Personal Views

Cultural adjustment and the overseas trainee

BMJ 1994; 308 doi: (Published 30 April 1994) Cite this as: BMJ 1994;308:1169
  1. Swaran Singh

    Two years ago I arrived in Britain on the overseas doctors' training scheme in psychiatry. This was my first trip to a foreign country. I came with little money and no friends or relatives in Britain. I was singularly unprepared, having gathered impressions of Britain from the books of P G Wodehouse and George Mikes. I had expected a country of cricket lovers; football hooligans took me by surprise.

    For someone who has always been one of us, it is impossible to imagine the feeling of being the other that engulfs you soon after arrival in a new country. The deafening silence of the countryside; the palpable discomfort at meeting a stranger's gaze; astonishment at everyone's attempts to hide behind a newspaper in the London tube; inability to react to the smile of a stranger that never quite reaches the eyes; and the early awareness of racial stereotypes are all disconcerting experiences. You are torn between the need to make human contact and a greater need to hide. For most people a summation of discrete experiences crystallises into this feeling of otherness. On my third night I walked into my first English pub and was immediately aware of the intrusive quality of my appearance by its effect on others. Later that night three young men decided to settle scores with someone for the Gulf war, and according to one of them I looked like Saddam Hussein. I was rescued in time by some nurses but for a few moments I experienced an intense, impotent rage with the frightening realisation that I was the other. It was a strange feeling, combining helplessness and fury at the helplessness, and for some weeks afterwards I was overvigilant when going out. Over the past two years this feeling of being the other has gradually receded, though it returns every time I confront overt or covert racism.

    Over the first few months two other issues led me to question my own sense of personal and professional worth. The first was the realisation that while being Western in India is an asset, being Indian in the West is a liability, a result of the stereotypes that colonisation has ingrained on our sense of national identities. The second was a struggle to maintain a sense of professional competence in an alien system where a large part of the decision making process for patient care does not reside solely with the doctor, diluting a sense of responsibility and control.

    Over two centuries of colonisation has led most Indians to believe that the West represents the pinnacle of liberal, secular, and tolerant attitudes to differing social and religious lifestyles. The westernised elite in India share this value system and the attributes of these few are transferred on to the West in general. So when you are confronted with bigotry and racism in the West it is not only personally humiliating, it also threatens long held personal and political beliefs. It was hard for me to accept that the entire Western education that I had proudly received in India had resulted only in producing a clever wog. It was even harder to understand how intolerance, ignorance, and prejudice could occur in an affluent society when I had always believed that these in India reflected harsh socioeconomic conditions.

    “The entire Western education that I had proudly received in India had resulted only in producing a clever wog.”

    The other unsettling experience was the feeling of a loss of power that I initially experienced at work. In India doctors are at the top of the medical hierarchy, and the concept of consensus by a multidisciplinary team, many of whose members are in the lower ranks, is virtually non-existent. Multi-disciplinary team meetings therefore seemed an annoying waste of time, besides allowing inaccuracies and diagnostic laxity. In addition, the Mental Health Act seemed an uncomfortable constraint as I was used to justifying my decisions only to my senior colleagues. The high profile of mental health issues and the negative image of psychiatry in the media surprised and angered me. I began to miss the almost continuous and positive reinforcement that you get from the patients and their families under your care in India. The six month rotation in Britain left me feeling dispensable, a small cog in a massive system that had a life of its own. I still find this unsettling.

    There are many other social, personal, and economic differences that confront the overseas trainee. The bureaucratic nature of the health care system, the fragility of personal relationships, the limited social network of many individuals, the neglect of the elderly, and the obvious inner void that people in the West fill by increasing material consumption are initially disturbing and require major attitudinal changes. But for me these were not as difficult--possibly a reflection of my westernisation in India. I have experienced violent and racist threats; I have met articulate young men justifying these as the result of unemployment and recession; and I am fortunate to have friends who feel genuinely apologetic for these events. I have begun to recognise the strategies by which people divide others into us and them and I try to avoid a similar mental set. More importantly, I have learnt that fragmentation of social bonds produces isolated individuals, disconnected from a shared cultural past, seeking immediate gratification, and with no stake in a collective future. The recent public reaction to juvenile crime indicates that many others in Britain are increasingly realising this.

    There is a lot that I have learnt in my two years and much that I now admire. The same multidisciplinary consensus method that I initially resented now seems admirable for the holistic care it provides. Other overseas trainees that I have met also seem to have survived the initial turmoil and now manage to achieve professional satisfaction and personal happiness in Britain. Some do this by idealising the home that they left behind, a sort of lost paradise to return to. But reintegrating back into your own culture may be as traumatic as first entering an alien one. Many others rationalise negative experiences as resulting from the obvious social and economic disparities between the two countries. Fortunately for most people unpleasant events are few and far between. In my two years positive experiences far outnumber the negative ones. I am glad that I came to Britain, to learn as much as to unlearn. There have been many changes in my life and it is impossible to be the same again. I see what Washington Irving meant when he wrote, “There's a certain relief in change. ... It is often a comfort to shift one's position and be bruised in a new place.”--SWARAN SINGH is a registrar in psychiatry in Nottingham

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