Summary: Dr Neel Sharma Description: Oh, I’m an alien, I’m a legal alien, I’m a British Indian in New York. As a nomad I feel my resilience is second to none. I have lived in the UK, Asia and the US. During a recent educational sabbatical in New York I blended in after the first month or so. I have my transition timeline in auto pilot: visa, accommodation and bank account. People ask me, ‘but what about your stuff?’ I tell them… ‘what stuff?’ I am a minimalist. Consumerists need that next purchase for their buzz. I simply need a cultural experience. Here I share some adaptations I made during my time in New York. ‘Stop knocking.. just come in!’ ‘Oh really?’ I replied. ‘I normally knock before entering an office.’ ‘Well in New York, no need.’ ‘Er ok..’ Safe to say I kept knocking around 15-20 times before I realised barging in was the option of choice. I kinda like it. My student teaching sessions were soon to commence. Hmm... UK medicine seems similar to US practice bar spellings. Surely I can survive. First feedback comment.. ‘He talks funny but in a good way.’ Not sure how to take this but ok. ‘Right guys let’s start with neurology as this is what students find tough.’ ‘After observing for muscle wasting or fasiculations, how do we assess for tone?’ Deadly silence. ‘Anyone know?’ ‘How do we assess for tone?’ ‘Hmm… Dr Sharma why would we assess the toe?’ ‘No no not the toe…. Tone.’ ‘Oh.. I thought you said toe.’ Great… my British flavour is causing confusion. I need to rethink how to survive. Session number two… ‘Right everyone… When we listen to a patient’s chest and hear crepitations what may we be thinking?’ Deadly silence. ‘Guys..crepitations.’ ‘Hmm not sure what that is Dr Sharma. I’ve heard of rales.’ Yikes, this is more complicated then I imagined. Note to self, read over US physical exam approaches. Faculty meeting… ‘OK let’s do a check in.’ ‘Er a check in… Where are we going.. the airport?’ ‘No no, a check in. See how everyone is doing.’ Hmm we don’t do this in the UK. In fact discussing our emotions is out of keeping with our stiff upper lip. Keep calm and carry on etc. ‘Er all good my end.’ Other faculty began discussing their thoughts and emotions at long lengths. Even negative ones. Woah! This is interesting. I’ve never known academics to open up this way before. Faculty meeting continues with discussions on how to improve the teaching session. I have never realised how many faculty exist at a meeting. Everyone is being asked their thoughts... Hmm I generally need some time to reflect before I have something of value to say. My introverted extrovert self and all. How are they speaking so freely? It’s eye opening. Are they not concerned of offending their seniors? ‘Neel so what do you think..’ ‘Er, Hmm. Er… yes all good.’ Note to self – I’ll email them later. I seek solace in the office of administration. ‘Guys I’m dying here! The faculty meetings are intense. Are we allowed to tell seniors what we think? I know the field but surely hierarchy plays a part?’ ‘Oh don’t worry Neel.… forget that noise.’ Huh? Ha. That must be more New York speak. ‘Just chill, say what you think… besides we’ve ordered pizza for lunch.’ Hmm I like pizza. Happiness reigns over me. Closing thoughts. Despite being both Western nations, the differences are grand. The freedom to say what you think and be spontaneous is a far cry from my UK upbringing where hierarchy is more evident. Not to say the UK system is problematic, after all many formalised movements in medicine originated from the UK but maybe some rocking of the boat may now be worth something. The US adopts a ‘can do’ attitude… promoting change is certainly tougher in the UK. But maybe we must in order to maintain our global competitiveness. Inspired by