Welcome to America!
IT WAS 4:00PM, SEPTEMBER 2002, AT HEATHROW AIRPORT, LONDON. Time to board the British Airways airplane for my transatlantic trip to Philadelphia. Leaving England is not easy. Having completed my residency at the prestigious Guys Hospital psychiatric training scheme, however, I finally bow to the pressure from family and friends to seek greener pastures in the US. Having completed and passed the three USMLE steps (of which I was among the first candidates in 1992 and one of the last candidates for the paper administration of Step 3 in 1999), just like most physicians outside the US, I find the allure of practicing as a physician in America irresistible.
In Europe, we constantly hear about the advanced technology, the newest medications, the educational and career prospects for children, and of course the improved remuneration in the US. Also, it is common knowledge to the outside world that in the US, you can get to any level to which you aspire based on your hard work.
I land at the Philadelphia airport at 10:00PM with six pieces of luggage. I left my wife and children back in England. They will follow me shortly. I undergo the intense post-9/11 security checks from the US Immigration and Custom Officials. After getting through the rigorous checkpoints, I attempt to remove a luggage cart from a line of carts that are pushed up against the wall—it will not budge.
“You have to insert two dallers,” someone says behind me.
“Two dallers,” I mimic under my breath, and think, “I have to start pronouncing things the American way.”
Outside the airport, I see the nighttime view of Philadelphia. To me, the city seems to exude a vibrancy that can only be ascribed to capitalism. The city seems full of life and opportunity, and I feel heartened as I remind myself of my reasons for leaving England.
I arrive at the hotel. An overweight concierge is devouring six pieces of fried chicken at 1:00AM. I am embarrassed for him. I ask him for the lift. Looking befuddled, he repeats, “Lift?” Once again I feel embarrassment, but this time for myself. What is wrong with my language? After all, I am coming from England.
“Something I can take to the third floor,” I explain. His face brightens. “Elevators!” he exclaims. My American language lessons begin in earnest.
He sets aside his fried chicken and helps me carry the bags to the elevator…and waits. Puzzled, I begin to wonder if I did anything wrong. Then I remember—I give him a two-dollar tip.
“Have a good night, sir,” he says, eager to return to his late-night snack, I assume. I hiss to myself, “Welcome to America!” and not for the last time.
First Day at My New Hospital
The next day I report to the Medical College of Pennsylvania Hospital. The ever-helpful departmental secretary tells me I will be starting with medicine. I also see Dr. Donna Sudak, the erstwhile program director (She left the post in 2004). Seeing her, I flashback to the interview process for a position in the States:
Before accepting the position in Philadelphia, I interviewed at University of Illnios in Chicago and Sinai Hopsital in Elmhurst, New York. The Elmhurst experience is one that I will never forget. I arrived in New York at 9.00PM only to find that my luggage was missing. With no place to shop that night, I had to wear my travel-weary sweater and slacks to the interview—I looked like I had been camping. On top of that, almost everyone around the Elmhurst hospital spoke Spanish. I suddenly wished I had spent less time learning French and more time learning Spanish, which here in the States would benefit me greatly. The program director at Elmhurst was very understanding of my predicament and did not use my “campy” look against me during the interview. I was offered a position in the residency program at Elmhurst and actually would have chosen this program if not for the reputation of yet another program director—the aformentioned Dr. Sudak here in Philadelphia. During the interview process, I found Dr. Sudak to be remarkably warm, helpful, and encouraging to all her residents. Apart from her humanity, she is also one of the best teachers and organizers that I have ever met.
My flashback is cut short, and I proceed to the medical floor to introduce myself and to negotiate the start date. I am suddenly standing in front of the Chief, who looks at me the way a dictator would look at one of his subjects. The last time someone looked at me that way was 15 years ago when I was doing my first internship.
“Take the pager and write SOAP on patient X and Y,” he barks. I become nervous. “Soap?” I thought. The only soap I know is the bathroom variety. After summoning courage to ask what SOAP means, he replies, very irritated, “Subjective, Objective, Assessment, and Plans.” Now I get it! The learning never stops.
TUMMY TROUBLES
One day, I develop diarrhea. I call the Chief and request the day off.
“I would like you to come in for a physical examination and stool samples,” he tells me on the phone. “Where do you live?”
I explain that I live an hour away. Considering my condition, it would be a difficult journey. To my relief, he drops that idea but apparently he is not satisfied.
“Call me every two hours to let me know how you feel. You might still be able to make it today. And I better see your home number on my pager each time you call,” he says, with no note of sympathy in his voice for my ill-working intestines.
“What have I gotten myself into,”I wonder.
When I return to work the next day, I am assigned to follow another intern who actually started two months earlier; hence, he knows the ropes. He is from India. He is so fast, I feel guilty for holding him up.
A Missing Zero and Rectals
Apart from psychiatry, during my residency here at MCP Hospital, the rotation I enjoy most is geriatric medicine. I have the privilege to work with a group of wonderful attending physicians, and based on my background in geriatric psychiatry as well as internal medicine, it is indeed a positive experience. With that being said, there are two less-than-positive events, however, that come to mind as I share my residency story.
The first is when I receive my first paycheck for $1150 for two weeks of work. To say that I am shocked is an understatement. I actually think there is a mistake and that one of the zeros is missing. My paycheck is significantly less than my paychecks from England, and I am not psychologically prepared for the decrease.
Another less-than-positive experience has to do with…rectals. During my first few rounds with the senior resident, we arrive at an elderly man with urinary retention.
“You will need to perform a rectal on the patient,” the senior resident states without looking up as he studies the patient's chart.
“Me? A rectal?” I ask. My inner voice nervously ponders, “When is the last time I actually performed a rectal?” I was a forensic psychiatrist in England for the previous five years and doing rectals was definitely not part of routine forensic psychiatric evaluations.
I put on the gloves and I am about to go in as the senior resident quips that he has done so many rectals in his life, he deserves a PhD in Rectology. I am a bit horrified, I admit, and I secretly hope I won't ever be qualified to make that statement.
credit denied
I need a credit card and pronto! I apply for one, and then another, and another. The replies start to come in: “We are sorry we are unable to extend a credit line to you due to insufficient credit history.”
“This is ridiculous,” I thought. “Why do I need a credit history to apply for a $250-limit credit card?”
I ask a fellow resident to explain to me what is happening. And he does, by saying, “The more you apply for credit and are refused, the worse your nonexistent credit record becomes.” I feel befuddled.
I surrendered all my credit cards when I left England—contrary to the appeals by the card companies to suspend the cards rather than cancel them entirely. My credit cards had as much as 10,000 British Pound limits, which is roughly double that in American dollars!
I, again, hiss to myself, “Welcome to America!” and not for the last time.
Are you Making a Pass at my Wife?
I go to the mall with my wife, who, by now with the children, has safely crossed the pond from England. We are shopping in Germantown, which is near Philadelphia.
“I love your pants,” a nearby woman says to my wife. I thought I misheard her.
“Her pants?” I asked. Could she be a lesbian? Is she making a pass at my wife? I wonder these things to myself.
“Yes,” she repeats pointing to my wife's trousers. My wife and I laugh, “Oh! My trousers!” my wife exclaims.
“Of course!” she says, now looking surprised and a bit indignant.
“You see, we come from England,” I explain to her, “and over there, pants refer to underwear…lingerie…” The woman bursts out laughing. I again think to myself, “Welcome to America!” I still have a lot to learn.
Brand Names
When I started in psychiatry, I thought I had all the know-how necessary to get along in medical world. No way! My residency here in the States quickly proves that the learning never stops. One of my first calls at the hospital is with an elderly woman in cardiac failure. She needs to be admitted to the hospital immediately. I recommend, of course, in-patient hospitalization. The admissions staff nurse asks me, “What sort of insurance does she have?” My initial reaction is, “What has that got to do with it? Do you think the patient will die? Why are you asking about her life insurance?” The admissions staff nurse patiently explains she means health insurance. Silly me! Yet another language barrier between English English and American English.
Once on the ward, I prescribe olanzapine to another patient. The staff nurse calls me to one side and says, “You realize that this drug is called Zyprexa?”
“Yes, of course,” I say.
“Well, we prefer that you write Zyprexa,” she explains.
I refuse. “Do we work for the hosptial or the pharmaceutical industries?” I ask her. She reports me to my attending who diplomatically tells me to write the brand names in brackets after writing the generic names. For a few weeks, I painstakingly keep writing something like ziprasidone [Geodon]; paroxetene [Paxil], etc.
I do not notice when I lose this seemingly rigidly held principle. At some point, I stop writing both the brand name and the generic name, and I start referring to the drugs by their brand names alone. I am well on my way to full acclimation.
Welcome Home!
Despite some difficulties in transition, I have no doubt that the move from England is worth it. Foreign medical graduates seem to go through a lot of hassles at the beginning of their residencies here in the States. It is worse now with the understandably tight security and safety issues secondary to the terrorist attacks, which make it difficult to secure social security cards, drivers licenses, credit cards, etc. With perseverance, however, and help from the hospital program, things eventually work out for me. I have the privilege of meeting great attending physicians and psychiatrists as well as interacting with notable people in the academic world. The tools I have in terms of patient management are excellent, especially from the psychopharmacological and psychotherapy point of view. Most of all, I am thankful my children are able to reap the benefits of our move. They are loving the whole experience!
Incidentally, we return briefly to England for a visit. Ihear my four-year-old daughter explain to my seven-year-old son how everything in our house in London has shrunken. Incredulously, my son asks her, “How could the ‘fridge and the TV shrink?” Well, she is sure of this, and turns to me for back up. “Daddy, isn't it true?” she asks.
“No, dear, things only appear to have shrunken because everything is so big in America.”
“Oh…really?” she asks, disappointed if not doubtful. I am not sure she agrees with me.
On our return trip from England, as we depart the plane in Philadelphia, I think to myself, “Welcome home!” (and not for the last time.)
Footnotes
Do you have a story you would like to share about your residency in psychiatry? Submit it (2000 words or less please) along with one or two photos (if you have them) to: Elizabeth Klumpp, Executive Editor, Psychiatry 2005, PO Box 445, Edgemont, PA 19028-0445 or e-mail: editorial@matrixmedcom.com. Stories to be published will be selected by the editors based on interest to our readers, uniqueness, humor, and/or expression.