Culture Shock: A Canadian Fellow Lands at the VA

I am no stranger to culture shock. My father is an academic, and for his job we crossed the Atlantic Ocean 3 times by the time I was 10, landing finally in the small town of Dundas, Canada. Each time, I reluctantly adjusted to a new place, new people, a new language, and a new way of doing things. As a young adult I moved again, away from my comfortable, nurturing home and into a college dorm several hundred miles away. Then there was another move to the big city for graduate school, and yet another for medical school. I got used to the disorientation and emotional rollercoaster that came from suddenly being plunked down somewhere new.Cultures can define more than just places, however. Donning my white coat and stethoscope, I was inducted into yet another culture, the culture of medicine. As a doctor-to-be, I learned another new language, a new way of thinking, and new norms—even a new way of washing my hands. As I journeyed around the hospital, I discovered distinct subcultures within medicine. Each hospital unit, surgical suite, and outpatient clinic had its own way of doing things. Like seasoned travelers, my classmates and I learned to be flexible, humble, and experts at the fine art of fitting in.When I accepted an offer for a fellowship in addiction psychiatry in the United States, I worried about my visa, my children's schools, my husband's career—everything but whether I would be able to navigate a new system. After all, Connecticut is just 9 hours by car south of the Canada–US border, and in any case, we all got through medical school on the same regimen of American textbooks and doctor TV shows. How different could it be?Perhaps I should have clued in to what lay ahead when my J-1 visa arrived indicating I was an alien physician. Like a little green creature from outer space, I was entering a strange new world called the VA (the Veterans Health Administration in the US Department of Veterans Affairs). In hindsight, my experience fits well with the Canadian anthropologist Kalervo Oberg's description of acculturation.1 He described an initial honeymoon phase that is characterized by a naive fascination for everything new. As the newcomer settles into her new milieu, cultural differences become apparent and create anxiety, frustration, and even anger. Slowly, however, she becomes accustomed to the new culture and develops new routines. The loneliness and homesickness fade, and her sense of humor returns. Finally, she begins to participate fully and accepts the new way as another way of being.During my first few weeks in New Haven, I romanticized about the old brick campus buildings, our quaint little neighborhood with its graduate student and faculty residents, and my new work at a hospital just for veterans. But soon the cultural differences of the VA hospital became more apparent and increasingly bothersome. Orders from above (you must see this patient within 7 days) came in close succession with orders from out front (this patient needs to be seen now, doctor). My “tour of duty” specified exactly where I should be at every moment of the day, whether there were patients to be seen or not. I attended meeting after meeting after meeting, where I soon discovered I sat at the bottom rung of an impenetrable hierarchy. Back home, this was not how things were done! I felt panicked, overwhelmed, and mystified that none of my fellow comrades seemed the least bit bothered by what to me seemed completely absurd.I am not sure how or when things changed, but over the following months I found myself struggling less often to make sense of my new environment. Some things still irked me, but increasingly I realized that all of those orders, meetings, and even the “tour” had meaning—to enable us to deliver care that was timely, coordinated, and responsive. Eventually, I came to admire and even adopt the hospital's mission of unwavering dedication to the veterans, whose battle stories somehow transcended the chasm between our lived experiences and touched my heart in ways that I never expected. I learned from my patients a great deal about American history, geography, and politics. I also bore witness to the ability of human beings to survive and even grow from great adversity. I now feel connected to this place, as if I belong. As I interview for jobs back home, none seem quite right, and I find myself proudly saying, “At the VA, this is how we do things.”As my last days of training slip away and another move looms ahead, I realize that my fellowship year was a sort of utopia: the perfect mix of practical experience, training, reflection, mentorship, and friendship set against a transcultural backdrop. I leave these days with a deep sense of gratitude for this amazing experience that has broadened my mind and changed the course of my career. To all those nearing the end of their residency, I hope you take that plunge and go somewhere new. You will be better for it.

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