Thank you so much for joining us this afternoon on Monday to attend this conversation, this session and workshop with us that looks at challenges for international medical graduates in psychiatry in 2023. We'll be discussing hopefully a number of issues that have come up and also some possible solutions and strategies. As before we get started, just wanted to talk and just provide a little bit of information about how this session came to be. As part of the scientific program committee, for the very first time, APA has decided to have an IMG track recognizing the integral role that international medical graduates play in the workforce within psychiatry and how important it is to help support and retain international medical graduates within the profession to provide better care for folks needing psychiatric services. Traditionally, a lot of the international medical graduate panels that have previously taken place look at it from the standpoint of the barriers that come along the way when individuals are seeking residency spots or are rotating or once they land in how it is in terms of navigating the system, the orientation. But what's unique and specific about this particular session is that we are looking at some of the challenges that come about after matriculating in residency, after starting, looking at processes, challenges that come about in the sense of visas and immigration needs, bias, discrimination, prejudice. Also taking a look at it from the angle of, since the pandemic, how has that changed? How has that forefront changed? So just wanted to provide that framework briefly before getting started. So this one, I'll ask Dr. Trent to come in and introduce our next speaker. Hi, everyone. How's everyone doing? Hope we're not sleepy and a little post-prandial you might be, that's okay. If you need a stretch, that's all right as well. My name is Neha Trinh. I'm a psychiatrist at Mass General Hospital. I wanna give full disclosure that I'm not personally an IMG. My father was and he came over here in the 70s when they were FMGs, right? And so think about how, thankfully, the wording, the nomenclature is starting to change and our understanding and our interest and desire to provide more inclusion and belonging has also changed. But we have a lot of work to do. But I wanted to say, I want to thank everyone for being here and then also my panelists for preparing such interesting slides and presentations. I will ask everyone to introduce themselves because these panelists have great titles and do amazing work. So without further ado, I'm gonna give you a sense of the agenda for today. We'll be talking about imposter syndrome, top challenges for Caribbean IMGs, immigrants and anti-immigrants, and then we'll do a little bit of an interactive workshop. So I hope to encourage all of you to participate and then have some moderated Q&A by our esteemed moderators. So thank you very much. And I'm gonna introduce it, Dr. Ohm, if you wouldn't mind joining us at the podium. Thank you. Hi, good afternoon. So my name's Eliyahu and I'm a psychiatrist in New York. I specialize in addictions and in forensics. I don't have any financial disclosures. Since we're talking about IMGs, I figured it's important to make it a little bit personal. So I'll tell you about myself, my journey and how I ended up in this position that I'm in today. So initially I was born and raised in Lebanon. I went to high school, college, medical school there. And I wasn't really planning to come to the U.S. I was getting ready to get started with residency over there and then I broke up with my ex, which is how often things happen. I'm like, you know what, I need a change of scenery. And that's how it happened. I reached out to a friend who lived in Pittsburgh and I'm like, hey, I think I'm gonna crash on your couch for a little bit and I decided to move to the U.S. And it was very spontaneous. The reason I'm mentioning this aspect is because what made this possible for me is because my father grew up in the U.S. and I had citizenship through him. So in a lot of ways, my experience as an IMG is different from the experience of a lot of IMGs and more similar to the experience of Americans who complete medical school in the Caribbean. So once I moved to the United States, I spent a couple of years doing a bunch of random things, trying to kind of stay connected, doing my step-by-step exams since I wasn't planning to do residency in the U.S. And then I applied to residency. I did my residency training in Providence at Brown and then I did a fellowship in addictions in San Francisco and another one in forensics in New York. But what made it all very much easier for me is the fact that as an IMG, I had a lot of the imposter syndrome and I figured that I had to affiliate with people who would give me credibility and that's really what I was pursuing early on. So I got involved with the APA, I got involved with all sorts of medical organizations, started doing a lot of work for these organizations and it was extremely rewarding. But now I can say it's probably done for all the wrong reasons when you're trying to find some legitimacy for your work. So the reason this is relevant is the IMGs represent a huge section, a huge part of the psychiatrists in the U.S. So when you look at the number of people who are accepted into psychiatry, a little bit less than 20,000 people are U.S.-trained physicians but 5,000 are U.S. citizens who trained overseas and then 7,000 to 8,000 are international medical graduates who are coming from other countries. So again, IMGs represent a huge number of the psychiatric workforce and of the medical workforce in general and the impact of IMGs is going to become even greater in the next couple decades as the number of physicians that are needed to serve the U.S. population is increasing. So this is what I was referring to earlier. When you're coming as an IMG, you always have this feeling that you have to do a little bit of an extra. You have to affiliate with people, you have to do some extra research, you have to work harder, you have to work longer and you have to do some quote-unquote observerships and there's no regulation for what these observerships mean, what kind of institutions can host them and there are a lot of stories that we're hearing more and more about IMGs being taken advantage of by places offering to sell them observerships where you pay for access to spend a month or so to shadow an attending physician in some community hospital in the U.S. And remember that all of this extra that you have to do as an IMG doesn't come for free, it comes with a significant financial burden that you have to expand. But the issues don't end at training. When you're trained, you're still an IMG, you're always going to be an IMG even if you're trained in the U.S. And there are some cultural issues that arise, you have to deal with a bunch of microaggressions all the time and the issue that I'd like to point out and highlight is there have been a lot of reports of IMGs being exploited by the institutions for which they work for, getting paid different salaries, getting employed through different lines, getting access to different kind of benefits in a lot of major institutions where IMGs are employed through one line of work and then U.S. physicians who don't need a visa are employed through another line with different salaries and different benefits. Which kind of brings up the issue of the imposter syndrome among IMGs. So what is the imposter syndrome? It's not a, there's no ICD code for the imposter syndrome. It's a phenomenon that's basically described by when a person doubts their own skills and that they have this internalized fear that they're going to be exposed as the fraud, the imposter they are. I call it a pseudo-delusional phenomenon because it almost feels like a real delusion except that it's not completely free of cultural basis. And it's driven by a weakened sense of self, straight personal relationships, insecurity, sense of isolation, et cetera. And it's not free of consequences. It does result in the person with the imposter syndrome not achieving everything that they could have achieved. So how does it end up working out? Because people with imposter syndrome still will have jobs, will succeed, will treat patients, will save lives. How do you make sense of this discrepancy when you feel like you're such a fraud but you're getting a lot of feedback, people telling you, no, you're actually not that bad or you're exceeding in certain things or you're getting some accolades, you're getting some awards, your patients are happy with you. How do you make sense of this dual reality of what your own perception of yourself is and how you seem to be accepted by colleagues? The first one is the pseudo-delusional aspect of it, that there's a tenuous acceptance that they deserve the success. There's a conviction that maybe I got away with this because I charmed people, maybe because I got lucky and I was the right person at the right time. And then there's some cognitive biases, some effects that have been described that are used often among IMGs to explain this imposter syndrome. The first one is the Dunning-Kruger effect. You might have heard of it because in popular culture, we often talk about Mount Stupid. So the idea of the Dunning-Kruger effect is it's a description of how much people know and how skilled they are versus how much they perceive they know or how much they perceive they're skilled. And the idea is people who don't have a lot of knowledge will perceive that they have more knowledge than they do. That's the first part of the graph. That's what they're referring to as, that's what's often referred to as Mount Stupid because it's people who don't really know a lot but think that they know a lot more than they actually do. And then the value of despair is for people who have a lot of knowledge but feel that they don't really have any knowledge and that's where a lot of IMGs fall, feeling that the amount of knowledge they have is less than it actually is or less than it's actually perceived. And then the Matthew effect is often used in the other direction. The Matthew effect is the idea that when you have access to one thing, it brings another. So meaning when you have wealth, it's gonna bring more wealth when you get some successful recognition. You're going to get a lot more successful recognitions. And it's another way that IMGs justify and use a cognitive dissonant model to justify why some of the things that they're succeeding in are working out. So this is all that I had and now I'm going to pass it on to the next speaker. All right. All right, how y'all doing? So I'm gonna talk a little bit about the Caribbean medical schools and some of our top challenges that IMGs face to go this route. So I know a couple people here and some of you may have been Caribbean graduates and can really understand kind of a little bit about what this pathway is. But I have no financial conflicts to discuss. Okay. So why would anybody want to go to a place like this to medical school? It's just, you know, disgusting, right? So there's a huge draw to wanting to learn in an environment that's peaceful, especially in one of your most stressful years of your life. And yeah. So talk a little bit about my story and some of the reasons why someone might decide to attend medical school in the Caribbean. So first we'll talk about experience, lower tuition costs, still pricey, flexibility in lifestyle, and then the limited availability within the U.S. medical schools. So if you're experiencing different cultures, that might be something that's exciting for you. But for me, it was a chance of a lifetime to live in an exotic and beautiful island. So my story was, I never applied to a U.S. medical school. I was in a situation where I had just taken my MCAT. I was in a rough place with a girl that I had been with for three years. We were breaking up, back together, breaking up, back together. Turned out that she had untreated borderline personality disorder. And it was rough on me. They know exactly what to say to bring you back. And it was a challenge for me because I kept coming into this relationship and out of the relationship and so on. But ultimately I knew I needed to go someplace and pursue my career. And rather than take my time and apply to a U.S. medical school, potentially be wait-listed, and who knows what the outcome would be, takes process, another year I would have had to wait around. I knew at that moment I applied to a medical school in the Caribbean, and I had immediate acceptance and I went for it. It was the best decision I ever made in my life, although it came with challenges. And we'll discuss some of these challenges. But one thing I'd like to mention are some reasons why other people may want to go. So lower tuition costs. In the United States, medical school is very expensive. And it's not cheap in the Caribbean, but it's not going to break the bank to the same degree. And that's if you match, okay? Coming back into the system as an IMG can be very challenging for many people. Not everybody makes it through the program. And not everybody that makes it through the program ultimately finds residency. There is a flexibility in lifestyle. So they are open to people that are a little bit older, that may have had prior careers, that may have done other things in their life and then decided to go into medical school. As opposed to a lot of medical schools in the U.S., they want a direct path. They want to see that this is what you wanted since you were a child. And so that gives you an opportunity for a second chance. And then there's limited availability within the U.S. medical schools. It's very competitive and it's getting more competitive every year. So it is a second opportunity for many people. All right, so Caribbean medical training faces many unique challenges. And these are very unique to traditional medical schools. So one, accreditation. There can be many different accreditation issues at different medical schools. Two, limited resources, which we'll go into. That can lead to limited clinical training facilities. And then there is a controversial weed out process and then there is stigma and bias that goes along with this. So accreditation issues. You need local, state, and international accreditation bodies. And these may change while you're in the process of your medical school. You can start at a medical school and things can all of a sudden in that country, political changes there can change that. There's people that have started at medical schools where they were once accredited in that country and lost that accreditation. And then because they weren't accredited in that country that they're in medical school in, now are not eligible for ECFMG certification. Which means you can't take the USMLE and you can't pursue medicine in America. Limited resources. This is a big deal. Okay, so there's not as much funding that goes into Caribbean medical schools and the training facilities may not be accessible to you. So what this means is that you may complete your first two years of medical school and you may not have a place to rotate at. Most of the Caribbean medical schools do your rotations in the United States. So sometimes there's no place for you to go and this can lead to a controversial weed out process. So in several medical schools, they may have only matriculated 30% of the class. Depends on where you're going. Okay, because if they don't have a place to put you towards third year, then what are they gonna do with you? Then you gotta find another medical school or switch some place and find a place to rotate. So this comes with the limited resources. So another really important thing to think about is this may lead to delays in your degree because if they're unable to place you immediately, you either need to move from place to place to get your next rotation lined up or you may just have to wait around for your next rotational to line up and be ready. So again, this is what I was mentioning about the controversial weed out process. So a lot of Caribbean medical schools don't have a place to put you towards third year so they weed you out. They require high scores on your comp shelves so that you, it's helpful in some ways because then you'll score higher on your step one but a lot of times they won't pass you through the program. And then the stigma and bias as being a foreign graduate or an international medical graduate. Why did you go to a Caribbean school? You might get asked that in an interview. Why did you not go to a US medical school? You were born in America. So you do have to face that bias. All right, so Caribbean medical schools often face unique challenges when trying to match into residency. So there's limited residency positions and you have to really decide that if you do go to a Caribbean medical school that you may not be able to go to any position that you'd like to pursue. So it's limited to what we call IMG friendly programs and that also limits your options for geography because not all cities and not all places are open to IMGs. And so that means that you're gonna have to apply all over the country and see where you can get interviews and that means you might apply to 200 places and end up with five interviews even though you've scored above the national average on your boards. All right, so some specialties you can say are not IMG friendly and that means no matter how well you performed on your boards, no matter how much research you did, no matter how much you've invested into that, they may still not be open to you. So before you decide to go to a Caribbean medical school, make sure that the specialties that you're interested in are matchable to IMGs from the Caribbean. Psychiatry in recent years has become more competitive. So many years ago, a lot of Caribbean graduates and foreign graduates would apply to psychiatry as a backup and that doesn't hold true to today because psychiatry has become more and more competitive for IMGs and if you don't have a solid foundation in psychiatry and a proof that you really love this field, then you're not gonna get an interview anyplace. And then as a graduate, as a foreign medical graduate as the same with the Caribbean, you need to do well on your USMLEs to be considered for an interview. All right, so a substantial number of students who start in the Caribbean do not ever receive their MD degree. Despite having a low matriculation rate, many of those who do obtain their MD degree from the Caribbean still have poor outcomes in the match process. So here's a little bit of advice for someone who's applying for psychiatry as an IMG or from a Caribbean medical school. Publish research, publish as much as you can. So I got into research when I was in medical school because I knew it was gonna be a challenge to come back into match in the United States and to pick the geography I wanted to go to and so I published as much as I possibly could in psychiatry and some other things to prove my interest in the field. So if you don't have any publications in psychiatry and this is your passion, that's one good way to prove yourself. Complete your clinical electives in psychiatry and after graduation, do some observerships and externships in psychiatry. Once you graduate, you're not done. You gotta keep showing how much you love this field and how much you love psychiatry and that you were meant to be a psychiatrist. Prepare well for the USMLEs, take the practice tests, do thousands of practice questions and make sure that you're scoring above the national average on your boards. Push the test off if you possibly think that you may fail it because attempts are looked as terrible for an IMG and consider taking the USMLE Step 3. More and more now that the USMLE Step 1 has gone past fail, the Step 3 is gonna become for IMGs in the Caribbean, okay? And if you haven't matched on your first cycle, all of these here are extremely important to get you through. They're gonna look at what you're doing from the time that you applied last into your next application cycle and if you haven't been doing much, they're gonna wonder why you haven't been doing much. So do as much as you can. Research, electives, observerships, externships and take your Step 3. So that's about it. Thank you. I'm an immigrant, so I thought I'd talk about immigrants and a history of immigration. I'm actually from Sao Paulo, Brazil. I was born there, part of a large Chinese-Brazilian family. Let's see, no disclosures. Immigration to the United States actually started from Asia, and this is a diagram a lot of elementary school kids and high school kids get. This is actually from a history textbook that the original immigrants to North America came from Asia and, in fact, North America and Asia were one continent. This thing that they often call a land bridge called Beringia was actually the size of Australia. Here, this is a map from the National Park Service. And then European immigration started around 1492. Columbus lands in what is now the Caribbean on the island now called Hispaniola, which is occupied by Haiti and Dominican Republic right now. And then other European immigrants came, Coronado into New Mexico. 1620, pilgrims landed at Plymouth Rock. And interestingly, in 1763, in what's now Louisiana, there was a Filipino settlement of Manila men. And so a lot of the Spanish people who came over were actually Asian. There were Filipinos who jumped ship from the Spanish galleons, and they wound up settling in Louisiana. And in New Mexico, where I lived for a long time, you can see pictures of Chinese people with their long queues in very old paintings. So it was then like now, a lot of Asian labor did jobs that the Europeans didn't want to do. And then in 1776, you get the Declaration of Independence. Okay, so I want to get a little bit into immigration and citizenship laws, which I think is relevant to all of us, including myself. So the first Naturalization Act was 1790. And before that, everybody just came over. They just, you know, it was like, there was no border, everybody came over. And then shortly after the United States of America was founded, they decided they need more people. There's not a lot of people here in North America. And most of the people here were Native Americans. And so the European settlers, the founding fathers, they put together the 1790, so this was the first Immigration and Naturalization Act. And it limited U.S. citizenship to white persons. And the word that they used was white. And the criteria was to be a free white person who has lived within the jurisdiction of the United States for two years. So that was the first Naturalization Act. Then after that, you have the Civil War. And then the next Naturalization Act occurred about 100 years later in 1870, after the Civil War, when at that time, they used the term aliens of African nativity and African descent were then able to become naturalized due to the 14th Amendment. And then the 15th Amendment gave African American men the right to vote. Okay, so remember the criteria to become a naturalized citizen of the United States was to be white. And so you had people who contested this, Takao Ozawa in 1922, he was a Japanese American. And he said, my skin is white, can I become a U.S. citizen? And the courts denied him because he said a white, they said a white person actually meant Caucasian. And a Japanese born in Japan, being clearly not Caucasian, cannot be made a citizen. So then the next year in 1923, Bhagat Singh Thind in California, he was Caucasian from the Caucuses and he was Aryan. And he said, well, I'm Caucasian, can I become a citizen? But the courts ruled that he was not white, he was Caucasian, but he was not white. So he was denied citizenship. And this is a poster that a law school did based on this history. Okay, so you notice that of the people who contested this, of the Asians who tried to become citizens, none of them were Chinese. And that's because of the Chinese Exclusion Act of 1882 through 1943 that basically excluded Chinese from immigration, not just citizenship, but immigration. They could not come to this country. The railroad had been built, it was done, their labor was not needed, their labor was a threat. So the Chinese Exclusion Act occurred in 1882. But it was actually the Asian women who were excluded first a few years earlier in 1875. And before, so like you were in California and around the time of the Gold Rush, 1849, the 49ers were Europeans, they were Asians. Everybody came over here to mine for gold and there were no borders. People did not have to have a passport or a visa to come and stick their pan in the river at Sutter's Delta and mine for gold. And then, so borders were created in 1875 to keep out Asian women who were called lewd and immoral. My take on that is that they did not want to be trafficked into prostitution, but yet they were blamed for it. This is an early, so we may all know that tourist attraction in Los Angeles, the Chinese Theater, and it started out as a World's Fair exhibit of Chinese slave girls. And that's a picture there. Um, so actually, this is my, I helped to edit this book, The White Devil's Daughters by my friend, Julie Franz Seiler, about how Asian women continued to be trafficked in the United States well into the early 1900s. And I'd say they're still being trafficked now. Okay, so after the Atlanta spa shooting in 2021, this is when a gunman went into three Asian spas in Atlanta and killed six Asian women and two others. And he said, I'm not racist. It's just that these, you know, I blame these Asian women for my sexual urges. So he initially was not charged with a hate crime, but APA leadership, including President Geller and myself, penned this statement from the APA stating that the sexualization of Asian women has been going on since 1875. And Asian women have suffered from this kind of maligning and stereotyping. And shortly afterwards, he was charged with a hate crime. I don't know if maybe we had something to do with it, maybe. So the Chinese Exclusion Act lasted until 1943, when 105 Chinese were allowed to immigrate yearly. So basically Chinese were still not allowed except for 105. This is my grand, these are my grandparents. And my grandfather was a general in China and he worked for Harry Truman. He was, he worked for the US government. But then after China became communist, my family had to leave because they were not communist and quite involved with it, being quite involved with the other side. But because of the 1882 Chinese Exclusion Act, my family was not allowed to immigrate to the United States, even though my grandfather worked for the US government. But Brazil welcomed my family and that's why I was born in Brazil. And so during all the anti-Asian hate that happened during the COVID pandemic, I decided to reclaim my name, Dora Linda, which is a Brazilian name that bears the memory of the Chinese Exclusion Act. In 1965, and this is really relevant to international medical school grads, that because of the 1964 Civil Rights Act, we have to thank African American activism, Martin Luther King and Malcolm X, for the 1964 Civil Rights Act. And then the year after, the 1965 Immigration Act occurred. And up until then, immigration was basically for whites and Europeans. But in 65, it was no longer based on national origin or being white, but based on skills and family reunification. So this kind of, I think, opened the door to international medical school grads. Okay, so I think maybe I'll just stop there. Shortly after this opening, this 1965 Immigration Act, Lindberg Sato was a Japanese American psychiatrist who said that moving forward, the workforce is going to be full of international medical school grads. And psychiatrists, particularly, will mostly be international medical school grads. So he predicted the current situation that we're talking about. But he said also that international medical school grads will provide a lot of the care at state hospitals. And then the challenge will be to give IMGs the support and education to do their jobs well. So, in any case, thank you. Thank you. Thank you. Yes. Thanks so much to everyone. And the next step that we're gonna do is we're gonna do a workshop. But before that, we wanna open the panel for a few questions. Out of these topics that we talk about, if anyone in the audience have any questions about it. Please, and go to the mic. The exclusion of all the immigrants. Do you mind speaking? The mic. In regards to the people that were excluded from immigrating before, there were Chinese people that were here and working in the railroads. And there's a history of a lot of people from the subcontinent actually being in California as well. What was their status? Did they have work visas or permits or something back then? I believe a lot of them were illegal. That they were brought over as laborers. And then a lot of them were descended from laborers who came over before the 1882 Chinese Exclusion Act. And then there was this whole thing of paper sons and paper daughters that people had fake papers saying that they were related to people living in the United States already, Chinese laborers. There was a big fire in San Francisco in 1906. Back then, we didn't have digital records, and so a lot of papers got burned. And then people claimed that they were actually born here in the United States. So that was something else that happened. But yeah, I think there was a lot of illegal immigration, just like there is now. Very good. I do have a question for the entire panel. And as everyone here very eloquently explained, there are different type of challenges that IMGs experience from the structure of entering into a residency and graduating to a program, to individual insecurities that we carry as immigrants, or has been the very isolated and unique in a residency and our experience. Do you have any of you have any thoughts or any experience in the way of mentorship from IMG to IMG into navigating these challenges? And if there's any experience you may have had with any formal programs that train IMGs to be good mentors to juniors that are coming in. That brings up a question for everyone. Yeah, okay, I think I'm the only one here, so one of the big things that I think in going into mentorship that I had was finding others that were in the same situation and going to social media, looking online, reading Reddit, podcasts, like Dr. Essam over here has a great podcast going on. But so when you go and you find these resources, they really help you. And you can develop mentorships and different people that can help you along the way. I found someone who really helped me with research, and I think I put out almost 30 publications before the time I even applied for residency. And when I went for my interviews, that was a tremendous difference because they said you look motivated, you love psychiatry, I want you to come here. Like, please come here. So I think having those things and building your CV up, it makes a difference. It makes it show that you really care about the field. So. Very good, thank you. I think that we can, do you have a question, please? That's okay. Absolutely, we have time, yeah. Great talk, guys. Quick question, the first two speakers, you guys spoke a lot about the challenges IMGs face and how IMGs have to prove their worth, per se, when, you know, they come in. And it doesn't matter if you've done medical school, it doesn't matter if, you know, you've worked overseas before you come here. When you come to the States, you start off scratch, like a little baby, and you have to rebuild your resume because the, whatever skills and qualifications you have outside of America are pretty much redundant to you applying to residency, getting in residency. What can, so obviously there's a lot of onus on the applicants to do well. What can we do to, the word I'm looking for is to maybe put some onus on the lead medical leadership to be more open to recognizing the skills and qualifications that IMGs bring to the table? There isn't a lot of leverage, and let's start with leverage because if you're going to put some pressure. But like I said, the role of IMGs is going to increase significantly as the number of US trained physicians is going to decrease as a result of growing population, growing need for physicians, and a lot of retirement from the baby boomers. The numbers play a huge role, but other than that, the biggest source of leverage is going to come from seeking out support from organizations that have a lot of IMGs. So whether it's the APA, the Association for Addictions, the Association for Forensics, the Association for Child Psychiatry, the AMA, all of these organizations have IMG-focused groups that can carry some weight in numbers. But the biggest issue really is going to relate to contract negotiation and some of the legal regulations that are unlikely to change based on our own activism or that kind of work. Can I trick you? I had the pleasure of having breakfast today with Dr. Dinesh Bugaro, who's the former president of the Royal College of London, and also Dr. Ike Ahmed, who's a geriatric psychiatrist and the former president of the AGP, the Association for Geriatric Psychiatry. And what came to mind when you asked that is that we need representation, right? And so they told, I told them about this wonderful session. They both are IMGs. Dinesh has, of course, written volumes about this topic. And they both shared with me really poignant stories of being discriminated against. Themselves, right? These are like Professor Emeritus, Clinical Professor. I mean, these are very, I don't know, distinguished psychiatrists. So number one, sort of the representation, right? So we're going to look to these guys. We're going to look to you guys, everybody, to bring that topic. And so I'm really glad that there is more focus to that. One anecdote, Ike Ahmed was a residency training director in Hawaii, and he was recruiting. And he was sitting there with the faculty, and they said, well, we just don't want IMGs, they're not qualified. And Ike just looked at them and said, you know, I'm an IMG. And they kind of took a step back, and they're like, oh, because of course he's a residency training director. They hired him for that role. They had a lot of faith in him. So that kind of brings the point home that it is about representation. That it's about calling people out when they use, you know, antiquated terms and are discriminatory against our colleagues who are, I would say, even more qualified than we are given all of the things that they've had to do to succeed in the states. Thank you very much, and I'm going to turn it back over to Dr. Trinidad for a few more questions. Very good. Now, we're going to move into an activity, Dr. Trinidad is going to explain the foundation of it, it's an interactive, it's going to be in groups of three people. It's a role play, and it's a role play that is going to spark some conversations and some experiences, and how can we together share some of those experiences and how we together are going to protect each other in the future to kind of upstand ourself as immigrants in face of these challenges. So anyhow, I'm going to get you presented. All right. Okay, I call this seventh inning stretch, all right? Y'all are going to get interactive instead of dozing off on me, I promise you. All right, here we go. So this is how to be an upstander, and I really firmly believe that each of us has a role, not to be an ally, ally is okay, you know, that's like maybe checking a box, but to be a co-conspirator, and I know co-conspirator might sound negative, but it's this idea that we're in cahoots together to change a system. All right. So many thanks to our moderators for organizing this session and inviting us, and then to particularly to Dharav Gupta who said, yeah, I think we should have an interactive portion, you know, and so kind of pushed me to be a little bit more active with you guys, okay? So none relevant to this presentation in terms of disclosures. So let me tell you a little bit about the Bias at the Bedside workshop. Carlos was an active participant and facilitator in its pilot, and we were talking about it this, at lunchtime, and I told him about a microaggressive comment that I experienced yesterday, and he said, it's all about a race, Neha, it's all about a race. So it's this hour-long workshop that this wonderful group here, so we have Adrian Gherkin who's now training director at Thomas Jefferson, Heather Vestal who's a training director at Duke, Chase, why am I blanking on his last name, Carlos, Chase Anderson, thank you very much. He's a child and adolescent psychiatrist here at UCSF. V. Fowler who's a graduating child and adolescent psychiatrist, and this was her brainchild, and she was an APA minority fellow, so for those of you who are in residency, I'd love to talk to you about that wonderful fellowship. So she created this, myself, and then Nadia Kihihe who's a consult liaison psychiatrist in the yellow, so that was from left to right. And this was one of the last conferences I went to pre-pandemic. This is the first one I've gone to post-pandemic, and it's really good to be presenting to you all in real life rather than to a screen on Zoom. So as I said, this was an hour-long workshop using the ERASE framework. We started first in person, and then we migrated to Zoom. And you could imagine, even on Zoom, it was actually quite effective because we were able to engage our audience using role plays, and so you guys get to do a little demonstration of that. As I suggested, this was a group, I think at Columbia, who used the ERASE framework, right? So this idea that we have to expect that mistreatment might happen, right? Even if we think that we have all the best intentions, unfortunately, our trainees, our faculty that are IMGs will experience mistreatment. We need to recognize it and call it out when it occurs, address the situation in real time, support the trainee or the faculty member after the event, and endeavor to establish a positive culture. So we do pre-work in the real workshop, and we do breakouts with role plays, and we have a large group debrief and discussion at the end, all in the span of an hour. Now, I have right here a content handout where I combine this ERASE framework with the Mayo Clinic SAFER model, right? And so this is a model that our institution at MGB has incorporated. So it's like this idea of a graduated way of responding to a difficult situation. And, you know, it's really this idea about stepping in, addressing, focusing on the values that we're all coming to in the healthcare environment, explaining those expectations and setting boundaries, and if needed, and none of those things work, to really report the incident to one supervisor and document the event. So here's a, oops, excuse me. Did that not come up? Oh, right. Well, this will come up. So this is the content handout. There's a QR code here. There's a Padlet I learned from my kids. So there's all this information and the references there that you can take home with you. But it's a toolkit, and we give this as kind of like a guide for our workshop. And I recently did a workshop with our acute psychiatry service, and the associate director was like, this is going to be my security blanket. So I'm going to, this is the way I'm going to respond if one of my trainees is mistreated. This is the same QR code. Don't worry. This is the role play. So if you have the APA app, I actually put those, the PDF of both the content handout as the role, as well as the role play that we're going to do there and the QR code for our resources there as well. Okay. So now's the time for audience participation. I saw a couple people walk out. I don't blame them. I don't, I don't, you know, it's like not, role plays are not for everyone. I hear role play. I want to head for the hills, too. It's not easy. So for those of you who are still with us, thank you. So here are the directions. So I'm going to ask you guys to break in groups of three. I think we might have, you know, one or two groups of a little bigger. Oh, yeah. Thank you. Thank you. Oh, I love this. My panelists are putting themselves out there as well. So we're going to ask you guys to break in groups of three. You're going to decide on roles. Who's going to be the patient? Who's going to be the learner? And who's going to be the teacher? In general, in mixed groups, I try to encourage the learner not to be the IMG or the person who's going to have mistreatment because that might be, trigger some responses. But if you feel comfortable being that learner, that's okay with me. But just to say, if you don't, please be forewarned. I'm going to ask you guys to read a script and then continue improvisation afterwards. Some people say, oh, yeah, I'm going to do this role. But, oh, what are we doing next? You're going to keep going. This is like an improv class. And then afterwards, you're going to go for a few minutes and I'll do a set of timer. You're going to debrief. What was the experience like to be a learner? What was it to be the patient and the teacher? All right. Yeah. Okay. Before you start, please introduce yourselves to each other if you don't know each other. Okay. All right. So heads up, here's the scenario. A trainee who identifies as black is rotating in the psychiatric emergency service at a major urban teaching hospital. The trainee is evaluating a patient who is on an involuntary hold for suicidal ideation with a plan. And the teacher, supervisor, is observing. So there are three roles, trainee, patient, and teacher. So decide on the roles. And then after that, you have the script in front of you. I'm putting it up here, but then feel free to read as you have it on your handouts. All right? And I'll give you guys about three or four minutes. And when I hear everyone, you know, you can call time when you feel like, okay, we're done. We've gotten enough about it. Yes? Oh, the role play should be here as well. The role plays are on your. Do you see the role play, Dora? All right. Action. Okay. So from here, it sounds like everyone's very engaged in a conversation, which I think is the goal of this. Now, this is the time where when we get together and start talking about what our thoughts are and how do we debrief these situations. Nia, I'm going to pass it on to you. Okay. So thank you all for being active participants. How did it go? What was it like for the learners, for those who played the learners? What was it like? Anyone want to say? The role of the learners? Intimidating. Yes. Other reactions? I was a teacher and I felt intimidated for her. You felt intimidated for her as a teacher. Yes. So you were feeling that. You were feeling that, too. In the back, I think you had your hand up. It just sort of felt like I wasn't there. You weren't there. So you felt invisible? Yes. Yes. Yes. It was a hard feeling. It was a hard feeling. How about the guys over here? How did it go for the learners? Intimidating, too. Yeah. In the back? No problem. Got it. Got it. So you took some. Come on in. Have a seat. We're just discussing the role play. I'll give him a hand out, I guess. Thank you. All right. How was it to be the teacher? You mentioned feeling intimidated on her behalf. Other teachers, how did it feel for you all? Trying to intervene. When you called the time, you were the real teacher. I hadn't dressed, I hadn't stood up yet. Oh, okay. Yes. So you felt like you hadn't done enough somehow. Some, a lot of people who play the teacher role feel like even if they're very experienced attendings or supervisors, that they're at a loss for words about what to do. They don't know how to help. How about to be the patient? That's also a difficult role. Oh, it felt great. So maybe some sublimating aggression. Sorry. Dora, go ahead. It was kind of fun. I've never said these really. Yeah. I hope I don't continue. Yes. I hear that. For some people, it feels very uncomfortable to say those things, right? Because it's not really your values and yet you're here you are. I mean, we sort of, it sounds like you all took a more lighthearted approach. But for some people, it can be very uncomfortable. All right. Now, as we were, as you all were doing these role plays, the first question is what do you think was underlying the patient's biased statements and are the reasons even that important? Does the intent matter? So in fact, that behavior was insecurity and he's kind of projecting it onto the learner. Exactly right. Yeah. And he's at the end of his rope. Sorry. Go ahead, please. So some avoidance there. You are very empathic psychiatrists. Because I would say even if we understand the intent psychologically or psychodynamically, it kind of doesn't matter, right? Because the impact is what we're focusing on, the impact of the learner, the IMG resident or trainee or faculty. And I would say that even if the person is at the end of their rope, even if they're not in their quote unquote right mind, we want to redirect them, right? So if someone was physically aggressive to us or to one of our team members, we would take action immediately. And the idea is here, they're being verbally aggressive and invalidating to our trainees and we want to step in. So number two is what are possible ways of responding? I gave you all the cheat sheet, the content handout that gives you some ideas. But there is a question that Carlos and I were talking about at lunch, who should respond and what are the pros and cons of different kinds of responses? I think coming as an IMG who's currently training in South Mississippi, these are literally everyday experiences that I have to go through. I think the best way to respond is to take the power into your own hands. I don't depend on my attendings because they've essentially grown up with the same culture and they don't see it the same way that I do. One of the things I usually fall back to when I get emails like this is, do you have any concerns about how your care will be impacted because of where I'm from? And then sort of put the background of the patient and then they either say yes or no and then they will actually move on to the actual patient care process. That's what I've found in mine. I think you make the invisible whistle there. Yes, exactly right. I think it's important in times. It is. You have to call them out and you can do it in a professional manner. Yeah. Well, first of all, I'm sorry to hear that that's like an everyday experience for you. You're being quite proactive in taking care of yourself and you figured out what to say. And at the same time, Carlos and I were talking about this, is that we're getting old. That our generation, we kind of think like this is just what we have to do and suck it up. But that's actually not right. And we're actually calling for a culture shift, which is why we're asking people who might have more privilege in that team setting to step up. I was just talking to Carlos and I was kind of like caught like a deer in headlights. I was about to give you a workshop about this. This happened. And he's like, well, that's because when this happens to you, you kind of lose all your druthers. And that's why you need sometimes either an approach where you say it right away and you're like, this is how I'm going to handle it. Or if it happens unexpectedly, that you could rely on a colleague, a teacher, a supervisor, a team member to intervene on your behalf. So that's what we're calling for. We know that this is kind of a shift maybe in the culture of medicine and culture of psychiatry and certainly regional cultures as well. I don't know if I mentioned this, but I grew up in the south in New Orleans. And I feel very strange sometimes when I walk around there and feel like people don't see me as from there. They see me as a foreigner still. Any other comments from the group? I think when it comes to relying on others to stand up for you, although it's great and obviously others should, when they don't and you expect them to, that comes off as betrayal in a way. And sometimes it even comes off as they don't have my support. And in the future, you're a little bit more on your toes about it, if that makes sense. So if there is going to be that reliance on others to communicate beforehand, I don't think it can be expected because without being communicated, that can lead to more negative consequences in the long term and actually impact your relationship with your teacher. You're totally right. I think that what Niha was mentioning is that sometimes it's going to take our leadership. Because we see these things happen and it's very difficult for the person who's receiving it and the receiving end for it to react. I've been on the receiving end of things and either you rationalize it or you cannot believe it or you're in the path of a conversation and it's very hard to deviate, to make a stance. But if somebody has witnessed of it, a lot of people like you are saying, well, that's so bad. That's wrong. That should not happen. But nobody dares to say anything in the moment. And sometimes once one person says it, it makes it safer for everyone else to also call it out when that happens. And this type of microaggressions or some very racist actions can impact the person who's being in the receiving end a lot of the time. And we thought about this for inpatient psychiatric units. Because it was a debate of, oh, the patient is psychotic and we should cut them some slack on that. But the problem is that there are patients that are around that that are also hearing those things and that the impact is not just the person who's in front of it, but there are other people around it that are also being impacted by hearing and seeing that nothing happens when those things get done. So sometimes it takes, for us outside that conversation, when interactions happen for the person who's outside to be able to kind of, because we have a little bit more leeway or because we're not part of the interaction, to say something about it. And once we make it safe, it can express that people feel safe stepping out on that. Yeah, I would just say I totally think that you have to protect yourself as an individual and not necessarily wait for someone to step in. And similar to the comments earlier about how a lot of the recommendations were about how each individual IMG needs to beef up their CV and be proactive. And there was a question of, you know, how is the structure going to change, right? And so we're advocating for both. Yes, if you feel comfortable and you feel like you can respond, please do. And we're advocating for everyone to also be a part of that change as well, if that makes sense. There were eight parrots there, and I remember that somebody who came in to San Francisco General covered with swastikas, so I could just see. Yeah. I mean, it's interesting because a lot of people who, as you all know, who might be dysregulated will say and do things that later they regret. And so for us as a care team to provide some verbal boundaries around that behavior, once they're back in their regular selves or their usual selves, they feel quite ashamed about what they were saying and doing, right? And so we're helping them. We're helping to set those boundaries. Yeah. Exactly right. When you have said at the beginning, they may have a good intention, but they're unaware of the impact that it's having. And you don't have to shame them, but you can make them aware of the impact. And they may themselves turn into allies when they understand that, oh, I had a good intention, but the impact is different. And we can help them in that journey. You were saying emphasize their anxiety and fear that drives the aggressive response. No, I mean, depending on the one, I was referring a little more in the some patients may not have the intention of being aggressive. They may have the intention of complimenting coming from a point of ignorance. They ignore the impact of their comment into the other person. In those cases, there's not much that is gained by using methods of more aggressively trying to shame the person or set boundaries, but to educate about how that could make someone feel bad. And that can be more helpful in the end than just taking the more aggressive stance or being shameful or setting a boundary when somebody's intention is even though we can educate about the impact. Thank you, Carlos. So here's some further reading. This is a paper that V. Follier developed after our pilot. We did a bunch of Zoom workshops in the year 2020, 2021. I got to know Carlos very well during that time. And also, the references for the Padlet, I put those in the Padlet as well. And I just want to say thank you. This is a view of Central Square in Cambridge, which is my neighborhood, my current hometown. And it is a snowy day, if you can see the snow on the ground. But it is always a new day and a new opportunity for all of us to make a difference. So thank you very much for being here, for being great participants, for all your questions. Thank you to the panelists for your amazing advice and wisdom and Q&A. And we have a few more minutes with our wonderful moderators. Any last questions or concerns, thoughts? Can we come to Padlet? Actually, this is related to previous aspects of our symposium here. Is there anybody here who is from Cuba? No. Because I think that one of the issues, and I'm a Follier graduate, but I'm from Jerusalem, from the Hebrew University. But what I encountered, I was very involved with the WPA, the World Psychiatric Association, and several others. I was in several places in the Caribbean, and including Cuba. And it's very difficult to tell American citizens that actually medicine in Cuba, and medical school in Cuba, in general, are better than the most American schools. And I think that it will be quite interesting if somebody from American citizens go to Cuba for medical school. It's politically not acceptable now, but there are older Cuban physicians who are practicing in the United States. And I think that we might also make a case, and this is very challenging. If you ask people in disastrous areas, in emerging countries, or developing countries, which physicians they want them to help them, consistently there are two possibilities, or two answers. Cuban doctors and Israeli doctors. And I think, but not Americans. Even though Americans have more money and are coming better equipment, and the Cubans and the Israelis are not, they want the Cubans and Israelis. And we have to ask ourselves, when we talk about biases, is there substantial evidence of biases against graduates from Caribbean schools, or from Cuban, or European, or anything that is not American? And I think that if this forum, even though it's so small now, can do something, is to say that American graduates are not superior. Some of them are, but most of them are not. The issue is how to overcome this bias against Caribbean graduates to be integrated and to be in leadership positions in the United States. Thank you so much. I think that you touched on something that it reminds me of the work of Amos Stravetsky on the halo effect, that we assign better value to everything that is ours and is less valuable if it comes from abroad. And I think that that's uniquely strong here in the United States in the sense that it's always the greatest country in the world. Everybody kind of repeats it and repeats it and repeats it. And it's hard to overcome from Hasan Emdy to come into a place where that halo exists around it, right? But I think the solution for that is actually representation. And when you have people, we strive to create that diversity in leadership, when we give opportunities and voice and microphones to people to express their knowledge. And I was in a talk yesterday about biomarkers on a skeleton that was all driven by IMGs. That was spectacular. They spoke with such eloquence and so much master of the topic that you can see how that leads to say, well, these people are really, really smart and they all come from abroad. There's something that we have to do. But those voices are slowly growing. And that is what speaks about this, that we have to create that representation. And those of us who have been lucky enough that we have given these opportunities, we have to encourage the ones who are behind us, the younger ones, to even have a louder voice than we have. And that we speak louder. And they do better things than we do. Because that's how we actually overcome those barriers, by creating that trust in the IMG, because they're competent and they're empathetic and they have something to add to the conversation. I don't know if anybody else thinks something to add. Thank you so much for the comments. That's it. Thank you all. Thank you, guys.

international medical graduates

psychiatry

IMG challenges

accreditation

visa issues

bias

imposter syndrome

Caribbean-trained doctors

immigration laws

ERASE framework

medical leadership