International Medical Graduates - Training All Over Again

Ashok M. Karnik, MD, FACP
Attending Pulmonologist
Nassau University Medical Center
Clinical Associate Professor of Medicine
SUNY Stony Brook, New York

A large number of physicians from various countries arrive in the U.S. each year to receive further training. This is a diverse group of individuals, with different socio-cultural backgrounds, varying standards of medical education, and a vast range of previous experiences. This transition, however, from a foreign medical graduate ("FMG") to a successful physician practicing medicine in the U.S., is not easy. Given below are areas where difficulties are often encountered. Differences between foreign medical education, hospital practices and socio-cultural patterns and those of the U.S. are highlighted. Suggestions are made which would hopefully make the transition smooth and painless.

Medical Education and Examinations: In most of the medical schools in India, Pakistan, Bangladesh and Middle East, the medical education emulates that in the UK. There is greater emphasis on clinical approach; the students learn to pick up subtle physical signs and are fond of diagnosing various syndromes by exotic eponyms. Because of lack of availability of advanced technologies in smaller hospitals, some students are not very familiar with investigational tools such as CT scans, MRI, and angiographies. They may not have seen cases with diseases such as sarcoidosis, collagen vascular diseases, and pulmonary embolism, etc.- either due to a truly lower incidence of some of these conditions or because of lack of recognition and diagnosis.

While both systems, the American and the British, have their strong and weak points, a successful resident would be one who is able to combine the good points of both systems. By using the "best of both worlds" and using tact and discretion while presenting cases on the rounds or in conferences, he/she might eventually turn out to be a better resident than an average one. For example, on the rounds, the resident might present the case lucidly with all the physical signs and arrive at a good differential diagnosis, but should avoid using various eponyms for signs and syndromes. The resident should familiarize himself/herself as soon as possible with the various investigations and conditions that he/she is not familiar with. Residents from some countries tend to "talk like a book" because of the "rote system" of education they have gone through. He/she must apply his "book knowledge" to a particular case under discussion rather than quote a list of causes or diagnose a fancy but far-fetched syndrome. The resident must remember that "it is better to be wrong for the right reasons rather than to be right for the wrong reasons."

In the American system, the students are allowed to be involved in the work-up and management of cases, whereas in most of the other countries, they do not get hands-on experience till they become interns. During residency, however, they get an opportunity to do many more investigations. The experience vastly varies due to the prevalence pattern of various diseases. Further variability arises from the availability/non-availability of various investigations and the differences in the legal atmosphere in different countries. For example, in the U.S., an average intern may perform numerous arterial blood gases and place many central lines, but may not get a chance to do special investigations such as liver biopsy, kidney biopsy, bone marrow aspiration, etc. till he/she does a fellowship in that particular specialty. On the other hand, a resident from an average medical school in India may not have done arterial punctures or placed any central lines and may have never seen a Swan-Ganz catheter, but he/she may have done some liver and renal biopsies and may have aspirated a few bone marrows.

The examination pattern in USA differs from other countries. The various board examinations in the U.S. consist of multiple-choice questions (MCQs), whereas most of the medical schools in the Indian sub-continent have essay type examinations. Clinical evaluations, in which the students and residents are allotted short and long cases, are an integral component of the examinations. While ignorance is quickly revealed by the MCQ, it can by masked by a verbose essay. However, the MCQ is rather rigid, gives you a fixed number of options, and sometimes two options may be equally correct in real life. The foreign graduates need to quickly adapt to the multiple choice-type of examination, which requires application of the book knowledge to a hypothetical clinical scenario. The best way to prepare is to do as many MCQs as possible from various sources such as Harrison's and Cecil's Review of Internal Medicine and MKSAP.

Although there is no escape from the various examinations, the FMGs who have passed examinations such as MRCP or have obtained experience in hospitals in the UK can often receive some exemptions from the required number of years for residency. Usually MRCP gives you a credit for one year, and one-half year of credit is given for each year of residency done in the UK. The Chairman needs to write a strong letter of recommendation, and an application for the exemption should be made at the earliest. FMGs must understand that there are three "tracks" and the requirements for each are different. To become "board eligible," the requirements for the completion of residency have to be fulfilled with or without any exemptions; for appointment to the position of an "Attending," one must be board eligible/certified and a permanent resident of the U.S.; for an academic appointment, the individual has to meet the criteria laid down by the university for various positions such as " Tutor," "Assistant Professor," "Associate Professor" or "Professor." Most of the FMGs follow the usual steps such as completion of residency, passing boards, getting an "attending" appointment in a hospital and then an academic appointment with the university to which the hospital is affiliated. Occasionally, an experienced and senior FMG, however, may be able to telescope the whole process in 1-2 years. He/she may obtain exemptions based on previous experience and get a direct academic appointment based on previous publications and fellowships in various U.S. colleges such as FACP or FCCP.

Working in a US Hospital: There are many differences between the pattern of rounds and working and the atmosphere in U.S. hospitals and hospitals in foreign countries. A resident has to mold himself/herself to these very quickly and assimilate in the rest of the residency pool. A few examples: the "morning report," starting at 8 am or even earlier, is a tradition almost unique to U.S. hospitals. Terms and practices such as "DNR," "withdrawal of various life-support systems," "health-care proxy," and "living will" may be unheard of in some countries and in remote hospitals, mainly because these issues do not come up in view of the type of social and family fabric of those countries. The agencies and concepts such as "ACGME," "JCAHO," "Quality Control," "Risk Management," "IPRO," "Utilization Review," etc. do not exist. The degree and the accuracy of documentation required to defend oneself in a litigious atmosphere does not even cross the mind of an average physician who is providing much-needed service in an ill-equipped clinic in a remote area.

The FMGs also face a cultural shock when they start working in a U.S. hospital. Calling a nurse "Sister" in a U.S. hospital would produce either no response from the nurse or a sarcastic one. Calling a senior resident or an attending "Sir" may be interpreted as a sign of submissiveness. Remaining silent on the ward rounds and waiting till you are asked a question may be misinterpreted as a sign of ignorance or an inability to participate in discussion. These are manifestations of a polite upbringing or the cultural background of a person; but some virtues, when overdone, may place a person at a disadvantage. While some of these qualities may be so deeply ingrained that a person cannot change his/her personality altogether, a smart resident would make astute observations and adapt quickly.

Many residents, in their own countries, have passed their post-graduate examinations, equivalent to American "Boards"; many have been on senior positions prior to coming to the USA. These physicians leave the shores of their homeland for further education, training and experience. Rarely, they are here because of circumstances beyond their control. In any case, it is heart-wrenching to have to swallow one's pride and take orders from a senior resident who may be half their age; to start preparing for USMLE or Boards all over again or take night duties when the brain and body are not as vigorous as when the resident was 15 or 20 years younger. It is admirable that a vast majority of these "old" first-year residents not only make it but also achieve academic, financial, and social success. The older foreign graduate should use his or her experience and clinical judgment to solve clinical problems and yet keep an open mind and learn newer techniques from his younger American colleague. He should not take an occasional brusque remark personally and should consider it to be part of cultural difference or impatience of a younger person. His maturity would help him see the things in correct perspective. Perhaps the secret of success of older FMGs is a constant reminder to themselves about their ultimate goal, their maturity, tolerance and persistence and a strong will to succeed. If you find yourself in such a situation remind yourself that "Today is the tomorrow that we worried about yesterday" and that there is always light at the end of the tunnel.

Author Bio:

Ashok M. Karnik is a graduate of King George's Medical College, Lucknow, India. He received his training in India, England and the U.S. Besides the U.S., he has worked in four other countries. Currently he works as an attending pulmonologist at Nassau University Medical Center and is a Clinical Associate Professor of Medicine at SUNY, Stony Brook. He serves as Director of Pulmonary Care Unit and Pulmonary Function Laboratories.

This article was prepared for the ACP IMG Web site in 2000.