Personal reflections of doctor starting psychiatry training in Kashmir

Personal reflections of a doctor starting psychiatry training in Kashmir

 

It was my third year in medical school and we were excited to be out of the classroom and with real patients at last.  My first clinical posting was in surgery and within few weeks I had made up my mind, ‘I am going to be a surgeon, maybe a neurosurgeon’.  

This continued till I passed the final year examination.  During my twelve month internship, I had a ten-day posting in psychiatry.  Apart from a few lectures and a random question in the medicine paper in the final examination, these ten days are the only clinical psychiatry experience most doctors will have during medical training in India.  Hence, psychiatry has no identity of its own in undergraduate training.  I do not remember having much interest in psychiatry during my medical school days that is, until I started the ten-day psychiatry rotation as part of the internship in Government Psychiatric Diseases Hospital, Srinagar.

I think it was early winter, there was a chill in the air and the sky was invisible under a shroud of clouds.  The Psychiatric Hospital is old; historically it has been part of a prison, an asylum, a mental hospital and finally ended up as being part of the Government Medical College Srinagar. This led to the establishment of a postgraduate department of psychiatry in the hospital responsible for training doctors as future psychiatrists.

The hospital shares a wall with the Central Jail of Srinagar, in an area which was once within the confines of an old fort called Hari Parbat. One can still see the huge walls and the entrance to the area, called Kathidarwaza.  To my surprise, most of the hospital was in ruins due to a recent fire, the cause of which remains a mystery to this day.  A few old wards were still standing and the outpatients department was being run from a temporary building.  A new small structure, rather better looking than the rest was the office of the Médecins Sans Frontières (Doctors without borders) who had constructed that recently with their own expenses.

Patients were seen in two small rooms.  In one room, there was a consultant psychiatrist and his registrar and in the other room a few post graduate trainees and SHOs.  The corridor was full of patients, mind you there is no appointment system and patients walk in to be seen.   Each room had a small table, a few chairs and a coal heater in the centre.  There was no room to move and one can see people in a range of moods, holding the hospital cards in trembling hands waiting for their turn. There was no privacy and I was surprised how the psychiatrists were able to listen to personal stories and make sense of it all.  A few helpers were trying to man the door to stop everybody from pushing inside at the same time.  There was a strange aura around probably from burning coal heaters, overdressed patients and their attendants, some silent as if they were not there and some indifferent and lost.  It was rather hard to make sense of it all at the time.

As an intern, I was supposed to shadow and watch the psychiatrists seeing their patients.   I think it was my second or third day when one of the registrars asked me to take a history from a patient.  The patient was probably in his fifties traditionally dressed in Kashmiri Phiran (traditional gown) and a round cap.  He was sporting a short beard and looked like a village elder.  But once he started talking, I could not make much sense and my curiosity increased further.  He told me a long story which is hard to recollect in full detail now, but I still remember that he was on the moon, had attended a wedding there and was planning his next trip.  For a minute, I was confused, not sure any Indian has been to the moon let alone a village elder from Kashmir. But his story fascinated me, he was talking to unknown people and seemed perfectly convinced of what he was saying and I was not sure whether I doubted him.  He was happy and full of energy.

This was the first time I thought about the psychiatry as a speciality and what psychiatrists do.  Within the next seven days, I had changed my mind and decided to be a psychiatrist.  I still did not discuss this with any of my colleagues, friends or family.  After finishing my internship, I again joined Surgery as a house officer and nearly everyone thought I would make a good surgeon, not knowing I had other plans.

In those days, there were only 2 placements for psychiatry training in the entire state of Jammu and Kashmir, despite having four medical schools and dozens of placements in other specialities like medicine and surgery.  Out of the two places, one was reserved for “backward category” (those from impoverished backgrounds) meaning there was actually only one placement on offer and hence competing for this single place was not easy.  Thousands of newly qualified doctors compete with each other; a yearly entrance examination is conducted and merit list is drawn as per the score in the exam.  At the time of counselling, the top scorer is invited first and can cherry-pick any branch and rest of the candidates follow as per their scores, meaning those at the end do not have much choice.  Hence to get to this single psychiatry placement, one has to be at least in the top ten on the merit list.  Fortunately, after working hard for a whole year and revising all that had been taught in the entire MBBS, I scored well and was 6th on the merit list.

At the time the result was declared, I was spending time with my parents and was off work.  It was my brother who called late in the evening confirming my score and place on the merit list.  My father asked if I was going to be a cardiologist or a surgeon. I replied “I am going to be a psychiatrist” without any doubt or ambiguity.  Both my parents went a bit quiet initially, but then said "if that is what you would like, why not".  I have to say I have been lucky when it came to my parents; they always believed in me and let me make my own decisions. But I know other people in my place, whose families opposed their becoming psychiatrists and one doctor was even threatened with divorce by his in-laws if he chose psychiatry.  The stigma was very much there and it still prevails.
 

On the day of counselling, when I went to fill in my preference, there was a noticeable stigma.  I was asked to give two choices and when I mentioned psychiatry as my first choice, I remember all three-panel members stopping in time, with their jaws dropping.  They probably thought that with my score, I can take any branch, surgery, medicine, paediatrics, orthopaedics, why is he asking for psychiatry? They could not resist and finally the Chair asked why do you want to do psychiatry?  Obviously my answer was not for their understanding.  I still remember while I was sitting in the waiting area, all the doctors who were supposed to be there that day, came around to have a look at me. They were also surprised why someone would do psychiatry when he could cherry pick whatever he liked. I am glad; my decision did make a difference as next year, candidates with even better scores than mine decided to join psychiatry creating a positive ripple.

Hence, I started my psychiatry training in May 2004 at the very same burned and gutted Government Psychiatric Diseases Hospital Srinagar. I was awarded MD Psychiatry by the Kashmir University after passing the final examination in 2007.  Later, I worked as programme officer for the National Mental Health programme, trying to take psychiatry to the community and was able to establish psychiatry outpatient services at few district hospitals. I was also organising training programmes for general practitioners and health workers with the help of faculty from Psychiatric Diseases Hospital. 

When I needed to move to the UK, I contacted the Royal College of Psychiatrists London, who advised that I could apply under the MRCPsych equivalence scheme which would help me to gain the GMC registration and allow me to work as a psychiatrist in the UK. Unfortunately, the College decided that ‘I could not prove that my degree was equal to MRCPsych' and advised me to take the examination instead.  Although, it was not good news, I was not disheartened; neither did it change my desire to continue practicing psychiatry.  After passing the PLAB examination conducted by the GMC, I applied to London Deanery and they gave due weightage to my experience and degree from India and I started working at the South London and Maudsley NHS Foundation Trust.   I passed the MRCPsych membership exam and currently I am working as a specialist registrar in consultation liaison psychiatry at the famous Guy's Hospital, London. I am involved in teaching and training core trainees and medical students. I am also an honorary researcher at the Institute of Psychiatry, Psychology & Neuroscience King's College London.

Looking back at over 11 years of being a psychiatrist, I do not think there was ever a dull moment. Every new patient I encounter is different and the curiosity to know the human psyche never ends. Reflecting back on my six months in surgery, where things are fairly similar, i.e.  One tries to avoid the same artery while taking out a lipoma, being a psychiatrist means no two cases are ever the same. I am still fascinated with the same energy and intensity as I was in 2002 when I met that Kashmiri village elder who had just returned from the moon. The value of life is not only in its physical form but what drives us underneath. I am glad I made the decision to choose psychiatry. While I could have been treating organs and systems being a surgeon, treating someone as an individual is far more satisfying and fulfilling and that defines being a psychiatrist to me.

Finally, I am happy to say that the Psychiatric Hospital Srinagar, through the efforts of like-minded doctors has developed as one of the centres of excellence in mental health. It has been renamed as The Institute of Mental Health and Neurosciences Srinagar, with an increased intake of psychiatry trainees and has also trained allied mental health professionals in the last few years. The stigma among doctors is much less and for the first time in the history of Kashmir a few female doctors have qualified as psychiatrists.

http://www.rcpsych.ac.uk/discoverpsychiatry/overseasblogs/psychiatrytraininginkashmir/personalreflectionsofadoct.aspx