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Archive for the ‘medicine’ Category

Back in 2013 I wrote a post about an accident I had with a horse which resulted in two broken metatarsals (the long bones in your foot). That post was about how healing takes time, and indeed, my foot did heal with time and patience.

 

Alas, it’s time to remind myself, again, that healing takes time…

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Goofing around on that fateful day… 

A few weeks ago I was out mountain biking with a friend. The irony of the story is that while we pushed ourselves to try out some new skills and sessioned a jump for a while, it was the relatively tame trail back to the car that had me hit the dirt. I can’t tell you what happened (I didn’t hit my head, thank goodness, I just have no idea what happened!) but as my hip and fist collided with the packed earth I was acutely aware that I’d broken something in my hand. In fact, my first words were “I’ve broken my hand” (repeated 3-4 times).

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My X-rays from 2013 needed arrows for emphasis. No arrows needed here: Spiral fracture of the 5th metacarpal and fracture at the base of the proximal 4th phalynx.

The doctor who saw me in the local Urgent Care was confident that I could continue working with my injury. Sure- I couldn’t suture or do some specific physical exam maneuvers, but otherwise I shouldn’t be too limited; at least that’s what he thought. Looking back on it, it wasn’t a smart decision to work with a bulky splint on my freshly-broken dominant hand. Yes, my brain was fully functional, but I could only examine patients using one hand, could only type with one hand, and had to use my left hand to use the mouse and navigate my computer (a task that required a surprising amount of focus- I couldn’t “drive” my computer and listen to a patient at the same time). Despite adding in some extra breaks and a brief stint having a nurse work in parallel with me it became obvious that I couldn’t carry on with work as usual.

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When my patients saw me in this they often said “It looks like you need a doctor more than I do!”. Another classic was “You’ve been in the wars!”. 

 

While I’ve working in the New Zealand medical sector for just over a year, this has been my first experience as a patient.

 

In my last post I wrote a bit about the healthcare system in New Zealand, but I didn’t mention how it’s all paid for and provided. I am no expert on the NZ health system, and the whole system is certainly more complex that I could (or should) spell out in a blog post, but the core organizations are the DHB (the district health board) which uses government funds to provide health care, ACC (the Accident Compensation Corporation) which is New Zealand’s Universal no-fault accident insurance scheme, and some private coverage (either paid out of pocket by patients or by optional additional health insurance).

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The DHB pays for medical care which is needed as a result of illness while ACC pays for medical care (and more) that is needed as a result of injury. The DHB only covers healthcare for citizens and those with working visas 2-years in duration, so if you are travelling (or working in NZ for less than 2 years) and become unwell you are financially responsible for your own medical expenses. ACC, however, covers everyone in New Zealand. If you are travelling in New Zealand and injure yourself you have access to healthcare through ACC. You may have to pay co-pays (For example $35+ for a GP or urgent care visit, $45 for an X-ray, and $20+ for physio visits), but if you have a massive accident requiring a helicopter ride and a prolonged ICU stay, you won’t get a bill…

 

ACC doesn’t just cover medical expenses, it also functions as disability insurance. If you can’t go to work due to an injury, they will compensate you at a rate of 80% of your normal income after one week. If you can go back to work part time they will help subsidize your until you are recovered and back to full time work. They have return-to-work programs, and try to get people back into the workforce in whatever capacity and quantity they are able.

 

ACC helps with other things: if you can’t drive they can provide taxis, if you can’t keep up with your daily tasks they get you in home help, if you need physio and strengthening they subsidize therapies and gym memberships, if you need counseling they cover that.

 

Essentially, ACC is a massive, national, accident insurance policy that is paid for by levies placed on employers, workers, and vehicles. Does the system have flaws? Certainly, what system doesn’t? There are people who defraud the system, and people will complain about declined coverage, but as a clinician and now a client I am very impressed with the system.

 

The day after my injury I was seen at urgent care where I paid $120NZD to be seen (this would be much less if I had a 2-year visa and was thus entitled to healthcare in NZ) and $45 for an X-ray. I then had a splint put on and a week later went back in for repeat X-rays, evaluation, and a more permanent splint at no additional cost. I’ve since seen the hand therapist and visited a physio twice because of a pain in my hip that wasn’t settling with time- both with a reasonable co-pay. I worked for a week with my initial injury, but came to realize that I wasn’t able to doctor one handed and in a splint, so after talking with my boss it was decided that I’d be off work while I was in my current splint and limited to the use of my non-dominant hand. ACC promptly recognized my claim and called me to see if I needed help getting to appointments, help around the home, and what was appropriate compensation while I couldn’t work (information based on last year’s tax return). Thinking about what my ACC levy was last year and what it’s likely to be this year I suspect I’ll get about as much out of ACC as I put in. I’d be very happy if I hadn’t had to use their services, but I’m incredibly glad that a national accident insurance exists in NZ*.

 

I’ve extended my time in New Zealand through March but plan to return to the United States to work and live after that. As I start to mentally prepare myself to return to the US and think about working in a for-profit healthcare system, I find myself already missing the public health system in NZ.

 

5 years ago, when I broke my foot, even though I had medical insurance I ended up owing over $2000 out of pocket for a single, simple, medical encounter.

 

For one medical encounter where I was evaluated, X-rayed and given a walking boot and crutches the total bill was well over $5000USD. The old orthopedist who walked in and said “Doctor, heal thyself!” sent a bill for $2479, including global billing codes for evaluation and treatment of 2 fractured metatarsals (at $1027 a pop, or perhaps I should say a hair-line crack), despite needing no treatment other than protection in a medical walking-boot. My foot healed with time, and my hand will heal with time, but it is high-time that the US figures out how to provide affordable healthcare for its people.

 

(*This also has huge implications in “Treatment Injuries” and physicians are not sued for huge sums as they are in the US in the case of adverse outcomes, but that is more than I care to go into today!)

 

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My dad writes good get-well cards…

 

 

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A World Apart

It’s hard to believe that I have been practicing medicine in New Zealand for 7 months. The time has flown by.

 

There are so many differences between the medical system where I’m practicing in rural New Zealand and where I trained in America. In medical school I predominantly trained in inner-city hospitals, and in residency I largely worked in urban hospitals and clinics. I had occasional electives in rural settings, but the majority of my time in medical school and residency was spent in or near major medical centers. The clinic where I work in New Zealand is rural, but we’re also only 45 minutes from a major hospital in case of emergency. There are also 24-hour surgeries (which would be considered Urgent Care in the US) that will see our patients in town on nights and weekends. This means that my colleagues and I don’t have any night or weekend call, which is fantastic for having a life outside of work.

 

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Rural General Practitioners are not limited to one species…

 

I work in New Zealand as a GP- a “General Practitioner”. GPs are the entry-way into the medical system in New Zealand. Pregnant women can directly go to midwives, and patients can see physiotherapists without referral, but if you need non-urgent medical care in New Zealand you go to the GP who will refer you on to a specialist as needed. Being in a rural, farming, community I see some different medical issues than I did back home. In my first month of practice I joked that I could easily compile a book on 101-ways to be hurt by a cow (or a sheep for that matter), but while there are a few illnesses that people get in New Zealand that I never heard about in training (take Orf for example) the human body is remarkably consistent around the globe. Practicing medicine on this side of the world is the same as practicing anywhere else, just in a different medical system with slightly different practices and medications.

 

In America, healthcare is largely a for-profit industry that relies on individuals having insurance. In contrast, New Zealand has a robust public health care system funded largely by taxation. While some of my patients have private insurance, it is a luxury, not a necessity as it is in the United States. I have been blown away by the effectiveness and efficiency of the healthcare system here- when I have a patient that needs acute medical admission, I call the medical registrar (essentially a senior resident) who agrees to evaluate my patient in the acute assessment unit in the hospital and works-up, treats, and/or admits my patient to the hospital as appropriate. If I have an unwell child that I’m not comfortable managing in the community, I call pediatrics. If I’m not sure which specialty will admit the patient, and the patient needs further workup before that decision is made, patients will be evaluated in the emergency department. But we’re often able to bypass the emergency department, saving everyone’s time and money.

 

If you need non-urgent specialist care in New Zealand, and you don’t have private insurance, you will have a bit of a wait. When I ask a specialist to see a patient I give then triage information, and they may have to wait 4 months to see a specialist. But urgent matters get urgent care, and as a GP I can always call a specialist and ask for recommendations while my patient is waiting for formal specialist review.

 

One of my favorite aspects of the public medical system in New Zealand is Pharmac- the Pharmaceutical Management Agency- the government agency that buys and supplies pharmaceuticals for the New Zealand healthcare system. In brief: Pharmac negotiates and bulk-buys product and supplies all the pharmacists in New Zealand. If a medication can be prescribed by a GP and is a subsidized medication (something that Pharmac buys), patients can get a 3-month supply for $5. They can get a 3-month supply of a blood pressure medication for $5. They can get a 3-month supply of insulin, or a 3-month supply of a necessary inhaler, each for $5. On average, Americans who need insulin spend hundreds of dollars per month on insulin, and I had patients in this category. in New Zealand they pay $5 for 3 months (or maybe $10 if they have 2 types of insulin). I recently started one of my patients on Spiriva- an inhaled medication used for COPD (Chronic Obstructive Pulmonary Disorder). This is an expensive medication, but a General Practitioner can prescribe if they apply for a special authority number. In order to get this special authority I open up a tab on the electronic medical record, confirm that my patient has COPD, confirm that her pulmonary function warrants this treatment, confirm that her symptoms are not controlled on her other medications (and that she’s on other medications) and hit “submit”. In under 10 seconds I can now prescribe this medication for the patient. In the US getting “prior authorization” for specific drugs through insurance companies can take weeks…

 

On the other hand, routine drug prescriptions in the US can be for a year, potentially saving three visits to the clinic every year…

 

I could write about how much I love Pharmac for hours. I’ll admit there are some shortcomings, and in America there are a myriad reasons we can’t and won’t have a system like Pharmac, but I love being able to give a patient a prescription and know they can get a medication for 3 months for $5, and not having to worry if the patient’s insurance will cover a medication for a small copay, not cover the medication at all, or require pages of paperwork from my office to get the medication approved. Of course Kiwis pay for this in their taxes, but New Zealanders see this as a no-brainer…

 

Outside of medicine, life in New Zealand is grand. In the last 7 months I’ve read more books than in the last 3 years. I’ve racked up many Ks on my mountain bike, explored a lot of the south island, and made many new friends.  New Zealand is a great place to work and play, so it’s no suprise that I love it here!

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About 24 hours into the Old Ghost Road… You can see the trail climbing and traversing the mountain to my right. 

Till next time!

 

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