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First Person

Lost in Translation

Lim, Stephen, MBBS

doi: 10.1097/01.EEM.0000552802.48810.c1
First Person

Dr. Lim is an emergency physician in southern Louisiana and a clinical assistant professor with the Louisiana State University Emergency Medicine Residency Program in New Orleans. He is also the medical director for a number of fire department and law enforcement agencies in the New Orleans area.



It's a long flight to get Down Under. Feels even longer coming home. Canadian by birth. Medical school in Sydney, residency training and first professional attending position in the United States. Now building a family in the Crescent City. It's about the long game—delayed gratification.

But this story isn't just about focus and perseverance. It's equal parts luck and determination. None of this mattered when boarding that plane. I was going. The details would work themselves out.

Moving to Australia for medical school wasn't a difficult decision. World-ranked universities. First-world living. Multicultural. Progressive problem-based learning curriculum with clinical exposure the first week of the first year. An emphasis on evidenced-based medicine and comprehensive, clinical examination skills. Competitive tuition rates. Residency and fellowship training programs. Even a path to Australian citizenship. But I wasn't planning on staying. I was on a schedule.

Australian medical schools aren't feeder programs for Canadian or U.S. residency programs. They have a mandate and responsibility to produce graduates for the Australian medical system. This is right. A full fee-paying international student status doesn't change that reality. They don't owe you time off to study for the MCCEE or USMLE. That's on you. They're not going to place you in a Canadian or U.S. clinical rotation. Start calling and planning. Teaching and examination methodology is fundamentally different—short cases, long cases, essay tests: “Discuss the fundamental components of a comprehensive asthma action plan.” Study for the Australian academic requirements because you cannot fail. Then start working on the medical trivia endemic to the USMLE. Switch and continue. For the next four years.

You have benchmarks and deadlines to meet. Score above the mean on the USMLE Steps 1 and 2. Secure an emergency medicine clinical rotation in the United States. Where to apply? Somewhere busy and prestigious. Probably urban and county. Make phone calls and send emails. Lady luck intervenes because the Louisiana State University-New Orleans student clerkship director has never had an Australian medical student rotate with the program and likes the idea. You'll be excited on your first day of your elective. You're finally here. And then you feel totally inadequate because medical students are accessories on Australian hospital treatment teams. You examine for clubbing during a pulmonary physical exam. But how do you order a chest x-ray? Or write a SOAP? What measurement units are they using? Look invisible during shift-change rounds because you don't know which vitamin in excessive quantities causes pseudotumor cerebri. You'll compensate by working harder. Be the first to arrive, the first to volunteer, the last to leave. Learn fast.

Apply for the match. How many programs? Every single one. Try not to be disappointed that the majority of programs won't offer you an interview. There are plenty of strong U.S. graduates and they don't want the hassle of sponsoring you for a J1 visa. The strength of your letters of recommendation opens doors that were probably closed to you: “The only reason we invited you here is because of Dr. W's letter.” Endure the grind of secondary screening as you fly one way across the United States post 9/11: New Haven to Tampa, Norfolk to St. Louis, points in between. Probably best that you don't know that only 50 percent of international medical graduates match or that you were one of 11 that year to match in emergency medicine.

Lettered agencies and credentials will cast a long shadow over your entire career. USMLE. ECFMG. NRMP. USCIS. J1. H1B. MCCEE. LMCC. RCPSC. Health Canada. ABEM. Successfully navigating through the various bureaucracies should earn you a doctorate. Would knowing any of this have made a difference to you? It might have made you pause. But add it to your reading list. You've got time to work out the details. It's a long flight home.

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