Denise 0:00
Hi again and welcome to Myth, Magic, Medicine Season 3. Today, my guest is Nadia Mujahid who is from Pakistan, and has been practicing medicine now for several years in the US, She is also an Associate Professor at Brown in geriatric medicine.She's going to talk to us about all the differences, pros and cons, between the Pakistani system and that here in the USA. Hi Nadia, thank you so much for joining me today.
Nadia 0:30
Hi, Denise, it's an honor. Thank you so much for inviting me.
Denise 0:34
So what would you like to start with? Would you like to start with why you decided America was where you wanted to be? Or because you had family here you thought it was?
Nadia 0:46
That was a one of the reasons so I believe, I might not have told you my my dad came to Stanford. He was the first Fulbright Scholar out, you know, from Pakistan, to Stanford back in the 1950s. So, you know, he came, he studied, he was here for a couple of years, many, many years. And then my eldest sister came here to do her postgraduate training, also physician and stayed here. So somehow or the other it was kind of always inborn within me that I wanted to come to the United States for postgraduate training, once I was in medical school, and I wanted to become a physician, like, literally from grade one. And I think my eldest sister was one of the reasons because when she started medical school, I was a very young school girl. And I just love the white coat and the big books. I had no idea. I just loved it
Denise 1:44
That looks like fun thing to do.So just briefly, most people don't know a lot about Pakistan, other than it's somewhat north of India. And very close to Iran. What What, where in Pakistan did you does your family live?
Nadia 2:02
So we are originally from Karachi, Pakistan, so which is the south most portion if I may say, of Pakistan? It is a sea port. So the Arabian Sea and the Seaport , it's the only seaport in Pakistan. Very big, one of the largest cities in Pakistan -heavily populated because of all the economic and everything is there, like every every headquarter kind of thing. And highly based, I would say, like a lot of educated people. A lot of educational institutes are in Karachi. So a robust, it's also called the City of Lights. That's where we are from.
Denise 2:43
Okay, good. So when you decided to study, it was natural for you to just study in Karachi? Yeah. Yeah. So you were able to live at home?
Nadia 2:56
Oh, yeah. So in Pakistan, what are the differences because we are talking about differences. You know, in Pakistan, in general, I would say most people don't leave to go away for college. You know, 99% of the population of college graduates would live at home will go to the college within the city, very few will go to another city to pursue a specific college or a specific interest. It's very norm for children, both males and females to stay at home, get educated, whether it's undergraduate or graduate. And generally speaking, they don't leave home until after they get married, or they buy a home or they move out of the city or out of the country.
Denise 3:41
How common is it to relocate within Pakistan for training, postgraduate training?
Nadia 3:47
You know, because I am from the largest city and a lot of people. I mean, I had all the institutes, we didn't have to - right? There were few people, it would be hard for me to give a percentage because I didn't want to give like misinform people, people would come to Karachi from within Pakistan to be educated. So for example, in my medical school, there was like a five person seats for foreign graduates and graduates of other, you know, other cities and other provinces. I'm not sure if that has changed, because it's been a while. But there would be like a quota system for those people.
Denise 4:27
When you say foreign students, those are people from the east or from or they say your children want to go to medical school or you do you think it's reasonable that they might go to Karachi because it's a different system and you don't have to do all that undergraduate stuff first.
Nadia 4:42
Yeah, but you know, it's difficult because they will have a difficult time adjusting to the language because the prime so the educational curriculum is all in English. So I studied in English all through my life I went to a private school, I went to like English was part of my day to day activity back home. But when you're in the medical school because I went to one of the largest public medical schools in Karachi, the patient population you're serving is not very fluent in English. They are fluent in Urdu. So for my children to go back home, theny'd have to really you know Urdu, number one, which is difficult for them to learn. But also, you have to take into account that if you go even as a US citizen, they go back home for medical school, let's say they go to Pakistan or India, anywhere, when they come back, they will have to give the USMLE and they will be not in the pool of US graduates. So as you know, in residency, there are pools there, the pool of US graduates, like people coming from the US medical school system, then there are people coming from the DR for example, because they went to basic science education back in DR but they did clinicals in the US, that's another pool. And then there's the pool of IMGs, which is anybody else from throughout the world. So having them come in that pool would be a little difficult
Denise 6:19
to pool, the pool you were in?
Nadia 6:23
Yeah. And you know, you're competing against, like the entire world. And very smart kids. Very, very smart kids.
Denise 6:33
All right. So let's, let's go logically, so you you went to school, you had some advantages, you've got, you know, a father who was a doctor, a sister who's a doctor, it's an advantage, you have a little bit of the inside track on medical school, you got through a fairly competitive school.
Nadia 6:51
So I just to mention, my father was not a physician. He was a PhD. And he was a scholar, but he was not a medical doctor. The medical school was, I would say, when I started, it was the first year when they started doing the entry testing. And I will tell you that there are 1000s of students sitting down for that entry test. And because it was the first year it was a little difficult, like I had no idea what I'm getting into like
Denise 7:25
Prior to that it was if you have the qualifications, you can get in? A lot of schools do that in Europe, also, you can start it doesn't mean you're going to continue. It's just if you have the basic qualification....,
Nadia 7:37
Right, so prior to that it really depended on the percentile and the percentage you got in your college. Right? So back home colleges two years, and depending on what percentage you have, so if you have for example, 90% and 93%, you're gonna get stuff
Denise 7:58
Some people say college when they mean high school, What age are you when you enter medical school? You're 18 you're 18. So College is the last two years or three years. So last few years of Secondary Education. Yes. And so not equivalent to an Associate's degree?
Nadia 8:18
No, it's not. No, it's not. So you do High School, which is either 10 classes, which is the matriculate system, or you may be able to do the British system, which is "O" levels and then "A" levels. And then if you do "A" levels, you do not do college, that's equivalent of college, and then you apply for medical school or engineering school. I did 10 years of school schooling with a matriculated system, and then two years of college in which my area of study was pre medical. So, you know, everything Science related. And depending on what percentile and what percentage would the result is, you know, the top, whatever 300 students will get into the first, you know, the top college and I'm talking about the public medical school, and then the next 300 or 400, the class sizes are huge back back home. We'll get into the other college. So that's how it is. And then people who might not get into the public school, public medical schools, they would apply for private schools. There are one or two really sought after private schools in which people even if they get into the public school, they really want to get into that private school. They are extremely expensive. But they also are extremely expensive, but highly competitive.
Denise 9:44
Now you're speaking expensive based on the local economy, presumably not expensive like the US.
Nadia 9:51
Well, the US system is very expensive, but even back home there semester would be I'll have to do a conversion in my head, but let's say I did five years of medical school or back home for 20,000 rupees, I think that was pretty much at 22,000 Rupees.
Denise 10:10
Not each year - the entirity?
Nadia 10:12
Five Years! Yes, yeah. And the private school, my sister went to the Aga Khan University at that time, I think her year was a couple of lakhs. [ 1 Lakh = 100,000 rupees] And right now, each year, or each three months is a couple of lakhs like, like 1000 times more than the public school. So not everybody can afford it. Yeah, very few people can afford it.
But there are there are a number of public schools that people can get into, or is there just a one in Karachi?
No, no, no, there are a couple. So two main ones that I remember, you know, it is a lot of private schools have come up as well. But there are two main public schools and again, the class sizes are significantly, the number of students is significantly high. So 300 or 400 students each class
Denise 11:16
Does the first year, for the most part pass into the second year, or is there a bottleneck?
Nadia 11:22
They do. If somebody gets a supli, that's what they call it, like they if they fail a certain subject, they have the ability to sit down again for the test in a couple of months, I think one or two months. Thank goodness, I never had to go through it's I don't know, necessarily. And then if you pass it, you move on. If you still fail, you stay back.
Denise 11:46
It's okay. Do you have to repeat the entire year or you're able to study just for that one thing that you missed?
Nadia 11:51
I think if you so you sit down for this supplementary again. And I believe if I'm not wrong, if you fail it again, you You stay back for the entire year. Yeah, okay. Yeah.
Denise 12:04
All right. So you didn't have to do that.
Nadia 12:10
To my friends, you know, a couple of them did had that. And I will tell you, they are pretty strict, because it's not only the written examination, it's also the Viva. So a lot of times people would do really well in the written exam. But if you fail the Viva, which is the oral examination, you have to sit down for the entire exam, which is the written and the Viva. And I will also just say this, that back home, at least my experience for it's not only your medical knowledge, but how you present yourself, you know, sometimes certain professors would be very strict, and they will, you know, sometimes we felt like, oh my god, you know, we know this thing, but they would only pass a certain number of students. Yeah. So it's, it's a little iffy. There were a few
Denise 13:05
other schools that have that issue. Right. There's also a few schools that I'm familiar with, where if you are unlucky, and you have one of those, maybe the next year somebody else is teaching, so you'll be able to get but then if it's if that subjects only that Prof it's going to be really hard.
Nadia 13:24
Right, right.
Denise 13:26
However, that is not that's not Pakistani issue. That is definitely a worldwide issue for many of us. So what you decided pretty much from the get go, you are going to try and come to the US to get your Postgraduate but you chose after you graduated from medical school to take an internship in Karachi.
Nadia 13:46
I did in the same medical school, you know, the the main hospital I went to was the General Medical Postgraduate Center, the largest public hospital in Pakistan. So it serves a patient population like, I don't know, from throughout Pakistan, like people from rare cases will come will travel to come and be seen because it's a public health care system. And as I mentioned, it's one of the largest It is the largest hospital. So I did my the three years of clinical medicine was right there because my medical school is associated with it, just back to back, side to side. And I did my internship there as well.
Denise 14:29
Let's get a little bit medical. What did you see as the biggest, most common medical issue that you saw when you're in clinical?
Nadia 14:42
Lots of things. I will tell you I saw very complicated patients there. i When you were asking me right now I will vividly remember this female and this is like almost 20 years ago that I'm talking about it almost like because I'm talking about the clinical rotation. I saw this lady who had a thyroid mass, a goiter, it was almost like half the size of her face. And she had lived with it for many, many years. She used to be she was living from the most northern portion of Pakistan. And after many years when she could no longer swallow, that's when she and her family came all the way down to Karachi, to get it seen,
Denise 15:32
was like not wishing not able to find a doctor there who was able to diagnose and treat this, or was it a financial thing
Nadia 15:40
I didn't like. So a combination, she was coming from a very remote portion of Pakistan. So they are not necessarily a lot of clinics and hospitals, even if there are I think a lot of people sometimes in Pakistan, or maybe in other poor, underdeveloped countries will wait until they can no longer function. There's not a lot of focus on preventive care in Pakistan, if I may say. So imagine having this much of something coming from your neck. It had to be couple of years, it had to be like eight years or so. But she she you know, I would see a lot of these rare, very complicated things that I've never seen here in the US, which is great. But you see a lot of complicated things back home.
Denise 16:36
I trained, I don't qualify as a guest on the show, because I was already living in the US. And then I went away to medical school, but I commonly saw complications of measles, which Americans have not seen, I routinely saw people who were victims of polio, I very commonly saw tuberculosis.
Nadia 16:58
Oh, yeah, me too
Denise 17:00
More common now in the US than it was but it one of the advantages of training abroad, for you people who think America is wonderful - it is but you learn to think on your feet a little bit if you're in a country that's underfunded.
Nadia 17:18
And, and if I may say, I think if I may say my clinical diagnosis is really, really well, because we cannot order lab work on every single patient every single day, we just cannot. Because even if it is a public health care system, like the hospital, they still have to pay. So somebody who is selling their cattle or a cow to come down to Karachi, to live somewhere in Karachi. And to seek medical help. I as a physician or house officer, we had to really think Do we really need the test? The CT scan was at that time, there was a CT scan, there was a machine, but you again really had to justify the use, you really had to even justify the use of X rays and whatnot. Yes, they were available. But we really, really had to. Now, same study across town from where my sister trained, Aga Khan, It's a private entity, it's a private hospital. People going there are, you know, it, it still serves a lot of poor community. And they have systems to serve the poor community because they use funds, which is charity funded. They may have more availability. But a lot of times, for example, people who have means they would go there, and they will get a CT scan, because they are paying out of pocket. But here in the hospital where I trained, I had to really listen to the auscultation and really pick up I cannot rely on X rays do tell me whether there's a pneumonia or not. So I think the clinical diagnosis of physicians who were trained back home, or anywhere in the world, I think we are there are limited resources, you really, you really get to pick up diagnoses. Also, the other thing is, and that is a limitation back home. Again, I'm talking about the public health system, the public hospital, there are maybe four or five antibiotics that you have to choose from. So that might not be the best antibiotic to treat that pneumonia. But you only have those five antibiotics to choose from. And you pick one and you you treat the patient and you hope that it helps and and diagnosis is you know the condition has treated
Denise 19:44
others antibodies available if you have sufficient funds, or is there just no but from research other places have other things. Right. So lots of pharmaceutical companies in India,
Nadia 19:55
in Pakistan too. Yes, yeah. But again, Um, when we're really talking about people with limited resources, like people, we really might only have these three or four antibiotics to choose from, you know, yes, if somebody is, and there is a lot of charity that happens in Pakistan, quite honestly, a lot of hospital systems may be fully for poor people off low resources, actually fund their medications and their medical illness, diagnosis and treatments. But again, you know, what, if you cannot, then you have to kind of choose.
Denise 20:37
So you wouldn't else you said, you saw tuberculosis and...
Nadia 20:41
A lot and now that you're talking about it, you know, like, here in the US, you know, if there's even a suspected tuberculosis case, you know, there are so many precautions, you know, there's there's the, the flow, and the gloves, and the gowns, and this and that, and the respiratory precautions. And now looking back, you know, we had nothing back home, we were just like, there will be a curtain. And you're, you're interviewing those patients, and you're taking care of these patients, and like they are coughing on your face, and whatnot, and, you know, and thank goodness, now that I think about it, sometimes we then get all these, you know, diseases but
Denise 21:26
so as a slight aside, is there the same anti Vax movement, that vaccinations may not always be available in in some rural areas? Sort of have hoped the bus come with by soon and vaccinate everybody, but do you? Do you see any of the same anti Vax movement that we have here?
Nadia 21:45
If it's related to the COVID vaccine, there was a lot of initial hesitancy to the COVID vaccines back home as well. I also
Denise 21:54
was thinking, like childhood illnesses. Oh, yes. Right.
Nadia 21:58
Polio. So in general, again, in Karachi, there wasn't, but I will tell you that. Actually, I take it back there, there was maybe not as profound. But with the polio vaccine, I remember doing with a bunch of my medical school friends, we actually took up this project for community medicine. And we actually went in these huge buildings, there were like, you know, maybe 40 apartments in these buildings like high risers and, I don't want to call it rural, but in a more lower socio economic area of the city. And we would literally go from door to door, ringing the bells and knocking the doors and convince them to give polio vaccines. And even then a lot of people were really good about Yes, go ahead and give it it was an oral polio vaccine. And then there were still a lot of people who would say no, what if there's something and so yes, yes. You know, you didn't. You're asking me that's
Denise 23:06
That's disappointing.
Nadia 23:09
Yeah, absolutely.
Denise 23:12
I originally trained as a pediatrician, I moved into emergency medicine, but I originally trained in peds and it just broke my heart. When I was an intern., we had to intubate an eight months old, who was too young... at that time measles shots was given at 15 months. And she had she had, it was a mini outbreak. Not that mini, in New York City you can get a lot of people, and we had to intubate her because she had that severe tracheitis that it will sometimes give. She still had a trach when I left fellowship I was an intern when she was tubed.
Nadia 23:44
Like, I'm so sorry.
Denise 23:47
Yeah, it wasn't my child, but it felt like it.
Nadia 23:50
But yeah, it's it's a sad story for it's sad that if we are if we have the means to do preventive care, and we we are not able to use it,
Denise 24:01
and she and she, of course, for sure, relying on herd immunity, because eight months, even if it had been given, she wouldn't have mounted much of a response I don't expect but anyway, that's a sideline. I was hoping it was just an American disease. We don't want to have vaccinations. But the cost of them the cost of them of courses is pretty prohibitive in a lot of places.
Nadia 24:25
You know, the if I may say the World Health Organization has done tremendous work in Pakistan and other countries, I'm sure, but I definitely know the community program that I volunteeered with, I and my medical students, like bunch of people did this. It was all WHO-funded and this was all to help eradicate polio from Pakistan. And all of the funds all of the vaccines were were coming so you know, thank goodness for WHO and other, you know, organizations and NGOs obviously there has to be NGOs back home based in Pakistan to help with this transition and to help reach out to medical students and community physicians to help do this. But thank goodness for them.
Denise 25:17
Okay, so let's move on, let's move you away from Pakistan, you decided you're coming to America, you've taken your Steps 1 & 2? While you were a student or while you were doing your internship?
Nadia 25:27
I, not when I was a medical student. Right. During the time I was doing my internship, I started studying. But it was more towards the end of the internship and I took a couple of months after that, like another four or five months to really kind of polish up is a different.
Denise 25:51
I know it's a while ago, can you remember the things that struck you was funny, because you're talking about a different ... Medicine is the same. We all have, you know, hearts and lungs and kidneys, and all those bits are all the same everywhere, people, but the attitude towards medicine, the names of the drugs, or all of those things. Were there any particular things that stood stood out to you? Why would they do that? I have to learn this because I have to take the test. Were there any things that that stood out to you?
Nadia 26:25
It's been so long, but I do remember I think it was so Step 1, if I'm not wrong was all like the basic science though anatomy, you know, biochemistry there's, I think physiology and maybe a little bit of pharmacology if I'm not wrong. And I was like, oh my god, this is so detailed. I've not learned such detail pharmacology so so much now. And I have to our physiology, that things I had forgotten, because I was doing it after I'd already completed my five years of medical schools, it was kind of going back in time. I think I was stressed. Not so much funny, but I was stressed. It's an expensive exam. I wanted to come here. But I also wanted to do the internship in case I don't match in residency and I do not get the visa even if I match into residency as an immigrant, like an IMG. I needed a J-1 waiver visa, because my residency was after 9/11. And throughout the US the H1-B spots had been markedly reduced. And you know, I'm coming from a Muslim country. And interestingly speaking, you know, one of the times when I had the visa interview in the, in Islamabad, which is a capital of Pakistan, to come for the US, like, you know, like a visitor's visa, and that was when I was in medical school, I wanted to come here for medical school electives, and I did, but the initial visa appointment got cancelled because of the Iraq War. So all the embassies in Muslim countries, especially in Pakistan, were cancelled. And it was like I, I still was able to do medical school electives, but it was now in final year 5th year rather than 4th... So you know, you have all these hoops and things to, to come across. When you're coming from an
Denise 28:27
they're not always always something you can map out there can be some...
Nadia 28:33
So I did my internship to make sure that even if I do not match in the US residency system, or do not get a visa, I still have the ability to practice as a physician and do postgraduate training back home in Pakistan then. So I actually give my USMLE 1 January of 2006. And then six months later, or five months later, I did my Step 2-CK. And within a week, I hopped on the plane to come to the US, my sister already lived here, so it was easy. And then literally two weeks later, I gave my Step 2 CS, She wanted me to apply for the 2006 residency match, like to get into the match cycle at that point. And she was literally after me. She was she would call me. No, I'm serious. And there was no WhatsApp. There was no like, you know, those internet free calls at that time, she would actually call me and say, Hey, are you doing it or not? And initially, at that time, I wanted to delay my USMLE Step. You have an extension of three months I wanted to do it. And she's like you better not. You need to get into this system and apply because what if you don't match you will apply next year. But if you don't, if you keep on delaying, she was of the impression that the longer you wait after medical school graduation, the harder it is to get interviews and to get into a residency. That's
Denise 30:00
absolutely true. Two years, two years is hard. Five years is impossible.
Nadia 30:06
Absolutely.
Denise 30:07
So yeah, that's the you flying from Karachi, to the left coast, going off to California. How long how long before your exam, you had time lags, and all sorts of things to get over before you took the exam.
Nadia 30:22
Two weeks, oh, I come to Los Angeles, I get picked up, she's in San Diego, I will go to San Diego, maybe a day or two of rest, which is a blur. I come with all my books for Step 2-CS examination. And I just literally, at home alone, I'm just reading and trying to practice and making sure I do the SOAP Notes on time, because it's a time limit, right. And then within that time, I am getting on a plane to go to Houston because my Step 2-CS exam is in Houston, I get no dates anywhere else close by like LA was one of the sites. But I didn't get a date. And again, there was a time crunch. I gave my usUSMLE Step2- CS, I believe, late August, again, like literally back to back to back. And I just didn't wait for my exam results, I do not have the result of Step 2-Ck, I do not have the result of Step 2 -CS. I passed Step 2 CK, but I'm waiting for CS. And in the meantime, I'm applying for residencies I applied throughout not in California, because in California, they needed the California letter or they need there is more, there's an increased if I may say you have to have something in addition for California residency programs, which is a California letter. So I did not apply in California with
Denise 31:55
A letter of recommendation from somebody or a specific form?
Nadia 31:58
I think it's a specific form that you need to get. And because I was a recent graduate, it needed and they need to have it in place for applying for residency. And because I was not I needed some time to get it done from my medical school. And that is in addition to for you to practice any medicine in California. So I took California off my list, but I applied widely throughout the US and I basically going to widely but I literally was looking for residency programs who will interview IMGs and who will be able to offer a J-1 waiver. So my my application and my a lot of time was spent searching these things. And a lot of programs like you know, you know people from Pakistan like you know, family friend or somebody's siblings, somebody. But a lot of the programs that I got to know were- had offered each H1-B visa but now that was not a choice. So you know, your your pool becomes even smaller.
Denise 33:13
Actually, there will be a lot of people of the people who listen to this. It's not a massive audience. But although doctors are very familiar with the term J-1 visa, most don't really understand what it is unless they've had to use one. And and very few people understand all the h1 h2 visas, those are very so can you speak very briefly to what the criteria are for those two? Sure. So
Nadia 33:38
J-1 waiver or J-1 visa is, if you get into a residency in the United States, the ECFMG,, which is the one that kind of overlooks the postgraduate training in the US will send a letter and say you have received, you know, you're in let me
Denise 34:04
It doesn't it doesn't oversee US graduates . It's the umbrella that all foreign-trained people must be under you have to be certified by them in order to proceed. Yes, yes.
Nadia 34:16
Thank you. Thank you. And then what you basically a J-1 waiver is that you will be granted a visa to stay in the United States for postgraduate training. It can be as long as seven years. So you can do three years of residency and up to four years of fellowship. So a total of seven years in a J-1 waiver. But the point of a waiver is that after you're done with a postgraduate training, you return to your country of origin for three years. If you decide not to return to your country of origin, you basically will be you need to go to a remote area in the United States and practice medicine for at least three years
Denise 35:02
An under-served, area, ,
Nadia 35:04
So a remote area could be remote area in the middle of Midwest or it could be an underserved area. And it could be an area that is basically catering to the Medicare and Medicaid population.
Denise 35:17
Right. I trained, I didn't have a J-1 visa but I trained in Manhattan, which is hardly an underserved area, but it's got huge pockets of underserved community. Right. Those of the people I trained with who had J-1s most certainly would have been able to remain in New York.
They had hospitals able to give them J ones, it's not that a hospital doesn't feel nicely towards immigrants. They have certain criteria they have to meet in order to offer J-1visas.
Nadia 35:49
Absolutely - your contract gets renewed every year. I've never had an H1. But from my understanding, it is a visa that again, your hospital will sponsor for you. If you qualify.
Denise 36:03
Your H1/H2 system is different. The basis upon which your residency in the States is based you serve to serve population.
Nadia 36:11
Okay, right. Right. So I did my three years of residency in family medicine, in a J-1
Denise 36:16
So you've applied, you've gotten a place on the opposite side of the country. Rhode Island, which makes me feel great, because I'm in Delaware, my state's bigger than your state. Two tiny, tiny states with you know, we've just passed a million population what's the population Rhode Island, something similar?
Nadia 36:40
I have no idea I'll have to google that. It's, it's, you know, probably more than a million if I may say just on top of my head. It's the smallest state but it's a very heavily populated state. Right, let me put it this way.
Denise 36:54
And it is also the home of Brown University, which is definitely a name most people will recognize.
Nadia 37:01
Right, right. Exactly.
Denise 37:04
So you got a residency there? How hard was it to adjust from California to Rhode Island, quite different climate,
Nadia 37:14
very different climates. Um, you know, I had a very different mindset if I may say, Denise? I was not really looking for location. I only had so I'm just gonna give you one quick, more information. I was very lucky to get into residency I, I gave all these exams, I applied for residency, I started my research. I got no interviews until around after the Christmas of 2006. So most of the interview slots are already gone. I got ECFMG certified December 22nd 2006. So right after Christmas, when likely though, offices and the you know, the the secretaries were back to work after Christmas, they saw that I was ECFMG certified. So within a week, I got three interviews. But that's not a lot. You know, you know that and no, but all three were in the specialty chosen, which was family medicine, and I was I was just going to give the best shot ever to my to the people who had actually invited me for interviews. So in January, I went to all over the place I came to, I had one interview in Milwaukee remote, remote area family medicine. I had another interview in West Virginia. And then my third and last interview was in Providence, Rhode Island. And, you know, I go back I wait, and then you know, I magically match at Brown for Family Medicine. So when I moved to Rhode Island, the weather was different. I had no family I didn't have my sister and a brother-in-law and nephews, right. I do know people here in Rhode Island, through my sister, her sister's, you know, juniors from medical school and whatnot. But my my mindset was very different. I was there for I was here for three years, I was going to do the best possible job. I was going to learn a lot. And then I'm gonna go and maybe live somewhere close to my sister. That was my mindset. So you know, weather and cold and snow was not something that I was fixated on or thinking about. I was literally on the get go, uh, you know, head-down, learning, doing what I needed to do, and making friends and whatnot and making up community. But literally, my mindset was very different at that time.
Denise 40:08
It was a temporary it was like being in college, this is where I am but not where I'm going to be,
Nadia 40:12
this is what I am. And and I was very grateful. I was like they have given me the opportunity. So I'm gonna do XYZ, and I'm gonna do the best thing possible. I was the chief scheduler, in my third year in family medicine. The Chiefs are generally in the third year. So I was one of the chiefs. We had a total of four chiefs. I was one of the chiefs. Almost at the end of my third year residency. I was always interested in geriatrics, I was like, you know, maybe I should do attending physician for three years, because I did not want to go back to Pakistan. I wanted to go and take care of the waiver position. So going to pick up a job to do the underserved population. And then I remember one of my attendings, mentors in family medicine, Dr. Goldberg said, Why do you want to go and do an attending position? Why don't you just go into a fellowship, first, it's a year. And then you can always go back to you can always go and start earning as an attending. And I took it as wise and I applied to one Geriatric Medicine fellowship program here in Brown, because I just wanted to not move for a year.
Denise 41:26
And that was not that hadn't been on the radar, geriatrics.
Nadia 41:31
It was, I was contemplating, but I was not kind of I literally had already interviewed for primary care positions, a couple of slots. And again, because I needed a waiver, I was looking October of my third year in residency. So I was looking almost eight months before I was graduating, You only have 30 spots for a waiver position, each state. So Rhode Island is a very small state, it has 30 spots, and so has Texas. It's a huge state. So the competition in Rhode Island is not as robust as in other heavily populated states. So I was looking for primary care positions, and I interviewed a couple of places. And then he mentioned to me, why don't you just go into the fellowship. And I was like, You're right. And I had done my geriatric medicine electives at Brown, again, across within the same city, and I literally just, you know, went and I did an application and they called me for the interview, and I got into it. And I'm so blessed to have had that opportunity. Things just lined up. In the start of the fellowship, I thought, I'll go back to being a primary care and I never did, within two or three months of me being a fellow at Brown geriatrics, my division director called me and asked me if I would be interested in joining them as faculty. So it would be an academic position, it would be a new program that I would be starting as a geriatric co manager with an orthopedic surgical subspecialty. And it was for me, again, things just lined up. It was a robust opportunity. I wouldn't be doing a waiver in a huge academic teaching center. I would not be moving cities and places. And it was an opportunity with a lot of growth. And I said, Yes, and I've never left it, I've never looked back.
Denise 43:43
You don't see any any reason to move from where you are now. I see even even the weather even though... At what point in all of this did you have children because I know you have two small children?
Nadia 43:58
I did not have any children during my residency or fellowship. I was an attending at least three years when I decided me and my husband decided okay. Yes, yes. Right. And, you know, my husband is a physician too. And we did three years of long [distance] relationship because when I was doing my fellowship, he started his residency, out of state. And I, we had both decided we don't want to have any children until we are back to living together. And it made sense for us. Yeah. What's his residency? His residency was in Louisiana. He did Internal Medicine in Shreveport, Louisiana, and then moved back home to do his J-1 visa requirements.
Denise 44:47
Was Rhode Island Home for him or just where he gone to medical school.
Nadia 44:51
No, he's from Pakistan too same medical school as myself. Rhode Island was home for us. The entirety of me coming here as a resident, and when I was doing residency, he was working as a research assistant at the VA medical center up in Boston. So used to take the train early morning, go there, do his research, and then come back.
Denise 45:14
That's nice. Okay. So let's, - we talked about what was the difference between your your Karachi internship and the one you got to do again here because you always start at the beginning in America.Very occasionally, that's not quite true very occasionally people will place into fellowship if people are senior physicians coming from abroad, but right, General, the general thing is you basically start again, and no matter how experienced you are abroad, you will have to go through some degree of graduate medical training in the US in order to have a license. This is not so in many countries, but absolutely it is. Here it is. So what you must remember internship, if only because both of them, both of them probably very long hours, what was the biggest difference for you? Or a surprising similarity?
Nadia 46:15
Yeah. So I will. I now that I'm thinking about it actively, while you're asking me this question, so the patient population was very different for me. of all, although I did three years of family medicine, it's a community hospital, and you're basically again serving people in the community, a lot of them are on Medicaid and Medicare, but there are also people who are coming from different aspects of life and whatnot. When I say the patient population was different, here, I was seeing in family medicine, you know, pregnant woman delivering their babies and doing a whole spectrum in family medicine. Back home, there is no family medicine, per se, you pick up a specialty kind of like specialty in the sense that you pick up either internal medicine, or surgery or OBGYN
Denise 47:13
You as a trainee, as a trainee, as a trainee -training. So you meaning because you know, a general practitioner is roughly equivalent to family practice feels a bit different. But in the UK, it's now a separate training, it didn't used to be you either did that or you're specialized. So in in Pakistan, you you have to train in something or ...?
Nadia 47:38
Okay, so you even if you want to become a general practitioner, you will do internal medicine and a lot of people will do OB GYN because as a general practitioner, you will be seeing a ton of pregnant females or a female of childbearing ages, and you should be very confident and accustomed to treating taking care of woman of childbearing ages. Again, contraception is available, but again, the general practitioner and mostly females will prefer a female physician taking care of their gynecological and obstetric needs back home in Pakistan. So a lot of woman physicians would do OB GYN, you know, six months internship and then internal medicine to become a GP, for example. Here I was doing everything within a year, you know, I was delivering babies, I was taking care of newborn babies, I was taking care of elderly so that was different for me in family medicine. And it was challenging as well. If I may say, you do two months of OBGYN in family medicine here you get really, really, really good at it. And then you go the next ward is internal medicine. And you will see nobody prenatal, you're really taking care of pancreatic pancreatitis and CHF and pneumonia. So you use switch a lot, but also that makes you really learn a lot in family medicine. The other thing was back home I pretty much knew the system, right? It was the same hospital where I had done three years of clinical medicine. The professor's some of the nurses knew me. The people who were doing internship with me were all people from my hospital system and from my from my medical school, so that was also very different. And it was, you know, doing our very hard part of my training but doing it with friends. We would also cover each other so at nighttime if three of us were on night calls for internal medicine, you know, two will stay awake and one will say Go lay down sleep for two hours. Come back You know, that kind of thing here? I knew nobody in internal medicine in my residency, I
Denise 50:06
was just and even if you knew somebody, you weren't going to be allowed to do that,
Nadia 50:09
Yes, yes, yes. And then there, you have to have multiple people on call. Because it's a very big ward. Here, it's like one intern on call. And then there might be another senior. But it's a very different that kind of system.
Denise 50:25
When you were on duty, during the day, not night call, obviously that's different. But during the day, how big was the was the actual patient load for you? Not the emergency come here and help me I needed another body. But how many people were you responsible for? As an intern, through which you had to report through the ranks everybody else that was responsible?
Nadia 50:47
In Pakistan, or
Denise 50:48
Here , well in Pakistan first, and then here.
Nadia 50:51
Um, you know, in Pakistan during morning hours, because there was a lot of house staff. We didn't have a lot of patients, maybe five people.
Denise 51:01
Okay, and so here, here, it was,
Nadia 51:04
it would, it was much more, you know, seven to eight, there was a cap of 10, no more than 10 When I started internship,
Denise 51:12
and when you were a third year, how many were you responsible for? I think, obviously, all the juniors were reporting to the higher, right. So in the US when I was training, I usually had 10 or 15 people, as an intern and or maybe 10,10-12. But as a senior during the day, I have two interns under me. This was a senior, I wouldn't have both of theirs to worry about. Yeah. Yeah, that night, I had multiples that to worry about. Right. So I just don't look at the patient load.
Nadia 51:47
I think as a senior, you pretty much had the interns, you had two interns and the interns each could carry 10, we tried not to give them 10 maximum, because that was a little bit too hard for them to complete, especially because when I became the senior they were work, hour restrictions for interns. So we were I was supposed to carry, you know, like, follow up on imaging and things like that anyway, but you could have a total of two or three by yourself. So maybe like 20 to 23 as a senior,. We tried not to have that max, because we thought that that's too much for even a senior resident to to related to patient safety, basically. And one other patient difference was also, if I may say the patient, how they treat physicians, back home, physicians are treated like, like literally like kind of gods and goddesses, they would respect you a lot like literally they would be again, I'm talking about the public health, the largest hospital system where I trained and I was serving as a house officer. So me going in, they would be literally giving me a lot of greetings putting me like treating me with the utmost respect. And also like really thanking for the services, they were very grateful. The patients and their families, like I would say, like to the point that as of they are the kind of worshipping
Denise 53:32
We don't really want that but we would like respect for our knowledge.
Nadia 53:36
You don't want that either
Denise 53:37
You don't want to be worshipped. It is a job in some ways. But it's a job that comes in. It's not just, I do this for several hours, and I get money at the end of it. There's a whole lot of other costs to the physician. I think we want recognition of that,
Nadia 53:52
right? And now I mean, hear it's like, yeah, depends. They might respect you. Or they might say, Okay, you're an intern. I don't know, where is the attending?
Denise 54:02
Yes. Or I just looked this up, and they suggest on Twitter that I should do this instead of your brilliant advice. Yes.
Nadia 54:11
And and here I will be honest with you. So back home again, this that. Another difference, if I may say is something that I've encountered, not uncommonly, in the US. I am in academia I am in as a faculty. I work very closely with fellows. It is not uncommon over the last couple of years, especially over the last four or five years that I've had fellows who were older than me, and they were males, because they went on to doing something else they did primary care or they did something else when he went into private practice for five or eight years got burned out and came back to doing geriatric medicine fellowship. And they would go in seeing a patient they've already seeing the patient there, go back with an attending. Attending female physician and the patient's family is asking all questions to my male fellow. And he's saying this is Dr. Mujahid She's the attending and they're kind of totally ignoring this position, and then calling me Nadia.
Denise 55:24
And, in, in fairness, do you think that is the politically correct here, the propensity for there to be nurse practitioners around is I, when I first went into practice, after residency and fellowship, I was in a rural area in the US, and I was one of a dozen doctors on staff, everybody else was male, and then a couple of 100. So most patients assumed I was a nurse, apparently, I mean, I dressed differently, had a different coat on, I had a stethoscope around my neck, not in my pocket. And I would walk in and introduce myself as Dr. Billen, not as Denise. And yet they would not they would not nurse nurse. They didn't know how to. And I would walk in with especially burns you in July walking with an intern. And they were direct the questions to the male intern.
Nadia 56:24
Right. I don't know, I think it's just some in one biases that people have that I think we are noticing more now that we are aware ourselves, I think I might not have noticed that 10 years ago or eight years ago. I'm starting to notice it more now. thanks to all the courses about like biases and whatnot that we have been through, you're like, oh, yeah, that happened. And this happened.
Denise 56:51
Yeah. Do you think that the male non-attending with you is aware of it and will help correct the impression?
Nadia 57:00
I? Yes. All of my male fellows who this
Denise 57:05
must particularly must be difficult for the male fellow who's been out in practice. And he's been the head doc there for a while, and should be going to training again, that must be hard.
Nadia 57:16
Right? Right. You know, and he would always say, Well, I'm remember I talked about I'll come with my attending physician. She's my supervising attending. Yes, it kind of clarifying. Not that I want anybody to do anything. But I just noticed that. One other last thing, in the interest of time, I would say that back home, sharing bad news, you almost never do it with a patient. Yes, thank you pretty much. And again, I did it almost like, you know, it's been a while that I practice back home. But the whole idea is you tell the family and the family decides how much and whatnot, the patient needs to know. This is a lot of I know, here in the US in the Western countries, it's all about patient autonomy, it's about patient rights? Back home, it's all about protecting the loved one for a bad diagnosis or terminal illness, that they might not be able to change. But they also don't want their loved ones to give up or to get depressed or whatnot. So I have seen it both ways. Back home versus here as well.
Denise 58:31
Now you're not a surgeon so how do you deal with informed consent if you don't give them all of the information? I'm not assuming, assuming that they are competent to make a decision?
Nadia 58:45
right. So again, back home, I never really encountered that kind of, you know, consent or something like that. Here I actually take my own consent for you know, the code status and as a geriatrician with orthopedics. Pretty much everybody's a full code. And I walk in the room and I, a lot of times, it's a DNR DNI after I have had my conversations, now, when patients are going for surgery, it's very reasonable, they be a full code. But a lot of that is also that after the surgery for hip fractures, which I commonly see that the patient or their family member request that, you know, please reinstate my DNR because yes, I'm going in to give myself a chance to recovery and therapy and walking again. But I don't want to be resuscitated in case of a cardiac arrest.
Denise 59:40
Thank you so much for joining me today. It was wonderful. Thank you so much for spending all this time. Thank you. Bye bye.
Nadia 59:46
Thank you, Denise. Take care
Transcribed by https://otter.ai
