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'Driving Change' panel: Advocacy, peer support among keys to Holder and Nguyagwa's success

MinnPost has assembled a panel of leadership experts and scholars, who are rotating in commenting on each of the examples of leadership profiled in our series, "Driving Change: A Lens on Leadership." Today Marcia Avner, of Avner Consulting and the U of M-Duluth, comments on aspects of leadership presented in "Ground-breaking support system creates a win-win for medically-trained immigrants, Minnesota."

The logic seems obvious: Minnesota is home to tens of thousands of refugees and immigrants. Like everyone else, they need medical care. Their ranks include doctors who understand their languages and lifestyles.

So why not enable those doctors to help provide the care and also to fill other holes in the health-care delivery system?

Obvious, maybe. But it took leadership on the part of Dr. Wilhelmina Holder and Stephen Nguyagwa for Minnesota to see it that way and for the foreign-trained doctors to meet state licensing requirement.

Indeed, those founders of the program helping foreign-trained doctors win credentials to practice in Minnesota have led on several levels, said Marcia Avner, whose company, Avner Consulting, advises clients on public-policy advocacy.

Marcia Avner
Courtesy of the MN Council of Nonprofits
Marcia Avner

Multiple forms of advocacy
"Their advocacy takes multiple forms," she said. "They are advocating collectively for access to the system. They also are advocating for and with individuals ...  supporting them and preparing them and staying connected with them as they navigate the system and seek the opportunities."

At the same time, she said, they are advocating for Minnesota to recognize that foreign-trained doctors arrive with talents and cultural knowledge that precisely fit urgent medical needs.

Take the practical example offered by Mimi Oo, the Burmese-trained physician who recently replaced Nguyagwa as program coordinator for the African & American Friendship Association for Cooperation & Development.

A Burmese patient comes to a clinic with high blood pressure. A typical Minnesota-trained doctor asks through an interpreter, "Have you been adding salt to your diet?" The patients' honest answer is "No." But the doctor had unknowingly asked the wrong question. A Burmese-trained doctor would know to ask whether the patient had been eating salt-laden fried fish paste.

"If you don't understand culture, ceremony, food practices and food preferences, how would you know what to even ask about the cause of the problem or lifestyle modifications that will improve a person's health?" Avner asked.

Dr. Wilhelmina Holder
MinnPost/Sharon Schmickle
Dr. Wilhelmina Holder

Beyond cultural divides, Holder and Nguyagwa also led the state to see how these newcomers could help relieve a shortage of doctors practicing family medicine, especially in rural areas.

"We need these people in our health-care system," Avner said. "We have a structural work-force shortage of certain trained, experienced professionals in health care in this country. …We should be welcoming and inviting them."

From personal need to collective action
It was no surprise to Avner that the leadership in this example rose from personal experience. Holder, a physician from Liberia, was unable to land the residency she needed to practice medicine in Minnesota. Nguyagwa, a physical therapist from Kenya, couldn't get the required credentials to treat patients here.

"Nonprofit organizations and associations form in a variety of ways, but almost invariably they grow out of a need and a passion," said Avner, who is a Senior Fellow at the Minnesota Council of Nonprofits. She also is on the faculty of the Masters in Advocacy and Political Leadership Program at University of Minnesota-Duluth. 

Individuals who are frustrated by an unmet need often will find like-minded others and begin to exercise the power of collective action, she said.

"They start out with informal discussions and collaborations and then recognize the ability to come together sometimes more formally and to build a sustainable effort to address the problem," she said.

Doctors should be particularly effective with that strategy because they are well educated and many come here with vast experience, she said.

At the same time, she said, they are wise enough to respect Minnesota's medical standards.

"They don't deny that credentialing is important, and that they need to demonstrate that they know what they need to know," she said.

Walking together
One effective leadership strategy deployed by Holder and Nguyagwa was to organize peer support among doctors who had come from around the world and were strangers to one another as well as to Minnesota.

"It's critical," Avner said. "Psychology tells us that one of the most toxic things that can happen to a person is isolation."

The isolation could be particularly chilling, she said, for newcomers who are taken by surprise to realize how difficult it will be to practice their professions here in Minnesota.

But mutual support — especially when the group includes some people who have successfully navigated the system — creates a sense of strength in numbers at the same time it fosters the sharing of practical information.

"To encourage one another — to walk together, if you will — makes an enormous difference to the individuals," Avner said.

Stephen Nguyagwa
MinnPost/Sharon Schmickle
Stephen Nguyagwa

Leveraging strength and courage
Under the association's guidance, dozens of doctors have passed the three rigorous exams required in Minnesota. And 20 or so have won residency slots.

Had they acted individually, very few could have broken down the barriers, Avner said.

"Having peer mentors makes an enormous difference," she said. "Certainly, when the changes you are working toward come with a steep learning curve about systems and points of entry, it is critical."

By bringing the foreign-trained doctors together, Holder and Nguyagwa leveraged not only strength, but courage too.

"They use their collective capacity in a way that is strong and courageous and appropriate," Avner said. "They are not asking for a handout or even a hand up. They are asking for access to provide needed services to which they bring a wealth of expertise. I really see it as coming to the table saying, ‘There is added value here. Let's try to figure out how to make it work. Don't shut us out.' "

Coming not to be helped, but to contribute
Indeed, Nguyagwa insisted that the foreign-trained doctors see themselves as professionals and leaders. He said, "They are coming not to be helped, but they are coming to contribute."

It was a wise approach, Avner said, to emphasize that they are potential assets to their communities — particularly at a time when the United States is wrestling with questions about immigrants and refugees.

"There is a potential to operate from a position of weakness because there are language barriers and there are people who may not be welcoming," she said. "That could be debilitating."

Nguyagwa resisted the common tendency to take on the role of a victim, Avner said, and instead emphasized: "We were leaders in our home country. We are leaders in our field of professional expertise. We are leaders in our communities here."

Even so, it was bold for a relatively few refugee doctors to take on the mighty medical system, to knock on doors in Minnesota and insist: We are doctors. We want to heal people. Let us in.

"I don't interpret that as arrogance," Avner said. "There is a potential mutual benefit here."

Not an easy tradeoff
On the other hand, she said, it was appropriate for the established medical community to weigh the tradeoffs involved in opening some of the limited residency positions to foreign-trained doctors. It's not an easy tradeoff.

What Holder and Nguyagwa have done is opened minds to considering that tradeoff and recognizing the potential for foreign-trained doctors to fill important unmet needs in Minnesota.

"They have a legitimate value that they bring to the community, and they have a right to say that they should be treated fairly," Avner said. "I personally think that when needs are significant and opportunities are being curbed, it is not a time for shy people."

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