Everyone is created equal—but some people need to be "more equal than others."

Which is why international medical graduates (IMGs) may need to work harder and be more resourceful in seeking out opportunities in training if they are going to be successful within American psychiatry, said Mantosh Dewan, M.D., distinguished professor and chair of the Department of Psychiatry at Upstate Medical Center in Syracuse, N.Y., and winner of the 2010 George Tarjan Award.

In a lecture last month at APA's Institute on Psychiatric Services in Boston titled "Imagine: The Untapped Potential of IMGs," Dewan said discrimination is undeniably a part of the IMG experience in America, but it should not be blamed for every setback faced by residents and early-career psychiatrists who received medical training in other countries.

"I have no doubt that for IMGs discrimination is real—not a lot, not always, not everywhere," said Dewan, "But there is an element of that."

He recounted his own experience coming from Bombay, India, to train in the United States at Syracuse, which he described as very positive. But when applying for a job in the South following training, Dewan said he felt the sting of bias. "What I pledged to myself was that I would have to be ‘more equal than others,’" he said.

"Very often when IMGs get together, they blame every setback on discrimination," he told attendees. "And that is simply not true. There is no doubt that some people are better qualified than you. So if you don't get something, it is a fallacy to complain that it is always because you are an IMG."

Dewan added, "If you must be discriminated against, America is by far the best place for it" with abundant opportunities that do not exist in other systems. IMGs have thrived in American medicine in ways they could not in other countries, and there is no question that they can provide care of a quality on a par with that provided by American-trained colleagues.

Dewan referenced a study in the August Health Affairs that analyzed mortality rates for 244,153 hospitalizations in Pennsylvania among patients with congestive heart failure or acute myocardial infarction. The study, "Evaluating the Quality of Care Provided by Graduates of International Medical Schools," found that patients of doctors who graduated from international medical schools and were not U.S. citizens at the time they entered medical school had significantly lower mortality rates than patients cared for by doctors who graduated from U.S. medical schools or who were U.S. citizens and received their degrees abroad.

So rather than complain about discrimination, Dewan said, IMGs in residency programs will serve themselves far better by seeking out ways to make themselves "more equal than others"—through pursuing research opportunities and publishing, obtaining additional credentials through electives, taking on administrative jobs others are unwilling to do, and following other strategies that will make them attractive to employers.

Dewan's most strident criticisms were directed to the gap that exists in certification by the American Board of Psychiatry and Neurology (ABPN) among IMGs, a gap that he said is the responsibility of teaching programs—not the trainees—to rectify. (IMGs have consistently had only a 50 percent to 60 percent pass rate, and overall, psychiatry has had a lower rate of board certification than most other specialties.)

The result of the gap has been that in state and rural psychiatric hospitals, where salaries are significantly lower, the vast majority of psychiatrists are IMGs who are not board certified. "Many of them are dispirited because they don't see an option," Dewan said. "There is a palpable sense of demoralization because they have fewer job opportunities and lower salary. It is something we should not be tolerating.

"The differential in pay is something like $30,000 a year," he said. "Think about this young person who takes a state hospital job and is going to be working for 30 years losing $30,000 a year. I think it's unconscionable.

"It is our responsibility, the training program's responsibility, to teach so that we can get a 100 percent pass rate. We have failed in that."

But Dewan was also critical of the decision by the ABPN to phase out the Part II oral examination. Those aspects of clinical care that had been tested by the oral exam—the ability to relate to a patient, conduct an interview, and make a case presentation—will instead be assessed by training programs for documentation of specific competencies prior to a resident's being credentialed to take the new ABPN board exam.

Dewan asked his audience—composed of IMGs and educators—to predict the probable success rate under the new credentialing system, and there was general agreement that 100 percent of trainees would likely receive approval.

"Instead of addressing why 50 percent of these residents who were credentialed by their training programs as [meeting the training requirements to enter the certifying system] failed the [Part II] exam and improving our training efforts so that they can all pass, we are going to a system where we make no change, eliminate the exam, and get training programs to ‘pass’ or credential 100 percent of residents," Dewan later told Psychiatric News. "What we should be doing instead is setting very high standards and encouraging all psychiatrists to achieve them—not simply changing the standard."

Dewan related strategies that in his capacity as director of residency training and later as chair of the department he used to help increase the number of IMGs in training at Syracuse and to help them be "more equal than others." Among them:

"Everything we have been doing is good for American graduates as well as IMGs," Dewan said. "We should set universal high standards and help everyone—U.S. medical graduates, IMGs, and U.S.-born IMGs—achieve them."

He added, "What I would love is to be able to replace the phrase ‘there is a good IMG psychiatrist’ with "there is a good psychiatrist.’"

"Evaluating the Quality of Care Provided by Graduates of International Medical Schools" is posted at <www.ama-assn.org/ama1/pub/upload/mm/18/health-affairs-imgs-usmg.pdf>.