Dr. Shanny Tosounian, DO. (On the IMPORTANCE of International Medical Graduates)

Thank you Shanny for your amazing story. Respect for you my dear. You are source of inspiration. 

Of the 75 doctors in my internal medicine residency program, I am a minority. There are 14 of us who are American Medical Graduates (AMGs), while 61 of our residents proudly studied in some of the most elite universities from around the world (International Medical Graduates, abbreviated IMGs). And no, there is no exaggeration when I use the term "around the world." The current residents in my program obtained their medical degrees from the following countries: India, Pakistan, Nigeria, Jordan, England, Georgia, Thailand, Venezuela, Greece, Ecuador, South Africa, The Philippines, Indonesia, Brazil, Germany, Spain, Korea, China, & Iran (not to mention my previous co-residents who have since completed training, having graduated from Mexico, Argentina, & Tanzania. I think that about covers it.)

A medical student once told me that residency programs were recruiting him so hard because they were sick of taking so many IMGs. A piece of advice: never say a statement like that to me, thinking its okay because I'm American. You'll regret it, as I'm sure he did. When candidates come to interview at my program and they ask why I like it, I'm not giving a generic mediocre answer by saying "seriously, it's the people here." I mean that in every sense, in every scenario, in every situation of my training thus far; my 81.3% IMG and 18.7% AMG co-residents have been the single most enriching part of these formative years. I'm using terms such as "they" and "their" frequently in this blog, but I don't mean to generalize. The unique personas of each of my co-residents is unreal-- and if you've ever spent a day here then you'd understand the true sense of the word diversity. I wouldn't have it any other way.

I'm not writing this to share statistics on why America's healthcare system is better off because of IMGs. In fact, my program director and his colleagues already did that so eloquently in a rebuttal letter for the journal Chest, and you can read the full paper HERE. It's hard to argue that bringing in highly qualified doctors is in some way hurting our current American medical students or status quo of healthcare. Nope, I'm not here to justify anything with numbers, but rather to share my personal experience of training alongside some of the most well rounded, brilliant, not-from-America doctors I know. I don't want anyone to think for one second that IMGs are anything less than #goals.

You see, because when I groan about there being a shortage of IV morphine at our hospital and whine "but how am I going to treat this patient with pancreatitis?" I get practical and thought-provoking responses from my co-residents. "Shannon, you do realize that in my country morphine is reserved for the actual dying.. and even then it's used sparingly?" With every paradigm of how I believe something should be, I have 61 people who can share a slightly different perspective. Like the time I freaked out about our patient having a diagnosis of malaria. I had never seen malaria before! Obviously he has to be admitted and monitored right? But to my friend who has treated this time and time again in his country, he calmly wonders if we can discharge the patient from the ER with the appropriate prescription. I don't need a text book or an attending to learn in these moments. My co-residents' experiences alone have helped shape me into a well-rounded and well-trained doctor.

(“I think America is really in denial about the degree to which residents, particularly foreign medical graduates, man the county hospitals of this country, and but for their services, I’m not sure how exactly we could manage.
-Dr. Abraham Verghese”)

They’ve also shared stories that make me feel privileged to be exclusively trained in the US, to have avoided certain scenarios of observing human suffering simply due to lack of resources. One story echoes in my head and gives me chills -- of a crashing patient requiring intubation, and the intubation gone wrong simply because there wasn't a single working suctioning device in this small ICU of a poorer neighborhood. The patient died right in front of my friend- not because of lack of skills or knowledge, but because of a lacking resource. A few of my friends share similar experiences to this one, and have to watch from here as not only their country's hospitals crumble, but the country itself. There are a thousand things wrong with the United States and while I could sit and complain about all its issues, they make me realize that I am privileged. I need that reality check from time to time.

Working alongside these 61 IMG co-residents, I grumble over my stacking med school debt while they deal with (the other kind of) Visa issues. H-1B, J-1, the pros/cons, the limitations, the cost, the fear, the risks they have to take if applying for anything, the struggle of getting back to their country and waiting in line at the embassy, of translating pages of contracts in order to get their visa approved for the next step in training, etc. While I'm just looking for a good debt consolidation plan, they're making life-altering career decisions by factoring in their visa status, regardless of their incredible resumes, skills, and personalities. I walk into work with all my academic accolades and abilities without even the faintest fear of missing an opportunity because of my citizenship status, or worse, the fear of being deported. Now THAT is privilege.

As a general rule, IMGs who match here have better "numbers" than their American counterparts: higher test scores, more publications, more experience, etc. Not a big deal, right? Except for the part of thriving in an application process that is not innate to your own medical system. They take the USMLE and answer questions about US guidelines, learn all the ridiculous abbreviations for medical terms that might not even exist in their original method of learning medicine, most often taking exams in not-their-first-language and YUP, still school me. My co-residents are the cream of the crop and I reap all the benefits. While many are straight out of medical school, others are with years of work/life experience. I have co-residents who previously worked as attendings (in specialties like hematology, surgery, family medicine, and so on.) What it takes to get here is insurmountable, and their work ethic follows them here. Their collective drive inspires me to know more and do more.

So with all that hard work and academic accomplishment, you'd wonder if having a well-rounded life and personality would be lacking. This couldn't be further from the truth. It's the old mantra of "work hard, play hard" and while I'm falling asleep in my quiet suburban house, I'm getting text messages wondering why I'm such a grandma and missing out on Philly night life. "How do you have so much energy?!" I wonder, as I fall fast asleep. The humor and sarcasm of some of my co-residents is second to none, and how someone can be so brilliantly funny in their second language is beyond me. I truly don't understand and I belly laugh until I don't care :-)

I hope that I can be half the doctor that my IMG co-residents already are. When I answer that question of "So... what do you like about your residency program?" I hope my initial meek answer of "the people" doesn't get ignored. Because what I really mean to say is that I work alongside the most diverse, bright, hilarious group of humans and I wouldn't trade them for anyone else. American or (probably) not, these are my people! To my co-residents-- thank you for being my greatest blessing in training. I love each and every one of you <3