs entering training in the U.S. These programs are offered in the institution of training and last a few days to two weeks in duration. These sessions are offered in the last few days of June, prior to an IMG starting training. These orientation sessions are designed to teach residents' basic communication and sociolinguistic techniques useful for negotiating the U.S. healthcare system. They are provided with a basic packet of information that covers most of the topics covered during the orientation period. Approach to difficult patients, how to obtain a Do Not Resuscitate and Autopsy consents are incorporated into these sessions. Medical record documentation and the legal, ethical and financial ramifications of the same are stressed throughout these sessions. The effect of structured and systematic cognitive thinking and evidence-based decision-making in patient care are stressed throughout the period of orientation. Formal instruction in questioning, attentive silence, eye contact, teaching, feed back, correcting, information giving, and persuasion is provided with role-playing and video replays of actual patient encounters. Dress code, punctuality, promptness and decorum are an integral part of an orientation program. After completion of this period of orientation, IMGs are better at communicating with patients, faculty and nursing staff. They have a better understanding of the American healthcare system and they are better equipped to handle delicate and often misinterpreted issues, which allow them to function better as healthcare providers. Bedside observation of seniors and faculty during patient encounters completes the required curriculum of most orientation programs.
- Acculturation: Resident well being is a fundamental requirement and a social need for all incoming IMGs. Orientation is the time when future residents arrive in a new country, acquire coping skills, and learn patient management skills through formal instruction. During this period of orientation, the IMG gets an opportunity to adapt to the U.S. culture and system. Enculturation occurs during formal and informal interaction with peers, medical, nursing, and secretarial staff. A pleasant social environment is conducive to learning. Hence the orientation and acculturation program prepares an IMG for a smooth July first transition.
- At this time, all residency programs in the U.S. do not provide orientation programs. International Medical Graduates starting training in the U.S. must plan to arrive at least two-weeks prior to July Ist. in the town where they will train. This will give them an opportunity to complete paperwork, seek accommodations, start a bank account, get a Social Security Number, and identify means of transportation before starting training. This period of adjustment will prepare an IMG and identify problems related to day-to-day living. Waiting until the last minute to make all these arrangements may lead to additional stress and distractions when starting training. In addition if requested in advance, most program directors will welcome the arrival of a resident earlier than the stated start date and will approve of a few days of observation and attendance on rounds to a future resident.
- To conclude, all IMGs starting training must allow themselves a two-week orientation period. The problems related to a July transition will be fewer and overall the new residents will adapt well to their new roles. Last minute and late arrivals do not allow for this transition period, and hence must be avoided.
Tanveer Mir MD, MACP, is a graduate of the Medical College of Kashmir, India in 1981. In the U.S. she completed her training in Internal Medicine at Long Island Jewish Medical Center, New York in 1989. After completing a Chief Residency in Internal Medicine at Nassau University Medical Center, she stayed on as a faculty member. Dr. Mir was the Associate Program Director and Division Chief of Geriatrics at Nassau University Medical Center until 1999. She was also affiliated with the State University of New York at Stony Brook. Currently Dr. Mir is the Senior Medical Director of Hospice Care Network, an affiliate of North Shore Long Island Jewish Health Care System. She was the Governor of the ACP Downstate III Region (New York) and was chairperson of the International Medical Graduate subcommittee of the ACP New York Chapter.
This article was prepared for the ACP IMG Web site in 2000.
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