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Archive for the ‘New Zealand’ Category

One month ago I broke my hand. I’m back to work now, but as I mentioned in my last post I ended up taking disability time off because I wasn’t able to doctor effectively with only one hand.

 

I’ve mentioned it before on this blog, but my dad is a pretty good sport, so the morning after making the decision that I’d be taking some time off work I gave him a call and said “Come visit!”.

 

Without hesitation, he did. Within 24 hours he was on a plane and winging his way to Christchurch. We had a fantastic visit, which I have dubbed “The Broken Hand Tour”.

 

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I picked my dad up at the airport early afternoon, and without any break took him directly to the Canterbury Agricultural and Pastoral Show (or “A&P show” as everyone knows it here). I had spent a few hours at the show last year and had loved it, and it was great to share the experience with my dad. It has all the classic “Farm Fair” things”: animals, classic tractors, fair-food, etc. but also some wonderful kiwi-extras. There are pens of ewes that are lambing, sheep-herding competitions, (I believe there are shearing competitions but I’ve missed these both years), and I love the mix of wares for sale in the expo hall where you will find “the most efficient possum trap” for sale in a booth next to children’s bouncy toys. There are rows of fleeces on display, and lots of silver cups for the champion merino fleece. Both years I’ve loved watching some of the wood-chopping competition, and this year got to see the Jiggerboard event, where competitors make notches in a large trunk which they then stand on to make more notches, ultimately placing three steps before chopping half-way through the top of the trunk before repeating the process on the other side and removing the top of the trunk. (You can see the various ax events here)

 

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The Jiggerboard Ax event: It’s impressive to watch these guys in full swing standing precariously on boards resting in notches they just cut.

 

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Prize winning Merino fleece.

 

This was actually my dad’s third visit to see me in New Zealand, having come over once in the summer to explore and once in the winter to ski. I’d been hoping to get him back for a trip down to Stewart Island (Rakiura), so when he agreed to a last-minute visit I quickly put together plans to do just that. I planned out a southern route, down along the southeast coast, through the Catlins and then over to Stewart Island and then returning through an inland route.

 

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Our loop. Not pictured, the Ferry ride over to Oban on Stewart Island.

 

We set out the following day (after a visit with my hand therapist) and made our way to Dunedin, the second largest city in the Southern Island. We stopped in Oamaru, the “Steam Punk Capital” of New Zealand, where we visited the Steam Punk Headquarters and had lunch at a brewery. Oamaru is an interesting city, with some beautiful old architecture and an interesting vibe. I’m not sure how much the steam-punk scene has changed Oamaru or how much the steam-punk scene just fit in there, but it’s cool, and definitely worth a visit if you’re in the area. If you visit the actual Steam Punk HQ (on Humber St), make sure you spend time in “The Portal”.

 

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From there we stopped in Moeraki, famous for its boulders on the beach, where I spent last New Year camping in the bush and exploring. While other visitors were busy posing by the boulders we spotted a couple dolphins playing in the surf. We made it to Dunedin in the evening in time for a stroll around the octagon and train station before turning in at the Law Courts Hotel.

 

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Moeraki Boulders. This pic is actually from my New Years trip when the skies were blue…

 

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Classic Dunedin architecture

 

The next day we headed off (in the rain) into the Catlins, the sparsely populated south east corner of New Zealand. We spent two days visiting sites such as Nugget Point and multiple waterfalls while spotting birds such as the Royal Spoonbill and various gulls, shags (cormorants), and oyster catchers. On the afternoon of the second day we made our way to Invercargill and spent a couple hours in Queen Park before heading to the southernmost town on the South Island, Bluff, from which we caught a ferry to Stewart Island.

 

 

Stewart Island is 30km south of the South Island and you can get to it by a catamaran ferry or small airplane. It has one town, Oban, with under 400 fulltime residents. The main industry historically has been fishing, and while fishing and aquaculture are still significant enterprises, the main industry these days is tourism. I’ve wanted to visit Stewart Island partly to see some of the cool New Zealand birds which I hadn’t yet seen. New Zealand is famous for birds, but sadly many are quite limited in number and habitat because of introduced predators and habitat loss. Stewart Island is a good place for seeing birds, and Ulva Island, a smaller island within an inlet on Stewart Island, is a predator-free island where native birds are thriving.

 

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The view from our Airbnb across Paterson Inlet: great for watching storms roll in. 

 

Unfortunately, the weather during out trip wasn’t ideal for really exploring Stewart Island, but we did get out on a guided night tour on the day of our arrival and saw kiwi in the wild. The Southern Brown Kiwi are doing well on Stewart Island (in part due to predator control and programs such as dog kiwi-aversion training). We saw about 5 on our hour-long patrol of the airstrip. They really are funny looking creatures. As my dad said “Proof that God has a sense of humor!”. Or proof that funny things evolve in the absence of predators!

 

The next morning, we spent hunkered down in our Airbnb watching storms roll over Patterson’s Inlet. When the wind would die down, Tuis would flit around the trees around the balcony and a Kaka, one of New Zealand’s resident Parrots, would stop by. In the afternoon, the weather settled enough for us to have a stroll around town, and we had a wonderful dinner at the Church Hill Restaurant (the Stewart Island Salmon was delicious).

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The next day, despite the rain, we set off on a van-tour of the island and learned the history of the island and its inhabitants. In the afternoon, we hopped on the Ulva Island Water Taxi, and after a quick briefing from the captain “It’s going to be very bumpy”, we took the short ride over to Ulva Island. I’d checked out various options online, including self-guided tours and multiple commercial options, and ended up asking Peter from Sail tours to take us round. He’s been on Stewart Island since 1969 and has a wealth of knowledge about the human and the natural history of the area. I was very excited to see a number of Saddlebacks, as well as Red Crowned Parakeets and Brown Creepers- birds I hadn’t yet spotted on Stewart Island. (I like birds, and I’m enjoying learning the New Zealand birds, but by no means am I a “birder”.)

 

 

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While Ulva Island has been cleared of predators, it’s not just for the birds… It’s good to give Sea Lions a wide berth. 

 

The seas were so rough on our second day on Stewart Island that none of the three scheduled ferries back to Bluff were attempted. We were scheduled on the 8:30am ferry the following day, which thanks to the cancelled ferries the day prior was quite full. We made it across the Foveaux strait safely, though the crew were kept busy helping a number of passengers who weren’t comfortable on the rough crossing. The boat was called Stewart Island Experience – and some passengers had rather more experience than they probably wanted!

 

To complete our southern route we drove back up through Invercargill and along Lake Wakatipo, skirting around Queenstown, and stopping at the Gibbston Valley Winery before making it to Cromwell where we spent the night.  On the last day of our Tiki Tour* we stopped at the High Country Salmon Farm, where they raise King Salmon in freshwater lakes (specifically in hydro canals outside of Twizel). We had a late, yummy sashimi breakfast before heading to Lake Tekapo to see the classic (though now seemly always crowded) views of Aoraki Mt. Cook. We finally completed our loop back to the Christchurch area via the inland scenic route.

 

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In the last 14 months I’ve used most of my free-time in New Zealand to explore the South Island, and I’ve seen quite a lot of it. There are always new things to see and explore, and in New Zealand there seems to be no end to the natural beauty. I always feel lucky when I have someone to enjoy it with!

 

*A classic kiwi-name for a sight-seeing journey

 

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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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