To The Editor: It is 5:45 A.M. Buzzing from the borrowed alarm clock harshly awakens me. I rise, and the uncertainty of my whereabouts slowly fades. I am in Fort Defiance, Arizona, near the center of Navajo Nation, at the beginning of an elective that will change me as a psychiatrist and as a person. Slowly, I dress in warmer clothing, even though it is July. At an elevation of 7,000 feet, cold and darkness persist across the plateau. I head downstairs and put on my red dirt-colored shoes. As I walk out behind the Indian Health Service government housing, a landscape of endless canyons and desert opens before me, and the sun begins to rise over a breathtaking skyline. I began this routine after starting work at Fort Defiance Indian Hospital in their residential adolescent unit. There, a Navajo Traditions class taught me that, each morning, the Navajo used to greet the rising sun, running towards it and letting out a guttural whoop to give thanks for the day and their health. I feel that in order to understand a culture, I should do my best to be immersed in it. I do not take this daunting task lightly, despite a constant sense of feeling out of place that plagues me.

Even the hospital and government housing for employees starkly contrasts with the town that encompasses it. I consider this discrepancy when passing the makeshift housing to the left of me as I walk to work. Lean-to–like structures, vehicles, and sheep all occupy the living spaces. I think of a statistic that I had heard recently: up to 50% of the Navajo on the reservation do not have running water. After entering the hospital, I weave my way through the outpatient clinic, past the psychiatrists', psychologists', and traditional counselors' offices. I go outside the adolescent unit and join the already-formed circle of staff and patients starting morning prayer. "Koodoo' Hozhoo—dooleel" they begin. "From here, where I exist, I greet you in positiveness." The leader passes around a bag of cedar chips. Each participant takes a pinch, and speaks his or her intention for the day. As a sign of cohesiveness and the circular nature of life, we each place our chips into the center where the groups' pile of cedar has been lit. The rhythm of the prayer is meditative. I struggle to pronounce the difficult Diné language with its breath-like sounds. Looking around the circle at the adolescents who will be here for the next 8 weeks, I see trauma, addictions, severe depression, and scars from cutting; but, most of all, I see teenagers who were once very alone being healed by their tribe.

At noon, I head to the cafeteria for lunch. In line, I look around and feel, for the first time in my life, what it means to be a minority. Overwhelmed momentarily, I think about my patients over the years who have felt different or out-of-place. The theory of existentialism pops into my racing mind, and I think I finally know what this means. I am just a small part of this huge system. After some deep breaths, I grab a tray and consider options for food. It seems as if every item has corn in it. On the wall, a poster with types of corn I have never known about hangs over me. "Blue cornmeal, please." Into the bowl is spooned a thick gritty substance. It is hard for me to imagine how such a flavorless porridge is sacred to the Navajo people. It is a symbol of fertility and new life, representing more than what is in the bowl in front of me. Even the Navajo creation story involves man and woman formed from corn pollen. I realize that corn is more than it seems, depending on one's perspective.

After eating, I return to the outpatient clinic, where I have been given a caseload after initial training and observation. I am distinctly aware of the cultural differences. My patients avoid direct eye contact, do not grip tightly when shaking hands, and use a circular narrative to tell their stories. During the evaluation of an individual with a history of fetal alcohol syndrome, prolonged and complicated psychiatric hospitalization, and neuroleptic malignant syndrome, I was about to focus the interview on his mental health, but noticed the patient and his family withdrawing. They began physically pulling back in their chairs, looking down, and falling silent. I paused, confused and unsure of my next move. My supervisor, to my surprise, asked about the family's livestock. The family discussed the care of the sheep on their land for 20 minutes before moving on to the patient's history. On this reservation, it is necessary to understand the patient's origins before one is privileged to hear his story.

During a break in the clinic schedule, I began working on one of my objectives for the rotation: journaling. July 2^nd, 2008, reads, "Yesterday was my first day of work. Sue and I saw "Miss S," an 86-year-old Navajo lady with dementia. It was very interesting: She is afraid of her mother, brother, and sister, who are all dead…Ghosts are a very big concept here—apparently the old hospital is full of them. The article I read said that the Navajo people bring their family members to the hospital to die because they do not want to come into contact with their spirit leaving their body (chi'itti?)." By reflecting on the day in written form, I was able to amplify the experiential learning that was happening at an astonishing pace. The residential adolescent unit holds separate weekly male and female sweat-lodges as a therapeutic modality. Late in the afternoon, I felt honored by an invitation to join. Because the lodge on site has an ant infestation, we drive to the community sweat-lodge, located on the top of a hill on the outskirts of town. I feel my heart pounding and my breathing becoming shallow with anticipation. Much care goes into preparing the stones, which represent the Navajo ancestors. The sweat-lodge leader, a middle-aged Navajo woman, explains that these stones are called grandparents. All Navajo are related through their original clans. I look at the birch-encased structure lying low to the ground, with a small canvas-covered opening and wonder how we will all fit in there. I enter the domed Hogan on my knees, crawling to the left in a circular fashion. All sweat-lodge entrances face east in Navajo culture, reminding me of the start of this day, walking towards the sun. Soon, I hear the rhythmic sound of the leader splashing water on the coals. They tell the story of the sweat-lodge's origin. A sense of well-being surrounds me. We are gathered in this dark, safe space, eight women in total, to support two teenage girls in the time-honored Navajo way of healing. All my senses are engaged in this process: the smell of the juniper, the feel of steam, the thickness of the air, the warmth of my skin, and the darkness that surrounds me. "Hozho hazlee," we chant, invoking a catharsis for the posttraumatic pain of one of the girls. On exiting the sweat-lodge after the first round, I feel intensely lightheaded. The ceremonial water that is passed after each round seems not to be enough. My clothes are drenched when I reenter. By the fourth round, I am lying on the ground because of the heat. The traditional healer tells us that the girl's pain, combined with our emotional response, which was focused on her, heated up the sweat-lodge so much that this was one of the hottest sweats she has ever attended.

I feel depersonalized and think again about contrast. My earlier alienation is gone; in this sanctified space, the feeling of being different leaves me. On exiting, my skin feels translucent. I have completed the full cycle of the sweat, which is symbolic of the Navajo life-cycle. A sense of purity and starting-anew fills me. Awakening the next morning, I consider that I can now return to North Carolina with a new humility and a clear mind. I carry this invaluable gift that was bequeathed to me in this sacred place: how it feels to be different, to have a greater purpose, and to share in a culture with origins as old as time. Although this elective study has an N of one, the power of immersion and experiential learning has not been wasted on this future clinician. (Author's note: This narrative represents a composite day modeled from a 6-week elective.)

The education of a physician relies heavily on experiential learning. Generally, exposure to cultural aspects of psychiatry occurs in assessing and treating patients whose ethno-social backgrounds differ from that of the psychiatric resident. Awareness of, and respect for, cultural influences usually results; empathy does so much less reliably. The design, and particularly, the setting of Dr. Kitten's elective emphasized empathic appreciation of Navajo culture. The combination of didactics and immersion in the daily practices of traditional ways maximized her opportunity to empathize with, if not fully share, her Navajo patients' perspective.

Although Dr. Kitten emphasizes the profound personal impact of her experience, I recall also the skill she acquired in accurately verbalizing what her patients felt, thought, and valued. Of importance in planning and executing on-site electives is the openness of the learner to the reality of the immersion experience. Knowledge, understood as the meshing of theoretical understanding with lived experience, can be acquired very rapidly if, like Dr. Kitten, the resident can respond in a participatory fashion to the novelties of the situation. Journaling and supportive supervision facilitated Dr. Kitten's innate willingness to suspend her usual routines and clinical style. She ate new foods, attempted phrases in the Diné language, and chose not to debate about sharing prayer in an inpatient unit. She used awareness of being an overt minority on the reservation to rework her previously less-informed understanding of that perspective. She underwent the ordeal of the sweat-lodge along with her patients and was deeply moved by it.

Another potential benefit of such electives is the more general development of the learner's ability to recognize and absorb aspects of other cultures. For instance, Dr. Kitten could reflect on the specific steps she took to adapt her interview to improve rapport and then inductively apply those methods to subsequent clinical interactions. As she so cogently explains, Dr. Kitten gained far more than just an awareness of Navajo culture, and her future patients will benefit as a result.

Thank you to Fort Defiance Indian Hospital Mental Health Department for their invaluable contribution to my education and the education of others. Thank you also to Kathy Cable, MLS, Information Services Reference and Liaison Librarian.

At the time of submission, the authors reported no competing interests.