Good afternoon to you all, and thank you for coming. It's going to be a fairly intimate setting, it looks like, so feel free to get closer if you would like to. My name is Ramatze Saunders. I'm a psychiatrist and faculty at UCSF. I'm boarded in Consultation Liaison Psychiatry. I also practice Interventional Psychiatry, and originally trained at SUNY Downstate Medical Center in Brooklyn. My co-presenters are Moniza Majoka and Ali Haidar, both of whom also trained at SUNY Downstate, though some time after myself. Dr. Majoka did a Geriatrics Fellowship at Mount Sinai and is currently doing an Interventional Fellowship at Yale, and Dr. Haidar is currently working at Mount Sinai, and he has done a Child Psychiatry Fellowship. Our topic for today is Double Minorities, Exploring Systemic Barriers Faced by Non-U.S. International Medical Graduates in Academic Psychiatry. None of the presenters has any disclosures to make. Unfortunately, due to vagaries of time and space, my co-presenters are remote, so I will now be pulling up pre-recorded presentations that they have. They are also live on Zoom and will be participating in the meeting that way. Hello, everyone. Welcome to our talk on Double Minorities, Exploring Systemic Barriers Faced by Non-U.S. International Medical Graduates in Academic Psychiatry. My name is Moniza Majoka. I'm currently a Yale International Psychiatry Fellow and an IMG, and I'll be starting off the talk. Just as an overview of our talk today, we'll start off by expanding on the demographics of the International Medical Graduates. We'll talk about what the IMG experience entails, the trial and tribulations. We'll talk about the concept of double minorities and intersectionality, and then we'll kind of review the immigrant experience, particularly the psychological aspects. We'll look into the barriers which are faced by women IMGs, LGBTQ plus IMGs, and IMGs of color. We'll then go on to address mitigation strategies to address these barriers, and also the role of mentorship. I'll start off by talking about the demographics of International Medical Graduates. So International Medical Graduates are medical graduates that have basically attended and graduated from medical education outside of the United States. Traditionally, this group has been divided into two groups, one of them being U.S. IMGs, who are IMGs who carry a U.S. citizenship, but went to and completed their medical studies abroad. Non-U.S. IMGs, on the other hand, are IMGs who carry the citizenship from another country and also completed their medical education outside the United States. Historically, IMGs have fulfilled an area of need within the field of medicine in the United States, and this need is going to be continuing for the foreseeable future. The Association of American Medical Colleges estimates that there's a shortage of around 54,000 to 139,000 physicians, which will appear by 2033, and this will impact both primary and specialty care. When we look further into IMGs and their numbers over the past 50 years, the numbers of IMGs have increased from 10% in 1963 to around 18% in 1970, and then currently about 25% more recently in 2020. When we reviewed the graduate medical education statistics from the year 2019-2020, they show that there were around 32,000 IMGs in residency, making up around 23% of the residency workforce overall in medicine. In terms of IMGs in psychiatry and the psychiatric workforce, a 2012 analysis, I apologize, that analysis in 2012 showed there were around 31% IMGs in the total psychiatric workforce, and in 2020, that estimate has gone down a small amount to around 23% of the whole psychiatric workforce, still accounting for around 16,500 psychiatrists. Around a quarter of those are U.S. IMGs, and around three quarters, or 77% of the cohort are non-U.S. IMGs. When we look further into the background of IMGs, in terms of gender, mostly male presentation, so around 57% of IMG psychiatrists are male. The average age of the cohort is around 55 years, plus minus 14 years. They're more likely to be employed as full-time hospital staff or as locum providers when compared to the United States medical graduates, and also are less likely to be administrators or medical teachers. There are some very large numbers of IMGs in certain states, such as New York, California, and Florida, and in two states, IMG psychiatrists make up around half of the total number of psychiatrists in those states, in New Jersey and Florida. When we look at the countries of origins of these psychiatrists, medical school in Pakistan and India account together for around 30% of all IMG psychiatrists, and the other top 20 countries in a descending order of representation include Philippines, Mexico, Dominican Republic, Grenada, Barbados, Russia, Egypt, Nigeria, Samaritan, Romania, China, Israel, Colombia, Poland, Iran, Argentina, South Korea, and Bangladesh. So all together, they come from very diverse racial and ethnic backgrounds and cater to various populations. Traditionally, they have filled a gap in psychiatry. Department of Health and Human Services estimates a workforce shortfall of around 18,000 adult psychiatrists by 2030. The psychiatrist numbers are expected to also decrease by over 25% in that time due to the number of practitioners approaching retirement age or seeking or reduced patient workload. So this combination together tells us that there's going to be ongoing need for more psychiatrists in the country, where even currently the state is such that 75% of counties across the U.S. have a shortage of prescribing mental health clinicians, particularly psychiatrists. So when we look at the trend of graduate education in psychiatry, there has been overall change in the numbers available every year. The change remains small, yet it is significant compared to a few years ago. But if we are to meet the shortage of psychiatrists, we will need to see an ongoing further increase for sure. One thing to note over the last few years is that there has been an increase in interest of U.S. MDs or U.S. medical graduates applying to psychiatry. This is a very welcome change in the field of psychiatry, of course, which ensures that we have more psychiatrists, hopefully in the future, who are interested in this very interesting and wonderful field, but also an area of need for the population. The one aspect of that increase is that there is a decrease in non-U.S. IMGs overall who are matching into the profession, which rings with its own discussion of possible changes in the diverse workforce that we do currently have, which also is known to be working mostly in the rural areas and in a lot of underserved populations. This graph is just to show that over time, there has also been an increase in U.S. IMGs who are applying and successfully matching, and that number is almost at par with non-U.S. IMGs. Furthermore, recently, we have also seen a decrease in non-U.S. IMGs, which has been attributed to a lot of different changes happening around the world. Concerns about immigration status, for example, and also issues related to COVID and effects on travel. So the overall number of applicants who are applying to get an ECF-MG certificate, which you finally get after doing all your USMLE examinations from non-U.S. IMGs, numbers have decreased, especially from specific areas, which can be concerning. So when we are talking about IMGs and their ongoing need for the presence of IMGs in psychiatry, given the need, we also need to appreciate the IMG experience. The various issues that IMGs do have to deal with when they are coming to be a part of the workforce. These issues include issues that they faced before coming to the United States, once they have come to the United States, and then after, when they're trying to integrate with the population post-residency. So of course, when they're moving to the United States, there's concern, of course, about immigration, but also generally about the ability to match. The percentage of graduates who are non-U.S. IMGs who are actually matching into psychiatry has gone down steadily as the field becomes increasingly competitive. And so that means that for them to be viable competitive candidates, they need to have scores which are on par or even better than those of their fellow graduates from the United States or the U.S. IMGs. Further, they also have to have experience in the United States, either in the form of observerships, electives, or externships. There can be a financial burden in obtaining all that experience. There's also been limitations in the time of COVID to get that experience. And of course, there's issues of not having as much social support when you are in a different country. There's also the waiting period and the unknown, whether their matching chances will be successful or not. Once, however, they have matched, they still have to go through the immigration process, which still can be very tricky and as straight as the convoluted loops of an ephron. They are most likely to come into this country either on a J-1 visa or an H-1B visa. The J-1 visa, of course, carries the requirement that they work in an underserved area for at least three years after residency or they have to go back home for at least two years. And that is a choice that many cannot make at that point in their lives or is definitely difficult to make. Further, they're also, once they've moved to the United States, have lost a lot of their social support that they had in other parts of the world. They are also going through the separation from family and loved ones and friends, which can be difficult. Once they are here and they are starting to work, there's different biases that they are facing. There is a culture shock. There is adaptation and acculturation processes that Dr. Haidar will talk about further in the talk. But there's also some language barriers, different systems in health provision. The use of electronic medical records might be new for some. They also might belong to some ethnic or some ethnic minorities and racial minority, or as we'll talk about, multiple minority statuses, which together could lead them more prone to face discrimination and, again, explicit and illicit biases. So all of these together, it is a stressful journey from the time you're applying to be a resident in psychiatry to the time that you have graduated. Once you have graduated and are now facing the next steps, there are still significant barriers to advancement. As I mentioned, immigration and visa restrictions are one of the more concerning aspects. Coming from somebody who currently is trying to figure out this very crime-related process, it can be very stressful and unclear and unsure. In terms of, again, the J-1 visas, you have to be working in specific underserved areas or go back home for two years. One aspect of it, specifically when we're talking about academic psychiatry and the systemic barriers, which are a part of it, is a lot of these underserved areas may not have academic programs or academic positions to offer. They might be in rural community programs with limited resources. That would mean that they're, as we know, that a lot of times people are more prone, likely to stay and be retained in a program where they did advance medical training or move to academic programs, and that chance or ability is very limited for IMGs, which is a very significant barrier to further advancement, or at least starting an academic psychiatry career. When initially the IMGs move to a new country, they do not have the social professional circle. They are starting fresh, and they might have very limited interactions with others who are also hoping to have a similar career in academic psychiatry. Of course, the APA provides wonderful platforms, and they can be helpful, but there is a large IMG cohort that needs to be catered to and not all get access to having a thriving professional circle. Initially during residency, a lot of the non-U.S. IMGs also match in basically community programs. There are limitations to these programs' abilities to enhance the academic and social opportunities, to enhance the academic portions of these residence trainings or supplement them with research prospects or projects, which can inhibit the growth of possibly a budding researcher. Another important thing, especially that comes into play after graduation, if somebody is going towards a more research-based career, is the restrictions that are in place in terms of the NIH for giving grants. Those are based on citizenship, so initially, at least for a while, non-U.S. IMGs are not able to apply for grants or start off on a specific research leg of their career as they might have wanted to. Another aspect of the immigration process also comes in here, is that even after the J-1 process of working in an underserved area is done, and even if you had an H-1B and did not have to work in an underserved area, you still have to apply for a green card and go forward with your immigration process, and certain countries have a very long waiting list for them to be able to get a green card. And so that means that they continue to need to be on visas, they might need to get support from their employers, a lot of academic centers may not have enough experience, or the desire to have somebody whose status there is a bit more unclear compared to somebody else who will be able to continue on if they were a citizen. So there are a lot of difficulties that these specific IMGs might also face, and possibly there is some room for there to be an overhaul of the system of immigration, especially as it pertains to medical practitioners in this country who are non-U.S. IMGs, particularly in the field of psychiatry, so that this can be streamlined further. When we look at further cultural differences are a very important aspect of differences that are to be addressed. So as we mentioned, a lot of these non-U.S. IMGs are coming from very diverse ethnic and racial backgrounds. However, there might be a lack of understanding of the various differences, even after graduation, and they might be facing some challenges in their post-graduation life based on certain explicit and implicit biases associated with either their training or their cultural differences. One of the things that has been talked about in literature, for example, has been the Latinx US IMGs who come from various countries, and although there may be some linguistic or cultural similarities in the Latinx countries, they are all various different countries with different cultural set of rules and references. And to assume that one person would be able or represents a whole continent of people is a bit unfair. So more cultural education for our colleagues, our patients, everybody else that we work with, of course, it's something that we continue to work on. And one part that is important to mention is that the non-US IMGs are also an important part of diversity in the workforce. And as such, under the DEI aspect that is being implemented, and hopefully will continue to benefit from the DEI efforts across various institutions and across the country. A lot of the barriers that one faces do lead to this almost harken back to this idea of imposter syndrome, where initially one felt different, and this led to more chronic feelings of self-doubt and fear of being discovered as an intellectual or professional fraud. And a lot of the issues such as immigration, such as the discrimination, which many physicians, many non-US IMGs do face, brings back that imposter syndrome, makes it hard to shake. So that's definitely another barrier to advancement. A very significant barrier to further advancement is also a barrier to finding mentorship. Sometimes there might be cultural differences that might make it harder, or some non-US IMGs just might lack confidence in approaching senior clinicians and initiating that mentorship interactions. Mentors might also not be familiar with the work environment, with the cultural background of the mentee, or have previous mentorship experience. A lot of the times when, especially in training, there's lack of role delineation. Supervisors are taught to act as mentees, but there's not a clear delineation between the supervisor and mentor role. There's also a struggle to find a suitable mentor with whom the IMG could feel comfortable with, and who feel that they can relate to them. They necessarily don't have to be non-US IMGs from a similar background, but at least somebody would be able to understand the struggles of the new non-US IMGs, their cultural point of reference, and also their future ambitions and hopes. There might also be a geographical limitation that might affect the ability of the non-US IMGs to find appropriate mentorship. So taken all together, there's a lot of various issues that do also occur in the forms of finding appropriate mentorship, which again is a significant barrier to advancement in academic psychiatry, as many of us here can attest to. Having a good mentor can not just be life, but also career changing. And a lot of the times, these are the opportunities that might not be available to non-US IMGs. I'll quickly define the role of double minorities before I hand over the session to Dr. Haider. The idea of double minorities is that the psychological state created when two devalued identities interact to influence the individual, it's in such a way that the overall effect is greater than the sum of the independent effects of those two identities. So it's related to this concept of intersectionality where different identities overlap and the barriers that might be faced at that overlap have that part of the immigrant experience, but also specifically for double minorities who are minoritized based on other aspects, for example, gender, for example, sexual orientation, race or ethnicity, or all of these intersectionality aspects might play into having even more barriers to advancement than one would just suspect, for example, for a cisgender heterosexual male non-US IMG. That's an interesting concept that we'll be talking further about in the talk. For now, I would like to thank you for your time and hand over the microphone virtually to Dr. Haidar. Thank you. Hello, hello, everyone. Hello, thank you for the presentation. I'm a medical student. I'm currently a student in Mexico and I'm from there, all my life I lived there, and I would like to know about the possibilities of getting to study a residency here in the United States, especially more like a guidance or advice or steps to follow because as you said, as the presentation said, it is harder to find mentorship, especially when you're not from here. So which kind of advice you can give to medical students who would like to find their way into applying to our residency in here? Okay, I'd just like to make sure my co-presenters heard the question, did you? Yeah. Yeah, I think we're trying to give advice to folks, especially as one of our attendees here from Mexico about coming into a psychiatry residency in the United States. And so when I was kind of going over the presentation, I didn't focus on that part, but mostly an important thing to kind of, again, kind of tying in the talk to is making sure that you're trying to create relationships and mentorship here, even before you're matched into a psychiatry residency program, you can do it through doing electives while in medical school, doing observerships, doing any other forms of clinical experience that you can get to first ensure that you're able to understand and work within the medical system in the United States, but it also is a great opportunity to work with wonderful mentors who can then help you figure out the next path forward. Over time, it has become a more competitive specialty than it was maybe five to 10 years ago, but there's still a need and a space that is there for international medical graduates. And we should definitely try to get more experience in the United States and also form relationships. I think those are the two key things. Anything that any of the other panelists want to add? Yeah, I think I would echo that. I remember training and training in my country, which is Trinidad and Tobago, and under attendings whom were highly respected and known in that country. And they were writing me letters of recommendation, but they weren't known here. And American programs often, I would say almost always, want to see letters from American physicians. So it's really important to, if you do have the opportunity to do electives and form relationships with clinicians in the US who can write you letters of recommendation. There is sometimes also, it's harder in COVID times, but the possibility for an audition rotation. As a med student, if you have electives, rotating in a place not only where you think you could get good training, but where you think you would have a possibility of matching and taking the opportunity, if you have it, to do a rotation there. Okay, maybe I can go on to Dr. Haidar's presentation. Hello, everyone. Thank you for joining us today. I'm sorry I couldn't be there in person. It is actually related to being an IMG and having to be in my home country for visa reasons. But I hope we can get to have a good conversation today on this recording, and then I'm hoping to be able to join for the discussion piece later. So for today, I wanna talk about two things. I wanna first talk about what goes on in the mind of an immigrant in general, what are the particular challenges that people go through as they immigrate, because we are mostly focusing on foreign international medical graduates who undertake an immigration path when they come here for training. And the second piece is I'll talk a little bit about the double minority status of subgroups within immigrant foreign medical graduates. All right, if this was in person, I would have asked who in the audience is an immigrant. I'll pause if people want to just raise their hand if they are an immigrant and just look around the room. All right, so the United States is a nation that welcomes many, many immigrants every year. This had been the norm for many years, though there might've been a dip in the past century. Numbers have been steadily increasing since the 70s, consistently, as you can see here. However, despite that, we should keep in mind that not all immigrants are created equally. The trends of immigration to the United States have changed significantly over the past several decades. In this graph, you'll see that in the 1960s, the predominant chunk of immigration used to come from Europe, Canada, or other North American regions. However, in recent years, that gap has changed significantly. The breakdown has changed significantly so that now most immigration is coming from Latin America or Mexico or Asia. What does that mean? There are different ways of dealing with immigrants depending on where they're coming from, how they're coming, what they look like, what's their background. And that has certainly been in the news a lot recently, but has also been consistently reported. We'll start by also adding that the language that we're using does matter when we're working with immigrants. Are we dealing with refugees who are forcibly displaced? Are we dealing with people who are looking for more resources? Are we dealing with people who come here with the intention of going back to their home countries? Who is the trainee that you might have in front of you or the colleague or your resident, your trainee, your colleague? Keep that in mind and keep in mind that it may not always have been a choice. It might've been a constellation of reason that drove the person to come to you and they may not be fully at peace with the fact that they had to leave their home country. When you're thinking of an immigration process, you have to think about three stages of that process. So that includes pre-migration, which is once you've made the decision to prepare and to move. The migration, which is the actual physical relocation, the trip, the resettling here. And finally, post-migration, which is assimilation or no assimilation, depends on the person, but it's basically what happens when the immigrant is in the new society and how do they react to the new society. Keep in mind that any of these could have been difficult or traumatic or easy and different people will have very different experiences of their migration journey, depending on that. The mental health of the immigrant is what we're gonna talk about further the next part of this section. So in general, immigrants to the United States, and this is not specific to psychiatrists or to physicians. This is immigrants in general, regardless of socioeconomic status. Immigrants to the United States have low rates of mood anxiety and substance use disorder. They have it regardless of their age of immigration. They have less rates of that than the local population. There might be some higher risks of psychosis when compared to natives, but that persists in the second generation. Younger age at immigration equates an increased risk of mood and anxiety disorders. And then the longer they stay in the U.S., the higher the risk of psychiatric illness. These are all data points to keep in mind. We can try to understand them in a little bit. We'll try to talk about them. And this brings us to kind of the next thing that's often talked about in immigration literature, which is the immigrant paradox. So first-generation immigrants, as I mentioned before, have better physical and mental health outcomes than the U.S. counterparts when corrected for major confounders. However, the second-generation immigrants, so the children of those people, tend to have lower health status than their parents, and they actually are similar to the native population. This is the acculturation hypothesis, which is that the more an immigrant remains in the U.S., the more likely that their health status is gonna resemble that of the U.S. Obviously, there's difference between different subgroups. Some people may not experience this, people from certain social backgrounds, ethnic backgrounds, cultural backgrounds. But the general rule is that most people kind of start to look like the general population in terms of mental health stats. There's several theories that try to explain these observations. One of them is that there might be changes in the practices that the migrant is undergoing. So what kind of food do they eat? What are the values that they adopt? Are they coming from a collectivistic society where their parents had a lot of support based on that, and they kind of integrating into an individual society so it becomes harder? There's theories about structural racism playing a role where immigrants who come into this country from different nations were not subjected to structural racism before coming into the country. However, people who were born here get treated with the same kind of, or get subjected to the same structural racism that their parents would have been subjected to had they been born here. Another one is the health selection bias, which is that immigrants are healthier generally. People to be able to go through an immigration journey, they tend to be physically and mentally more resilient. And finally, one of those thoughts is that an added stressor, psychological stressor to the second generation is that they're in a conflict between trying to retain the cultural identity of their parents and trying to assimilate with the new adopted culture. And that might add to some of their anxiety or stressors. No matter what we, what is behind those kind of notions, what I wanted to highlight predominantly today is that immigrants are first and foremost extremely resilient. So although I'm gonna talk a little bit now about a lot of the challenges that an immigrant faces, I want us to keep that in mind is that we're mostly talking about very resilient people. So here are some core themes in an immigrant psyche. Immigration can be a traumatic event. When you're talking about that, you have to think about an uprooting from everything you've known, a possible loss of an identity because we lose places and spaces to anchor our identity, possible regrets and being conflicted about the trip. You might have not been fully on board with it. You were trying it and then you might feel disappointed. And that brings up a lot of regrets, a lot of stressors. And a very important piece that we often don't keep in mind is that most people who come here and work with our populations here tend to not use their mother tongue. And unless they have another community where they could practice it, they tend to lose that piece of everyday familiarity. Immigration can be destabilizing to the immigrant, the family of the immigrant themselves in the host country and in their original country. It can also be destabilizing to their entire world or psyche. The effects of this can be felt in the core of the person's sense of self. We're gonna talk a little bit about self-esteem regulation in a minute, but it can also be a very emotionally charged state. As I mentioned earlier, though you might've been extremely excited when you made a decision to immigrate, regret can take over at times, and it might overshadow the novel environment and the novel experience that you're going through. There might be anxiety and uncertainty, but that could still exist with the hope and optimism of advancing one's career or getting the training they need to go back home and help other populations. And it can also be a very emotionally charged state. There might be anxiety and uncertainty, but that could still exist with the hope and optimism of advancing one's career or getting the training they need to go back home and help other populations or whatever their motives might be however Keep in mind Basic life realities also settle in here. It's not all just intrapsychic. There's also how do you get housing? How do you get food? How do you get? health insurance If you have children, how do you ensure that they? Get good education How do you I Often mention this when when giving such talks about How do you deal with? Rent issues if you're ambitious with your landlord. I live in New York City those of you who live there might relate I remember thinking as an immigrant. How do I sue my landlord when they have clearly made a significant mistake? Another thing is the fear and the anxiety of how the new society will perceive them People have very different notions of how they perceive immigrants whether it's physicians or Any kind of other immigrant worker? There's always a lot of Frequency of notions that might be a play and the person might be Anxious or worried about how they're being perceived All right, so we'll talk a little bit about self-esteem and how that pertains to immigration particularly so self-esteem Can be regulated internally and externally But a lot of it the internal representation can be rooted in family and culture and one's own identification with their family and culture Iraq of lack of social recognition in In the new culture that you're part of might Might Give a significant blow to the sense of someone's sense of self-esteem And it might disrupt the balance between their internal and external poles of self-esteem regulation So that's always something to keep in mind about an immigrant One There are various ways There are various ways of how one can negotiate different identities between where they come from and how they're integrating into The host culture in this case usually we're talking about the united states predominantly There could be splitting kind of completely Dissociating from the older self or the older version of oneself It could be total withdrawal from the new society and not engaging at all outside of going to work or to the hospital We're not even there at times And there could be a counterphobic assimilation, which is kind of the complete rejection of the original Culture and an absolute identification with the host culture Always keep in mind a lens of intersectionality when when talking about these issues because oftentimes Religion, race, identity, sexual orientation, gender identity, all of these things interplay in how someone integrates into one host society or the other One thought about how an immigrant can regulate their sense of self this way is the notion of self-state Which is your goal may not be to have The immigrant assimilate or they may not want to assimilate fully into the host culture They might want to maintain different self-states which is a normative way of reacting to this and and basically what that can lead up to is to basically oscillate between the self that is in the original country and the self that is in the united states and kind of Without necessarily having to integrate the two but to be able to maintain the two states at the same Well at various times and pull each one in whenever it's needed This is kind of summarizes what I talked about earlier, which is that you could either have assimilation integration separation marginalization They're all different outcomes or different possibilities. We don't have to go into the details of those Right now, but we might be able to talk about them in the discussion um A couple of additional thoughts that we'll go through about Predominant struggles that might be related to immigration particularly It's a journey of guilt and growth The person might have guilt about having left the home country and we'll talk about the sense of a loss in the second slide uh, but there's also a very um Important notion to keep in mind developmentally that was brought up actually at an APA meeting About 25 years 27 years ago by Salman Akhtar, which is the third individuation. So We could think of an immigration immigration as a third Separation individuation process a third individuation where the person has another separation from their maternal or host or original culture original context and kind of they try to Re-imagine redefine themselves in a new context and it's a developmental Change it's a significant developmental change to keep in mind Ainsley talked about cultural mourning And several defenses that might come up play and trying to repair The loss or trying to separate from someone's host culture i'll touch on that a little bit more now When you're talking about the sense of loss We're talking about general Significant mourning we're talking about Retrospective loss of what you had but also if you could have had if you had stayed there loss of the mother tongue as I had mentioned before Family that you might have left behind and if you brought your core family, maybe it was extended family that you're mourning Food tastes specific things that you might get used to that. We don't think of as much music familiarity of that music The cultural context the ability to kind of pick up things that you might not be able to pick up No matter how familiar you are with the new culture and that can be clinical settings we might have been Much more astute and you might have been much more Able to pick up the cultural contact which is very relevant in psychiatric care And you might have lost that but also at work and how people engage at work loss of potential Class or aspiration for class As we know residents generally Can or often underpaid for the amount of work that they're doing so that's one level And an added layer is also a loss of architecture for them. You might have as I mentioned earlier Sometimes we use spaces to anchor ourselves And that may not be something They have access to anymore. It might they might used a very different architectural setting than whatever they um setting is in the city where they're practicing And finally and this might be brought up by the hospital patients general context politically of the country or the general climate that The sense of being a farmer might be viewed as a bad object reviewed as an other could be carrier of Trauma or of You might be subjected to xenophobia You might have a lesser pedigree in terms of schools No recognition of the schools you might have went to though You might have thought that you went to some of the best schools in your home country It's you've lost that recognition in here All right, so Generally psychiatry is a field that requires significant introspection And the clinicians of the experiences matter markedly in this clinical encounter So from what I described so far, it may be evident that foreign medical graduates will be Dealing at different stages with their identity as immigrants There's little literature Very little literature has attempted to address the challenges of img is in the psychiatric workforce general and Moniz has done a great job summarizing most of those But even additionally in the scope of our talk today, there's all Less literature as well talking about particularly double minorities and the term double minority can describe a psychological state when Two devalued identities interact to influence the individual in a way that each of those identities In a way that's greater than the sum of each of those identities separately. And in this setting we're talking about Minorities in the medical field which are img's but also who happen to be Another form of minorities. We'll focus a little bit on three different types of minorities and then we'll talk more about that and how to try to help and how to try to Support but also in the discussion and the clinical vignettes that are to come So what we try to do there's very little data on So what we tried to do there's very little data on img's who belong to these groups. We're just Just going to go over briefly the major So the kind of Major things to think about when talking about three different minority groups, so we'll talk about lgbtq plus physicians at the beginning Again, there's very little research that focuses on Lgbtq physicians particularly there's more so recently on patients who identify on lgbtq and how to support them Some of the data available shows that students and faculty in higher education might experience more isolation Discrimination and harassment due to their sexual orientation or gender identity They might have less interest in academic career And less satisfaction and less retention There's higher level of anxiety in medical students who are self-identifying as lgbtq plus And how although there's change in recent attitudes However, there's little data to kind of assess how much that change has trickled down for the physicians Sebastian Suarez writes this very interesting piece on the whole process of Trying to see if One should or should not disclose their sexual orientation as an img while applying and it's often a question that amgs ask as well, but it's also quite pertinent with imgs where they often feel that Their chances of matching are less and would that Hurt them if they do disclose who they truly are One Study from 2011 that surveyed lgbtq physicians experience in the workplace. They mostly surveyed physicians And reported that data did find some improvement over What was experienced in 1994 compared to 2009 and we would hope that that kind of improvement continues predominantly people still Reported witnessing discrimination and disrespect of lgbt individuals in the workplace however, if you notice it Did sound to be trending down Over the span of these two intervals. The hope is that that is something that has continued Now I'll talk a little bit about others challenges and physicians of color. There's a little bit more data here And generally what was found is that there's higher prevalence of discrimination particularly for black physicians and women of color There's adverse effects on career work environment and health And there's greater job dissatisfaction and intention to leave to leave academic jobs And In those reports people kind of reported overt things ranging from microaggressions to overt discrimination Finally we'll talk a little bit about women physicians And again, there's also more data here than for the lgbtq plus physicians Women physicians in general have been found to have slow when compared to non-women physicians I've had slower advancement less favorable evaluations. They're underrepresented in leadership positions There are fewer invite invitations to lectures lower salaries Lower salaries more imposter syndrome more chances of reporting imposter syndrome and more burnout again we invite you to kind of think about these three subgroups and we're hoping that through the vignettes we can reflect on how that can even be more pertinent to immigrant imgs when they're When they belong to one of those double minorities Thank you All right, i'll pass it on to dr. Saunders now Okay, so now for a live part Can everyone hear me? All right so Once again, my name is Ramatze Saunders. I'm faculty at University of California, San Francisco I'm going to be talking about mitigation strategies and the role of mentorship So several years ago While I was a resident in an early career faculty I actually got to participate In putting together an annotated bibliography of the professional literature on imgs And that really has helped shape my thinking about imgs Sort of having this intentional process of reading through a lot of articles A lot of articles about imgs up to that point in time What was published? and the The domains of the img experience can be distilled down to these five categories acculturation education and training workforce quality and competence and discrimination And for the purposes of today's talk i'm going to be focusing on the ones you see in red Okay So regarding education and training there has been a well-established Acknowledgement that there is a need for mentorship kramer published on this in 2006 he was actually on that img committee as well. They worked together And there is some literature on what it takes to feel like you've been successfully mentored through residency and included in the the top sort of criteria are Introduction to submitting proposals for scholarly meetings making a first poster peer review And getting something published So important to to think about that when you think about the trajectory of a trainee an img trainee and things that they will Reflect on later and say okay. I think that that training experience went well and while a trainee who has a lot of initiative can accomplish maybe finding a mentor and You know, they're a go-getter. So they they really get in there and And push to be a part of an academic process and publication and presentation It helps much more if there is a formal process For mentorship and it's not left to the trainee and their initiative alone so Formal mentorship is built into some residency training programs. And in fact, some programs will have multiple mentors Some places Usually larger centers may even have some sort of training in how to be a mentor not Specifically an img mentor, but there comes as part of this package of becoming an educational scholar My institution has that for instance additionally mentorship relationships provide an opportunity for longitudinal relationships so a trainee can grow over the years and move from one stage of Educational and academic growth to the next with the support of their mentors But challenges persist so I have two vignettes here. I I have tried to de-identify institution and Individual as much as possible while retaining the essence of the vignettes So vignette one, I think I'll read it a highly published MD PhD IMG enters a university-based training program By early PGY 2 they have begun to receive highly critical feedback from attendings regarding their clinical performance Additionally, they are specifically identified as having a difficult to understand accent accent reduction classes are recommended a A Decision is made by their training program to put them on academic probation and a specific faculty mentor is identified so in this situation the mentorship started after a problem was identified it wasn't started before and It was a mentorship situation and someone who maybe on paper You would not have expected to need that level of mentorship and support Any questions based on this yes, we have one question So so the question for the recording is what was the issue with the clinical performance so among the issues were that Patients could not understand the physician but also from the clinical supervisors concerns that the resident had difficulty formulating cases or developing a robust biopsychosocial understanding of the patient And so you see there can be concerns that would be Concerns you you would expect clinical supervisors to make but then there are the other sorts of comments and statements that seem to isolate an IMG more Here's another vignette a Highly published MD PhD IMG who has already completed psychiatry training in their country of origin enters a university-based training program. From the beginning of residency, they have been assigned a mentor for twice-yearly meetings, and those meetings line up with semi-annual evaluations, which is part of the ACGME requirement for residency training programs. By early PGY-2, they've begun to receive highly critical feedback from attendings regarding their clinical performance. Additionally, they are specifically identified as having a difficult-to-understand accent. Problems worsen in between scheduled meetings, these scheduled semi-annual evaluations. They come to a scheduled mentorship meeting with a growing crisis. So even when you have a program that designates mentors and has various levels of mentorship set up, you can still have problems. So it's not that just having mentorship is enough and having scheduled meetings is enough. There is more. Any questions related to that second vignette? Okay, so the question again for the recording is, other than the accent, was there another problem? So in terms of the clinical performance, clinical supervisors made similar complaints to the first vignette, that the trainee was not making very robust, particularly biopsychosocial, clinical assessments. So that was the main additional concern. And I think that's what I'd say for now on that one. This is someone who's already completed the psychiatric training. Right. The question is, where? Right. So I'm trying not to identify that person's country. But so the resident had particular problems with patients with severe psychosis and thought disorganization. And they came from a culture that did not have a high prevalence of these disorganized psychoses combined with stimulant use disorder that we see in a lot of our urban centers. So it was particularly psychosis spectrum disorders and makes you wonder if there's a particular cultural mismatch or jump there. But your points are well taken regarding level of training when somebody is coming into a training program. So after residency, there's also a need for mentorship. And that includes early career and mid-career stages. And for instance, in a setting like the one I'm in, there is a faculty and career mentor who's assigned. But what I've seen is that whole mentorship process really benefits from initiative being taken by the mentor. When someone who's new to a system, maybe they've moved from one city to another, and they've entered a system, they may assume that, okay, there's a template and things are going to be provided to me. I'll be informed of things. It really helps for the mentor to take the initiative and say, hey, this is who I am. We're going to set up some meetings. Let's put it on a calendar so we have a schedule, and so on. The last bullet there is about something that's not written about at all, but I think of it as paying it forward, which is that if you're an IMG who has had a measure of success and who has benefited from engagements like a mentorship engagement, to take it as a responsibility of yours to help pull up the next generation of IMGs. And it varies, and it relates to the acculturation bullet, how willing you are to continue to identify yourself as an IMG if you've made it. The next domain that I wanted to touch on was workforce. And just briefly, I might be preaching to the choir, but IMGs often find themselves in programs that are less funded, and there's a lot of literature out there on that. And particularly in programs like that, there's competition between clinical needs. The reality is that residents provide a low-cost workforce. And training needs, a lot has been written about that as well. And in terms of my proposed medication strategies there, it is about, particularly in the resource poor programs where trainees may not have assigned mentors or designated mentors and may be facing a deluge of clinical work to seek mentorship, but also for potential mentors in those environments to seek mentees. So again, an intentionality from the part of the more senior clinician who maybe has a bit more time as well. And a reality is that some of that may have to be in informal settings because there may not be a structure within the formal workday. Just a bit more on post-residency. There are these productivity considerations, so-called RVUs. So work, basically having your work output measured and having to meet a certain quota or amount of work output to meet your pay, et cetera. And that's how a lot of places are, and that's a reality. But in a situation like that, where there's a mentor who may also be a supervisor, you get this blending of mentorship issues and productivity issues. So hey, are you making the RVUs that you need to be making? And that can occur in both academic and private sector settings. I've had a journey that's been mostly in academia, but I did have a two-year sojourn in the private sector, and I've experienced that in both types of environments. And recommended mitigation strategies there are a blend of formal and informal mentorship. You can have formal mentorship even in private sector settings, but again, it tends to be a mentor who's also maybe the person who at some point will decide whether you make partner in that group. So there's a bit of blurring of the boundaries. All right. So there we've gotten through the formal slides of my presentation, and we can move on to the discussion. Let me return my colleagues to the screen, and thank you for your attention and participation so far. And now we move on to the discussion part of our presentation. Are there any immediate questions from the audience? Oh, I'm sorry. When a friend of mine who was on a J-1 visa but managed to overcome it, his father passed away and he couldn't go to the funeral, I realized that it might happen to me, and I would not be able to do that. I couldn't look at myself. So I packed up, shed tears, left my babies, and went for two years. I'm not going to bore you with all the fights that I had with the United States Information Agency. The number of times that I went to Congress, while I was doing a PhD in neuroscience, I also did a PhD in waverology. And basically, my comfort was that after the first day, I would already have less than two years. And that monkey gradually diminished until two years have passed and the tail was gone. Nobody knew that. I was able to come back. I mean, I could pull out, I've got an American passport right here. That was over 20 years ago, this whole thing. I came back to a demolished marriage and a disaster with my kids. I mean, my son's a doctor, my daughter is an MBA, but it demolished a whole lot of things. And that's the price that I paid for this. It's like that book, if you're familiar with, The Monkey's Paw, the story, The Monkey's Paw, where you can make a wish, but you pay a horrendous price. Read it. It's by E.B. White. And that was that. That was like the price that I paid for being an American psychiatrist, going through that J-1. Today, you could basically, you know, it'll cost you three years of your life and you would work at an area that is a shortage area, but you can get it. You don't have to go and, you know, you could bring your family, you would still be in the United States, which is kind of like, what's the point of this USIA with the J-1 visa if basically they're stealing, we're stealing doctors from other countries? I mean, the whole idea was two years of working. I did do, I worked, I did exactly what the USIA said that I should do. I worked in my country of origin. I even did research in my country of origin, so even the PhD, I paid for that. But let me tell you, don't touch that J-1 visa if you know what's good for you. Thank you for that very moving vignette, and I think it's a reminder that there has been incremental or in some cases very substantial change, even when things still do feel very disparate. Thank you for sharing that, it just resonates a lot, I think, with a lot of our experiences and why we kind of do this talk. I did not have a similar experience, I was on a J-1, but I had a, I guess, in a way hearing you speak kind of made me a little bit kind of thankful for who came before, who kind of like paved the way for it to be easier for us. My major reason for kind of developing a niche in immigration specialty is because I got stuck because of like visa issues and had not been home in five years, so I'm currently zooming in from home, so it's quite the experience, but I think it's kind of something that we have to continue to pay forward, because these things, we do take for granted what we have, though we complain about it, it has advanced teams and we should continue to do so. Absolutely, I will just echo everything that the other panelists have said, and of course, thank you so much for that, that was really heartbreaking to listen to, but also kind of shed light on how things are in a different time, but it also kind of highlights that there have been incremental changes, as Aline mentioned, but there is still a way to go. It's just unfortunate that our part of the story is not paid attention to, or it doesn't seem like it matters to many, but the other part, the cost that psychiatric care in the country at least has to bear when we have to go out of the country or when we can't work because of our visa status, and it's in jeopardy. Given the current crisis and given the current need, I think it just renews the fact that there should be even further work on this area, for sure, but thank you so much again for sharing that. Well, I'd like to bring up just a few other topics then. One is that very personal vignette that we heard. It's something that's easy for us to not have as part of the immigration story as physicians. It's easy for it to be lost because it's at a meeting and then not heard again, so I wish there were a way for us to capture that. This meeting is being captured digitally, but a way for us to have that kind of history remembered, especially if there are changes which might make IMGs less and less present in the U.S. clinician workforce. I think that every immigrant physician has some story of the price they pay, the challenges they faced. Briefly, in my own case, at the end of what I thought was a very successful residency, I really wanted to do a fellowship. It was a brand new fellowship, and none of the fellowship programs knew how to handle someone who was on a visa, in my case an H-1 visa, so I opted for the employment route rather than going through the formal fellowship. I think my loss pales in comparison to yours, but I did experience it as a compromise that I had to make. The funny thing is, I managed to do a fellowship, I was admitted to an NIH fellowship at UCSD. I mean, I did that, I worked, and all the while fighting that visa, that USA, United States Information Agency, all the way to Congress and everywhere, I was willing to do anything, go to do a three-year or whatever. None of those were available, and the trouble was that when you work with Congress, they always tell you, hey, don't do this, so I could have theoretically found a VA or something like that, that would get me that waiver, but the congressman was a very nice gentleman, but he's deceased now, long deceased, basically said, no, no, no, we're getting that. I had a debate in his office with the USIA, and I prevailed. They said, no, why don't you, we'll give it to you, we'll give you the waiver, just ask again for the INS to determine hardship, and I pleaded with them, I said, I already have it, I have that determination, and of course, he said, no, no, no, do it, do it, and I did it foolishly, and of course, they said, no, there's no hardship, wife, two small kids, there won't be any hardship, and then he said, he was embarrassed, he said, oh, why don't you go to this lawyer, the lawyer said, do you know what they did to you, they put you back on square one, and at that point, he was like, what's the point, my parents are going to die, and I'm not going to see them, I would not be able to face anybody here if that hadn't happened, so I was there for two years, my mother's life was exactly a month and a half after that, and my dad survived a year and two months after she passed away, that's, but the thing is, you look at me, you wouldn't know that, you wouldn't know that, you'd say, man, you're probably born here in this country, you know, you're probably privileged, yes, my mother was a pediatrician, my dad was a professor of chemistry, I was, you know, on faculty, when I didn't have a visa, I couldn't get a grant, I couldn't get a grant, but I was on faculty, I taught residence, I did everything, but I just couldn't get that, that USIA thing shaped, and people would just look at me and think, what a lucky bastard this guy is, they didn't see that monkey. So thank you again for sharing that experience. We are about out of time. I would like to thank everyone for coming and participating in this session, and I wish all of you well. Thank you.

systemic barriers

non-U.S. international medical graduates

academic psychiatry

challenges in education and training

importance of mentorship

double minority IMGs

shortage of physicians

immigration challenges

language barriers

cultural differences

support and mentorship