Dominate the Match Episode 7- Applying to Residency as an International Medical (Part 2) Graduate

Hello and welcome back to another episode of Behind the Knife. Today we're continuing our discussions around international medical graduates and applying into surgery training programs in the United States with tips to help navigate the system. Coming off a great conversation with Dr. Raghavendran and Dr.

Hughes, we wanted to extend this dialogue with another guest who has extensive experience as an IMG himself and now as the department chair at Northwestern University. I'm Jessica Millar, general surgery resident and BTK fellow. And I'm John Williams, also a general surgery resident and a behind the knife fellow.

Today, we're thrilled to be joined by Dr. Hassan Alam, who's the chair of the department of surgery at Northwestern University Feinberg School of Medicine. Dr. Alam was originally born in Quetta, Pakistan, and completed his medical degree at Aga Khan University Medical College in Pakistan. He then moved to the United States to complete his general surgery and subsequently trauma surgery training at the Washington Hospital and Georgetown University in Washington, D.

C. After completing surgical training, he spent time as a postdoctoral

research fellow at the Uniformed Services University of Health Sciences in Bethesda, Maryland, where his prolific research in trauma resuscitation and innovations in the management of hemorrhage was catalyzed. He then became a faculty trauma surgeon and program director of the Surgical Critical Care Fellowship at the Massachusetts General Hospital, where he founded the institution's first multi specialty intensive care unit.

Back in 2012, he then moved to University of Michigan to serve as the section head of general surgery, a position that he held for about eight years before being brought to Northwestern to become chair of the department of surgery, where he is today. In addition to being a renowned trauma and acute care surgeon, Dr.

Alam is also a prolific surgeon scientist, leading a highly productive lab investigating traumatic injury, hemorrhagic shock and coagulopathy, and is primarily funded by the NIH and the U. S. Department of Defense. He's been central in the development of trauma interventions such as RBOA and QuickClot, both of which are now commonly implemented in the military and civilian worlds today.

Dr. Alam, it's an honor to have you join us today. Thank you so much for taking the

time. Absolutely, it's a pleasure. So to get us started our goal with this series is to kind of focus in on the IMG experience, and since you've kind of navigated this process yourself during your early career, let's start by having you just kind of talk about your experience.

Tell us a little bit about your journey, your medical education abroad, and kind of your training in the U. S. Yeah, I think the the experience is not uniform for everyone. It's it's very different for different people. It has changed and evolved over time. When I came here in 1990s for my residency, I mean, there were no work hour limits it was a different world.

I think the it's an uphill battle it's a competitive field. It's difficult to get in and it's. Probably even more challenging to succeed. But it's clearly possible. So, the way I look at it, it's like, you know, you have, um, multiple challenges. You have to come to a brand new system get into the system, then prove yourself, and then

excel.

And all of those are not sort of a given. But also, there are multiple different ways of succeeding. And success is not measured by just one criteria. We have a huge workforce need. So we look at some of these things through the lens of academic surgery, and that's not where most of the surgeons practice in the U.

S. If I think about it, if you look at the projections, we are projecting about a 30, 000 surgeon deficit by 2035. We have an aging population in the U. S. The U. S. graduates are dropping out of the workforce at about two and a half fold higher rate. then IMGs. Who's going to provide care for all these aging patients who have surgical needs?

Fast forwarded about 20 years from now, we will have a crisis. It's already getting to that stage, but it'll be a huge crisis. The other issue is that if you look at your graduating medical school class, only about four to 7 percent of the students are going into surgery, right? So you

have an aging population, growing need.

A workforce that is retiring and aging as well, and only low single digits of medical students going into surgical training. The writing is on the wall. And the way I look at it is the talent is now global. You have to find talent where it is, as opposed to just looking for talent within a small pool.

You can look at this thing from two different perspectives, maybe three. You know, the person who will come from abroad and try to navigate the system, the training programs and the hospitals that need a workforce. But eventually also patients who need to be taken care of. So, there are multiple different perspectives and I think I was, I had good mentors and I was lucky I happened to be in the right place at the right time, but it was hard work.

But I I don't, I try very hard not to look at this thing through my own experience because that only applies to one

person's experience. You can't generalize it, but I think the needs that I see it's not as a department chair or, you've been in the field for a period of time. I look at sort of, you know, we're going towards this cliff where we'll have a perfect crisis with aging population and a workforce deficit and the pipeline that's running dry.

So we just need to create a better mechanism whereby we can recruit talented people from across the world. Absolutely. That's such a good point. You know, I think. A lot of folks have brought to light this impending challenge that we're going to have going forward in the next. One or two decades in terms of the surgical workforce and the need of the population in the United States, especially.

I think one of the things you mentioned as one of the big challenges for IMGs looking to come and train over in the U. S. and work in the U. S. is just those initial connections to get you in the door. Could you elaborate some more on what you think are. Kind of the contributing barriers of making those initial connections and also maybe some strategies to

facilitate it.

Well, I think this is not different from anything else. I mean, when you're trying to recruit somebody brand recognition matters. So if you're recruiting somebody from University of Michigan, I know what the students would look like if you're recruiting them into a residency program. If you're recruiting somebody from across the world, you don't have the brand recognition.

They may be really good, but they may not be well trained, right? So, so there is that uncertainty that goes into it. And I completely get that. You are making a big commitment, a multi year commitment to bring somebody to train them. And if you don't know how good or bad the product of that medical school is, then that.

The second set of barriers is all regulatory and bureaucratic, you know, visas, licenses, all of that stuff. And neither one of them has an easy solution. But I think the first one, the brand recognition, I think it gets easier and easier if you're recruiting medical students from schools where you have

recruited them.

So at least you're not completely flying without any visibility or any data when you have your pre past experiences to go by. Not perfect, but at least you have, you know what you're trying to recruit and then you have experience working with those graduates. The the bureaucratic hurdles, I think that bureaucracy doesn't change quickly and I think there's a vested interest in terms of licensing and creating a sort of, barriers to workforce so you can, there's some protective instincts at work as well, and that's a financial drivers as well.

Once you have the workforce prices, I think people will realize that, and they will try to change those rules, but it takes a while. You know, it takes many years, so my concern really is that if we see that there's going to be a problem 10 years from now, then many years before that, you have to create those changes so you can actually bring people in, train them in a training residency

program.

I mean, that's a multi year process, get them out in the workforce, so you can't just sort of pivot. Very quickly here. Yeah, a lot of those barriers you mentioned were similar things that we talked about in our discussion with Dr. Hughes from a program director's perspective, the essentially just gamble you play when you're not sure of the standards of a IMGs quality of their medical education.

We talked about some ways to potentially highlight those. Are there things that you have noticed or have. Giving advice to students to either, you know, gain clinical experience in the U. S., which kind of helps to standardize, Or helps to kind of showcase that, like, yes, a student is up to standard with what we would consider to be, you know, also standard for U.

S. medical students or things that they've done back home or via their application to kind of also highlight that, yes, I am, I'm on the same level as these U. S. students that you're also looking at. Yeah, and I think that's a very fair question. So, I think if you

have. A little easier access to observerships or visiting internships or sub Is and things of that nature where you can give them an opportunity to showcase their talent and their ethics and, you know, how the commitment to the to the profession, then I think it would de risk it.

But again, that's where some of those bureaucratic things come in, like, you know, there are issues around licensing and practicing issues, liability, medical legal issues as well. All of these have a solution. I think when people feel the need and the urgency you can find a way around it. You can in a thoughtful fashion, craft those regulations that allow talented people to come in.

Right now, the need, you know, the last 20, 30 years, we didn't have a need, so, they are overtly restrictive. For somebody to come in and work at University of Michigan just for a month as a as a sort of an unpaid sub I just to do the work, it's just

impossible for them to do it. You know, they can just stand on the sideline and watch, but how are you going to judge somebody's work performance, you know, if they're just standing at the sidelines?

So, how do you engage them? It's not a difficult issue. It's just a matter of like, you know, just having, realizing that this is essentially going to be impossible to limit your recruitment to 5 percent of the world population, which is what U. S. population is. You know, you're leaving 95 percent of the world out there, and there are talented people out there.

But we do it for sports team, we do it for tech, we do it for everything else. This is not a novel concept. If I want to have a winning team in any sport, there is no barrier. You will go to the ends of the world to find the most talented person to bring to you on your team. And then you have camps, you have, like, you know, the minor leagues.

You have all kinds of stuff where you can actually

challenge them and have them prove themselves before they make it to the major leagues, right? So, there's a financial incentive to finding the top talent and we do it. Medicine is no more complicated or difficult. The financial stakes are probably less.

You know, as opposed to writing a huge contract to bring somebody from Japan to come and play. In the U. S. who doesn't speak the language, right? But we do it all the time. And, and give them like, you know, contracts that will just mind boggling. That's so true. I guess, it's like a, I'll have to think longer on what the minor leagues of surgery looks like.

But, uh, but I think, you know, you mentioned earlier that it seems like over time, it's only gotten more difficult for folks to find these opportunities and find these windows to potentially come over and, Perform and prove themselves. Are there anything else that you think has changed over the years and your experience in the U S for trying to seek positions?

I mean, I think the it goes through a cyclical thing. There are no big radical changes, just going back to how we find talent, if you approach it in an organized fashion, right? So if you are recruiting for a sports team, you will have objective criteria. You know, how, your springtime, your, how far you can throw and how much you can lift or whatever.

Like, you know, so you have objective criteria, you have camps. People come in and prove themselves. And then based on objective criteria, you take the top talent and you move it to the next level up and then you see how they play in a group and how they sort of like, you know, and then you take it to the next level.

So the investment up front is pretty minimal, if you think about it. I mean, how much does it take to, for you to have a camp where you can see how people can suture and how they can maneuver a laparoscope and how they can answer, questions about patient management scenarios and whatnot. I mean, what does it cost you?

Not much. , so then you're not just

flying blind. You are looking at eye hand coordination. You can looking at, you know, cognitive data analysis and management plans and all of that stuff. Just have a pep. Now, even right now, even for our internship interviews, which essentially do a zoom interview, look at the CV and take people most of the time they're okay.

And sometimes they're not, but if you're taking them in to be surgical interns, You should have a camp or a screening process that addresses that issue. Like, you know, how would you be as a surgical intern? The idea is that you're just smart and talented, you have good scores and you have a good transcript.

And then that translates into being a good surgeon. Sometimes it works, sometimes it doesn't. It could be all thumbs, right? That's what Dr. Raikevenger would say I would be, but it's a good point. I think it's so interesting that since the creation of surgical training, that's been the selection

criteria.

And there's really never been any sort of objective component to the evaluation and it seems like it's certainly an opportunity to open doors for folks that. Don't come from U. S. based medical school training where there's at least some bit of a track record that folks are familiar with. One of the things that I really wanted to kind of ask and get your perspective on are some of the common challenges that IMGs, like if they're, if they are super fortunate to get a residency spot here, what are some of the challenges they face and what are some of the challenges that maybe Like myself, I'm just not aware of, but can maybe help make easier, make that transition easier.

And any advice or any experiences that IMGs can kind of do now to help prepare for maybe some of these challenges? Yeah, so I mean, I think there's certain things that are very predictably the same. Anatomy is the same. Appendix lies in the same place. Your cardiac output is still dictated by preload and contractility and afterload.

So a lot of those things are,

but there are a lot of different changes. So, culturally you have to think about somebody who's coming from a totally different part of the world, the cultural norms, how you interact with people, um, conversations the At the expectations of patients and providers that are around you they may be different from the environment that they're coming from, right?

So being aware of that and making sure that people are onboarded appropriately would help. Just sort of stepping into situations or that can be prevented. The other thing is like, you know, we all count on our social support system during the tough years of residency training. Thank you. Whether it's your family, your spouse, your loved one, friends and then you bring in somebody who's in a different environment, they don't have a social support system, and it's a tough life to be a surgical resident or intern to begin with.

So again, just sort of thinking about their perspective and how you can, Be a little bit more accommodating would go a long way.

And these are sort of like very basic things that we don't think about, because these are not issues that everyone else is dealing with. There are some upsides to that as well.

There is definitely a filter. People who have made a conscious decision to move 10, 000 miles and be in a different culture, they have a different mindset and a different set of priorities. They're much more driven, willing to make sacrifices. So, as a matter of fact, if you look at the second trial data around Mistreatment and abuse and all of the stuff.

The one group that sticks out that has sort of not reported any bunch of that stuff that everyone else is reporting is the IMGs. So it's and some, you know, you can look at it multiple different ways. Maybe they don't feel empowered to report these things. So maybe their expectations of what is expected in this life is different.

Or maybe they feel privileged that they actually have an opportunity to, you know, so maybe a little bit of all of those things. But generally they are very well adjusted. Non complaining workforce, if

you create a little bit of a ramp up front. To onboard these individuals. It's always helpful if you have a track record of taking people from different parts of the world because that they may have a little bit of a community or people who can help them who preceded them.

But if you are starting it and you don't have a track record of doing that, then I think being aware of those things is important. It's not a whole lot different from other groups that were typically not in surgery. Yeah. Absolutely. Historically, women, underrepresented minorities, were not, well, you know, present in surgery.

I mean, it was not a very diverse workforce. So as we started being more open to all of those groups that were excluded from being surgeons, We had to create like, you know, communities that would welcome them and mentorship programs and people who they can sort of connect with and who they can go to if they're struggling with personal issues or professional issues.

So I think those are some of the things, but that's not rocket

science. I mean, that's what we should be doing for pretty much everyone. Anyway, right? It's just another group that historically has not been the mainstream of surgery, but if you're trying to bring those people, you just have to think about, like, you know, put yourself in the shoes and say, like, what their unique needs might be.

And one thing that I actually tell everyone is if you're wondering what the unique needs might be. Just ask them.

Sometimes it's as simple as getting some help to like, you know, getting, renting a place to stay because they don't have credit history. Like, you know, how would you go and sign a lease or open a bank account or get a credit card? Things of that nature. Definitely. I think that's super insightful.

And, you know, like you mentioned there's Other populations that are also underrepresented in the field of surgery and tailoring to the needs of those populations. It's important to being thoughtful in that way. Kind of shifting gears just a little bit. In our prior discussion with Dr.

Raghavendra and Dr. Hughes, we

talked a bit about how research opportunities tend to be a more common avenue to the U S for IMGs rather than clinical opportunities. And I was just wondering what your thoughts are on how to best balance in their application or in their approach to reaching out to general surgery, U S based programs balancing research and clinical experiences.

Yeah, I mean, I think it definitely helps. There are certain things that make your application stand out. Having some U. S. experiences and having letters of recommendations from people who are, uh, well known in the field, it definitely helps you. But then also have publications and presentations and things of that nature.

It definitely helps. The fine balance is that if you've been out of clinical work for many, many years, let's say you do like, you know, four or five years of research and you have a an impressive CV, but suddenly, if I'm a program director looking at your CV and select, but you haven't touched a patient for five years.

So

that creates another uncertainty. So. That's the fine balance. You it helps to take out a few years, do dedicated research, but not just do research time, but be productive. I think that's what people see. If you said that, well, I've done three years of research. The very next question I flipped to the back of the CV and said, like, so what the product is, you know, what have you produced?

And if you have invested time and there is little to show for it, that might actually be counterproductive. So you have to invest time, but be productive. Also, you have to balance it out with the fact that you're not away from the clinical life for so long that you start becoming irrelevant or start creating anxiety in your potential program directors.

Like, well, that's too long. If you are doing research in a place in an academic medical center looking for opportunities to at least periodically do some observership and attend the grand rounds and attend sort of educational conferences and things

of that nature to stay connected with the medical side of the surgical side of your life.

I think that helps and then highlighting that in your personal statement and your CV and in the letters that, you were just not sitting in a lab or doing outcomes research or, working with a mouse model, but you were also engaged. You know, periodically, you know, go spend a week on the service and also will help generate some letters.

So I think that's the balance. I don't think, I think it's a, the short answer is yes, it helps, but there is the right dose. It's like the whole Goldilocks thing, right? So if you do a whole lot of it then it might take something away from you being credible clinically. That kind of pivots to my next question, which may not be super IMG related, but just general surgery related, which is, I don't know, hopefully our listeners appreciate how successful you have been both clinically and academic.

And I

would love any advice or just how you sort of manage being like so clinical and so good clinically, but also being so productive in the research space and being present in both of those. I would just love to hear how you. Yeah, no, this is something very near and dear to my heart. One, I think the four or five things that that I've noticed you would want to think like, you know, there's some innate brilliance or smartness or desire to succeed or drive or it's none of those things.

So by the time you're an academic, You're surrounded by people who are smart. There is not a single person around you who's not super smart. They've gone through high school and college and medical school and exceeded at all those levels. And so the reason they are a faculty at University of Michigan or any other similar kind of a place, they are.

the top 1%, right? The reason they signed up for an academic job is because they want to succeed in

academic life. Otherwise they would have gone into private practice. So they have made multiple choices along the way to end up where they are. But now if you look at all the assistant professors in department surgery in any academic place, there's a handful that are super successful for using conventional academic criteria, publication, grants, and so forth.

And then there, there's another group that have the same background, same training, same drive, same intellect, and they struggle. So, the question is, what differentiates these two groups? Now, if it was your innate capability, then there's nothing you can do about it. My position is that this is not innate.

This is, these are all learned behaviors. So, as I see it, there are a number of things. One is your mentors and your collaborators. The biggest predictor for somebody winning a Nobel Prize is that they worked in the lab of somebody who won a Nobel Prize. It is whether you, smart people attract smart people, or you learn the skills from people who have done

it before.

Either one of them is true, but so having the right mentors Tremendously help. The second is as you move up the ladder and you start creating a presence for yourself, having team members and collaborators. It is absolutely essential if you are doing research, you don't know everything and you are not an expert in everything.

Knowing where your weaknesses are and as soon as you can, either you can collaborate with your weaknesses or you can hire your weaknesses. Work with the PhDs, work with data analysts, work with like, you know, the cellular biologists, wherever, whoever is bringing in talent that you don't have. If you are the smartest person in the room, you're probably in the wrong room, you know, so surround yourself with people who are smarter than you and more accomplished than you.

And if you're in a job where you are the smartest person in that department, that division, that group, probably look for another job where you're surrounded by people who inspire you, who you can learn from, and who are more accomplished. That's the

mentorship and team part of it. The second is is time management.

There, there's the only non renewable resource in your life. So there are only 168 hours in a week, no more, no less. So, if you watch TV tonight for three hours, that's three hours gone, they'll never come back. So, the question is, what are you going to do with your time? There are some people that you see always sitting in the cafeteria, and there's some people you never see in the cafeteria.

You know, they all consume food and calories, but they use their time differently. So, a lot of it comes down to being very deliberate and very thoughtful about allocating your time to activities that matter. Efficiency gets you just to a certain degree. As a surgical resident, you become very efficient at using your time.

By the time you're a faculty, it is what are you using your time for? So, and it's a zero sum game. If you're doing this activity, you're not doing that activity. So you have to make choices, and some

people are very good at making the right choices over a long period of time, and that translates into more academic productivity.

So, so think about the team that's emerging. You're working with smart people who are smarter than you. You're learning from them. You're using your time and allocating it for for activities. I haven't talked about talent or drive or any of that stuff. The other next thing is that you have to write on schedule, not when inspiration seizes you.

Just like how you OR schedule, there's a, Hernia repair starting at 7. 30 is on your schedule, so your writing time has to be on your schedule. So if it says that you're going to sit down and write from 8 to 10, you have to sit down and write from 8 to 10. If you write two hours a day, at the end of the week you have a manuscript.

It's as simple as that. And then people say, well, like, what should I write? Well, when you start, write anything. Write poetry for all I care. It's the discipline of sitting down and not getting out of your chair and writing something. You

write opinion pieces, you write review papers, you write standard operating protocol policies, you know, write ideas for what you're going to do with your next project.

There's always something you can write. Write a book chapter. The quality of what you write only improves. But it's the discipline of sitting down and writing. And I know people who can sit down and write, and the people who struggle to sit down and write. It's almost like exercising. Or if you're preparing for a marathon, you've got to put your shoes on and go for a run.

The first time, you're not going to run the 26 miles. But the fact that you are putting your shoes on and going out for a run, rather than finding a reason not to do it today. You know, you can always start tomorrow, but some people, they actually do it. So it's the discipline of, Realizing that written word is the currency of academic success with this grant, protocols, manuscripts.

So you, some people do it very, very well and some people just don't. I have all these years in different leadership positions when I meet with the faculty at, my

yearly meetings and say, well, you were going to do X, Y, or Z. Usually it's something about writing. Either grants or manuscripts or whatnot.

What happened? You know the commonest excuse that they give you? They just don't have time. You have to remind them they have the same 168 hours a week that everyone else has. They're just making wrong choices with their time, or they're not disciplined enough. So, you know, but some things are relatively simple, like, if you have a Facebook page, you, it takes some time to manage that.

If you watch TV, it takes some time to manage that. If you're cutting grass in your house, I mean, you know, each and every one of those activities, the question is, can you not do it? Is it meaningful for you? Or can you outsource this? So I, in my life, I mean, I look at everything that I can outsource and I outsource it.

I'm essentially buying my time back. So there are a few things that, you know, you have to be a parent to your children and there are some, you know,

there are things that are meaningful in my life. So if you see me in my yard doing something, it's because I'm doing it with my kids. I've never cut grass because as you're cutting it, it's growing right behind you.

I mean, it's a waste of your time. You can give somebody some money and they will do it, and you're buying your time back. But I see people doing it all the time. So, a lot of it is so fused. And then, the last thing is that you have, because it's a marathon, it's not a sprint, you need your support system around you.

Whether it's your friends, whether it's your spouse, whether it's your family members, or your community that you belong to. So if you make a list now, so you have to have the right mentor and collaborators. You have to use your time well, you have to write and schedule, and you have to be surrounded by people.

that care about you. That's all it takes. So I mean, those are four or five things that that makes the difference. It's not your innate brilliance. It's not that, you know, you suddenly get inspiration to do something

dramatic. You're going to do it for 30 years. So it has to be sustainable. So, so I hope that helps like, and especially as you get busy on the clinical side, you need.

Your team, people who you can count on. And then on your research side, you need a team people that you can count on. There is no way you can squeeze all of that stuff and be productive within the 24 hour period that all of us get. I feel like we're gonna need to bring you back for, you know, like another ep full episode on how to be a successful academic surgeon, because that was extremely, extremely helpful.

I guess, you know, for both of our, both our IMG listeners out there and just listeners otherwise, whether it's students, residents. Other trainees or even faculty surgeons. Any final pearls or words of wisdom for the folks? I think this is a great life to be a surgeon. It's a privilege. Yeah, I mean, it's very few professions where somebody honestly puts their

life in your hands.

And not to minimize anyone else's work, but if you are you know, family medicine doctors and my parents do it all the time, it's like, you know, they're PCP, they're just a medication selector. Do that. So now, no I decided I'm just going to take half the pill rather than the full pill. I don't, you know, you have, you can always second guess that you can get a second opinion, but in surgery is very unique.

You meet a patient and essentially you tell them that we're going to put you to sleep. You'll be completely senseless. Nobody's watching over my shoulder. We're going to open you up, do the best, you know, exercise my judgment and then close you back up. And they say yes. And this sign on the dotted line.

Another human being is placing their life and their well being completely in your hands. There is, just think about it for a second. I mean, you know, a person that you've never met before, they may not even give you the phone number if you meet them in the street. But here, They are essentially relinquishing full control and placing their life

in your hands.

So it's a privilege. It's, it never, if you think about it, it's a huge responsibility. I've given the same choice over and over again. I would, I would do it. It's a noble profession. And also, in the big scheme of things, if you are doing something that the society needs, that you care about, that benefits humanity, and also pays well, There are very few things that fall into all of those categories where you can check the box.

So, I'm very bullish about the future. I think the the field of surgery is a respectable, honorable profession that the society needs and will need more as the time goes on. So, the future is bright. I, it, I find it irritating when people Talk about sort of the doom and gloom because I look at it very differently.

You want to be in a profession where the, you as you look in the crystal ball and say, there's going to be more need for us and we are doing good work. That's noble work. That makes a difference

in the world. So the future belong to you guys. No, I tell every medical student I think I have the coolest job in the world and I look forward to going to work every single day.

Well, thank you so much, Dr. Alam for taking the time to chat with us today. We have really, really appreciated all of your insights into this topic and just surgery in general. It is my absolute pleasure. So it was fun connecting with you guys and hope to see you again. Absolutely. So that concludes our second episode focusing on international medical graduates and surgery.

We hope that all of our listeners really enjoyed this thoughtful discussion. Thank you so much again, Dr. Alam. We really appreciate you taking the time and effort to chat with us. And until next time, dominate the day.