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The demand for physicians in the United States (U.S.) continues to grow faster than the number of physicians trained, resulting in a projected shortfall of between 61,700 and 94,700 physicians by 2025.  As a result, many U.S. health care institutions supplement their physician workforce with international medical graduates (IMGs). According to the Educational Commission for Foreign Medical Graduates (ECFMG) an IMG is a physician who received their basic medical degree or qualification from a medical school located outside the U.S. and Canada.  The location of the medical school determines whether the graduate is an IMG and not the citizenship of the physician. Therefore, U.S. citizens and non-U.S. citizens who graduated from an international medical school are considered U.S. IMGs and non-U.S. IMGs, respectively.
About 1 in 4 practicing physicians in the U.S. are IMGs and play an important role in the healthcare system. [3,4] IMGs tend to more frequently practice in primary care specialties and serve in underserved and rural areas in comparison to U.S. medical graduates.  Research has shown that a diverse physician workforce improves access to healthcare for underserved populations, patient satisfaction with their treatment, as well as communication with their provider.  Therefore, IMGs diversify the physician workforce and help lessen health disparities and improve health outcomes. 
A total of 12,783 IMG applicants (5,323 U.S. IMGs and 7,460 non-U.S. IMGs) participated in the 2016 Match.  Out of 1,168 IMG applicants who ranked a Diagnostic Radiology (DR) position first, 177 (15.2%) IMGs matched (76 U.S. IMGs and 101 non-U.S. IMGs).  The overall match rate for U.S. IMGs versus non-U.S. IMGs was 49% vs. 47%; and 64% vs. 57% in DR, respectively.  Vascular and Interventional Radiology (IR) saw an increase of 49.1% among the number of active physicians and 27.3% among the number of first-year ACGME resident and fellows between 2010-2015.  However, DR and IR continue to face a shortage of IMGs and minority physicians.  In 2015, active IMG physicians made up 11.6% of the DR and 13.7% of the IR workforce.  Similarly, IMG resident and fellows made up 11.0% and 10.9% of the DR and IR workforce, respectively. 
A recent study conducted to assess the IR academic physician workforce diversity and comparative specialties concluded women (7.3% faculty vs 15.4% fellows) and Hispanics (1.8% faculty vs 6.4% fellows) are underrepresented in the IR academic physician workforce relative to the US population. These numbers suggest that given the prevalent health care disparities and an increasingly diverse society, research and training efforts should address IR physician workforce diversity. 
I had the pleasure to interview a very inspiring and unique Latina interventionalist. Dr. Gloria Salazar is an Assistant Professor at the Massachusetts General Hospital Department of Radiology. She graduated from medical school and completed her Radiology Residency at the Federal University of Sao Paulo in Brazil. Dr. Salazar then underwent IR fellowship training at the Beth Israel Deaconess Medical Center-Harvard Medical School (BIDMC). In the following interview, she discusses her journey into IR success and her experience as an IMG.
How did you decide to be an Interventional Radiologist?
I am the first in my family to pursue a career in Medicine, so I did not get a lot of exposure while growing up. While in medical school, I was initially interested in becoming a surgeon. As I progressed through my rotations, I enjoyed many specialties. It was then when I decided to follow a radiology specialty, specifically, interventional radiology, because it offered a clinical focus and patient interaction.
Why choose the United States to practice over other countries?
I was first exposed to the idea of practicing in the U.S. in 1995 when a Puerto Rican physician I met handed me a USMLE prep book. During medical school; I studied most of the subjects, read articles and participated in courses in English so that I could get used to the language. I considered the possibility of practicing medicine in the U.S.; in particular, because of the advances in technology, innovation and research opportunities.
Please tell us about your personal journey on becoming an Interventional Radiologist.
This was a long journey of hard-work, personal losses and discipline. My original plan was to do residency in the U.S. For some reason, my application for Step 1 was delayed and since I had already been accepted into a Radiology Residency in Brazil, I decided to postpone my plans. During residency; I was involved in many research projects with Dr. Salomao Faintuch, one of my senior residents at the time. He became a research fellow and later on an IR fellow at the BIDMC. One day, I received a call from him that changed my life forever. Dr. Elvira Lang was the principal investigator on a major study and she was offering me a research position for one year. I arrived in Boston right after the Patriots won the Super Bowl. I was alone and did not know anybody aside from Salomao. While working on research, I was able to pass my boards; and luckily there was an IR fellowship position available at the BIDMC. I began my training and decided to have a second year of advance fellowship. At that point I was married, and towards the end of that year, I had the most terrible personal loss. I had to suddenly fly overseas and attend the funeral service of my 14 month–old nephew who had acute mitral insufficiency and passed away in Sao Paulo. It was a horrible and devastating experience for me and my family, and at that point I really thought about giving up and going back to Brazil.
My father encouraged me to continue on my career path. So I did; and three weeks later, I was invited to interview at MGH for an attending position. I was emotionally broken but I had to fight for me and for my family. Although it was difficult to keep focused, I worked hard to get my credentialing paperwork ready to start at MGH. One week before I joined the staff at MGH, I took four days of vacation and unfortunately received another call. This time from my aunt saying that my father was being transferred to the ED due to cardiac issues. I could not believe that – and my whole world fell apart. I ended up postponing my start at MGH. When I arrived in Brazil, my father was already intubated and, five days later, he passed away. “Broken Heart Syndrome” is a real medical condition and affected my father who then experienced a hemorrhagic stroke secondary to these cardiac issues.
I returned to Boston and started my attending career with mixed emotions, but always focusing on doing my best at work. Despite my personal loss prior to becoming a member of the MGH family, I was blessed to have the opportunity to learn from many wonderful colleagues. I look back on the last 10 years of my career and am proud of how much I have grown both professionally and personally. I am truly thankful for all the support from my family, friends and mentors.
What are the biggest challenges you faced as an IMG going into IR?
Cultural differences: when I interacted with patients, I did not quite understand many of the social norms and values of the American culture. I read a lot of books before I came to the U.S. regarding politics, culture, and social values; however, this is a huge and diverse country, and you will only learn when you experience it. Now, I am happy to say that I can discuss baseball and football, and other topics that are intrinsically related to this culture, which makes it easier for me to connect with patients beyond the medical obligations. My accent was also an issue, I remember. I have undergone several training sessions on communication that helped me to be more confident with my communication style. On the other hand, my cultural background helped me connect with my patients in a way that is more common in my own culture where we value a more patient-centered approach.
Do you feel there were specific hurdles due to your ethnicity, gender or prior training at any point in your career? If so, how did you handle this?
Yes, definitely some specific hurdles were present due to cultural differences where perhaps ethnicity and gender, as examples, were part of the predicament. Lack of understanding of one’s culture and values, gender differences in communication style and problem-solving approaches, intrinsic biases, and personal individual’s experiences are all part of a great web of misunderstandings and wasted energy as to how to appropriately handle our differences in lieu of an optimal medical setting and patient care.
The way I handle these situations is firstly to have awareness that they exist within myself and everyone else who we interact with. Secondly, by using specific methods or techniques to foster, for example, effective dialogue where those differences are recognized and identified; and from there, all parties will have a better understanding of these disparities and open the opportunity for a common ground solution.
What are the things you would say got easier or more difficult now that you are an attending?
Having an attending position definitely makes things easier, particularly if the institution promotes diversity of culture and gender. The challenge for me now is to be able to teach others about cultural and multicultural competencies given that we have a very diverse patient population at Mass General Hospital.
If you could do it all over again, would you change anything? If so, what would you do differently?
I would not change anything about my career path, however I wished I could have been more confident in presenting my views and goals earlier on.
What would be the best advice you could give IMGs pursuing a career in IR?
Just like any career, believe in yourself and look for “good” advice. Medicine is a competitive environment, with many people being very passionate about their work and wanting to rise up to the top. As a result, teamwork and cooperation may be lacking, and criticism takes a harsh tone into detracting you from reaching your goals.
I have had so many different types of advices and, if I had listened to most of them, I would not be here today. Last year, I underwent a 360 evaluation during a physician leadership course, and as I was selecting names to provide feedback on my leadership style, I learned one very important lesson: choose people who know you and have your best interests at heart. If you have feedback from people who really care about you and want you to succeed, they will be truthful and help you improve on your career. On the other hand, it took me a while to learn who was giving me the right advice, since we all face many hurdles as we follow our career path.
Moreover, I have realized that even when people have your back, you need to follow your heart. As an example, about 60% of colleagues in Brazil told me it would be very difficult to validate my medical degree in the U.S., and that it was best to go back home after one year. Similarly, when I accepted the attending position at MGH, advises against my decision were given and more specifically about having to re-start my alternative pathway with the American Board of Radiology, but I did it anyways. And I have many other examples in which I followed my heart and it often lead me to the right place at the right time.
One more thing: do not underestimate the power of connections; be observant and open to every person you come across. Be curious, and life will show you the right way. I would not be here if it wasn’t for this power and curiosity.
Last advice: Be yourself, observe, process what you learn and be patient. As for being in IR, remember that hard work leads to practice and continuous practice leads to excellence.
1. Association of American Medical Colleges. Physician shortage and projections. The 2016 update: complexities of physician supply and demand: projections from 2014 to 2025. 2016; https://www.aamc.org/data/workforce/reports/439206/physicianshortageandprojections.html.
2. Educational Commission for Foreign Medical Graduates. Definition of an IMG. 2011; http://www.ecfmg.org/certification/definition-img.html.
3. Ranasinghe PD. International medical graduates in the US physician workforce. The Journal of the American Osteopathic Association. 2015;115(4):236-241.
4. Association of American Medical Colleges. 2016 physician specialty data report. 2016; https://www.aamc.org/data/workforce/reports/457712/2016-specialty-databook.html.
5. Higgins MC, Hwang WT, Richard C, et al. Underrepresentation of Women and Minorities in the United States IR Academic Physician Workforce. Journal of vascular and interventional radiology : JVIR. 2016;27(12):1837-1844.e1832.
6. Traverso G, McMahon GT. Residency training and international medical graduates: coming to America no more. JAMA : the journal of the American Medical Association. 2012;308(21):2193-2194.
7. National Resident Matching Program. Charting outcomes in the match for international medical graduates. characteristics of international medical graduates who matched to their preferred specialty in the 2016 main residency match. 2016; http://www.nrmp.org/match-data/main-residency-match-data/.
8. Underrepresentation of Women and Minorities in the United States IR Academic Physician Workforce. Higgins, Mikhail C.S.S. et al. Journal of Vascular and Interventional Radiology , Volume 27 , Issue 12 , 1837 – 1844.e2
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