The Making of a Roving Locum

Like almost all developed nations, New Zealand has a shortage of qualified primary care physicians. Why is this important? It’s because the efficiency, cost -effectiveness, and overall success of a delivery system measured in health outcomes are all directly related to the successful delivery of primary care. Without organized universal access and rational implementation of effective primary care strategies, costs soar and outcomes worsen. And in real terms, it is patients who suffer in proportion to the unavailability of this vital building block of any health system.

Why the worldwide shortage? The reasons that are as varied as the health systems themselves, but it has a lot to do with the hard work, long hours, low prestige, lower pay, socially disadvantaged patient populations, and non-urban settings that are often part and parcel of the practice of primary care.

As with many aspects of healthcare in the United States, issues surrounding primary care are complicated. On one hand, the United States represents the world’s single largest net recipient of primary care physicians trained overseas, often in countries that can ill afford to lose these physicians. On the other hand, there persists in the United States perhaps the greatest maldistribution of primary care vis-a-vis specialty physicians in any healthcare system in the developed world. The World Health Organization recommends that approximate 70% of the physician workforce be represented by primary care. In the US it’s almost the opposite, with the predictable excess expenditures, discontinuity, and general lack of access that all too often characterizes US healthcare.

In New Zealand there are far fewer organizational and systemic impediments to the provision of adequate primary care. With the legislative establishment of primary care organizations (PHOs) in 2001, which provided the organizational basis for the entire country, the philosophical, political, and to some degree economic commitment to primary care was made. Unfortunately, there is still a significant net loss of primary care physicians to countries with higher pay scales, most notably Australia and Canada. In an attempt to provide short-term (and ultimately long-term) coverage, the use of temporary physicians known as locum tenens is common.

There are several for-profit and nonprofit agencies that seek to facilitate the placement of both New Zealand and foreign physicians in such positions. I opted to utilize an agency known as NZ Locums, a nonprofit affiliated with The New Zealand Rural General Practice Network, NZRGPN. NZ Locums was my initial point of contact in the process and I’ve been working closely with them for a number of months to deal with the numerous credentialing, visa, and logistical requirements required to make such a placement occur smoothly. I would like to say publicly that NZ Locums did a great job and was a pleasure to work with.

The final component of my placement entailed a three day orientation during which time I was briefed by representatives of various agencies and organizations that a practicing physician must deal with here. The sessions included presentations by Pharmac, the New Zealand national formulary; ACC, the New Zealand accident compensation scheme;WINZ, the national income and disability program; the Medical Protection Society, a physician advocacy organization in the event of disciplinary action (it should be noted that in the event of malpractice, patient compensation and physician liability are separate and not subject to the contingency-based litigation).

Needless to say, these sessions were invaluable. Equally important was a talk on the day-to-day realities and demands of primary care practice. The orientation ended with an excellent discussion of the growing movement in New Zealand toward biculturalism. This took place in the National Museum,Te Papa, in Wellington. The two-hour tour was led by two extremely articulate and knowledgeable young Maori women who covered topics ranging from cultural issues in medical encounters to the often troubled history of interaction between the indigenous Maori and the European colonialists. I came away from the session with a much better appreciation for and understanding of the past and the new bicultural future being forged here in this country.

Finally, to round out my medical immersion in the New Zealand primary care world I had the opportunity to attend the annual New Zealand Rural General Practice Network conference for 2 days in Christchurch. It began with a traditional Maori Mihi Whakatau, an invocation ceremony of welcome and thanks that includes Waita (song) and the performance of Hongi, the pressing of the nose, a symbolic sharing of the breath of life which brings all together for the event. I was able to meet numerous doctors and even have conversations with a few colleagues from the US who have made longer-term commitments to practice here. Indicative of the personal scale of this country, there was a two-hour session during which the NZ minister of health,Tony Ryall, addressed the conferees and detailed concrete political measures being taken by the New Zealand government to address primary care shortages. (Imagine Kathleen Sibelius speaking to a convention of rural primary care physicians with actual policies to address actual needs!). Most inspirational was the chance to meet New Zealand medical students and registrars (what we call residents) whose intelligence and enthusiasm were really quite inspirational and cannot help but bode well for the future primary care here.

Today I arrived at my first rural placement where I begin on Monday morning. I plan to use my Sunday to practice left-sided driving on the quiet country roads and to gear up for day one.

Walking in Wellington

Although this blog is not intended to be a travelogue, it inescapably involves physical travel as well as a changing healthcare environment. I had heard that the flight from the US West Coast to New Zealand is almost interminable. I’m here to report that it seemed slightly longer than that. (There is a reason that studies on immobilization and deep vein thrombosis have been performed on passengers flying this route!). Fortunately, I was able to do lots of stretching en route and I did not arrive with any coagulation problems, only some serious jetlag. Even that resolved relatively quickly, however, and when I finally was able to get outside and stretch my legs in earnest, I was greeted by an extraordinarily attractive cityscape bathed in glorious sunshine with temperatures in the 70s. I’ve heard it said before that travelers from the US find Wellington reminiscent of San Francisco with its clear maritime light, hilly bayside waterfront setting and--at least to this Midwestern hick--exotic flora such as palm trees. Wellington has all that and more. Add to this natural beauty a compact density imposed by its location and it’s clear that it’s a place that simply invites exploration on foot.

With a weekend to recover from my jet lag, I opted to do just that. While I was walking past a city hard at play, and enjoying intimate neighborhood street streetscapes I couldn’t help but reflect on the process of walking and its relation to health care. ( You knew I’d work back to this!) Walking is indicative of something vital that we’ve lost and is a potential solution to some of the ravages of the chronic diseases that are increasingly straining our ability to care for our fellow citizens. As with so many things in medicine, it’s really pretty simple: we don’t have wings; we don’t have fins; we are bipedal creatures designed to ambulate. Our entire physiology and structure have evolved for this purpose. And yet, like the obese skeletally atrophic humans many centuries in the future depicted in the recent movie Wally, we seem to be developing infrastructure that makes the exercise of this fundamental physiological skill set almost impossible. Of course the most conspicuous enemy of all is the automobile and the seductive convenience that it allows.In this new environment of left-handed driving an additional threat to life and limb is posed by the fact that every intersection and pedestrian crossing is a hazardous exercise in relearning some very basic pedestrian skills--like looking to the right, not the left when crossing. And as much as I have been telling myself to be very careful, I almost had an incident today that would have allowed me to get an intimate unwanted first-hand exposure to the New Zealand health system.

So even walking has its hazards in my current setting. But I do hope to not only walk as much as possible as a means of everyday transportation, I also hope to experience at least some of the legendary system of “tracks” (trails) that supports the popular NZ activity known as “tramping” (hiking to us).So I hope not only to meditate on walking as a simple preventative health intervention and as a metaphor for more rational health interventions overall, I hope also, if you’ll pardon the cliché, to simply walk the walk.

I may even get a little healthier myself.

Tomorrow starts my 3 day orientation into the NZ health system. We’ll see how it looks.

Medical Tourism of a Different Sort

No, I'm not traveling to Mexico for a lap band, or to Bangkok for cosmetic collegen injections, or to India for a knee replacement--I'm going to New Zealand to spend three months taking part in a "roving locums" program sponsored by the New Zealand Rural General Practice Network (NZRGPN) to provide rural general practices and practioners with short term coverage to allow them to beef up staffing or take a break.

Why New Zealand? Well, aside from the renowned natural beauty of the place, they have a functioning single payer health system and I have a strong desire to experience, first-hand, how such a system really works. That's the Kiwi part of the blog title.

The second opinion portion of the heading reflects my need to reassess my career professionally and politically. In medicine, it is a time-honored tactic to obtain a second opinion if the diagnosis is unclear or if the therapy isn't working. Fresh thinking and ongoing collaboration often offer new insights and better outcomes. And for health care in the USA, a second opinion is desperately needed. While politicians argue and posture, patients are dying for lack of access to even the most basic care. Last year alone there were over 45,000 excess deaths in the US due to lack of health insurance. If over 1,000 wide-body airliners had crashed last year, we would be seeing more than political wrangling and corporate manipulation.

What will I find in New Zealand's health care system? Utopia? Bureaucratic dysfunction? Probably neither. But I do hope to see another approach to any number of questions such as:

• How do New Zealanders themselves feel about their health system?
• What do they love or hate about it?
• How would they change it?
• How is access to procedures and specialists?
• What is the approach to end-of-life care?
• Is there a problem with abuse of prescription pain killers?
• Are there class or ethnicity-based health disparities?

The specific questions are limitless, but I think a general picture will emerge. I hope to learn from these experiences, both clinically and as an advocate for reform at home.

One final note on the blogging process.Those of you who know me personally, are probably astonished to see me embracing this 21st century technology. After all, my data entry skills are notoriously 6th decade. But I can't think of a better way to communicate my experiences to my family,friends and colleagues who have already shown so much interest in what I find.

Bear with me as my skills evolve and I'll try my best both to explore this alternative health care delivery world and to come to a deeper understanding of the past and future of US healthcare.

Welcome!