Ahmad Adi, MD, was born to Syrian parents and went to medical school in Saudi Arabia. Heather Kim, MD, was born in Korea and grew up in Canada. Now, they’re both fourth-year psychiatry residents at Duke.
In this episode, they share what brought them to Durham, what psychiatry has taught them, and what it’s like to be immigrant physicians.
In the Department of Medicine, a cohort of faculty and trainees have been trained on how to offer informal support in response to incidents of bias, harassment or other unprofessional behaviors. See Championing Civility. That page also includes links to other Duke resources for support and assistance.
Dr. Ahmad Adi: Actually the person who kind of inspired me a little bit to kind of go into psychiatry was my great aunt. And my great aunt has schizophrenia. She just turned 100 not too long ago, making her the oldest person with schizophrenia that I know, because people with schizophrenia typically don’t live as long. But she lives with her sister and my grandma who is 102 and they both live in Damascus, Syria right now. Which to me just tells, speaks a lot about like human resiliency and like how life goes on regardless of what’s been going on.
Karishma Sriram: That’s Dr. Ahmad Adi. He was born to Syrian parents. And he went to medical school in Saudi Arabia. Now he’s a 4th year psychiatry resident at Duke and next, he’s going into forensic psychiatry.
Ahmad: Forensic psychiatry is basically the study of psychiatry as it pertains to legal matters. So like all the overlaps between mental health and legal issues. And I’m interested in pursuing it because I’m interested in immigration law. So like working on mental health evaluations for people who are filing for asylum or people who are here, like the immigrant crisis that’s going on right now and seeing if there like any mental health elements that can help these people. That’s how I ended up choosing that.
Karishma: This is Voices of Duke Health, I’m Karishma Sriram. Ahmad decided to bring his fellow psychiatry resident, Dr. Heather Kim, to talk about, among other things, what it’s like to be immigrant physicians. Heather was born in Korea, and then grew up in Canada. And for a while she really wanted to be a behavioral geneticist
Dr. Heather Kim: So off I went to the furthest I could get away from my parents which was McGill. So in Montreal at the time. And then I started my degree in biology and I was working in a lab looking at a lot of flies, ended up in a fish lab, took out a lot of fish brains. And just like day in and day out of that. Even though the research I was doing was something that I thought I would want to do, I just wasn’t happy. And I think there was one disastrous incident in the lab fish basement when a water main broke and just came through all of the tiles and it just killed all of my fish that I had at the time. It was a sign! And it was super gross so it was a holiday so I was like one of the only people left in the lab that were like supposed to be taking care of these fish. And I just I was like scoop out all of these dead fish. And it was like tropical fish so it was like very warm, just dead fish soup everywhere. And I was like, this is not what I want to be doing for the rest of my life.
And then after I graduated I actually ended up working as a behavioral therapist with autistic kids and I loved it. And I started thinking like you know maybe I can just do my boss’s job, I bet I can do that.
Karishma: So Heather took the MCAT, applied for med school, and ended up in this faraway place—North Carolina.
Heather: I had no ties to the area. I’ve never- Milwaukee was the most south I’ve ever lived. And I was like whatever my favorite band is here, the Mountain Goats. I love the place. You know why not, I’ll just rank it high and see what happens and then on match day I’m like, oh, now I guess I’m moving to North Carolina.
Karishma: And it was a pretty foreign place for Ahmad, too, coming from the Middle East.
Ahmad: People here seem to be very curious to know more about my background, if they find out that I’m not from the area, which is not something that I typically kind of immediately disclose to patients that I meet. But sometimes if they ask and I tell them everybody is very interested to know a little bit more about where I’m from.
It’s an opportunity for people to get to learn more about that part of the world that they usually don’t end up seeing like in the news or in the media. Unfortunately a lot of the stuff that comes out of the Middle East in the news and media is not the most pleasant things to read about out there. And I’m always kind of I’m happy to tell people a bit more about like where I’m from or how I somehow ended up in Durham, North Carolina.
Heather: I think what I get uncomfortable with is when people assume that I’m not from here or that like I must’ve grown up somewhere much more exotic. Like, where are you from? Milwaukee. Where are you from? Canada. No, where are you really from? I don’t know what you want me to say! It’s like OK, you want me to say I’m Korean. But you know just when people are just curious about it, I don’t think that’s as harmful as like, no, tell me what you are.
Ahmad: Right, that’s true.
Karishma: And assumptions about where they’re from matter. Malicious or not, those assumptions can lead to implicit bias. This is something Ahmad has been studying during his time at Duke.
Ahmad: Specifically like looking at it using patients show rate as an indicator for intake appointments because in some of our clinics our names are available for the patients. They know that it’s the resident clinic, but they know that it’s going to be with Ahmad or with Heather or with other people. And in some other clinics, our names are not there. They just know that they’re going to the resident clinic. And I tend to have higher show rates at those clinics, than the clinics where people do know what my name is before coming in. So that’s something that hopefully we’ll get to look at some data about before I leave here and perhaps I’ll hand it to another resident to look at it some more.
Karishma: Yeah. How does that make you feel?
Heather: That was a great psychiatry question!
Ahmad: I mean I found it, I honestly find it fascinating. I mean there’s a little there’s a little part of me that obviously does not appreciate kind of being judged solely because of what my name or what my name sounds like, but I still do think that it’s a very fascinating phenomenon because in most instances of implicit bias, that’s like in that literature, it actually occurs in a more unconscious level so people are not always very aware that they’re doing these things. And it happens both on the kind of like the patient side and also on the clinician side and people. And again people are kind of like not very conscious about it. The last time I kind of gave a short talk about this like to our residency program I kind of tried to really emphasize the self-care part of this is that like, really truly don’t try to beat yourself up this, this is not something that you’re consciously choosing. It’s very important that we know this is very important that we study this a little bit more to see where this is coming from and if there is anything to do about it. At this time, self compassion is important too, to not beat ourselves up too much.
Karishma: So obviously like you are more than just you know the place that you’re from or the color of your skin tone. But how often do you feel that either patients or people that do see you as your race or ethnicity?
Heather: I think it’s been kind of interesting within therapy interactions because I’ve had some Asian patients, or East Asian patients, Indian patients, who have a positive transference of me from the beginning because they assume that we share the same values. Like, I must be that good Asian daughter because I went to med school, right? So there’s a lot of assumptions about like, oh, you’re probably on my side, or like you probably understand why I’m mad at my husband or my kids. And sometimes I don’t necessarily correct that because I think it helps with the therapeutic alliance.
Karishma: That said, sometimes those assumptions are really noticeably negative.
Heather: In the ED when someone is agitated I might get racist comments. But I don’t really hold that against them because it’s an incredibly traumatizing and stressful experience.
Ahmad: Right, yeah. I wanna say like I’ve noticed it more not so much in the sense that from the Middle East, but it’s but I’ve actually noticed more from my other kind of minority identity of being the LGBT group. For example I’ve had a patient once in my clinic as I was typing up some stuff for her, she asked me whether- she was like, oh, do you like theater? And at the time I responded with, I’m neutral towards theater. And I kind of figured out what she was trying to say, but it was one of those, why do you ask? Like in a very psychiatry way. It’s like, I’m curious why you’re asking me this. And her response was like, oh, you remind me of like my son’s friend who also really likes theater. And I kind of, you know from your socks and whatnot. I like wearing colorful socks, generally it’s like my little accessorizing thing that I do. So there were instances like that that has happened, but what has really helped me to kind of look at it more from a curious lens rather than kind of get offended by it or get upset by, it in the sense that a lot of these people who are making this are, generally speaking, not doing it to offend you or insult to you they just genuinely truly don’t know how else to do it.
Karishma: So in those moments where you do face these comments from patients or maybe you know just like family members or anything like that, what motivates you guys to continue just giving them the benefit of the doubt? Like it’s really hard to be givers like that all the time.
Ahmad: Right. I guess there’s several kind of factors to consider. One is whether this happened once or is it kind of like a repeated thing that’s been going on. And another thing to look at is actually also the nature of the comment itself, like when someone says like, oh, do you like theater because your socks are colorful? It’s a little different than when someone kind of frankly makes a homophobic comment or like a racist comment or something. And responding to those is going to be very different. So when someone kind of says something that’s a little more on the offensive side then that kind of puts a little bit more pressure to address it, like at the moment.
I’ve honestly found it helpful as a, kind of like, as a time to be able to set a different example for those patients for being like, yes I am a foreigner. I’m from the Middle East. I’m also gay. But I can still be a good provider. Like I’m still like a reasonable human to hang out with or tell about your problems kind of thing.
Heather: It definitely does wear on you. When people assume certain things about the quality of clinical care because of the visible or other observable traits that you have that might peg you as a certain identity group. I think I have to usually assume the best, positive intentions because that’s what protects me and that’s what keeps me able to keep going. It doesn’t help me to be a better provider to kind of try to figure out like the real intent. Or like, are they really being racist or not. But I feel like there’s a lot of pressure on doctors to be forever compassionate, like endlessly giving, always be okay with things.
Karishma: And Ahmad agrees. He thinks, yeah, there is this expectation that doctors are always having good, positive feelings toward their patients.
Ahmad: However in reality that’s actually not true.
Heather: Oh my god!
Ahmad: I know!
Ahmad: But being able to as a physician also kind of understand that sometimes we don’t like the people that we are treating. And that’s part of being human. And so long as we’re kind of we recognize that feeling, we own that feeling, and we don’t use it to do bad things in our clinical care, then that is also, that is very valuable.
Karishma: There’s actually term for that—”countertransference.” It’s essentially when a provider has an emotional reaction triggered by their patient.
Ahmad: Countertransference is actually very helpful. It’s a very helpful diagnostic tool and psychiatry can be a helpful diagnostic tool in other fields as well. When you’re like, this person is making me feel angry, why are they making me feel angry? It must be because for example they’re tugging on this feeling or that feeling. And you can reasonably make an assumption, of course you need to talk to your patient about this first and explore it, but you can reasonably make an assumption that if they’re doing that with you, they’re doing that with other people. And that becomes a target for treatment is to kind of be like, all right, I noticed that when you say this I get upset. Does that happen with other people. Let’s talk about this.
Karishma: Just kind of like hearkening back to something that we talked to Dr. Mankad about, just about like how physicians and patients have with them just like a physician patient relationship. It really is like a relationship and interaction. But then kind of going back to your point, Ahmad, about how sometimes like having that kind of like countertransference and like maybe sometimes not great feelings about a patient can be helpful. I guess in my brain I’m like, I wouldn’t want that in a relationship, though. So I’m just kind of curious, how much does it either like detract or add to the relationship?
Ahmad: Generally speaking I find that being able to kind of bring something out on the table is always a lot more helpful than kind of keeping it a, I think they’re doing this because of that, or I think I’m feeling this because of this, or even kind of feeling like, why aren’t they doing what I’m telling them to do? These frustrations, if we kind of leave them and unchecked and undiscussed, they tend to kind of just stay there and fester as you keep going forwards with that relationship. At the end of the day we’re not doing anyone any favors by not bringing this out. And then if you bring it out and the other side the patient, like they’re not taking it or they’re being defensive, that’s data too. And now you know like why these patterns are surviving with time.
Heather: Yeah. Like you mentioned, if they’re doing it with you, they probably do that with other people, right? So if say you have a patient who always comes their session but doesn’t do any of the therapy homework and says, I don’t want to do that, I don’t want to do that, or it’s not working, it’s not working. And if you’re starting to feel frustrated or helpless like that’s probably something that other people in their lives feel, too. And you as a therapist like really have a great opportunity to be genuine, say you know I’m feeling helpless right now and I’m not quite sure what to do for you. Like is there something else going on, or you can talk about that genuinely, whereas you know if you’re friends with this person or if this is your sister or you don’t have any obligation to be nice to them, you might just tell them off or you might just cut them out. And that’s tragic and like they don’t really have an opportunity to get an interaction where they could get constructive feedback or really look at you know, that wasn’t my intent or this isn’t really what I want to be doing, or even maybe it is what they want to be doing and you can at least clarify that with them.
But I think by ignoring these negative feelings or negative feelings of countertransference, because of a lot of shame or guilt that we might have as doctors to be the perfect doctor and to be always giving, that leaves a lot of things on the table that could have been addressed. And I think I agree with Ahmad that it ultimately does a disservice to the patient.
Karishma: This conversation got Ahmad thinking about how culture affects all aspects of medicine, especially psychiatry.
Ahmad: I mean, the physician has a cultural background and the patient has a cultural background and both sides are bringing parts of that culture into the interaction. In psychiatry specifically, there are a lot of kind of cultural models for understanding mental illness. And it’s always kind of important to not dismiss that. So if someone kind of comes in they’re saying like, oh, I’m not depressed I’m just really tired because of witch put a hex on me or something. It’s important to not completely dismiss it and instead try to align with them on something that you two have in common. So it’s like, all right, regardless of what’s causing this you’re here to get better. So it’s help you do that.