International medical graduates (IMGs) are often deeply grateful to be matched and allowed into the system. Gratitude can be humbling, but it can also be silencing. When you feel lucky to be present, it becomes harder to ask for more – be it guidance, feedback, or opportunity.
As an IMG, no one tells you that pathology has a hidden curriculum. We arrive in a new country excited and prepared for the more obvious requirements of residency: reading Lester’s Manual of Grossing, practicing on the cryostat and solving PathDojo questions for board preparation. What we are less prepared for are the rules no one writes down.
I worked in three healthcare systems – Pakistan, Canada, and now the United States, and along the way, I learned that the hidden curriculum for IMGs is not written in Sternberg or Rosai, but in the nuances beneath the English language.
Pathology has its own dialect of polite and restrained English. “I’m not sure if the margin is actually positive” can carry very different meanings depending on who says it and how it is said. For many IMGs, the challenge is not vocabulary, but context and pronunciation. It becomes a mental exercise to pronounce a word in your head before articulating it.
“Respiratory” for example, has multiple accepted pronunciations globally, but only one that feels “right” in North America. I remember initially dreading conversations with thoracic surgeons at tumor boards and frozen sections – not because I lacked knowledge, but because I wanted to make sure I would pronounce the word correctly when I spoke. Accent becomes something you refine as time goes by, and you learn which pronunciations mark you as different.
What I had not anticipated is how much pathology depends on spoken and written English. We work with surgeons during frozen sections, oncologists at tumor boards, and clinicians who rely on us to translate microscopic findings into patient decisions. A diagnosis that is technically correct but poorly delivered can create confusion and delay care. We are expected to strike a balance between adding enough complexity to relay the diagnosis without sounding redundant or confusing. For IMGs, this adds another layer to the hidden curriculum: learning not only what to say, but how to say it with clarity.
Mentorship is another part of this curriculum, often described as something that “happens naturally”. Many IMGs come from systems where mentorship is either more formal or nonexistent. In North America, mentorship is often informal and ongoing. You are expected to find mentors and advocate for yourself while still navigating the system. Through the American Society for Clinical Pathology mentorship program, I was fortunate to be mentored by Melissa Hogan. She offered continued guidance, explaining professional norms, how interviews are conducted, and how feedback is framed.
I completed my pathology residency at Cooperman Barnabas Medical Center, a program notable for its diversity among trainees and faculty. Many of us came from different countries and training systems, and that diversity became one of the program’s greatest strengths. We learned not only from attendings, but from one another – not just about pathology, but how to exist in the new system.
We talked about how to disagree respectfully, and how to say “I don’t know” without sounding unprepared. Coming from a different culture, admitting uncertainty during medical school was often unacceptable. During consensus conferences, watching senior pathologists show intellectual humility taught me that sometimes saying “I don’t know” is not a weakness but a part of the learning curve. These were among the most important learning moments of residency.
We also learned how to navigate unfamiliar foods and social norms. Many of us carried small accommodations with us. I kept extra chili flakes in my bag, a way to make unfamiliar food feel familiar and a small act of comfort during long days. We were all accustomed to instant coffee and many of us kept jars of it at our desks. We shared midday coffee breaks discussing board questions, mnemonics for molecular alterations, and ways to remember different Aspergillus species, often using our own cultural and language-based humor. In that shared space, the hidden curriculum became less veiled and more fun to learn together.
As a surgical pathology fellow at Roswell Park Comprehensive Cancer Center in Buffalo, I encountered another critical lesson of the hidden curriculum: trust built through graduated responsibility. Fellowship training emphasizes progressive autonomy and ownership of cases with feedback focused on growth. For an IMG, this is important because graduated responsibility leads to the development of confidence. I was fortunate to train at programs that foster diverse trainees, offer mentorship, and have graduated responsibility.
With this hindsight, I would like to offer a gift to aspiring IMGs – the advice I wish someone had shared with me early on:
It is okay to ask whether those cells are carcinoma, even if the answer feels obvious.
You are not imagining the difficulty nor are you failing because you feel you do not belong.
You will understand the system slowly, and it will get better as time goes by.
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