Foreign psychiatrists moving to the USA need to undergo full residency training again. As one of them, soon to complete my US residency, I have been accompanied in this journey by many other foreign specialists who also embarked on the same path of apparent repetition.

It is hard to recall how many times I have heard colleagues asking how, or why, one could or would engage in residency again. Typically, the question is delivered in ways implicating that retraining must be horrible. And while it certainly comes with predictable challenges and costs, here I wish to cast a personal light on some of the pros I have found along the way of becoming a psychiatrist twice.

Retraining is a delicate game of balance. You cannot and should not forget what you know already, but you must maintain the openness of mind of an intern. You may have more clinical experience than your co-residents on average, but you must keep a humble stance and be ready to face new challenges. You are in a wonderful position to absorb whatever you might not have learned in your first training, yet you already have the chance to enrich your colleagues and workplace with your unique perspective.

Upon starting my second residency, I realized that while my former training prepared me well to be a psychiatrist in my own country of Italy, I had a long road ahead to be equally well-prepared to practice in the USA. Among the many learning areas to further develop, or acquire anew, were skills such as gaining a higher level of language proficiency, the ability to work with a much more diverse clinical population, and becoming comfortable with different prescribing patterns and an overall slightly different practical and intellectual approach to the field.

It was very clear that it did not matter what I knew about a subject, or what brilliant ideas I thought I had, if I could not communicate effectively. Learning how to actually practice psychiatry in a different language was, not surprisingly, a bigger and more nuanced challenge than just gathering patients’ history à la the bygone Step 2 Clinical Skills exam. Being metaphorically thrown into the pit of working with psychiatry patients in a different country was the most compelling, eye-opening linguistic and cultural exercise. Looking back, the mind gain was worth the tongue struggle.

This linguistic learning process was key to accessing new dimensions to understand patients, in ways I had not learned in my more culturally and ethnically homogenous country. The validity of the biopsychosocial model, the impact of culture on the forms of mental illness, and the process of psychiatric interviewing became clearer from the vantage point of managing a deeply diverse clinical population. And yes, one could argue this situation is not equally true in all US residencies, but as a foreign specialist, chances are you will absorb linguistic and cultural skills to boost your cultural psychiatry proficiency irrespective of your specific program.

Retraining has involved holding a stance of openness and acceptance in front of the unknown. Initially, I was not used to consider such a degree of social heterogeneity in my work with patients or to discuss psychiatry issues in a language I did not yet fully master. It felt as if an invisible barrier slowed me from expressing myself and understanding others. With time, I have found it was possible to transform that frustration into an opportunity to accept the differences embedded in a culturally heterogeneous environment and the uniqueness of my patients. This journey culminated with clinical encounters in which I remember relating with people from entirely different backgrounds precisely over our differences.

During my US residency, I have experienced the impact of third parties on patients’ access to mental health services. Coming from a country with universal health care, I was faced with a body of knowledge that was entirely new to my naive understanding of system complexities when private insurance is involved. It was a steep learning curve and one that enhanced my awareness of how important it is to advocate for my patients. I was also exposed to a more adversarial medicolegal environment, with a comparatively greater focus on careful and factual documentation. Adjusting to these and other system differences was great learning, but it also left me with the impression that, during my prior training, I had more time available to spend with individual patients.

Irrespective of how good a first residency might have been, there always will be areas one can further develop. For example, given that in Italy electroconvulsive therapy is underutilized [1], with only few centers offering it, I was lucky to acquire the foundations of this most efficacious treatment in the USA. On the other hand, in line with a trend discussed by Nancy Andreasen nearly two decades ago [2], a lot more emphasis was put on learning descriptive psychopathology and phenomenology during my former European training. I have tried to share that knowledge with my co-residents and directly experienced how retraining can become a reciprocal, fruitful exchange of perspectives and skills.

I do not want to sugarcoat it. Having to undergo a second psychiatry residency felt sometimes redundant, adding to other common international medical graduate struggles, from visa status to barriers traveling home. However, there were also many positive aspects, and I hope that these reflections will convince other foreign specialists that retraining is not a mere repetition.

Ultimately, I consider myself fortunate to have had the chance to be a full-time learner again. It has been a humbling time of personal and professional growth. I look forward to scholarly work focused on this particular subset of resident physicians and to proposals on how to formally value their prior training and experiences.