“Looking Back While Moving Forward:
Observations on IMG Education and IMG
Faculty Development by a Psychiatric
Educator”
Nyapati R Rao, MD.,MS
Chairman
Dept of Psychiatry and Behavioral Science
Nassau Univ Medical Center
Prof of Clinical Psychiatry
SUNY-Downstate Medical Center
Unpublished work © 2008 Nyapati Rao
LOOKING BACK
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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
Unpublished work © 2008 Nyapati
Rao
Reactions to IMGs
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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
Unpublished work © 2008 Nyapati
Rao
Language Proficiency of IMGs
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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.
Unpublished work © 2008 Nyapati
Rao
EVENTS INFLUENCING FIRST TIME IMG RESIDENTS
1950-2002
6,000
1976
Health
Professions Act
restrictions
5,000
4,000
1991
Increase in
H1b Visas
************
Proposed
exam
change
Period of
medical
school
expansion
Post
WW II
demand
1998
CSA
3,000
1985
COBRA
restrictions
2,000
*************************
Medicare IME
1,000
0
1950
Richard Cooper
1960
1970
1980
Unpublished work © 2008 Nyapati Rao
1990
2000
Rao NR: Recent Trends in Psychiatry Residency Workforce with Special Reference to I
MGs:Acad Psych 2003: 269-276
Unpublished work © 2008 Nyapati Rao
Unpublished work © 2008 Nyapati Rao
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):1228Unpublished work © 2008 Nyapati Rao
1248
Professional Activities of IMGs
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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
Unpublished work © 2008 Nyapati Rao
Why Study IMGs Background?
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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”
Unpublished work © 2008 Nyapati Rao
Presentation-Outline
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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.
Unpublished work © 2008 Nyapati Rao
Presentation-Outline
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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.
Unpublished work © 2008 Nyapati Rao
Interview Questions
Please describe your training in your country in the following areas:
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Behavioral Medicine/ Psychiatry
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Common disorders such as anxiety and depression
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Physician-Patient relationship
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Mental Health history gathering
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What is your understanding of American cultural practices such as
child rearing, marriage or cohabitation?
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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
Unpublished work © 2008 Nyapati
Rao
Beh Med/ Psych Training Before
the US Training
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“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
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“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”
Searight HR,Gafford J. Behavioral Science Education and IMG. Acad Med. 2006;81:164-170
Unpublished work © 2008 Nyapati Rao
Doctor-Patient Relationship
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“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”
Searight HR,Gafford J. Behavioral Science Education and IMG. Acad Med. 2006;81:164-170
Unpublished work © 2008 Nyapati Rao
Perceptions of Family Life in
the US
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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.
Searight HR,Gafford J. BehavioralUnpublished
Science
Education and IMG. Acad Med.
work © 2008 Nyapati Rao
2006;81:164-170
Perceptions of Family Life in
the US
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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.
Searight HR,Gafford J. Behavioral Science Education and IMG. Acad
Unpublished work © 2008 Nyapati Rao
Med. 2006;81:164-170
Specific Challenges
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Documentation and charting formats
Interdisciplinary relationships
Need to prove themselves to faculty:
under closer scrutiny than USMGs
Searight HR,Gafford J. Behavioral Science Education and IMG. Acad
Med. 2006;81:164-170
Unpublished work © 2008 Nyapati Rao
Factors influencing Performance
of IMGs
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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
Unpublished work © 2008 Nyapati Rao
POSSIBLE Differences in Previous Education
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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 teachers
AFMC: Curriculum on Training the Trainers of IMGs
Unpublished work © 2008 Nyapati Rao
Culture Shock- Garza-Guerrero
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“ 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
Unpublished work © 2008 Nyapati Rao
Migration- Third Individuation
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Akhtar notes that migration has lasting
effects on individuals’ identity ( the
Third Individuation): involving
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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.
Unpublished work © 2008 Nyapati Rao
AAP-Poster-Culture Shock
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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
Unpublished work © 2008 Nyapati Rao
Culturally Appropriate Models
of the Mind
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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
Unpublished work © 2008 Nyapati Rao
Psychological mindedness
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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.
Unpublished work © 2008 Nyapati Rao
Additional material on culture
& IMGs
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The influence of culture on learning of
psychiatry: the case of Asian-Indian
international medical graduates
Nyapati R. Rao
International Journal of Applied
Psychoanalytic Studies
Volume 4, Issue 2 , Pages128 - 143
Copyright © 2007 John Wiley & Sons, Ltd.
Unpublished work © 2008 Nyapati
Rao
Guru-Asian Traditions
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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.
Unpublished work © 2008 Nyapati Rao
Guru in the West
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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
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The word guru is derived from two rootsgu: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.
Unpublished work © 2008 Nyapati Rao
Qualities of a GURU
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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.
Unpublished work © 2008 Nyapati Rao
Guru
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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.
Unpublished work © 2008 Nyapati Rao
Guru-Hunger
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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.
Unpublished work © 2008 Nyapati
Rao
Ekalavya- A story from
Mahabharata
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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.
Unpublished work © 2008 Nyapati Rao
Ekalavya
Unpublished work © 2008 Nyapati Rao
Recommendations
Unpublished work © 2008 Nyapati
Rao
IMGs Adaptation to Medical
Culture
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IMGs are often times confused by the laissezfaire 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
Unpublished work © 2008 Nyapati
Rao
Residency Selection
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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 Programs
Acad Psychiatry, Dec 1994; 18: 178 - 188
Unpublished work © 2008 Nyapati
Rao
Programmatic Approaches
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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
Unpublished work © 2008 Nyapati Rao
Programmatic Approaches
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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
Unpublished work © 2008 Nyapati Rao
Psychotherapy Training As An
Acculturating Tool
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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
Unpublished work © 2008 Nyapati Rao
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)
Unpublished work © 2008 Nyapati
Rao
Other Acculturation Tools
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ECFMG
The IMG Institute
Unpublished work © 2008 Nyapati Rao
ORIENTING TEACHERS AND IMGs
Part A: Orienting Teachers – Understanding the IMGs’
World
Part B: Orienting IMGs – Understanding the
Canadian Health Care System and Learning
Environment-AFMC
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A Faculty Development Program for Teachers of
International Medical Graduates-AFMC
Unpublished work © 2008 Nyapati
Rao
Supervision of IMGs
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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
Unpublished work © 2008 Nyapati Rao
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
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IMGs should be cued to the variable
questions that teachers may ask
Unpublished work © 2008 Nyapati Rao
IMGs-Feedback
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Utilizing feedback is a crucial skill in the
development of lifelong learning
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Feedback can identify both gaps & strengths
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The inaccuracy of self-assessment
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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
AFMC
Unpublished work © 2008 Nyapati Rao
The “Bottom Line”
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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, selfdirectedness, reflection and critical
appraisal
AFMC
Unpublished work © 2008 Nyapati Rao
Faculty Development Resource Poor
Department
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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 load
Devoting 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
Unpublished work © 2008 Nyapati Rao
Research Careers and IMGs-Obstacles
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CSA exam may be prohibitively expensive
Visa requirements may prevent pursuit of
research careers
IMGs on temporary or student visas are
ineligible for awards, training grants etc
IOM committee recommended declaring
research training and research-activities
federally underserved disciplines.
Unpublished work © 2008 Nyapati Rao
IMGs Career Development
Strategies
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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
Unpublished work © 2008 Nyapati Rao
Mentorship
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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
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Women and IMGs may have difficulty in finding
mentor.
Unpublished work © 2008 Nyapati Rao
“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 boardcertification 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”
Unpublished work © 2008 Nyapati Rao