Diversity, Equity and Inclusion

Self Evident Truths

Welcoming foreign born medical professionals

BY Brad Fern

Unfortunately, many foreign-born physicians and nurses have to deal with prejudice and ignorance both outside and inside the workplace. Whether from corporate policies, well-meaning but uninformed colleagues, and most often from patients themselves, difficult and sometimes hurtful challenges set them apart. A better understanding of the process foreign-born health care providers encounter will lead to a healthier and more robust health care delivery system. A good start to this understanding is asking the question, how can native-born physicians and other health care professionals best support their foreign-born colleagues?

First, consider the impact of cultural bias, especially the insidious impact of microaggression. Then weigh the issues of cultural marginality, appraise the dynamics of culture shock and reflect on how they impact the lives of physicians and other health care providers. Finally, it is important to examine the professional barriers faced by foreign born-physicians.

Under the best of circumstances, immigrant physicians face considerable hurdles to practice in the U.S. — from state licensing requirements to rigid visa rules, Conrad 30 J-1 Waivers to education augmentation, and so on. In addition to being an already mind-numbingly arduous process, the COVID pandemic made becoming a physician in the U.S. even harder with office closures and suspension of visa services overseas. It’s just plain difficult for immigrant physicians. In addition to the bureaucratic obstacles, the subtle cultural dynamics can make it even more challenging.

Consider the impact of cultural bias.

Cultural Bias and Microaggression

Patrick Robinson is a psychotherapist who lectures on issues of cultural understanding. He immigrated to the U.S. from Korea when he was 14, and he now works as a mental health crisis intervention specialist for a hospital system in the Midwest. He stresses that it’s important we understand how physicians experience prejudice and bias like anyone else.

“When you come from a different culture, especially if you look different than the dominant culture, there are cues that constantly remind you that you are different. Whether you’re walking down the street, at work, or walking into a store, foreign-born people are constantly reminded.”

India is the country from which most foreign-born physicians immigrate to the US, with China second, and many more physicians coming from Pakistan and the Philippines. Nigeria and Jamaica are the most common countries of origin for immigrant registered nurses, and about 40% of home health aides are foreign born. That means a significant number of health care providers look different from those of the dominant culture, and they are more likely to feel set apart.

In his lectures, Robinson emphasizes the impact of “microaggressions.” Complimenting a person on how articulate they are, for instance, commenting on how well they speak English, or making their race or ethnicity the topic of conversation. Robinson says that a lot of microaggressions come from patients, the seemingly innocuous comments and cues that don’t let immigrants forget they are different.

But you don’t have to look different from the dominant culture to be reminded you’re different. Svetlana, a nurse who emigrated from Russia, describes how language can be a problem. “They know the minute you open your mouth, and it’s harder for us to know the common words for many medical conditions. That can put the patients off and make it harder to build rapport. For example, a physician might be advising a patient about the side effects of neuroleptic medications and talk about tardive dyskinesia. The doctor might not know how to talk about this colloquially. If I’m the patient,” Svetlana says, “I see this physician who comes in and talks to me highly with all these complicated words, and it turns me off.”

Age, gender and religion are cultural factors, too. Dr. Fatima is from Libya. Her son was transitioning from grade school to middle school, and she was growing more and more uncomfortable with the way American girls dressed and the way they were allowed to interact with the boys. Dr. Marek from Poland says, “America is the most youth-centered culture on the planet. The relationships between young people and adults, how you address, it’s coded in language, it’s coded in culture. In most countries in the world, age is still treated with respect.” And when you look at reactions to young African male immigrants as opposed to the reactions to young African female immigrants, or mothers with small children, the males will be less welcome or even seen as threatening.

The bottom line is that it’s difficult to acclimate and assimilate, and if a health care provider looks different from the mainstream providers, he or she will be challenged all the more.

Beyond helping ease the nation’s physician shortage, employers see the value immigrant providers provide: elevated levels of understanding, better serving diverse patient populations and a more expansive corporate culture, for instance. Health care systems and providers can support this important segment of the health care workforce by understanding — as best they can—how it feels to be caught between multiple cultures.

Understanding Marginality

Foreign-born health care providers often find themselves suspended between the cultural norms they’ve known since childhood and the strains, influences and cultural resistances of their new home. They are what social scientists call “cultural marginals,” individuals who straddle two (or more) cultures but are not fully part of either.

Encapsulated Marginals Some cultural marginals experience persistent emotional and psychological strain because they fail to reconcile the differences between their new surroundings, their former home and their own sense of self. Cultural competency pioneer Janet Bennett calls marginals who struggle to integrate “encapsulated marginals.”

Basha emigrated from Poland. When asked about feeling encapsulated, she says, “What’s funny for you is not funny for me, and vice versa. What’s appropriate for you is not appropriate for me, and I have had to learn by making mistake, after mistake, after mistake. At some point my brain would shut down. I couldn’t speak any more English. I was done. It gets exhausting.”

Encapsulated marginality is a state of mind that looks outside of the self for orientation, seeking clarity for expectations and relying on external sources for acceptance and belonging. It is a normal human reaction to culture change, and it can be very painful for whoever experiences it, consuming enormous amounts of cognitive and emotional energy. Left unaddressed, it can lead to withdrawal, feelings of isolation, feelings of alienation, depression, anxiety and burnout.

Predictably, there is a direct correlation between the likelihood of becoming encapsulated and the degree of differences between the cultures being straddled.

Hypervigilance Michael was a health care executive who had emigrated from Ghana and was working for a Chicago-based health care organization. Because he had emigrated when he was quite young, only the hint of an accent set him apart from anyone born and raised in Chicago.

Supporting foreign born colleagues often requires paradoxical thinking.

Michael’s culture shock issue was unique. He was certain that his colleagues were not racist, and he was convinced that no one in the company was discriminating against him. He was suffering hypervigilance. He was unable to forget about his race and was unable to relax and focus on his work, even around colleagues who emigrated from other parts of the world.

The CEO of Michael’s company, who was proactive about supporting his employees, had established an employee assistance program. With the help of several of Michael’s close colleagues and the support of the program, Micheal realized that he had been traumatized by the racism he experienced as a child when he first arrived in the U.S. With this new insight, he was empowered to shift his mindset, to relax and to focus.

Constructive Marginals Conversely, there is subset of cultural marginals Bennett calls “constructive marginals,” described as immigrants who create their own identity (often based on their marginality) and shift between cultures fluidly. Constructive marginals construct their new identities, and they are more likely to develop their own internal sense of authority, their own standards for success, and develop a well-established sense of agency. 

Constructive marginals tend to adapt by embracing the assumption that one has a place, that one belongs, but not necessarily that one fits in. They develop constructive assumptions while embracing complexity, contemplating nuance and making abstract connections. Very easy to say. Extremely difficult to do.

Understanding Culture Shock

In addition to the concept of marginality, an essential part of understanding the immigrant experience is understanding culture shock, loosely defined as: “The normal stage of adapting to a new culture when a person becomes troubled by the differences in values, norms and customs between their home culture and the new culture they are in. Typical feelings may be anxiety, confusion, homesickness, depression and anger.”

The term “culture shock” was first coined by Canadian anthropologist Kalervo Oberg in the 1950s and then refined by others. Experts agree that there are generally five stages to culture shock. They are the honeymoon, culture shock, gradual adjustment, adaptation of biculturalism, and, for some, re-entry.

Honeymoon At first, immigrants tend to be very positive and curious about their host countries, and just as an individual may experience a vacation to a foreign country, he or she may be fascinated by the differences. The doorknobs are different, the toilets, the architecture, the food, the way people relate, the priorities are different; so many things are unique. The tendency is to emphasize the positives when first immersed in another culture, to idealize the differences. It can be exhilarating. An immigrant experiencing the honeymoon stage will tend to be positive, curious and open to new and exciting experiences.

Elaina is an executive who emigrated from Ukraine. She cautions about the culture shock honeymoon stage, “Never confuse vacationing with immigration. Your experience staying somewhere for a couple of weeks or months is nothing compared with moving somewhere permanently.”

Culture Shock The culture shock stage begins when an individual starts to be troubled by the very differences they may have been fascinated by when they first immigrated. They may have been missing the subtle cues all along (the subtle communications, the niceties and the avoidances), but culture shock begins to make them aware of how missing those cues sets them apart.

Frustration with assimilation may transform into expressing contempt or disapproval for the host culture. The cultural differences become bothersome or seen as inferior. Fascination may transform into confusion, frustration, extreme homesickness, feelings of hopelessness or dependency, disorientation and isolation.

In extreme cases, culture shock can develop into depression, anxiety issues, insomnia and eating disturbances.

Gradual Adjustment The adjustment stage is a turning point, of sorts. The cloud of culture shock begins to dissipate. The individuals begin to develop a more balanced, objective view of their experiences. They begin to develop routines and patterns that begin to make them feel at home.

They begin to feel a new sense of belonging and sensitivity to the host culture. They may begin to turn their marginalized circumstance into a unique identity constructed upon their own priorities and belief in self. The internal operating system reemerges and the differences begin not to matter. The emphasis becomes about ownership and belonging but not necessarily fitting in.

Adaptation of Biculturalism The adaptation of biculturalism stage can be summarized as the great forgetting. One becomes released from the frustrations of culture shock in that they just don’t matter anymore. One begins to feel at home and doesn’t look back.

Dr. Marek says about cultural adaptation, “It’s partly a skill, but it is also partly a choice to navigate your marginality and play it to your advantage rather than being constrained by it. I can easily imagine that many people in many contexts feel limited by their immersion. But, in most cases, I play it to my advantage.”

Re-entry Shock The re-entry shock stage happens when individuals return to their culture of origin and realize that they’ve changed in relation to it. They may feel that they wouldn’t necessarily fit in “back home” anymore.

Mikhail, a medical student from Eastern Europe, says, “You go home and it isn’t what you expected it to be anymore. I didn’t fit in anymore. There were even words I forgot from my native language. It was weird, but it’s clear now that the U.S. is where I consider home.”

Conclusion

Harvard University professors Robert Kegan and Lisa Lahey regard the cognitive and emotional energies of people to be an organization’s most valuable resource. This is especially true of health care organizations. It behooves health care leaders to attend to the issues faced by their foreign-born physicians, nurses, PAs, technicians and others.

Hospital systems can educate their leadership and staff about the issues of marginality and culture shock. They can circumvent this staggering loss of their most valuable resource by anticipating the first two stages of culture shock and then being proactive when their negative manifestations arise. 

Know that new immigrants tend to be fascinated with cultural differences and that fascination may fade and turn to angst. Have the support systems in place and the organizational cultural awareness in place so your foreign-born physicians, nurses and others have the support to progress toward adaptation. 

Supporting foreign-born colleagues often requires paradoxical thinking. One must strive to understand as much as possible, while understanding that you will never completely understand. Know that you don’t know. Strive to listen, observe and empathize the best you can.

Generally, the best advice about supporting our foreign-born colleagues comes from Jean, a health care provider who emigrated from Asia. She says, “I just want to forget about it. You’re not reminded several times a day about your ethnicity or background. No one comes up to you and starts speaking German, Italian, or Norwegian. No one gives you a hard time when you’re eating potato salad or goulash. So, don’t do it to me. Just let me relax and forget about it. That’s what I want.”

Brad Fern is president of Fern EPC, a coaching organization that specializes in adaptive coaching for physicians and health care executives. He is a licensed psychotherapist.