Top 3 Things you wish IMG's would change about themselves

[relapse]

As a U.S. citizen studying in India, I heard alot of stories about IMG's performance profiles in the U.S. when they go to residency. I wanted to know from the grads of U.S. schools what you think are the 3 biggest things that the IMG's you see that need to be changed.

I'll start it off from what I personally have heard:
1) Bedside manner -- most doctors from India that treat patients at a government hospital know that the load of patients there is so voluminous that there is no "hello, my name is..." its just get out the tools and examine.

2) Clinical skills -- some of the skills we acquire here seem to be much different than those in the U.S.

3) Attitude towards the attending -- most of the time IMG's get kicked out of residency is due to the fact that they don't listen to their attending or have an attitude.

I would like to hear U.S. trained residents speak of what they see please.

[relapse]

bump

[fatman82]

Why are you bumping that post after less than 1h?

[J1515]

Originally Posted by fatman82

Why are you bumping that post after less than 1h?

epic

[pgg]

My top 3 IMG/FMG annoyances:

1) Poor English and/or heavy accents. It's worth working on. If you're an American studying in India, this probably isn't a problem for you.

2) Self-bumping own threads after 55 minutes.

3) I can't think of a third.

[Winged Scapula]

Originally Posted by relapse

As a U.S. citizen studying in India, I heard alot of stories about IMG's performance profiles in the U.S. when they go to residency. I wanted to know from the grads of U.S. schools what you think are the 3 biggest things that the IMG's you see that need to be changed.

I'll start it off from what I personally have heard:
1) Bedside manner -- most doctors from India that treat patients at a government hospital know that the load of patients there is so voluminous that there is no "hello, my name is..." its just get out the tools and examine.

2) Clinical skills -- some of the skills we acquire here seem to be much different than those in the U.S.

3) Attitude towards the attending -- most of the time IMG's get kicked out of residency is due to the fact that they don't listen to their attending or have an attitude.

I would like to hear U.S. trained residents speak of what they see please.

Before getting into any discussion about potential biases/complaints you hae to realize that they will differ whether or not the student/resident is an FMG or IMG. Traditionally, the former was a non-US citizen who studied abroad and the latter the US citizen training outside of the US. I am now told that everyone uses the term IMG to refer to both groups - not sure this is true and certainly the ECFMG still exists, but what people call themselves is not relevant, but the distinction in the minds of US faculty is.

Bedside manner is not just a function of cultural and training differences. There are plenty of arses here in the US who wouldn't know good bedside manner if it hit them upside the head and I've seen very gracious and tender FMGs/IMGs. Some physicians are socially awkward, some are arrogant and rude and others just pressed for time and tend to forget the niceties. But frankly, I've never heard of a generalizable bias against FMGs/IMGs because of their bedside manner. Patients may complain about accent but I cannot say I've seen wholesale rejection of physicians in either group because of this. Bedside manner is hard to teach; you either have it or you don't.

Clinical skills can vary widely even amongst US students. However, it is true that many who trained abroad are used to a professorial/mentor model where much of the clinical skills are not learned in medical school but rather as an intern and junior house officer. Many are used to simply observing rather than actually taking care of patients - this is why doing US clinical externships/electives can be so important - not just for the LORs one can get, but to see how US students function so you won't be totally lost on July 1. Many FMGs/IMGs are very book smart but haven't had the responsibility at an early stage like AMGs.

Now attitude towards attendings CAN be a factor. However, IMHO it is only a factor for those who have already done some or all of their residency training outside of the US and then come here to start all over. It can be incredibly hard to have a former attending as an intern. They *tend* to want to do things they way they used to do them and do not take to direction kindly. I am not sure that this is the case with AMGs who do a second residency - I think they understand the hierarchy a little better or at least are a little better at hiding their disdain for whatever someone is trying to teach them (that they think they already know). I am not sure that your statement that "most of the time when FMGs get kicked out of residency" it is for this reason is correct. Do you have references for that statement?

Some of the issues I see that are commonly addressed:

1) overconfidence: mostly a function of the US citizen trained abroad, but also seen in the foreign national, these are the students who assume THEY will be the 1 FMG who matches into Derm, or that they don't need to go on more interviews. Obviously most IMGs apply to every program they can afford, but there is a special breed we see here on SDN who assume because they got X on Step 1, that they will somehow rise above the chaff.

2) Not understanding the system - the medical system, the training system, the hierarchy. This is a problem when someone wants to come to the US but doesn't want to repeat training or who cannot understand the hierarchy in US medicine (see attitude above). This relates to the overconfidence in the case of the attending who wants to come to the US for training but has been out of medical school (and sometimes not even practicing in their home country) for years, decades even. They assume that having been specialty X for a century entitles them to a residency position in the US.

3) I have heard some complaints from colleagues about IMGs who are used to a different culture wherein using family connections or even bribes is common. There may be less of a tendency towards honesty for these IMGs. I have seen it enough myself to believe that this may be something that US faculty are worried about.

Another issue for the foreign national can be the tendency to isolate themselves within their culture. These are the residents who speak their foreign language in the hospital and only associate/socialize with members of their own ethnicity. We've even had some AMGs here on SDN complain that these IMG residents conduct rounds mostly in their foreign language, or frequently speak that language in front of the students and other residents. This is generally considered rude in the US. In my practice, I also tend to see ethnicity based referral patterns which makes no sense to me. I do not choose a specialist for my patients based on what country they are from, why would others?

I am sure there are plenty of biases that others can come up with. Whether changing these things means better options for the FMG/IMG I am not sure.

[error404]

Nicely said, WS.

And on a quick-to-generalize note, I'll add:
Many wear too much cologne/perfume.

There is no place for that much cologne in the hospital. Stop exacerbating my asthma patients.

/cultural clash

[relapse]

wow, thanks for the reply. that clarified alot. IMG is in fact the term used for a student that has a medical degree from a foreign school regardless of U.S. Citizenship.

I completely agree with you WS about doing U.S. electives and clerkships but the problem is that they require you to take step before you step foot into a U.S. institution to handle patients. What advice can you give to a student like me who isn't prepared at this juncture (2nd year of foreign med school) to do to make a better impression and gain more experience in U.S. clinical setting.

I heard observerships and the such dont' really matter that much but are there any other opportunities aside from clinical/basic science research that will ameliorate the difficult transition?

[Winged Scapula]

Originally Posted by relapse

wow, thanks for the reply. that clarified alot. IMG is in fact the term used for a student that has a medical degree from a foreign school regardless of U.S. Citizenship.

Actually, it is NOT a fact. Only recently have people been using the term IMG regardless of citizenship. I think you'll find most US attendings still use FMG to refer to foreign nationals.

I completely agree with you WS about doing U.S. electives and clerkships but the problem is that they require you to take step before you step foot into a U.S. institution to handle patients. What advice can you give to a student like me who isn't prepared at this juncture (2nd year of foreign med school) to do to make a better impression and gain more experience in U.S. clinical setting.

Why is that a problem? We require US students to have taken Step 1 before doing clinical rotations so why should it be any different for IMGs? So I have no advice but to take Step 1 like everyone else does and when you are ready, as a final year student, come to the US for clinical rotations. Until then, your only options are doing research during summer breaks.

I heard observerships and the such dont' really matter that much but are there any other opportunities aside from clinical/basic science research that will ameliorate the difficult transition?

As far as I'm concerned, observerships are worthless, especially to someone who is a student and has the opportunity to do electives. You may be overestimating how much research or other non-clinical opportunities help. If I were you, I'd spend my breaks studying for Step 1, knocking it out of the park, and then come final year, apply for clinical electives.

The transition is not so difficult. Hundreds, if not thousands, of students do it every year.

[lipomas]

In my experience (mostly from med school) IMGs tended to have more prior expertise in the field, so many of them thought residency was beneath them (since they already knew everything). Thus, they tended to scut out students more, lecture students, and not teach at all. Another big problem was communication - many IMGs just simply did not "get it" when talking to patients or other physicians. They would miss important findings, not follow up on certain things, etc, I think some of it was due to cultural differences.

[relapse]

Originally Posted by lipomas

In my experience (mostly from med school) IMGs tended to have more prior expertise in the field, so many of them thought residency was beneath them (since they already knew everything). Thus, they tended to scut out students more, lecture students, and not teach at all. Another big problem was communication - many IMGs just simply did not "get it" when talking to patients or other physicians. They would miss important findings, not follow up on certain things, etc, I think some of it was due to cultural differences.

what would eventually happen to these IMG's? where are they now?

[Frugal Traveler]

I can understand the purpose of this thread... but it is kind of ridiculous considering that this is America. I'm not an IMG (or even close to it)... but America is full of diverse people and that's just a fact of life. Even people of your own group (whether you group things by race, professional status, or whatever else) will have quirks... and I am sure we could start a thread about that.

The IMGs I have met are really incredible people and exceptionally smart... yes... there might be cultural differences, but there is a ton of other stuff I want to spend my time thinking about.

[Winged Scapula]

It appears clear to me that the OP is training abroad and wants to know what the potential biases are in preparation for applying for US residency.

Sure, everyone has quirks and things we wish would change. However, IMHO it would unreasonable to assume that there aren't biases against IMGs/FMGs, which is what the OP really wants to know. I, like you, have met some incredible IMGs/FMGs, and some lousy AMGs, so school of origin is not the defining factor.

[dragonfly99]

OP,
First of all I want to say that IMG/FMG's are certainly not considered a monolithic group. There are good and bad types in every pool (US grad, US citizen IMG, FMG).

I agree with Winged Scapula about the IMG/FMG thing.

As far as students trained in India, I'd have to say the #1 problem is being book smart but not having clinical skills. I had one from India doing a 4th year subI type rotation and he functioned more like someone beginning 3rd year in a US school. So clearly there was a deficiency...I actually like medical students, and didn't dislike him, and I think his knowledge base was OK but he just didn't know how to write a note or present a patient...I don't know about his exam skills...probably not that bad...but he didn't know how to function in a US hospital anywhere near the level he needed to. I think it is probably a function of the teaching system over there, which is probably more like the British system where they mostly observe and don't do as much direct patient care (at least not in writing up history and physicals, acting sort of like a "mini-intern" like our students do here).

From the patients' point of view, I have heard them complain about doctors who have thick accents or can't speak English well. This can be a big problem. If you're from the US I don't expect it would be for you.

I agree about no wearing too much cologne or perfume. Some US people do this too. I think it's more common in residents from places like Pakistan or the Middle East b/c it's more traditional in some of the Muslim countries to wear more...smelling good is important there and smelling like perfume there I don't think is a bad thing. Here a lot of people don't wear any at work, particularly in hospitals.

Also, with an N of only one it's hard for me to comment specifically about all Indian med students, but I can say that mine also didn't take feedback that well. I actually felt that he wanted to do well, but I felt like there was some pushback whenever he got any negative feedback at all, and that he wanted to keep doing stuff "his way" even though it wasn't working in our hospital. I also loaned him some study materials that he didn't return, which I felt was poor form.

I think if you are attending school abroad, than doing clinical rotations in the US would be really key. Also, maybe you could volunteer for some organization (? Unite for Sight or similar) or try to find US doctors who are visiting India to do missionary work or similar stuff, and see if you can tag along with them for a few weeks during one of your school breaks. You could translate for them, if you speak any of the languages from India. It would give you something to talk about in your residency application as well, as a lot of US students do similar volunteer work, etc. as part of their med school experience.

[relapse]

Originally Posted by dragonfly99

OP,
First of all I want to say that IMG/FMG's are certainly not considered a monolithic group. There are good and bad types in every pool (US grad, US citizen IMG, FMG).

I agree with Winged Scapula about the IMG/FMG thing.

As far as students trained in India, I'd have to say the #1 problem is being book smart but not having clinical skills. I had one from India doing a 4th year subI type rotation and he functioned more like someone beginning 3rd year in a US school. So clearly there was a deficiency...I actually like medical students, and didn't dislike him, and I think his knowledge base was OK but he just didn't know how to write a note or present a patient...I don't know about his exam skills...probably not that bad...but he didn't know how to function in a US hospital anywhere near the level he needed to. I think it is probably a function of the teaching system over there, which is probably more like the British system where they mostly observe and don't do as much direct patient care (at least not in writing up history and physicals, acting sort of like a "mini-intern" like our students do here).

From the patients' point of view, I have heard them complain about doctors who have thick accents or can't speak English well. This can be a big problem. If you're from the US I don't expect it would be for you.

I agree about no wearing too much cologne or perfume. Some US people do this too. I think it's more common in residents from places like Pakistan or the Middle East b/c it's more traditional in some of the Muslim countries to wear more...smelling good is important there and smelling like perfume there I don't think is a bad thing. Here a lot of people don't wear any at work, particularly in hospitals.

Also, with an N of only one it's hard for me to comment specifically about all Indian med students, but I can say that mine also didn't take feedback that well. I actually felt that he wanted to do well, but I felt like there was some pushback whenever he got any negative feedback at all, and that he wanted to keep doing stuff "his way" even though it wasn't working in our hospital. I also loaned him some study materials that he didn't return, which I felt was poor form.

I think if you are attending school abroad, than doing clinical rotations in the US would be really key. Also, maybe you could volunteer for some organization (? Unite for Sight or similar) or try to find US doctors who are visiting India to do missionary work or similar stuff, and see if you can tag along with them for a few weeks during one of your school breaks. You could translate for them, if you speak any of the languages from India. It would give you something to talk about in your residency application as well, as a lot of US students do similar volunteer work, etc. as part of their med school experience.

excellent response. thank you for answering my question dragonfly. As I am from the U.S. studying abroad, some problems like accent naturally won't be there. However, there are many aspects of medical education here that aren't emphasized as much as western medicine and thus present a huge problem. Part of this reason is volume overload of patients: the hospitals, especially government and free, don't have the time, the money, nor the resources to treat everyone that comes in and therefore handles patients in a completely different way. Another part, which I concur with you, is the fact that the British system is heavily emphasized here. Also, because India is still a developing country, the physical exam tends to rely more on abstract signs that will show up on any conventional CT, MRI, EKG, or X-ray test back home.
(e.g. we have to master how to do "fluid thrill" over and over regarding a particular case when any CT will show it or how to master EKG abnormalities clinically since an EKG isn't given in a patients file)

[Winged Scapula]

Relapse, don't get DF wrong. Having clinical skills as you described (ie, knowing cardiac sounds or fluid thrills) is HIGHLY respected in the US and someplace where IMGs/FMGs can excel.

However, as you indicate, not knowing how to read an EKG, CT scan, etc. IS a problem, because these tests are widely used in the US. But many attendings, especially the older ones, may have trained in an era when they weren't or like the old scenario, "well, the CT scanner is broken" when examining you, so expect that you can come up with a DDx without fancy machines.

She is also right about the lack of autonomy given abroad and how it affects foreign students who come to the US for rotations. So while studying for and doing well on Step 1 is important, you might also focus on the documentation skills, rounding, etc. that you would be expected to know when you do come to the states for rotations. Some of those skills can be picked up by simply observing or shadowing a physician with an inpatient census.

[WholeLottaGame7]

Originally Posted by Frugal Traveler

I can understand the purpose of this thread... but it is kind of ridiculous considering that this is America. I'm not an IMG (or even close to it)... but America is full of diverse people and that's just a fact of life. Even people of your own group (whether you group things by race, professional status, or whatever else) will have quirks... and I am sure we could start a thread about that.

The IMGs I have met are really incredible people and exceptionally smart... yes... there might be cultural differences, but there is a ton of other stuff I want to spend my time thinking about.

You're right, there are serious cultural (and occasionally language) barriers right here within the US. Occasionally I've had to translate words/phrases for attendings/residents who aren't from the South. My family has a decent (not overpowering) Southern accent, and I've lived in the South my whole life (granted in/around military bases mostly), but I've still run into patients with what we might call a "big 'ol" Southern accent that I've had to guess at what they were saying. The best part is attempting to translate regional/cultural slang; around here people got the "high blood" (hypertension), patients DFO (done fell out, syncope), and I had a patient with a foot ulcer caused by his AFOs (which I deduced to mean Air Force Ones, a type of shoe). Sometimes it's funny, sometimes it can be a barrier to providing care.

I think the point isn't that there aren't these problems here, but that maybe there's a higher chance of IMGs running into these problems. Alternatively, AMGs may have had longer to deal with the cultural/language barriers in their areas, and IMGs are having to deal with them during a very stressful time while trying to hone their profession. Not only that, they can be trying to care for patients that may not be thrilled to have a female or minority doctor taking care of them, much less someone who "ain't from 'round here."

[bucknut101]

How about FMG's (from any country) that constantly complain about the way things are here in the U.S.? I had one attending during residency that would always comment that Americans were "fat, lazy, and stupid". And he would treat nearly all of his patients like they were. Drove me nuts.
He would also comment on how arrogant Americans were and how much better things were in his home country. I always wondered if he thought it was so bad here, why did he come and why does he stay?

[Winged Scapula]

Originally Posted by bucknut101

How about FMG's (from any country) that constantly complain about the way things are here in the U.S.? I had one attending during residency that would always comment that Americans were "fat, lazy, and stupid". And he would treat nearly all of his patients like they were. Drove me nuts.
He would also comment on how arrogant Americans were and how much better things were in his home country. I always wondered if he thought it was so bad here, why did he come and why does he stay?

I think that's actually common in other places as well.

I had a few American classmates in Australia. A couple constantly complained about it, about how it wasn't like the US (why would it be? ) and how much they preferred the US. I thought the same thing - then why are you here? Either leave or learn to appreciate differences and the wonderful things here (hmmm....pasties).

[Apollyon]

Originally Posted by WholeLottaGame7

foot ulcer caused by his AFOs (which I deduced to mean Air Force Ones, a type of shoe).

Having spent 10 years of my life in the South (college, residency, and in practice), I became attuned to the jargon (such as when a very intelligent rads resident from a very noted and wealthy family said in his very genteel Southern accent, "the pone on that patient's head has no underlying insult", I had to laugh out loud), but "AFO" is MUCH more likely referring to "ankle foot orthotics", which are not localized to the South. I mean, it could be the shoes, but the device is more likely to cause ulcers than an athletic shoe.

[Winged Scapula]

What's "pone"? I've heard of corn pone, but nothing related to the head (and couldn't find it on Google).

[dragonfly99]

yeah, I'm confused about the "pone" thing too.
And I've lived in the South...

[Apollyon]

As was I - a "pone" is a "lump", like a hematoma after being hit with a bat.

However, DF, if you are from the South, then "pone" MUST also bring to mind, for you, "corn bread", a/k/a "corn pone".

[core0]

Originally Posted by Winged Scapula

What's "pone"? I've heard of corn pone, but nothing related to the head (and couldn't find it on Google).

Its hard to figure out. It appears to be used as either a lump (this pone here) or as swelling (she's all poned up). Of course you have to figure out what the rest of the words in the sentence are also. Having the patient put in their dentures sometimes helps.

[Raggaman]

Originally Posted by Winged Scapula

I think that's actually common in other places as well.

I had a few American classmates in Australia. A couple constantly complained about it, about how it wasn't like the US (why would it be? ) and how much they preferred the US. I thought the same thing - then why are you here? Either leave or learn to appreciate differences and the wonderful things here (hmmm....pasties).

Winged Scapula, I know you practice somewhere in the phoenix area. If you want great pasties then head on over to this great little hole in the wall place in Tempe, at W university and Hardy. Those are the only pasties I have ever had. Let me know how they compare to the real ones!

[Winged Scapula]

Originally Posted by Raggaman

Winged Scapula, I know you practice somewhere in the phoenix area. If you want great pasties then head on over to this great little hole in the wall place in Tempe, at W university and Hardy. Those are the only pasties I have ever had. Let me know how they compare to the real ones!

Thanks for the tip. My office is in the west side, but I live in N. Scottsdale so Tempe wouldn't be too bad a drive. I'll have to check it out.

[sam1999]

DF/WS: It seems like you have experience working FMGs/IMGs of different nationalities. Do you hang out (current or past) with any on these people? By hang out I mean like get together after work as a group or inviting someone at home party etc.

I have worked here for many years in research. But no one never or ever invited me or other fellow foreign researchers. It is a common theme which I heard from other labs as well. It is funny I even went out with some of the girls I used to work but no one never invited me to any of their parties as they always talk about it. It could be they did not like me but no other foreigner as we had people from all over the globe.

Just curious how is it in residency or hospital world. Is it birds of same feathers folk together?

[WholeLottaGame7]

Originally Posted by Apollyon

Having spent 10 years of my life in the South (college, residency, and in practice), I became attuned to the jargon (such as when a very intelligent rads resident from a very noted and wealthy family said in his very genteel Southern accent, "the pone on that patient's head has no underlying insult", I had to laugh out loud), but "AFO" is MUCH more likely referring to "ankle foot orthotics", which are not localized to the South. I mean, it could be the shoes, but the device is more likely to cause ulcers than an athletic shoe.

Touche, though it was a young gentleman whose main underlying problem was diabetes, so I don't know why he'd need those unless he had some pretty terrible neuropathy which I don't recall. I will certainly add it to the massive acronym list, however

[knockoutMice]

Hi, I'm a final year med student from India

Thanks everyone for the constructive comments.

I would like to say a few things -

it is true that many who trained abroad are used to a professorial/mentor model where much of the clinical skills are not learned in medical school but rather as an intern and junior house officer. Many are used to simply observing rather than actually taking care of patients

Although we follow the British system (or whatever remnant of it) here in India, learning clinical skills is very much emphasized upon. I mean unless you are talking about tertiary care centers, you can't even think about going for a CT/MRI at the drop of a hat. So people here mostly rely (or at least like to revel) on their clinical knowledge. Being able to show clinical skills is the basic criteria for passing exams. There is something that all attendings in my college (and I am pretty sure in all colleges in India) agree and tell us everyday - that unles you go and examine the patients yourself you'll never learn anything (There is this beautiful quote by William Osler regarding this)

So could you please kindly elaborate a bit more on the sort of clinical skills you are emphasizing here?

However one thing is true that we don't really take care of the patients until we are interns. So that definitely puts us behind AMGs as far as the management of the patients are concerned.


Another issue for the foreign national can be the tendency to isolate themselves within their culture. These are the residents who speak their foreign language in the hospital and only associate/socialize with members of their own ethnicity. We've even had some AMGs here on SDN complain that these IMG residents conduct rounds mostly in their foreign language, or frequently speak that language in front of the students and other residents.

Conducting rounds in a foreign language is totally unacceptable and yes I do believe that speaking in a different language in front of your AMG colleagues is rude and should be condemned.

However as far as the issue of isolating oneself and socializing with colleagues of one's own country. I think it's a very complex issue. I have seen this even in my college, particularly among the who people have come to study from different parts of India. I think it has to do a lot with the alien environment, the culture shock and the sense of insecurity that many FMGs feel. So a part of this issue can definitely be helped by the AMGs if they try to be more congenial and sensitive towards their FMG colleagues. I know its easier said than done cuz obviously it will be kinda awkward in the beginning. However I do want to point this out is the FMGs who are going there are doing it voluntarily and they are doing it out of respect for the American medical system and culture (to some extent definitely... obviously there are going to be some people who r doing it for the money or other reasons)... so I am pretty sure most have them are willing to adjust to great extents to this new culture if they are encouraged a little bit, helped out by pointing out in a sensitive way exactly what they can do in order to improve their situation.

[Winged Scapula]

Originally Posted by sam1999

DF/WS: It seems like you have experience working FMGs/IMGs of different nationalities. Do you hang out (current or past) with any on these people? By hang out I mean like get together after work as a group or inviting someone at home party etc.

I have worked here for many years in research. But no one never or ever invited me or other fellow foreign researchers. It is a common theme which I heard from other labs as well. It is funny I even went out with some of the girls I used to work but no one never invited me to any of their parties as they always talk about it. It could be they did not like me but no other foreigner as we had people from all over the globe.

Just curious how is it in residency or hospital world. Is it birds of same feathers folk together?

Interesting question. Having never been invited to get togethers the East Indian residents had, I'd say it works both ways. It wasn't until I joined practice with an Indian physician that I would get invited to these things but I am the ONLY white woman at these things. So yes I do socialize with foreign trained physicians albeit more now because l didn't meet many during residency or fellowship.

I might ask if the issue is not with ethnicity but rather jobs and/or outside interests. I think physicians often socialize together citing common interests and SES. If you are working in a lab and don't have a PhD then they may not recognize you as a peer.

However it is true that some people prefer to socialize with their own race and it's not just white AMGs.

[sam1999]

I don't think it is ethnicity alone. Well I was working as research fellow as I did have my own funding, research project, and first author publications. I was invited by other foreigners (white foreigner from Europe or other parts of world) post docs who had either MD or PhD so it was not SES alone either. We have people from Europe and other Asian countries and did use to have occasional get together. I was mostly talking about American post docs and techs. It was not only me but all foreign researchers.

[sam1999]

Originally Posted by Winged Scapula

Interesting question. Having never been invited to get togethers the East Indian residents had, I'd say it works both ways. It wasn't until I joined practice with an Indian physician that I would get invited to these things but I am the ONLY white woman at these things. So yes I do socialize with foreign trained physicians albeit more now because l didn't meet many during residency or fellowship.

I might ask if the issue is not with ethnicity but rather jobs and/or outside interests. I think physicians often socialize together citing common interests and SES. If you are working in a lab and don't have a PhD then they may not recognize you as a peer. However it is true that some people prefer to socialize with their own race and it's not just white AMGs.

You must be very brave to work with Indian lady. I was told by many of my friends who are now in private practice that not to work with desi as they was way too good business people. I have many such stories.

[Winged Scapula]

Originally Posted by knockoutMice

it is true that many who trained abroad are used to a professorial/mentor model where much of the clinical skills are not learned in medical school but rather as an intern and junior house officer. Many are used to simply observing rather than actually taking care of patients

Although we follow the British system (or whatever remnant of it) here in India, learning clinical skills is very much emphasized upon. I mean unless you are talking about tertiary care centers, you can't even think about going for a CT/MRI at the drop of a hat. So people here mostly rely (or at least like to revel) on their clinical knowledge. Being able to show clinical skills is the basic criteria for passing exams.

So could you please kindly elaborate a bit more on the sort of clinical skills you are emphasizing here?

However one thing is true that we don't really take care of the patients until we are interns. So that definitely puts us behind AMGs as far as the management of the patients are concerned.

THAT is exactly what I am referring to. In the US, 3rd year medical students are starting to round on patients, do procedures, etc. and by their 4th year many are fairly independent.

I am not referring to clinical exam skills, which frankly, many IMGs/FMGs have to a degree higher than US students because they don't have the CT/MRIs at the drop of a hat. They have to learn the subtleties of clinical examination.

I am referring to SKILLS - ie, rounding, charting notes, doing discharge summaries, placing IVs, drawing blood gases, removing or placing drains, placing NG tubes, urinary catheters. Most, IMHO, IMG/FMGs do not get this training in medical school. As a matter of fact, I was told during medical school that I would be taught those things in internship. The trouble was that my fellow interns, having trained in the US, already knew how to do those things, so I was behind.

Another issue for the foreign national can be the tendency to isolate themselves within their culture. These are the residents who speak their foreign language in the hospital and only associate/socialize with members of their own ethnicity. We've even had some AMGs here on SDN complain that these IMG residents conduct rounds mostly in their foreign language, or frequently speak that language in front of the students and other residents.

Conducting rounds in a foreign language is totally unacceptable and yes I do believe that speaking in a different language in front of your AMG colleagues is rude.

However as far as the issue of isolating oneself and socializing with colleagues of one's own country. I think it's a very complicated and complex issue. I have seen this even in my college, where people have come to study from different parts of India. I think it has to do a lot with the alien environment culture shock, sense of insecurity that FMGs feel. So a part of this issue can definitely be helped by the AMGs if they try to be more congenial and sensitive towards there FMG colleagues. I know its easier said than done cuz obviously it will be kinda awkward in the beginning. However I do want to point this out is the FMGs who are going there are doing it voluntarily and they are doing it out of respect for the American medical system and culture (to some extent definitely... obviously there are going to be some people who r doing it for the money or other reasons)... so I am pretty sure most have them are willing to adjust to great extents to this new culture if they are encouraged a little bit, helped out by pointing out in a sensitive way exactly what they can do in order to improve their situation.

I agree that it can be much more comfortable to socialize with member's of one's own culture and I do not begrudge FMGs who do that. What bothers us, are the very small percentage, that persist in complaining about the US, refuse to adapt to cultural mores and behavior and do things like speak foreign languages around others. You're right - the latter is rude and is unacceptable, but it reportedly happens.

I certainly understand why this is done (feelings of isolation and need for comfort- hell, I ate at McDonald's last week on Seoul [I hate McDonalds] but I wanted a soda with ice and no more rice, vegetables, etc.) but the OP was asking for things to watch out for. These are the things that irritate AMGs about FMGs - it doesn't matter that the FMG has a good reason to not fully adapt or to socially isolate themselves. Or at least some AMGs may not understand or care about the reasons.

[Winged Scapula]

Originally Posted by sam1999

You must be very brave to work with Indian lady. I was told by many of my friends who are now in private practice that not to work with desi as they was way too good business people. I have many such stories.

I'm not sure what you are referring to.

I want a partner who is a good business person. And everything is reviewed by an attorney, business manager and accountant. If anything, I know more about business than she does.

Besides, she's about as desi as I am. She was born and raised here in the US and except for the color of our skins (and her penchant for dosa) we are very much alike.

[Winged Scapula]

Originally Posted by sam1999

I don't think it is ethnicity alone. Well I was working as research fellow as I did have my own funding, research project, and first author publications. I was invited by other foreigners (white foreigner from Europe or other parts of world) post docs who had either MD or PhD so it was not SES alone either. We have people from Europe and other Asian countries and did use to have occasional get together. I was mostly talking about American post docs and techs. It was not only me but all foreign researchers.

Ahhh....that's probably due to the the lack of familiarity most Americans have with foreigners. I recall hearing a quote that up until last year, only 10% of Americans had passports.

Most Europeans are used to meeting and working with foreigners.

So there may be some fear or simple good old American centrism/jingoism at work here.

Foreign = bad/weird in some people's eyes in our very isolated country.

[sam1999]

If you are born and raised here in US then probably you both are not desi. I assume you know what desi is. If not I did a google search and I found this one. Well some of it are just for humor. My favorite is how you eat your cookies with tea.

http://www.rajkot.com/humor/desi.htm

[sam1999]

Originally Posted by Winged Scapula

Ahhh....that's probably due to the the lack of familiarity most Americans have with foreigners. I recall hearing a quote that up until last year, only 10% of Americans had passports.

Most Europeans are used to meeting and working with foreigners.

So there may be some fear or simple good old American centrism/jingoism at work here.

Foreign = bad/weird in some people's eyes in our very isolated country.

No I don't think so as I never understood this. Remember I mentioned earlier that I even went out with some of the American techs in our lab/department.

[relapse]

Originally Posted by Winged Scapula

I'm not sure what you are referring to.

I want a partner who is a good business person. And everything is reviewed by an attorney, business manager and accountant. If anything, I know more about business than she does.

Besides, she's about as desi as I am. She was born and raised here in the US and except for the color of our skins (and her penchant for dosa) we are very much alike.

plain dosa or masala dosa

[Winged Scapula]

Originally Posted by sam1999

If you are born and raised here in US then probably you both are not desi. I assume you know what desi is. If not I did a google search and I found this one. Well some of it are just for humor. My favorite is how you eat your cookies with tea.

http://www.rajkot.com/humor/desi.htm

Yes, I know what desi means. And I didn't actually call her a desi, you assumed she was one when I said she was Indian. Perhaps I should have been clearer and said Indian-American, but she refers to herself as Indian. As you'll note, I said she was about as desi as me, which means not at all.

However, she married a desi and her parents were born there so she has retained many of the customs of desis. The link did make me laugh as I identified many of them which I see in her:

You ask before eating any meat "Is this beef?".
You take off your shoes before stepping foot in your living room.
You find taco bell sauce packets in your kitchen drawer. (she has them in her desk at work)
If your full name contains more than 15 characters.
You use grocery bags as garbage bags.

Originally Posted by sam1999

No I don't think so as I never understood this. Remember I mentioned earlier that I even went out with some of the American techs in our lab/department.

Ok, so when you worked in the lab the AMERICAN PHYSICIANS did not ask you to socialize but the techs did? So don't you think then it may be a function of presumed social class and academic achievement? I don't know many physicians who socialize with techs, research assistants, etc. Also were you an employee of these physicians? If so, most employers don't socialize with their employees.

There may simply be an assumption you wouldn't be interested. Also in America, as in many countries, I find that people with children do not often socialize, especially outside of the home, with single/childless people, at least while the children are still young and at home.

Originally Posted by relapse

plain dosa or masala dosa

Well, I've had both at her house, but it is my impression that she mostly makes plain. Chapatis are very popular...when she and I went on a low carb diet she was shocked as to how many carbs there are in her food.

[howelljolly]

Well there you go then WS, she probably is more desi than you. Its a continuum.

[Winged Scapula]

Originally Posted by howelljolly

Well there you go then WS, she probably is more desi than you. Its a continuum.

I dunno (about her being more desi than me):

I also use grocery bags as garbage bags
I also have Taco Bell salsa packets in my drawer
She is vegetarian not for religious or ethnic reasons; no one else in her family is, so I didn't connect it with "desi-ism"
I take my shoes off when I come home (because I have light carpets).

Perhaps I am more desi than I thought!

[sam1999]

Originally Posted by Winged Scapula

However, she married a desi and her parents were born there so she has retained many of the customs of desis.
You use grocery bags as garbage bags.

Did she marry a desi or arranged to get marry a desi ?

I am sort of helping environment by using grocery bags and when I moved to my current place we place our trash every morning outside of our doors and someone will come pick up in the morning. I used grocery bags and my other neighbors used trash bags and soon they changed to grocery bags as well. I guess more people are becoming desi.

[Winged Scapula]

Originally Posted by sam1999

Did she marry a desi or arranged to get marry a desi ?

Oh no, she would have never agreed to an arranged marriage. This is an American woman, after all. No she met him on-line and dated for quite awhile before getting married.

I am sort of helping environment by using grocery bags and when I moved to my current place we place our trash every morning outside of our doors and someone will come pick up in the morning. I used grocery bags and my other neighbors used trash bags and soon they changed to grocery bags as well. I guess more people are becoming desi.

Maybe (becoming more desi). I think of it as being economical and reasonable since what am I going to do with all those bags anyway (yes, I could use the fabric bags that I have so many of, but I forget to take them to the store with me)?

[sam1999]

Originally Posted by Winged Scapula

Ok, so when you worked in the lab the AMERICAN PHYSICIANS did not ask you to socialize but the techs did? So don't you think then it may be a function of presumed social class and academic achievement? I don't know many physicians who socialize with techs, research assistants, etc. Also were you an employee of these physicians? If so, most employers don't socialize with their employees.

No it is not that simple. My supervisor was PI of the lab and he used to invite people twice a year to his home. Any that was kind of work socializing and I hope you know what I mean. I was not working for any of the fellows so none of them were my supervisors. I think it was kind of mixed. Some tech/grad students (who were about my age back few years ago) did have some get together and basically I was more interested mingling in that age group but never was asked to and so do other foreign people.

I think there are more depends but in general more AMG either tech, grad students did only hang out within their own group. I did have good interaction with other fellows who happened to be only foreigners. Most SES what you are referring to is usually comes once become an attending and I have seen that with many fellows (regardless of ethnicity) and basically by then most people already leave the lab to start actual job else where.

[sam1999]

Originally Posted by Winged Scapula

I'm not sure what you are referring to.

I want a partner who is a good business person. And everything is reviewed by an attorney, business manager and accountant. If anything, I know more about business than she does.

Besides, she's about as desi as I am. She was born and raised here in the US and except for the color of our skins (and her penchant for dosa) we are very much alike.

I guess most people already know very well, when it comes to money you can't compete a blonde.

[dragonfly99]

I haven't worked with all that many foreign physicians. We didn't really have any FMG's at my residency program, except 1 European person. I've had a couple of foreign med students rotate through, and we did invite them to suitable work events (like a journal club/lecture outside the hospital). I don't usually socialize with med students since they are about 6 years behind me in training and mostly much younger. When I worked in a lab, it really depended which lab I worked in how much we (lab staff and attending docs, etc.) would socialize together. Most of the older docs/PI's of labs were married with kids so I generally didn't socialize with them. Occasionally the "boss" might have a work type party at his house, but then one would be on one's best behavior and yes, go over to socialize. But I didn't socialize with my boss on a regular basis.

Personally, in the labs I've worked in we (techs or students or postdocs) didn't necessarily socialize together outside of work related parties, but it really depends on which lab you work in. Actually, in my last lab I was one of the only ones not married and without kids, so the others tended to socialize and get together with their spouses and babies/toddlers, and I was the one left out b/c I didn't have that common interest. I haven't observed that foreign trained PhD students or post docs got left out of social gatherings @the places where I've trained. In fact, I have several close friends who did PhD's where I did my medical school and they all socialized w/all the PhD students of different nationalities, from what I observed.

As far as residency and fellowship, I didn't necessarily socialize all that much with all the residents in my program. I did socialize with a smaller number who I was really closer friends with, but as there were a lot of us in IM residency, there were many I didn't know too well. And generally I did not socialize with attendings or even fellows, as the places where I trained were fairly hierarchical. Again, there are work type "parties" but these were more semiformal occasions that casual social events. This does differ somewhat by the institution where you train, your department and perhaps the area of the country you are in (West may be less formal than the South or Northeast for example).

[bluealiendoctor]

First of all, Winged Scapula....your post on FMG/IMG's was absolutely fantastic. And Dragonfly..well you know you're one of my favorites. I can say as an IMG I have worked with many AG's as well as foreign. By foreign, I mean United States not being there country of origin nor completing school in the States. I can also say I feel there is a significant difference between IMG/FMG. IMG's like myself are plain Americans who went to school outside the USA. Actually, there is a 'sub-classification' as well. Obviously I get the occasional "oh, a foreign grad" that to me really doesn't hold a lot of weight. Why? Well, I really don't think where someone studied basic sciences has a whole lot to do with his or her ability to be a physician in the USA. I do however feel that clinical rotations done in the US does play a significant factor especially as fars 'adaptability' goes. This is why I find it a bit perplexing that when someone of little Caribbean school knowledge,understandable, learns that all of our rotations are done in the US..they still make statements like...oh, well they probably weren't very good ones. I'm not about to say that Caribbean schools have the quality of US schools, but it's not any different than saying Columbia is a better school than the University of Nebraska. As difficult as it is, the best way to really judge someone is simply by individual analysis. Unfortunately, this is not possible in many cases which is why things like test scores must be used to draw some sort of denominator to move things along. These criteria backfire often, which is completely normal. I've seen AG's who are unbelievably incompetent, I've seen FMG's who don't speak enough english to order Tylenol, I've seen people who scored above 240 on both exams having to repeat their internship due to 'failure to progress'. Heck, we've all probably seen these things. I can't see through the eyes of foreigners who have come here for residency without having any US experience at all, but I do feel that having 100% of my clinical training here in the US certainly validates my education. I'm certainly no DragonFly, but I'm not going into cardiology. I'm a down to earth southern gentleman who just likes to take care of families then maybe see them later at the local I-hop. Just my two cents on the matter.

[sam1999]

Originally Posted by bluealiendoctor

First of all, Winged Scapula....your post on FMG/IMG's was absolutely fantastic. And Dragonfly..well you know you're one of my favorites. I can say as an IMG I have worked with many AG's as well as foreign. By foreign, I mean United States not being there country of origin nor completing school in the States. I can also say I feel there is a significant difference between IMG/FMG. IMG's like myself are plain Americans who went to school outside the USA. Actually, there is a 'sub-classification' as well. Obviously I get the occasional "oh, a foreign grad" that to me really doesn't hold a lot of weight. Why? Well, I really don't think where someone studied basic sciences has a whole lot to do with his or her ability to be a physician in the USA. I do however feel that clinical rotations done in the US does play a significant factor especially as fars 'adaptability' goes. This is why I find it a bit perplexing that when someone of little Caribbean school knowledge,understandable, learns that all of our rotations are done in the US..they still make statements like...oh, well they probably weren't very good ones. I'm not about to say that Caribbean schools have the quality of US schools, but it's not any different than saying Columbia is a better school than the University of Nebraska. As difficult as it is, the best way to really judge someone is simply by individual analysis. Unfortunately, this is not possible in many cases which is why things like test scores must be used to draw some sort of denominator to move things along. These criteria backfire often, which is completely normal. I've seen AG's who are unbelievably incompetent, I've seen FMG's who don't speak enough english to order Tylenol, I've seen people who scored above 240 on both exams having to repeat their internship due to 'failure to progress'. Heck, we've all probably seen these things. I can't see through the eyes of foreigners who have come here for residency without having any US experience at all, but I do feel that having 100% of my clinical training here in the US certainly validates my education. I'm certainly no DragonFly, but I'm not going into cardiology. I'm a down to earth southern gentleman who just likes to take care of families then maybe see them later at the local I-hop. Just my two cents on the matter.

I have to disagree with you on that being carib graduate and having done US clinical rotations are as good as US medical school. I don't think there is any comparison although there can be exception due to particular individual.

I have seen many carib students doing rotation at my medical school outside of USA. First of all there was a big difference in knowledge base and most of the faculty there used to ignore all elective students as it was none of their business.

Same was true when I came to do my electives here in USA during my senior year as I was ignored even though I doing hands on clinical elective and I think it due to being an elective student and it was mostly true for many other people who were doing electives as faculty don't evaluate them same way. There was biased what kind of cases I got versus case students from the same medical school got. I had to work hard to grab as many cases or good cases or making presentation as I can to show my interest.

Now carib students spend like 2 years in such an environment to get clinical experience and you are saying there is no difference in clinical training of carib vs US grad or difference is like between Columbia vs U. of Nebraska like of absurd statement. Training is not just doing bunch of electives as it is whole environment or institutional culture what matters.

[leorl]

The OP's question is really difficult to answer, because there's such a wide spectrum and you cannot generalize. As an IMG myself (American citizen IMG), I've found that the answer isn't in IMG culture / practice vs. US, but in the personality ofeach individual IMG. I work with a lot of IMGs and have met absolutely brilliant ones who are extremely intelligent, very good at documentation, have an accent but can still communicate very pleasantly and effectively, and are adored by both their attendings and their patients.
I've also met IMGs who are absolutely horrible communicators, seem very brusque and rude (even though I know that's not what they intend), have an attitude, or really have depressive issues because they cannot get accustomed to the US culture and US way of doing things.

I've also seen US grads do all of the above, and frankly, I've seen US medical students who study abroad be extremely annoying and have a sense of expectation far beyond the realms of reality. I think most IMGs (American or not) know what I'm talking about.

There are no "top three things" which IMGs should change, but rather what each person and each doctor, no matter where they train, should strive for.

[bluealiendoctor]

Sam, sorry but I didn't really understand your response. "carib grads at your school OUTSIDE the US'? That has nothing to do with what I was saying. Also, I didn't say that Carib Grads have an equal clinical rotation to any US grad...that is ridiculous. It is also ridiculous to think that all US clinical rotations are equal as well. My point is that for someone to say that a Carib grad doing clinicals in the US are doing inferior clinicals compared to any US grad is absurd. Many of my rotations/electives were done side by side with US medical students. I'm sorry you felt you were ignored, but I never had that experience during my 3rd and 4th years. About the Nebraska thing....I was saying that if you are going to tell a Carib grad that his/her rotations were of 'lesser' quality even though he/she served these rotations along with US medical students...well, then that really doesn't make sense and doesn't say much for the US students doing them....just like a Columbia grad telling a U of N that his/her clinical experience is sub-par to theirs. As others have stated, it really comes to the matter of one's character and integrity. You don't have to have a lot of character or integrity to do well with basic sciences. Understanding a country's culture and realizing that your own customs may be considered rude in this country and learning to accept the customary practices expected in this country are however paramount in becoming a good physician. And those qualities are quite difficult to teach whether you went to school at St. James in nowhereland, west indies or Columbia.