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.

As winter grabs ahold of Southland, the mood has changed here. We've had lots of rainy cool days, with "frisky" winds as they say on the TV. When we have had a sunny day, we've been sure to try to walk outside. On Vicki's last weekend here, we walked in Forest Hill reserve, and the next day drove out to Lora Gorge road and walked up the stream to the end of the road high in the Hokonui Hills. The pastures are still brilliant green, but there are less sheep about and days are short, and often windy.
I worked Urgent Care on Tuesday night 8 days ago, and coming home at 10 pm, pulled off the road at Forest Hill to look at the stars. The valley floor was foggy, but taking the side road up the hill to the Forest Hill cemetery (very small rural location, maybe 30 graves) I drove up out of the fog and into clear air. I parked and turned off the lights and got out. The moon was setting over the mountains of Fiordland in the west, and I could barely see the Takitimu peaks in the reflected light. But overhead, the winter stars were brilliant. It is so rare to find a truly dark place anymore, but on Forest Hill there were only 2 or 3 farm lights visible in the distance. I had wanted to look for Comets NEAT and LINEAR, but was unable to spot them without my star map or binoculars. No matter, the Milky Way was luminous, and something I had never seen before, the dark gas in our galaxy could be clearly seen to blot out the stars. This was only because in a truly dark sky, the gas clouds are blacker than the "sky between stars". In other words, once your eyes adjust, you can tell the difference between sky that has minute stars in it that you can't resolve into points, and patches of sky where the dust clouds in the Milky Way blot out everything. It was so amazing I dragged Vicki back the next night, and even though conditions weren't as good (moon still up) it was still fabulous. We were able to see both comets, but you had to know where to look, and even with binoculars they were still just fuzzy snowballs in the night.
One of the traditions here is that each locum in the practice gives an in-service to the staff at the monthly educational lunch. Last week, it was my turn, so we talked about "hypertension". I chose this topic because my patient log (see previous blog) showed this was 18% of visits to the office, and that "only" 25% of patients were at goal pressures (which is actually pretty good compared to many other countries stats). And also because there is good community awareness of cholesterol and PSA facts, but it seemed, much less awareness of the dangers of high blood pressure. My focus was to talk about the current guidelines, and I made clear that I wasn't telling the practice what I thought they should do. Our visiting cardiologist, Dr. Patrick Kay had kindly sent me the recent Australasian guideline for Hypertension, from the Australasian Heart Foundation, so that is what we reviewed. (It was also a bit more up to date even than JNC7, as it is newer.) New Zealand has also produced a downloadable cardiac risk calculator that is used worldwide so we also talked about that. That same week, I wrote a small article on hypertension for the Winton Record, the local paper. Because the practice is now part of a PHO here in New Zealand, the Winton Medical Centre will need to do a quality improvement project in this next year, and I am hopeful that they will decide to address hypertension in our patients.
Vicki walked around town every day last week, and up on Forest Hill several days. She spent most of last week getting packed, cleaning the house, and taking care of details, before her flight back home last Saturday. As we backed out of the driveway, she said, "Goodbye, 33 Queen Street!" She has loved our time here in this little house. She made it back to Cedar Rapids ok, after a 30 hour trip, several delays, and the usual Customs and baggage hassles. Elizabeth is still here with me, looking forward to attending the Central Southland College Ball tomorrow night. Liz has been doing most of the cookings and I clean up and we get by ok.
I am really glad plans changed, and I am not here the last 3 weeks by myself. My patients are being really lovely and expressing their sadness that I am not staying permanently. We have many geriatric patients here, and the older men frequently say goodbye like this: "Doctor, I want to thank you for taking care of me and I hope you come back here some day for good. I won't see you again, I know, but it's been really nice knowing you." With the unspoken implication that they know they are not going to live long enough to see me return.
Now I really think this highlights one of the wonderful things about rural practice that is often forgotten. In medical school, we are "rotated" through different wards and practices. One of the effects of this style of training is that it reinforces the practice of keeping distance between doctor and patient. We are encouraged to be "objective". In fact, the Professor who interviewed me in Christchurch for my NZ license gave me, as parting advice, the admonition, "Don't get too close". I have only been here five short months, and many of these patients I've only seen 3-4 times. And even though people know I am a temporary doctor, they have invested something in making friends with me. It would be tempting to think that its something I am doing, but I don't think that is true, having practiced other places. I think it is the nature of the people here in Southland. They just connect to each other. They are a true rural community. And it is a darn shame that rural towns like Winton are becoming "endangered" worldwide, and its sad that so many of these little towns, in both New Zealand and the U.S. can't find a doctor. Because it is these friendships that make practice enjoyable and worthwhile.

At the local nursing home, a demented 98 year old lady whacks her 93 year old roommate with her cane, causing a large scalp laceration and much consternation for the staff. A local boy riding his dirt bike is hit in the kneecap with a rock. A retired farmer presents with deafness due to many years of tractor noises. A young woman requires counseling for sexual abuse. And a patient suffers a drug reaction because her doctor forgot to ask about past allergies. And finally, my personal candidate for this year's Darwin Award: a young Israeli tourist parks her car on Oreti beach where it is promptly buried in the incoming tide, and then in response to being jilted, decides to walk the Milford Track alone in the beginning of winter, falls down a cliff, climbs back up same cliff only to fall down again and break her femur requiring her to lie in the cold rain for 2 days waiting for rescue because she didn't rent a $15 locator beacon. What do all these cases have in common in New Zealand? They're all covered by ACC.

ACC is the "Accident Compensation Corporation". It is a "scheme" (which in New Zealand has no sinister connotations, but rather means "an organization") that provides no-fault insurance coverage to all permanent residents of New Zealand for any accident, pretty much regardless of the cause. In return for this extensive coverage, in New Zealand law there is no provision to sue for personal injury, other than for "exemplary damages". To quote their web page:

The scheme:
• provides cover for injuries, no matter who is at fault
• eliminates the slow, costly and wasteful process of using the courts for each injury
• reduces personal, physical and emotional suffering by providing timely care and rehabilitation that gets people back to work or independence as soon as possible
• minimises personal financial loss by paying weekly earnings compensation to injured people who are off work
• focuses on reducing the causes of these problems – the circumstances that lead to accidents at work, at home, on the road and elsewhere

To emphasize how different this system is, let me make a few points. Unlike "Worker's Compensation" in the U.S. and other countries, ACC covers any accident, anywhere, whether the injured person is employed or not. This means it covers auto accidents, injuries to single mum's who are unemployed, schoolchildren on the playing fields, and even foreign tourists who are hurt in New Zealand. Because it is" no-fault", ACC's only concern is to be sure that the injury was truly accidental and not a form of illness- and even then it will cover an illness aquired at work, such leptospirosis in a dairy worker.

The same company that is paying the bills for injuries and accidents is also charged with ensuring worker's and citizen's safety from accidents. Thus we see wonderfully shocking public service announcements on television. In 15-second shots interspersed between other commercials, a dropped cigarette burns down a child-filled house over the 3 minutes of the commercial break. Or the anti-speeding ad, which shows two cars crashing into a lorry, the car going 5 kph over the speed limit being totally demolished compared to the law-abiding driver's car which has a slight fender bender. Or, most painful to watch, ads that seem like they are selling house paint, or cleaning products, only to have the actors take tremendous falls down stairs and off ladders. And my personal favorite, 2 minutes of progessively more and more serious car crashes in intersections, to the tune of "Don't Worry/Be Happy!". ACC even pays for the bus and part of a program helping police keep drink drivers off the roads here.

Additionally, once patients enter treatment, ACC is committed to having doctors follow the best evidence for rehabilitation and treatment. Thus, in only 5 months here, I have received in-service material that includes evidence-based guidelines for treating back injuries, complete with a kit of patient education materials; a one-hour visit from the local ACC health educator who talked to us about the best ways to obtain services for occupational hearing-loss and sexual abuse/rape patients, and a providers handbook with more resources and references than I've had time to read. ACC also has a phone hotline that I've used a few times to facilitate referrals or entry into rehabilitation services under special case management.

Malpractice is also covered by ACC. In fact, its not even called malpractice here anymore. It's now "medical misadventure". Recent changes in the name and administration of medical accidents make New Zealand a world leader in preventing malpractice. As outlined in "To Err is Human", medical accidents are inevitable. The no-fault system supports the principles of error recognition and management outlined in that report, and currently used in the airline industry. If I discover a medical misadventure, I can open an ACC claim, and the patient will receive accident compensation and medical insurance to correct the problem. Furthermore, ACC will use the report data in its ongoing efforts to prevent errors, just as it uses accident data from other industries in accident prevention programs. The report is not automatically shunted through the medical disciplinary board, and the patient does not have to prove medical "negligence" to get some help. Also, doctors are more likely to report colleagues errors when they know the report is not going to automatically generate a suit.

There are a few downsides to the system. There is paperwork to do for every accident; even a sandfly bite or a foreign body in the eye requires some forms to be completed. But I am getting pretty good at finding the Read codes for injuries on cheat sheets, and I can file and sign a claim in less than 1 minute now. Eventually I expect this will be done electronically as part of our office computer system here. And overall I think I've probably less time here doing ACC forms than I would have spent composing letters to lawyers, employers and insurance companies in the U.S. The system does consume quite a bit of money, but since any society is paying for the accidents one way or another (in lost productivity, medical expenses, legal fees and court time, etc) the estimated NZ$9 billion in future liability in the system just makes the cost more easily visible. Patients who use the system report an 86% satisfaction rate, and ACC has its own internal auditing, quality improvement and dispute resolution programs which contribute to this.

I won't hold my breath that something like this will ever happen in the United States. For one thing, the country with the most lawyers in the world would never stand for abriging the rights of anyone to sue. And I despair that the public would accept true equality for all accidents. By this I mean the concept, that if you're injured, you are paid standard amounts of disability compensation, based on your previous earnings, and not on "pain and suffering". In New Zealand, if you do not hold a job at the time of your injury, you receive only the basic "Benefit". It is clear to me that we in the U.S. pay a very large price for our cultural support of "victimization", where anyone who gets a bad break in life is victim of some injustice. Sometimes bad things just happen in life. I have felt comfortable practicing under the ACC scheme. Every day I'm glad that my patients- especially working farmers- aren't going to be wiped out by an injury. Losing the "right to sue" for damages seems a small price to pay for the benefits this scheme provides. Instead of a "right to get revenge" via lawsuit, ACC substitutes a "right to be cared for and compensated". Its cheaper, its better, and its a lesson we Americans need to take to heart in these times, when its clear revenge does not work.

Monday morning I awoke to the most beautiful combined moonrise/sunrise over Halfmoon Bay on Stewart Island It was a bit difficult to come back to reality and pick up seeing my afternoon patients later that same day. We left last Friday very early and caught the 0830 AM ferry across the 35 km Foveaux Strait, from Bluff to Oban, on Stewart Island. It was a bit drizzly and the sea, although not terrible, was choppy enough to make Liz feel poorly, and make me and Vicki keep our eyes fixed on the horizon. The catamaran is fairly fast, and the crossing took only an hour. We checked into the Bay Motel, a lovely, new place on the hill above the harbor, and recovered a bit. Then we explored the town, checking out the DOC visitors center, and having lunch at the Aquarium and Empress Pearler's center. After lunch we called Bravo Adventure tours and confirmed our arrival. We'd previously booked with them for a Kiwi spotting tour. After an hour and a half walk around the bay on some local trails, we returned to find a message that our tour left at 5:30pm.
Now the kiwi is an endangered nocturnal bird, and very wary in the wild. We met the cruise operator, along with two other bird lovers, and boarded his boat for a 45 minute cruise in the dusk across Patterson Inlet, to Ocean beach. We pulled up to the jetty just as it was getting black outside. After a briefing, we each took a "torch" and followed the guide up the trail into the forest. I have never walked though the bush in the dark, and since it was a moonless night, it was pitch black. We had to stay bunched together and follow the guide as he swung his torch back and forth in the brush, looking for a kiwi. Since they are solitary birds, each having a 6 hectacre territory, this took some time. We reached the beach, across the island without seeing a bird, and I began to wonder if we weren't on a snipe hunt. But we walked up the beach, and the guide found fresh kiwi tracks. After a bit he stopped suddenly and whispered, "There's a kiwi up ahead." So we crept up the beach in pitch darkness, the surf in our ears, the wind blowing cold on our faces until he suddenly spotlit the bird, who was feeding on amphipods, little crustaceans that were popping out of the rotten seaweed like popcorn. The kiwi looked at us a bit, and then fairly briskly walked up off the beach into the driftwood. We kept on down the beach and coming back, were able to spot the same bird again farther down the beach. This time we got up to within 2 meters of the bird while it was feeding. This was great. The bird didn't seem stressed, but kept feeding for a few minutes, plunging its long beak into the sand, before ambling off into the brush. Another hour's walking down the beaches and back through the brush didn't reveal any more birds, although we could hear the males calling in the hills, and answering the guide's birdcall. But we didn't care. We were now some of the few people privileged to see this ancient, strange creature in the wild.
The next morning we woke late and had a good breakfast at the South Sea Motel At noon, we took a water taxi over to Ulva Island. Ulva is a bird sanctuary, and its special because the DOC has eradicated rats on the island. It's also never had deer or possums. We spent the rest of the day walking around the island, watching the bird life and fending off hungry weka. It was a cool beautiful day, and we were treated to red-crowned parakeets, many kaka feeding together, NZ pigeons, bellbirds, tui and South Island robins, and tomtits. The beaches were fabulous. We had lunch on one beach. It struck me that there were only 5 mammals on this huge island that day; the 3 of us and a couple other walkers. You can see our pictures of Stewart Island and Ulva Island in this slideshow.
We were really hungry Saturday night after our walk, and we went to eat at the Church Hill restaurant. The seafood was really great, and the atmosphere quiet and intimate- we were one of only 3 tables served because they were having water problems. The waitress asked us to let her know if we used the toilet because she would have to bring water over from next door. We felt sorry for the staff as they turned other diners (who had not made a booking) away. But they soldiered on, and the food was delicious, including dessert.
Sunday we slept in again, but were in the mood for a longer, steadier walk. We took the trail up to Ryans Creek. This follows an old logging road into the hills in back of town then comes down a gully to the coast and returns back into town along the bays of the Patterson Inlet. We took a side hike up Fern Gully, which had the most ferns per inch of any place I have seen so far in New Zealand- and that is saying a lot! We hiked up to Observation rock and then Vicki and I tramped down the road to Horseshoe bay and back at sunset. I finished the day with muttonbird for supper at the Boardwalk Cafe. Again, we were one of only 3 tables. If you like quiet and few people, I'd recommend Stewart Island in winter. Our weather was cool and brisk at 10 degrees C., but we were lucky to have sun every day. Monday we awoke early for the 0800 ferry and were greeted with the fabulous moonrise/ sunrise, and calm seas for our trip back. It was so clear coming across the Strait, we could see the Humpridge, and behind it the snow covered peaks of Fiordland stretching off into the West. To the North, the Takitumu gleamed in the dawn light, and to the East, the sprinkling of the Titi Islands appeared as we sped over the sea. A great trip to a very special place.

Another week has flown by, and as I walk to work in the morning, I am struck by the differences in the town since I started in WInton. Not only is it a little colder, but while we are still a month away from the winter solstice, the days are already very short. I watch the sunrise most mornings as I walk down the street towards the school, among the children in their school uniforms. We have had a bit more clouds and rain, but mostly it is 10-15 degrees Centigrade in the mornings, moist and not at all unpleasant. I enjoy that, this late in the autumn, many of the yards still have roses and quite a few have blooming lilies, mums, or other flowers I don't know the names of. The hills are quite green, and I usually arrive at work feeling warmed up and alert after my 1.2 km walk. The reverse walk at night is now in the pitch dark at 6pm on cloudy nights, and I am seriously considering carrying a "torch". Last weekend Vicki and I went to Invercargill for the day on Saturday. We did a wee bit of shopping in the morning, then visited the Southland Museum. This is housed in a building noted to be the "largest pyramid in the Southern Hemisphere". I was surprised at how much stuff was crammed into a building that didn't look that large from the outside- the magic of the pyramids I guess. Besides very nice galleries of art, natural history, and local historical objects, there is a tuatara breeding program and a great exhibit called "Beyond the Roaring Forties- New Zealands SubAntarctic Islands". The tuatara is a unique reptile, sole survivor of its order from the time of the dinosaurs, and lives only on a few offshore islands in New Zealand. "Henry", the icon of the museum is over 100 years old, and is quite a specimen. I was intriged to see the small fused "feathers" that form these animals dorsal spines.
The highlight of the museum however, was the art exhibit, "Te Ara O Takitimu/ The Path of Takitimu" by William Berry. Vicki and I were both struck by the unusual pictures of this exhibit, which featured landscapes covered with calligraphy. The writing included small diagrams from history and geology textbooks, mariner's maps and other sources that formed a palimpsest over the colors of the topography. At first it looks busy or odd, but then you get up close and read the paragraphs and look at the diagrams. As you step back, or look at the picture from across the room, suddenly the landscape jumps out at you, and you see it not only in 3D space, but also in dimensions of time and culture. Very memorable. We were impressed enough that we bought one of the pictures this week. After our museum visit, we took a walk through Queen's Park. This lovely English-style park includes a beautiful Winter Garden (greenhouse) and an Aviary. The aviary was great- I finally got to see some keas up close. They are huge mountain parrots, the size of one of our bald eagles. And obviously quite intelligent- I'm sure he was sizing me up for dinner as we looked at each other through the cage wire. I can see how they could eat live sheep and destroy car windshield wipers and hikers packs.

Sunday we dragged Liz out and took her for a walk up in the Forest Hill reserve. This lovely chunk of bush is only 5 minutes from Winton. We parked the car at the Forest Hill cemetary and walked 2 km up the road to the trail head, then up into the bush and all the way to the lookout. There was snow on the Takitumu and in Fiordland mountains, and for the first time we could see all of Stewart Island off to the south. This was the third time Vicki and I have walked up there, but this time there were more tui than I have ever seen before. They were singing like mad, and I managed to get a few photographs (difficult!) and record their amazing song.

I worked 4 days this week, and last evening took the 1st call at the Urgent Doctor clinic in Invercargill. I sent both of the first 2 patients over to the hospital for appendicitis. The first, a young lady planning to go to the school ball this weekend, had a fever of 39, shaking chills and a 3 day history of abdominal pain which her mum had treated by taking her to the massage therapist. The therapist sent her over to me last night, but I suspect her appendix had already burst. The second patient was dragged in by her husband who told me she'd been in agony with "back pain" for 2 days. On exam she had focal tenderness in the right local quadrant. The surgical registrar was not happy to get 2 calls from me within 30 minutes, but at least I sent the third abdominal pain patient (who showed up later in the evening) home with instructions for treating constipation.

Tomorrow we take our last "expedition" of this trip to Stewart Island. I'm looking forward to a long weekend of hiking, eating, shopping and hanging out with Liz and Vicki. I have only 5 weeks left now, and Vicki leaves in about 2 weeks. Some of the older patients that I have bonded with, have started to wish me goodbye. Its clear that they know they will not see me again in their lifetimes, as they tell me, "its been nice knowing you, and thanks for coming to work here in Winton". It wil be nice to get a break, as I know it will be tough to say all the goodbyes to come.

I stopped in and gave blood at the community blood drive last week. Liz and Vicki went down with me. As we were checking in, I got to thinking that maybe we'd all be rejected just because we come from America, a country with one of the higher prevalences of HIV and other blood bourne diseases. In fact, during the history process, they gave us a world map asking if we had "been to any of the countries colored red". Let me put it this way, the only countries on the map that were NOT red, were South American, European, or Australia. The rest of the world is "red" for HIV risk. But we went ahead with the screening process anyway. I passed the questionnaires, but Vicki and Liz were deferred- because they had both gotten their ears pierced in the preceeding month! I must confess part of my motivation was interest to see if there were any differences between US blood drives and those in New Zealand. For the most part they were the same: cold echoing church hall, equipment brought in big duffel bags, little stickers for donors to wear afterwards. The nurses proudly wore their uniforms, the juice was replaced with milk, and cookies with "bisuits", but it was mostly very familiar. Except that the nurses did not wear gloves.
I asked the nurse drawing me about it. "Oh, they used to give us gloves, but when they improved the donation kit they told us we didn't need them anymore. Blood stays inside the tubing and all that. Besides, the gloves were very expensive."
Now that got me thinking. You can imagine how that would go over in the United States, where we call in the Hazmat team for a nosebleed at nursery school! Yet in New Zealand, the prevalences of blood bourne diseases are very low. The nurses are surely immunized against Hepatitis B, and other blood bourne infections are difficult to transmit by "splash". It probably makes a lot of sense to save the money used for gloves, and use it for better needle-stick boxes and advanced punture-prevention kits.
In our office I am often the only one to put on gloves when dressing a wound as well. Even when my hands are cut and nick-free, I psychologically just can't stick my finger onto an oozing leg to check for tenderness or heat without a glove on. There is also a more relaxed attitude toward antisepsis. I don't mean that its not important, and that we don't follow it. However, every little cotton swab does not come in its own sterile pack. We often use clean, sterilized but not sterile packed instruments out of an autoclave tray for minor work like suture removal. And many of the wounds here are highly contaminated anyway- it is a farming community- so that strict antisepsis is rather silly, and quickly use antibiotics if there is any sign of a wound infection or if its a high risk wound.
All of this highlights a peculiarity of American medical culture. Lynn Payer, in her 1988 book, Medicine and Culture notes that British medical culture has been focused on the bowels, while the French favor the liver, and the Germans the heart in their explanations for the sources of vague symptoms. To this list, we should add Americans' obsession with infections. Dr Weil, not an author I always agree with, makes the point in one of his columns that this is a

"general American fear of foreign invaders. We are a big, isolated country and have always been obsessed with subversion and invasion. That cultural perspective distorts our thinking about illness as well. We commonly ascribe unexplained symptoms to viruses, get worked up about chronic yeast infections, and now are becoming paranoid about parasites."

Think about the major problem in America of patients with a minor cold, bronchitis or influenza presenting to their physician and demanding antibiotics. Many hours and dollars have been spent trying to educate both doctors and patients about this inappropriate prescribing, and yet we still have one of the highest uses of antibiotics in the world, at a time when antibiotic resistance is becoming a major problem. In almost 4 months here in New Zealand, I have not had one patient come in demanding antibiotics, and in many cases, I have had to talk patients into taking medicine that they clearly need for an infection. "I worry about taking antibiotics" is a common refrain here. New Zealand patients seem much more interested in "boosting my immune system", and indeed, reassuring patients that they "have a healthy immune system that will take care of this infection" is a very effective phrase, I have found. However, at the far end of that extreme, many patients take Buccaline Berna, a pack of 7 tablets, costing around NZ$65, containing "1000 Million PNEUMOCOCCUS I, II, III, 1000 Million STREPTOCOCCUS, 1000 Million STAPHYLOCOCCUS, 1500 Million HAEMOPHILUS INFLUENZAE, 25mg FEL BOVIS SICC", i.e. dead bacteria. These tablets are marketed as an adjunct to flu vaccination, to boost the immune system and "prevent the bacterial complications of the flu". A search on PubMed (National Library of Medicine) shows only 1 scientific article on this product, published in French, in 1977. The product is no longer sold in Australia, and the New Zealand Immunization Advisory Council recommends against it.

Yet is this so crazy? What about the recommendation by the USPHS Task Force, promoting the use of pneumococcal vaccine? In a previous blog I noted that Pneumovax is not recommended nor funded in New Zealand, and I wondered about this disrepancy. This vaccine is widely recommended for healthy older adults by health promotion authorities in the U.S. It is even funded by Medicare for any patient over 65 years old . But there is no evidence that it is effective in the general population. Brian Alper, the editor of Dynamed, kindly sent me a page listing all of the relevant studies, some of which show it may be effective in nursing homes, but not in high-risk patients. In particular, there is a Cochrane review that concludes that pneumovax is not effective in preventing pneumonia or death, just "invasive pneumococcal disease", with a number needed to treat of about 20,000 to prevent one case of infection, and 50,000 to prevent one death. At about US$25-40 per vaccination, that is a lot of moolah that might be better spent on smoking cessation programs (which by the way are funded for all patients in New Zealand, but not in America!).

So there is the answer to my question of "why is pneumococcal vaccine funded and promoted in America but not in New Zealand?". We fund it in America for the same reason that E.T. the extraterrestrial is locked away in a giant sterile bubble by men in spacesuits. For the same reason that we worry so much about bioterrorism and less about "two guys in a fishing boat with a nuclear weapon motoring up the Chesapeake". Perhaps we American doctors and patients should become more aware of this phobia, and rethink our attitudes. After all, there is some evidence that dirt might even be good for us!

We were awakened yesterday by a tremdous volley of gunshots at exactly 0700 AM. It was the first day of duck hunting season in Southland, which begins at exactly that minute. All weekend the valley has echoed to the sound of shotguns and barking dogs, which reminded me of the classic joke about the doctors who go duck hunting:

Five doctors go duck hunting -- a general practitioner, an internist, a psychiatrist, a surgeon, and a pathologist. They're sitting in the duck blind, telling doctor stories to each other, when a magnificent flight of ducks passes by.
The general practitioner raises his shotgun and aims at a duck. He says, "It looks like a duck, it sounds like a duck, but I need a second opinion." He lowers his gun and defers to the internist.

The internist draws a bead on the lead duck and says, "It looks like a duck, and it certainly sounds like a duck, but I read in the New England Journal of Medicine that it might not be a duck. Rule out goose, rule out pigeon, rule out penguin! I need a consult." And he signals to the psychiatrist.

The psychiatrist puts down his pipe and raises his shotgun. He says, "It certainly looks like a duck, and sounds like a duck, but it maybe it only thinks it's a duck."

He defers to the surgeon, who raises his shotgun and quickly squeezes off five shots -- dropping five ducks. The surgeon then kicks the pathologist into the water and says, "Go check those and tell me if they are ducks."

I've been thinking lately about the role of the GP (or FP) in making diagnoses. The old doc I worked with when I first went into rural practice, Jim Stansfield, used to say, "Chuck, the rare diseases as a group are common. The problem is, you only see one of everything". I think one of our jobs is to separate the wheat from the chaff, or the ducks from the geese as it were. One thing I notice in my own practice is that I rely a lot on intuition in order to do this. By intuition, I mean "having a hunch", or "getting a funny feeling", or as they say in Star Wars, "I've got a bad feeling about this". Its the impulse to just "add on a TSH" test that comes while I'm working, not as a conscious decision or as "rule I always follow" in a type of case. Its waking up in the morning and "knowing what that patient had". Its feeling sleepy in the middle of the afternoon, listening to a routine visit history and then suddenly pay close attention because the patient just said something that "set off a bell" in your head.

An example. A young fellow came into the office with back pain a few months ago. He was very tall and skinny, and his pain was around the upper spine, and appeared to result from reptitive movements at his job. He didn't really look that out of the ordinary, but as I examined him I remarked that he was really tall and slender. "Yeah, no one in my family looks like me, " he said. At his next followup visit, I remarked that he was very flexible and loose-jointed. We were wondering if that might have something to do with his being injured. "Well, no one I know can do this," he said, taking his hand behind his back and touching the upper border of his scapula on the same side. His appearance kept bothering me, and we explored hyperflexibility on his exam. Ehlers-Danlos syndrome popped into my head, and before his 3rd visit, I went back to the textbooks and read about it. This guy just looked odd. And as I was reading about E-D, I read the rest of the chapter about connective tissue diseases. Like Marfan's syndrome. Yeah, Marfans. Something clicked. At his 3rd visit, I measured him. Armspan is greater than height. "Any problems with your eyes?" I asked him. "Yeah," he says "for the last year or two I can't see well out of the left one. I've been meaning to see the eyedoctor". A quick look with the opthalmoscope shows the left lens seems dislocated inferiorly. So we talked about this possible diagnosis and he'll see a specialist for further evaluation in August. Note that continuity was important in this case. I had a funny feeling about this, but it took awhile to really pin down what it was.

Example #2. A man came in with a cough. As I was listening to his back and asking him to breathe, I noticed a large mole on his shoulder. It was pretty big. "What do you think about this mole here?" I asked. "Is it changing?".
"I don't know" he said, "I can't see it".
"Well, it looks funny to me" I said. Because of its size, (and because he wasn't worried enough about it to want to be cut on I think) he elected to get dermoscopy. It took 2 months, but the result was "almost certainly a melanoma, scheduled for excision".

Example #3. A man in his 50s came in complaining of constipation. He had all kinds of reasons why he should be constipated; change in diet, he never exercised, etc. He just wanted some medicine to take care of it. Review of systems and symptoms all totally negative, "just give me a good laxative please, doctor". Something just didn't seem right. What did the stools look like? Well, this is a problem in New Zealand, because the design of the toilets here is different. They are very funnel shaped and deep and narrow at the bottom. Most of the time they are in dark bathrooms. And the water closets flush them with tremendous force. And no one "ever looks" anywhere in the world of course, but if they did they'd have a heck of a time seeing anything in these toilets. So he couldn't tell me, but as I pressed my history, it developed that he had not had a satisfyingly large stool ever in the last 6 months, and they seemed to becoming smaller and smaller. Now this is a classic "medical school" history of altered bowel habit. I had a heck of a time doing a rectal exam on this man, who could not relax; and an even harder time convincing him that he needed a colonoscopy. However, he finally relented. Result: rectal carcinoma. I just had a bad feeling about his history.

Example #4. A 4 year old came to see me urgently with a 7 day history of trouble urinating. It had become so bad that he would go to the toilet every 20 minutes, and stand there crying because he couldn't empty his bladder. His mother had even seen some blood come out. The rest of his history was totally negative, including stool habits which mom said were daily and normal. Wow, this was a really odd history. His urine was totally clear, so it wasn't an infection; and his exam seemed perfectly normal. What could this be? I had never really seen heard a story like this before in 25 years of practice, and that fact really alarmed me. Bells were going off in my head, something about "posterior urethral valves" or other congenital problems presenting outside the newborn period. I called the pediatric registrar, who as usual was never happy to hear I couldn't figure something out after hours, but agreed to see the child. This one bothered me so much, I copied down the mom's phone number and called her back 4 days later.
"Hi, its Dr. Zelnick, I was just calling back to check that your son got taken care of.." I began tentatively.
"Oh hi doctor, yes, the problem's not fixed yet, but we're working on it and he's doing better."
"I wonder if you'd share with me what they found at the hospital, I don't get any followup from the urgent care center on these cases."
"Well, he was really badly constipated. I couldn't believe it- he'd been using the toilet every day. But now that we're getting that cleaned out, he is doing better..."
Great. A simple diagnosis that a rectal exam would have revealed. "Most often an ususual story is a common disease with an unusual presentation" goes the rule. Sometimes intuition is just plain wrong, and a duck really is only a duck.

Do I make any conclusions from these cases? Only that I really enjoy the challenge of seeing a lot of patients and trying to figure out which 2 or 3 every week will have something odd or unusual. Southland has high incidences of leptospirosis, hemochromatosis, and celiac disease compared to Iowa, so I have had to read up and learn about those problems so I don't miss them. Oh, and never be afraid to do a rectal exam. And remember, duck hunters, "guns don't kill people, doctors kill people".

Shrek the Hermit Sheep has dominated the headlines here in Southland this week.Finally caught after 8 years of evading the fall muster, Shrek had a huge fleece which made the headlines of local papers and TV news. Shrek was living as a "hermit" sheep, away from his flock in the high hills of Otago district, near Cromwell. This is rugged, rocky tussock country, above 900 meters, very tough going. He apparently survived the harsh winters by finding a cave in the rocks for shelter, not to mention his huge fleece. The Shrek frenzy culminated this week with his live shearing on the Holmes TV show last evening. Final weight of his fleece was 27kg! His owners at Bendigo Station made a charity event of it, with proceeds going to Cure Kids. Events included an online auction of locks of Shrek's fleece, and an inpromptu "Full Monty" performance which raised $700 at a local bar. Phone calls can be made to a freephone number to donate $10 and be entered in a drawing for two tickets to the Australian premiere of the movie "Shrek 2". My opinion is that this story resonates with Kiwi's not only because its unusual, or they appreciate sheep, but because it resonates with so many New Zealander core values. Shrek is an individual; he leaves the flock to live his own life. He endures rugged country and harsh weather with only his wits and his warm wooly coat. He scratches out a living in an area where grass and clover is difficult to find. This bloke does it his own way. And finally, he is wily, tricky and difficult to capture. But when he is brought in, he's not wild- he's really just a nice, gentle sheep.

Last Saturday we drove over to the Borland Road in Fiordland National Park. This is a road that penetrates 90 km into Fiordland and was constructed in order to build the power station on Lake Manipouri. About 14 windy, narrow, potholed km along this road, it crosses over a saddle in the Hunter Mountains. From there a short trail climbs up about 300 meters above the treeline. It was a beautiful blue fall day, even a bit of a hot hike. Click here to see the view. There are small tarns, lots of alpine plants and wonderful views. Beautiful country. The highlight for Vicki however, was during the drive over. Taking a short cut on a gravel New Zealand back road, we looked down into the valley below and watched as shepherds and dogs moved a flock of about 1000 sheep from one paddock to the next. From the top of the cliff, the sheep began ina pattern that looked like Brownian motion, which suddenly organized and flowed like sand in an hourglass through the paddock gate.

Today is ANZAC Day. While ANZAC is the name of a biscuit commonly found in the stores here, it really stands for "Australia and New Zealand Army Corps", and was the designation used for the cove assigned to those troops taking part in the ill-fated invasion of Turkey, at Gallipoli, in 1915. The invasion was a bust, the forces were pinned down on the beaches, suffering daily shelling, starvation, disease and lack of water for 9 months before being evacuated. Out of 10,000 Kiwis in the Allied forces, 3000 were killed and 5000 were wounded. To compare on a per capita basis, it would like the U.S. today sending over 3 million troops, and having 2.4 million of them killed or wounded. ANZAC day commemorates the Gallipoli campaign, and all the sacrifices and losses made by Australian and New Zealand servicemen and women since them, including the Korean War and Desert Storm campaigns. Kiwi's here tell me that in recent years, families have become more involved, and more younger people are honoring this special day.

We bought poppies this last week and I've been wearing mine on my polarvest in the office. One old fellow looked at it and told me, "Good on ya, mate. If it wasn't for you Yanks helping us out in the Coral Sea, I'd be slant eyed and speaking Japanese". "If it wasn't for the British, I might be speaking German", I replied. "Our countries all have a lot in common."

This morning, like thousands of people in New Zealand, we awoke at 6 AM, dressed and walked down to the Memorial Hall in Winton for the "Dawn Parade". This is a simple ritual of rememberence, following a traditional order of bugling, wreath laying, and the reading of the following poem:

The ANZAC Dedication:
For the Fallen
by Laurence Binyon

They shall not grow old,
As we that are left grow old.
Age shall not weary them,
Nor the years condemn.

At the going down of the sun,
And in the morning,
We will remember them.
We will remember them.

The Hymns are the "Navy Hymn", with special words for Anzac day, and "Our God, our help in ages past". In Southland, there is also a bagpipe lament, reflecting this area's Scottish heritage. The Hall was filled with about 350 people. Many of the older patients I have met in practice here. Family members, some teenaged boys, pin on the medals or ribbons of their grandparents or parents. The local fire and ambulance brigades were there in uniform, and a few of the older men were still squeezed into their old service uniforms.

It is a solemn 20 minutes, but very moving. It led me to reflect about Memorial Day in the U.S., which seems to have become more of a "beginning of summer" holiday, barbeque time and shopping day, rather than a time for remembrance. Perhaps our current involvment in the Middle East will change this. I was particularly moved by the last stanzas of one hymn (click the link if you don't get the irony right away):

Far-called, our navies melt away;
On dune and headland sinks the fire:
Lo, all our pomp of yesterday,
Is one with Ninevah and Tyre!
Judge of the nations, spare us yet,
Lest we forget, Lest we forget.

If, drunk with sight of power, we loose
Wild tongues that have not Thee in awe,
Such boasings as the Gentiles use,
Or lesser breeds without the law-
Lord God of hosts, be with us yet,
Lest we forget,
Lest we forget.

The phrase "World Famous in New Zealand", slogan of L&P soda, applied to Winton this week. National news picked up the story of "Whipper" the mutant budgie. An open house for the odd bird made the national telly news programs, as well as being picked up by all the regional newspapers. Liz has been enjoying her two weeks off for Easter School Holiday, walking daily with Vicki, shopping for a dress for the "Ball" coming in June, and just lazing around the house. While they've had fun spending "dad's hard-earned money", I was on-call over the last weekend in Invercargill. This involved working at the Urgent Doctor clinic. On Saturday, I saw patients in the office from 0930 until 10 pm, with a 1200-1400 pm lunch break and an 1800-2000 "tea break". On Sunday, my relieving doctor and I swapped places, and I worked in the office during his breaks. On Sunday when I was "2nd call" I was also on call for home visit, but there weren't any. During my time between breaks I drove down to Oreti Beach and to one of the local forests for some walks, and spent an hour in a cafe with a chocolate milkshake, and a good book ("Quicksilver" by Neal Stephenson). Best thing was being able to go home both nights, when the "3rd call" doctor comes on and takes phone calls and makes home visits. I can't complain at all- this was my first weekend call in about 3 months. I could really get used to this!
One of the things I did during Sunday's "slack time" was compile an analysis of my practice in Winton. I want to apply the 80:20 rule to improving my practice here, so I need to get a good handle on my case mix. I'm applying the principles we taught in our PBLA workshop at the Atlanta STFM conference last year. One of them is to analyze your practice by simply keeping a log for 100 consecutive patients. I kept a log on a piece of graph-paper for each half-day, recording diagnosis and age bracket using hash marks. The half-day logging works well because you can quickly tally up your visits, and if you made an error, you haven't blown the whole week. During my slack time on call, I summed the talleys, and now I've reentered them into a spreadsheet. In order to have something to compare to, I cut and pasted data from the National Ambulatory Medical Care Survey on the CDC website.

Be SURE TO Click on this link to see the spreadsheet and charts, which show my practice here at a glance.
Here are some of the important points I noticed after doing this:

• There are NO well-child visits. Well, I only do newborn checks a few times a month next door at the birthing center, and an occaisonal 6 weeks check. All the rest of the visits are done by Plunkett nurses for the most part.
  
• There are not a lot of diabetes management visits. I'm not sure why. I see a fair number of diabetics, but most are under control it seems, and most are coded in my sheets as "hypertensive" because that's what need managing. It may be because almost all of them receive free yearly diabetes checks and are co-managed by GP and specialty clinics who both see them regularly.
  
• Everybody seems to be hypertensive. That is why there are no "lipid" visits- I'm working on the hypertension and the lipids simultaneously, and most patients have controlled lipids and uncontrolled HTN
  
• Only 1/4 of my HTN patients are controlled. The chemist has noted my agressive dosage increases.
  
• There are not a lot of sore throat visits. Most patients here are wary of antibiotic overprescribing, and I notice little demand for antibiotics for URIs.
  
• There are very few visits for neurosis (anxiety) and depression. Patients are also very wary of antidepressants.
  
• There are a TON of primary dermatology visits. I don't know why this doesn't show up in the NAMCS surveys (or why the other common diagnoses on the right of the graphs are not seen frequently by "General/Family Practice" doctors surveyed). They are a WIDE variety of problems: acne, allergic rashes, changing moles, ingrown toenails, lumps and bumps, lots of BCC and SCC type skin cancers, head lice, scabies, etc. This reflects my U.S. experience as a rural doctor also. Note that I did NOT include the 7 patients seen and treated at the Wednesday evening "liquid Nitrogen" clinic in my talleys.
  
• Asthma and CHF are common problems here that patients are used to managing with regular visits. One of the advantages of the "free" medicines under Pharmac is that patients are motivated to come in every 3 months for prescription refills. There are no inhalers "over the counter" such as Primatene Mist, and the chemists here are really good at educating patients about disease management also.
  
• This was a "light" week for injuries, so they may be underrepresented in this talley. However, the Practice Nurses here in Winton are superb when it comes to wounds, and only wounds needing suturing are generally booked into my rooms. Wound infections, dressing changes, and wound monitoring are the daily business of the nurses, and we doctors see these patients in a supervisory capacity to the nurses. This is probably about 5-10 patients that I see with the nurse daily.
  
• Adding up the nurse supervision (conservatively) at 25 patients a week, plus the LN clinic of 7 plus my 96 yields a total of 128 patients in a week, which seems about right.
  
• The age distribution explains some of the reason this seems a lot of patients. The schedule is heavily geriatric. About half of the ">71" patients are actually over 80 years old. As a new locums, trying to see a complicated older patient in 15 minutes is fairly stressfull. It has only gotton easier these last few months, as I've gotton to know a lot of the "regulars". I remember in my first practice how things suddenly seemed to get a lot easier after I'd been there 3-4 years and knew the patients well. I do think having a well organized EMR here is a great help to quickly getting up to speed on an older patient- especially for managing those long lists of medications. Its hard to believe I used to handwrite all those long geriatic med lists.

Its Easter Sunday here, and a good day for a ghost story. A cold front has come over the South Island the last 2 days, with very windy, blustery wet weather and highs of 4 degrees C. That's kept us in a bit the last two days, and the weather seems more reminiscent of Halloween or Thanksgiving then Easter. Easter is a BIG holiday here. The entire country shuts its doors for Good Friday, and also Easter Monday. I have no work for the 5 day holiday. Most people seem to visit relatives, because the schools have a 1-2 week break at this time also. There are some activities, like a big airshow at Wanaka, but at least down here in Southland, life just slows down for the break. We did get a chuckle out of the annual Easter Bunny Hunt in Alexandra. Rabbits are not held in high esteem here, and no one feels bad about shooting them and eating them for breakfast, as Liz found out when she visited a friend's home recently. Helen's teenage brothers, mighty nimrods of the night, went out for 90 minutes with flashlights and returned with 4 hares and a brushtailed possum. (They didn't eat the possum. Kiwis, however, make great mittens from them- one of my better buys here.) Most Kiwi's feel the only good possum is a dead possum, because of they destruction they have caused to forest and birdlife.
Friday Vicki and I walked the track on Forest Hill just southeast of Winton. It was a fine, cool day and we were rewarded with spectacular views of Winton with the snowy peaks of the Takitimu and Fiordland mountains in the distance. We walked from the Tussock Creek parking area northward about 4 km. to the Forest Hill picnic area. The short trail is mostly along the hilltop, and includes a huge rata tree that sprouted around the time of Columbus, and at the summit, a variety of huge limestone outcrops, covered with ferns.
Yesterday we drove over to Gore to do some shopping and see the world's largest fiberglass trout. The winter clothes are in the stores now, and we are buying some warmer things, including more polypropylene underwear, but this time for daily use. I found a nice NZ wool sweater, and Liz found a Thai restaurant for lunch. We toured the Hokonui Moonshine Museum in Gore. The very large range of hills between Winton and Gore, the Hokonui Hills was a haven for moonshiners 100 years ago. The Gore and Invercargill districts were "dry" for over 50 years, a result of the collision of the Presbyterian and Christain temperance movement with the wild behaviors of sealers and sailors at the coastal ports of the first country to give women the right to vote. However, immigrants from the Highlands of Scotland brought with them their own stills and recipes for whiskey, and many of the farmers living in the hollows of the Hokonui made more cash from their distilleries than from their crops or stock. One moonshiner even entered his whiskey in a competition, and proclaimed that "it passed all tests, except the police". We also enjoyed the litte art musuem in Gore, an eclectic collection of ancient African wooden statuary, watercolors of New Zealand plants and seaweed, and contemporary Maori art and poetry.
So now, from history to the "ghost story". We visited the Winton Cemetery on one of our walks a few weeks ago, and when I mentioned this to the office staff at tea one day, they told me the story of Minnie Dean. In this part of the world, children who are bad are told they "better behave, or I'll take you to Minnie Dean's farm, and you'll never be heard from again". Minnie Dean emigrated to Winton in the 1870's. Times were tough, and her husband was not a good farmer. When they became destitute, Minnie became a "baby farmer", taking in illegitimate children for a fee, with a promise to find them adoptive homes. The story goes that she would kill the babies with a hat pin, and bury them in her garden. The local police became suspicious after she boarded a train with a baby and a hatbox, and left the same train with the hatbox alone. Minnie was tried and convicted, and is the only woman ever to have hanged in New Zealand. She was buried in an unmarked grave in the Winton cemetery. The legend is that grass would never grow on her grave. Although one of the locals here claims that it never grew on her grave because the caretaker fo the cemetery used a weedkiller on it, on a regular basis. Over the web, you can hear a folk song, or view a music video, about Minnie Dean. The music video is pretty good, and uses pictures of the Kingston Flyer steam train for scenes about the famous railway journey. There is even a revisionist history of her crime and trial.
Well, I gotta go now, 'cause its time for our regular Sunday evening family get together, watching New Zealand Idol. I'm voting for Big Dave. You should too!

In the first 10 weeks I've been here I've diagnosed 3 cases of cancer. One woman in her 50's presented with an obvious breast lump, but the other two were elderly patients with colon problems. One gent, who was quite severely in denial, had the classic med school history of "constipation" with altered bowel habit and development of "pencil-thin" stools. The other woman had several episodes of vomiting, one with GI bleeding that sent her to A&E. When I saw her in the office a rectal exam was suspicious for a mass at the very tip of my finger, and colonoscopy confirmed that this week.

By themselves these are routine "bread & butter" cases for family practice, and they cause me, as cancer cases always do, to wonder if they could not have been found earlier. Very few patients here come in for a "well adult" visit- I spend at least 95% of my time in our office dealing with chronic and acute illnesses. But I did print off the "Men-Stay Healthy at Any Age" checklist from the AHRQ, and I've reviewed it with the local doctors here, to use it in the clinic but be consistent with New Zealand guidelines and practice. This was timely, as the New Zealand National Health Committee recently announced a national policy of NOT supporting prostate cancer screening.

This got me thinking about variations in practice. Now W. Edwards Deming, the great efficiency expert, noted that variation in process is a quality issue. Logically, if there is more than one way to do things, it either means that both methods are equally valid, or is an opportunity for study, to discover which method might be "best". (This assumes that you can define "best" in terms of measurable outcomes.)

So in this light, I thought it might be interesting to look at the New Zealand variations of the USPHS guidelines for preventive care. It’s a good opportunity to think about what the USPHS defines as "best", and the reasons for its conclusions. Or at least wonder what the evidence to date is- but that's a question I will come back to after I return home. These variations will provide excellent fodder for teachable moments for years to come- for both my students, and me!
FOR SOME REASON BLOGGER HAS PUT A BUNCH OF BLANK SPACE IN HERE, SO BE SURE TO SCROLL DOWN TO SEE THE TABLE! {I'M TOO TIRED TO DEBUG HTML TONITE- EMAIL ME IF YOU KNOW WHY IT DID THIS...THANKS.}

USPHS Guidelines	New Zealand Practice	Comments:
Cholesterol check every 5 years	Same	The number one killer in NZ is cardiovascular disease, and the population here is very aware of high cholesterol; including knowing the importance of HDL vs LDL levels
Blood Pressure check every  2 years	Same	In contrast, few patients know the numbers for an acceptable blood pressure, and its not a routine Vital Sign on office visits, so this guideline is often not met
Colorectal Cancer Tests: Begin regular screening at age 50	"your doctor will help you decide which  test is right for you"	Almost no patients are having colonoscopy or flex sig tests here unless they have a strong family history.  Interest in stool testing is very low, just as in the U.S.
Prostate Cancer Tests: "Talk to your doctor about the possible benefits and harms of prostate cancer screening if you are considering having a prostate-specific antigen (PSA) test or digital rectal examination (DRE)."	NZ Medical Council recommends against routine screening with any tests	Lots of PSA tests have been done on men in our practice, by past locums and the local physicians.  This is likely to become less common now that the NZMC has recommended against it.
Mammograms Have a mammogram every 1 to 2 years starting at age 40.	Curently mammograms are paid for between ages 50 to 64, yearly.	In near future, the lower limit will drop to 45 years old and the upper limit extend to 70. Its not yet in place..
Pap Smears Have a Pap smear every 1 to 3 years if you have been sexually active or are older than 21.	For screening, only once every 3rd year, ages 20-69.	The nurses are keen on Thin Prep which has been marketed to the practice and is available.  However it costs the patient an extra NZ$23 out of pocket, and I've been discouraging it for low risk patients.
Diabetes Screening  "Have a test to screen for diabetes if you have high blood pressure or high cholesterol."	Same plus must be older than 50.	I have to remember to screen at  younger ages  if obese or Maori or Pacific Islander descent.
Depression "If you've felt "down," sad, or hopeless, and have felt little interest or pleasure in doing things for 2 weeks straight, talk to your doctor about whether he or she can screen you for depression."	Same....,	although a Christchurch professor recently made headlines here when he warned against "overuse of antidepressants" for the "normal ups and downs of life"
Chlamydia and STDs: Women: Have a test for Chlamydia if you are 25 or younger and sexually active. Men: "Talk to your doctor to see whether you should be screened for sexually transmitted diseases, such as HIV."	Same	There seems to be little to no worry here about HIV, to the point of lack of worry about strict blood/body fluid exposure rules.  Patients do not seem very aware of HIV, and the rates in New Zealand are low, with only 160 some people diagnosed last year.
Osteoporosis Tests:  Women Only Have a bone density test at age 65 to screen for osteoporosis (thinning of the bones). If you are between the ages of 60 and 64 and weigh 154 lbs. or less, talk to your doctor about whether you should be tested.	Bone density screening is done based mostly on risk factors.	Alendronate can only be subsidized if patients meet strict criteria of having low DEXA values + a fracture.  Calcium and cyclical etidronate are subsidized without jumping through hoops.
Immunizations: "Stay up-to-date with your immunizations: Have a flu shot every year starting at age 50. Have a tetanus-diphtheria shot every 10 years. Have a pneumonia shot once at age 65. Talk to your doctor to see whether you need hepatitis B shots."	Flu shots are given every autumn (thats NOW, April, here).	We do not give routine or preventive pneumonia vaccine in either children or adults.  I'm not sure why our office doesn't do it, but it might be a funding issue, because they are not on the New Zealand routine immunization schedule.. The nurses just say its not available here. Its not in the Pharmac schedule. One of those things to ask about.