Academic Psychiatry, 28:4, Winter 2004 http://ap.psychiatryonline.org 347

Challenges Faced by International WomenProfessionals

Nalini V. Juthani, M.D.

Dr. Juthani is Clinical Professor of Psychiatry at AlbertEinstein College of Medicine, Bronx, New York. Address corre-spondence to 17 Pheasant Run Scarsdale, NY 10583; nalini.juthani@gmail.com; (E-mail).

Copyright � 2004 Academic Psychiatry.

During the first half of the last century, femalephysicians of international origin arrived in the

U.S. in significant numbers, predominantly fromWestern Europe. During the second half of the lastcentury, they came from almost every part of theworld. Most of these female physicians were nottrained as psychiatrists in their country of origin, nordid their medical schools offer an education in psy-chiatry during their medical school clinical trainingthat was equivalent to clinical training in the U.S. Infact, only select international medical schools offeropportunities to receive postgraduate psychiatrytraining. However, female physicians entering psy-chiatry training in the U.S. present a wide spectrum,varying from being directly out of medical school topracticing other medical specialties in their countryof origin prior to arriving in the U.S. For internationalwomen, the decision to pursue psychiatry is not asimple task. Training opportunities usually have tobe balanced with the needs of their spouses and theneeds of their families. Opportunities to train in theU.S. are available based on academic credentials suchas scores on USMLE and the Clinical Skills Assess-ment (CSA) Exam, visa status, ability to communicatein English, and clinical experience in the U.S. For in-ternational physicians, most opportunities to train inpsychiatry as a specialty exist in the U.S., especiallysince most training programs offer more training po-sitions than can be filled by American medical gradu-ates. Several female physicians pursue psychiatry tobalance career and family needs and to pursue theirinterest in child psychiatry. Empirical data indicatesthat the majority of female physicians arrive in theU.S. with their spouses.

Conflicting demands (some of which are derivedfrom within their own culture, and others are exter-nal) are often made on these women to receive ap-propriate training, provide financial support to their

families, and fulfill the cultural expectation to carryout their domestic responsibilities, and they con-stantly juggle between family and career, which fre-quently leads to tremendous stress. Male psychia-trists, on the other hand, can leave the bulk ofresponsibility for running the family and householdto their wives. Most international women do not haveprofessional women as role models and mentors dur-ing their professional training in their country of or-igin. This often leads to self-imposed as well as cul-turally imposed expectations to be a superwomanand do it all. While some international female psy-chiatrists have succeeded in cultural adaptation,managing time, and receiving professional satisfac-tion, others have compromised by not pursuing lead-ership positions and sacrificing promotions and fi-nancial opportunities.

To our knowledge, a systematic study of chal-lenges faced by international female psychiatrists iscurrently unavailable. There are, however, data onstudies of female practitioners in Australia, London,and Denmark (1). In these studies, key issues that af-fect the professional and nonprofessional lives ofwomen included job satisfaction, balancing work andpersonal life, autonomy, availability of flexible workhours, fair remuneration, and having a voice in de-cision making. Key nonprofessional issues includedself-care, time for relationships with a partner, chil-dren, family and friends, and time management toallow pursuit of nonmedical interests. These conflict-ing demands made on female professionals diminishtheir job satisfaction and lead to stress and imbalance

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in their lives (1). A supportive family, an understand-ing work environment, and changes in culturallybased self-expectations of female professionals canlead to more fulfilling and well-balanced professionaland family lives for women. Another study (2) iden-tified specific pressures at work and at home experi-enced by general practitioners and their spouses andconcluded that a female physician’s workload anddecreased interest in her family are important stress-ors that affect her entire family unit. Other stressorsinclude time pressure, hours on call, lack of support,and amount of paper work. Many women bring workhome and spend time away from home at meetings,and family life is constantly interrupted by telephonecalls. This study also identified role conflict as a majorstressor for female general practitioners (2).

Some international female psychiatrists entertheir training in the U.S. at an older age. Culturally,their prime responsibility is to enhance the career oftheir spouse and raise their children. In cases wherethe husband is unable to find a job equivalent to histraining, the woman becomes the prime breadwinner,yet career goals do not have a priority in her life.

Younger international women are less pressuredculturally. They pursue their career goals while rais-ing young children, and their husbands share the re-sponsibility of household and family. Internationalfemale physicians are not usually comfortable leav-ing children in day care centers. They invite familymembers from their country of origin to live withthem to help raise their children until they reachschool age. This arrangement presents challengeswithin the extended family setting. Usually the fam-ily member that arrives in the U.S. to assist the youngfamily is the woman’s mother or mother-in-law. Con-flicts may arise at various levels, and issues of control,autonomy versus dependency, and envious feelingsmust be managed. International women tend to pushtheir spouses to success rather than to enhance them-selves to their best potential. This maintains the hi-erarchy in which the man holds a superior positionin terms of power, control, and authority. In caseswhere these women surpass their spouse’s accom-plishments, family discord is likely to occur.

International female professionals of Caucasianorigin can merge with the mainstream U.S. profes-sionals with ease, while others struggle for far longerperiods to obtain equal opportunities.

I originated from India and arrived in the U.S. in

1970 with my husband. I knew no one in this vastcountry. I had earned my medical degree in India,and it was my family’s expectation that I would trainfurther and become a pediatrician or an obstetrics/gynecologist specialist. These specialties were widelyaccepted for female physicians in India.

Female physicians rarely opted to compete for apsychiatry training position during the 1970s. Myhusband, who is also a physician, was sponsored bya hospital in the U.S. on an exchange visitor visa (J1visa). I entered the U.S. on a spousal sponsorship. Itwas important that my husband finish training whileI became familiarized with the cultural ways of thissociety. My first observation was that the people inthis society consisted of primarily Caucasians, whowere in the majority, and African-Americans, whowere in the minority. There were very few peoplewho were the shade of brown that I am. From thedisembarkation forms that I filled out at the airportwhen I first arrived, to the employment applicationsthat I would later complete, I had to check my ethnicidentity as “other.” The struggle to know “who am I”and “where I fit in” created a conflict that remainedwith me for a long time, consciously as well as sub-consciously. I felt comfortable with other immigrants,no matter which part of the world they originated. Ibegan to identify with the trials and tribulations ofminorities in the U.S. My first close friend in thiscountry was a highly educated African Americanwoman, with whom I remain friends to this day.

In my day-to-day life, I saw my role as to helpenhance my husband’s career goals, and only whenhe completed his training did I begin my own.

Many years later when I told my story to Amer-ican female medical students, they questioned why Iwould sacrifice 5 precious years of my life not prac-ticing medicine, although I was fully qualified by theexams that international physicians are required topass prior to being accepted into training programs.My answer was clear and succinct. I was raised to bea wife and a mother. My internal values were to prac-tice my profession only after my culturally acceptedrole was fulfilled. Perhaps younger international fe-male professionals may not feel the same way today.

When I began my training in the U.S., I had a 2-year-old child. Daycare was unacceptable to us, so weinvited my mother to come stay with us to help withour child.

I chose to pursue psychiatry, a specialty that my

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extended family in India had never imagined that Iwould think of pursuing. For several years, I did nottell my family that I was a psychiatrist. I knew theywould be disappointed. On one of my visits to India,I informed them about my specialty and educatedthem about the role of a psychiatrist. My grandfathersaid, “I thought you will be a real doctor.” My hus-band’s internist colleagues of international originsaid to him, “I thought your wife had more brainsthan to think of being a psychiatrist!” I felt that I wasin a minority group within the medical profession. Ihad learned from other international physicians toapply for residency training in inner city programssince large academic centers would not offer a posi-tion to an international physician. I followed their ad-vice. I trained with some terrific American male psy-chiatrists who became my role models. They offeredme an opportunity and identified my ambition, en-thusiasm, and motivation to excel. They reinforcedmy strengths and guided me throughout my career.I was offered the position of residency-training direc-tor and medical student clerkship preceptor, in myown training program, within 1 year after completionof my training. One of my mentors had warned methat I would face many challenges in this position. Itwas a young program that required vision, structure,and hard work to attract and recruit the best and thebrightest of applicants. I accepted this challenge, nev-ertheless.

I had a Chairman who had vision, and he pro-vided tremendous support. In no time, our programreceived full accreditation for 5 years without any ci-tations. I attended my first meeting of the AmericanAssociation of Directors of Psychiatric ResidencyTraining (AADPRT) in 1979, where I observed thatthe majority of training directors were Caucasian,and few were female. This was an exciting as well asintimidating experience. I felt very different and iso-lated. I attended every AADPRT meeting, and, sub-sequently and eventually, I noticed that the scenariowas changing: diversity among training directors hadincreased. I have been a training director for 25 years,one of the longest tenures of any training director andthe first among international psychiatrists. I sat onmy medical school’s executive and academic councilsfor many years as the only woman who was bothinternational and dark skinned. I began to accept my-self as a triple minority. I observed intently, listened,

and rarely talked in these meetings. I knew my col-leagues considered me mature and wise. I learned agreat deal about academia by listening and reflectingon the process of these meetings.

To date, I have trained over 400 American medi-cal students and more than 100 international resi-dents, many of whom are women. I have observedfirst hand the differences and unique challenges thatfemale professionals face. I understand their trialsand tribulations since I have experienced them my-self. As a result, I’ve identified creative and culturallysensitive ways of training them.

IMPLICATION OF THESE EXPERIENCES FORPSYCHIATRIC EDUCATION

1. Culture plays an important role in the trainingand education of residents and medical students. It iscritical for international as well as American traineesand educators to be aware of beliefs, values, and dif-ferences among people from different cultures. It isreflected in the trainees’ learning styles and adapta-tion to stressors in the training program. Femaletrainees of international origin face many stressorsthat are unique to them.

2. Educators may have cultural exchangesthrough focused discussions among trainees. Femaletrainees should be provided female faculty as men-tors who can guide them in managing their multifoldresponsibilities. Listening to difficulties, gentle prob-ing, and support go far in assisting the female pro-fessional develop her career. Some female mentors,however, may expect more from their female traineesand send messages such as: ”I did it, you can do ittoo. ” Such messages should be discouraged.

3. Female international trainees, with supportand encouragement from experienced educators,must be taught to develop the perseverance and pa-tience that is necessary to reach leadership positions.

4. Female international trainees should be ad-vised to keep their primary goal in mind and not be-come disheartened because of obstacles. As one of mymentors told me, “Keep a thick skin and move on.”

5. Female international trainees who are willingto share and educate their colleagues about their cul-tural belief system, values, and differences tend tofeel better accepted by the host culture and less iso-lated.

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References

1. Kilmartin MR, Newell CJ, Line MA: The balancing act: keyissues in the lives of women general practitioners in Austra-lia. Med J Aust 2002; 177:87–89

2. Rout U: Stress among general practitioners and their spouses:a qualitative study. Br J Gen Pract 1996; 46:157–160