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International Medical Graduates

Finished Your Residency - What's Next?

Faroque A. Khan, MB, MACP
Professor of Medicine
State University of New York at Stony Brook
Former ACP Regent

All trainees in Internal Medicine, usually during their second year of training, have to decide on the future course of their training. Will they start practice after completing their three-year training? Will they pursue specialized fellowship? If so, how do they go about it, and what's a good or "hot" fellowship?

As a Program Director and Chairman of Medicine, I had the opportunity to talk to and advise over 300 trainees, most of them IMGs. What follows is basically a summary of those discussions with some concrete take-home messages.

Q. Where do you intend to settle after completing your training?

A. I want to go back home.

The answer to this question gives a good indication of the choice of post-career pathway. For those who plan to return to their country of origin, it makes a lot of sense to pursue further specialized training - the reason being the scarcity of specialists. For example, when I visited Malaysia I was informed there were only three rheumatologists in the entire country of Malaysia. This type of situation is not unusual and, thus, any specialized skill an IMG acquires in the USA will be in great demand. Several of my former trainees, after completing their specialization in the USA, have returned to Pakistan, India, Jordan, Qatar, and Saudi Arabia and are making major contributions to the upgrading of health care in these countries.

A. I am determined to stay in the USA.

In this type of a scenario, my advice follows in the following format: The health care environment in the USA is changing rapidly. Solo practice is being replaced by group practices that, in turn, are being driven by Managed Care with heavy focus on cost containment. Many parts of the USA are facing a surplus of specialists. The fastest growing patient age group is above the age of 85. There is an explosion in information technology, and health systems are trying to incorporate these modalities to maximize efficiency and cut down on costs.

So, after studying the environment around you, one should make an intelligent choice about specialization based on what will be needed in 5-10 years, rather than what you may have desired while you were in medical school. Thus, if you choose to specialize, you might like to pick an area in an emerging field that is in great demand; for example, informatics, geriatrics, etc.

A. I have done enough training. I want to start a practice and make a living.

In this type of a scenario my advice would be to be flexible regarding geographic preference. Many of my trainees have settled in mid-western and southern states where, in addition to being able to start a practice, they have been "sponsored" for a permanent visa, as well.

To enhance one's marketability, I would suggest getting additional competence in clinical skills that would be of use in an office setting, such as arthrocentesis, skin biopsy, hospice care, pharmacokinetics, women's health, etc. These can be obtained by taking additional CME courses. Organizations such as ACP offer them at national and regional meetings.

A. Dr. Khan, I really want to be a cardiologist.

I can't begin to recall how often I have been asked about the prospects for cardiology fellowship, particularly by trainees from South Asia. Perhaps it's related to the role models the trainees are exposed to as students, the stature of cardiologists in their home countries, and lack of the availability of other specialties particularly dependent on laboratory support such as immunology, oncology, rheumatology, etc.

One house officer even remarked, "My father insists I become a cardiologist. Any other specialty will be perceived as a failure." This young man's real interest and passion was in oncology.

I have always tried (not very successfully) to show the house officers the advantages and options of other specialties available in the USA.

A. How do I get into a good fellowship program?

Here again there are some practical steps that the trainee can take to enhance their prospects for entering into a highly competitive fellowship. One of the things that helps includes academic productivity during training. A house officer who has participated in ongoing research, such as presenting or publishing material at regional and/or national meetings considerably enhances their chances for fellowship, as does the support from key faculty members, particularly if they are from the same specialty, and more so if they make personal calls on behalf of the applicant.

Q. Does visa status change the prospects for fellowship?

A. The answer is yes and no.

Some programs do not accept H-1 or J-1 applicants, while other programs may prefer J-1 applicants. I recall once being successful in having one of my trainees placed in a highly competitive program in another state. One of his "selling" points was that he was a J-1 visa holder, and I was able to assure the Program Director that after completing his fellowship this candidate would return to his home country. He did just that! This candidate's J-1 visa became an asset instead of a liability.

Q. I didn't get the fellowship I was looking for. What should I do now?

A. Well, this doesn't represent the end of the world.

Let's move on and think of another field. I, personally, wanted to become a gastroenterologist. In fact, I was accepted by a very prestigious program. There was one problem. They didn't have a salary to support me. After that rude awakening, I took the first opportunity that came my way, which was Pulmonary Medicine. I enjoyed the training in Pulmonary and my subsequent career.

Like everything in life, one doesn't always get everything. Be prepared to make choices, accept alternatives, and move on.

Brief Bio:

Faroque Ahmad Khan is a graduate from Srinagar, Kashmir. He trained in Internal Medicine and Pulmonary Medicine, and was a Pulmonary Fellowship Program Director for 10 years, followed by Chairmanship of Medicine for 12 years. Dr. Khan was awarded Mastership in ACP in 1993, and in 1995 Dr. Khan was elected a Regent of ACP, the first elected IMG Regent. Dr. Khan chaired the ACP Credentials Committee and the Education Committee and was a member of the International Subcommittee.

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

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