London calling.

I applied for the London job only because I was sure I wouldn’t get it. In 2006, I had finished seven years of post-graduate training in Northern Ireland and it was time to look for a Consultant post. There weren’t any openings locally so I looked at vacancies on the ‘mainland’. If nothing else, it would be an opportunity to practice my interview skills. Halfheartedly, I applied for a job in London and kept absolutely mum about it. When I was short-listed, I was a bit miffed as my only free weekend that month would be spent preparing for an interview the outcome of which I didn’t really care for. But I didn’t want to look like a complete fool so I did prepare.

I also went shopping for a black pencil skirt with a smart white and black jacket. Why not? I already had a nice white top and black shoes to match.
“Will we have to move to London?” Saagar asked. He was 12.
‘I don’t think so. Unlikely. Let’s see.’

Early one Wednesday morning I checked into my flight at the then brand new Belfast City Airport. As I was saying bye to Saagar’s father, I asked him, “What shall I do if they offer me the job?”
Take it, he said.
The Big Ben spooked me as it peered through the window of the office where I was waiting for my turn. What am I doing here? The panel seemed friendly. I felt relaxed and shared my thoughts freely, to the point of being quite blunt about the unrefined appraisal process and such like.
Why did you apply for this job? They asked.
I had been looking at your job adverts for a while and finally they stopped asking for ‘a female doctor from ethnic minorities’. That’s when I applied.
Why do you think you are right for this job?
Because I have trained twice for it – once in India and then in Belfast.

I found myself smiling as I left the room. I had enjoyed the conversation but there was no reason for them to offer me a job. I was sure London had its own candidates, like Northern Ireland had its own.

That afternoon, I was waiting for my return flight at Heathrow when the phone rang. I flipped the silver Vodaphone open.
“Hello. Is that Dr Mahajan?”
‘Yes. Hello.’
“I am Dr Cunningham from St Thomas’. We met at the interview this morning.”
‘Oh yes. How are you?’
“I am well. I am ringing to offer you the position of a Consultant Anaesthetist at our Trust.”
‘Oh. Are you sure you have the correct number?’
“Ha. Ha. Yes. I am.”
‘Right. Wow. Thank you.’
“Would you be willing to accept the post?”
‘Yes. Thank you.’
“Great. The HR department will soon be in touch with you. Good luck.”
‘Thank you. Bye.’

I said yes only because I couldn’t say no. My ego was on an all time high. Of all the people in the world, one of the most prestigious teaching hospitals in London wanted me. Why in the world would I ever say no?

When I shared this exciting news with a senior colleague in Belfast, he said, “So, from being a rich doctor in Belfast you will be a poor nobody in London?” Another said, “Oh! We might find you swanning around the Royal College in a saree?” I smiled. May be this was a lucky escape.

Working in London was one thing but living in that city was quite another.
On our first day we parked our car in front of our rental flat. While we were waiting for our truck to arrive with our household stuff, we kept an eye on the car, expecting it to be stolen within minutes. When we came down to the car an hour later, an orange plastic envelope was stuck to the front wind-shield. It was a parking ticket. A big lady in uniform stood there with her hands on her hips, “Yo’ front wheels’ half on top’o da pavement. I don’t make the rules. Innit?”
Welcome to London!

From a detached three bed-room house in a friendly, modern development to a random three bedroom flat on a random Chestnut road. From having a front and back garden, a driveway and a double garage to no gardens and parking on the street. From a safe and quiet neighbourhood of friends and acquaintances, to a nameless road-side flat in one of the fastest metropolis, with no friends or family. Once again we were going to make a start with ‘just us’.

Resource: At present, more people than ever live in a country other than the one where they were born.

Evidence for suicide prevention strategies with populations in displacement: a systematic review

Every day a good day?

After one year of near-perfect climatic conditions, when it rains non-stop for three whole days and nights, one starts to notice the changing inner weather-system.

Isn’t everything pristine as is? A day is a day. Clouds are nothing but clouds. Trees are simply trees. Nothing good or bad about them. They are what they are. When seen through a clean lens, things can be seen as they are. The smudges come from our judgements. It is one thing to notice how they make us feel and another to blame them for being there.

He shouldn’t have made that horrible remark.

The car was seriously misbehaving.

That fire-door nearly broke my arm.

What a noisy bunch!

Mango good. Jack-fruit bad.

Sun good. Rain bad.

Birth good. Death bad.

Untimely. Preventable. Tragic. Etc. Etc. Blah…blah…blah…

It is absolute. So is the mango, the rain, the love. Absolute.

One day I will die. I live, remembering that each moment that I am alive is a miracle. I am way beyond my preferences, opinions and thoughts. I am not them. They are not me. That every day is a good day, I am beginning to see.

Two overlapping worlds.

The Bhagavad Geeta addresses the ethical and moral dilemmas around the questions of who we are, how we should live our lives and act in this world. If this voluminous text was to be summarised in two sentences, they would be:

  1. Do what needs to be done, knowing that all actions come from God.
  2. Do not be attached to the results of your actions.

Six weeks ago, I re-entered the world of Suicide Prevention due to a presentation I agreed to make. It took me back to a familiar battleground where strong currents of injustice flowed through me. I went over our story yet again, in mind and body. It burnt me up. It made me restless and irritable. It kept me staring at the ceiling at night. It brought back the shit of guilt in big droppings. It was silly of me to agree to do it, but it was too late already. I wrote it down, prepared a set of PowerPoint slides to support the story.  I repeated it for the nth time to many. I wondered, to what end, but I did it anyway.

Four and a half years ago, when my road gradually swerved from the Suicide Prevention world towards peer support with other parents, it was like a cool breeze gently blowing in my face. That conversation felt like a proper invitation. Instinctively I knew it was good for me. Despite huge self-doubt, I trusted that path. I went with it. This work was also about preventing isolation and possibly suicide amongst parents, as our risk is 60-70% higher than others. It did not feel like work at all. We formed strong bonds of friendship. We shared deeply and held each other in understanding and compassion. This felt like home.  

The organisers at National Confidential Inquiry into Suicide and Safety in Mental Health provided me the best possible support to be able to present my thoughts. The comments on the chat were that of gratitude and inspiration to change. One person said that it was better than any training course they had attended. I am glad that I did what was needed. The strength to do it came from somewhere. Now, it can do its work and I can go back home.

The recording is here (‘Bridging the gaps’ starts 6 minutes and 45 seconds in).

Wrap-around?

“What can we do to offer wrap-around care to our patients?”

In the live Q&A at the end of the NCISH conference yesterday, this question was asked of the panel. The Chairperson directed it towards me. I can’t remember what I said. This morning I woke up with what I would have liked to say.

For wrapping, we need two things. One, the fabric which we are going to use to wrap and the person we want to wrap. Let’s discuss them one by one.

  1. The fabric

The fabric of Suicide prevention in Health-Care is made up of two things – people and systems. Let’s look at them a bit closely.

  1. People

What are the beliefs of the people?

I know of an ENT surgeon from another country who wanted to move to the UK and the only job he could find was in Psychiatry. So, he is now training to be a Psychiatrist. Is he interested in suicide prevention? Do Health-care professionals believe that suicides are preventable? Are they content that simply by treating mental illness they are doing their job?

What are the attitudes and abilities of the people?

When the Emergency department calls to say there is a suicidal individual waiting to be seen, how do they feel? Are they excited to have an opportunity to make a difference? Or is it a drain on the limited time and energy they have? Do they know how to build a compassionate connection with someone who has lost all hope? Have they received any training in Suicide Prevention? Do they have enough self-compassion to look after someone else well?

Do they have the resources and the knowledge to do a good job?

Do they have access to their past history? Do they have beds on the ward? Can they ask a colleague for a second opinion if they have a doubt about how to involve family or friends in their care? Do they know of other resources, like charities, activities and people that may help this person? Do they have comprehensive and informative leaflet they can share with them? Do they have the means to follow them up?

b. Systems

Does the system have capacity? Are the various parts of the system effective and joint-up enough to be able to hold the person they are trying to wrap or are there big holes in this part of the fabric? Do the various parts of the system share the same mental model, a shared knowledge, pre-suppositions, and beliefs that can be used to help achieve mutual goals? Are their practices evidence- based? Do they investigate deaths with a view to learn lessons and implement change? Do they look after the well-being and emotional health of their employees? Do they hold themselves accountable when things go wrong?

2. The person

Allowing space for them to express themselves. Help maintain their sense of agency. Inform them it is safer for them to involve other people who care for them. Equip them with resources. Give them the support they need. Ask them what would help them? Listen. Sit with their despair. Acknowledge it. Keep them connected with their life as they know it. Keep hope alive for them.

Know that the person at the centre of the wrapping is of great value.

Information is useful if it becomes knowledge. Knowledge is useful when it becomes wisdom. So, let us not stop at information.

Ref:

Reaching common ground: The role of shared mental models in patient safety : https://journals.sagepub.com/doi/full/10.1177/2516043518805326

The older I grow, the lesser I know.

A book with frayed edges sat tucked inside the pocket behind the driver’s seat. After an overnight train journey from Sakleshpur to Goa, we were going home in a taxi. No coffee yet. I was not quite switched on. Bleary eyed, I pulled the book out of the elasticated edge. It was Walden by Henry David Thoreau. Some poor tourist had mistakenly left it behind while traveling to the airport to fly back home.

Thoreau wrote this book while he lived in a cabin he built near Walden Pond, hundred and eighty years ago. He was testing the idea that divinity was present in nature and the human soul. He stripped his life down to the barest of essentials and secluded himself as much as he could, living off the land as much as possible. He wanted to find out just what in life is necessary and what is superfluous.

(Picture, courtesy Maria Popova )

Having chosen to live in a place where, for hundreds of miles very few people speak our language, with no cinema halls, restaurants, therapists or book shops, where the food is of one particular kind, but nature is abundant, that question has arisen for me too.

A few weeks back, a quote by Thoreau had whistled right into my heart:

“Life! who knows what it is, what it does?”

Such a beautiful sentiment. I had wished for more of his writings. After learning some more about him and his love of birds, streams, woodlands and meadows, I got busy with other things.

When I brought this question to CORe, it generated a rich discussion.

“What is our relationship with not knowing? What feelings does it provoke?”

Some excerpts from our conversations:

  • It is a real test of oneself, dropping how things should be and taking each day as it comes. It took me a long time to realise how much my mind was tied to certainty. In Africa, the relationship with death is very different. They have many ways to remember a loved one. They believe they’re still here and it gives them great joy.
  • Anxiety of the need to know at work. I have to change my mind set to curiosity. Some things we’re not meant to know, such as, where is he? It would spoil it. I must accept that I’m not meant to know.
  • When he went, I didn’t want to be here. Now I do. I have a life that I want to have. I have lots of godchildren who have promised to take care of me. I have a vision of him and his dad, which I hope will come through in my own death. Maybe when it’s my time they’ll be there, and their peace will be shattered.

Yes. The older I grow, the lesser I know. There is a freedom in that, to be with whatever is happening. It allows for the mystery of life to unfold as it will and it allows me to witness it without conditions, with an open heart. The smallest things. The book that I had wished for a month ago, appears right in front of me after I had forgotten all about it.

Life. Who knows what it is, what it does?