IMGs: More Than Meets the Eye

Recently a fellow resident seemed surprised to learn that I am actually a foreign-trained doctor. This was met with equal surprise on my part, as I had never considered myself to be “different” in any way, although I had emigrated from Canada. On further reflection, perhaps I was taken aback as I had denied the differences between training in Canada and the States and focused on the similarities. Maybe I even repressed the fact that, despite my prior family medicine residency in Canada, I had to restart training from my internship year to ensure future U.S. board eligibility in psychiatry.

I suppose I am not an international medical graduate (IMG) by the strictest definition, but I feel this to be an artificial distinction. Although being considered foreign by my fellow resident was not ill intentioned, it did give me pause. I began to question how IMGs are perceived and their increasing role and importance in psychiatry residency programs and the field of psychiatry overall.

Debates concerning IMGs have existed for decades, starting with a climate of relaxed immigration policies in the 1960s, which addressed physician demand at the time. Public policy and attitudes toward foreign-trained physicians have waxed and waned ever since, as concerns regarding physician oversupply emerged. As a result, IMGs may face many obstacles such as barriers to immigration, assiduous application procedures to residencies, and more stringent criteria for licensure to fill medical positions.

There is a broad range of attitudes toward IMGs, which reflects a general sense of ambivalence among physicians. While some doctors may perceive IMGs as coworkers who share the profession, others may view them as competition. Some IMGs themselves are reluctant to be lumped together and labeled as a group, with a concomitant loss of individuality. Rather, they are multifaceted and unique physicians who have simply trained in countries outside the United States.

Endurance to withstand immigration and multiple examinations selects out those more motivated, diligent, and goal oriented from the pool of foreign-trained physicians. Often these doctors have undergone a career change and received additional training in other specialties in their native country, and this brings an added dimension to their patient care. At times they bring additional psychiatric views from their country of origin, which, combined with American training, enriches their vision and conceptualization of cases. Certainly in my opinion, these characteristics serve to help form a well-rounded physician.

Numerically, the AMA 1999 Census of Graduate Medical Trainees showed IMGs to be very significant, with more than 40 percent of psychiatry residents being foreign trained. I was pleasantly surprised to learn (from analyses of the 1996 Survey of Psychiatric Practice) that nearly two-thirds of IMGs in psychiatry are women, which contrasts with many other specialties. This coincides with a similar trend among U.S.-trained psychiatrists and may help further strengthen the voice of women psychiatrists in American psychiatry.

IMGs are also a more varied group than U.S.-trained psychiatrists in terms of race and ethnicity. This information parallels recent national census data showing the United States to be a “melting-pot” society with a trend toward racial and ethnic diversification. Reflecting these changes by a corresponding increase in the ethnic diversity of psychiatry residents would thus have positive effects. Foreign-trained psychiatrists help increase representation of minority groups within psychiatry.

Coming from many diverse backgrounds, IMGs may help bridge cultural and ethnic barriers. Cultural competency, which includes the skills to understand cultural differences between groups and their presentation of mental illness, is of particular relevance to psychiatrists and their patients. Residencies increasingly support the development of such skills, and requirements to do so are evolving. There is no one better to understand patients (and help teach other psychiatrists to do so) than physicians who share similar backgrounds with their patients.

Sensitivity to and familiarity with the ethics of a culture and its attitudes regarding mental health are vital. Patients from groups with greater cultural prejudices about seeking psychiatric treatment might feel more comfortable being treated by someone from a similar background, thereby reducing the occurrence of their being underserved. If it is taboo to shake hands with a member of the opposite sex due to religious reasons, who better to understand than a doctor from a similar culture?

Lastly, speaking the same language greatly facilitates the interview process and increases the detection of subtle details that might otherwise be missed through translation.

While I understand the notion of supply and demand and the anxieties over future physician oversupply, I believe that training more IMGs would actually benefit our field. With the current immigration climate, many foreign-trained doctors must return to their countries of origin after receiving their training and having provided service in their teaching hospitals. Those who do remain in the United States seem to work in different settings. Psychiatrist IMGs who stay in the United States after residency tend to focus their practice in particular areas, such as in public psychiatry, groups with limited access to care, and the chronically mentally ill. They tend to treat minorities and underserved populations, sometimes in remote geographical areas that may place added burdens on them but enable them to remain in the country.

There have been arguments to reduce the growth of the physician supply by decreasing the numbers of IMGs. This would have a negative impact on mental health care, particularly for poor, underserved patients. Recently nonmedical practitioners had cited a reported paucity of psychiatric services in underserved areas as supporting their attempt to extend their scope of practice to include prescribing medications. Thus, ensuring the availability of psychiatrists might actually protect our specialty and safeguard the quality of mental health care.

I can’t help but think back to so many of the historical figures in psychiatry and how they received their training in other countries. How different would things be if they were working in America today? I believe that enlarging the IMG portion of the psychiatric workforce would greatly benefit the future of our specialty in many ways, but especially by enabling us to maintain accessibility of psychiatric care. As I reflect on my personal situation as a Canadian-trained doctor, I realize that although I do spell some words a little differently and had to use the spell-checker several times while writing this piece, the language of medicine should be more universal than that. ▪

Dr. Reinblatt is a chief resident (PGY-4) at Hillside Hospital–Long Island Jewish Medical Center in Glen Oaks, N.Y. She is also the MIT representative for the Queens Psychiatric Society and the Assembly’s MIT representative for Area 2.