Recent Changes May Affect IMG Psychiatrists
Despite psychiatry’s growing need for their services, IMGs continue to face major career challenges, according to Nyapati Rao, M.D., chair of APA’s Council on Medical Education and Career Development.
“It is crucial that the APA membership as well as the leadership appreciate the extent of psychiatry’s growing dependence on IMGs and the potential impact of recent changes of exam and immigration policies affecting IMGs on the future of the field of American psychiatry,” said Rao at the February retreat for APA’s Council on Medical Education and Career Development in Washington, D.C.
According to Rao, the AMA’s Census of Graduate Medical Trainees showed that in 1999 more than 42 percent of the 5,682 residents in psychiatry were IMGs, or graduates of non-U.S. medical schools.
While many IMGs have made major advances in psychiatric research, particularly in neuroscience, psychopharmacology, and biological psychiatry and made other important contributions to the field, the vast majority have filled major workforce deficits in underserved areas of the country, continued Rao.
“Physician maldistribution is ameliorated by having IMGs in the system,” said Rao.
He believes that psychiatry, and APA in particular, has been welcoming to IMGs. “Many of APA’s leaders are IMGs,” he said. He named Rodrigo Muñoz, M.D., who served as APA president for the 1998-99 term, as just one example.
IMGs, however, face a number of challenges beginning shortly after they graduate from medical school.
On July 1, 1998, the Educational Commission for Foreign Medical Graduates (ECFMG) began to administer the Clinical Skills Assessment (CSA) exam for IMGs. The CSA requires that IMGs are able to elicit an appropriate patient history, perform a physical exam properly, demonstrate good interpersonal skills, and write an accurate account of the patient encounter. Administered in English only, the exam also requires that IMGs demonstrate proficiency in English.
To be certified by the ECFMG and enter an accredited residency program, IMGs must pass Steps I and II of the U.S. Medical Licensing Examination (USMLE): Test of English as a Foreign Language (TOEFL) and the CSA exam. However, while the USMLE exam is offered in nearly 500 test centers worldwide, the CSA is administered only in Philadelphia.
“This presents some major problems for the IMG,” said Rao, “due to the enormous expense involved in coming to the United States to take the CSA exam and the difficulties with obtaining visas.”
Rao also said that it is not easy for physicians from the developing world to obtain visitors visas to enter the U.S. to take the test.
In the four years since the CSA exam has been administered, the number of IMGs registering for the test has declined each year. According to Gerald P. Whelan, M.D., vice president of the Clinical Skills and Assessment Program for the ECFMG, the number of IMG registrations has dropped from almost 67,000 in 1997 to 27,000 in 2000.
Rao explained that due to the CSA administration, only 6,000 IMGs will be available to enter graduate medical education for all medical specialties beginning in the next couple of years. This number is much smaller than the current IMG pool available to enter residency programs, which contains between 12,000 and 15,000 IMGs.
If the CSA exam was held in foreign centers, as well as in the U.S., Rao indicated, more IMGs would be able to take the test and therefore be eligible to enter residency programs in psychiatry.
Reciprocity Not Granted
Another problem is that for IMGs, states do not permit licensure via reciprocity from another state, which is not the case with USMGs, according to Rao.
“Even those IMGs who are fully licensed and practicing medicine in the U.S. must undergo verification of their medical school credentials all over again each time they apply for a license in a different state,” Rao said. He explained that this process is time consuming and repetitious because the ECFMG also carries out an investigation of IMGs’ medical school credentials before certifying them.
Other Obstacles Common
Other barriers to the progress of IMGs in the U.S. are not so easy to identify. According to Rao, many IMGs believe that managed care panels do not readily accept them as members. “We must find out if any IMG organizations have studied this issue, and if this is found to be true, we must facilitate IMG inclusion on these panels,” said Rao.
Rao, who is also director of psychiatric residency training at the State University of New York–Downstate Medical Center Brooklyn, stressed the importance of a supportive and communicative relationship between IMG residents and their residency training directors.
“Because of cultural and communication issues with IMGs,” said Rao, “the training director needs to communicate very clearly his or her performance expectations to the IMG resident, as well as the consequences of not meeting these expectations.”
Further, training directors should address IMG performance deficiencies early in the residency and initiate remedial steps if necessary. These may include English language training, said Rao.
“The downside of not addressing these deficiencies with the IMG resident is that he or she is condemned to a lifelong pattern of professional underachievement,” said Rao.
One key aspect of resident training for IMGs, according to Rao, is psychotherapy training. “This gives the training directors a chance to address many issues with the IMG around acculturation, communication, and interpersonal relationships with the resident.”
Mentoring can also make a world of difference to IMG residents, in Rao’s view. “For IMGs, the mentoring opportunity provides them with a culturally sensitive, empathic experience where life and training issues can be addressed.”
Rao pointed out that the American Association of Directors of Psychiatry Residency Training (AADPRT) sponsors a highly successful mentorship program for IMG residents to help integrate them into mainstream medicine. ▪
