Classes teach new IMGs American-style medicine

As the number of foreign-born international medical graduates grows, residencies seek out ways to ease their transitions.

By Myrle Croasdale — Posted Dec. 11, 2006

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Pelvic exams are not his forte. Male physicians do not perform such exams on women in India, where Venkata Mahesh Alla, MD, trained before heading to America to begin an internal medicine residency.

While many newly arrived foreign-born international medical graduates have to fumble through unfamiliar territory on their own, Dr. Alla was fortunate enough to be part of a week-long orientation program for foreign-born IMGs that Creighton University School of Medicine's internal medicine program created in 2005.

The Nebraska school is believed to have one of only a handful of formal programs geared toward helping these physicians. At least 14.7% of residents and at least 27.8% of internal medicine residents are here on a visa or are permanent residents, according to the AMA. With an increasing number of foreign-born IMGs coming to the United States, some expect more of these programs to develop.

"Educators are becoming more sensitive to this issue" and are increasingly aware that IMGs need a clinically focused orientation, said Edward L. Langston, MD, American Medical Association board chair-elect and a family physician in Lafayette, Ind.

Unfamiliar with the U.S. medical system, foreign-born IMGs face a different learning curve than their U.S. counterparts, which can lead to medical errors, irritated patients and frustrated hospital staff, educators said.

Joann Porter, MD, associate program director for internal medicine at Creighton, said growing complaints from hospital staff inspired her department's orientation program. About half of Creighton's nearly 70 internal medicine residents are IMGs.

"We were fearful of prejudice starting from our nursing and clinical staff," Dr. Porter said. "They felt our IMG residents weren't up to speed, but if you knew the residents, it didn't match up."

Some of the brightest IMGs were being criticized as not being smart, she said, because they were not participating during rounds. It turned out the IMGs considered it disrespectful to speak up or question attendings.

Rugmini Warrier, MD, an assistant professor of medicine at Creighton and an IMG from India, helped shape the program based on her experiences as a resident and as a faculty member who teaches IMGs. "They are hard-working and knowledgeable, but they need to adjust to a different system."

Adapting to a new work culture

One adjustment is working with a multidisciplinary team, including social workers and other ancillary staff, which may be absent in developing countries, Dr. Warrier said. "We had a complete lack of those resources. Even when they did have them in the big hospitals, patients wouldn't accept these services because of the cost or for cultural reasons."

For example, a patient with a hip fracture would go home after surgery without any rehab, she said. Here, however, her residents often oversee postoperative care. "The interns will ask me, 'Why are we taking care of these patients?' I explain they have a lot of medical problems that we manage. ... All this is new for them."

The Educational Commission for Foreign Medical Graduates, which oversees certification of IMGs before they apply for U.S. residencies, currently hosts one of the few other formal programs for foreign-born IMGs. The group is holding a series of day-long sessions for IMGs in the Philadelphia area covering topics such as Medicare and who pays patients' medical bills in the United States. The Educational Commission plans to develop orientation resources from these sessions and make the materials available to IMGs and program directors nationwide.

"When I was a resident, nobody really gave you any guidance. Sometimes you embarrassed yourself. I wish something like [this] was done years ago," said Vijay Rajput, MD, internal medicine program director at the University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School. He attended two of the Educational Commission's sessions with his residents.

The Educational Commission has discovered that working with nurses is often a new concept for IMGs and included nursing among the professions highlighted in its session on team-based care, said Nayan Kothari, MD, internal medicine program director for Drexel University College of Medicine/St. Peter's University Hospital in New Jersey. He is involved with the commission project.

"Most foreign graduates don't have any respect for nurses, and that shows in their interactions," said Dr. Kothari, who went to school in India.

As a result, residents do not tap their expertise, which can compromise patient care, he said. The reason, Dr. Kothari explained, is that nurses in other countries might not be as highly trained as in the United States.

Among other issues IMG orientation programs are trying to tackle:

  • The physician-patient relationship. Many IMGs had unquestioned authority and are surprised if patients ask for a second opinion.
  • The U.S. health care system. How Medicare, Medicaid, private insurance and the uninsured factor into patient care.
  • The high level of documentation expected.

Dr. Alla, a resident at Creighton, said records were almost nonexistent where he trained in India. "I didn't know how to put in an order here; then there's a difference in the way you give a prescription to a patient," he said. "You need to know this before jumping into the rotation."

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IMG work force

International medical graduates make up a quarter of practicing U.S. physicians. By specialty:

Internal medicine 31%
Psychiatry 30%
Anesthesiology 30%
Pediatrics 29%
Family practice 18%
Obstetrics-gynecology 17%
Radiology 15%
General surgery 14%

Source: 2004 AMA data, includes both foreign-born and U.S.-born IMGs

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Cultural catch-up

Most new international medical graduates need to learn to:

  • Understand Medicare, Medicaid and private insurer billing.
  • Read ECGs and order appropriate IV fluids.
  • Perform a pelvic exam and appreciate the importance of routine gynecologic exams.
  • Document a patient's history and physical.
  • Write prescriptions and order tests.
  • Interact appropriately with nurses, pharmacists, social workers and other patient-care staff.

Sources: Creighton University School of Medicine

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