To the Editor: International Medical Graduates (IMGs) need to become the subject of greater interest and attention by medical educators in general and, in particular, psychiatric educators. The reasons for an interest in IMGs are: 1) IMGs are an increasing percentage of physicians practicing in this country (25%) and an even larger percentage of the psychiatric resident population (41%) at a time when we may be approaching a physician shortage (1). 2) IMGs serve the underserved, both as trainees and practitioners. 3) IMGs meet the needs of specific primarily immigrant populations. 4) Most importantly, IMGs serve the poor, the psychotic, and the elderly (2).

Attention in the psychiatric literature, as evidenced by a special issue of Academic Psychiatry (3) on the psychiatric workforce, has been primarily directed at advocating for the reduction of barriers that make entrance into the American medical system more difficult for IMGs and at the biases against IMGs in being selected for residency programs and in being hired for certain positions after the residency (4). However, very little has been written about the learning problems that have been identified in IMGs and even less about what might be done to deal with these problems (5).

International medical graduates come from many different cultures, and certainly individual differences exist. Yet there is essentially no literature that delineates the learning problems that are culturally specific. Certain generalizations about learning problems of IMGs may be possible. The issues in learning that IMGs have are not related to intellectual differences, as graduates of foreign medical schools have made most if not all of the innovations that underpin modern psychiatric practice (6) (e.g., psychotherapy, psychopharmacology, convulsive therapy, humane treatment, and the structure of the nervous system). The clinical skills assessment examination currently shows almost identical scores for U.S. medical graduates and IMGs (7). Yet the pass rates on the American Board of Psychiatry certifying examination reflect a significantly lower pass rate for IMGs (8). The rates are no longer reported to avoid stigmatizing IMGs. The Board, in an effort to improve the pass rates, has encouraged training centers to provide special board training experiences and has developed a program with the American Psychiatric Association at the State University of New York Downstate to offer special preparation for IMGs who have repeatedly failed the Board examination.

The educational approach that might be considered in meeting the educational needs of IMGs in psychiatric residencies is to move to a more structured form of instruction with more explicit feedback to the trainee (9). There is an expressed need for more verbal recitation of assigned reading and case reports. The inclusion of written exams has been suggested to facilitate the organization of the understanding of various subjects covered as well as providing practice in conveying ideas in a written format. The desirability of more individual supervision is apparent as the situations in which the IMG trainees find themselves are more perplexing than for U.S. medical graduates. The IMG experience requires that they be offered more demonstration and supervised interviewing than the usual psychiatric resident. The need to function in a collaborative role with other disciplines is a challenge to those IMGs who are from more hierarchically oriented cultures. Exercises that provide the opportunity to learn alternative problem solving techniques may prove helpful (10). The suggestion that the practical, namely nosology, pharmacology, and somatic issues, should be taught first and psychological and social theory should be taught later, places the emphasis on the disease and not the person with the disease (9). This potentially serves to alienate the IMGs from the patient and impedes the learning of psychotherapy later, and psychotherapy is then seen as a secondary intervention. Examining the psychological aspects of all transactions between doctor and patient facilitates the learning of the impact of the interpersonal dimension in all human interactions.

Those IMGs from non-English speaking countries may benefit from language training focusing particularly on pronunciation, slang usage and accent reduction (9). All IMGs could benefit from courses in American history and culture. Mentoring relationships to deal with the myriad of personal and professional problems that arise during training have been found to be useful (11).

Special tutoring for various examinations such as the Prite, The Columbia Psychotherapy Test and the certification examination of the American Board of Psychiatry are desirable adjuncts in the training of IMGs as are post career planning sessions. Training centers need to continue to assess the needs of their IMGs and provide better training opportunities including some centers devoting themselves to the education of IMG, and their integration into mainstream psychiatry.

It may be possible for some programs to begin to adopt the view that they should seek such trainees and turn a so called liability into an asset because they have become particularly adept at training IMGs (12). A program at the Maimonides Medical Center in Brooklyn is a case in point. At Maimonides, 25 of 27 residents are IMGs, and, from 1994—2004, the pass rate on part 2 of the Psychiatric Boards has been 75%.