On the Importance of International Medical Graduates

Of the 75 doctors in my internal medicine residency program, I am a minority. There are 14 of us who are American Medical Graduates (AMGs), while 61 of our residents proudly studied in some of the most elite universities from around the world (International Medical Graduates, abbreviated IMGs). And no, there is no exaggeration when I use the term "around the world." The current residents in my program obtained their medical degrees from the following countries: India, Pakistan, Nigeria, Jordan, England, Georgia, Thailand, Venezuela, Greece, Ecuador, South Africa, The Philippines, Indonesia, Brazil, Germany, Spain, Korea, China, & Iran (not to mention my previous co-residents who have since completed training, having graduated from Mexico, Argentina, & Tanzania. I think that about covers it.) 

A medical student once told me that residency programs were recruiting him so hard because they were sick of taking so many IMGs. A piece of advice: never say a statement like that to me, thinking its okay because I'm American. You'll regret it, as I'm sure he did. When candidates come to interview at my program and they ask why I like it, I'm not giving a generic mediocre answer by saying "seriously, it's the people here." I mean that in every sense, in every scenario, in every situation of my training thus far; my 81.3% IMG and 18.7% AMG co-residents have been the single most enriching part of these formative years.  I'm using terms such as "they" and "their" frequently in this blog, but I don't mean to generalize. The unique personas of each of my co-residents is unreal-- and if you've ever spent a day here then you'd understand the true sense of the word diversity.  I wouldn't have it any other way.

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I'm not writing this to share statistics on why America's healthcare system is better off because of IMGs.  In fact, my program director and his colleagues already did that so eloquently in a rebuttal letter for the journal Chest, and you can read the full paper HERE. It's hard to argue that bringing in highly qualified doctors is in some way hurting our current American medical students or status quo of healthcare. Nope, I'm not here to justify anything with numbers, but rather to share my personal experience of training alongside some of the most well rounded, brilliant, not-from-America doctors I know. I don't want anyone to think for one second that IMGs are anything less than #goals.

You see, because when I groan about there being a shortage of IV morphine at our hospital and whine "but how am I going to treat this patient with pancreatitis?" I get practical and thought-provoking responses from my co-residents. "Shannon, you do realize that in my country morphine is reserved for the actual dying.. and even then it's used sparingly?" With every paradigm of how I believe something should be, I have 61 people who can share a slightly different perspective. Like the time I freaked out about our patient having a diagnosis of malaria. I had never seen malaria before! Obviously he has to be admitted and monitored right? But to my friend who has treated this time and time again in his country, he calmly wonders if we can discharge the patient from the ER with the appropriate prescription. I don't need a text book or an attending to learn in these moments. My co-residents' experiences alone have helped shape me into a well-rounded and well-trained doctor.

I think America is really in denial about the degree to which residents, particularly foreign medical graduates, man the county hospitals of this country, and but for their services, I’m not sure how exactly we could manage.
-Dr. Abraham Verghese

They’ve also shared stories that make me feel privileged to be exclusively trained in the US, to have avoided certain scenarios of observing human suffering simply due to lack of resources.  One story echoes in my head and gives me chills -- of a crashing patient requiring intubation, and the intubation gone wrong simply because there wasn't a single working suctioning device in this small ICU of a poorer neighborhood.  The patient died right in front of my friend- not because of lack of skills or knowledge, but because of a lacking resource.  A few of my friends share similar experiences to this one, and have to watch from here as not only their country's hospitals crumble, but the country itself.  There are a thousand things wrong with the United States and while I could sit and complain about all its issues, they make me realize that I am privileged. I need that reality check from time to time.  

Working alongside these 61 IMG co-residents, I grumble over my stacking med school debt while they deal with (the other kind of) Visa issues. H-1B, J-1, the pros/cons, the limitations, the cost, the fear, the risks they have to take if applying for anything, the struggle of getting back to their country and waiting in line at the embassy, of translating pages of contracts in order to get their visa approved for the next step in training, etc.  While I'm just looking for a good debt consolidation plan, they're making life-altering career decisions by factoring in their visa status, regardless of their incredible resumes, skills, and personalities.  I walk into work with all my academic accolades and abilities without even the faintest fear of missing an opportunity because of my citizenship status, or worse, the fear of being deported. Now THAT is privilege. 

As a general rule, IMGs who match here have better "numbers" than their American counterparts: higher test scores, more publications, more experience, etc.  Not a big deal, right? Except for the part of thriving in an application process that is not innate to your own medical system.  They take the USMLE and answer questions about US guidelines, learn all the ridiculous abbreviations for medical terms that might not even exist in their original method of learning medicine, most often taking exams in not-their-first-language and YUP, still school me.  My co-residents are the cream of the crop and I reap all the benefits. While many are straight out of medical school, others are with years of work/life experience. I have co-residents who previously worked as attendings (in specialties like hematology, surgery, family medicine, and so on.)   What it takes to get here is insurmountable, and their work ethic follows them here. Their collective drive inspires me to know more and do more.

So with all that hard work and academic accomplishment, you'd wonder if having a well-rounded life and personality would be lacking. This couldn't be further from the truth. It's the old mantra of "work hard, play hard" and while I'm falling asleep in my quiet suburban house, I'm getting text messages wondering why I'm such a grandma and missing out on Philly night life. "How do you have so much energy?!" I wonder, as I fall fast asleep. The humor and sarcasm of some of my co-residents is second to none, and how someone can be so brilliantly funny in their second language is beyond me. I truly don't understand and I belly laugh until I don't care :-)

I hope that I can be half the doctor that my IMG co-residents already are. When I answer that question of "So... what do you like about your residency program?" I hope my initial meek answer of "the people" doesn't get ignored. Because what I really mean to say is that I work alongside the most diverse, bright, hilarious group of humans and I wouldn't trade them for anyone else. American or (probably) not, these are my people! To my co-residents-- thank you for being my greatest blessing in training. I love each and every one of you <3


Shanny DO



For Better or for Worse, We'll Be There.

I'm not the first to talk about this, but I'm certainly feeling the most emotional reaction to it after reading hundreds of responses to my simple question for healthcare providers: "What's the most ridiculous personal scenario in which you have still shown up to work?" 

Not only was the quantity of responses alarming, but also the range and severity of situations. From family emergencies, death of a close loved one, natural disasters, and most frequently, severe/debilitating illness, healthcare providers are frequently putting themselves at both physical and emotional risk by coming to work. We candidly speak about the affects that certain health conditions can have on "absenteeism," or missed days of work due to illness, but perhaps in the case of healthcare we should be speaking about "presenteeism."  How does showing up to work under dangerous and extraordinary circumstances affect our caretakers and our patients? And why does it happen in the first place?  Over the next few stories that were so kindly shared with me (kept anonymous and some with paraphrasing) , I hope to unravel the "why" and put out a plea for solutions. 

1. "I'm a physician assistant in the Emergency Department and went to work 5 shifts in a row with flu symptoms.  I felt terrible but we have such a hard time covering night shifts as it is; I couldn't let people down. I wore a mask and kept Tylenol in my system the whole time. We just do what we need (or think we need) to do."

 Just a little infographic from a wonderful study that really highlights a major problem.

Just a little infographic from a wonderful study that really highlights a major problem.

I received a rendition of this story several times, many of them with a similar sentiment-- the desire to not let people down or put others in an "unfair" position.  We feel such a strong commitment to our team that we try to be the hero, even if it's self-detrimental.

2. "When I was pregnant with my daughter I was diagnosed with a subchorionic hematoma and told I would most likely miscarry. I was sent home to rest with plans for repeat ultrasound later that week. This was very scary, but I BEGGED to go back to work. I work as a nurse practitioner in a 'high needs' area where people have very little access to healthcare. While I was worried about my baby I felt like I HAD to be at work. I returned, and went into preterm labor multiple times and had many days where I would lay on my office floor with my feet up in between patients." 

To the non-medical personnel, this one might seem absolutely ludicrous. But this is a perfect testament to what so many of us feel-- an intense and unrelenting responsibility for our patients.  I imagine a million thoughts running through her head regarding the wellbeing for those she cares for, and how her "situation" may be letting them down.  [For follow up, just wanted to let you know that this NP and her baby are both healthy and doing fine! But, that's besides the point. It sucks she ever felt that way.]

3. "I'm an RN.  I have gone to work multiple times running a fever, or with a nasty cold/cough, because our policy is no more than 3 call offs in 6 months. Any more than that requires discipline.  I have accrued loads of days for paid time off, but am afraid to use it in the event of a "true emergency."

This one hurts too.  Aside from a commitment to our team and our patients, there is sometimes fear for discipline if we use the small amount of dedicated 'sick days' allotted. There is a nagging threat of your job being at risk, despite the possibility of factors outside your control.  As another person who messaged me so eloquently said, "no one should have to worry about facing disciplinary action if they make the responsible decision to protect their patients from infectious disease." In another beautifully written email that outlined an unfortunate series of health events, one nurse had to put her entire wellbeing on the line for the sake of keeping her job, almost all of it seemingly preventable had there been a more compassionate method of management and work organization.

4. "I took an exam in med school 1 week after giving birth. Hard chairs and long exams are no fun postpartum!"

Well, are exams ever really fun? Let alone, 1 week post-partum! Even our earliest medical students feel a pressure to show up, regardless.  I recognize this isn't unique to careers in healthcare when it comes to education, but in a field that requires so much compassion- maybe it ought to be. Medical students and residents are in a particularly challenging scenario because of a pressured timeline; residency programs start July 1st. End of story. Even the smallest delay in training can set you back an entire YEAR. 

5. "Found out I failed step 1 [US medical school board exam] at the beginning of clinic and had to stay and work through the rest of the day.  Took a call with one of the school Deans in between patients crying on a bench outside the hospital.  Then I wiped my tears and went back to clinic.  My attending asked if I was in 'trouble" and I laughed and went to see my next patient."

This feeling of commitment isn't just limited to practicing clinicians, but it perpetuates early on that there's never a good enough excuse to grieve or react.  For context, failing Step I could be considered one of the most devastating situations in a medical student's education with severe effects on someone's career outlooks. For the protection of this person's mental health, having an environment where it's appropriate to step away (especially when you're still a student and not technically essential to patient care) could really make a difference in how we nurture and support new generations of providers. 

6. "As an intern I worked a 12-hour ICU shift with the flu. I was having active chills and my nose was running to the extent that my mask was getting wet.  Instead of being told to go home by the ICU attendings and fellows I was told to change my mask.   At the end of my shift I went to Walgreens to get my prescription for Tamiflu (called in by a 3rd year resident who could see how sick I was) and a thermometer. My temperature was 102.3 on Advil."

An intern, the "bottom of the totem pole," is just expected to grin and bear it.  Sometimes we're able to hide our illness, and thus it's a self-infliction to work while sick. But I received so many of these stories too-- evidence of severe (and obviously contagious) illness being observed by peoples' bosses and superiors, yet being told to suck it up. Another resident physician wrote saying, "We have this book we get as interns that have phone numbers, key codes, etc., and a nice little note that says 'Never Call in Sick Unless You're Dying.'"  To me, this is abuse. Not only to the interns, but the potential risk to all of the patients exposed. Higher-ups, we HAVE to do better. End of story.

7. "Last year when I was an intern [at a hospital in Florida] I was working during the worst hurricane of the year. Half of us were on an evacuation team and the other half were on lockdown at the hospital.  I was on the evacuation team and I was evacuated to Tampa around 10pm. They called the "all clear" around 2am and I got a text saying I had to be back at work at 7am as usual. So I had to turn around at 2am and drive back across the state in a tropical storm."

Many reached out about the impossible scenarios surrounding natural disasters. This one's a tough one for me to swallow-- on the one hand I feel for anyone who is putting their own life at risk for the sake of their job. On the other hand, who else can care for the sick and injured in a time of crisis? We signed up for an incredibly demanding career, and on occasion it's going to be impossible to evade situations like this. The best I can hope for is that the hospital or employer does everything in their power to ensure the safety and care of its providers.

8. "I went to work while my sister was dying of cancer in the ICU. I am a hematology/oncology fellow. I live that day everyday."

And this is one that just broke me. The simplicity, sincerity, and pain that could be palpated through this message was just too much. And unfortunately it's not an uncommon story- I received a few other stories similar to this one. We are so used to seeing suffering, that we feel able to work through the most devastating personal tragedies. On a personal note,  I remember thinking how strangely fortunate it was that my beloved step-mom died during my vacation week. It meant that I could fully be there with my family. I knew that if I were working, there's no way I could have made arrangements to be gone for more than a day or two, maximum.  My heart aches for anyone without the appropriate time to grieve.

9. "I went to work as a physical therapist 4 days after having knee surgery. *Shakes my head.* "

It's like that old saying about the plummer with leaky pipes in their home.  I feel like we're particularly the worst at caring for the area we know the best! Maybe it's the feeling of being comfortable with what happens when we push the limits.  Along those lines, the number of people writing in saying they worked through entire shifts with broken limbs was quite astonishing. Either way, we can do better at this whole self-care thing. 

10. "A few months ago I left my 16-month old at home with a terrible upper respiratory tract infection and conjunctivitis which I obviously caught too.  But I was on call with no back up resident, so I came in for in-house 24-hour call generally feeling awful.  I was a walking germ! But the self-guilt and expectations are deeply seated."

I picked up on this theme across all professions-- nursing, nursing assistants, doctors etc., that there is a lack of back-up.  In a field so dependent on a workforce for life or death care, why are so many people left feeling like they're the only one available? That in the event that they are putting their patients at risk, they have no choice but to accept it and work it? Another common theme I got from this message and many others, was the inability to be there for our families due to work's extenuating circumstances.  A wife being unable to get to her husband whose truck got stranded up in the mountains. So many parents having to leave their very ill children in the care of others. And many having to leave their sick parents in some far away hospital while they continued caring for strangers.

When I first asked this question, I expected the majority of rationale in showing up to be self-inflicted, meaning that the individual felt such a strong sense of pride to "bear through it" and be the hero.  While this was definitely a common underlying motive, I was more alarmed by the other factors: fear of discipline and lack of compassion from bosses, fear of gossip regarding laziness or lying about their circumstances, and by far the worst-- fearing that in their absence, patients' lives may be put at risk due to not enough staffing or coverage.  Don't get me wrong, I also want to make it clear that for every absurd scenario that people showed up, there's probably so many of other moments in which people felt supported by their coworkers and in a position to take time off. But more often that what's acceptable, that simply isn't the case.

In a vicious circle, as a consequence of health problems caused by burnout, workers may not reach the desirable performance at work, which in turn may lead to increasing levels of emotional exhaustion. The worker’s weakened health along with his/her diminished functional capacity may lead to absenteeism, a great cause of concern for the worker and the organizations that has both social and economic consequences.
— Salvagioni et. al., Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies. PLos One. 2017

People outside of healthcare might have a simple question: "If it's so tough and unforgiving, why don't you quit? No one is forcing you to be there."  See, the problem with this question is it's truth; for hundreds of reasons, more clinical providers are opting for non-clinical roles in hopes for improved quality of life. But the more we allow for a culmination of toxic environment that lacks the support for self-care and backup, the deeper we'll dig into the hole of the problem.  More people quitting = less healthcare providers = a vicious cycle of creating an unsupportive environment.  There's a remarkable paper published last year on all factors contributing to burnout, and it's one of the first meta-analyses to really touch upon this concept of "presenteeism" (see quote, and click here for full source.)

Instead of quitting, we need to advocate for our caretakers.  And that advocacy starts with every single one of us right here right now, reflecting on our attitudes toward this issue. Really sit and think about how you'd feel about calling in sick if you developed a violent stomach flu tonight.  What factors are supporting you or holding you back from taking a day off to heal and protect your patients?  Now, sit and think about the other scenario: a busy schedule or jam-packed unit and a co-worker calls out sick. What's your immediate reaction? Is it a feeling of understanding, and a desire to reach out and support them? Or do you feel personally offended and angry at how this will affect your own work day? Do you join in on the sighs and groans with other co-workers when you hear the news?

We can't change management or policies overnight, but we can certainly halt any underlying micro-aggressions running rampant within yourself and your work environment. If you're reading this and you ARE a clinic/unit manager, an attending, or anyone else in a position of power, I want to first say I know your job is incredibly demanding and that the healthcare system has not done you any favors. But you are in control of your reactions and responses to others' extenuating circumstances. Let's aim to make them all supportive-- everyone here works too damn hard for anything less than that.

In summary: healthcare is tough for everyone.  Be kind to others, go out of your way to provide support, be in tune to your self care needs.. and if you have the flu, stay the hell at home. Doctor's orders ;-)


Shanny DO