Episode 25: Trials and Tribulations of Foreign Trained Physical Therapists

Richard: So welcome back to Agile&Me a PT leadership podcast series. Today I’m excited to talk to Anal Shah , a licensed physical therapist who, like myself, is a foreign trained physiotherapist or physical therapist. So welcome!

Anal: Thank you Richard, for having me here.

Richard: It's going to be a great chat. So, the title of today's podcast is trials and tribulations of being a foreign trained therapist. Before we go into our stories, I’d love the listeners to perhaps know a little bit about your background and clinical experience.

Anal: I did my entry level Bachelor of Physical Therapy, which is 4.5 years of course in India, after 12th standard. I was working for three years before coming to states in all the settings. The patient is home health and inpatient specifically with ventilator dependent patients. After coming here, I also have done a transitional doctorate in physical therapy.

Richard: That's interesting. It's funny, the training, I believe it is very similar to training in England. I trained for a bachelor's degree as well as a bachelor's equivalent. You mentioned working as a respiratory therapist and again in England we served a dual role is as a physical therapist and has that skill set. In fact, I worked in intensive care for a year as well. So, I never realized you did.

Anal: It was fun experience for me. I still miss it here!

Richard: Yeah, absolutely. So, I'm sure you had, as I say, trials and tribulations for moving and working in the U S and I've known, I've got a couple of funny stories that, I'm sure. Would you be able to perhaps give me an idea about your experience as it pertains to trying to seek verification of credentials because there's really two parts? Aren't there any jobs in the states? One is the credentials’ part and then one is the, is the kind of the visa and you know, I'd love to tackle both of those. Do you have anything you can kind of tell me about your experience with verification of your foreign credentials?

Anal: It's very lengthy procedure, as you know. So, my journey in the state started 10 years ago. I moved here after getting married with my husband and I started preparing for my license exam. I had applied from New York state to ask for any prerequisite credits at that time. I worked hard and cleared the examination. I thought the hard part is over because NPT, our license exam is a tough one for, for foreign trained physical therapists. As a passing rate for non-use strain, PT is around. 30 to 40%. My real journey began after that. I needed certain credits to apply for a state license to FCP I started searching for different ways to gather credits and one of them was giving clap, which stands for college level examination program. I may have given number of claps to get the credits because they vary and one to four credits. It was another requirement with very specific scores in all four sections. So that was challenging, and it took few attempts for me to get the exact score. I sent an application to have some sensibility and they generally take six to eight weeks to get back to us. And my fingers were crossed. My report came back with few deficiencies, and I had to take more courses, exams to fulfill. One of the professional credits I took it, it was from Philippines. And that wasn't very interesting experience because they were in different time zone, and they were a little bit laid back. They were not replying to our emails or phone calls. So, at some point me and my husband gave up the hope that, okay, I think this might not be the right thing or so, but eventually professors contacted and everything all then they'll after that. So, I fulfilled all the credits and finally reimbursed my license kind of from New York.

Richard: Yeah. It's crazy. I hearing you talk, I've got some funny stories and again, it would mirror a very closely, so. I had to do additional courses. In fact, I got my credentials looked at twice first when I first came to the states and then a second time back, 10 years later when I wanted additional licenses. And one of the stories is basically the credentialing requirements changed in those 10 years. So, when I had first credentials checked. I was eligible and then in those 10 years they moved the goalposts. So, I became ineligible for credentialing as a foreign trained therapist, which was bizarre given the fact I'd worked in the states for 10 years. And the, sorry, the thing that I was ineligible for, I had to do certain courses like you. And one of them was humanity. Needed a credit hour in humanities, quite how that helps the professional. I have no idea, but I ended up having to do an either testing out, which was a clap, as you say, or taking a humanity. So, you know, I ended up thankfully take testing out using the clap, but that was amusing because the humanity in the US is very different than the humanities that is taught in the, in the UK. Plus, the fact, obviously it was a few years ago since I went to school. So, you know, I'm sure you, thought yourself at the time with various courses, what is the point of this? How does this. The clinician, I'm sure that went through your mind occasionally. Yes.

Anal: Because I took biologic physiologic, like very basic anatomic courses and ethics was one of them. That was funny because I studied from seven-day Adventist college and ethics was part of my syllabus, but they still didn't consider that I studied for one year. They want it from here.

Richard: Credits don't transfer and more bizarre story you mentioned having to take TEFL Tinder English as a foreign language. Well, I remember recently playing for my Kansas life. And as being a foreign trained therapist they requisite was I had to take my TEFL and I rang them up for the state board and said, this is a rather strange and bizarre asking in English trained therapists, trained to take an English as a foreign language to. And they, they kind of somewhat acquiesced. So, what I had to do, or they asked me to do was get my school of physical therapy in the UK to write to the state board saying that my PT course was taught in English. So that's just another example of the. Stupidity associated with these kinds of prerequisites, isn't

Anal: Yeah, I haven't. That was very strange. They're asking.

Richard: I kind of almost gave up during the process because I think it took me in total about 14 months to get credentials checked and sit for the examination and achieve licensure. You know, it seemed to be quite a long road for you.

Anal: Yeah. So, it was a long journey. And you feel like you want to give up at some point because you don't see the light at the end of the tunnel, because one thing after another and the rules keep changing from state to state, it's like, oh yeah. When bill you, and you feel at the end of the day. So yeah, that was a little bit tough road.

Richard: I remember sitting the examination and I spent a reasonable amount of time training and know. I'm sure like yourself, you know, have several academic qualifications and I have four degrees, but that wasn't really and a lot of post-graduate education as a physio therapist. I had a little trepidation as I'm sure you did with the gods, the licensure exam, but what was strange to me was the questions in the licensure exam. 20 years ago, when I took the examination, I used textbooks that were published in the 1960s because the content of the examination was. What I would say somewhat out of date compared to current practice. Did you think that, or what was your perception of the licensure examination?

Anal: So, for me, license exam was tough because it was more rational versus what I taught. It'll be easier since you know, I graduated in 2008 and I'm here after four years of practice. But I was wrong. The questions were big. You feel like a hundred questions, hundred different patients’ scenario you are dealing with. So, I had to prepare a lot because. I had my friends, seniors who had to give two, three times, and I had decided I'm not going that route. So, and, and thing, thanks to my husband. He had me prepared very well, as well as like, okay, do this these days. And I think having someone to talk with and having, I had a study buddy, so those kinds of. Co-factors helped me a lot and I remember before a week, my whole house was full of sticky notes. Everywhere I go. I see something. So yeah, I had to prepare a little bit hard.

Richard: Well, you did a great joke. The foreign trained therapist there isn't that much help out there is that for, What I'd like to do, perhaps is move on a little bit from the trials of the trying to get to vote, prepare for the state license credentialing and perhaps move to the employment side, because there were significant difficulties with, as we mentioned, credentialing and then licensed share. And then that was really. Only half the story for me, the other half was obtaining or finding a position. I found personally that as a foreign trained therapist, either employers dismissed out of hand or were unwilling to you know, take the extra steps to employ a foreign therapy. Can you tell me a little bit about your experience, whether it's like me or whether you have an easy time finding a business?

Anal: No, that was an interesting story. I used to live in Louisville, Kentucky at that time of the requirement for the PT license for Kentucky state is to have an SSN. But since I was on dependent visa, which is after two, I cannot have a citizen. So, I wasn't a wishy of circle. It's like, I can't have a job that belt license and I cannot have vice versa. So, I started looking for the state who were agreeing for PDL license without SSN and Michigan and New York were on my list. And for H1B, which is a sponsored visa to work here. There are two ways to get one through from private company and the other is through the non-profit and for-profit company. There's a lottery system, which is like a computer generated. Your chances of getting picked as one into four. But luckily, I found an employer from New York who sponsored me, but I was not lucky enough. No, I didn't get selected in my than co computer-generated system. So, I was very disappointed and frustrated because after going through all the credentialing process and I still don't have a job. But I didn't get up and started applying to all non-profit organizations in both the states every single day. And fortunately, I got hired by one of the hospitals in Ironwood, Michigan in upper peninsula. A bold move from my side, because I grew up in India, tropical country, and I have never seen snow. So, but I wanted to just get started somehow and start treating patients. So, I accepted the job.

Richard: Yes, it's crazy. Isn't it? You know, what, what blows me away. You have qualifications checked, you get licensed here and then they don't tell you that. Congratulations, you can work here, but you can't have a job. Being difficult, nobody really wants. To employ you as a forum therapist. And I don't think it really matters where you trained as a forum therapist, you are kind of categorized in the same way. And you know I came with an H1B. I met my wife, but we weren't married at the time. And didn't see it necessary to get married, to work. I wanted to do it in my own. Right. But as an H1B I struggled with what surprises me somewhat is there such a shortage of physical therapists in this country, but they continue to limit quite significantly the number that can have a work permit or visa regardless of the type of visa that might be. Have you It is. Do you believe that that's kind of accurate near affects the situation? I don't know if you have colleagues or friends that have gone down this route as well and experienced what we've experienced?

Anal: Oh, I hundred percent agree. I think that they are trying to limit the non us train PTs, as I feel like they must find placements for us train PTs first. And you're right. Very many of my friends they're still back in India wants to come here, but they think it twice before applying because they know the process is very lengthy and requires big chunk of money. So, at the end of the day, you always think, is it all worth going to hassle because you always must balance your professional life and personal life. So, yeah, I, I believe the system is, is a little bit off. Hiccup on the road.

Richard: Yes. As an employer, as a leader myself, I get very frustrated where we have open positions and, you know, I know that globally, there are plenty of therapists that would like to come and work here and from a competency perspective, extremely competent. So, I think there, there is obviously some. I would assume some sort of perception that foreign trained therapists are not sufficiently trained, which. Again, upsets me and surprises me because whilst I wouldn't say foreign therapists or any back to the U S therapist, I would certainly say that foreign therapists are as good. You know, the way that they get trained is slightly differently, but from the skill set perspective, many of the best therapists in the world certainly foreign trained and not us therapists something.

Anal: Yeah, I would have to agree. Yeah. And, and you can always train a person whose foundation is strong. So, I totally believe a person from any country. If the foundation is strong, they should be hired here.

Richard: Yes. I'd like to touch on is the idea of DEI as well as diversity, equality, and inclusion. I believe that if there were more foreign trained therapists, more differences in perspective and treatment approaches could only help the profession, I think would admit I, I believe that, you know, we're myopic here in many respects of how we treat and the tools that we use. What I mean by tools is kind of skill sets compared to other countries.

Anal: Yes. It would bring cultural diversity to the clinic because every country has something different, even though we always operate from the same foundation, but. I always try to learn something from everybody. So, it will be helpful even for us a PT industry to bring them onboard by just easing up some regulations.

Richard: I'd love to get a little bit of your experience. You worked several years. Before coming to the states like I did the practice acts were very different. So, what I could do in the US was very different than what I was allowed to do in the UK. So, for instance, in the UK, I could manipulate in the UK, I could inject quarter corticosteroid in the UK, I could prescribe. Basic medications. We had direct access since 1970s, mid 1970s. I was able to use dry needling and we are allowed to call it acupuncture as well, obviously. Postgraduate training for those things. But, you know, 20 years ago, coming to the states, none of those things were really you're allowed to do so. I felt as if I was, I was constrained and how I could treat patients now it's changed somewhat since then. But did you find that how you treated patients and the skill set you're allowed to use was different than how you were trained?

Anal: Yeah, it's similar story. We are not allowed, or we don't give a. Physical therapist, but yeah. Other than that, VSV are allowed to prescribe certain medication because. The industry is a little bit different. We don't have much restriction on over the counter versus behind the counter medications. So, it was a little bit of ease. So, we don't have to ask doctor to prescribe a tapered down steroid course, you know, to accelerate a recovery process. So that was an ease in the system.

Richard: I think the one of the key differences was working in a national health service in England. As a therapist, I felt as if I was. And an equal of equal importance within the collaborative health care team in which I worked. And so, I didn't feel that there was this so much of a hierarchy as in the US I felt that my contribution was valued equally, and my skillset loose was used. And an example, obviously, as the. Direct taxes 30 year, 20, 30 years ago. Did you find that as a therapist in the U S you, I wouldn't say a second-class citizen, but certainly you know, there was a place and that place was not one of equality, shall I say?

Anal: I agree. Over there. We were on the front seat. I feel like, yeah, we are in the back seat, even for a simple Walker or braces or anything. If we must reimburse WIA insurance company over here, we must ask doctor and half of the time physicians didn't know. Even know, or they're not aware of what we have written. They, they sign off and, and insurance company will agree. So I feel a little bit we are in the back burner at some point. We should be treated a little bit equality.

Richard: I don't get me wrong, but it just seems to be significantly behind other countries. So, I think we'll get that of insurance companies’ pharmaceutical companies and physicians I think don't necessarily help us do as a profession. Moving on. I know we've mentioned how tough it was to get a job in the beginning. For me I was very lucky to get a position sponsor me worked for a physician dome practice for a neurologist in Detroit area in the beginning. But. You know, we can, we can say that employers are somewhat of full of regards to not considering foreign trained therapists, but you know, to defend employers. It certainly isn't easy for employers. The government and bureaucracy involved with employing somebody on a visa is significant and there's an additional cost for, and risk associated with 70 with the H1B. But that's not to say that I think employers should just dismiss foreign trained therapist Y and if you have the chance to talk to, to therapy leaders, what would you say to them? As it pertains to why they should consider foreign trained therapists, even, even if there are the additional risks and costs associated, what Y what would you do to encourage them to consider foreign trained therapists?

Anal: I would vouch to have higher foreign trained physical therapists, because I think they work harder to prove they're placing they have more drive to prove themselves that because the company's investing in them and they need of course better results. Also, the brain different cultural diversity to the company. Because they're of course coming from their home countries with their different set of trainings. And I think they are not afraid of any challenges. cause they know once you leave the country, you are up against anything. So, for example, I feel like EMR was not part of my training at all. That was very surprising add on to my journey and still. You know, I learned and have more my way in a way that it helps us now, because back then, Outpatient patient practice was just a piece of document where a patient's name was there. What body part we are treating, and person paid or not a detailed evaluation setting. Long-term short-term goals were not part of that. My daily routine. Even though I was in the same outpatient setting, but we, we are up against the challenges, and I think that, that helps that mindset. That if, if we are slammed, we'll, we'll get through this or it's like never, ever. Kind of policy. And we were trained over there. It's like, we always say, it's my family physician or, oh, that's my kids' pediatrician. We all at school to him. So why not? We create some rapport with the patient. Beach people say that she's my family physical therapist. So, I, I think everybody has an asset. They, they bring different things on the table and I, I would, yeah, I would bring some other foreign PDs onboard for that reason.

Richard: Yeah, interesting. I was asked the question I would probably add as well, the, the idea that. If you have a diversity of clinicians, then I think that allows you to effectively treat a diverse patient population as well. I don't necessarily believe. If you don't have diversity in, in your healthcare team, then how can you, how can you really manage successfully the great diversity of your patient population? So, I think that's important. The other thing that I, I think we bring to the table as foreign therapists is that. Certainly, looking back to how I was trained when I was trained and imagine you're probably very similar. We did approximately 2000 clinical hours during the training, and I know that Pete USP T schools. When they qualify, they've done significantly less than 2000 hours. Not only that, but we had to rotate through many sub-specialties before we could really start to specialize. And even when we specialize, we couldn’t say we were a specialist until we spent five years in any one specific. Area within PT. So, I think we were much around, more rounded. We had a much more clinical hours in the clinic hours we had were, were across many more sub-specialties. So, I believe we are much more rounded as a clinician, which helped me as a, as an outpatient therapist, is that like to what happened.

Anal: yes. And more rounded experience, as you say, it's like, we were doing a lot of duties at, at same point in the clinics or sometimes Front desk person sometimes you are an aid. And we don't have a PT assistant category over there. So yeah, we were doing a lot of job at some point w like one-man army and, and that helped you to see different perspective from if I must think my, how to. Be in the, my FOCs, my front office person's shoes right now. I would be more empathetic that, okay. Yes. She, her hands are full. Let me give a doctor a call doctor's office called myself. And that helps you. Things from a different person's different angles. So yeah, it does help. Yeah.

Richard: I'd love to know what you found either difficult or strange. Oh, just unusual when you started in your first job. So, for instance, when I started, the thing that I found completely bizarre was the concept of, of billing based on units. Obviously in England, healthcare is, is funded directly by the government. So, there’s, no, it doesn't work in, in. Similar manner and I found it strange that I would apply a charge to two unit, so that that's, that's probably, for me it was a big learning curve and, and trying to understand the billing component. I'd love to perhaps know what, what stood out to you when you started working in the U S.

Anal: Oh, that was a big cultural shock for me to begin with. I would say funny story. I started while entry observation while I was working on my, all this credentialing process. I, I couldn't stay home. So, I just follow a couple of PTs in Louisville, Kentucky. And my first day my clinical instructor, she asked me, can you get Bob our next patient, please? And. If I'm not wrong, her, his name is Robert. You mean? It's like, oh, Robert goes by Bob. And then my journey started like, okay Lawrence go by Larry. And it's like, okay, that's. That was the first thing. And then the EMR was a twist and then. On top of this insurance authorization and pre-approval from insurance companies, everything was overwhelming for me because in India, its patient controlled because most of the time patients pay out of their pocket for the. Process. So, they, they decide like, okay, I would like to continue a couple more sessions or not or turn down the frequency. So, everything was very new to me that okay. Insurance company agreed just eight visits and unit to help that patient in eight visits. I would like to, but we are not magician. So, one funny thing was one of the insurances for one of my patients. They agreed only for evaluation. And I cannot treat in the first visit. So, everything was very surprising for me in the beginning. It took time to process and go with the floor situation. Yeah.

Richard: Yeah. There are many examples that just don't make sense. And you've highlighted a few of those, you know, from a clinical perspective, it just makes no sense. And, you know one can get frustrated, and I did get frustrated a lot when I first came to the states, but really. That's not to say you accept it, but suddenly you must work within the parameters. Otherwise, you drive yourself mad.

Anal: Yeah. Yeah. It's very frustrating. In every single day, I feel like I can sit for an hour with the insurance company, or I just give up. So, it's like, there was no options for me, but you want to help patients, but your hands are tied.

Richard: Yes, time is taking on a little bit. I think probably the, the, the last major question I would probably ask is we have people from abroad that listened to this podcast a few, and, I'm sure. One or two listeners either themselves or they have friends that may be considering the idea of working abroad or working in the U S I know that I have colleagues that teach in the UK, and they occasionally have students that ask about the U S what advice perhaps would you have for anyone that's trying or considering the idea. Of seeking to work in the U S as a physical therapist.

Anal: I would say success is a marathon, not a sprint. So, keep running until you reach your goal. I think with, even though the processes Lang you, you feel frustrated meanwhile until you reach you. American dream, I should say, but it's all worth it at the end of the day, because after treating a couple patients every single day, it's, it's very rewarding. Eh, yeah, you, you will shine if you work hard, and all your hard work will never go off. So, if you are considering coming and working here, it's, it's really, nice and acceptable.  I have never come across any, anything, which I would say I want to go back or so I, I should say yes. They should give it a chance. Just have a companion with you who stays with you for all the time talk to your seniors or friends who has gone, gone through the same process so that you can talk them through. I'm sure the rules are changing every day but hearing them we'll help you know to go forward. So yeah,

Richard: I think it's The concept of being patient, I think is crucial. So, thank you. And then I think the other thing is just be prepared to take some additional courses. So, this one's foreign credentials, qualifications are very unlikely to match for what you need. Aren't they? That you're going to have to take further education and it's going to be a cost associated with that. And that's probably the first gating item to get your credential kind of lined up with the US, isn't it?

Anal: Yes. I agree. Being patient is a virtue

Richard: I don't have much. And then finally I. I always ask my guests what they think of the future of the profession. So, overall I know those challenges and, but I I'm pretty bullish overall as a foreign trained therapist. How would you see the future of therapy within the U S what's your thoughts?

Anal: Oh, interesting question. Future is bright. I'm seeing into different directions since COVID hit us. We are seeing more white jewel inclination in the now and people are opting for that. So, it's a good thing. A second thing, I know physical therapy itself says physical, but I would still agree with the word chill. Something is better than nothing a virtual session would be. Okay. And second thing I would, I'm seeing. More artificial intelligence playing role in our system, because I think we can predict more logistics for day-to-day operation and get better results. Better outcome. More decides from an operational side and for, from outcome assessment side. So, I would like to see a little bit faster, fast forward. We have artificial intelligence role in our physical therapy world.

Richard: Yeah, preaching to the choir here, as it pertains to utilization and implementation of technology. So, I think there's so much that can be offered to help with patient care that were dirty. Just touching the surface. Aren't where that. Well, and I'll time is run out. I want to thank you very much for taking the time today to chat with me. And for me go down memory lane and some of the, some of the wounds that perhaps I

Anal: had

Richard: hope you've enjoyed this and thank you for being my guest.

Anal: Yeah, thank you so much. It was really an honor to be here with you. Thank you so much for considering and letting me share my journey with.