Giving people a chance: Foreign-trained physicians in CDI
by Carolyn Riel
While many people from bedside nursing and coding fields choose to enter the realm of CDI later on in their careers, foreign-trained physicians are often drawn into the world of CDI because of the difficulty getting a license to practice medicine in the United States.
“The funny thing is, no matter where you’re coming from, it’s the same medicine and really nothing is different, but there is a system here where to be licensed to practice you have to go through a residency and take the boards, but it’s competitive because you have U.S. graduates as well and only so many programs,” says Chinedum Mogbo, MBBS, MSHIM, RHIA, CDIP, CCDS, CCS, manager of CDI at Tenet Healthcare in Dallas, Texas, and a foreign-trained physician who immigrated from Nigeria.
Because Nigeria and West Africa were colonized by the British, Mogbo could have gone to Britain and immediately been able to practice as a full-fledged physician; the United States, however, makes foreign-trained physicians go through the full process starting from the beginning.
“It also gets to be expensive because you pay to apply to residency programs. You could spend thousands of dollars to apply anywhere and everywhere just trying to get into a program,” Mogbo says. “Some people are lucky and come in and get into programs, but some of us try and get frustrated.”
Though transitioning to a physician position in the United States after receiving schooling elsewhere is difficult, Mogbo says the beauty of the country is that it allows foreign medical school graduates to use their knowledge in other ways.
“Where I come from, there’s a one-track mind of everyone needing to be a lawyer, an engineer, or doctor,” she says. “If you come to the U.S. with that mindset, you won’t succeed. I found CDI as a way of indirectly practicing medicine (though administratively) by utilizing my knowledge without patient care and making an actual difference.”
When coming to the United States, Mogbo says she had no prior training in CDI and was not sure what it was. Nigeria’s payment system is different than that of the United States, and without the prevalence of payers and Medicare regulation, CDI wasn’t as prominent there. After trying to join the physician ranks in the United States, Mogbo stumbled into CDI.
“I was lucky that the system I found was run by a physician who was picking out foreign-trained physicians because he knew the challenges of being foreign-trained and getting into residency programs with the goal to obtain the license to practice in the United States,” she says. At this organization, Mogbo entered a coding and auditing role where she looked through records, which opened the path to CDI. “Though we were formally trained in coding and obtained the necessary certifications, I didn’t need to be a coder to get into the CDI space. I already had the background and mindset of what a CDI role requires, so CDI came naturally after that.”
Aside from having to face a new system for acquiring a license to practice, foreign-trained physicians might be met with a slew of struggles when coming to the United States. Often these struggles come in the form of discrimination or biases based on their country of origin. For Mogbo, her accent posed an obstacle at first.
“My accent is interesting because people confuse me with different things. They think I’m from Jamaica or Haiti and never quite get it right with their first guess,” she says.
Often, Mogbo receives surprised comments that she speaks English fluently, along with questions about her native language in Nigeria. “But English is my first language. Because Nigeria was colonized by the British, English is what we speak,” she says. “It’s those types of biases I’ll notice, where people assume my English will be bad simply because I have an accent they don’t recognize.”
Just because you are from another country and might have an accent or other apparent differences about you, Mogbo says that doesn’t mean you should conform to the new country to ease some of the biases directed at you. “My accent is my identity, and people have to learn that yes, it’s different, but that’s not bad,” she says. “That’s the goal.”
Instead of conforming, there may be ways to compromise without relinquishing your identity. In general, Mogbo feels the speed with which she speaks, not her accent, is why people sometimes don’t understand what she’s saying.
“I think people automatically assume that when they don’t understand me, it’s because of my accent, but really it’s because I tend to speak quickly,” she says. “I’m capable of changing my accent, but I won’t and instead will speak more slowly.”
Though Mogbo has remained positive and worked to the point of people accepting her accent, she feels there are times her immigrant status may have held her back in her career.
“When I first came into CDI, I guess I didn’t feel any setbacks initially because the company I was with had a lot of immigrants, so it was our safe space; we understood each other and there were no biases based on race or accent,” she says. “But by the time I started interacting with other people outside of my then-company/department, I realized being from another country and having an accent was something I was going to have to work through.”
Though people are not often intentionally rude about her accent, they also will not often put in an effort to understand her either. “Some people will nod, but I know they don’t hear me or understand,” Mogbo says. “That’s not outright bias, but I’ve been in those situations where I’ll think, ‘Maybe because of my [skin] color, people don’t first think I’m Nigerian and speak English and instead expect some exotic place.’ ”
Along with experiencing biases because of her accent, Mogbo says she often can tell just by the way someone is looking at her that they are passing judgment.
“There was one experience where I had a meeting with the CEO [chief executive officer] and CFO [chief financial officer] and I walked into the room, and you could tell they didn’t think it was me who they were waiting for and were expecting someone else just by the look on their faces,” she says. “And then I started speaking, and you could see their countenance change from ‘is she the one’ to ‘oh, she’s making sense.’ ”
In Mogbo’s opinion, she has been lucky that she hasn’t experienced outright bias as a foreign-trained physician, but there are subtle things that people do to show they are passing judgment. “You might have these subtle things people are doing, but if you’re confident and know your audience, that can really help change those implicit biases,” she says. “One thing I learned from my dad is self-confidence. I do not care your opinion of me as long as I am not disrespectful. This is what you got, and this is who I am.”
The most important characteristic that helps one overcome obstacles and implicit biases is self-confidence, Mogbo says.
“First of all, know yourself. I know I sound like a life coach, but I come from a family where my dad empowered me as a little girl, and that helped me a lot,” she says. “He empowered me and made me understand that you have worth and value and it doesn’t matter what other people think about you.”
Mogbo says that empowerment played a significant role in her life, and while she knows not everyone has that support, building self-confidence is an important skill. “I know people might not always be super confident or comfortable, but it’s most important to know yourself,” she says. “When you don’t know yourself or your worth, it’s easy to get bogged down by what other people say.”
When facing obstacles, whether as a foreign-trained physician or for other reasons in your career, another important factor is being able to defend yourself and your knowledge.
“You can’t just say, ‘I’m a CDI specialist.’ You have to know your specific skill set and what you’re supposed to do,” says Mogbo. “There might be a lot of people out there with credentials, but they can’t actually defend what they’re doing. Home in on your skillset and defend what you’ve learned.”
Knowing your background and how it prepares you for your current role is imperative to defending yourself in your career. In addition to leveraging your background, you need to cultivate an attitude of continuously learning. Mogbo suggests always studying and making sure you know the evidence behind your opinions, as people can tell when you are spewing nonsense and when you are actually making sense.
As for her accent and her speed of talking, Mogbo says that compromise may be warranted, but only when the other party wants to meet you partway. “When someone says they don’t understand, I have to ask myself if they truly don’t understand, or just don’t want to,” she says. “If they just don’t understand then I’ll compromise and speak more slowly, but if they just don’t want to understand then I move on and don’t let it get to me.”
Foreign-trained physicians’ value
While foreign-trained physicians are starting to find a home in CDI, they may sometimes still be met with some resistance. These folks, however, play an important role in an organization and can often serve as the bridge between CDI and physicians, ultimately improving all-important physician engagement.
“It’s important for organizations to see the skill set these people bring,” says Mogbo. “I’m not saying that other people don’t bring the same skill set, but organizations have to realize that foreign-trained physicians do as well.”
Foreign-trained physicians, as expected, think clinically, Mogbo says, and in some organizations they can interact seamlessly with physicians because of their similar training. “To CDI departments that are hiring, I would say be open-minded and see that foreign-trained physicians do bring a skillset that will help—and from my experience and my own team, they already have the core knowledge, they just need the [CDI] training,” she says. (For more information about hiring practices, read the article on p. 10.)
It is important to keep in mind that physicians coming to the United States often will not have a full understanding of U.S. payment systems, because their country of origin uses a different system. Yet while they may not have the base understanding of Medicare, Medicaid, and major insurers, that should not negate the clinical knowledge they have; it is simply a reason to develop a robust CDI training program.
“You need to be open to training them,” Mogbo says. “They already have clinical skills and critical thinking aspect of CDI, but might need to be shown how to review [a record] from a coding and CDI perspective.”
Good training on chart reviews doesn’t have to come from within the organization either, Mogbo says. Organizations like ACDIS or other outside contractors can be a great source of this training. “You have able people, you just need them to know what to look for,” she says.
In general, organizations are becoming more open to hiring people from diverse backgrounds, according to Mogbo, whether they be a foreign-trained physician or someone with a nonclinical background.
“Before you’d see a job posting looking for licensed RNs only, which is kind of interesting because why do you need that license if you’re not at the bedside, conducting direct patient care?” she says. “I’ve seen organizations become more open to different experiences.” (For more information about diverse backgrounds in CDI, read the article on p. 31.)
This increased openness to foreign medical graduates does not mean the battle for equal opportunity is over, however. “Even though I’ve seen expansion for taking in foreign-trained physicians, I’ve noticed there’s a problem with them moving up the ladder,” Mogbo says. “Not everyone is lucky enough to be given a chance, and there’s the glass ceiling they can’t seem to break through.”
When people reach out and ask for a chance at learning the CDI role, Mogbo says organizations have to be open to extending the opportunity, while keeping in mind that the new CDI staff will need training. This training typically takes anywhere from a couple of weeks to six months, but the return on investment is immeasurable.
“Physicians are like sponges, used to having to learn under tough conditions, and ACDIS helps with those trainings and the fundamentals of CDI when people need that experience,” she says. “CDI isn’t rocket science. We have to give those who want to learn the training. We have to give people who don’t ‘fit’ into our mindset mold a chance to earn and apply their skill sets, which will go underutilized if not harnessed. There is really nothing to lose, but lots to gain.”