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IMGs’ Views of Psychiatric Conditions
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International medical graduates often have different views of psychiatric conditions compared to US-trained residents and faculty. In a qualitative study investigating the behavioral science training of IMG residents prior to coming to the United States, the majority of respondents commented that rates of mental disorders appeared to be higher in the United States than in their home countries. International Medical Graduate residents will sometimes attribute these higher rates to differences in the US social structure—such as the widespread use of nursing homes, elders without visitors in the hospital, and mothers raising several children alone—as the primary reasons there is more depression in the United States. These residents perceive family support to be stronger in their home countries, buffering against mental illness. The well-established finding by the World Health Organization of better outcomes for persons diagnosed with schizophrenia in less-developed versus more-westernized countries provides some indirect support for these observations.
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International medical graduates also tend to perceive strong religious faith as a valuable coping skill. These residents suggest that Americans often become “depressed” in response to chronic or daily struggles, in contrast with their international counterparts who may be more likely to accept their fate and avoid converting emotional distress into a medical condition:
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It is a religious society (India), so if there is a difficult life event, people accept it and move on … The strong belief in God means that if something bad happens, that’s because of God.
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Other cultures share with the United States the belief that psychiatric mental disorders are a form of illness, but the perceived causes of mental illness may differ. For example, in Karachi, Pakistan, Qidwai and Azam found that 30% of primary care patients believed that psychiatric illness was caused by supernatural powers and spirits. These patients commonly sought treatment from a Hakim (12%), spiritual healer (12%), and family support (2.5%).
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The stigma of mental illness also affects how these issues are addressed by IMG residents in primary care. In many cultures, mental health issues are viewed as shameful and taboo: “You practically never do this … [in my country] … psychiatry is for the mad man.” Due to their own culturally based misgivings about mental health issues, many residents fear they will offend patients and therefore avoid such questioning.
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Views of Mental Health Treatment
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Not surprisingly, many IMGs report minimal exposure to behavioral medicine prior to residency education in the United States. Many cultures view anxiety and milder mood disorders as variations on normal functioning rather than as illnesses. In these societies, the prototype of a psychiatric condition is a severe illness such as psychotic depression, bipolar I disorder or schizophrenia. Clinical training often involves observerships or walking rounds in institutions for patients manifesting debilitating psychiatric conditions. One resident from India reported:
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I had minimal training or no training in anxiety and depression. I was in a mental hospital and I had one month. It was in my fourth year. We had lectures for two weeks and two weeks in an institution. We looked at locked-up people all the time. We did not interview patients; we just walked through. It was like looking at specimens.
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Even in countries in which primary care physicians inquire about and treat psychiatric symptoms, there may be little diagnostic specificity. For example, one IMG from Bosnia stated:
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Mental health does not look the same there as it does here. In my country, our people are simply “nervous.” All psychiatric problems, depression, posttraumatic stress disorder, everything, it is just “nervous.” … People in my country, they come to the office and say they are nervous, so we just give them some benzodiazepines.
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The sociopolitical history in IMGs’ home countries may influence how they approach mental disorders. Family physicians in Russia revealed a reluctance to refer for mental health care, in part due to a history, in which psychology and psychiatry were used by the State to control political dissidents. In the Stalinist era it was said, “No person, no problem.” Diagnoses such as schizophrenia meant that there was “no person,” and the “patient” could be locked up indefinitely in a mental hospital, which was little different than a prison. (This practice has recently been resurrected in Russia by the Putin government.) People became afraid of psychiatrists. As one of the interviewees said, “The fear of that kind of specialist is probably somewhere in the genetic code.”
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International medical graduates, particularly from East Asian countries and the Philippines, are startled by many aspects of US family life, including single-parent families, cohabiting relationships, and serial monogamy. Before beginning residency, IMGs obtain their knowledge about the U.S. families from several sources, including television “talk” shows as well as from listening to the discussions of the personal lives of office staff in settings where they were completing observerships.
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Usually, IMGs are stunned by the permissive parenting practices in the United States and the childhood behavior problems that they believe result from this approach. Many find it odd that conditions like childhood ADHD, not commonly diagnosed in their home countries, are so common in the United States. As one resident from Eastern Europe said:
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Parents in this country, they let the kids do whatever they want … ADHD is not diagnosed in my country—it’s simply a matter of discipline. Here it seems to calm down parents and teachers when you give the kids medicine.
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International medical graduates tend to view parental discipline, even when physically harsh, as important for preventing oppositional and disrespectful behavior among children. The notion of child physical abuse is new to many IMGs. They are surprised that the state becomes involved when parents physically discipline their children. Child protective services’ power to remove children from their parents’ custody is very troubling to many of these residents. What is considered abusive in the United States may be seen as responsible parenting that builds character in their home countries. A resident from India noted that the children of strict parents do very well in school and college. In addition to influencing the clinical context, many IMGs have children of their own that they are raising in a new country with different parenting practices. They may themselves be experiencing conflicts regarding appropriate discipline.
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Early sexual experiences are particularly troubling to IMGs raised in traditional societies governed by strong religious and collectivist values. Sciolla and colleagues suggest that IMGs raised in many non-Western cultures may view sexuality as intensely private or even shameful. Premarital sex, while occurring, is a taboo subject.
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Our observations of IMG residents suggest two common patient management styles. One approach is to avoid discussing sexuality with adolescents seen in the office. Preceptors often need to remind residents repeatedly to raise these issues (see Chapter 32). Even then, residents often appear uncomfortable with the topic—speaking awkwardly while looking at the floor rather than the patient. The other approach is to accept that the West is a sexually permissive society. The resident may address sexuality in a matter-of-fact, almost business-like manner. For example, an IMG seeing a 14-year-old girl who recently had her first sexual intercourse approached the patient in much the same way as an adult. A Pap smear and pelvic examinations were conducted, and customary guidance about pregnancy, contraception, and safe sex provided. There was no discussion about the circumstances under which the girl had intercourse (e.g., was it coerced?), the age of the partner, or the patient’s perspective on the experience. Despite research evidence that early sexual activity is associated with sexual abuse history, smoking cigarettes, and using marijuana, the resident raised none of these issues until some of them were suggested by the behavioral scientist observing the encounter.
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Nonmarital cohabitation is also a unique experience for many IMGs. In one instance, a resident from the Asia-Pacific region was seeing a hospitalized patient with injuries reportedly sustained through an assault by her boyfriend. The supervising physician had urged the resident to address the issue with the patient and provide her with resources for victims of domestic violence (see Chapter 38). The IMG was confused and didn’t follow through at first. When asked about her reluctance, she responded: “It’s not domestic violence. They are just boyfriend and girlfriend; they’re dating. Each of them has their own house.” The resident was surprised to learn that adult “boyfriends” and “girlfriends” often live together, and domestic violence can indeed occur in these situations.
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The increased nuclearization and isolation of generations among the US kinship networks is troubling for IMGs from non-Western cultures, where extended families are common. To those from East Asia, for example, domestic violence in their home country was not a dyadic event with a perpetrator and a victim, but a situation in which the wife’s family members would rightfully intrude into the marriage to protect her. The family should handle this problem rather than the medical–legal system:
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Back home, if I hit my wife, they would not take that to the doctor. There is family support. Women are abused here, and they often do not want to do anything about it. Back home, women are hit and their dad says: “Come home.” Here, women get put out on the street.
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Caring for geriatric patients in institutional settings contributes to a view of American families as isolated and cut-off from their extended kinship network. Residents from societies that care for aging family members at home have difficulty comprehending the practice of placing senior family members in impersonal nursing homes: “Nursing homes do not exist in India—because no son or daughter would ever lose the honor of caring for his or her elders, especially a parent.” Similarly, hospitalized patients receiving no visitors—even when family members live nearby—are troubling to IMGs. One resident commented that he could now understand why he saw so many depressed patients here in the United States compared with his home country: “Back home families are crucial. Here, people are left alone. You have a chance to get depressed much more here.”
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Challenges In Learning Behavioral Science
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At a fundamental level, many IMGs are challenged by the inclusion of psychiatry and psychosocial aspects of the patient’s life as a significant component of Western medical practice. Coming from societies where diagnosis of mental health problems was often less common and those syndromes that were diagnosed were typically severe, many resident IMGs initially feel inadequate to diagnose and treat these conditions. Early in residency, some IMGs respond by referring nearly all depressed and anxious patients to psychiatrists. It is important that preceptors establish early in training that diagnosis and treatment of common mood and anxiety disorders, dementias, childhood behavior and adjustment problems, as well as sexual dysfunction, are expected competencies. Unless the case is complicated and beyond the scope of a nonspecialist (e.g., schizophrenia), the resident should learn to manage the patient.
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Diagnostic interviewing for mental health conditions is particularly challenging for IMGs. After taking the United States Medical Licensing Exam (USMLE), most IMGs are familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM) system and the use of explicit criteria for diagnosis. It may be difficult for them, however, to convert these dimensions to conversational questions. Often the questions tend to be verbatim recitations of the DSM criteria and have a stilted quality that confuses the patient (e.g., “Are you having feelings of worthlessness or inappropriate guilt?” Or “Do you have chronic feelings of emptiness?”). IMGs often recognize that they do not know how to ask about these types of symptoms and consequently omit them. This reluctance may be particularly pronounced for questions about self-harm, suicide, abuse, and illegal acts. One IMG resident describes his experience of learning how to ask sensitive questions:
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First, you are very uncomfortable, then you feel better and better … how to ask questions, how to ask about suicide. For me, that was very embarrassing. I was surprised people responded normally to these questions. “How will this influence her relationship with me?”
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In my country, if I asked a woman with a child if she was married, she’d get mad at me.
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During their behavioral science training, we have noticed unspoken discomfort when IMG residents are asked to interview, for example, a 14-year-old unwed mother, an openly lesbian couple, or divorced parents—each present with their new spouse. The resident who has done quite well interviewing other patients with psychosocial issues often seems at a loss about how to proceed with these family configurations. After sensing that they are uncomfortable asking the patient(s) further questions, the behavioral science faculty member will take over the interview for awhile. Later in the interview, we typically try to turn it back over to the resident who often at this point appears less confused and can follow the faculty member’s lead. After the encounter, when asked about their reaction and reason for not continuing the interview, a common response is something like:
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I know these relationships exist in America, but I have never seen them face-to-face. I don’t know what to say to these people.