I was born in India and decided to move to the USA for further training in Surgery. When I was finishing medical school in India.
I could have stayed in India for my post-graduate training or gone to England as most Indian medical students did at that time. I chose to come to America since I thought that most innovations were coming from the USA, and I perceived it to have less discrimination than England. I came on J 1 visa since I wanted to move back to India after training. I matched at the University of Medicine and Dentistry New Jersey, now Rutgers University, in Newark, New Jersey few years after the 1968 riots. The city was still smoldering and divided. I finished my surgical training and subsequently vascular fellowship at the same institution. The training was excellent, though I had to work harder than the local medical graduates to avoid a cut in the pyramid system. One chief resident, James Lott, saved me from losing my spot, which would have resulted in me being sent back to India. After finishing my training, I decided to go into Academic medicine since I was passionate about learning, teaching, and research. I was promised an appointment as an assistant professor of surgery, but my appointment letter said Clinical assistant professor of Surgery. I did get it changed, but I learned that the system was not as fair as I envisioned. I left New Jersey. I was offered an academic appointment at other institutions. I went to Dr. Rush, the chairman of the department of Surgery, for advice. I had worked with him for one year in a research lab. He was like a father figure to me. He told me, "Krishna, you will make the best professor in any department but will not become chairman of the department of Surgery. If I have taught you right, you will be fine". This did not come as a surprise but changed my future direction, and this article reflects my experiences in academic, private practice that we built from scratch with the support of my partners.
I went into private practice in Kalamazoo, a medium-sized midwestern town in MI with a strong Dutch heritage. The city had not been exposed to many Asian physicians. We had access to medical students and residents in an affiliated program with Michigan State University. I also had access to research labs at Pfizer until they closed their cardiovascular division. Kalamazoo now has its medical school. Initially, I joined an existing practice. After three and a half years, I started my own practice. The practice grew to include five vascular surgeons.
Being an international medical graduate (IMG) from India posed unique challenges. There is overt and open discrimination in private practice as well as in academic practice. There is difficulty getting a promotion in an academic center, getting leadership positions in national societies, getting patient referrals in private practice, and getting recognition and support from hospital administrators. I had to work at least 50% harder than others to succeed, which was not different from my residency days.
It is well established that to succeed in the practice of medicine; one has to follow three As (Availability, affability, and ability). I have added a fourth A to it: Adaptability. Coming from a foreign country, one has to learn the cultural and social ways of the adopted country.
Availability: From my experience, I can give the following advice. Never say no to a referring doctor. Walkthrough the ER to let the ER physicians know that you are available. Even if not on call, always take the call from a referring physician and give advice. If the referring physician feels that the patient needs to be seen urgently, do so.
Affability: You have to be nice to people. Never get mad at the referring physician. Never criticize the referring physician in a private or public setting. Private conversations have a way of becoming public. Develop a social relationship with the referring physicians. Respect coworkers and staff since they are your ambassadors.
Ability: Unfortunately, ability comes last in the Three As in building a practice. If you are a board-eligible or board-certified vascular surgeon, it is given that you are a competent vascular surgeon. There will be complications following operations; you must take ownership of your difficulties. You should collect data to show your competency at the local, regional and national levels. In today's information-driven society, your results count.
Adaptability: This is where one has to consciously work as an Asian vascular surgeon. You and your family have to adapt, and the practice has to adapt. Coming from a foreign country, there are cultural differences between the country of origin and the USA. The country is not going to adapt to you. You have to adapt culturally and socially. Everyone loves some sport. I was a huge cricket fan. There is almost no cricket here, but baseball comes close to Cricket in some ways. I started following the Yankees. Ron Guidry was my favorite pitcher. I taught cricket rules to many colleagues while waiting to do my next case.
The practice has to adapt to the changing environment. As the referral systems change, you have to learn the system and be a part of it as technology changes. Try to be an early adopter and promote it. As the government regulations change, have a dynamic practice that can adapt to the changes faster than the competition. Do not count on a few referral sources. Create an extensive network. Create a vibrant outreach program. And finally, keep harmony in the group. Disgruntled associates cause significant harm to the practice. In Kalamazoo, I Started nine satellite clinics in an underserved area and started a mobile non-invasive vascular lab to support the satellite clinics. We opened an OBL in 2007 to meet the dialysis access maintenance needs of the nephrologists. As a result, we got more than 90% of referrals from the nephrology group. I helped create a multispecialty organization to give us more bargaining power with the insurers and the hospitals. I became involved in the workings of the department of surgery and became chief of the Department of Surgery. I got involved in organized medicine and became president of the Kalamazoo academy of medicine. This gave me access to local physicians and strengthened referral patterns. It also gave me access to state and federal elected officials to promote agenda favorable to physicians in general and vascular surgeons in particular.
In conclusion, I decided to come to the USA, and despite the challenges I faced, it has been the right decision for my family and me. I have been thrilled in an academic, private practice, and along with my partners, we were able to save a lot of limbs and lives.
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