Christmas and New Years
There haven't been many posts lately and its all Leah's fault. Our house is usually quiet and peaceful, but when she comes home from college its full of noise, music and laughter. That's not a bad thing. She has enjoyed staying home with us, NOT practicing violin, and cooking a lot in the kitchen. The Food Channel and Martha Stewart are apparently favorites of her college crowd, and she is constantly coming up with little food fact tidbits that are funny or surprising.
Our tradition is for me to take my daughters out shopping, for their Mom, on Christmas eve. I was on call that day, so we went the weekend before. As they've gotton older, we bring Vicki along also. We went to our favorite restaurant, Sushi Popo, in Iowa City, then to complete the day, took in The Last Samurai for our holiday movie. It was a great day. However, it led to some fallout later in the week when the girls made Christmas cookies. True to form, this was the LAST Samurai cookie to be eaten.
We kept Christmas simple, staying at home. We've wanted to spend a lot of time with Leah since we won't see her for 6 months. Liz did most of the Xmas decorating- her "5 minute" decorations could give Martha a run for the money I think.

We ARE getting ready to go. There are a million things to do. Spent last weekend doing financials and backing up data from computers in the house. Doing a lot of cleaning and organizing. Going to the store for last minute things, or ordering them express on line. My electronic stethescope went on the fritz last Friday, so I had to frantically order a new one rushed, so it wouldn't arrive the day after we leave. Found a good deal online, and it arrived today.

Leah and I did have time to sneak away Sunday for an hour to see the new IMAX movie here in Cedar Rapids: Shackleton's Antartic Adventure. I'd read South a number of years ago. Ernest Shackleton, the explorer, was an unsung hero who is only now, almost 100 years later getting the recognition he deserves. His book is very "matter of fact"; when you see the size of the ocean, icebergs and mountains he survived, it just takes your breath away. This is the kind of film the IMAX was invented for. The views of the icebergs, wildlife and seas of the Southern Ocean and South Georgia are stupendous and have an otherworldly beauty. I don't think I'll ever get to Antarctica, but I do hope to at least see some penguins in N.Z.

Everyone has been asking me if we're packed, ready to go, feeling excited. I would say that we're excited but also a little terrified. Vicki's dislike of flying, the terrorist alerts and the distance all make it a little daunting. I can find new things to worry about every day. I think it is natural, with only a few days to go, to wonder what we've got ourselves into. The Shackleton film was helpful in maintaining perspective. New Zealand is a civilized and friendly country. It helps to remember: "No matter how bad a fix you're in, its never going to be as bad as the one Shackleton encountered." And he brought every man back alive.

What Have I Forgotton

This week feels like I've done most of the "do way ahead" (passport, documents, reservations) stuff, but its still too early to pack. It feels like I'm in limbo, and a little unreal. Because three weeks from today we start driving around NZ. I have this terrible feeling that I've forgotten something crucial.

The one cool trick I've found in the last week involves the mail. The post office will let us do a temporary "change of address" so I can forward all our mail for someone to check through while we are gone. They will only forward magazines for 60 days- and frankly I could miss most of them, but it seems a waste to just pitch them. I found that its a snap to change your magazine addresses on-line. You just go to the site- like Newsweek- and put in your old address. The magazine will find your subscription, and then let you change it to a new address. I guess like Rings of Power and nuclear physics, this trick could be used for evil purposes, but in this case I've sent the magazines to my mother-in-law who knows a lot of people who might like to read them. And she can save the Natural History magazine for me.

I've spent a lot of time in my clinics the last month talking to patients about "who will cover for me" while I am gone. While there is much bemoaning the statistics that show patients don't value "continuity of care" [one study showed patients would switch doctors for $5 difference in price!], I sure don't find this to be true. Some of my patients have been really upset. Goodness, its only 6 months, and it might mean 1 visit with someone else for many of them! I don't feel like I'm that special or irreplaceable. But then I think how I've missed some of the professionals I've seen for years- my optometrist from Quincy, my dentist when she injured her hand- and I can see their point of view. Its the security of seeing someone you know, versus the anxiety of having to meet a new person when you don't feel well. The most poignant visit was with one of my little ladies who is in her late 90's. We both knew there was a great chance I might not see her again at all, or at least in her current state of health. That will make me sad. I'm not sure I've done much good for her, but we've had some great talks about end of life care, and the death of her husband a few years ago. I imagine it must be very hard to lose so many people, and be one of the last survivors of your generation. She said goodbye with such grace and humor however; I only hope I can emulate her in my dotage.

Plans

I don't start actually working in Winton until January 19. So we are going to do some traveling around New Zealand before that. I have my interview with the representative of the New Zealand Medical Council in Christchurch on January 6, and then I've reserved a campervan for the next 10 days. When we've traveled other places, we've followed a philosophy of picking one area, and learning about it in depth, rather than hopping all over the map. I like this approach, and some of the best travel memories we have are of the little places not found in travel guides. New Zealand is a large country, so we've decided to focus only on South Island, and not go to the North. So far I am trying to resist the urge to plan every moment down to the tiniest detail. However, I did give in to making a "booking", as they call a reservervation, to swim with the dolphins in Kaikoura. I read about this in the book "Kiwi Tracks", and the advice to "sing to the dolphins" through the snorkel just sounded like a lot of fun.

However, I got to thinking about snorkeling, and realized that withouit my glasses, I might sing to them but never see them. This led to a bit of web research about low vision in divers. Turns out you can order specially made diving masks that have corrective lenses. These are, understandably, pricey. There are some "stick on" inserts you can order to put into a mask, but they only go up to 3 diopters, and I need 7. However, one site suggested getting some disposable contact lenses. So I called my optometrist, Dr. Kimberly Cruise who was just wonderful, and has provided me with some trial disposable lenses. I will need to put them in and try them out before the trip, since I've not worn contacts for about 10 years. So we should be all set, providing the weather is not too bad, and the dolphins show up.

The plans after that are to NOT have a plan, but to creatively wander around the north part of South Island and talk to people, and follow any leads. Vaguely we might go to the beach in the north, and visit the glaciers on the West Coast. We will save Southland for day trips on weekends later in the summer and fall.

The next thing to do is finish up the To Do list and start packing. I did find a cool site, for a Universal Packing List, that is going to help us get organized, I hope...

Little Details
When I was about 10 my favorite author was Robert A. Heinlein. His science fiction was really great because of all the little details he put into the stories. These little changes, like the invention of something to permanently eliminate the need to shave facial hair, really made his alien cultures and far planets come alive.
We're dealing with some of these details now. New Zealand runs on 220 volt current: U.S. has the 110 volt standard. Even the plugs are differently shaped, and I guess that's a good thing to prevent blowing out U.S. made equipment with the higher voltage. However, it sure is strange that so many parts of the world use different standards for voltage and TV transmission, etc.... Turns out my laptop runs equally well (through the charger "brick") on either 110 or 220, so all I'll need is a plug converter for that. However, the Braun toothbrush only runs on 110 volts, so we will either need to buy a voltage converter device or buy a new electric toothbrush in N.Z. Vicki doesn't think she can use a "manual" for 6 months and still feel she has clean teeth. I agree that the Braun is a superior instrument.
We will have to set up a bank account in N.Z. on arrival, but how to be sure of cash flow is another detail. I read that ATMs in N.Z. won't work with a credit card that doesn't "have a PIN built into the card". How do we know if our cards have built-in pins? I don't think ours do at this point. A doctor I met at Mayo earlier this fall told me to avoid taking a cashiers check or bank transfer papers, as her transfer took over 4 weeks to clear. The modern electronic age! Vicki is checking with the bank.
The other detail we looked at was baggage allowance. Air N.Z. allows "2 pieces of baggage per person with a maximum combined dimension (length + width + height) of 158cm (62in) per piece
Each piece cannot exceed 32kg in weight". Carry on allows purse, walking stick, raincoat, and " 1 piece with a maximum combined dimension of 115cm, Maximum weight of 7kgs per piece". If we carry 2 laptops, and Liz's viola, we might be able to stuff in a bunch of stuff into "purses" and get by. But to plan for 6 months of varied activities from hiking, to working in clinic, to social events and get it all in to 64 kg. per person will be a challenge. I think my size 13 shoes probably weigh 4 kg. per pair alone.

There's an interesting article today on Stuff.com about lack of physicians in Gore district, Southland, NZ. Gore was an area that I was very interested in going to at one point this fall. We got as far as a telephone interview, but apparently the NZ Government filled the locum spot with a physician from their pool, who took priority over me. Winton is not far from Gore, and I suspect has the same type of needs- we'll see when I get there.

Yesterday and today spent some time working on my checklist of Things to Do before leaving. One of them is health insurance. Our current insurance, John Deere Healthcare, will cover any accidents overseas, but no illnesses or hospitalizations. Also, since 1/2 of my leave is unpaid, I would have to COBRA in order to keep coverage for the 3 months, and that would be very expensive. New Zealand has comprehensive coverage for all permanent residents and emigrants, but not for guest workers or visitors. EVERYONE in the country is covered for accidents and emergencies, but that is all. Global and others have recommended purchasing health insurance and comprehensive "cover" as they call it for other problems. I contacted Medical and Health Insurance Brokers of NZ. It turns out that a very reasonable family coverage that includes travel insurance, health and illness, disability, death, kidnapping, hijacking, loss of possessions, and repatriation or air evacuation covers the 3 of us for NZ$618 (or US $399.11) for 6 months. This about what 1 month of COBRA for John Deere would cost. We will arrange to use the vacation days to keep daughter Leah covered at the beginning and end of the term, and use college health insurance for her coverage in the interim during the unpaid leave.

Other things on the checklist have to do with getting the house ready to mothball. I spent Saturday afternoon digging a drainage ditch for a gutter, in case there is a heavy rainstorm. Will have to arrange for a plumber to come winterize the house, in case the power goes out. Tune up the burglar alarm, install large guard dogs and the kid from "Home Alone". I've had a few anxiety dreams about the house getting hit with a tornado while we are gone. But when I woke up, I thought, "what better time to be in New Zealand than when a tornado hits the house!"..

Paperwork, Paperwork, Paperwork

How did we end up going to Winton? This process started over a year ago. The first paper I filled out was Global's application, which included some letters of reference. This essentially "got me in the door" as a viable candidate for their marketing. At that point, I was assigned to a marketer, Julie, who talked to me on the phone about my interests and answered questions about the opportunities. Global sent me an information packet, which included some really nice information- including testamonials from other docs who have done this, and a "survival handbook" for being a doctor in Australia (sample tip: "never let the vacationing doctor you are replacing leave without getting his computer password!"). Julie also sent me 1-2 page summaries about different communities in both countries that were looking for help in my areas of experience. This led to hard decisions for me and my family- did we favor one country over the other, did we want to stay in just one place or move around, large or small community, tropical and hot (northern Queensland) or cold and rainy (South Island, NZ)? We looked at all the communities, and it became a periodic dinnertime discussion. Ultimately we focused down to New Zealand over Australia (we'd lived in desert and tropics before), access to ocean and mountains (we live in IOWA now), and stay in one area. I wanted to return to rural practice and we decided to visit and learn one area well, with a goal of making friends and maybe Liz would even go to school. Global helped us focus then on New Zealand. We considered several spots, on both North and South island, but as things just worked out over several months, were able to secure a posting in Winton. (I did make an error along the way and get too attached to the idea of going to one community which didn't work out. I think its really important to be flexible and open to new experiences, and not try to control too much about what is going to happen. At least that's what I'm telling myself about this whole experience. Hard for a doctor to not be in control!).
Then the paperwork starts. First we had to renew passports, which expired this year. Not hard to do, but we all had to go down to Walgreens for the cheapest (and ugliest) passport pictures in town. Second, I had to apply for a New Zealand license. This required filling out another form, getting 3 original letters of reference from doctors who knew me, and sending documentation of

• MD Certificate
• Internship Certificate
• Residency Certificate
• Board Certification
• Original Certifcate of Good Standing from State Medical Board
• Copy of Face page of Passport

The 3rd major task is getting Visas: a work visa for me, student visa for Elizabeth, and a visitor's visa for Vicki. For the visa, we had to prove we were married. But, NO marriage certificate in the lockbox! So I had to write to Maine and get them to send me a new one. And Elizabeth needed a notarized birth certificate. But thats not all; now that the tentative temporary license has gone through, I will have to bring originals of most of the certificates and diplomas above to a final interview in Christchurch the day after we arrive, where I can be examined and certified to speak adequate English.

When is a Sabbatical NOT a Sabbatical?
When I've talked to friends in Family Medicine about my plans, their first questions are always "How did you get your boss to pay for this?", and "How can they let you go for so long?". Actually, Global really wants doctors who can stay an entire year whenever possible- 6 months is not optimum for them. However, the Foundation I work for does NOT provide for formal sabbatical leave, so I can only stay 6 months. I don't know of any community-based residency programs that do this; just a few universities, and its seems to be fewer and fewer all the time, with budget cuts, etc.

The way this is working for me is, first, I have an incredibly supportive boss who has encouraged me for the last year and 1/2 to do this. He has supported me by going to our Board and encouraging them about this, and in working hard to provide coverage for my job while I am gone. Secondlly, I have accumulated a large amount of "vacation time" not taken over the last 12 years. I am going to use all my vacation days up during the 6 months process. That will give me pay for about 3 months. The other 3 months are an official "leave of absence". Global pays a living stipend for the days I will be working in New Zealand, and that will help fill in the gaps.

When my boss and I first started talking about this leave, he asked me to do some "goals and objectives" for the Leave of Absence (LOA). Here they are:

I would like to experience medicine in a country with a different health system and medical values. I have become particularly interested in Australia or New Zealand, as they both have national health systems and networks of small medical offices that are more computerized than those in the United States. I hope to see and treat a different population of people with problems that I have not seen before. Because I have always seen myself as primarily a rural physician, I hope to reconnect with this identity. And above all, I hope to learn from my coworkers and patients to be a better physician and teacher. With these thoughts in mind, I have prepared the following plan.


Goals and Objectives

Goals	Objectives	Activities/Timelines
1. Experience Family Medicine in another culture	" Perform locum tenens in a rural or suburban practice in New Zealand or Australia" Work as a member of a egalitarian healthcare team	December 2003-June 2004 Keep diary of daily practice and activities Possibly post web site for CRMEF with "tales from the front" about my experiences
2. Learn to diagnose and treat a different population, with assorted unfamiliar medical problems	" Look for opportunities to serve some underserved population, may include aboriginal peoples " Possible practice location with tropical diseases " Possible involvement in community health activities " Possibly gain perspectives on obstetrics as performed overseas	Planning: Now to Dec 2003, may include study of tropical diseases or other preparations, readings, etc. Onsite Dec 03-June 04: CME and reading, use of Internet if available
3. Examine the use and management of medical information (medical informatics) in a different health care system	" Learn to practice in a national health care system " Learn charting and preventive care practices, examine from an evidence-based perspective	Orientation and training before leaving and on arrival Keep track of practice differences between American and foreign systems
4. Gain new perspectives on office and practice management	" Work with office manager to understand payment, coding and office systems	Ask for help and guidance from office staff and hospital
5. Refresh time management skills needed to work in a "production" setting	" Keep up with expected numbers of patients seen daily in office and hospital	Use PalmPilot for reference when possible, learn appropriate reference use for office practice. Learn efficiency rules/tricks from other staff
6. Spend time with my wife and daughter exploring another country's culture, geography, and history.	" Vicki may work if opportunity available " Side trips on weekends or break time; 1-2 weeks at end of locum tenens to explore interests	Plan to visit historical sites, natural areas. Will take advantage of community activities in the arts, festivals, etc.
7. Provide my daughter with new perspective on her education and future career, from experiences overseas.	" Elizabeth will make new friends overseas. " She will listen and learn about a different culture	Elizabeth will attend school overseas if in session; if not available, will pursue guided independent study
8. Revitalize and rejuvenate myself	" Eat right, get plenty of sleep, and exercise and find joy every day in the act of discovery and learning	Ongoing

Thought I'd fill in some details today. I've been overseas in a medical capacity once before. From about 1985 to '89 I served as medical advisor/board member to Adoption Services of WACAP. As part of my service, I traveled to South Korea and visited the Holt Adoption services center in Seoul. Our team met with the Korean doctors, and examined and gathered information on special needs children looking for families. It was a great experience, and got me interested in overseas medical work. However, my private practice as a rural doc in Quincy, WA (1982-1992) kept me really busy and offered no other real opportunities for this kind of work.

In 1992 I joined the Cedar Rapids Medical Education Foundation, a family practice residency in Cedar Rapids, IA. I remained interested in an overseas experience, but again time and resources and kids made it a low priority.

Then a variety of things happened. In the mid 90's l learned that I was becoming hard of hearing, and started wearing hearing aids. This restricted my options for overseas practice, i.e. ruled out any country where English was not spoken! It is hard enough to understand medical histories in English with hearing aids (especially when the housekeepers are running the vacuum cleaners just outside the door- but that's a rant for another day!). It became clear to me that I could never handle Spanish or another language, or even an interpreter with any facility.

In 2001, my oldest daughter Leah graduated from high school and went off to music school in Cleveland. 9/11 happened, ruling out about 1/2 the world for medical missionary work, from the point of safety. However, I attended the AAFP annual meeting and met some very nice people from Global Medical Staffing. These folks specialize in placing academic doctors like me in locum tenens spots in Australia, New Zealand, and a few other countries. I began talking about doing this with my wife, which led to the talk below with my youngest daughter, and here were are!

I'm now in my 22nd year of practicing Family Medicine, and feeling time for a change. So I'm taking my family (wife, youngest daughter) with me to New Zealand for 6 months, where I will be working in a small town medical clinic in the South of South Island.

Why am I doing this? The main reason is that Elizabeth, my youngest, just graduated from High School last Friday. In a few months my wife and I will become "empty nesters". When I was talking about doing this "after Liz finished high school" last year, she piped up and said, "Why are you waiting? I want to go too!". This means she will miss graduation ceremonies, Prom, last 1/2 of Senior year- but she has consistently wanted to go during the entire last year and a half that we have been mulling this idea. So she gets her wish.

Also I've just turned 50, I had knee surgery last year that put a dent in my hiking abilities, and life is short. Maybe its midlife crisis. Let New Zealand be my "Red Ferrari"! We intend to have a great time.