“Looking Back While Moving Forward: Observations on IMG Education and IMG Faculty Development by a...

“Looking Back While Moving Forward: Observations on IMG Education and IMG Faculty Development by a Psychiatric Educator” Nyapati R Rao, MD.,MS

ChairmanDept of Psychiatry and Behavioral

ScienceNassau Univ Medical Center

Prof of Clinical PsychiatrySUNY-Downstate Medical Center

Unpublished work © 2008 Nyapati Rao

LOOKING BACK

My presentation is based on my experiences as an IMG resident and as a training director for 13 years in a community hospital and later for 6 years in a medical school

I believe that academic psychiatry is only a state of mind-not an exclusive model of practice of Psychiatry determined by the institution.

IMGs are eminently educable given proper structure, sensitivity and support


Reactions to IMGs Char states that these residents (IMGs) are “accepted

into a training program as ambivalently valued objects. The foreign resident is valued because he is needed to fill the critical shortage of residents, and to satisfy our ‘missionary’ need to train foreigners, but he is rejected because of his handicaps”. He adds that overt rejection, subtle rejection, denial of reality, and combination of the above three may form the reactions of training programs to IMGs much like the response of parents to their handicapped child.

Char W: The Foreign Resident: an Ambivalently Valued Object. Psychiatry; 1971 (34): 234-238


Language Proficiency of IMGs

Mittel states that “it is a striking comment on the lack of sophistication, the intensity of motivation, or the cynicism of these trainees that they should choose to pursue a specialty where their language difficulty may

be more crucial than any other.”Mittel N. Training psychiatrists from developing nations. American Journal of Psychiatry 1970;126: 1143–1149.


EVENTS INFLUENCING FIRST TIME IMG RESIDENTS 1950-2002

0

1,000

2,000

3,000

4,000

5,000

6,000

1950 1960 1970 1980 1990 2000


Post Post WW II WW II

demanddemand

19981998

CSACSA

Period of Period of medical medical school school

expansionexpansion

1976 1976 Health Health

Professions Act Professions Act restrictionsrestrictions

19911991Increase in Increase in H1b VisasH1b Visas************************Proposed Proposed

exam exam changechange

19851985COBRA COBRA

restrictionsrestrictions**************************************************

Medicare IMEMedicare IME

Richard Cooper

Rao NR: Recent Trends in Psychiatry Residency Workforce with Special Reference to IMGs:Acad Psych 2003: 269-276



IMGs in American Psychiatry

They comprise 30.5% of General Psychiatric

Residents, 32.8% of Child, 42.5% of Addiction

and 61.7% of Geriatric Fellows. 23% Forensic; 50% Psychosomatic

Fellowships 27.5% of members of the American

Psychiatric Association. Brotherton SE, Etzel SI: Graduate Medical Education, 2007-2008. JAMA.2008; 300(10):1228-1248 Unpublished work © 2008 Nyapati Rao

Professional Activities of IMGs The vast majority of IMGs, are engaged in direct

patient care. Smaller percentages of IMGs are engaged primarily

in research, medical education, or medical administration.

17% of full-time MD faculty at U.S. medical schools are IMGs.

Among the 1,941 U.S. medical school department chairs with medical degrees, nearly 11% are IMGs; more specifically,

Some 17% of department chairs in the basic sciences and close to 10% of department chairs in the clinical sciences are IMGs.

Cohen JJ: The Role and Contribution of IMGs-A US Perspective: Acad Med 2006; 81 (12): 517-521


Why Study IMGs Background? It will provide a foundation from which to

effectively teach psychosocial content and other material not commonly addressed in non-U.S schools.

Through appreciation of the values and worldviews of those trained outside the United States, faculty may have a broader context to consider and evaluate IMGs

“Differences in educational process and content are simply differences and are not inherently superior or inferior”


Presentation-Outline

Major differences between foreign medical systems and the US will be examined based on a qualitative study in Academic Medicine that looked at the Behavioral Science Background of IMGs.

Culture’s influence on IMGs’ performance will be highlighted: the impact of migration, and culturally determined expectation of student-teacher relationship called “Guru-Hunger” will be discussed.

Discussion of training implications and recommendations will conclude the presentation.


Presentation-Outline

Faculty in the US who understand this “Guru-Hunger” as well as the impact of migration on IMGs will be better able to draw out the best in them.


Interview QuestionsPlease describe your training in your country in the following

areas: Behavioral Medicine/ Psychiatry Common disorders such as anxiety and depression Physician-Patient relationship Mental Health history gathering

What is your understanding of American cultural practices such as child rearing, marriage or cohabitation?

Have you experienced any challenges in your adaptation to the US?

Searight HR,Gafford J. Behavioral Science Education and IMG. Acad Med. 2006;81:164-170


Beh Med/ Psych Training Before the US Training

“Medicine was the focus. . . . You didn’t really study psychiatry unless you were planning to choose it as a specialty.”

“We looked at locked-up people all the time. It was a crazy hospital. We did not interview patients; we just walked through. It was like looking at specimens”

Searight HR,Gafford J. Behavioral Science Education and IMG. Acad Med. 2006;81:164-170 Unpublished work © 2008 Nyapati Rao

Medical Interviewing Training

“We had no formal training. Nobody taught me how to talk to patients”

“We had a semester course in medical school with lectures about how to take the interview. Then, we would divide into groups of 10 or so, and 10 of us would have one patient, and we would do the interview”


Doctor-Patient Relationship

“In India, the doctor is Godlike. “The doctor cured me, saved my life, my God…Whatever my doctor says that’s enough”

“Patients don’t ask questions. I am the physician-if you are coming to me, my rule goes”



Perceptions of Family Life in the US

Respondents were surprised by U.S. family dynamics, child-rearing methods, and marital issues.

A common theme was that social and family problems were often converted into medical conditions.



Perceptions of Family Life in the US

The dyadic marriage contract was seen as isolating. Back home marriage is often a union of two clans or extended families.

Similar to child abuse, partner violence was seen by some IMGs as appropriately handled by the extended family rather than the medical-legal system.


Specific Challenges

Documentation and charting formats

Interdisciplinary relationships Need to prove themselves to

faculty: under closer scrutiny than USMGs



Factors influencing Performance of IMGs

Difficulty with language Differences in medical education background Time since graduation from medical school

and the last clinical experience Different life stages with attendant family and

financial obligations Traumatic experiences as refugees Cultural differences

Bates J,Andrew R:Untangling the Roots of Some IMGs’ Poor Academic Performance. Acad Med. 2001;76:43-46


POSSIBLE Differences in Previous Education

Hierarchical structure Lecture-based format Process of clinical reasoning Patient presentation format Less contact with patients, or limited by

age and gender Acknowledgment of knowledge or skill

deficits Deference to teachersAFMC: Curriculum on Training the Trainers of IMGs


Culture Shock- Garza-Guerrero

“ A reactive process from the impact of a new culture upon a newcomer ”

A violent encounter that challenges the stability of the personality of the immigrant..

Who faces a very “stressful and anxiety-provoking situation” accompanied mourning brought on by “gigantic loss of a variety of love objects”.

The co-existence of these two factors causes a serious threat to the newcomer’s identity. Growth occurs when this crisis is handled successfully.

Garza-Guerrero, A. C. (1974). Culture shock: its mourning and the vicissitudes of identity..J. Am. Psychoanal. Assoc., 22:408-429


Migration- Third Individuation

Akhtar notes that migration has lasting effects on individuals’ identity ( the Third Individuation): involving the dimensions of drives and affects, psychic space, temporality, and social affiliation.

Akhtar, S. (1995). A Third Individuation: Immigration, Identity, And The Psychoanalitic process ... J. Amer. Psychoanal. Assn., 43:1051-1084.


AAP-Poster-Culture Shock

Method/Design: Using a cross-sectional design, an anonymous survey was administered to 139 residents in all 9 specialties at a community teaching hospital in southern West Virginia. The survey included measures of culture shock, cultural distance, burnout, anxiety, anger, depression, fatigue, quality of life and social support.

Conclusion: As expected, IMG-Other experienced the highest level of culture shock and distance. Contrary to our hypothesis, IMG-Other reported the lowest levels of burnout and fatigue, with social support and quality of life comparable to the US residents.

Siddhu K.A, Sirbu C: Comparison of International and US Medical Graduates on Adjustment to Stress During Residency: some unexpected findings-AAP Poster 9/26/08


Culturally Appropriate Modelsof the Mind

Alan Roland (1984) states that different inner psychological development and emotional cognitive structures are necessary for functioning effectively in Indian Group and family relationships governed by cultural principles of hierarchy. This is in sharp contrast to those necessary for adapting to relationships based on the more egalitarian-contractual principles of American individualism. Inner psychological structures that are highly congruent and adaptive in one society and culture will often not be so in another. Based on extensive psychoanalytic work in India and Japan, he proposed that there are three aspects to the self in these cultures, as opposed to the single dimension in the West. They are: the family self, individualized self, and spiritual self.

Roland A. Psychoanalysis in civilization perspective: the self in India, Japan and America. Psychoanalytic Review 1984; 71: 569-590


Psychological mindedness

The Western type of introspection, called “psychological mindedness,” in which “the definitions of self and of identity become contingent upon an active process of examining, sorting out, and scrutinizing the ‘events’ and ‘adventures’ of one’s own life,” is alien to many Asian cultures where.

The introspective activity focuses on a self “uncontaminated by time and space and thus without the life historical dimension which is the focus of psychoanalysis”

Kakar S. Shamans, Mystics and Doctors – A Psychological Inquiry into India and Its Healing Traditions. Boston, MA: Beacon Press 1982.


Additional material on culture & IMGs The influence of culture on learning

of psychiatry: the case of Asian-Indian international medical graduatesNyapati R. RaoInternational Journal of Applied Psychoanalytic StudiesVolume 4, Issue 2 , Pages128 - 143Copyright © 2007 John Wiley & Sons, Ltd.


Guru-Asian Traditions

In many Asian teaching traditions the teacher is viewed as a friend, philosopher, and guide with parental commitment to helping his pupil. In his search for similar teachers, the IMG may be oftentimes disappointed by teachers who may view his demands as dependency needs immaturity, and childishness.


Guru in the West

Highly controversial Became popular in the 1960s: The

Beatles and Mahesh Yogi Seen mostly as manipulators,

psychopaths, psychotics Many Gurus accused of forming cults

and sexual exploitation; flamboyant life styles

Considerable misunderstanding Unpublished work © 2008 Nyapati Rao

Qualities of a GURU

The word guru is derived from two roots-gu:darkness, ignorance; and ru: complete annihilation

It has twin connotations: Educational as the teacher and in the spiritual realm as the preceptor

Hindu texts refer to him as a purusa (person), tattva (principle) or as sabda (word)

Neki JS. Guru-chela relationship: the possibility of a therapeutic paradigm. American Journal of Ortho Psychiatry 1973; 43: 755–766.


Qualities of a GURU

He is expected to be of noble birth and pure disposition know the scriptures, be competent in Yoga and have his senses under control.

Manu, the Law-giver says:” the guru who imparts knowledge of the Self is greater than the father and even the mother, for, while parents give a physical body, he gives the spiritual, eternal body”



Guru

Important truths don’t come through study of books or contemplation but as a result of inherited wisdom handed down from inspired gurus.

Many meditative techniques require expert guidance Similar expectations exist in Islam-Pir; Japan Sensei The guru does not teach, but trains, imparting the

disciplines of persistence and silence He often asks than answers questions He fosters dependency



Guru-Hunger Guru Hunger is defined as an unconscious yearning for

connection with an idealized teacher who is expected to pay attention to the educational/personal well -being of the student.

Occurs in mostly non western group oriented culture where teacher is an idealized figure.

IMGs from Asian cultures experience this in their interaction with their supervisors. This manifests itself as dependency needs.

When the supervisor recognizes it without condemnation, leads to growth in the student.

When it does not happen, it results in student’s disappointment and consequent withdrawal.


Ekalavya- A story from Mahabharata

In the Hindu epic Mahābhārata, Ekalavya (Sanskrit: एकलव्य, ékalavya) is a young prince of the Nishadha tribes, and a member of a low caste, who nevertheless aspires to study archery in the gurukul of Dronacharya. After being rejected by Drona, Ekalavya embarks upon a program of self-study in the presence of a clay image of Drona. He achieves a level of skill equal to that of Arjuna, Drona's favorite and most accomplished pupil. Fearful that Ekalavya will excel him, Arjuna begs Drona to take action. Drona goes to Ekalavya and demands that Ekalavya turn over his right thumb as a teacher's fee. The loyal Ekalavya cripples himself, and thereby ruins his prospects as an archer, by severing his thumb and giving it to Drona.


Ekalavya


Recommendations


IMGs Adaptation to Medical Culture

IMGs are often times confused by the laissez- faire atmosphere that exists in US training programs with the consequent feeling of abandonment

IMGs are used to more structured training and exams.

Many enter psychiatry without much support from their families

Giving up tools and rituals of clinical medicine causes anxiety and depression :culture shock


Residency Selection Medical school transcripts & reference letters useless Use such stringent criteria as high USMLE scores to

screen applications. Use questions from the paper we discussed earlier Set a rigorous assessment of candidates’

psychosocial skills- Vignettes from : “the Sopronos” Nyapati R. Rao, Arthur E. Meinzer, and Sheldon S.

Berman :Perspectives on Screening and Interviewing International Medical Graduates for Psychiatric Residency Training ProgramsAcad Psychiatry, Dec 1994; 18: 178 - 188


Programmatic Approaches

Organize a rigorous multi-source evaluation system

PRITE and Clinical Skill Assessment crucial PRITE forces residents to study and prepares

them for the Boards Elevated self-esteem that comes out of the

process is immeasurable in counteracting immigration induced dysphoria

Similarly, regularly conducted Clinical Skill Assessment provides concrete evidence of worthwhile engagement in America


Programmatic Approaches

Clear articulation of the program’s expectations for participation, feedback, work ethic, and commitment

Clear articulation of policies regarding performance evaluation

Offer help with language instruction Don’t make exceptions, hold them to

the same standards as USMGs


Psychotherapy Training As An Acculturating Tool

The concepts of psychotherapy are intimately related to the concepts of DPR.

Improves communication and writing skills. Improves interviewing skills Great instructional tool for management of ethical

conflicts Model for other dyadic relationships Through analysis of Countertransferential

enactments, one obtains greater access to one's own Ucs issues, thus ameliorating culture shock

T-Groups, Training supervision; Personal Psychotherapy and Psychoanalysis; consider CBT


Training Supervision- J. Borus

Training supervision is a longitudinal, nonclinical focused personal relationship between a faculty member and a resident for exploring the latter’s professional development. The training supervisor’s role is that of a non evaluative senior colleague who orients and advises the resident and systematically reviews training progress and problems.

(AM J Psychiatry 139:1339-1342, 1982)


Other Acculturation Tools

ECFMG The IMG Institute


ORIENTING TEACHERS AND IMGs

Part A: Orienting Teachers – Understanding the IMGs’ WorldPart B: Orienting IMGs – Understanding the Canadian Health Care System and Learning Environment-AFMC

A Faculty Development Program for Teachers of International Medical Graduates-AFMC


Supervision of IMGs

Engaging the IMG may not be easy Win Trust: Concerns about revealing self due to

immigration, program’s issues Focus on self-esteem; inquire about previous

experiences Assess the candidate’s social support system Assess expectations of the training director as

a Guru


Teacher Questioning-AFMC

“Teaching is not telling but questioning.”

Wilkerson, Armstrong, & Lesky, 1990

“The process of how we learn as physicians eclipses and surpasses the

content of any factual data.” Orientale, 1998

IMGs should be cued to the variable questions that teachers may ask


IMGs-Feedback

Utilizing feedback is a crucial skill in the development of lifelong learning

Feedback can identify both gaps & strengths

The inaccuracy of self-assessment

The differences between formative and summative evaluation

Feedback will often be delivered in a ‘sandwich’

AFMC Unpublished work © 2008 Nyapati Rao

Feedback Sandwich

What was done right

What was done wrong or needs to be improved

What to do next time

AFMCUnpublished work © 2008 Nyapati Rao

The “Bottom Line”

Both feedback and evaluation can be areas of significant difficulty for some IMGs. You need to understand that these processes will not only include factual knowledge but also clinical reasoning, communication skills, self-directedness, reflection and critical appraisal

AFMC Unpublished work © 2008 Nyapati Rao

Faculty Development Resource Poor

Department

• Substantial clinical load, lack of discretionary professional time, lack of support staff, lack of research infrastructure, lack of research environment, inflexibility in the department, lack of enthusiasm and support from colleagues.

• Most senior faculty in resource-poor department lack appropriate research training themselves.

• Increased sub specialization, is not always encouraged in departments with heavy clinical loadDevoting time to research the other creative scholarly activities may result in a loss of departmental or institutional income.Bakhai Y, Halbreich U: Development of Junior Faculty in Resource-Poor

Departments of Psychiatry. Acad Psych 1993; Summer


Research Careers and IMGs-Research Careers and IMGs-ObstaclesObstacles

CSA exam may be prohibitively CSA exam may be prohibitively expensiveexpensive

Visa requirements may prevent pursuit Visa requirements may prevent pursuit of research careersof research careers

IMGs on temporary or student visas are IMGs on temporary or student visas are ineligible for awards, training grants etcineligible for awards, training grants etc

IOM committee recommended declaring IOM committee recommended declaring research training and research-activities research training and research-activities federally underserved disciplines.federally underserved disciplines.


IMGs Career Development Strategies

Learn the difference between a career and a job Seek advice from mentors outside your program Join professional organizations; develop an area of special

interest Learn psychotherapy-it has acculturating value in addition

to helping you with clinical practice Complete the Boards Remain open to the culture at large- do not limit yourself to

your ethnic group physicians Be prepared for professional rejections and learn from each Read Joel Yager’s Paper” Many Quests of Psychiatrists: How

Well Can We Fulfill Them” from Acad Psychiatry; 1990


Mentorship

Proper fit may satisfy the search for a Guru Useful if the mentor is from a different program Especially helpful to launch a research career Mentorship was reported to have an important

influence on personal development, career guidance, career choice, and research productivity, including publication and grant success. JAMA. 2006;296:1103-1115

Women and IMGs may have difficulty in finding mentor.


“The Cow Path to America”Abraham Verghese, The New Yorker, 6/23/97, pp 70-88

“Sir, craving your indulgence, I want to train in a decent, ten-story hospital where the lifts are actually working. I want to pass the board-certification exams by my own merit and not through pull or bribes. I want to become a wonderful doctor, practice real medicine, pay taxes, make a good living, drive a big car on decent road, and eventually live in the Ansell Adam section of New Mexico and never come back to this wretched town, where doctors are as numerous as fleas and practice is cutthroat, and where the air outside is not even fit to breathe”


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