By: Reilly Wilson, administrative assistant, department of pediatrics
The road to becoming a physician is widely regarded as a difficult career path. For most, the choice to be a doctor requires almost 21 consecutive years of schooling, exams, several years of residency, possibly a fellowship, and all the intricate steps in-between to finally join the ranks of one of the most respected professions in the world. For married couple Jorge Gonzales, MD, and Maria Gamarra, MD, two international medical graduates (IMGs) completing their pediatrics residency at Indiana University School of Medicine, those challenges were exacerbated while studying and working in a second language, adapting to the customs and culture of a new country, and leaving their families to pursue their goals. Despite myriads of difficulties, this couple has persevered, thanks in part to the support of their family back home and of each other.
Gamarra and Gonzales first met in 2008 on their first day of medical school at Universidad Peruana Cayetano Heredia in Lima, Peru, though they didn’t begin dating until after they graduated in 2016. Together, they went through the simultaneously challenging and formative process. Prior to attending university, they each made the tough decision to jump straight into medical school. Unlike the traditional American system of higher learning, where students first attend undergraduate programs then attend medical school, Peruvian students who wish to become doctors begin medical school upon completing high school.
“It takes a lot of commitment if you want to go to med school in Peru…it’s a big decision for a 17, 18-year-old student to decide if they want to be a doctor eight years from now,” Gonzales shared. They were able to start medical school right away and had plentiful, first-hand experiences with patients and working in hospitals and clinics. As undergraduates, students in the United States have time to figure out what career path they want to pursue or change their mind if they become interested in a new field of study, but the two were fueled partially by witnessing, first-hand, the issues with the Peruvian healthcare system which was lacking funding, resources, and qualified personnel. Gonzales and Gamarra may have questioned their choice to become doctors at one point or another early on, but their decision to start medical school out of high school proved advantageous, as they each soon had first-hand experience working with patients and found a passion of serving others through medicine.
After graduating from Universidad Peruana Cayetano Heredia, medical students are required to participate in a government-run program that sends them to live and work in isolated areas of Peru that lack access to health care for a full year. Once completing the program, the medical graduate can then go on to their residency. Since Gonzales knew he would be applying to residency programs outside of Peru, he opted out of participating in the program, however, Gamarra, unsure of her plans for residency at the time, fulfilled her year-long assignment. Gamarra and Gonzales referred to this government program as SERUMS, which stands for Servicio Rural y Urbano Marginal en Salud [The Rural and Marginal Urban Health Service]. There is a high demand for medical professionals in Peru, but individuals who live beyond heavily populated areas or cities, like Lima, are unlikely to receive care they need. Thus, the government has developed this program to increase the number of medical providers in these high need communities. Gamarra served her year in a secluded jungle providing medical support to her assigned community.
“You’re in the jungle with limited resources. They see doctors as the leader. They come to you with real needs and unfortunately there is very little you can do for them,” Gonzales said. Gamarra faced many challenges that made her work all the more difficult such as a lack of clean drinking water, the local custom of bathing in a nearby river, limited services and equipment to do her job adequately, and the inherent dangers of her location. She recalled, “It is just you, your stethoscope, and some basic medicine like Tylenol or Motrin. I was their only provider and was just a recent graduate. It was very difficult, but there is a lot of need.”
Despite the dire need for such services, Gamarra and Gonzales said that the program may change or dissolve entirely due to the dangers present within these isolated communities. “Unfortunately, there are four or five people that die every year. Some communities deep in the jungle don’t welcome the doctor as part of their community. They feel they are there to endanger them,” said Gamarra. Regardless of the future of SERUMS, both Gonzales and Gamarra plan to return to Peru several times a year to volunteer in underserved communities in need of healthcare.
Gonzales already planned to do his residency in the US, but Gamarra had initially planned to continue her medical training in Spain. To get into an American residency program for international medical school graduates is a “grueling process” according to Gamarra. Gonzales agreed with Gamarra that on a global scale, the United States is viewed as one of the best countries to study medicine, but it is very difficult for international medical school graduates to get accepted. Gamarra and Gonzales explained that there are three exams that they must pass to study in the US, but Gamarra would have only needed to pass one exam to do her residency in Spain. Then there was the process of being accepted into residency programs. This is easier when you have contacts in the United States and can participate in shadowing programs or even get into rotations at a clinic or hospital. When considering the application process the exams alone require much more rigorous preparation, not to mention the expense of taking multiple exams.
Both Gamarra and Gonzales had to also overcome a language barrier to be able to read articles, textbooks, and exams that were all in English. “I learned English when I was about 10 years old, however, the lack of practice – not having someone to talk to in English – affected my fluency,” stated Gamarra, “In Jorge’s case, he learned English at 16 years old, so he didn’t have as much of a gap in his fluency.” Gonzales and Gamarra had shared some of the reasons why they decided to come to the states instead of continuing their training in Peru. There is currently not a lot of funding for Peru’s health care system, which makes finding resources or hiring appropriate staff difficult. Gamarra, during her last year of training, had to sometimes beg her coworkers to get lab results back for her patients and most of the time she found herself doing most of the clerical and housekeeping work needed to be completed, when most places in the US have many different employees that can help to accomplish these tasks, leaving the physicians to focus on the care of their patients. The couple have found during their time at IU School of Medicine that they have felt very supported by their coworkers, and that they actually “have time to become a doctor.”
When asked what led them to IU School of Medicine, Gonzales stated that he was the first to start applying to residency programs since he was one year ahead of Gamarra. After speaking with fellow students to see where they were planning on interviewing or applying, Gonzales heard someone mention the IU School of Medicine. “I applied all over the map [of the United States] and I had never heard of the IU School of Medicine.” Gonzales had interviewed at other programs in New York City and Chicago because those schools and communities were generally more accepting of international students and had more diverse cultures. After researching the IU School of Medicine, Gonzales was told about another IMG that had found his way to IU School of Medicine from Peru.
“Someone mentioned there was a doctor here from our med school [in Peru] that has been working here in the Pediatric ICU for a while, Dr. Alvaro Tori.” Gonzales emailed Tori to hear his thoughts on IU School of Medicine and to potentially do a clinical rotation in the states to observe fellow residents. Despite not accepting students to observe, Tori encouraged Gonzales to apply to the program. Gamarra and Gonzales, wanting to stay together, both came to IU School of Medicine once Gonzales interviewed and was accepted. “Everyone from the Pediatrics program was so encouraging and sincere, and they weren’t overselling themselves. And now that we are here, I don’t feel that I was told something that it’s not, which made my decision really easy,” said Gonzales.
As Gonzales started his residency program, Gamarra looked for opportunities to work some rotations and gain experience before she applied to residency programs. “I applied very broadly and was open to any possibilities. Fortunately, they [IU School of Medicine] knew about me since Jorge and I were together, and they knew I wanted to do pediatrics, so they gave me an opportunity to do an observership at Methodist Hospital’s NICU. I was able to see how things work and how people get along with each other because your work environment is important,” Gamarra expressed. Gamarra’s observership allowed her to gain some experience and work on building connections with providers. “I interviewed in New York and Texas,” exclaimed Gamarra, “I really liked Texas because of course there is more Spanish population and it felt more familiar there, but IU’s program and having him [Gonzales] made me decide to stay here, which made the decision easier for me.”
The couple had no idea what to expect from Indianapolis, but it is strikingly different from Lima, Peru. Latin and American cultures have many differences, but Lima has a population of ten million people compared to Indianapolis’ roughly 864,000, which added to the culture shock. “I was surprised by the amount of Spanish speakers here in Indianapolis. Since Chicago is so expensive, Indiana or Indianapolis has become a new hub for Hispanics to come to. I’ve really enjoyed working with this population,” Gonzales alleged, “Indiana was a good change of pace. You can walk and there isn’t a lot of noise outside. It’s a very laid-back city and everyone in the program was so nice.”
Gamarra appreciates the friendly nature of the community. “People in Peru are nice, but there is a lot of violence and insecurity in Lima. We aren’t encouraged to talk to strangers because you are afraid someone will rob you from behind,” Gamarra shared. Gonzales and Gamarra laughed as they shared how there is a lack of diversity when it comes to the population as well as the food here in Indianapolis. “The biggest challenge was the cuisine. I would say that is what I miss the most outside of my family. There is no place to find true Peruvian food,” Gonzales said through his laugh. The cold weather and public transportation were also discussed. “The other thing that was a shock was the weather. We never have snow in Lima,” Gonzales stated, “The coldest it gets in the winter is probably 60 degrees!” Gamarra continued, “Another thing is in Peru we don’t drive so we don’t know how to drive. In Lima we never had the need to because it [public transportation] can take you everywhere.” Gamarra and Gonzales both currently live downtown so that they can easily get to and from campus and are both working on getting their licenses. “We are working on getting our licenses so we can discover new places around here and move around a little bit more,” said Gamarra.
Aside from adapting to American culture and working through their residency program, Gamarra and Gonzales opened up about the difficulties on not seeing their friends and family back in Peru. Typically, they can use their vacation time to go see their families, but with Peru currently being shut down due to COVID-19, Gonzales and Gamarra were unable to return home. Gonzales and Gamarra shared that both of their families are currently healthy, and they are both able to Skype and call their family on a regular basis. They would like to return to Peru once a year and have a spare bedroom for their parents to come visit them here in the US. COVID-19 has also affected their time at the IU School of Medicine. Gamarra shared, “Jorge probably has a better comparison because he had a whole year without COVID and now he is doing his second year with COVID. I feel like it has affected our learning so that means for us that we don’t round together anymore on all of the patients. That is the time and space when you learn the most. You get to hear everyone’s perspective and we aren’t having that anymore due to social distancing.” Gamarra and Gonzales have seen a significant increase in COVID-related cases within their pediatric patients, which has limited their exposure to other patients with infections such as the flu or viral bronchiolitis. Everyone is exhausted from the adjustments that have to be made due to COVID-19, but Gonzales and Gamarra are hoping that the field of medicine will return to some type of normalcy so they can have that collaboration with other residents and providers, and gain the experience they need treating all kinds of different ailments.
Gonzales and Gamarra shared the difficulties they faced, but never once made it seem like they did not appreciate all the experience that they accumulated on the way. Both acknowledged that they have faced hardships but used their positive outlooks and support of one another to overcome them. “It [their relationship] has definitely helped, 100%. I would feel so lonely here. We have friends in residency, but they usually have their own families or family around and they are working a lot. Having him with me makes this transition a lot easier. There is somebody else who understands what it means to be here coming from Peru,” stated Gamarra, “It feels a little more like home with him here.” Both praised IU School of Medicine for accepting them and treating them so well. “The program has been so welcoming. I feel that they’ve opened up to IMGs coming to IU. I feel the program is now actively trying to recruit people from other places. I feel that is a highlight of our time here, to see that change for the better,” Gonzales said, “We are happy in our program. We are surrounded by a group of people that care about us and want us to thrive, not just as doctors, but people.”
The next steps for Gonzales and Gamarra are to return to Peru sometime soon to celebrate their marriage with their family. The couple were married back in August of 2019, but their plans to return to their home country were delayed due to COVID. Upon completing their residencies, Gamarra and Gonzales also aspire to establish practices here in the states because they feel that there are more opportunities to participate in global health initiatives, which is something the two are passionate about being international medical students and knowing first-hand how much help is needed in other countries, especially Peru.