Featured topic and speakers
Stepping into U.S. residency as an IMG? Consider these practical tips and cultural insights to help you succeed from day one.
Speakers
- Ricardo Correa, MD, endocrinologist, Cleveland Clinic, AMA Council Member on Medical Education
- Brendan Murphy, senior news writer, American Medical Association
Host
- Todd Unger, chief experience officer, American Medical Association
Listen on the go to the full episode on Apple Podcasts, Spotify or anywhere podcasts are available.
Transcript
Dr. Correa: So it gets stressful during those months and even the first weeks that you are in the U.S., besides doing your clinical or your orientation things, you have to start doing other things that many U.S. citizens assume that it's normal, but when you come from the outside, they are not.
Unger: That’s AMA member Dr. Ricardo Correa. He’s an endocrinologist and serves on the AMA Council on Medical Education. In this episode of Making the Rounds, Dr. Correa talks how IMGs can prepare for their intern year and what to expect as they start residency. He’ll talk about navigating cultural differences, learning about the U.S. health care system, going to the DMV and more. Here’s AMA senior news writer, Brendan Murphy.
Murphy: Hello and welcome to Making the Rounds. I'm Brendan Murphy, senior writer at the AMA. International medical graduates can experience a steep learning curve when it comes to stepping into residency. Today, we're talking about how IMGs can prepare for what's ahead, what to expect as an IMG intern and how to succeed in that role. My guest on this episode is AMA member Dr. Ricardo Correa. He is a faculty member and endocrinologist at the Cleveland Clinic and serves on the AMA Council on Medical Education. He's also an international medical graduate who attended medical school at the University of Panama. Dr. Correa, thanks so much for being here. How are you today?
Dr. Correa: Thank you so much, Brandon, for the invitation. Very good.
Murphy: Can you start off by sharing a bit about your own journey as an IMG and what went through your mind when you found out you matched?
Dr. Correa: Yes, definitely. So as you mentioned, I did my medical school at the University of Panama in Panama City, Panama. There after finished that I did two years more of research and I wanted to continue a career more in academics, meaning I wanted to do more research and education than clinical. So I wanted to pursue a fellowship in endocrinology, that in that at that time in my country, it was not offered. So I thought about the options and U.S. was the first one. So I did all the process that was in place at that time, including the ECFMG certifications with the USMLE steps and all of that, and applied for the Match in 2010. So then definitely March came and the Match, they came and then I match in a residency program. So the emotions are, in that moment, incredible. We have to understand that approximately 54 % of international medical graduate match. So, one out of two match. So being one of the two, it's so incredible feeling. I really enjoy it. It was indescribable. I match in a place where it was close to home. I'm from Panama, I match in Miami in Florida. So, it was my first choice and a very nice program. So, I was extremely happy and even more because I was going to be close to home and in a program that was very Latino-friendly.
Murphy: So, once you match, what's next? What are the practical steps IMGs need to take to get prepared both clinically and to live their life in the U.S.?
Dr. Correa: Yes, so it's a complicated question in the sense that once you match, you know that you will enter to the U.S. health care system as a resident. But there are things that not everyone from every single country will experience the same. I can tell you my experience, but there's other countries that have different experiences. So one of the things is that in Panama, we don't have electronic medical record. We don't have things how the health care system works here. We have a more public health care system. So that things you have to start adapting yourself. And it's a learning curve that usually happens when you start residency. Now Intel, that is the prior ECFMG has a course on electronic and medical records. So that you can understand how it works and all of that kind of things. And of course now, probably many countries had adopted electronic medical records. So in my experience, it was one of the most difficult things for me was trying to go from paper to electronic medical record and use all the computer systems and all of that kind of things.
The second thing that it's important to prepare during that time is understanding the U.S. culture. So I was coming from a country that has very U.S.-oriented. So it was nothing difficult for me to adapt to that culture. But I know that coming from other cultures, that's very, very important to understand where you're going, things that you can say that you can...you things that you cannot say, things that you can do and things that you cannot do that are different from your own culture. And that also takes time. So the period between when you match and you enter to your residency, approximately three months. It’s a period of focusing on one, I always recommend that well-being. Being calm, try to take deep breaths. Start preparing a transition that is difficult depending on your life. For me, was first time leaving home. So I was in school and always living with my parents. Now I'm going to be alone. So that kind of preparation that you have to start in life. And then, so use those months for that. And probably if you feel that you need some more clinical or medical knowledge, start reading about your area that you're going to do in my case, internal medicine. I just read every small books, just to be on top.
One of the things is that in international medical graduates, many of the times comes with a lot of clinical background. Sometimes in our country, we have to do some internships. For example, in Panama, we have to do two years of internship. That's intense clinical rotations and knowledge. So that part, I don't think that was a really big issue for me. And many of the residency programs know that when you're coming from this kind of country that you have to do so, your clinical background is higher. I think that in my personal case, my transition was more about leaving home to being alone for the first time in my life, how to adapt to that setting, plus how to understand a different culture, even though I was living, as I mentioned, in Miami, that is Latin American. So it was not such a big difference. And understanding the health care system. One of the recommendations I also give to international medical graduates is prior to start all the application process, always it’s good to come and do rotations in the U.S., not only for their letters of recommendation or for this that we usually recommend people to do it is to see if you like or not the U.S. health care system. It's not for everybody and it's always good to explore beforehand. I did this, I did several rotations prior, and I knew what I was getting into and then that helped me a lot during my transition.
Murphy: You mentioned that you recommend medical students, IMGs do visiting rotations before residency. Why is that? Can you elaborate?
Dr. Correa: Yes, so that's extremely important because I have seen some IMGs that has come to the U.S. and really don't like the whole health care system, so this will not be a place where you can do your training and stay or your training and come back. And I have seen other IMGs that like it. So I think that there's two main roles of the rotation, not only to get the letters of recommendation, but also to understand and get a little bit the culture of the U.S. health care system. So as I mentioned, I did this in the past prior to starting all my process of getting the ECFMG at that time certification. But I really enjoy the time that I was here. And many of the things that I thought was how can I contribute to the U.S. health care system and fix it in a way that possible in my limitations.
Murphy: In addition to being an IMG, you're a faculty member and you touched on earlier that there are cultural challenges that some IMGs might encounter. What are some of those challenges that you've witnessed?
Dr. Correa: Yes, so definitely, as I mentioned, this will be very different from the country you are coming from. In my personal case, of the most challenging things was that English was not my first language. So I come from Panama, Spanish country, so Spanish was my first language. And it was a little bit difficult, even though I study English, and I was in a bilingual school. I was not used to all the common things that an English speaker can, will face. So for me, accent and trying to translate at the beginning, everything from Spanish to English was a difficult barrier. Again, I was blessed because I was in a place where probably 90% of the population is Hispanic in Miami. But it's important because even though the population is Spanish speaking, in the hospital you speak English, and there was a learning curve on that. So I think that that's one of the things.
The second is that the U.S. culture is very strict. So when you think about Latin American culture, it's a more flexible one, more charismatic compared with the U.S. culture that is more strict. So you never knew at the beginning in your evaluations or when you were rotating with someone that was from the U.S., if you were doing the things right or wrong, just because they were very plain in their face. And that's something that is, you need to understand that's the culture. The culture is that kind of way different from in Latin America, doctors will be more passionate and more passion in the sense of expressing things and sometimes can be extreme, extreme bad ones. But that's things that you learn. For another thing in my personal experience was the role of the different members of the health care system to learn. For example, in Panama, nurses do certain amount of things. But the majority of the things have been done by physicians and most of them done by the interns. So, when I came to the U.S. and I saw that many of the things that I did back in my internship was done by nurses, I was extremely surprised. But all of this, just to put into context, is learning curve that you understand when you enter a new system, and you stage in your life that make you stronger and better at the end of the wait.
Murphy: Can I ask a follow-up? You mentioned that you had been an intern. Many IMGs are doing essentially their second residency. What is that dynamic like for you?
Dr. Correa: Yes, so in my case, I didn’t residency. So the mandatory things in the country has six years of medical school and two years of internship to obtain your license. This internship is more like a rotation internship where you rotate through the four or five main areas of medicine to gain more clinical knowledge. So that's when I call myself intern. That's what we call internship. It's different from residency because after internship there you go to residency. I have many friends that have done their own residency in their country and then when they come back, following the rules you have to repeat the residency. I think it's extremely stressful because some of the people that I have known had very well, very well known in their country. Some people have been even chairs of departments in their country, and they have to repeat all of this process again. But I think that when you have an objective in life and if your goal is something, well, sometimes you have to do different pathways and doing again residency to understand more how the U.S. health care system works and how the U.S. culture work. It's a positive thing.
Murphy: What are some key logistical challenges IMGs face between Match Day and residency?
Dr. Correa: Yes, so there are certain things that can happen. So, from Match Day to enter residency, one is filling the paperwork for the work that you are going for, the hospital that you are doing. And this is extensive paperwork. You have to do all the training that is in the learning systems of the hospital. And you have to get clearance many times if you are going to go work in a VA hospital and all of that, so you have to get all those clearance. On top of this, of course, your visa issue, if you are not a green card permanent or a U.S. citizen, you have to start all that process of the visa that your program really start when you match, but then you have to follow up certain things. You have to get an appointment in your embassy. You have to stamp the visa in your passport and then finally you have to come. And this you only have three months. So, imagine sometimes immigration system is not as fast as we want. So many of the times, I think 99 % of the times the Intel prior ECFMG has been doing amazing work on getting the visa to everybody on time. But sometimes it takes a little bit longer on top of everything, the paperwork that you're doing, the visa that you're getting, then it's a transition of your life, as I mentioned. Depending if you have to go coming with family or not, you have to do your movement from your country to a different country. That costs you stress. You have to have some reserve, funding reserve, because you come, you have to rent a house or an apartment or where you are going to live, you have to start at least with two or three months of food, all of that kind of things that require money, you have to be prepared for that.
Subscribe to free AMA email newsletters
Get the latest news from the AMA on the topics that matter to you—delivered to your inbox.
So in total, three months are extremely stressful because you have to coordinate everything to happen, and you cannot even enter the country until you get the visa. So you cannot even start renting and everything. And when you arrive, you face different things. One, that is not common for people, you don't have a social security number. So then you have to obtain a social security number. The second thing is that because you don't have a social security number, you have no credit. So you cannot, unless you get some sponsor, you cannot obtain, for example, a car that is so important. So you have to find other ways to obtain that kind of things. Or use public transportation, depending on the place that you are and all of that kind of things. So you have to obtain a driver license, if you want to obtain a car. So that other stress, have to go to a DMV that usually takes longer time, at what time you schedule that because you enter and most likely you got your visa one week prior to start orientation and during orientation, you have to do all of these kinds of things at the same time. So it gets stressful during those months and even the first weeks that you are in the U.S. besides doing your clinical or your orientation things, you have to start doing other things that many U.S. citizens assume that it's normal, but when you come from the outside, they are not.
Murphy: Have you seen people do this process more efficiently? Or is it just sort of clunky no matter what?
Dr. Correa: I think that I have seen different things. I think that efficiency depends more on the time that you have been in the U.S. Many of the IMGs already has been in the U.S. They already have a place, they already are prepared, they already had a visa prior. They're just changing the status of their visa and that makes things easier when you come directly that you were not living in the U.S. and you come directly, that's when it's a little bit less inefficiency. And there are institutions that you cannot predict efficiency like the DMV, the Social Security Office. Those are government institutions that depends on other things.
Murphy: What are the clinical expectations and responsibilities IMGs should be prepared for as they start residency?
Dr. Correa: So the clinical expectations is any, it's the same as any U.S. medical graduate. So it is expected that when you start residency, you are very well prepared to be an intern, to be a PGY-1, means that we are not expecting also that you have all the medical knowledge in the world, but that you are willing to learn and to...and to continue your training. Also, are willing that you have some resilience that can support some stress that will happen during all these times, plus the stress that you have in your personal life on all this transition. So I think that if we think about clinical knowledge and what programs expect, it's the same thing that we expect of a fourth-year medical student that just graduated one month prior to site residency.
Murphy: What advice do you have about adjusting to life in the U.S.?
Dr. Correa: So the main advice is that take one step at a time. There are many different things that happen between your country and the U.S. And that's a learning curve, as I mentioned, during all this time. Do not get frustrated with things and just try to always have a support group and ventilate. One of the things that was very successful to me was in my program, we have our group of 12 Latinos that come through in the same year, and we were able to just ventilate things that were happening and that decreased stress, anxiety, relief, all the burden that we were having during those difficult, the first difficult year.
Murphy: So you mentioned you had that support network. Do you have any advice for IMGs making this transition to build a support network?
Dr. Correa: Yeah, what I would recommend is always to pair, if you have the opportunity to pair, with someone that comes from a very similar background, even if they are from a very similar country. There are many now those programs started in many programs called the body program or the Patrino programs, as we did it in Miami. So it's just to pair with someone that is very similar to you because sometimes this helps you understand like if somebody says something, you just ventilate that and the other person will tell you, know, this is always happened with that attending and you're like, okay It's not just something against me. So that kind of thing decreases anxiety.
Murphy: Imposter syndrome is very common among residents across the board. How do you recommend IMGs maintain confidence and manage imposter syndrome or self-doubt in those first few months if it arises?
Dr. Correa: Oh, I think that's extremely difficult question. Impostor syndrome, think, I still have imposter syndrome. Management is difficult. I think one of the things that I used to do is like, for example, in my case was trying to do more and more and more, and get more and more involved to make me understand that I was good. And I think that happened to not doing, I am just both for everybody. It's like, there is a point when you are so stressed and so sleep deprived that you feel that you are not good enough and that's not true. That you're good enough that you're already in a residency. The only thing that I think that if for some reason you need to handle this through psychotherapy or having a mental health provider to help, I think that that's the best option. It's not a bad option. It's an amazing option. Other times through, as I mentioned, social support and talking and ventilating. That's another recommendation. I think that it helped me a lot when I talk to my friends about this.
Murphy: Earlier you mentioned that sometimes it's hard to read your colleagues and peers. I'd be curious if you had thoughts on how IMGs can solicit feedback from attendings and peers and how they should be open to it.
Dr. Correa: Yes, so I think that solicit feedback is mandatory and should happen every single time in every single rotation. And it should be probably a half hour rotation and the end of the rotation because that always make you be better at the end. It's important for IMGs to learn as feedback. It's not so common in our country to get feedback. Majority of the feedback is just sometimes it's not constructive. It's destructive feedback. So everybody is afraid to ask for feedback. In the U.S., the majority of the feedback is constructive feedback. So it's important to understand that culture of asking for feedback and the way to receive it is always in a positive way, in a way that a person is trying to help you because that's the system how it's built. The system is built that is trying to help you to succeed in your career. It's not trying to prevent you to finish your career that is different from different countries. So here it's very important to understand that helping you is great and that feedback, in the not just in the first months of your career, but in your entire career is extremely important for your job.
Murphy: Are there things you would have done differently during your own transition to residency in the U.S.?
Dr. Correa: I think that at this point, I will not do anything different. I think that was a learning curve. I enjoy every single moment from knowing certain things, from having accent, from saying some word in Spanish when I was talking in English. I think that that make me the person that I am right now. Probably something different that I will do was just get more instead of having three months of U.S. experience, would love to get like six more months of U.S. experience in the health care system just to understand more in my time that in electronic medical record, that was the thing that cost me the most in my transition.
Murphy: If you could give one piece of advice to every IMG starting this journey, what would it be?
Dr. Correa: My piece of advice is that nothing is impossible, and the sky is the limit. So, you can do whatever you want and you can achieve everything that you want. You just have to have clear objective and go for it.
Murphy: Well, we've covered a lot of ground here. Do you have anything to add to our IMG listeners, many of whom will be starting residency in the coming months?
Dr. Correa: First of all, for the IMGs, I congratulate the ones that starting residency in the upcoming months. It's a great step in your career and we are so happy that you decide to come to the U.S. There's so many needs. There's so many things that we can do to change the health care system. So with that, with others are in the process of taking all of the... of finishing the steps and finalize your applications. I think that there is a lot of opportunities for many organizations, including the American Medical Association to help you and guide you, and provide you sometimes mentorship and sponsors and coach that can guide you during this process. Don't be afraid to ask, just ask. You probably will get 10 no's with one yes. And that yes is the most important.
Murphy: And you bring up the AMA's role in this. We have a toolkit that has many resources to help IMGs with that transition. Dr. Correa, thank you so much for your time. This has been enlightening.
Dr. Correa: Thank you so much, Brendan, and thank you so much to the AMA for this amazing episode.
Murphy: With that, I'm AMA senior writer Brendan Murphy. Thanks for listening to Making the Rounds.
Unger: Don’t miss an episode of this series as you prepare for residency. Subscribe to Making the Rounds on your favorite podcast platform or visit ama-assn.org/podcasts. Thanks for listening.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
