You are not alone - Episode 5: International Medical Graduates (IMGs)

Shevonne Matheiken: The Psychiatric Trainees Committee of The Royal College of Psychiatrists is proud to present, You Are Not Alone. A podcast series looking at the well-being of healthcare professionals. There is a lot more talk about wellbeing since the pandemic began, but wellbeing is complex, dynamic, and personal. It is not always something that can be resolved with just resilience training or mindfulness. Both those things are useful and have its place. But concepts such as intersectionality explain why there is so much more to consider while discussing the well-being of healthcare professionals.

This is what we hope to achieve through our conversations. Episode 5, International Medical Graduates, IMGs.

Deepa Bagepalli Krishnan: I'm Deepa Bagepalli Krishnan, an international medical graduate. I graduated in India and moved to the UK to train in psychiatry. Currently, I am an academic higher trainee, and Trent Division Psychiatric Trainees Committee representative, and Treasurer for Association of University Teachers of Psychiatry, a medical education charity. I was fortunate as I had family here to support me and help me navigate the system, but there were challenges along the way.

We know that many international medical graduates face considerably greater difficulties from direct discrimination, isolation, financial difficulties, visa-related stresses, differential attainment, and many other issues due to the lack of familiarity with and inadequate support from the UK system. All this has had a significant impact on our wellbeing, and in the process, we hardly get time or energy to harness the strengths they bring. Every IMGs journey is unique, and today, we have two inspirational and experienced guests. Dr. Ananta Dave and Dr. Raja Adnan Ahmed, sharing their experiences with us.

Dr.Ananta Dave is a Consultant Child & Adolescent Psychiatrist and Medical Director at the Lincolnshire Partnership NHS Foundation Trust. She is the President of the British Indian Psychiatric Association, BIPA. Dr. Dave was awarded Churchill Fellowship in 2019. She chaired the Royal College of Psychiatrists Task and Finish Group looking into growing concerns about the disproportionate impact of the pandemic on Black, Asian, and ethnic minority staff. She's passionate about helping develop a leadership culture, which promotes equality, inclusivity, and wellbeing of the workforce.

Dr. Dave has a career-spanning interest in medical education and training. She's actively involved in mentoring and supporting doctors. We have Dr. Raja Adnan Ahmed. He's a consultant psychiatrist working in South Wales. He's interested in raising awareness on mental illness and fighting the stigma around mental health. He's passionate about medical education and supporting junior doctors. He's done a lot of work in supporting many international medical graduates. Hello and welcome, Ananta and Raja. Thank you for joining us today.

First of all, I will ask both of you about your early memories as an international medical graduate in the UK.

Dr. Ananta Dave: Yes. Thank you, Deepa and Shevonne. Really good to be part of this podcast today and thank you for asking me to share my memories and my journey. I came to the UK in 1995 from India. I'm originally from South India but grew up in Mumbai. It was called Bombay then. So, I was used to a bustling place, a big city, a lot of noise, and a cosmopolitan culture. When I came here actually, right from the time I sat on the plane, it was a very different environment. Because it was the first time, I was making a plane journey and I wasn't sure whether I had buckled the seatbelt right.

And I remember having to turn to my neighbor in the, you know, in the plane and asking them to check whether I was buckled in correctly. So, it began with, I suppose, a deep awareness of how different the culture was going to be, where, you know, in the UK, from where I came from, although I considered myself a confident cosmopolitan person. And from that time on, I mean, when I landed, I can still remember the bone-chilling cold of November and how it took ages for me to-

I think I continued, wearing what would be termed winter attire well into [chuckles] the spring and summer the next year because my body just wasn't used to the cold and, you know, the temperatures here. But, so it was a- it was, very big gap, I think, in my cultural awareness, which I tried to bridge very quickly because I wanted to be seen as somebody competent. I think I totally understand that feeling of wanting to fit in and wanting to be seen as knowing everything, and feeling very confident. And how, therefore, I was hesitant in asking for help sometimes.

But I was fortunate to have very supportive people around me, right from my husband who had come here a few months earlier, to people who had come from my part of the world earlier into the UK and helped me, settle down and get a sense of being connected, which I think is really important. And I still remember the fact that when I joined, it was very close to Christmas, and there were a lot of decorations and celebrations on the wards, and a mistletoe tree. And I still remember being petrified when I was dragged under the mistletoe tree.

I didn't know what that meant. [chuckles] I didn't know what was expected of me. So, a lot of memories, big and small, but the overall impression of there being enough people who were supportive to me to overcome, I suppose, the prejudice or the bigotry of people who did prove to be difficult as well. So, that's how I started.

Deepa: Some really, interesting, and sweet memories there, Ananta. So Raja, what about yourself?

Raja: Thank you very much for inviting me Deepa and, Shevonne. So my memories, like a lot of IMGs are sort of very exciting from the start. I came in 2005 from Pakistan, and I was a very young graduate. I only had done my house job from Pakistan. So it was a journey of excitement and fear at the same time. And I remember feeling that sitting in a plane, you know, then thinking myself that "Should I really be excited because I'm going abroad?" it was my first time going outside Pakistan and taking a plane journey that big.

Um, so there was a lot of excitement, 'because I was thinking that I'm going to a new country, it'll be a new experience. Part of me was thinking, "You know, even if you fail your exam--" I was coming for PLAB 2. That was my first time. So, even if you failed the exam, it would be an amazing experience, you know, to still meet so many people, to see a new country. And then there was this fear and anxiety, that, will I be able to actually achieve that? Am I actually good enough? Because I have never tested myself outside Pakistan.

Is my English good enough? You know, can I be understood there? Again, will I be able to understand their English, and be able to fit in, and pass the exam? So then, I think it was a very exciting and exciting time and some fear. And I remember I was coming to UK, I was landing at Heathrow and one of my friends was going to come and pick me up. Um, and then I was going to stay with him for a few days, and he say, he-he asked me, "You know, what do you want to do?"

I said, "I'll come and sleep at your house. And next day, we're going to buy a underground ticket, and I'm going to go and have a look at all the landmarks." The next day I was out taking pictures with the- at the Big Ben, and the Tower Bridge, and the whole day. And then the next whole day when I was jet-lagged and tired, but I was just couldn't have enough of the scenery and the new environment. And then, and you know, everything new that was going around me. So, I think those were my, early memories, you know, having a fear, I think.

And when I speak to IMGs now, they have similar feelings, you know. They also talk about excitement along with anxieties.

Deepa: So, Raja, I can certainly resonate with those mixture of emotions that you mentioned. The excitement, fear, happiness. Also, you know, like asking yourself whether, you know, "Can I do these things?" So yeah, resonates with my own early experiences as well. Ananta, I know you mentioned some of the challenges, just when you were describing early memories there. So, can you tell us a bit more about what these challenges were, and what sort of help and support did you get that helped you face these challenges?

Ananta: I think the challenges, both on a personal and professional level, I think the first challenge was, I think just being confident in myself. I mean, I was experienced in psychiatry. I'd done, postgraduation MD psychiatry in India. And I'd practiced for a year before coming to the UK. I think it was just, you know, remembering that I did know -my subject, and I should, think of, mental health care and patient care, the principles of it being the same everywhere. But I think sometimes, because of the cultural differences, it just, you know, overwhelms you.

So, on a professional level, I think it was about just taking the time to understand the cultural inflections, the idioms, the colloquialisms. So, I remember, you know, starting to watch some, TV programs on BBC, although I never really got interested in the British soaps. And to this day, I've not watched many at length, but I do remember listening to the news and watching some programs just to get used to the, you know, the inflections of the language, and, you know, the local expressions, et cetera. I remember, deliberately actually making myself spend time with my local colleagues.

See, the instinct was to band together with people who were from my part of the world. And in fact, they were very, very helpful in helping me settle down. I remember on the second day when we were called for dinner to one of our friends' houses, they were our senior colleagues from India. I mean, the sense of just being able to relax, be myself, the relief, and, you know, the homesickness that vanished when I saw Indian food on the table was immense.

I mean, I still remember, I can remember those flavors, the exact dishes, and, you know, the decor of the house, it's still so fresh. So, I had to get away from just banding with people who were like me, and spending time with others who would actually help me learn about the local culture, local ways of doing, et cetera. So those were the challenges. Luckily, as I said, I mean, although there were people who would react in an either awkward or a dismissive way at the way I spoke, or the way I dressed myself or the way I wrote in the notes, I think there were enough number of people to counteract that.

To, you know, come to me and say that, you know, they wanted to- they were very interested in how we did things in India, or how did I arrive at that particular diagnosis or treatment, and how did we prescribe-- So, I think the curiosity, the compassionate curiosity that I really think is very helpful, was shown by enough number of people to help me settle down. On a personal level, I think again, being in India, I was both privileged, and, perhaps disadvantaged in living in a joint family. So, I used to live with my husband, in-laws, and his siblings.

And, we had lots of, family, extended family members visiting. Now, while that gives you a sense of belonging and being connected, and you're always taken care of, it had also not prepared me for independent living in the way that I would otherwise have been prepared. So, coming to this country and setting up home, so, it was as if I was doing several things at the same time, you know. Getting used to a new country, defining my relationship, you know, with my husband, a fairly new marriage, settling down as a nuclear family.

This was before we had children even. So, on a personal front as well, lots of adjustments to go through. And I think navigating, uh, you know, the balance between work and life, thinking back, I didn't do it very well. So, I'm very passionate about helping people now do it in a better way. I think I was so intent on proving myself to be as good as everyone else that perhaps I didn't focus on my own well-being enough.

Deepa: Very, interesting, journey and some experiences there, Ananta. And I, certainly, you know, balancing that work-life balance really resonates with me. So Raja, did you face any challenges, and what kind of things helped you?

Raja: So, um in, terms of challenges, there were a few challenges. And I think they are, uh, fairly common challenges that a lot of IMGs-- We've already talked about, um, trying to fit in the workplace and how- improving your clinical competence. But for me, I-I first came as a- as a single man, and I didn't have much family around here. So isolation, social isolation, having- not having any social support or support network was the biggest challenge I felt. Because I was living with my parents, and my family, and I had loads of friends in Pakistan, and I was a very social person.

You know, I was kind of person who would go out almost every evening with my friends and socialize, or every weekend we were out and about somewhere. So I wasn't really used to sitting in a house on my own, uh, or even sleeping in a house or a flat on my own, you know. That was all new for me. I always said to my IMG colleagues as well, that we underestimate the impact of, the social support network we leave behind. And, you know, certainly, when you come here, you don't have any friends anymore, you know.

You have friends, you can talk to them on the phone or Skype or whatever, but still, you don't have physically, physical contact with them. You're living in different time zones now, and that can have a huge impact on somebody's wellbeing. You know, you can go to work and do a good job, and when you come back home, you need to have somebody you can sort of talk to, or socialize, or do some activities with them. Just like that, you know, losing your hobbies, the things you used to do, you use-used to play some sports,.

You're not doing that anymore, you know. You used to go out and-and watch films or do-do other things, you know, which you can't do anymore. And you know, when we first come here, we don't drive so we are kind of geographically isolated as well. And you-you are using public transport and stuff. I felt that was too much for me initially. And the way I overcome is that I realize that, you know, if I need to have a good social life, I need to start making friends. I need to be more open about making friends. I need to start approaching people, you know, in, even in hospitals or in social settings.

And, you know, need to have a social support network that will, break me through this, period of isolation. And I think that's- that's what I did, but it can- it can be very challenging, you know. And a lot of my IMGs talk about, uh, the feeling of homesickness, you know. We all read about homesickness, but until it strikes you don't understand the impact of that, you know, that you-you actually start-- You have a lot of fears and feeling that I might-- I just should just drop everything and go back. This country is not for me, or maybe I'm not just coping. And that sense of belonging here is very important to develop, you know, and that you develop by developing new social networks there.

Deepa: So, thank you for sharing those, experiences, Raja and Ananta. Certainly, you know, when we first come here, it can be really overwhelming, challenging, quite isolating as well. And adapting to a new system very quickly, learning some new behaviors, and unlearning some of the old behaviors, again, adds a layer of challenge, and it can affect people's self-esteem and confidence. So, just thinking about this, another concept of intersectionality, where, you know, different aspects of person's identity can interplay and have an impact on well-being.

So Ananta, for yourself, uh, being a woman from an ethnic minority, and also being an international medical graduate, how has this shaped your journey, both professionally and also with acculturation?

Ananta: Really important point, and in fact, I'm really pleased to see two very dynamic women trainees, uh, doing this podcast and leading on it. And just to see the general development, more diversity in, leadership, and in a lot of initiatives in psychiatry certainly. So, I mean, I think here, I have to make reference not only to intersectionality as a concept but also with specific reference to South Asian culture, you know, where I come from. And I think the-the cultural expectations are different in different societies, and in different parts of the world.

And particularly, in, South Asia, you know, from where I come from, they are quite marked. So, I think all along, I've always had to justify having the same kind of career ambitions as my husband, [chuckles] Subodh. It has been one of always having to be very clear about why I wanted to concentrate on my career, for example. Why couldn't I have kids, you know, being asked questions regularly in my life about why I was waiting, and, you know, this was the right time. And why was I doing training twice? Because I had trained in India already, and I was having to train in the UK to do my MRCPsych.

So, right from those pressures, and I remember for many years, and I'm sure Subodh won't mind saying this, for many years, I was doing the cooking and the meals, and, you know, the cleaning in the house. And especially when people came round, the expectation was always that I would be in the kitchen, and rustling up, you know, food and serving them, or making tea and coffee. And my husband would be the one entertaining and staying with them. And it took a lot of time to overturn those kinds of beliefs. So, these are simple every day, personal matters, and very culturally specific, I think.

But, you know, I think, uh, you know, Subodh helped me beautifully, and we like the place we are at in terms of not only, you know, in, in terms of our own personal values, but I think the values that I want to, uh, show and demonstrate for my children. We've got two daughters, and I'm really keen that they don't face the same barriers that I did. I also remember, in terms of being a woman, a very personal, situation where, um, I suffered a miscarriage, and it really affected my health. And some-some of my trainers not being very supportive initially, when I was in training.

And it had an adverse impact on me. But some other people being very supportive, and, uh, understanding that, you know, people having children, losing babies is, you know, this is part of life. And it's not something which adversely affects, or reflects a person's ability But those, those comments were made too, in my career, about me becoming pregnant at convenient times, or, you know, being unduly affected by life events, and therefore, not being able to, concentrate on my career. So there have been comments made from that point of view.

And I think the particular problems associated with, balancing childbearing, child-rearing, fall much more to women. I mean, the practicalities of women bearing the child and the pregnancy, but also afterwards, you know, the rearing of the children once they're born. And I'm really keen, I think, on sending a very strong message that actually, these events, uh, give more strength to you. They shape you, they make you very adaptable, they, uh, they give you a unique perspective.

So rather than being seen as a disadvantage, I'm really keen that if people do choose to go down that path of having children, rearing them, becoming parents, however you become a parent, through adoption, IVF or you know, natural pregnancies, those- that time is well spent and should really be seen as adding strength to one's competencies. So that's from some practical point of view. From a professional point of view, I found it really hard to, not only at the time that I was in training where I would see very few, in those days, not many, women trainees, for example, going out in the evenings to meet up other people, or to go out for meals,

You know, to the pubs, for example, or common joint meals where all trainees and trainers were together. Women trainees or women colleagues from, international backgrounds held back, and I found myself, one of a minority of people who would do these things outside work. And I always wondered how that was being taken. And there were many times when I would be asked questions like-- Especially when I think when further in my career and I started taking on leadership roles, I would be asked questions like whether I had my husband's permission to apply for the job.

And how would I manage if I was not there at home for the children? And, you know, how would this affect my children, and, you know. So, questions to that effect, which, it really pains me to think that I did not feel able to respond in an appropriate way then. And my life's mission is really, if people are faced with those situations, that I stand up for them, or if I can't do that directly, to empower people to stand up to this-this kind of discrimination, sexism, or any kind of prejudice really, and where people are held back. And I think on a more practical level, the higher I went up the career ladder, I just did not have enough role models.

So, I remember when I was applying for the medical director's job, I did not know at that time, now, I know a handful, at that time, I did not know many women from an international background who had become medical directors. I found it really hard to ask people. And when I asked men from all cultures, you know, international cultures, local white culture, not all of them were equally encouraging of my ability to make this work, I remember I was thinking about how I would do it with my children going to university, and me perhaps not being able to spend as much time with them.

And there were questions asked as to whether I was doing the right thing, and, you know, not focusing enough on my family. And I don't think that similar question would have been asked of a male person applying for these senior positions.

So, unfortunately, prejudice exists, sexism is rife. And when all these factors combine the fact that I'm, from an international background, that I'm a person of color, that I'm a woman, that I don't look and sound like the people who are normally in leadership positions.

I mean, we still have only around 9% of board members from an ethnic minority background in the NHS today, which is really startling when you think of 21% of the NHS workforce being from an ethnic minority background, and 77% of women being the workforce in the NHS. It's very, very stark. The only thing I can say is that for every ten naysayers, there was 1 person who stood up for me. And you have to make that one-person count. And, you know, I'm a child and adolescent psychiatrist.

And I say always that when a child is going through, an abusive situation or a difficult situation, if there is one responsible adult whom he trusts and who can stand up for that child, that can really turn the tide for that young person, the child. And it was similarly with me. For all the prejudice and the flak, I faced, and the remarks, the snide remarks, there were few people who really helped me, who never stopped believing in me even when I went through a period of having, uh, you know, mental health difficulties. Even when I went through a period of having to take time off when I seemed to lose confidence in myself, they did not lose confidence in me.

And I really pay tribute to and salute those people who were able to see the true me often even though it was obscured by a lack of confidence and problems. So, yeah, so those are some of the personal examples I've gone through. And I don't think it is very dissimilar to what many other women from international backgrounds, ethnic minority backgrounds, might have gone through in the NHS.

Deepa: No, thank you for sharing that, Ananta. That's truly inspirational. And certainly, many of the things that you mentioned, I can, resonate and relate to many of those things. So just thinking about, you know, the GMC's Caring for doctors, Caring for patients, report, which talks about the ABC of doctors' core needs. And B in it is for belonging. So, Raja, you have empowered, uh, lots of international medical graduates in a very personalized mentoring capacity. And I wondered if you can share something about your, high-altitude supervision sessions, as you call it.

Raja: I think mentoring is very important for the international medical graduate, especially when they first join the NHS. Uh, and they may first join as a non-training doctor, you know. So, mentoring is all about, understanding, their needs at that point in time. That could be their social needs, their needs about their education and training, their needs about getting into training, and getting the right support for them at that point. Uh, so what I have been doing, you know, I'll, explain, in some simple words. That I trying to identify IMGs when they first join in our Trust or who I see, or who approach me through the social media for help.

So, the first thing we do is sort of try and understand, you know, which stage of training they are on, which stage of, uh, job they're on. And, you know, what are the needs and how do they want to get, move forward. And a lot of the times, you know, I believe the IMGs are underestimating themselves and that is something I keep seeing, you know, that, we need to sometime push them, or tell them that, you know,  they got more energy and more motivation, and, more knowledge than they're actually experiencing it at that point there.

Because they're under, underestimating themself. The other thing I do is, which I started doing a couple of years ago, and I thought they had a psychological impact. That you kind of open your house to them, which means that I tend to have these little parties where I invite the IMGs to my house. It could be a barbecue, and I mean, it got stopped during the COVID time because of the obvious restrictions, but opening your house is sort of, I think psychologically it's very important for somebody who's just come in the country to come and see you.

And then-then feel a bit more relaxed with you and see you as somebody who they can approach for help. And as earlier we were talking about, even if you are going through difficulty in a Trust, you know, you might not feel you can approach your education or clinical supervisor, or your consultant. But if there's one consultant in the Trust who you think will stand up for you, or you will advise you if you're going through a difficulty, that is very, very important. I try to become that one person, you know, for those, group of doctors who are working around us.

So if they are getting undermined, or if they're getting any difficulties, I can sort of, guide them through that. The high-altitude supervision was, was a sort of an idea. When It came around when we were doing our groups. and one of the things our group leader used to do was, he will say, "It's a very nice day, you know, why are we sitting inside? Let's go and sit outside." We were doing it in a hospital, which has amazing, grounds.

So, we'll go and sit outside, and enjoy the weather as well, and also the outdoors. And then I start realizing, see, when people come to Wales, it's a very beautiful place, and it's very beautiful country. Unfortunately, when you first come, you don't drive, and you're restricted geographically. So, you are only working in the hospital and going back home. So, I want people to actually enjoy Wales as it is. Even if you're working in a city like, Cardiff, you're only half an hour away from the mountain region of, Brecon Beacons. So, myself, I fell in love with Wales because of the mountains, the waterfalls, the beaches we have, the green, lush green landscape we have.

So I'm trying to introduce those IMGs to all these outdoor activities. and the term high altitude supervision came. And I take them on hiking, and sort of, on the way up, sort of talk about their careers and how can they move forward, and, you know, how can we help them to get to the next stage of training, and all that. Supervision or mentoring, doing in that way that you are actually out and about with them, and enjoying the landscape.

And, you know, we are recording this in South Asian Month. The countries where we're from, India and Pakistan, you know, having a lush green landscape is something that, you know, we kind of dream of going in holiday. So, when I first came to Wales, I realized, you know, this is not a dream anymore. I am not on holiday anymore. I'm actually living in a place where I am just only few minutes away from a waterfall, or a beautiful river, or a beautiful mountain. Uh, so I think that is something we need to, uh, build on, you know.

As I mentioned earlier, you know, when somebody's coming to UK, you have to develop that sense of belonging. So it's not just about going to work, or enjoying work, or having a little circle of friends there. It's about actually connecting with the place in a more fuller way, uh, trying to enjoy the outdoors, try to enjoy the landscape, and sort of feel that, you know, you are in someplace where you can go and get relaxation outdoors as well.

Deepa: So this is a really innovative way Raja, to introduce new doctors to Wales and also to give them that sense of belonging and connectedness to the place where they work. I wish I could have some high-altitude supervision. Although where I live, we don't have the peaks that you're talking about. So, yeah, just moving on to, you know, what is the current topic of, the pandemic? We can't possibly not talk about the pandemic and how it's affected the international medical graduates. Many of them having to grieve from afar and not being able to visit, their families during this, uh, tough times.

The poem that you wrote, Ananta, uh, resonated with many of us. We wondered if you might want to share that with us today.

Ananta: Yeah. Thank you, Deepa. I think writing poetry and connecting with nature, and I think collectively, I think sharing and talking about, grief and what was happening, has been really important, I think, during the pandemic. So, one of the poems that I wrote, which was at the height of the pandemic in India when we were really seeing horrific images and horrific stories. And I think you can all, you know, identify with that, contacting families from afar and trying to help them. So this poem is called, Waiting.

Waiting for sunrise and the calls to start

Dreading the call, yearning for the call

For the neighbor to say, "She's breathing, she's eating"

Waiting for the money transfer to go through

'Cause we need to pay within two hours or lose the bed

Waiting in the reception for entry to the hospital

The living and the dead, equally silent

Waiting for air

Hell has no oxygen.

"Sorry. Ventilator for four hours only

Others are waiting."

"The doctor had a kind voice," she says

While waiting in the corridor for our beloved's body to be bagged

Waiting in the car park for the cremation

His body shrouded in her Sari

Ambulance number, 7122

Token number, 284

42 degrees Celsius

Dozens of pyres lighting the sky

The long journey home with an empty house waiting

Waiting at home, imprisoned by the virus

Waiting for vaccines without borders

For shares, not hoarders

For larger hearts, smaller egos

Meanwhile, we live, work, and breathe

Waiting for the thump-thump of guilt to subside

For the flat tide of despair to recede

Waiting for a different dawn

Waiting to embrace my motherland and mine.

Deepa: Thank you, Ananta. That was very touching and very beautifully written. We hope that, we never face such, tough and challenging times ever again but thanks for sharing that today with us. So, when we discuss this topic of international medical graduates, I mean, we tend to focus only on the negative aspects and the challenges. So I think for those who are listening today to this podcast, overseas and thinking about moving to the UK, I was wondering, Raja, what are the positives of being an IMG in the UK?

Raja: I think that's, very important, as you mentioned, to also talk about the positives because, otherwise, our discussion may only, end up, talking about negative points. There are a lot of positive points, which I try and, reiterate as much as I can. The first thing is you see, when you come to UK, is you're coming to a different culture and a different country. And the whole experiencing of, working in a different culture, in a different country, always enriches you. You know, the training you get here, the social interaction, the interaction with the general public, you know, that all, improves you as a human being.

You learn a lot of things from here, which you may not learn if you are just working in your home country, and only in one place. The second thing, I think, uh, we don't celebrate NHS enough for its diversity. So, when I was, uh, working in Pakistan, you know, see, I was only working with Pakistanis. There were very few, or rarely, you'll see somebody who's from abroad working with you. But one big advantage of NHS is that NHS is a family of international workforce. Not just doctors. You'll find so many different nationalities when you first come here.

And I remember, you know, when I first came to UK, that was one of the things that struck me. That I got Indian friends, and Egyptians. I got a friend from Nigeria, friend from so many different parts of the world, which I wouldn't have made if I was, if I was only working in Pakistan. So, I think that is a big advantage that you'd get to know many cultures. You get to meet so many different people, which is not possible if you're just working in your home country in one place. You know, I like to mention here, see, I was from--

I am from Pakistan, and, uh, while working in Pakistan, you know, we were always fascinated by India. We have some political, differences. So we were not able to go and make Indian friends. And, uh, but we were always fascinated because they are just like us. Quite a lot of Indians talk the same language as us and have the same food. So when you come to UK and you are certainly working with a lot of Indian colleagues, and, you know, you're finding so many common things between them and yourself. And then you start realizing that they can actually be your best friends, you know?

And that is an eye-opening experience, you know. Suddenly, you know, you  have that luxury to have that, which wouldn't be able to do if I was in Pakistan.

I think another advantage is that NHS, also gives you, I felt a bit of financial independence, social independence as well. I came here as a single person. And I felt that I had to kind of almost like build a life here in UK. So, building from scratch. So, making new friends, making all the steps of building a life, you know, getting a license, getting a job, getting a new house.

And then, at the end, you feel like you have done something remarkable, you know, when five or six years have gone past, and you think, that you actually did that independently. During that process, you develop a lot of other skills, I think, which-which you may not be able to do while you were working in a situation where you have a lot of support around you when you're in your home country. So, all of these are-are very good experiences. You know, when you go through them, it might look like a difficult time initially, but, you know, once you've gone through them--

And I also like to mention that the training, especially the psychiatry training I got from UK, I think that was amazing. Um, I met some amazing supervisors. I have a lot of interaction with the Royal College of Psychiatrists doing the MRCPsych exam. I think that was all a very enriching experience for myself, to learn, psychiatry in a way because it's practiced fairly advanced in UK in comparison to the developing country. So you are learning, always learning new things, you know. And psychiatry is also related to a lot of cultural aspects as well.

And you are experiencing a lot of different cultural aspects there, which you may not be able to, uh, learn while you were in-in your home country. I feel those are the main advantages, that making new friends, meeting new cultures, and-and that all helps you grow as an individual. And-and I always sort of try to explain to my IMG colleagues, "You see, UK is not just about coming here and doing a clinical exam or doing a clinical experience. NHS also, focuses on developing you as an individual, which means that you'll can develop leadership qualities, you can develop expertise in medical education, management of a hospital or a team."

So, all those skills you are actually getting from here, other than your clinical skills, they are sort of lifelong skills. And they sort of stay with you if you want to go back or if you want to continue working here.

Deepa: So, you've mentioned quite a lot of positives there. You've just touched upon the, uh, multicultural aspects of, uh, of living here and, you know, the potential of professional and personal growth, and how it changes your outlook towards life, and also your working. It's, incredible. So, thank you for highlighting that. So I hope that, uh, sends a message to people who are thinking about coming to UK, so that it's not just about the negative experiences, but it's also about, there's a lot of positives and lots of potential for growth and development.

So just thinking about some more positive aspects, a question for both of you really, what strengths do you think international medical graduate leaders bring to the NHS workforce?

Ananta: I think, you know, at every level, and I think, whatever position we are in, whether we have a formal leadership, role or not, I think, you know, as clinicians, we lead in many ways, and even showing clinical leadership is important. So, I think firstly, I would just like to highlight that IMGs bring strengths along with them. Apart from themselves being strengthened by the experiences in the UK, and you know, what-what they go through, they come with strengths. So, the first thing I want to say is we need to be, as leaders, highlighting their strengths for them.

So, if somebody comes to me and says, "I can't speak English very well," I always say to them, "Remember that that means you can speak at least two other languages very well, [chuckles] which not many people might be able to speak."

So, I think if you have people who are in leadership positions who are IMGs, they are able to, I think, understand, tap into, and harness the existing strengths of the workforce, wherever they may come from, whatever their orientation or beliefs. I think being able to see beyond the obvious, beyond the outer trappings, and look at the strengths that lie underneath, would be possible if you yourself have come from those multiple experiences and perspectives.

So, having people with those diverse perspectives in leadership positions is important. I think everybody who goes through the IMG journey, and acculturates, and adapts to another country is showing inherent strength. The other thing is that if we are to provide patient care for the diverse populations that are in the country, we also need to have a workforce which is diverse so that people who are accessing care can relate to the people who are providing the care, you know. Both in terms of how they visibly look, but also in terms of their attitudes, cultures.

Their ability to understand people from different perspectives and how they present distress. In our case, mental health care and emotional distress. So, really important to give confidence to the communities and to the people accessing services. There should be representation in the workforce, but also diversity in the workforce because, uh, homogeneity, can kill creativity and growth. It needs to be a variety and a diversity in approaches, which leads to new thinking, new ways of doing. And, of course, the other thing is, you know, a blended approach is talked about quite a lot nowadays in the wake of the pandemic, you know.

For example, when you talk of digital and face-to-face. So, if you want to make the best use of resources, sustain resources, healthcare, the NHS, you have to make use of a variety of influences, approaches, and strengths. And so, once again, having that diversity at leadership level helps us to keep things sustainable and harness different ways of doing things. So I think it's really important that we are able to cultivate the inner leader in all of us. And I say to people, "It's not about formal leadership positions alone, it is about the leader within you, whatever role you're doing." And ultimately, that is about identifying and tapping people's strengths, harnessing it well.

Sponsoring them along with the mentoring and along with the teaching and the training. You need somebody to say about you to another person, "She's really good at that. I wonder whether she could be considered for it. I'm going to ask her to apply for it." So, that kind of active sponsoring is very important too. I think an important message needs to go out that everything doesn't need to work the first time, or you don't have to be successful the first time. There is something about the vulnerability in leadership, which needs to be talked about openly.

So, the people who become leaders, whether formal, informal, or whatever, are not people who have sailed through things, you know, very smoothly with never a failure to their name. It isn't the case. I'm in a senior leadership position. That's certainly not the case with me. So, I think people coming from an international background can help people see you don't have to be perfect. You don't have to be correct, and, you know, succeed at all times without failing, in order to be a good leader.

You can actually learn and grow from each disadvantage, a pause or barrier that you've gone through that can help you, grow as a person and give you many more perspective and strength. So I think there is sometimes a fear amongst international graduates that if they ask for help, or if they show signs of weakness or failure, they might be thought of as not good enough. So, I think if we are in these leadership positions, we should be able to empower people to say, "I need to pause, reset. I need help." And that's a sign of maturity and wisdom.

So, these are all perspectives, I think, that international leaders, IMG leaders, can bring and that we should be seeking to nurture and cultivate amongst our coming generation of clinicians and leaders.

Deepa: Thank you, Ananta. There's a lot of learning from what you have said so far. And almost there's that permission to fail and learn from mistakes. I think that's one key thing, as IMGs, we struggle with that notion of, of failing, and that it's okay to fail, and learn from that, and move on. Raja, any thoughts from your side?

Raja: Yeah. I think I agree with what Ananta was saying. a lot of the points she mentioned were very, very important. I personally, when I'm mentoring IMGs, I always sort of say to them, "You don't need to underestimate yourself. You have to understand your-your strengths." And we have a lot of strengths, you know, even-even if you think about a young doctor coming from, India or Pakistan, any other country, to UK to do PLAB, you know, that's a massive step they have taken.

They have actually gone to a different country and doing a licensing exam for a different country in a language, which is usually not their first language at all. So that shows the strength of the young person who's coming through there. And we need to celebrate and build on that strength because that mean that this person has at least lived in two different countries, as an Ananta was saying. That means that at least they speak more than two languages, um, sometime more, much more than that.

And they have the ability to adopt to change. They have the ability to actually make new networks. They have the ability to lead. They are also already doing, making all these changes in their life, which, to improve their own-own life. So, why can't that translate to NHS when they're working in the NHS? and the other thing I always mention to my new IMG doctors is the NHS IMG workforce is something that we need to celebrate. Once you start working in NHS, you know, NHS is not a foreign health system anymore.

You are NHS, you know, you are part of the NHS now. Once you got that first badge for the NHS, and it is your responsibility to make it better for other IMGs as well. Also, you make a responsibility to actually do like some quality improvement work. If there are things you don't agree with, if there are things you think could be improved, you know, you need to be start taking some lead on that. Just starting from very small bits around how your ward is going on, and how you're working on the ward. Um, so I think I trying to encourage that.

And I think the other thing generally speaking, we don't celebrate the IMG workforce that much in like NHS. But in simple words, well, from my experience is, you know, NHS is actually benefiting a lot from the IMG workforce. Not just doctors, but other, um nurses and all the other MDT staff. And I don't think NHS can actually function without the IMGs, without the diversity it-it has. It won't have the same strength without the diversity it had. If you look at the mental health services, you know, wherever you go, you will find so many IMG doctors.

So many IMGs are actually doing the exams and taking up the consultant positions. Um, so, IMG workforce is not something alien to NHS anymore. You know, we are actually the backbone of the NHS now. So, we need to start understanding our strengths, and we need to start taking those important roles, you know, beyond our clinical roles. That is very important that we recognize that and move forward.

Deepa: Thank you, Raja. So we just heard from both of you how diversity in itself brings a lot of strengths. So, we've had such an interesting and important discussion, and there- there's so much to think about from this discussion and take back. So, just wondering, any final thoughts from you, Raja?

Raja: I just like to, um, say to my, colleagues and my junior colleagues, actually, who are looking at UK right now, listening to this podcast, thinking about coming to UK, that it is a- it is a wonderful place, you know. And in NHS you will, you know, I would say initially everybody faced some, some difficulty in terms of settling in a new place, understanding the new system. But once you go through that, and we all go through that, you know, we all pass that, and once we become part, properly become part of the NHS family, it's a very enjoyable place to work.

It is something that will help you grow. It is something that will, uh, lead you to become a, not just a good clinician, but also a much stronger human being as well. So, please, if you are considering that, you know, considering it seriously, and take up that first step, you know, of maybe registering from PLAB, or doing the PLAB, or coming to UK.

Deepa: Thank you, Raja. And just thinking about, you know, from all that you've said the role of allies, the mentors, the supervisors, it's so important in shaping our, career here as new IMGs. Uh, so I was just wondering, Ananta, just last few thoughts on, you chair the diaspora committees, and you're also the president of the second-biggest organization of psychiatrists in the UK, in terms of the numbers, BIPA. For those who are not familiar with BIPA, it's British Indian Psychiatrists Association. So, just a couple of things.

One is, what role do you think such groups can play for IMGs all over the world, and, if you have anything else to add?

Ananta: Thanks, Deepa. I mean, I think, you know, we've talked about the necessity and the power of belonging, wherever you are from, you know, in the world. International medical graduates coming from all corners of the world. The necessity, the-the need to belong to connect, to feel part of, to not be othered is a really core part of how we function, and how we bring out the best in ourselves. So therefore, what IMGs really look for, and which sometimes they take more time than local candidates to build up, is that social capital.

The social networking, the social capital, the social connections, and that is something that these organizations like the Diaspora Committee and organizations like BIPA can provide. And I think it is about belonging in an authentic way, and that's really important. Because if you have to give the best of yourself, you can do it by being authentic. If you are pretending to be something you are not or someone you are not, you can't be your best. So, if IMGs have to give off their best, and they have a lot to give, as Raja was saying, they're the backbone of the NHS.

And if they have to give off their best, they need to be able to feel that they can be who they are, express themselves in the fullness of their identity, which is actually very rich, and, very, very important for the NHS. So, I think networks, and organizations like BIPA, and all the other diaspora organizations can help do that. And I have seen it like never before, in the wake of the pandemic.

While we have seen a lot of grief and suffering, the way people have come together and supported one another from all corners of the world, and how we have done things together, right from raising funds to looking after the wellbeing of doctors, and nurses, and other clinicians, and, sharing our grief and our loss. So everything has really been made easier by sharing, by having that collective voice, and by belonging. So, I think that's a really important part, the courage to be myself, and the reassurance of belonging. And that those things can be nurtured through these networks and groups. Thank you.

Deepa: Thank you, Ananta. So we've heard about some of the challenges faced by IMGs, and that there's so much of support out there for IMGs, and the positives of being an IMG in the UK healthcare system.  We will share some useful resources on the Royal College of Psychiatrists website, along with the podcast link when it's released. And do keep an eye out for the IMG guide, which is in the pipeline. It's a collaborative project between The Psychiatric Trainees Committee and the Trainees Support Committee at the Royal College of Psychiatrists.

So, once again, thank you both for joining us today. It's been wonderful listening to both of you. Such an interesting and enriching discussion we have had. And thank you for all the great work that, you both are doing in various platforms.