As mentioned before, the path is very long for a FMG to get into an American residency program, often the end result of a process that can take anywhere between 3 and 7 years. Most FMGs enjoy tremendously the training period. Even if they have completed a residency in surgery before, they treasure the teaching in pre- and post-operative care, the multi-disciplinary approach to the care of the patient, the progressive independency in the operating room, the evolving role as teachers for those who come after them. There is no question that at the beginning of the training the FMGs feel a sense of pressure, the need to prove to themselves and the people that put their trust in them that it was not a mistake. The completion of training brings a unique sense of relief, the realization that it was possible to function at the same level as an American medical graduate and succeed in a different system.

As the end of the residency gets closer, however, the FMG has to make an important decision, something that has a tremendous impact in his/her future, both personally and professionally. It is the difficult choice between securing a job in the US and starting a path toward citizenship versus going back to the country of origin. Clearly it is a balance between different powerful forces. On one side, there is the realization that working in the US is very gratifying. As shown by the example of others who have reached the pinnacle of American surgery, the US system allows the individual to reach his/her full potential and be rewarded for hard and high quality work. Along with the professional satisfaction there is the certainty of an economically safe life, with the possibility of providing opportunities and an education to their own children, something often not possible in their country of origin. On the other hand, there is the realization that staying in the US means to be away from family, friends, habits, and life style as it was. In a way, it depends on the degree of assimilation that has occurred during the years of training. Some FMGs have chosen integration, the conscious decision to accept different rules as a need to function in a culture different from their own, a culture that is not embraced, with preservation of their own values. This is typified by the FMG that goes home after work and spend time only with members of his/her own cultural group, speaking the language of their childhood, trying to raise his/her own children if they were not in the US. In such a situation the individual feels a tremendous pressure and lives a dichotomous life, American while at work, foreigner when at home. For other FMGs a slow process of assimilation occurs during training. It is based on the acceptance of new values, different beliefs, and a different life style. For a person who has only reached a state of integration, there is often the regret of “what life could have been” if he/she went back to their country of origin after completion of training in the US. However, the person who has been slowly and consciously assimilated into the US culture lives without regrets, enjoying the newly acquired status.

Clearly these different emotional situations have a very profound effect on the way the person will behave if in a position of leadership. The person who tries to hold on his/her own culture will try to impose the values and characteristics of two different worlds, often failing and creating tension in the work place environment.

In contrast, the individual fully or partially assimilated in the American system will show a leadership style that conforms to the “Anglo cluster” previously described. This person enjoys his/her acquired position and is grateful to the system, frequently trying to help others along the same difficult path.

Some of these concepts are better explained by personal examples.

I was born and raised in Catania, a town on the west coast of Sicily. After completing high school (there is no college in Italy), at age 18 I enrolled in medical school, one of 1,500 new students who aspired to become physicians. I completed medical school at the top of my class, and I was accepted in the General Surgery program at the Vittorio Emanuele II hospital in Catania. Needless to say, I was enthusiastic about this choice. I was motivated by the desire to become a competent surgeon and by the ability of making a difference in other people’s lives. The enthusiasm and the dreams, however, were short lived as I soon realized that the system was not designed to prepare one for an independent practice before age 45–50. The Chairman of the Department of Surgery performed all the difficult cases, leaving very little to other faculty members and residents. Interestingly, he had trained in the United States where he had enjoyed very much the educational system. Back in Sicily, however, he felt he could not change the culture of the place and went back to the dictatorial and autocratic system that he had left (please note that I always refer to male figures as there were no female faculty or female residents). There was no formal mentoring or teaching, and we mostly learned by observing, reading, and performing simple cases. Needless to say, I soon became disillusioned and I looked for a way to escape this reality. This presented in the form of a fellowship that supported research abroad. With the blessing of my Chairman, I applied and was accepted for a 1-year research position at the University of California San Francisco (UCSF). There I worked under the guidance of Lawrence W. Way and Carlos A. Pellegrini. I have to confess that the cultural shock was tremendous, and I am not only talking about the different language. Professionally, I soon realized I was in another world. Even though both Drs. Way and Pellegrini were very busy surgeons, they were always available for meetings during which they took the time to teach the intricacies of research, from formulating a hypothesis to designing an experiment to test it. But what struck me even more was the way resident education was structured. Interns and junior residents were taken through simple cases, while senior and chief residents were performing complex procedures. Residents were given progressive responsibility for patient care and Chief residents managed their services and were treated as junior colleagues by the faculty. This world was present and close, but yet incredibly far away for a foreigner. One year of research became 3 years, and after passing the required examinations, I applied through the National Residency Matching Program. In June of 1986, I started all over again as an intern in General Surgery at UCSF.