Academic Psychiatry 25:181-183, September 2001
© 2001 Academic Psychiatry
Buy American: Choosing Psychiatry Residents
John Norton, M.D., Director of Psychiatry Residency Training, University of Mississippi College of Medicine, Jackson, MS
Key Words: International Medical School Graduates • Admissions Criteria
TO THE EDITOR: As a relatively new residency director in psychiatry, I was given the charge of recruiting American graduates. I was all-too-aware of the fact that only 3 percent of American medical graduates were choosing psychiatry and that this was down from close to 10 percent in the mid-1970s (1). I was not told to get the best possible residents, but to make sure that I had a certain percentage of American graduates. I pursued this goal with vigor and set out to read the applications of all possible candidates. As I read, I realized there were outstanding international medical graduates (IMGs) with varied experiences and credentials. There were some excellent American graduates, but also a remarkable number of marginal students. In the back of my mind, I felt the pressure to overlook weaknesses and to interview American students regardless of class rank, board scores, or letters of recommendation. I was rejecting IMGs with far better qualifications than some of the American graduates whom I felt obligated to interview.
Currently, 58% of the first-year positions in psychiatry are filled by American students, up from 48% in 1996. Specialties such as pathology, neurology, primary pediatrics, and family practice still have a large number of their first-year spots composed of international graduates. Emergency medicine, many of the surgical specialties, and radiology have almost no IMGs. There is still a large difference in the number of international graduates who apply and match, compared with the American medical school students. The West and the Northeast had the highest percentage of first-year positions going to American graduates, whereas the Southeast, excluding Florida, had a lower percentage (1).
The culmination of this process occurred when we interviewed an American-trained graduate who had been away from practice for several years after his intern year. We did not have all of the pertinent information about the candidate, but interviewed him because he was a graduate of an American medical school. His credentials were marginal, and his time away from medicine was not completely explained. During the interview process, we found that he had been arrested for writing bad checks. This practice continued even while he was on probation, and he was incarcerated for 2 years. We had set up an interview that, in the end, had no real possibility of success.
I realize there are some programs that retain many of their own graduates and fill their class with a majority of American graduates (2). I question whether this is the best possible alternative in all circumstances. Our program has close to 40 percent American graduates, but that does not imply that these residents are clearly superior to their international colleagues. There is value to the idea that IMGs will have a difficult time in acculturation and will be at a disadvantage. I contend that there are IMG residency applicants who come from cultures that are too divergent to realistically succeed in an American psychiatry training program. However, there are several advantages to having a residency program with at least a partial cohort of international medical graduates (3,4).
The IMG pool is quite diverse but does contain individuals who were outstanding in their home countries. They often have advanced degrees, research training, and diverse life experiences. They commonly have had to sacrifice a great deal to get to our country. They frequently accept positions such as research technician in order to increase the possibility of being interviewed for a residency slot. I have found the vast majority of foreign residents to be humble, appreciative, and willing to do whatever is asked of them. There needs to be screening for the exceptions to this generalization, but, unlike many American-trained residents, the international graduates seem to realize the gift of training that has been offered to them.
We have noted that diversity strengthens our residency program in many ways. We have developed a broader perspective about ourselves and the patients we treat. It has made us much more aware of the topic of cross-cultural issues in psychiatry. We have been able to discuss issues such as divorce, long-term care placement, and child-rearing practices from a spectrum of religious perspectives. This has not developed from a book or lecture series but rather from a reality of our everyday residency program experience.
There are clear obstacles, however, that must be overcome. Language is the largest factor that correlates with a successful training experience. English-language skills can be evaluated during the interview process, so that residents will have the greatest opportunity for success if they are chosen. There may be certain cultural perspectives that make it difficult to train in the United States—for example, when a resident has an absolute taboo on divorce and believes that a woman cannot leave a marriage, regardless of circumstances. If this belief is completely inflexible, then it may lead to negative countertransference, with a severe impairment in the doctor–patient relationship. I have found this case to be the exception to the rule (5,6).
The complexities of our culture may be very hard to grasp. We have found that providing cultural education to international residents from the first year of training can produce significant improvement in their performance. International residents are also remarkably adept at making this transition, given their varied life experiences. They are able to challenge our American graduates to defend their beliefs and values. We have found this to be a very constructive process for the whole program (7).
The question of whether to take a more qualified applicant from a foreign country or an American graduate, regardless of his or her background, is important to address. I realize that there is a perception that residencies with fewer American graduates are weaker. This perspective is, in part, our own doing. We have allowed other disciplines to define success—namely, filling the residency completely with American medical graduates. We apologize for programs that cannot meet this mark. It is a valuable quest to try to retain qualified American graduates. The reality is that there are a limited number of American graduates interested in psychiatry. There are a variety of forces that have contributed to this situation, including the difference in salary ranges and the perception that psychiatry is less rigorous than other specialties. This places pressure on residency directors to compete for American graduates at all costs. However, taking a less-qualified applicant simply because he or she is American may be more problematic.
Although there is no clear closure on the issue, there are several suggestions that I have to offer, based on the experience of other training directors to whom I have spoken. American medical students must have experiences during their first 2 years that may pique their interest in psychiatry. Psychologists, who, although qualified, are not role models for students considering their future medical career choice, often teach the courses during the first 2 years. We have the chance to show students how exciting it is to evaluate and treat patients with such interesting clinical conditions as mood and anxiety disorders. The faculty with the most clinical experience may be the best candidates to teach these courses to first- and second-year medical students.
We have also identified students from the start of medical school who have an interest in psychiatry. We have then attempted to include these students in department social and recreational activities with our residents to give them increased exposure to our residency program and the field of psychiatry. The directors of residency training and medical student education meet regularly to try to coordinate and refine educational experiences to increase competency and interest in psychiatry. In this way, potential psychiatry applicants can be identified and encouraged from the early stages of their career.
We have also made it an expectation that our residents and faculty spend more time on clinical rotations in teaching the students. This is helpful to both the students and residents. Furthermore, our residents are expected to pursue medical issues rigorously before asking for consults. They initiate and modify medical issues, taking consults for suggestions, and not as an excuse to turn over the case to someone else. The development of a medical psychiatry unit has facilitated this process dramatically. Students often comment that seeing the residents act as residents on other rotations has increased their interest and respect for psychiatry. We have made our residency program more demanding, with morning report, 7 hours of didactics per week, mock oral boards, and three extensive written examinations per year. By setting the standards of our program higher, we have instilled more pride in our residents and improved the perception of our department within the medical center. This appears to have improved the students' perceptions of psychiatry as a discipline and increased the number of students interested in the field.
We have also made significant attempts to demonstrate the unique nature of our field. We have stressed discussions about psychotherapy, transference, boundary issues, and the patient interview, and have not simply discussed biological aspects of our field. We discovered that this is often the most significant learning that students identify; they see it as something they can use in whatever field they enter. To do this, we have maximized the exposure of students to faculty that have an eclectic perspective on psychiatry. We give clear and direct feedback to faculty on how the students evaluate them. This is stressed as important in their yearly evaluations. Students are removed from rotations that consistently fail to meet the mark, regardless of the rank of the faculty involved in the rotation. We stress to the faculty that it is valuable to have students on a rotation and that students must be encouraged. This is not the typical perspective they are given on other services, where they are often used as "grist for the mill."
We have also tried to make our clerkship more rigorous, while not exhausting the students with a surgical-type experience. We expect students to function in the role of a sub-intern and take major responsibility for the care of their patients. We are instituting both oral and written examinations to determine students' competence. Students are expected to research topics for rounds and encouraged to write up case reports on interesting patients they see. This has helped to debunk the perception of psychiatry as a "blow-off" rotation. Our experience is that this approach increases the students' appreciation and interest in psychiatry. We have improved from a total of zero to two of our first-year residents being from our own institution. Furthermore, we have doubled the number of students this past year that chose psychiatry as a field and have had four students in the third year ask for sub-intern experience in psychiatry because they are interested in the field.
This is clearly a complex problem that requires more extensive study. There are many institutional pressures and stereotypes that must be addressed so as to encourage American medical students to choose psychiatry. We also need to appreciate and utilize our international residents for all they can bring to our training. Perhaps the objective should be to have the best residency possible. This will likely include both American and international residents, each of whom can bring unique gifts to the program. Trying to fill all slots with American students, regardless of ability or motivation, presents its own set of problems. As with car shopping: buying American is not always the best policy; a Mercedes may, in the end, be a better investment than a Ford.
REFERENCES
- Results and Data 2000 Match National Resident Matching Program, April 2000
- Whitcomb ME, Miller RS: Comparison of IMG-dependent and non-IMG-dependent residencies in the Resident Matching Program. JAMA 1996; 276:700-703[Abstract/Free Full Text]
- Nafees AK: The advantages of foreign training (letter). Am J Psychiatry 1974; 131:329[Free Full Text]
- Balon R, Mufti R, Williams M, et al: Possible discrimination in recruitment of psychiatry residents? Am J Psychiatry 1997; 154:1608-1609
- Tinsley JA, McAlpine DE: Another explanation for the apparent discrimination against international medical graduates by residency programs. Am J Psychiatry 1999; 156:496-497[Free Full Text]
- Lewis DJ: Foreign medical graduates: the treatment of the alienated by the alienist. Am J Psychiatry 1973; 130:438
- McDermott JF Jr, Maretzki TW: Some guidelines for the training of foreign medical students. Am J Psychiatry 1975; 132:658-661[Abstract/Free Full Text]
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