The Almost FMG

FMG–foreign medical graduate. This translates to any physician practicing medicine here in the United States who had received their basic, and sometimes advanced, medical education outside of the medical education system in the U.S. There are a significant number of FMGs practicing throughout the country with a percentage of those being U.S. citizens who studied medicine abroad as they, for a variety of reasons, were not accepted to study medicine within the confines of their native country. From mid 1975 though the first half of 1978 I was one of those. Through the years I have been periodically asked about this; here is my perspective on those years.

While medicine ran in our family (father, grandfather, and cousin were physicians, grandmother a nurse) and my parents were silently hoping I would continue the tradition, I hadn’t firmly decided that was what I wanted to do until…I almost flunked out of college. Not a great start. I worked hard to recover but a combination of a less than optimal GPA and some rather tepid interviews for med school entrance did me in. So for the next two years I tried a variety of strategies (grad school; work in medical field) with two more reapplications failing again in each instance. Time to move on until a phone call from one of my uncles eventually culminated in my acceptance to medical school at the Autonomous University of Guadalajara (UAG = Universidad Autonomo de Guadalajara)) in Guadalajara, Mexico, a mere 2500 miles from where I lived.

The UAG at that time (1975) was a large medical school with a total enrollment of approximately 5,000 students, 50% Mexican and 50% from the U.S. The Mexican students were overall younger as they enrolled after high school ( which was a year longer than here in the States). The U.S. students were invariably older, late 20’s, 30’s, and a few in their 40’s and were a mix of singles and marrieds with some of them bringing their families. The vast majority were either from New York or California but there were representatives from almost every state. Most, if not all of us, had an underlying sense of inferiority to our counterparts who were matriculating in U.S. medical schools. That sense, based on our non-acceptance to a U.S. medical school, was that we weren’t good enough or smart enough or too old (in 1975 the vast majority of medical students studying in the U.S. were in their early to mid 20’s). There also was concern on our part that our medical education would be substandard when compared to the medical education provided in the U.S.

Our first challenge was the language as all courses were taught in Spanish. It was a requirement that, if one did not have at least some fluency in the language, a semester of Spanish was mandatory prior to starting med school proper. UAG offered this instruction known as “Intensivo.” In conjunction with learning Spanish we also had basic courses in Mexican law, history, and geography (the phrase “Los Lagos de Mexico”[the lakes of Mexico] still resonates). It was also during this semester that we were trying to integrate into the Mexican community and to share common, as well as unique, experiences and perspectives with new found friends from across the United States.

So how do you accommodate 5,000 medical students in a 4 year medical school program without classes becoming overwhelmingly large? First, by having two entering classes, one starting in January and the other in September. Second, by then dividing each semester into “blocks” of study. In light of the former a student identified themself by semester (1st, 2nd, 3rd, etc) and not year in school. With this scheme there could be two “first (second, third)” semesters in a given year, one in the Fall and the other in the Spring. . In first semester anatomy, embryology, and histology were taught concomitantly. Anatomy was especially challenging (as in the U.S.). Spanish terms for the body parts had to be mastered as well as descriptions of organ function, the skeleton, vascular and nerve placement, direction, and function. Starting with the second semester there would be a block of classes all with related major subjects but each subject would be taught solely in a “block” of 6 weeks. For example, second semester included 6 weeks of physiology, 6 weeks of biochemistry, and 4 weeks of “minor” subjects (e.g. medical statistics). So while I may be in the physiology block one of my friends could be in the biochemistry block, and so on. This kept the classes small and, for me, I found it much easier to study one subject at a time, understand and master it, and integrate it into the next subject.

The first 3 semesters at UAG were on one campus and students then moved to a larger campus starting with the fourth. Pathology dominated the fourth semester but there were other blocks of courses to round things out including an intense course specifically on physical examination. Who did we examine? Why our classmates, of course, although there was an understanding that certain parts of the female or male anatomy were off limits. Rectals were also a no-no. Semester five saw us moving into clinicals. These were blocks of instruction on a specific discipline, e.g. cardiology, pulmonary, and so on. In addition to the didactic side of the discipline we had the physical exam aspects to learn by examining “patients”. This is where it got interesting. With the size of the school it would have been impossible to troop students through the campus hospital. Instead we had separate clinical exam sessions where we were required to supply a “patient” for examination. Regardless of whether one was in the pulmonary, GI, dermatology, etc. block, supplying patients for examination was a requirement. Fortunately an enterprising Mexican had solved the problem some time ago by creating a cottage industry whereby he would procure a “patient” for a fee. The “patient” would also receive a small fee and life was grand–as long as the “patient” showed up (most did). Not surprisingly many patients did have findings (rashes, wheezes, heart murmurs) that corresponded to the discipline being studied. (As an aside, in my years at a teaching hospital it was quite common for a teaching physician to ask if there were patients with interesting physical findings that medical students could examine–maybe I should have started my own “cottage industry.”)

Then there was Guardia (pronounced gwardia). This was a 2-4 week block of time each semester whereby we med students were “farmed out” to the community to provide, as least on paper, medical services. It was a crapshoot where one ended up and sometimes there was no community service to provide. I was fortunate for two semesters, ending up doing school physicals outside the city for grade school children ranging in age from 6 to 10 years of age. The interaction was fun and we got to practice our Spanish and the kids picked up some words of English. The “well checks” centered mostly on heart and lungs or something else if the student was concerned (rash, lumps, etc). We were also tasked with health screening, usually questions about parasites or certain illnesses, e.g. diabetes. My basic parasite question (tailored to my Spanish and a kid’s understanding) was, “Ha visto animalitos in la caca?” (Have you seen little animals in your s___?). I never got a “si” that I can recall. On one occasion a classmate, D., overheard my health screening questions, asked me about them and was quite upset that he had been remiss in doing his due diligence. Armed with the questions after we reviewed them, off he went to his station firing questions right and left at the students he was examining. Peals of laughter soon after began to drift from where he was stationed. Flustered, he walked over to me trying to figure out what was so funny about his questions. We started by reviewing the parasite question which, it turns out, had devolved to, “Ha visto arbolitos in su casa?” which translates to, “Have you seen little trees in your house?” D., understandingly, then decided to forgo the parasite question and focus on others. As we were leaving for the day I asked him how things had gone with the other screening questions and he sheepishly admitted he had stopped asking. He realized it would be a futile endeavor as he recalled asking “Do you have diabetes?” to which the child replied, “Yes.” D. said his heart sank as this was the first time he had asked the question thinking about the number of children he had seen previously but never raised the question. How many others with diabetes had he missed? He said he was at the point of despondency thinking he had utterly failed in his duty until he noted a not well suppressed smile on the face of the kid who had responded “Si.” So D. asked the question again, the kid responded affirmatively, which prompted D. to ask, “Donde?” (where?). The kid was now grinning ear to ear and pointed to his elbow, “Aqui” (here). D. never asked another health screening question.

Although Guardia was a requirement for each semester an alternative was to join a freestanding health clinic and volunteer time on a weekly basis. I was able to do this eventually but not before one final Guardia. No school physicals this time but rather a remote freestanding clinic in a small town in the country. Dirt streets, adobe houses, huts, no street lighting, toddlers running around naked. All that was missing was the Magnificent Seven. Our small group was supervised by a “pasante” (Mexican med school graduate doing her [in this case] social service obligation). We treated the kind of problems you would now see in an Urgent Care here in the U.S. The clinic was invariably crowded and the pasante was invariably pulled in many directions in trying to supervise us and dealing with her own set of patients. One time this lead to one of my classmates (realize, we, at this time, had been in med school for 1/1/2 years) delivering a baby as the pasante yelled instructions to him while she dealt with another emergency. What a learning experience for us all! During one of the quieter times at the clinic I asked our pasante why the townspeople all seemed happy and content in light of their circumstances and lifestyles. “Because they don’t know any better,” she said, then added, “and they will be content for the most part until someone comes along and tells them things could be better, makes promises, stirs them up, and then doesn’t deliver.”

After my third Guardia I was able to join a local freestanding clinic which relieved me of future Guardia obligations. It was another equivalent of an Urgent Care and we did our best with students of different experiences and knowledge mentoring each other as there was no pasante. There were several medical textbooks (the Merck Manual was a Godsend) well thumbed through. We did our best and were not hesitant in directing some patients to the hospital to address problems we felt were out of our league.

Not only were the courses taught in Spanish but the exams were also. While difficult (especially anatomy) they were multiple choice or short answer. Essays would have been a disaster. After each block a student received a grade (no pass/fail) and moved on to the next block. If one failed a course then one stayed for “segundos” (seconds). These were repeat exams given one week after the end of the semester. Fortunately I escaped segundos.

I finished 5 semesters at Guadalajara, took part I of the medical boards (same ones Stateside students took), did well, interviewed to return to the U.S. to finish as a new federal law mandated expansion of medical student seats with schools scrambling to fill, and made the cut to return to finish my medical education in the U.S. (Penn State Hershey). (As another aside, Hershey accepted a total of 5 U.S. “almost” FMGs, one each from different foreign medical schools. Since we were unknowns we were “sequestered” for several months with additional didactics until the school realized that we were as knowledgeable (or not) as their current crop of Hershey medical students. The rest, as they say, is history).

So what were some of the life lessons I learned while studying abroad? First, for the first 2 years of medical school in Mexico I came to appreciate that the instructions and disciplines were very similar to what was being taught stateside and I felt well grounded in the basics of medical science. To bolster this confidence I was fortunate to have had a younger brother in medical school in the States and we would often compare notes. Same topics, same books, similar labs. And, as stated previously, once I returned to the States to finish medical school I found myself with a foundation of knowledge similar to my fellow stateside classmates. Second, as there were no dormitories, we students rented houses or apartments that were scattered throughout the city or surrounding country. This contributed to we Americans having to integrate into the community. Yes, we could cluster in our American “barrios”, speak English, follow American customs but at least a degree of integration into the Mexican society was prudent. Third, issues with international finance came to the forefront. Tuition had to be paid in dollars. Many of my classmates would bring their tuition money with them to deposit in the local bank where those dollars were converted into pesos (8 pesos = $1) then, when tuition was due, withdraw the money in dollars and pay. Catastrophically in either 1975 or 1976 the peso was devalued and suddenly classmates were short of tuition money. Hard lesson learned. Fourth, while we did our best to integrate we faced discrimination routinely. Virtually every Mexican thought every American was rich. I was once stopped by a policeman because I was “speeding” (I drove a used Ford Pinto). When I asked how he knew I was speeding he replied, “I counted how fast your wheels were spinning.” Bribe paid. (In all “fairness” bribes were a common way of life). Class registration was in person and the “cajas” (cashiers) were only open for a few hours a day. We Americans would start lining up in the early hours of the morning (4-5 am) as, when the Mexican students would start showing up, they would routinely cut in line (they typically would send a Mexican student as an early morning “place holder” in line who would then allow 10-20 students to join him when they arrived much later). Protests were muted, if at all, as one feared getting kicked out of school. On one occasion I recall being verbally berated by a Mexican as I stood in line at a local taco stand. You quickly realized that you were never a “winner” in a fender bender with a Mexican and prudence dictated just to drive on if the car was drivable. Fifth, overall the Mexicans were kind, friendly, tolerant, and helpful to us from north of the border. Government officials were another issue. Sixth, time spent in the Guardias, especially my last, as well as the freestanding clinic, traveling the 600 miles from the U.S. border over 2 lane roads winding through desert and mountainous terrains and through small towns, as well as my wanderings through the city itself, gave me a different perspective on life in the States and how blessed we were. Lastly, there were a number of smart, dedicated people who were not fortunate enough to transfer back to the States, graduated, went through a winnowing process (“Fifth Pathway”) upon returning to the States, and went on to become great physicians.

One final thought–while I am grateful to have received my M.D. (thank you Hershey) here in the U.S., my overall experiences and education in Mexico as an “almost” FMG were, in some ways, superior in many ways to any education I could have received in the United States.

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