by Dr. Ricardo Marin, PGY-2

The journey to residency in the United States is probably one of the hardest tasks for medical students. For Non-US Medical Graduates (or IMGs), it is well known that this is a highly competitive process, with a consistently lower proportion of IMGs matching to PGY-1 positions compared to US Medical graduates, especially in competitive programs or specialties. IMGs face many obstacles, including being of older age compared to US graduates, the need for good USMLE Step scores, differing medical school evaluation systems,

making it harder for programs to assess our performance, the language barrier, and the lack of formal mentors or advisors to guide us through the application process. These hurdles could discourage anyone from going through this lengthy and costly process. However, this is not the case for the ever-increasing number of those IMGs who decide to go for it. To me, it seemed like a never-ending journey with lots of uncertainty. I thought it would culminate on Match Day.

Fast forward to March 18th 2022, and I could not contain my excitement when I found out I was going to be an Internal Medicine resident at UAB, a place that had captured my interest as a visiting medical student through its philosophy that could not better characterize the program: “Excellence without Ego”. I was highly motivated to start living my dream of becoming an internist, and little did I know that the path to achieving this would be full of surprises and overwhelming at times. From the very beginning, I faced many little problems, such as needing extra time to get to places for conferences in an enormous hospital and handling a great amount of logistical information in a short amount of time, including emails, document submissions, and orientation activities. I faced new technology problems, including delays with access to the EMR and missing important orientation. And on top of all this, there was the new experience of starting to do “adult things” for the first time by myself, like getting a SSN and a bank account, setting up the utilities for my apartment, buying a car, and moving into an unfurnished apartment with just a little over one thousand dollars, while being thousands of miles away from my friends and family. All of this added up to an incredibly frustrating start, and as weeks went by, it felt as if there was no way of catching up.

Fortunately, a few months in I had gained some experience and felt more used to this new setting. However, after overcoming these initial hurdles, I knew my performance and well-being would fluctuate, but in the long run, they continued to decline with new situations, and I believe this was in part because of my background, and mostly my personality and mental health. For reference, I was born and raised in Lima, the capital and biggest city in Peru where about one third of the country’s population live, located on the pacific coast. I completed 7 years of medical school at Cayetano Heredia University (UPCH), a private non-profit health sciences university whose mission statement is “Spiritus Ubi Vult Spirat” (“The Spirit Spreads Wherever it Wants”). UPCH was founded in 1961 when hundreds of faculty members and students from the medical school of the oldest university in the Americas, San Marcos University, parted ways with their Alma mater in protest against the overwhelming political influence in the medical education, hence the motto. They were led by Honorio Delgado, founder of one of the two main psychiatry and psychoanalysis currents in Peru, and Alberto Hurtado, the dean of the medical school at that time.

As with the majority of medical schools in Peru, our clinical training would take place in public hospitals and primary care clinics. In essence, our health system is quite similar to that of the US in that there are private hospitals that work with private insurance companies that can only be afforded by the upper and middle classes, and then there are public hospitals. These work with government-funded health insurances available for the formally employed, the military (and their families) and the socioeconomically disadvantaged. All of these offer affordable and free services for the vast majority of their services, but as good as this sounds, this is only an ideal and the reality is completely different. Public hospitals are severely underfunded and human and material resources are not enough to meet a huge demand, which makes tasks like getting an echocardiogram, an elective surgery, a CT scan or even obtaining certain labs an administrative and economical (for the patient) ordeal. The emergency departments are boarded with patients, getting appointments can take several months, and hospital infrastructure is sometimes even dangerous.

For these reasons, our training focused on the diligent use of hospital resources, plenty of compassion and resilience, as this was probably the only way of providing a good quality of care and fighting against burnout. When addressing medical problems, our approach would mainly be to narrow as much as possible our differential diagnoses through before requesting additional tests. There was excess time to process the information we worked with as simply there was not much overload. Each patient was treated as new to the system every time they got admitted since getting medical records (outside or institutional) was cumbersome in the absence of digital platforms. Our efforts were not directed at discharging patients but rather at accommodating for the high demand, stabilizing our patients and trying to find the cause of their problems, as discharging patients without a definitive diagnosis for outpatient follow-up would mean that the patient would probably have to wait months before their appointment. Additionally, some treatment would often not be available in the public health system or covered by the public insurance, so we would resort to working with the patient’s family and friends, and the assistance of private hospitals to try to obtain their treatment. These were our main barriers for discharge, and placement issues were rarely a problem, most of the time because family was available, and sometimes because nursing homes, inpatient rehabilitation centers or shelters are virtually nonexistent.

When I started residency, I was forced to change this paradigm in a very short time as I encountered a setting in which obtaining labs, procedures, surgeries and medications occurred overwhelmingly faster than I expected before I could finish elucidating my patient’s active and chronic problems from their extensive hospital records, while at the same time to try to come up with an assessment and plan, learn the administrative processes, meet the implicit expectations of always giving a good impression, show confidence and being likable, and to adapt to new challenges alone since I felt there was no one I could relate to. This new paradigm, I have come to realize, places more emphasis on time efficiency, achieving quality over quantity, multitasking, and running a healthy but competitive race against ourselves to become excellent doctors. At this point, my impostor syndrome played really well against me and won, as I felt I hit rock bottom quite prematurely in residency. I would constantly feel immensely overwhelmed and my time-management and organization skills, two aspects I had always taken pride in, were reduced to zero. I would not be able to sleep before a new rotation, no matter how “chill” everyone told me it was, and I would get a knot in my stomach before rounds, calling consultants, or even day-to-day interactions with my team. All of this translated into disorganized and extensive patient presentations, constant mental blocks when asked about my patients, and awkward interactions with interdisciplinary teams. I even avoided contacting my family and friends for weeks in a row just because of the inevitable question “how are you doing?”, as I would not want them to unnecessarily worry about me. In short, I felt I was doing a poor job and this became part of my daily life.

Of course, everyone has their own challenges, and my experience is probably not very different from some of my peers, but here is when I encountered something extraordinary about training at UAB. I initially attributed all of my problems to my anxiety and overthinking, to my developing working memory in English, or to my quite steep learning curve, something that other IMGs from Peru and Dr. Centor mentioned was common and that I would eventually overcome, but being six months into residency I felt this was never going to happen. It was at this point that I finally decided to ask for help. And it is not like I never had a helping hand since the beginning: my co-interns and senior residents would always notice I was struggling and would constantly offer their help, my attendings would always give me positive feedback at the end of each rotation I avoided resorting to them as I erroneously thought that it would be best to show independence. What tasks should I achieve before rounds other than knowing my patients in detail? Should I wait for my attending to approve of my plan before implementing it? Should I try to solve all problems on my own first before calling my upper level? How could I better prioritize the plan for my patients when there was so much to do and all tasks seemed equally important? What are my expectations when it comes to being a team player? How much of what I did would be seen as offering my help to my coresidents versus overstepping? How should I prioritize the most important problems when presenting patients and do it quickly when all of my patients had innumerable conditions? How was I supposed to improve in my efficiency when chart-reviewing my patients when everyone would tell me that one finds their own method eventually?

There were some challenges that I identified early and that I was expecting, based on conversations with other Peruvian IMGs and faculty feedback sessions. For example, IMGs tend to have a steeper learning curve than the rest of our class. We tend to rely on our notes way more as our working memory in English is not as well-developed, and our interactions with patients could be awkward at times due to cultural differences. I knew I was not alone since many of my co-interns were probably going through similar situations, but for some reason I was not able to achieve a good performance like they were. I was not able to "fake it till I make it".

Eventually, my faculty mentor quickly put me in contact with the right professionals and even set up informal coaching sessions with one of my chief residents, and I would say I had never realized up until that point how big of an impact taking care of my mental health could have had. After receiving appropriate help, all of a sudden my problems started to make sense, and once identified, I started to tackle them one by one: my anticipatory and social anxiety, my forgetfulness and disorganization, and my lack of prioritization skills. But most importantly, I learned to identify my limitations and to ask for help. For the first time in residency, I felt there was light at the end of the tunnel, and, without realizing it, I soon regained my confidence and motivation. I was finally able to enjoy my daily interactions with residents and faculty, to be more intellectually curious about my patients, and to engage in research activities. All of this happened between my 6th and 8th months of the intern year, and my only regret is not seeking help earlier in residency. Looking back on my first months of residency, I realize that we have all come a long way, just as Dr. Willett and Dr. Kraemer said we would during orientation week.

Being aware of the areas in my performance that I can still improve no longer gives me uncontrollable anxiety but, instead, excitement, as somehow I feel these are upcoming challenges that I am confident I will overcome with all the resources I can find at UAB. I am deeply grateful for having such amazing peers, who, despite facing similar challenges and being just as stressed out as I was, continue to impress me with their energy and positive attitude; for my senior residents, whose infinite patience showed me the way to becoming an empathetic upper level; and for the outstanding leadership and faculty, who offered me their unconditional support whenever I needed it the most and no matter how tough the journey can be. When applying to residency, I mentioned in my personal statement that I was looking for a place where I could become not only an excellent health care professional but also a compassionate human being, and UAB has not only met but exceeded my expectations, providing me with the perfect environment for this purpose.