What pops into your head when you hear the word Iran? In 1995, I was an ophthalmology resident in a small college town in the Midwest, doing a rotation in the retina subspecialty clinic, when a patient asked Ali, the fellow, where he was from. Ali hesitated for a moment and I thought he would say, “Virginia.” Instead he smiled graciously. “My family is Persian,” he said in his minimally accented English. Ali’s educated and successful family had fled Iran when the Shah was ousted. Experience had taught him that when older Americans heard Iran, they pictured a hostage standoff, and the ensuing silence detracted from the therapeutic relationship. “Saying Persia just makes them think of nice things. Exquisite rugs. Fluffy cats. Aladdin,” Ali said.
Pairing the word Persian with rugs and cats is an example of a thinking shortcut called the availability heuristic described by Daniel Kahneman, PhD, and Amos Tversky, PhD, to explain how our brains fill in ignorance with recently available impressions.1 When asked which is the more common cause of death in the U.S., people are more likely to incorrectly choose murder over diabetes. After all, diabetes seldom makes headlines. Ubiquitous media coverage of terrorism refreshes an association in people’s minds that may prejudice them against people of certain nationalities.
Mahzarin Banaji, PhD, and Anthony Greenwald, PhD, wrote a book called Blindspot: Hidden Biases of Good People, about how our judgments of various social groups are influenced by previous experiences. They used on the implicit association test to demonstrate that bias affects the likes and dislikes of even well-intentioned people. Many people are shocked to find the degree to which they harbor bias.
How can well-meaning people minimize unconscious bias? In 2012, researchers challenged psychologists to test 18 different strategies for decreasing bias. “Counter-stereotypic exemplars” and creating positive associations proved most effective. Ali now tells his retina patients in Virginia that he is from Iran, hoping they develop lasting positive associations with Iranians.
In 1995, Ali took his written board examination, and the following year sat for his oral examination. For many years as a volunteer examiner, I have marveled at the way foreign-born candidates elocute their way through the exam, describing clinical details in idiomatic English sprinkled with the arcane hash of Greek, Latin, and German that makes up ophthalmology terminology. It reminds me of the old quote about Ginger Rogers, that she did everything Fred Astaire did, only backwards and in high heels.
Empathy, as patients know, is the secret sauce of good medicine. Empathy is multifaceted, and appreciating a differing viewpoint is part of it. Bilingualism has been shown to be associated with stronger theory of mind and awareness of diverse perspectives. A recent observational study found that patients’ 30-day mortality was significantly lower under the care of an international medical graduate (IMG) hospitalist compared with a US medical graduate. The authors suggested that the difference was due to the rigorous selection process for IMGs. Perhaps an extra helping of secret sauce played a role as well.
We hope that our brightest young people choose medicine. This year, 17-year old Indrani Das won the $250,000 Regeneron Science Talent Search for a project involving neuronal damage in brain injury. Five of the top 10 finishers were Indian American. More than 80% of finalists last year (when it was called Intel Science Talent Search) were children of immigrants. Advances in science in the United States depend to a great extent on foreign-born and first-generation students.
More than one-fourth of practicing US physicians are foreign born. Many others are offspring of immigrants. Many of these individuals had training overseas before entering a US program. Because of visa requirements, IMGs often work in rural areas or underserved communities. By 2025, we will be facing a shortage of 46,000 to 90,000 physicians.6 Increasing visas to admit more international trainees appears to be an uphill battle in the current political climate. Care quality and access will likely suffer if the United States becomes a less welcoming place to train and work.
At a state medical society meeting a few years ago, a member proposed having a representative for IMGs on the board, pointing out that IMGs made up more than a quarter of the students and trainees in the state and were an increasingly important part of the workforce, particularly in the underserved areas of our largely rural state. The medical society needed to engage them, he argued, and they in turn needed the state medical association’s support and information. Scanning the ballroom, I recall noting that there were few IMGs present, aside from the petitioning member, who was born and educated in Sri Lanka prior to further training in the United Kingdom and United States in internal medicine, hematology, and oncology. The proposal was voted down.
A JAMA article recently discussed the question of measuring tolerance when screening for health. Xenophobia is maladaptive and wrong. We physicians need to examine our own scotomata with regard to not just our patients, but also our peers. Moreover, it is time to move well beyond tolerance and into active promotion and wholehearted support of our diaspora health care work force. We need excellent IMGs and children of immigrants to advance science and deliver high-quality, accessible care. We need them in our boardrooms as well as our examination rooms. In addition to passing grueling examinations in a second language, they work overtime as the “counter-stereotypic exemplars,” thereby changing the implicit associations of patients and communities and shrinking blind spots. To do this effectively, they must repeatedly explain “where they are from,” even if they are born here. It is a lot to expect, but I am confident they are up to the task, having danced backward in high heels most of their lives. The therapeutic relationship, the focal point of our endeavor, can move patients and communities beyond mere tolerance of differences to respect, affection, and trust.