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Actually this is now the last post.
Now, in 2007, I've moved on. To a new life.
To Western Australia.
Working in Aboriginal Health and teaching medical students.
You can read about it at http://notiniowa.blogspot.com

This Is My Last Posting on This Blog

Its been the Fourth of July here Cookouts, hotdogs, parades, fireworks. Vicki and I walked down to the Czech museum to hear John Kerry speak in the pouring rain. Despite the downpour and occaisonal lightning in the distance, he spoke with poise and energy about where our country has been and where it needs to go. And I've been thinking a lot about that too, these last 2 weeks. For the 14th time, I am initiating a new group of residents into medical practice during our orientation month. And just coming back from New Zealand and my practice there, i've had a lot to think about.

"Bottom Line: What have you learned?" My boss is always challenging our Residents with this line. Educationally, we know that having to sum up the "take-home" message after an experience really cements it in the student's mind. So for this last blog, I'm going to try to draw from some observations and make some conclusions.
As I said back in January, my purpose has not been to compare New Zealand to the U.S., or even to compare medical systems. Although some comparison is inevitable I have tried to avoid thinking in this fashion. And I am under no illusions that I am here to change either place, or that I have the power to make much of a change. The question here is really, how have I changed from this experience.

I have been back home for 2 weeks now, and I have been welcomed back like a long-lost son. My first day back in clinic I got hugs from half my patients. Everyone seems happy to see me, and tells me "I bet you're glad to be back, aren't you?". And that's really felt good. Yes, I'm glad to be back, although I also miss New Zealand a lot. One thing I learned is that I'm not very attached to Cedar Rapids, despite living here for 12 years. We have some friends here, and my mother-in-law lives here when she's not gallivanting around the country. But I don't really have an attachment to this place like a lot of my patients and friends do. I didn't grow up here, there are no childhood memories, no exended family. Like a lot of Americans, I don't really have any roots in one particular locale. The place that I live is not a part of my identity- I can separate myself from that. I find it amazing that I could uproot my life and family so easily, and fit so comfortably in another place and culture so far away so easily. I feel a great sense of freedom about that.

Part of that is a boost in self-assurance from just being able to fall into a foreign practice and care for patients. I know I was feeling a bit out of touch, as an academic, with the day-to-day realities of practice. Having not been "in the trenches" for 12 years, it felt good to just be a doctor, see over 100 patients a week and experience that key exciting and terrifying challenge of being a generalist physician: i.e. never knowing what's going to walk through the door next. I like that challenge, I like relating to the patients and trying to understand their lives, and how life is for them. And it's helped me reaffirm that I am teaching my residents truely valuable skills. "Yes, computer skills will be critical in practice, but the trick is work the computer into a good bedside manner, to help BOND with the patient." "Yes, knowing how to look things up is essential, you need to do it with half of each day's cases." "Yes, prevention is really important, and building systems in office practice to facilitate prevention is the only way we'll ever get it done in medicine." "Yes, tracking your own data on your practice is useful to improving your quality of care." These were all things that I reaffirmed from my experience. And their being relevant in New Zealand, as well as in America., tells me that these beliefs are more universal than they are local or cultural.

I learned that I am a lucky man, as it doesn't take much to make me happy. We lived in a small house in New Zealand, with a wood/coal stove and "only" 1 car. It was not a hardship at all. I learned that daily exercise makes me feel better. I ate well, and lived a lower stress life, with amazing effects on my blood pressure. I have resolved to try to not be so driven or stressed, and to continue to take better care of myself, including getting adequate sleep and rest. I reconnected with my love of the natural world, and learned an entire new biology. Our walks in the woods and mountains, our nights under the stars, walks on the "ordinary" beaches of New Zealand put my place in the universe in perspective. I am only very small, and here for a very short time. And there is only this moment.

And I reconnected with the core reasons I became a physician in the first place. I remembered how I was originally admitted to medical school with a research background and an essay that could have been titled, "Why I want to be a research physician". After taking care of a struggling, low-income, new family in my First Year, I was seduced to join Family Practice. I liked patients a lot more than labwork. And it is the opportunity to sit and talk with people about their lives, and incidentally, their health, that to me is the core reason for becoming a doctor. I was lucky to have the opportunity to be a small-town G.P. in New Zealand. You can't be more of a physician than that.

This means I see with new eyes the effects of unbridled capitalism and consumerism on medical practice here at home. On returning to the U.S., some of the first concerns I heard were about the effects of malpractice on our health system. One of our local OB/Gyns has quit delivering because she can't get insurance, and our governor recently vetoed a package of malpractice reform. At the same time, an entire hospital system in the state has terminated its contract with an insurance administrator for the Medicaid program. This means that many low-income patients can no longer see their physicians or use their hospitals. An OB patient due to be delivered by Cesarian last week had just moved to Burlington, and had to come all the way back to Cedar Rapids (over 100 miles) to deliver because no one would see her in her home town. Our non-system is paradoxical. We have the best and most high tech medicine at some centers, and can truly perform miracles, but basic healthcare is lacking for over 10% of our population. We spend the most of any industrialized nation, and have the most unsatisfied patients. Part of that is high expectations that can't always be delivered (hence the number of lawsuits), but another part of the dissatisfaction is in being rushed and pushed though a system that too often treats the patient as a "head sheet" to be processed. And the financial pressures on this non-system will accelerate in the next 10-20 years. I've had a chance to think long and hard about what is ahead as I prepared my annual "Futurology" talk to the residents this week. I am sure we can do better than this in the U.S.

So what does all this mean. I'm not sure yet. Its too soon still to tell. Maybe I will move back to New Zealand in a few years. Maybe I will be more aggressive about challenging the assumptions of our current healthcare system. Maybe I can keep my blood pressure down by walking more. Only time will tell.

I have new stories to tell my residents, and new memories to make sense of. I've exceeded my objectives for this sabbatical beyond my wildest expectations. All I can say is that I can tell that I've changed from the experiences. And that was the whole point.

Homecoming

I woke up at 5 am last Monday to the tremendous rumble and crash of a huge Midwest electrical storm. Our trip home was long and uneventful. Well, at least once we got to the airport in Invercargill. Saturday I realized early in the day that there was NO WAY we were going to get everything into our suitcases, so I ran down to town and bought one more at the Warehouse. That made 5 huge suitcases, so we were one over and would have to pay NZ$175 for the extra bag. Each bag could weigh only 32 kg due to ACC restrictions (to prevent airline worker injury). I had told Geoff, who kindly volunteered to drive us to the airpor, to "bring the truck". He showed up in his car at 0845 on Sunday and was surprised to see that it all wouldn't fit. "Not a problem", we loaded the stuff in his car and some in the Medical Centre vehicle and after a phone call, drove out to Paul's place to gather another driver. At the airport we hauled the bags in from the carpark, and queued up to weigh them. I had used the clinic's scale the night before and was worried as all the patients say the scale weighed "heavy" compared to their home scales. Not a problem: 4 bags weighed in between 31.5 and 32 kg, and 1 bag hit 32.0 right on the mark! Liz was rather oblivious to all this, having stayed up all night with her friends, who left at 3AM, then spending the rest of the night cleaning the house and doing final packing. We said our sad goodbyes, boarded the plane, and then spent the next 28 hours in planes or airports. The high point was our layover in Christchurch, where it was a beautiful sunny winter's day. We went up onto the observation deck, those areas now only a memory in security-paranoid U.S. airports, and sat in the sun, enjoyed the clouds and the wind. The rest of the flight was mostly a blur of movies, sleep and occaisonal walks around the plane to prevent blood clots. I do have to put in a plug for Air New Zealand however, which has great food; the lamb supper was delicious and the eggs for breakfast were hot. Their attendants are solicitous and the plane is as comfy as it could be given the circumstances. So these things are possible after all.
On arriving in Los Angeles, the first thing Liz and I noticed was how fat everyone was. I've decided that when you travel to a foreign country, you expect things to seem strange and maybe even a little bizarre. But when you return home and things that used to be familiar suddenly seem strange and unusual, its very unsettling. The size of Americans really stood out to us after being around Kiwi's for the last 6 months, and this has only gotton progressively worse as we flew thru Chicago and have spent the last few days in the obese Midwest. The other strange thing I noticed in LA was the number of people talking to the thin air. Now in my befuddled jet-lagged tiredness, the first thing that came into my mind was memories of long-ago psychiatry rotations on the locked ward. Had someone let the looney-bin loose in LAX? No, these folks weren't schizophrenics, I surmised, once one got closer and I could see the tiny wire of a cell phone snaking up her neck into her ear. But everywhere we looked, people were yakking away on their phones, filling every minute of time with conversation. What on earth could they be talking about at 10 AM on a Sunday that was so important? The other thing I imediately noticed in the airports was the number of tobacco ads. They were on the sides of buses, the backs of magazines, billboards around the airports, and on the racks of the kiosks. They are subliminal to us, until we are away from them for awhile.
We were glad to arrive home, although the change from winter to Iowa's humid summer temperatures and the many hours of daylight have been a shock to the system. Where I was watching sunrise at 8:45 AM in Winton, here it's getting light at 5AM and sunset is 8:45 PM. I think this has complicated the usual jet lag for me, as the melatonin I tried, that worked so well on my trip to England in '99, has not worked a whit this time. And its really funny how your body lags your mind, so that I find myself reaching for the gearshift with my left hand, using the right hand to signal turns, and in my own home pushing light switches the wrong way.
After the thunderstorm wake-up call Monday, I hauled myself out of bed to find that neither Liz's nor my car would start, as the batteries were not connected. So Vicki drove me in to the hospital, where I joined the "Welcome Breakfast" for our new class of First Year residents, who began their studies that morning. My boss has been incredibly nice, giving me lots of time this week to readjust. I have joined in some teaching sessions, but mostly puttered around resetting my office computer, and opening mail. Among the first things I opened was my DEA number renewal, to find that it has expired last month. So no narcotics Rx for at least 2 weeks from me. I did however, call the DEA and discover that you can re-up online, which saves 4-6 weeks in the renewal process when compared to paper applications.
The topic of mail brings me to the biggest "first impression" on returning, which is that the pace of life here, at home, in Iowa, is just crazy. Vicki received 3 huge garbage bags of junk mail when she came home, and that was only for the first 3 months we were gone (the post office won't hold junk mail for a longer time). Each evening the telephone rings at least 3-4 times with telemarketers. We are bombarded with billboards, ads and commercial come-ons everywhere. Even the post office has teamed up to co-market passport services and the movie "Shrek-2" ("Are you going far, far away?"). And unbridled capitalism has just presented us with too many choices, and it's making us crazy. I had to buy deodorant at the drugstore tonite (another discontinuity, the drugstore is still OPEN here at 8:30 PM). Now, I've used Old Spice in the little round stick since I was a kid, and my father used the same brand before me. Tonight, I counted 17 different kinds of Old Spice on the shelf at the drugstore. That includes different sizes, different shaped containers for the same kinds, and even differences in the color of the deodorant after you roll in on, although god knows I hope no one is inspecting armpits that closely! And this is for just one brand of men's deodorant. I won't even rant about the competition in the women's shelves, or the number of choices in the drug aisles, "nutriceutical" aisles, or natural food aisles. It literally drives me to distraction, wastes time and energy to make all these choices.
And then we come to the biscuit aisle. Where we have a choice among only 3 kinds of cookies: oreos, fig newtons and chocolate chips (in about a million variations of brand, color of filling and fat content, all of which taste like cardboard.) Why, oh why, if we need so much selection in our lives, can't we at least have to spend it choosing which kind of yummy biscuit to have with our tea?

Remember when you were a teenager, and you had a great experience at summer camp? At the end, on the last day, we kids would say goodbye, and tell each other "Have a nice life"; implying we knew we would never see each other again.
Tomorrow is my last day at the Winton Medical Centre, and it feels like the end of camp to me.
Way back when at the beginning of this blog I shared my goals and objectives for this experience, and I typed a lot of words about how I would behave and how I expected to respond. I set up rules for myself and imagined what it would be like, obsessed about how I would perform, visualized problems I would face, etc... Judging from some of the emails I'm now answering from other docs considering an international locum's job, I think this may be a common expression of performance anxiety. Despite trying not to expect anything, its only human nature to have a lot of expectations.
Yet I never imagined what would really happen to me here. I've fallen in love with this country, this community and the people here. Its a heady feeling, and I'm a bit distrustful of it- just as, so long ago, we never trusted our feelings about the romances we had at summer camp.
Maybe things feel so great just because they are so new, and so different from what we've known before. Or maybe its just endorphins from finally getting enough sleep, having only 6 night calls in so many months. Maybe its being free from the constraints of usual customs. Or the feeling of freedom from lack of being supervised, and being freed of our daily chores.
But its definitely very emotional, and I know I will miss everything so terribly much. (I could write a list of things I'll miss, but it would be humungous. And, like a lovestruck girl's gushing praises of her new fiance, the things one loves (e.g. apricot ice cream) are so personal that they ultimately bore others.)

Suffice it to say, that at the end of the day, what I will miss most is not the tui birds, or the mountains on my morning walks, but the people I've met here; my caring coworkers, the welcoming townspeople, and the lovely patients. This has been a very special time in my life. Like those golden days of summer camp, I know in my heart that it has been a once in a lifetime experience, one I will never forget. To the people of Winton, and especially the Medical Centre, thank you for everything. Here is a little slideshow, an Internet valediction.

This is my last week in Winton, and I'd rather blog than pack.










I have been savoring my last weeks of work here by walking along the edge of town in the mornings, watching the sunrise over the Takitimu. The sun came up this morning at 0845 AM, very late, as we approch midwinter at the end of the week.
The medical centre had a "midwinter dinner" hosted by the local hospital board on Friday, at Red's in downtown Winton. It was very nice, an opportunity to sit and visit with my coworkers outside of the office. Liz came with me and we ate a huge dinner. The staff presented me a great picture book about Southland. Most of the coffee table books you see of New Zealand try to capture the stunning monumental scenery in large pictures, and there are certainly some of those in this book. But I especially cherish it for the everyday scenes it contains: pictures of the local people, cows in pastures, hills and bridges, sheep of various types, shearing, etc. It is very unusual for the great job it does of capturing this region's special character and charm.
Saturday morning I ran "down to town" (Invercargill), did some quick shopping, stopped to say bye to the keas and kakas in the Queens' Park aviary, then came back home. Liz and I hung out in Winton in the afternoon, and I took a nice walk around the outskirts of town, on a blue-sky day that was absolutely still, no wind. The winter weather pattern here is 3 days of rainy weather followed by a day or two (3 if lucky) of quiet sunny cool weather.
Since yesterday was the rare third day, at least in the morning, I went fishing out on the Foveaux strait with friends. This was near Centre Island, in the ocean, about 1/3 of the way to Stewart Island.
It was just stunningly beautiful; a bit cold and windy, but with sun breaks. The mountains were all snowscapped in the distance, you could see the Takitimu mountians from the ocean, and the HumpRidge and Fiordland beyond shining in the sun under tatters of ragged clouds overhead. At one point we had a dozen mollymawks swimming off the back of the boat. We filled a large chillybin 3/4 of the way full with blue cod- they were biting like crazy. At one point I climbed up on the bow to pull the anchor, and I just sat there and looked around for 10 minutes, it was so beautiful and wild and untamed. It took my breath away.

The Ball was this last weekend and we are still recovering. Well, at least Liz is. I got off work a bit early on Friday to come home just in time to meet them all heading out to "the Hideaway", a private hall where the pre-Ball supper was being held. I'm not sure who did all the organizing of things for the young people this last weekend, but my admiration for their organization is unbounded. The evening began with a "supper" from 5:30 to 7:30, which was really a chance for everyone to admire everyone else's outfits, and for parents to quickly pop in, grab their photos, and pop out. It was held in a little hall and garden place 5 km down the road from Winton. I took my pics and left the kids to it. Liz reports that The Ball, an "official school function" ran from 7:30 to Midnight. There was no alcohol at this dance, which was held in the Memorial Hall in downtown Winton. The theme was "Bonnie and Clyde", so some of the kids were dressed in retro-30's fashions I've heard. The Ball had a live band, and there was dancing, so much that they complained of sore feet. Then, after the Ball, Liz and her friend returned home (where I was falling asleep watching an old film noir from the 50s on the telly) to change clothes. Then off again to the police station, where chartered buses took them to the After Ball party. Now this affair is "NOT an official school function", so alcohol is permitted, but only beer and premixed drinks (no bottles of whiskey, etc). The police have been notified and approve of the functions, and they escort the buses to the hall, which is held in a [wiggle fingers] secret location [end wiggling fingers]. No one knows where the After Ball is going to be until the buses arrive. (It was held at the Drummond Community hall, about 7-8 km from town). One at the After Ball, the young folks are allowed in the hall, but not back out again until the party if over. This is enforced by 8 huge ex-rugby players who are hired as bouncers for the event. The goal is to prevent party crashers, drink drivers, fights and general disruption of a fun evening. The AfterBall was deejayed and loud by report. At 0530 sharp the kids pile back on the buses, are dumped back at the police station in Winton (in the pouring rain) where they walk home to promptly crash until the late afternoon on Saturday. I woke up about 0830 to find the morning newspaper already brought in and on the coffee table. So most of my long Queen's Birthday weekend (we had Monday off) was spent keeping quiet in the mornings.
I was struck by some of the eminently sensible things that happened around this Ball. First of all, the drinking age in New Zealand is 18. And this is a source of great controversy, since the drinking age was lowered in 1999. And it is not illegal for someone over 18 to supply a minor with alcohol. Now I won't say that there aren't some people with drinking problems in New Zealand, but the entire attitude towards young people's behavior is less prudish and more practical that in the U.S. It seems to me that most children here learn to drink alcohol in a family setting, and most emulate their parents behaviors. In many restaurants you will see younger teenagers having a glass or wine or a beer while eating out with their families. This certainly has to be better than learning how to drink for the first time from your friends, or at university, as in the U.S., with little parental advice or supervision. And the involvement of the police, to approve parties, with plans to hire bouncers and chaperones who can handle undesired behaviors has the effect of preventing those behaviors. It also reinforces the social message that "if you're going to use alcohol, you will be help responsible for your behavior". New Zealand has drink drivers for certain, but there is much less tolerance here for having ANYTHING to drink and getting behind the wheel. This is in contrast to America, where the focus is on staying "under the legal limit" (which is the same here, 80 mg/dl as in many States). And New Zealand police routinely set up road blocks and test every driver that comes along. In 2002 the N.Z. police administered 2 million breath tests- that's 1 for every 2 citizens in the country!. You can imagine how American lawyers would have a field day with "illegal search and seizure" with that one. ([RANT MODE ON] Note that my oldest daughter, a U.S. citizen, recently returned from Canada WITH HER PASSPORT in hand, and was hassled at the border about whether she was really a citizen or not, and had her car searched and questions asked about all the items in the car. We in the U.S. now have NO problem with search and seizure for anyone who might have the smallest potential of being a terrorist- including a young 5 foot tall Korean-American violinist returning from visiting a school friend. And yet, I'm just TERRIFIED every time my children go out on a Friday or Saturday night, because I know that drunk driving is the most common cause of death among teenagers, but god forbid that we might do searches of people privileged to drive in America because it might violate their right to drink at the same time. [RANT MODE OFF]) And any doctor who has ever worked in an Emergency room for any length of time has at least a little post-traumatic stress disorder from witnessing the terrible carnage drink driving can do to innocent people.
All I'm saying is that when Elizabeth told me about these arrangements, I worried a LOT less about her being out (and the weather was simply awful with rain and hail) than I would have in the States. And you can draw your own conclusions about the effect these customs would have on the American tradition of losing one's virginity on Prom Night, a subject hilariously portrayed in the movie, American Pie, which made millions of dollars. I won't even talk about the attitude towards family planning in the United States, because the Bush Administration has said it all. In response to the court decisions recently overturning some abortion laws, they declared that "The president is committed to building a culture of life in America ". This is compared to his work in Iraq, where he has successfully built the opposite culture. [RANT MODE REALLY OFF NOW!]
In my mornings, when the house was quiet this weekend, I went walking in Forest Hill reserve, around the town, and yesterday, up the country roads in the hills above Ohai, a town in the foothills of the Takitimu range about 40 km from Winton. Here are two pictures which capture the early winter mood in Southland that I alluded to in my last posts.