Dr. Davies Insider Scoop from Baylor, TX.

Advice for International Medical Graduates
Seeking Training in US Programs

Al Davies, M.D.
Associate Professor of Medicine
Baylor College of Medicine

The Financial and Political Picture.

I am the Director of our Critical Care Medicine Training Program, which is intimately integrated into the Pulmonary - Critical Care Medicine Program. I am also a member of the Internal Medicine Residency Selection Committee. Put together that means I am very familiar with the status of IMGs in American training programs. I am directing these comments to IMGs who are seeking either residency or fellowship positions in the US who have their own set of particular issues to resolve separate from routine applicants. You may be interested in the other documents I have included in the Medical Education and Training page in www.MediScene.com. A number of the issues I address in those documents would be quite applicable to IMGs.

IMGs fall in a special category of people in American society. Many hospitals, especially in inner city locations along the Eastern Seaboard have grown dependent upon the labor provided by IMGs which would be expensive to replace if staff physicians were used. IMGs are frequently the very best newly trained physicians in their countries, and may be on par with many domestic residents. This is particularly true when an IMG has already completed training elsewhere, has emerged as one of the most talented of the graduating class, and then applies in the US at the level of intern. Therefore, IMGs as a skilled portion of the labor force are welcomed by many. On the other hand, IMGs are only a very small portion of the recently rapidly expanding influx of people worldwide who for political or financial reasons find it appealing to come to the US. The influx of people has created some fear, some paranoia, and some legitimate concerns about how far the immigration can go before there is a breakdown of what it is that foreigners and domestic people alike seek in the US. Simply, the US can’t have the entire rest of the world move in and expect to have the same economic, political, and personal conditions as are currently the case. Therefore, there have been efforts at curtailing the availability of federal funds which can be used for IMGs. One such effort is now before the American Congress, and if passed as it now stands would eliminate IMGs entering the US for five years.

That may sound bleak to you, but it would be helpful to remember that for the last decade some group or another has tried to eliminate federal funding for any training of any physician of any type. These types of proposals fare very well among political groups whose themes are protectionist, but they never seem to find much support when the broader society sees them. As a general rule, the largest segment of American society is very fair, very giving, and very open to give newcomers a chance. Were that not the case, the IMGs who are here would be unable to work, and those who become citizens would starve from lack of patients. Therefore, before you panic and feel there is no chance for you, realize that Americans traditionally have a very big heart.

The current presidential election year will probably yield many forceful headlines in the newspapers, here and abroad. Always regard such headlines with skepticism. Most of it will blow over. At this moment most predictions are that the final election will be between Bob Dole, a moderate Republican, and Bill Clinton, the incumbent liberal Democrat. The candidates most aligned with protectionism are dropping in popularity. In the political system here, the composition of Congress has a lot to do with how smoothly changes occur. Most predictions now favor a modest move towards a more conservative Congress, but there is a good chance we will be keeping the liberal president. If that happens it would be unlikely that a truly immediate and universal discontinuation of federal funding for IMGs would occur. There may be only modest changes initially.

The reason federal funding is an issue is that most but not all training programs are heavily centered around Medicare funding. This is federal (central US government) money which pays hospitals to take care of people generally over 65. That subpopulation is the largest user of money even though they are not the largest subpopulation in America. Currently the federal funding can be used equally for an IMG and a domestic resident. Again, some people want to stop all federal money going to any resident. That is unlikely since it would probably eliminate most training programs. It would certainly severely hurt the best ones. Several proposals, though would allow continued funding for domestic residents but shut off funds for either subspecialty fellows who are IMGs or all IMGs.

It is likely that there will be some change, and the most likely group to be decreased will be IMGs seeking subspecialty positions. For the purposes of this discussion, a subspecialty position under fire includes all subspecialties of internal medicine and pediatrics, any surgery other than general surgery, all subspecialties of OB - GYN other than general OB - GYN, and all others. The idea is that primary care physicians (family practice, IM, OB - GYNB, and pediatrics) are to be increased and all others decreased.

If all these changes occur there are still ways you can come here to get training. First, tehre are soem programs whose funds do not come from federal sources, adn these may remain open to you. Expect the competition to get fierce. Another is to bring your funds with you. I currently haave a very fine Filipino fellow workign in the Program who came to use fully funded, and he is guaranteed to go back to the Phillipines. We are happy to train him, and doubt anyone would object to that arrangement.

You may soon see prograsm which sell traingin to foreign govenrments or individuals. A strong local sentiment is that training in medicine is an expensive commodity we have been foolishly giving away for years, adn that it is time to reverse that error by beginning to sell it, just as we sell plans for aircraft to China or wheat to Russia. If you have any access to funds in your country, it would be wise to begin to work out a way to pay for your education here.

All of that is of course beside the point if your real goal is to stay in the US. Don’t expect to be welcomed, becasue in many parts of the US there are more doctors than can reasonably be supported by the available patients adn funds. If you are truly interested in primary care, adn especially if you are willing to go to a place considered by domestic doctors as less appealing (federal hospitals, American Indian reservations, prisons, and so forth) you may have a chance.

The best chance is to train here, adn return. Even if you do plan to practice here, in most cases you must return to your country for two years after your training before you can come here to actually stay.

The Immigration Laws.

These laws change often, and they are many times specific to a particular country. For example, a Libyan doctor probably could not come here even under ideal conditions due to the political antagonism between the US government and that of Libya. My advice is that you contact your own embassy in the US, and ask what specific current immigration laws apply to you, and for how long they will stay that way. Don’t make plans for coming to the US 5 years form now and forget to recheck for changes in the laws.

While in training you are licensed with an "Institutional Permit." This is not actually a license you personally receive. The training program gets it for you, and it only applies to work which is part of the training program. That means you cannot work outside your training program either as a doctor or as anything else. Your family may accompany you here, but they will not be able to work here, generally.

Most residents and fellows are here on a J - 1 Visa, which does not allow you to obtain your own medical license. Most states require IMGs to have an American residency, so any residency you had in another country does not count (though Canadian and British residencies may be an exception). Again, this generally means going to your home country for two years, then returning. Note, this is not simply leaving the US - you have to go to a country in which you are a citizen for 2 years.

Some physicians accept positions in Veterans Administration Hospitals. These are federal hospitals for post military people. Conditions there are definitely inferior to the typical private US hospital, but may be fine by standards in many countries. The typical VA has modern equipment and well trained doctors. You may be able to work there for 2 years to escape the requirement to return to your country for 2 years. This exception is closing, and may or may not be permanently gone.

What Are We Looking For?

For the moment we are still interviewing IMGs for residencies and fellowships. We still believe the avenue to pay for them will be there, though possibly with fewer positions. Therefore it is still appropriate to talk about what qualities we Are looking for in an applicant.

The most important single qualification is excellence in education wherever you received it. We have come to know the better medical schools in various countries, and prefer to have an applicant from such a known entity. It is hard to judge what grades may be when looking at a medical school never before encountered here, in a country with an unknown system. Countries with medical education systems based upon the American style, the British style, and the French style are the most easily accepted. Countries based in the old USSR system, mainland China, and various others are less likely to fare well. Just as immigration makes it difficult for physicians in some taboo countries to come here, familiarity with the medical education system in those countries is less, so acceptance of medical school credentials from those schools is less.

No matter what the system, credentialing is a must. It may be difficult, but we need to actually see your diploma. It ill also have to be translated into English. In one case a physician from Afghanistan said his records were destroyed in war. So were his chances of being accepted here.

The next most important feature is the capacity to communicate well in English. This is a two - part condition. You must be able to communicate well. You must also speak English well. Many times the selection committee has members who speak your language. If it becomes clear that you cannot communicate well in your language you probably are wasting your time applying. Domestic American applicants who do not communicate in their native English are also not welcome, so you need to realize this requirement stems from the basic requirement of physicians to communicate well. Failure to communicate make the medical care process ineffective, costly, and dangerous, and that is intolerable when we already have too many doctors.

Measuring your capacity to speak well in English is based upon multiple factors. First is your own writing and speech. If someone calls me to request an application for a fellowship and they cannot make the request well, I will send the applicant but usually will table it when it is received. The personal statement is a great place for me to look for fundamental flaws in reasoning as English. Letters of recommendation, especially from physicians whose primary language is English are vital. I expect to see a comment in such a letter subtly grading your communication skills. Finally, if you are asked for an interview you should practice speaking in English, practice what you will say, and think carefully before you answer. I once was beginning an interview with an applicant for a fellowship who had been trained in an English - based medical school, and had done additional training in Britain and three years of medicine residency in the US. He should have been able to understand English. He mentioned he had come in the night before and was looking around the city for familiarization. I asked him if he was in search of a good time. He responded, "Yes, I have inserted many lines. Perhaps 30 or 50." He thought I was asking about central venous catheters. The interview was brief, and he was not listed further.

If you can, do some externships in the US. It does help to come here to do a cardiology rotation as a student while you are in medical school. It does not really help to move to the US in hopes of finding a position, and actually spend your time in a menial post in a research laboratory. If you find yourself studying for standardized tests, you’d better show that the time was used wisely and that you succeeded.

Scores on standardized tests are very helpful. If you have done well it may overcome unfamiliarity with your medical school or residency elsewhere. If you have not done well (generally, below the 80th percentile) you should readily explain why, and even better, show that you have taken additional training since the test was taken. One common reason for an IMG to not do well on a standardized test is laziness about English, or poor English skills. Interestingly, the most common reason for American students to not do well on standardized tests is laziness about English. If you do not do well initially, consider retaking the test.

What Will the Interview Be Like?

Eventually we have to meet you face to face. I doubt a program would rank anyone very high if there had not been a face - to - face interview, at least with a well trusted intermediary (well trusted by the residency). Some interviews have no particular structure or content - they are simply an effort to get to know you, examine your communication skills, and tell you about the program. Most programs will not formally test you during the interview, though you should be aware that unintentional or unexpected clinical questions may come up. On one occasion an interview was interrupted by a call for the MICU. Only hearing one side of the conversation the applicant waited till I hung up, then offered his advice on what I should do with the patient. What he advised was not very good, but the fact that at a time when he should have been working hard to show his best side he made a terrible error in judgment in offering an opinion without getting the facts. That interview ended shortly later.

Even if you make a mistake it may not hurt too much, In another interview a fellow burst in the room and related an urgent problem on the MICU. We all rushed down to the unit, where we placed lines and intubated the patient, What an interview - he stood there and watched, and enjoyed seeing what it was really like in our program. As I washed my hands afterward he offered his assessment of the patient. He was not terribly close to the correct assessment, but happened to have the same idea as the fellow who had burst in. I decided that he was no better or worse than the guy we already had, so I let it pass. That applicant did well in the ratings because his flexibility in that situation, intelligence, and training were reasonable.

Be relaxed, open, and responsive. The interviewer will expect you to have questions, unless the interviewer was so exhaustively complete that everything was answered. Ask about research opportunities. Ask what it is like to live in that locale. Compare housing prices. Are there others in that program from your country? What portion of recent graduates have become academic physicians, and have there been notable problems with pass rates on boards or in getting positions easily. What is the worst aspect of the program and what specific steps have been taken within the last year to remedy the deficiencies. Have any deficiencies led to a serious threat o losing accreditation. Don’t be afraid to ask tough questions - it shows you are serious, that you are sincerely trying to find a great program, and besides if you put the monkey on their back it won’t be on your own. Fair is fair.

Summary.

Odds are that residencies and fellowships will become more competitive in the US no matter who wins the elections. Your best opportunity is to have a great record of achievement and to aggressively present it. Focus on residencies in large cities where more IMGs are likely to have been previously successful. Get lots of information about the programs you consider before interviewing. Follow - up with a phone call to make sure your application was complete and that you were remembered.