A day in the office
Today I finished my 9th day in the office, and its become enough of a routine that I thought I might describe a "typical" day, if I can do that after only 9 days...
I have been getting up around 7 am, although I have usually been awake for at least 30-45 minutes- the sun is still coming up before 6 AM here. Get dressed, have a cup of coffee, and watch the first 15 minutes of the daily news on New Zealand "ONE" TV station. About 8:20 to 8:30 I start walking to work. Its about 20 blocks, a very nice 12 minute walk which goes past the "College", the local high school. This morning was first day back for all the upper level students. The boys slogged along the street with me, all with their heads down, like they were heading to their own executions.
At work I get the computer up and running, tidy up my desk, look in the bin for lab results or other paperwork left over from the previous day and generally mess around a bit. The office here uses i-Macs, and I have a very small desk in the corner of my "Room" with the computer on it, some shelves above and two chairs. Across the room is an exam bench. It is a simple bench, with a pillow and some sheets. It sits on 4 posts and there are no drawers nor stirrups; but it is nice and high- something I appreciate with my height. There is a wooden box forming two steps that patients use to get up on the table, which must be about 3.5 feet off the floor at least. We have the usual Welch-Allen diagnostic kit on the wall, mercury sphygmomanoters, and a goose neck lamp on the wall also. There is a "trolly", or wheeled cart to my left, which has various materials on it- tongue blades, culture swabs, pap smear stuff, etc. I have a sink with a nice fluffy towel for washing. On my bookshelves there are only a few key patient handouts- a set of about 10 topics so far that are commonly used- hypertension, diabetes, UTI, gout, etc. And there are two small drug books that I shall mention below.
The computer program we use is called "Profile" and its made here in Auckland. It features a nice daily schedule screen, patient lookup screens with a "summary" page and buttons to call up "Scripts", "Previous Visits", "Investigations" (Labs), "Problems" and some other patient information. It took me about an hour the first day to get my bearings on it- mostly because writing a new script is a bit complicated. But I must say that "repeats" (refills) are a breeze, and I do a lot of that.
So I begin my day looking at the schedule. I have patients scheduled at 15 minute intervals during the day. In that time, for a typical patient, I go to the desk and find the patients paper folder (which contains all the old records before 1996 as well as any paper letters or government forms since then.) I call the patient out of the waiting room myself, introduce myself and we walk back to my "Room" (consulting room) together. I have been asking patients to take a seat up close where I can hear them well, and also trying to sit them so they can see the computer screen. Most of them have little or no interest in what I am doing on the computer however. I then take a history: chief complaint, HPI etc. I've discovered its usually a lot more efficient if I do that first and only AFTER that, review the electronic and paper charts. Often the visit is highly focused, so it helps to know what I am looking for- e.g. past blood pressure values, a heart echo done in 1990, recent lab results, etc. Once we've got an established agenda (I ask the "any other concerns" question at this time and really get things focused!)- we move on to the exam. I am really glad I brought my automatic battery-operated Lifesource BP machine with me. I put the cuff on and get my vital signs while I am finishing up my chart review, and entering a few details of the history, etc. If needed, we then move to the exam table. But for a lot of geriatric patients, I simply am doing heart and lung exams, etc right next to the desk, with them in the chair. This is quite quick usually, although many of the older folks are wearing 4 layers of clothes while they complain about our recent "hot" weather (its been in the mid- to high-70's (degress F)), and it might take them a few minutes to unbutton their shirts. Once the focused exam is done, and they are buttoning up, I go back into the computer and order drugs and labs. Most common labs are easy, on a pick list. Drugs are another matter. If I am prescribing a new drug, I often need to look up the drug in one of the New Zealand formulary books, to be sure its covered. I'll blog on the medicine system here later- its a separate topic. If a referral is to be made, we figure out who they are going to see, and I compose the letter right there. Then we say goodbye, the patient collects his or her papers and heads for the desk. I quickly finish up my note, re-tidy up my room and march out to the desk to collect the next patient.
A word about the office notes. I have not found any text templates in Profile so far, except for the referral letters. Fortunately, one of the previous locums ahead of me has loaded a little program on the machines here called "TypeIt4Me". It will type out simple macros, like autoComplete in Word. I wish is was as full-featured as Shorthand for Windows, with branching text functions; but alas, I have been unable to find anything like "Shorthand" for a Mac! Last week I set up a bunch of macros for my normal physical exam, and labeled them z1 through z5. So to document a normal exam, of the HEENT + Neck + chest say, I just type z3 and my whole normal exam is pasted into my note. I just go thru and edit to add any abnormals and that's very fast. Since the drugs and labs are pasted in the note automatically by the system, the only real typing I'm doing is the HPI and history now. And I may build some more macros next week to speed that up for common problems, like HTN.
Today I saw 21 patients in my Room in this fashion. The nurses only come in when I drag them (reluctantly!) to chaperone a pelvic exam. Otherwise they are quite busy doing their own jobs, which also entails a lot of patient care and treatments which they do with variable supervision, as needed. I'm often called back to check their work, for documentation and billing, for things such as wound care- which they really do an excellent job on, and are teaching me a lot about doing NZ style. Nurses also do all the triage, review and order of recalls for things like 6-monthly diabetes labs, and other things, like draw all the bloods. Most of the lab here is "send out" except for urine dipstix. We have a microscope, but it is really old, and I've only used it once.
A word on pelvic examinations. Because stirrups are not an office tradition here, I am doing most "smears" as we call paps here, in the left lateral supine position (side). I ask the women what they prefer, and if they've done it before they usually will say side. It is much easier doing this to see the cervix and get a good quality exam. I certainly see the posterior perineum better than in stirrups. I have the women roll back over for the bimanual exam; and my only difficulty here is that I am accustomed to using my LEFT hand as the internal hand (taught that way 25 years ago), so either have to reach around at an awkward angle (the bench is set up with the woman's head to my left side), or I'm going to have to learn to switch hands. I've tried the right hand swap once, but that side of my brain is just not used to doing it. It's like trying to write with your non-dominant hand. I think I will stick with the awkward reach and just have patients scoot down as far as they can on the table, and be glad I have long arms.
So thats an introduction to a very busy rural office, that is well-organized. As a guest, I am content to just mesh into this machine, and have worked hard and sucessfully resisted putting even 1 cent in, not to mention 2 cents. I'm just going with the flow. The patients are delightful and I'm really enjoying the chance to just see patients and not have to have administrative responsiblities.
I'll close with the best part of the daily schedule: morning and afternoon tea. I am motivated to stay on schedule, because we all break at 10:45 AM for morning tea. This is 10-15 minutes of a cup of tea, some goodie like Edam cheese on crackers or a sweet, and a chance to talk to others in the office. We usually avoid talking about work- and I have learned a lot about the local area, customs, walking tracks, history, good areas to visit on "holiday", etc. Yesterday I learned the proper pronounciation of "pikelets"- the 'pike' part rhymes with "bike". [They thought that rhyming it with piglets was VERY funny.] Tea is a really nice break in the day; and after seeing the 7th or 8th patient, I find that morning tea recharges me for the 9th and the rest of the morning. Lunch, which today included pikelets (Yummy!), lasts from 1 to 2:30 (usually I am not done with the AM till 1:30 however). Then there is afternoon tea at 4pm. Same idea. From 4-5 pm the office schedule is all "acutes" and we stay to see anyone who makes it inside the door by 5pm- so I'm usually out by 5:45 or 6.
My workday ends with a walk home, a nice wind-down from the concentration at the office. Today it was raining at the end of the day; and all the farmers and herders are VERY happy because the area is having a severe drought. I took off my hearing aids and walked home in it, and didn't mind a bit.

A Busy Week in Winton
This has been a week of adjusting and getting settled in our house here and in the clinic. I'm not really disposed to say much about the medical practice this week as I'm still getting used to it and feeling a bit overwhelmed. But I was pleased that Friday afternoon I was in the office all by myself for the last few hours, and at the end of the day the nurses and office staff congratulated me for surviving the first week and doing "good as gold" as they say here. That was a great feeling. The biggest adjustment for me has been to learn the New Zealand Pharmaceutical schedule, and the procedures for referrals and forms. I'm coming with the drug schedule, although there are some things I commonly prescribe that are unknown here, like Pepto Bismol. This precipitates a scramble to adapt and try to figure out what people here use instead. I've already learned about some things, like tea tree oil (melaluca), which is great for stings and bites and itching. The nurses and the local pharmacists are both big helps in this regard. I had a lot of fun in the office last week meeting the patients, and figuring out what to do. I'm looking forward to tomorrow, Monday and a new week.

Vicki and Liz have been busy getting everything unpacked and organized in the house. It is a great relief to have a place to just call home. The house is great- really comfortable and light and airy and quiet. They have been grocery shopping, and the previous doctor and his wife left a garden in the back full of delicious vegetables that we have been picking and eating. Thank you Dr. & Mrs. Cantlebury! Dinners have been great; we even had roast lamb shoulder with roasted veggies last pm. We have a car provided by the local medical Trust, a little manual Mitsubishi Lancer, which I have NOT had a chance to drive yet 'cause the girls are having so much fun with it. They took it down to Invercargill on Thursday and checked out the Southern Institute of Technology for Liz. This didn't seem like a good fit. The curriculum is a set course of study (not at alll like our community colleges with their menu of courses), and the cost for her as a foreign student is relatively high. Liz and Vicki are going to check out the local secondary school, the Central Southland College, here in Winton tomorrow.

Yesterday was the Winton A&P show. This is an agricultural fair, where people bring their stock and compete for ribbons and honors for the best entry. The livestock, especially the sheep, cows and horses were a very big deal. But there were even competitions for best funny food sculpture and best farm or home invention. I really enjoyed watching the kids with their pet lambs. Some of the youngsters came dressed in traditional Scottish attire, and competed in Highland dancing, complete with live bagpipe music. This is a reminder of the local Scottish heritage here. But the best thing to watch was the dog trials. One dog and the shepherd have to move the sheep through a series of fences and gates, and finally into a pen. If you've ever seen the movie "Babe", you've seen this competition. The old shepherd who was judging the trials took a liking to Vicki and came over many times to explain and comment on the performances ("This next dog should be really good", "Perfect score is 100, I've only seen that once in me life", "Bloody sheep aren't working well today- they only want to stay with the mob"). It was great, a beautiful sunny day and perfect weather.

Today we had a lazy Sunday morning at home. This afternoon Vicki and I drove over to near Gore and went hiking in Croyden Bush, a nature reserve with huge trees and wonderful bird life. We heard the beautiful bellbird, and saw tui and New Zealand pigeons. We hiked up the hill 300 meters all the way to the lookout on the top, and then back down to a wonderful little waterfall in a ferny nook. The cloudy afternoon slowly burned off. From the top we could see the ocean and Bluff, way to the South. A day to remember. I've tried something new, posting the pictures on a separate page. Be patient- if you have a slow connection it may take 5-10 minutes to load!