"What do you think of that George Bush? Kind of a warmonger, isn't he?" the elderly man said to me. I've had enough patients ask me what I think of Mr. Bush, the war in Iraq, and politics in the U.S. that it doesn't take me back as much as it first did. Because we are the only Yanks in town here, patients are very curious to know my opinion about these matters. I've been asked by patients in the states if I'm relegious, a "Christian", "born-again", believe in God, and would I pray for them. But I can't remember a patient at home every asking me my political views, barring an occaisonal gripe about Medicare. So the first time I was asked, I stumbled a bit, before blurting out, "well, like 51% of the population, I didn't vote for him last time and don't plan to vote for him next time either". This answer has worked surprisingly well, usually eliciting a "Good on ya, mate!" in response. Kiwi's will typically guess that I am a Canadian first. I think they often suspect that I am American, but they've learned that if they guess that a Canadian is American, they will be quickly and swiftly corrected for making the insult. Mr. Bush isn't well liked here, and the vast majority of Kiwi's see the war in Iraq as a vast miscalculation. And they are just as harsh on Tony Blair, and the U.K.'s involvement as they are on the U.S. Kiwi commentators bemoan the "lack of news" for New Zealand radio and television, and imply that some of the airtime is therefore filled with stories from overseas. Most of these feeds seem to be from the BBC, but the major channels also have affiliations with American ABC and CNN networks, so we see those logos in the lower screen corners on a regular basis. My impression is that many of my patients keep up on the international news quite regularly. We've been able to read Time magazine each week because my next door neighbor, a former schoolteacher, brings it over for us when he's done reading it. I have to wonder if the average Kiwi isn't a lot more informed about U.S. events than many of our own citizens. During the primaries, many of them knew all about the Democratic contenders, and I was often asked who I liked, and who I thought would win the nomination. As part of small talk. In the exam room.
So I've trotted out some of the phrases my mother taught me to use when I was overseas, age 11, in case I was asked about the Vietnam war (which I never was, but thanks for preparing me anyway, mom!). Here are a few I have rehearsed in my head:
"Many people in my country disagree with the current administration policies, and this is likely to be a major issue in our next election."
"I agree with the president's goals to stand up to terror and dictatorship. I just don't agree with the means he has chosen."
"My country is so large, and so diverse that there are all kinds of people and ideas. It is as hard to describe what people think in the U.S. about these issues as it would be to describe what the average New Zealander thinks about the foreshore and seabed."
Of course, it never comes out that smoothly, but I try to engage the patients with humor, and not take offence. They are truly interested in what I think. And they are really incredulous that the events of the past few years could have taken place in America. As are we all!

Yet despite all this, America retains an almost mythic quality for some of the people I meet. I was talking with a registrar (resident physician) recently, and he was asking me about opportunities for training in the U.S. Now this man has moved to New Zealand and is in the emigration process from the Indian subcontinent. He has two preteen children, and in his words, "I have sacrificed my position at home to provide better schools and a better life for my children." Now he is wresting with a window of opportunity to perhaps move on to the U.S. It would mean more sacrifice for him, in terms of amount of work, renumeration, prestige, and separation from family. Yet he is wondering if it would be worth it to help his children attend an American university. "If I move now, no matter what their scores, they will have an easier time getting into a U.S. school" he says. "You see, you may not understand this, but for me, I want my family to move up, and America is the top, if you can get there." I am sitting there thinking about all the problems they might have- discrimination, crime, exposure to a highly materialistic culture while being separated from their own roots, even risk of terrorism, etc. But it is not in my heart to take away his dream for his children. "Go and visit", I tell him. "America is a very big place- so big you can't imagine it all. There is a good chance you can find the place you are looking for".

One of the things that prompted me to write on this topic was some recent conversations with folks here in town. A fellow we had supper with last week listened to Vicki and me discussing issues about schools, racial equality, medicine, economics, etc "back home" for an hour or so. Vicki has a keen mind and is not reticent about sharing what she sees as faults or opportunites for improvement in American systems. This gent, a born Kiwi, after politely and nicely listening to this for awhile, said, "well, at the end of the day, we really are very much alike, aren't we? We are comfortable in each others culture, barring minor differences, which are really sometimes quite amusing." It was one of the nicest things a Kiwi has said to me since I've been here, and really great to hear.

The first patient on my list last Friday was "Greg, Best Practice". This was a bit out of the ordinary, and when I went to the waiting room to call him back, Betty, our receptionist, flagged me down and pointed me back to the conference room. It turns out that Greg was visiting our practice from bpac^NZ. This is the Best Practice Advocacy Centre, an independent agency that has been charged with setting a single standard for pharmaceutical practice in New Zealand. Here's how it works. Greg and bpac^NZ had sent each of the regular doctors here a case study on depression, as well as information about their own personal antidepressant prescribing practices. The doctors were encouraged to fill out the case ahead of Greg's visit. By faxing back the one-page case and answers, and participating in the discussion, the rural doctor can earn continuing education credit, which is a big incentive when out here in "the back of beyond". Greg then takes no more than 15 minutes to review the case and the principles involved. He was very open ended in his approach. "Did this case seem like one you might see in your practice?". "Have you treated cases like this in the past, and if so, what did you do?". We then reviewed the questions and answers together, and Greg highlighted several issues based on best evidence: lab evaluations for the model patient, the general equivalence of all SSRI's, the continued place of TCAs for some problems and situations, situations where these medicines would be appropriate or not, and expected good effects and side effects of treatment, etc. All of this in 10 minutes, and using flip charts similar to what the pharmaceutical reps use. At the end, we problem-solved and discussed common problems- e.g. what to do when a patient balks at using fluoxetine, because they've "read stuff on the Internet from the United States about how bad Prozac is for them". Finally we ended up discussing how to use the medicines available on the Pharmac list effectively, and we were given a patient education handout produced by bpac^NZ to use with patients in our office.

This just blew me away, because this type of "academic detailing" is just what studies of continuing education for physicians suggest is needed, and effective. I was very familiar with the concept, but was unaware that it was being used in any health system, beyond experimentally. In Cedar Rapids, we have been proponents of this model for the last 3-4 years, and use something very similar- PBLA's- in our regular teaching. In fact, last year we had done a PBLA on depression, and I had, much to my surprise, discovered that I was the poster child in our program for Paxil prescribing! That feedback, and other things I learned on that unit had significantly changed my practice. So I was very excited to see this being actually done, with rural New Zealand GP's, in a system wide fashion.

According to a Wall Street Journal article from a few years ago, at that time, pharmaceutical companies had a U.S. sales force of 70,000 people in direct representation to physicians, at costs of over US$7 billion a year [number does NOT include the costs of drug samples]. Obviously, the drug companies wouldn't be investing this kind of money into direct sales if they didn't have data that it worked.

The question is, how can we reform the U.S. system to provide this method of continuing education for our own physicians? It would help promote best practices, disseminate the latest research on effective medicines, and provide far better education than a "learn and ski" weekend at Vail or Aspen. I'm sure the cost savings alone to our "health non-system" would be enough to pay for the venture.

We've been doing a lot of walking the past few days. This is because we've booked to hike the Humpridge Track beginning next Wednesday. Two of Liz's friends from high school, Pat and Tim are flying in from the States for Spring Break this weekend. Their request was to "see Middle Earth". So we decided to attempt to "do the Hump" while they are here. It has coastal bush, Fiordland alpine terrain, viaducts and gullys and the 3rd day is a walk along the seashore back home. Its 18k each day, and friends here tell me to expect mud. Lots of mud. So much mud that they recommend we wear gaiters.

Friday night after work, it was a beautiful blue evening here (unusual lately). So we skipped tea and drove out to Hokonui, a bend in the road about 7km outside Winton. From there we took the gravel up into the hills until we were "in the back of beyond" as they say here. It was an area of sheep paddocks on hills rolling down into little vales and valleys. A small stream ran by the road, and there were woodlots of pines and gum trees. The three of us put on our boots and walked 4km up the road and back. It was a great walk- we talked about a lot of things- geography, school, work, politics, and where Liz will go to college next year. There were sheep everywhere, and at one point Liz had them "baa"-ing back at her. We decided it is disconcerting to round the bend and have 2000 pairs of wooly, vacant eyes looking back at you. On a silent evening, with no wind, it was a scene that Steven King could use to great effect in one of his novels. The creepiness of the mundane.

Saturday, needing to do some expedition shopping, we drove to Invercargill and hit the outdoors stores. Possum-merino fur knitted gloves, to be covered by "rain mittens" were the big find- to prevent cold hands. I figure if we have good enough rain gear, we might have sun on the tramp for at least 1 day out of 3. We drove on to Bluff, the southernmost town in New Zealand. This is a small port and run down fishing village. Anywhere else on earth it would be a funky artists colony and a "hidden treasure" seaside resort- but it's remoteness means not many visitors make it here. It is famous mostly as being the place to catch the ferry to Stewart Island. However, Bluff DOES have a bluff. There is a great trail we walked, beginning at the road's end around to Steward Point. From there, its a stiff climb up Bluff hill to the top: about 236 meters. We did it in about 50 minutes, and it is a HIKE. And only 1/4 the height of the Hump! But the view from the top is spectacular: weather was great, sea calm, and we could see Stewart Island, the Hump in Fiordland, the Hokonui hills near Gore, and Slope Point, the southernmost point on the South Island. We came back to Winton that evning and went to dinner at my sponsoring doctor's home.

Sunday was rainy, and we decided to hang in Winton as next week will be busy with "the boys" here. Vicki and I walked out into the country and back around into town: 7.5 km. Came back in via the cemetary which has no new graves, and is quite dilapidated- I've gotta get the story about that. The advantage of this route however, is that it passes by the "Day and Night" dairy store in the last kilometer. Vicki had chocolate carmel, and I had an apricot cone. Yum!

Still working on getting my computer fixed. Dell has promised to send a repair tech, a new motherboard and a 3rd new hard drive. So far, no call in almost a week. I figure the repairman is coming from someplace nearby, like Tierra del Fuego. I've bought a card reader, so I can at least download pictures off the camera onto the old laptop. Problem is, CD burner is not working on that machine. Sigh.

Sunday PMs is watching New Zealand Idol with the girls. They are down to the "top ten" now. I'm voting for "big Dave"- he's got charisma and style and soul.