“Looking Back While Moving Forward: Observations on IMG Education and IMG Faculty Development by a Psychiatric Educator” Nyapati R Rao, MD.,MS Chairman.
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“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
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
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.
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”
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.
“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”
“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”
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.
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
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
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.
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.
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”
Neki JS. Guru-chela relationship: the possibility of a therapeutic paradigm. American Journal of Ortho Psychiatry 1973; 43: 755–766.
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
Neki JS. Guru-chela relationship: the possibility of a therapeutic paradigm. American Journal of Ortho Psychiatry 1973; 43: 755–766.
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.
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
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.
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
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
• 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.
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
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”