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.

Is a picture worth a thousand words? Now you can be the judge; I only ask that you read yesterday's entry before you look at the pictures from our Humpridge tramp.
Pictures from Day 1
Pictures from Day 2
Pictures from Day 3

Impressions from the Humpridge Track

Wednesday morning we wake up in Winton and find ice on the car. We
have spent Monday and Tuesday last week preparing "the boys", Liz's high
school friends, Tim and Pat, for the tramp.  With all the gear in
order, Vicki took Liz and the boys to the track briefing Tuesday night,
and then left them at the Rarakau farmstay at the trailhead, because there
was not enough room in the car for 5 people and all our gear and food to
get to Tuatapere in one trip.  A cold front was forecast, but in the
night it begins to hail and sleet.  We wake up at 5:30AM and pack
the car.  It is hard to back out of the driveway with the windows
iced and fogged.  We drive an hour through the darkness, passing rainy
farm fields and sleepy soggy sheep to Otautau, then over a low pass to
Tuatapere.  As we come over the crest, the sun comes up and breaks
through clouds to light up the newly snow-covered mountains of Fiordland
in front of us.  Then 20 minutes over gravel to get to Rarakau. 
Our breath condenses in the cold air as we gather up Liz and the boys,
stash our helipacks in the shed, and head out through the forest. 
The first hour is through bush along the cliff tops, with the sound of
surf coming through the trees.  Then down a steep stair to the first
swing bridge.  A three kilometer walk along the breezy beach brings
out some sunbreaks.  We walk together in a group until time to go
back into the forest, then single file another klick along the road to
the Track Burn swingbridge.

The group has now got ahead of me, and it is starting to sprinkle
rain.  I stop to put on my raingear.  I am struggling on
my pack and juggling the walking poles, wondering why I bothered to bring
them, when up comes Alice.  "Hello" she says, and we introduce ourselves
and walk together for awhile in the beautiful, dense Waitutu rainforest. 
I can't keep up with her on the hills however, and soon I am the straggler,
coming last into Flat Creek as it starts to rain a bit harder.  We
start out as a group up the hill now.  Its 928 meters up to Okaka
hut.  At first we are walking on boardwalk through the forest. 
From time to time we walk on the mushy ground.  "Why all the boardwalk?"
the boys ask.  I see this planking as ominous.  "Because we need
to save energy for the climb ahead." I tell them.

The forest is huge, ancient, full of ferns and changeable. 
The wind blows and gusts of rain come down.  In the forest this is
just a spinkle and drip, but through breaks in the trees I can see it is
pouring rain in the gulleys.  Then the sun breaks through.  I
am hot in my polypropylenes, and take off my rainjacket.  Now rain
comes back and I put the jacket back on.  We cross 3 streams. 
At the last bridge, the little plastic cap covering the nipple on my water
bottle pops off when we stop to refill our bottles.  Pat sees it swirling
around in the pool below.  We carefully lower the metal bucket hanging
from the bridge and try to scoop it up, but the waves from the bucket move
it into the current and it is gone.  It starts to rain more heavily
so we move on.  Up another hill and then there is a spot of sun and
some windfallen trees to sit on.  We have lunch.  Vicki has carried
the billy, and we fire it up for hot soup and tea.  Nutella on open-faced
bread, peanut butter and salami sandwiches, ramen, biscuits and dried fruit
recharge us. 

A black and white New Zealand robin joins us and entertains
us with his cheekiness.  He is not afraid to perch right next to us
looking for a handout. We pack up as the rain comes back and head up hill. 
There is no keeping together now.  The boys are out of sight and sound
in minutes.  Liz is third.  Vicki and I stay together for awhile. 
Vicki has a strategy.  "I climb from marker to marker, then stop to
catch my breath".

I stop to take some pictures.  Really it is an excuse to
breathe.  The climbs are steep, but having to stop is ok.  Each
time I pause, I look around.  Here is a gnarled tree root.  Next
stop is a new kind of fern I haven't seen.  One stop, when my breathing
quiets, I notice that the forest is silent.  No wind.  It is
full of spirits.  It is ancient and it is just there.

I yell at Vicki to wait a bit, and we stop for a water break. 
She says, "I hope that was the 'steep climbing' part we read on the map." 
I take off my boot and rewrap a toe.  I tell her to go on ahead, as
it is getting cold.  A gust of wind starts blowing down from above
as she is heading up.  I scramble to jam everything back into my pack
and throw on my raingear.  I know a big shower is coming.  Instead,
snow and sleet pelt my rain hood, tapping louding against the fabric, rattling
in my hearing aids.

Now comes the steep climbing.  It is 10 or 15 steps up and
then stop to breathe.  Over and over.  It is rocks and roots. 
I am using the Leki poles to balance and help push myself up.  Without
them I would need at least one hand on a root or tree at times.  I'm
glad we helipacked.  I know I can make it to the hut, but it has been
7+ hours of tramping and climbing now.  I'm worried- will I have anything
left for tomorrow?  And the 3rd day?  Suddenly the trees are
getting smaller.  I come over a little rise and go down 10 steps. 
No "down"!  It means I have wasted 10 "up" steps!  But there
is a gap in the trees, and I can see the Okaka hut.  Its doesn't look
very far away.  The sign says "Okaka Hut- 1 hour ->". 
The path comes up against the mountain, and goes down between huge rocks. 
The wind is howling now and it is snowing hard, but in the cleft it is
a bit sheltered.  Snow drifts down.  I look to the my right and
a beech tree has wrapped huge roots around 3 giant boulders, each rock
at leat 2 meters tall.  I've never seen anything like it.  The
tree above is not that large.  The roots are humongous.  This
tree is not going anywhere without taking a piece of mountain with it. 
It is determined, it is resolute.  I push upwards to find boardwalk
and more stairs.  Finally the ridge.  It is gusting 80 kph winds
and there is razorback ridge to walk along, too narrow for two feet side
by side.  I use the poles and still almost get blown off.  I
can feel my face getting frost nipped on the left as I come down over the
ridge.  There is only slanting boardwalk now down into the cirque,
to the hut, but it is slippery.  I have to concentrate to keep from
slipping.  When I get there, no welcoming committee, no cheers. 
Everyone is inside around the warm stove.  I work off my boots and
hurry to join them.

The night is freezing cold.  The wind shrieks.  The
sleeping rooms are unheated, and it is 1 degree C. at bedtime.  Vicki
and I are each in our sleeping bags, but we cram into one bunk together,
so at least one side stays warm.  If I roll up against the wall I
am instantly cold.  Several times I fall asleep only to wake up shivering. 
In the middle of the night I have to run outside to the toilet.  I
put it off as long as possible.  It is pitch black and my flashlight
illuminates the slush I walk through in flip-flops.  I take the opportunity
to put my polyprops back on under my dry clothes.  I've had them hung
up for 3-4 hours and they have dried themselves out even in the cold, so
they work, and I am less cold the rest of the night.

Morning, and the wind is only moaning a bit, not screaming any more. 
Its cold, I run to the toilet again and then into the common room where
the warden is making porridge for us all, and the stove is relit. 
The room is cold, but Vicki and I, first up, watch the sun rise over the
sea and the mountains to the east.  It has cleared off mostly, and
we can see the ridge we climbed yesterday, and all of the country to the
east and north.  The Takitimu mountains, which do not look that big
from Winton, are a huge block of snow-covered rock rising out of the plain. 
We eat breakfast, repack the helipacks and lug them down to the platform. 
We discuss climbing up to the summit, about 80 meters above Okaka. 
The boys and Alice want to do it.  We decide to dump the packs at
the trail junction, and take our chances that the keas will attack them. 
I do "foot clinic" for everyone, taping and patching red spots and sore
spots, so I am last one out the door, after doing my own feet.  I
take Alice's picture for her as I climb the summit boardwalk.

The boards protect the alpine plants and tussock grass.  But
they also wrap around the cliff face.  As I walk around the western
edge of the loop, I can see more and more of the mountains of Fiordland
in the distance. The sky is broken clouds, but I can see forever, over
to Lake Poteriteri, the Wairaurahirir river curling through the forest
below, and around up to the north as well.  I am glad we are not fogged
in- this is the view I walked and climbed for all day yesterday. 
The mountain top has many tors, towers of rock sticking up, with tarns,
small mirror-lakes between them.  I walk around the summit quickly;
it is still freezing and the wind is about 40-50 kph.  I have three
layers of thermals on, but I cannot stay up here long.  It is a place
full of power and mana in any case.

As soon as I reclaim my pack (no keas, darn it) and start into the
forest, I am hot again.  I shed the thermals, but not the raingear-
it is still windy.  Day two, like Gaul, comes in 3 parts.  The
first is a walk down the hump ridge to Luncheon rock.  It is undulating
up and down, with some real stairways from hell.  There is a group
of 3 young men from Wisconsin who are now doing their 5th Great Walk in
2 months.  They leave an hour after we do, but in mid-morning blow
by me on the stairs, lugging huge packs.  However, the views are spectacular. 
I stop to look often; as the weather evolves, the sun moves, and the clouds
shift, so the vista changes.  I am last into Luncheon rock, and glad
to sit down.  I have drunk all my water, and have to refill my bottle. 
It is easy to get dehydrated on the walks; despite all I've had for breakfast
and walking, I am still thirsty by noon. It is sunny, and I can see the
terraced slopes ahead.  These are ancient beaches, lifted up in succession,
and "famous among geologists worldwide" according to one guidebook.

The second part is mud.  Lots of mud.  There is even
a little ditty on the map about it:
"Mud, mud, glorious mud,
nothing quite like it for cooling the blood,
So follow me, follow me
down to the hollow,
and there let us wallow,
in glorious mud."

It is all downhill in the mud.  I have gaiters on, and decide
to just plow through.  Going down in general is harder then climbing,
and I am glad again for the poles.  The articles say they protect
your knees from the shocks going down.  They also protect you from
going in too deeply in the mud, and they make great probes for deeper looking
mudholes.  I stay with Liz and Vicki going down.  Liz picks her
way around the mud so it takes her longer.  I squelch in over my right
boottop several times in holes that didn't look that deep.  The two
boys have decided to race down the mountain, despite my warnings that it
is very dangerous and that I am not in a mood to set bones.  They
are gone, like gangly deer leaping off through the bush.

Coming down is a lesson in plant succession.
Suddenly, ferns!

Part three is a lesson in the works of man.  We come down
to the Edwin Burn viaduct.  The last part of the trail is along a
tramline, built by the Port Craig lumber company in the 1920s, when they
logged this section of the coastal forest.  The Percy Burn viaduct
is the longest, tallest and largest wooden viaduct still in existence anywhere
in the world.  All 3 viaducts have been restored.  We walk along
flat, graded trail and have to watch out boots don't catch in the iron
nails sticking up above the sleepers which are still present in the grade. 
There are cuts through the hillsides that are dark, moist and full of earth
smells and ferns, and of course, mud to slop through.  I am amazed
at the way the bush has grown back.  The huge ancient trees are gone,
but there is still dense bush and forest full of birds and young trees. 
In another 100-200 years it will look as it did before the logging. 
The viaducts are impressive works of 19th century engineering, but they
seem out of place here. Still, I am happy not to have to climb down and
up the deep gullys.  But soon these works are behind us, and the sign
says 2 more hours to Port Craig village and hut. This is a hard two hours;
we are tired from two days walking, we are sore from going down mudholes
for 3 hours and using unaccustomed muscles, and it is hard to just match
your stride to the gaps between sleepers.  I work hard to notice things,
like an old iron rail, or the insulator in the tree, left from the old
phone line to the Point Puysegur lighthouse.  At the end sandflies
start biting so we just keep moving, until we flop down on the benches
at Port Craig, haul off our boots and duck inside the screens.

The silly boys, who ran down the mountain, got here an hour earlier,
and ran down to the beach (5 minute walk).  There were Hector's
dolphins surfing in the bay, so they jumped in for a swim with them. 
Now they are playing chess, and eating the rest of the huge sack of snacks
they carried and having a good time.  Vicki, Liz and I make dinner,
brush our teeth, and leave the beach for later.

Port Craig has lots of hot water and sandflies.  But after
dark, when the sandflies retire a bit, we take a bucket of hot water down
to the ablution block and take "spit baths".  It is dark and the clouds
clear.  The Milky Way and Magellanic's appear.  In the distance,
a morepork, NZ's native owl, starts to call.  My bird book says, "every
New Zealander recognizes the distinctive call of this owl, which can become
tiresome".  The owl moves much closer.  Every 30 seconds were
are treated to a loud call of "MORE PORK!".  I'm too tired for it
to keep me awake, and it is kind of amusing.

We are awakened to the sound of Bellbirds.  Vicki and I
walk down to the beach to watch the sun rise.  It is beautiful, noisy
with birdsong, and the sandflies want breakfast.  We return for porridge,
and the warden has missed the weather report.  Oh well, its always
a "fine day" in Southland.  Somewhere.  We pack up the helipacks,
and I decide to lighten my daypack and not take any warm overclothes. 
I do "foot clinic" again.  We decide to give the boys the carkeys
and have them organize things at Rarakau as they will get there first.

Alice leaves just as I am taking off also.  For the first
two hours I keep up with her mostly.  The walking poles are helpful
on this track, with undulates through the coastal forest, crossing many
small streams.  Of course, there is mud, but less of it.  Mostly
we just walk silently, but for awhile we converse.  She is doing a
masters in industrial engineering at Frontera, the food firm, in Southland. 
Her brother works at a ski resort in Colorado.  Do I want to immigrate
here?  Her parents would like to, but are too old to qualify. 
What do I think of the healthcare system here.  It is a nice conversation
between people who enjoy the forest.  It starts to rain and we come
to some hills, and I am walking by myself again.

As I come down to Blowholes beach it starts to pour rain.  I
duck back into the forest and put on my full raingear, including mittens. 
The beach is fantastic in the rain.  The surf is pounding, the blowholes
are spouting spray, there are shags clinging to the rocks right on the
beach.  The rain is pelting down and I am soaked everywhere except
my shorts.  There are deer tracks and sign on the beach, mixed in
with bright red kelp and flotsam.  I climb back up into the forest
where the rain continues.

In my 4th hour of walking, in the 3rd day, I lose my mind. 
At some point during this rain, I stop thinking and just walk.  It
is a mindless, empty, feeling-less state.  I am in the moment. 
I am not "one with the forest" or having any type of epiphany.  I
am just walking.  Just walking in the forest.  Just walking in
the forest, in the rain.  I do this for about an hour or so. 
I am not thinking of any thing.  The first thoughts that come into
my mind as I come out of this fugue state are about fungi.  I notice that
there are all kinds of fungi here.  Little gelatinous, shiny buttons
that are as hard as nails.  Shelf fungi growing out of the trees,
that look like they have clamshells for a roof. Small purple capped mushrooms
growing out of the trail edge.  I meditate for awhile on the rain. 
Rain is good for the forest, for the fungi, for the ferns.  Without
this rain, there would be no forest, no waterfall, no birds.  It is
a Daoist thought.  "The pot is valued for what its not."  It
is a fine day in Southland.

Such peace cannot last forever.  I reach Track Burn and
Alice has stopped to have a chat with 3 fellows who are smoking on the
porch of their crib at the edge of the stream.  Two are obviously
Maori and they are preparing to go deer hunting.  At least the cigarette
smoke keeps the sandflies away for 10 minutes while I stop for a drink
and muesli bar.  Alice takes off shortly after I arrive.  I leave
5 minutes after her.  As I'm leaving the 3 Wisconsin boys blow by
me.  We go over a hill and then out onto the beach.  I'm beginning
to get worried because Vicki and Liz still haven't passed me, and I know
I am the slowest one usually.  As I follow the young people up the
3 km beach, the rain slower dissipates.  I look back, and a figure
appears out of the mist.  It is the hut warden, walking out. 
As he churns by me, I ask him about my wife and daughter.  "They're
ok" he says, "your wife lost your daughter and went back to look for her,
but I turned her around".  He rapidly disappears ahead
of me.  I keep looking back all the way up the beach.  Even take
out the binocs, but no sign of them.

At the end of the beach, there are a bunch of "bachs". 
These are shacks, traditionally begun as a government benenfit for returning
veterans.  The Wisconsin boys have stopped there and are drinking
beer with a bunch of blokes who are down to the shore for their biennial
5 day holiday.  They offer me a beer too, but I accept a cup of coffee. 
The rain has stopped.  One of the men is cleaning 25 of the hugest
mussels I've ever seen, and another bloke proceeds to show me the best
way to eat them.  Raw.  He gets two of the college boys to eat
some also.  I tell him they didn't go well with coffee.  As we
are talking, a fellow pulls up in his ute with an 2x3 meter trailer behind
it.  The trailer is 1/2 full of cases of DB Draught beer and 1/2 full
of propane and diesel.  One proud fellow shows me around.  "Its
taken us years to get this place like this."  It is a wooden shack,
ramshackle with tile roof and excellent ventilation through holes in the
eaves.  There are many old couches and a few cots, a wood stove, a
TV and diesel generator for watching sports, and even a shower and flush
toilet.  They are very proud of having put the toilet in.  "You
used to have to run down to the little house around the corner, and the
sandflies would eat you alive" they tell me.  It is sunny and beatiful
now, and the blokes are beginning to sing "Que sera, sera!" (and its only
2 in the afternoon).  I walk back to the dune edge and see Vicki and
Liz coming up the beach.  I thank the blokes for the java, and go
meet them.

Liz has a very sore knee, and has been slow all morning.  She
got her cotton clothes soaked, and Vicki made her put her polyprops back
on.  Now it is sunny and the end is in sight, she is cheered up a
bit and moving better.  We walk up the 145 steps to the bluff top
and walk through the last km of forest together.  Twice we see pairs
of NZ pigeons up close, along this nature trail.  It is a nice goodbye
to the forest.  The boys have been back for 2 hours, and already taken
showers at the trailhead.  We somehow manage to stuff all the gear
in the trunk, and ready to stuff ourselves into the car.

I take a last look up at the Hump.  The sun has come out
again, and now that I know where to look, I can see the Okaka hut from
the trailhead.  I can see the tors proturding from the ridgetops. 
I can't believe I've walked 54 km in 3 days.  It's hard to believe
I was up there, that high on the mountain.  If I had known what was
ahead, I'm not sure I would have done it.  But I hope I never forget
it.

"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.

Every clinic experiences some afternoons when it feels like the circus is in town, but last week it really was! Vicki and Liz were startled to hear two men speaking fluent Spanish in the grocery store on Tuesday, but it all became clear once we saw the big top of the Weber Brothers Circus set up on the green grass of the second-best rugby field in town. (You didn't think they'd use the BEST rugby field, did you?). It was a real tent, with red spires topped by the circus name in lights. Vicki and I walked down to see the show one evening. Elizabeth took a pass as she has never recovered from catching coulrophobia as a child. We came in a bit late, due to a mixup reading the paper for the start time. The tent was pitch black and full of children eating "fairy wool" (cotton candy) and playing with small strobe and lighted toys. There were maybe 400 people sitting in bleachers watching the single ring in the center. I was impressed at the advanced lighting and special effects- there was smoke and mist, huge larger-than-life puppets, and great sound effects well coordinated with the funnier acts. My favorite was the fellow on the trampoline. His acrobatics were nothing special, but his Chaplinesque moves and mugging to the crowd made the children (and us) howl with laughter. There were minimal animal acts; a trained dog jumping through hoops, and a goat and llama on a teeter-totter were about it. But the acrobatics and the aerialists were quite good. The final act, a pair of men from Colombia on a giant rotating metal device that looked like an eggbeater from hell had them scrambling around rotating cylinders about 25 meters in the air. It was an act I'd never seen before and quite enjoyable. But the best part was listening to the children laugh and exclaim, and letting ourselves remember the wonder of the circus through their eyes.

Speaking of childhood, this last weekend we were visited by Don and Betty Ritter, now of Southern California. Betty was Leah and Elizabeth's first Suzuki violin teacher when they began at age 3. She and her husband were visiting New Zealand and we had invited them to include Winton on the itinerary. It was great to see old friends again, and we enjoyed sharing what we have learned about New Zealand with them, including bragging about "our town" and the other great finds we've made here. Sunday we drove over to Riverton, on the south coast. There was a Sunday market at one of the local schools, complete with arts and crafts booths, and even a whole mutton roasting on a spit. For NZ$2 you can get a "mutton foldover" which is a large piece of white bread, slathered with butter. You carry it over to the rotating, wonderfully aromatic roasting sheep, and the cook carves off a large piece of meat and slaps it on the bread. You then apply Waddie's ketchup if you desire, and fold it over and chow down. I had one and gave Vicki a bite; whereupon she sent me back for one for her and another for me. "Tell him 'no fat' on mine though" she said. I passed this on to the cook who smiled and said "Well, YOU want some fat, don'tcha mate? All the flavor's in the fat!" as he carved off a chunk of fatty mutton and slapped it on my bread. As I fought to keep the grease from running down my chin, I had to agree that he was right. After lunch, we went walking on the beach, and up in the hills over the town. There is a wonderful walk that takes you to the top of the bluff, where we saw the bay and Riverton, and turning around, looked out over the Southern Ocean with Stewart Island rising out of the mist in the distance. Then down through lush temperate rain forest, full of tree ferns, to break out in sheep paddock and walk down to the beach among huge rocks sticking up out of the hill. Finally a walk back up "sandfly alley", through the bush again, and back to the car park for a great 2 hour excursion in the sea breezes.

Work in the clinic continues to be very agreeable the last few weeks. It is hard to believe this is now the middle of my 8th week. I have been here long enough that I have seem many people multiple times. I have even sent one gent back to the hospital twice now. The practice tends to a lot of geriatrics, with high prevalences of hypertension, heart disease and peripheral vascular disease, especially venous insufficiency. I think the latter must be related to long years of agricultural work standing on your feet- I remember seeing a lot of it when I was a country doctor in Quincy, WA. It sure seems like we don't see that much (at least in the non-obese patients) in my Iowa patients. I am impressed however, by the number of patients who "quit smoking 20 years ago". Very few of the older patients still smoke, and I haven't seen nearly as much smoking-related COPD as I do in the states. Obviously the public health folks here did a good job in the 60's and 70's. However, there is still a problem with new smoking among some young people. However, I realized today that I have not seen ONE ad for a tobacco product since I got here- not on any sporting events, sponsorships, billboards, magazines, etc. NOT ONE AD. We've only seen some very GRAPHIC anti-smoking ads- graphic as in an autopsy showing a human atherosclerotic artery being dissected on television. It made a big impression on Liz. I concluded that banning tobacco advertising is having some significant effects here, and a web search tonite finds actual data showing a halving of tobacco use. Way to go New Zealand!

We continue to delight in the foreign language the New Zealanders speak. I was reflecting to Vicki about some of the differences in medical terminology. When worried that something is ominous, such as a funny looking mole, or a sudden case of bloody diarrhea, patients and staff often refer to it as being "sinister". I have adopted this word in my vocabulary, replacing my phrase, "Oh, I don't think that {mole, etc} is something to worry about", with "That {mole, etc} does not look sinister to me". Besides being a more definite phrasing, the new phrase does not carry any emotional connotation that the patient is (or I am) "worrying" about something. "Sinister" also implies that an abnormal mole might be "evil" as well as dangerous or harmful. It feels more like the focus is on the possible behavior of the mole, and not on my opinion of it!

In a similar vein, diagnostic exams of blood, xrays, etc are termed "investigations" instead of "tests". I've thought a lot about this one. A "test" is something you pass or fail. You are graded on tests. You might get an A or an F. And a test implies that the result will be binary: its either good or bad. Compare that to an "investigation". This term reminds me of a detective story. A "private eye on your xray" or a "sherlock of cytology". There is nothing to pass or fail- we are looking for clues to the illness. We are investigating the body, looking for bad guys. And sometimes its unclear: is the mole good, is it bad, or maybe its in between or unclear. That can happen on detective shows you know. The nice blonde is really bad at heart. The whore has a heart of gold. Things are unclear, but if we are good detectives, we will eventually figure it out with timely and carefully chosen investigations.

It was a very clear night, for once, earlier this week. Lately the unseasonable weather has kept the sky overcast, and its been cool and rainy. Monday it was downright cold, with a noon high in Winton of 3 degrees C. on the clock downtown. But we had at least one "fine" day on Wednesday, and that night I went out to the shed for wood about 11 oclock. The Milky Way was brilliant across the sky, with the Southern Cross and the other constellations I don't know visible. This was the best night for viewing I have seen since we've arrived, and I took a few minutes to look up. The Greater and Lesser Magellanic clouds, satellite galaxies of our own great whirlpool were easilty visible, shining in the South. And this got me thinking about humility. This experience has reminded me daily of my "place in the universe", as Vicki calls it. In the clinic, I'm daily talking with 80 and 90 year old patients. They have been reflecting back on their lives, what it has meant, and sharing how they deal with the surprise of waking up each morning at their advanced ages. And then there is the immensity of this New Zealand landscape: the power and size of the ocean, the force of the winds, the towering hills and mountains, combined with the age and luminosity of the starry dome above to put me in my place. It is hard to express these feelings without seeming trite: "we are only very small, and only here for a short time", etc. But I admit I was thinking (smugly) about how this was good for me, how it was helping me to reduce stress by putting things into perspective, how great this was to be here and know my place in the universe.

Which is why my hard drive crashed the next day. Not the hard drive on my older back-up laptop that I brought. No, the hard drive on my new, 9 months old Dell Latititude. The one with about 300 pictures on it, taken since we arrived in Winton, that WERE NOT BACKED UP YET. The one with all my work and passwords and notes on it. Just dead. The machine wouldn't boot and the drive just clicked and clacked. 3 hours work downloading the Dell diagnostics disk on the other machine and testing the machine confirmed the problem. Dead drive, no way to resurrect it. I even tried freezing the hard disk for awhile. No joy.

This is one of those times when you just have a sick feeling in the pit of the stomach for a day or so. Never being good at facing reality, I have looked at costs of data retreival services. Yes, they do work. They got back 100% of the Columbia's hard drive. But the cost would be about $1000 any way you look at it. So time for some hard facts. The pictures are gone. Thank goodness I have posted a bunch to this site. I've asked people at home to back the site up so I don't lose those too. And I did back up my laptop (5 GB of data) at home before I left, so I haven't lost all my teaching files. But I am going to have to let the pictures go.

And again learn that important life lesson. You can't hold on to anything. The Buddist lesson: everything changes, all is impermanent. So to get attached to things or ideas; like "the idea that I was going to have 1000 great pictures of this trip to cherish forever and ever", is to just invite pain.

So yesterday we drove up to Wanaka, and then up the Matukituki river valley to Raspberry Flats (love that name). This was a great drive, in the rain, through a huge, glacial valley. There were waterfalls pouring down from the heights everywhere, "9 cattleguards in the next 20 km" as the sign told us, and 5 streams to ford with the car. At the carpark, we put on our raingear and set off to visit the Rob Roy Glaciers. This was described as a "gentle tramp". Which means, I gather, that you don't have to use your hands all the time to go up, as in a "steep tramp". It was 4 hours and 7 miles round trip. But definately a walk through the Misty Mountains of Middle Earth: huge tree roots, a roaring stream, and at the top the bright blue hanging glaciers above the cirque. I had hoped to see Keas on the tramp, but they were too smart to come out in the rain. But I enjoyed the walk, and tried hard to stay in the moment. Because the moment is all we ever have.

Now excuse me please, while I log off and call Dell, to send me a new hard drive. It may be awhile before there are any more pictures on this blog.

It wouldn't be a trip to New Zealand without a rugby game. Now I'm certainly not a "keen" sports fan, and I'm the last one to teach you the difference between the All Blacks, the All Whites, Black Caps and the Blues. But the local chemist kindly invited me and the girls to accompany him to the season opener of the Southland Highlanders rugby team. Unfortunately, no one can plan for the weather. We have been having very unseasonable cold and rainy weather here for February, and after the severe drought in January, we are now very close to having the local farmers complaining about TOO MUCH rain. (But at least we aren't as bad off as the poor folks on the North Island, who have been flooded out. Daily we see pictures of homes and cars filled with two feet of mud, rivers washing out bridges, "landslips", and stock washing away in the currents.) So we ended up attending our first rugby match in about 14-15 degree C. weather, with howling wind and rain. The stadium stands have a back, but we were uncovered. I had made Vicki buy a nice raincoat earlier in the week, and we took trashbags to put over our knees. But frankly, cotton clothes do not cut it in weather like this. I had on a pair of warm-ups under my jeans, 3 layers on top all under my nice gore-tex hip-length raincoat. Lesson learned: you need polypropylene "thermals" in this climate. But a little suffering while watching the game really puts you in the right mood anyway.

That's because, out on the playing field, there is a lot of suffering going on. Not that any of the players are going to let on. The game consists of two 40 minute halves, and there were only two stoppages for injuries, and in neither case was there a substitution. Geoff, the chemist, explained that mostly these were a ruse to buy a little time and regroup. The goal of rugby is to move the ball quickly down field by running or kicking. You cannot pass the ball forward in any way. So you pass it laterally or backwards. The receiver then charges up field until he slams into a defender. The SMACK of the bodies colliding is the sound I will most long remember from my first game.. There was no blood on the field that I could see, but that may have just been a function of all the blowing rain. There should have been blood. Lots of it. These guys wear no padding or helmets. And there is a reason that they call two of the major types of play a "maul" and a "ruck". Cause that is what the players do to each other. As you can imagine, it was GREAT fun. A very fast game mostly, with lots of action. As a viewer, you need to really watch where the ball is going. And there is nothing like the sight of one of YOUR guys sliding on his belly and hydroplaning into the end zone to complete a try. And oh yes, by the way, our guys WON.

Saturday the rain continued heavily, so we mostly did some shopping in Winton and stayed around the house. It has been cold enough here to need to keep the wood stove burning most of the time, to heat the house. But on Sunday, I prevailed upon the girls to drive up to Te Anau. This is a drive to the northwest, up the river valleys about 1.5 hours from Winton. Most of the drive is through farmland, past some more of NZ's 39 million (recent census) sheep. But some of it is past the Takitimu mountains, and over some tussockland into Te Anau. The small town is the headquarters for Fiordland National Park, and it is quite small- mostly an outpost for backpackers and trampers, as compared to the resort atmosphere in Queenstown. I had wanted to hike along the shore of Lake Te Anau, a deep glacial lake nestled in the mountains. The first part of the Kepler track (one of the Great Walks) has one of the only two examples of mature red beech forest left in the world, the other being in Patagonia. We drove to the start of the track and ate lunch in the car during a brief but heavy rain shower. Once this passed over, we crossed the control gates of the lake, and walked 5 km through the forest to Brod Bay. This is a fabuous forest, with a very open understory, unlike most New Zealand "bush" which is usually impenetrable. The forest was filled alternately with huge ferns, thick green moss, tree ferns, or occaisonally a segment of understory full of moss, a "goblin forest". Its a fun walk because the forest changes every 5 minutes from one type to another. All the time, you can hear the waves breaking on the lakeshore 20 meters away. The red beech are a beautiful tree, many of them I figured are 600-800 years old. We arrived at Brod Bay and had a quick bite of dessert on the beach (quick due to the sandflies deciding WE looked like dessert to them). I hiked up another 5 minutes to look at the climb from Brod Bay up to Mount Luxmore. I would dearly love to walk the Kepler track, but I'm just not sure I can physically do it with a pack- its very steep and a climb of 800 meters in about 5-6 hours. We'll see. We walked back through the forest, hopped in the car, and scooted home in time for New Zealand Idol, our Sunday night family obsession. Its kinda hokey, but a kick to watch together. And if this weather keeps up, we may know all the New Zealand commercials before we come home. (Did you know the female breast vertically bounces 8 cm without a sports bra, and only 4 cm with one? There are some very graphic commercials here you will NEVER see in Superbowl-shocked America!).

Prescribing drugs here in New Zealand has been an interesting experience, especially with all the debate in the U.S. last year about the Medicare drug benefits bill. This is sure to be an issue in the upcoming election, especially since the current administration is running huge deficits due to the Bush tax cuts plus the war spending. Time magazine recently (Feb 2nd) had a cover story "Why Your Drugs Cost So Much", about the situation in the United States. In a nutshell, they said the pharmaceutical companies, the largest lobbyists in Washington, are ripping off the American people by ensuring that government regulations protect their oligopoly. The article states that these massive profits are NOT used for research and development, but for shareholder profits and direct advertising. Furthermore, protections for the industry have grown tremendously via the fine print that was snuck into the recent Medical benefit bill. New Zealanders who have read the Time article here are very surprised when I tell them that NZ$ 30 is a great deal for the same Cipro that would cost US$130 at home.

The system in New Zealand is both simple and complex, and I can only really speak to it as a prescriber, as I'm not really sure I understand all the in's and out's of how it works for the consumer. The country has a national pharmaceutical schedule administered by Pharmac, a "a Crown entity established by the New Zealand Public Health and Disability Act 2000". Their goal is "to secure for eligible people in need of pharmaceuticals, the best health outcomes that are reasonably achievable from pharmaceutical treatment and from within the funding provided." They also have a mission to encourage responsible prescribing. Their main activity is to manage the drug schedule and to negotiate reasonable and lower prices for drugs for the entire population of the country. The entire mission statement and details are available at their web site if you want to know more.

For me, what is means is that as a "GP" here, I can only prescribe out of the book. Not only that, I can only prescribe "non-restricted" medicines in the book. For example, I can prescribe baby formula, but only milk-based products. If a child is having feeding problems and needs a soy-based formula, they have to go to the hospital outpatient department and see a pediatric registrar (i.e. Resident), or I have to fax one of my consultant pediatricians with the details and hope he or she will be nice enough to sign off on the form. This particular example has only happened once in the last 5 weeks, and is an unusual one, because for the most part, all the patients here breast feed (and are delivered by midwives). Well child care occurs at Plunket, but that's another story too. Another GP example: I can prescribe any SSRI I want as long as its fluoxetine, and it will be fully subsidized. Citalpram, Nafazodone, and Paroxetine can be prescribed, but the patients will have to pay the difference between the subsidized price (NZ$5.25 for 90 days of generic fluoxetine capsules versus NZ$35.02 for 30 days of paroxetine) [See, I TOLD you drugs were cheaper here!]. Most of the older tricyclic antidepressants that I used when I was a country doctor in the 1980's are on the GP schedule however, so I am thankful I have had a lot of experience using them in the past.

What this means for me, is that if I want to prescribe a class of drug like an antidepressant, the first thing I do is pull out my little Pharmac handbook and look at what is available. Because New Zealand has this program, some pharmaceuticals are not even available in the country. Thus some of the antidepressants I used in the U.S. cannot even be purchased out of pocket. They just aren't marketed here. The flip side of this, is that some European drugs that we cannot use in the States ARE available here, so I have to look them up in the Compendium or on the internet if the patient is already taking them or if I am considering using them. The issue of unfamiliar drugs was especially acute for me the first two weeks here, particularly for hypertensive drugs, as there are ACE inhibitors and thiazide diuretics I had never heard of before. If you'd like to see the list of drugs, I've made a little Excel spreadsheet out of the data that Pharmac kindly emailed me.

Every day there is at least one patient with a drug need that I makes me scramble about. Some things I've recommened a lot in the past, like triple antibiotic cream (Neosporin) are not on the formulary here, so it is a challenge to find a substitute in the book to do the same job. Sometimes there is no substitute, and on several occaisions I've called the local "chemist" (pharmacist) for advice and discussion and he has been very helpful.

I've read and heard from other locums doctors that have worked here that figuring out the drug system was their major difficulty, and that the biggest frustration was the limited prescribing powers. However, I have tried to look at the whole big picture if I can, and it has led me to wonder about a lot of things.

Certainly, with the push to use evidence-based medicine and limiting such things as overuse of antibiotics, this system seems to have a lot of potential to eliminate poor prescribing and encourage good medicine. Most patients here have respect for antibiotics as "powerful drugs that should only be used when the immune systems fails" as one patient told me. I am not allowed to prescribe the macrolides Biaxin or Zithromax (except in a gonorrhea/chlamydia treatment regimen) as a GP, so these drugs are preserved for hospital use. If I have a patient who needs a macrolide, I may use erythromycin, or decide that I want a hospital physician to see them. This can usually be arranged, but is a barrier to both me and the patient that must be overcome. Does this prevent overuse and ultimate drug resistance to the newer macrolides? I'm not sure, but it is a very interesting experiment that I hope is monitored and evaluated.

The other side effect of the government negotiating directly with pharmaceutical companies is on TV. Or rather, is NOT on TV. We noticed the first few days that we were here- there are virtually NO drug ads in the media. No patients coming in asking for the latest antihistamine, antidepressant, etc. by brand name. In fact, when I prescibed fluoxetine to an elderly man recently, I gently explained that this drug had become rather famous and controversial under the brand name "Prozac". I was about to discuss any questions or concerns he had about that, when he cut me off with "well, I never heard of it before!". That was a bit of a shock, I'll tell you!

Finally, one of the first things I noticed about a New Zealand pharmacy is that 4/5's of the floor and counter space is taken up by cosmetics. There is usually only 1-2 small shelving racks for drugs, and usually over half of those OTC drugs are common herbals, like ginseng, ginko, black cohosh, etc. However, the herbals here are most often at homeopathic strengths, so I don't worry much about drug interactions or effects as the strength is so low.

Most people treat a cold at home, with home remedies like tea, hot and cold packs, and for children, nasal suction and saline drops. You can sometimes find Dimetapp or Benadryl cold products on the shelves of the pharmacies, but the chemist will get them for you and discuss their use. You never find OTC cough and cold products in grocery stores, or in the "dairy" store (New Zealand's answer to "7/11"). So I don't worry a lot about patients taking OTC meds. The most commonly sold medicine here is Panadol (paracetamol or as we would know it, acetominophen [Tylenol]). By and large a lot of folks don't even take that when they should, as in the sheep farmer I saw who walked around on a fractured fibula for 3 days with no pain meds or treatment, and only came in when the swelling interfered with getting his boots on.

All this makes me think that for a lot of things, more expensive, newer drugs are not the answer. Pharmac's system certainly attempts to balance evidence, cost and public health with the needs of patients. I don't feel I can conclude how well it works, but I can say that it is a great example to look at closely when we consider the 44+ million uninsured patients in our own country who have NO access to affordable medicines. And I really enjoy not having to listen to patients tell me how their drug costs are forcing them to choose between food and medicines. It gives me time to really work on the compliance issues of how and when they are taking their medicine, instead of wasting time talking about why they can't even buy it.

It's been a nice weekend here in Winton. Yesterday was cold and rainy in the morning; so much so that we had to start up the stove to warm the house. I never expected to see coal mines in New Zealand, but there are quite a few small strip mines in the Hokonui hills around here. Mostly they are places where a trench has been dug, or a hillside dug into and the coal is taken out with a backhoe. You can buy it by the gunney sack here, and I must say it does heat the house wonderfully well- lasting lots longer than wood would! [sorry, I could't resist]. At first I felt bad about all that greenhouse gas going up the flue, but when you think about it, its probably more energy efficient that burning coal in a huge powerplant, converting the heat to electricity, transmitting it over power lines and then converting it back into heat. These stoves seem to burn pretty well, although occaisionally we'll get an acrid smell while on a walk around town, and I wonder if it isn't somebody's coal burning stove. Or then again, maybe somebody is just burning a tyre, as they spell it here.



















In the afternoon the girls were busy cooking or knitting or doing things, so I took the car and drove over to Browns and the Hokonui hills to walk at Dunsdale. The road takes you up into the hills, on 8 km of gravel through half-grown pine forests that are being farmed for eventual logging some day. The rain held off as I drove into the carpark. I was the only one there. I put on my goretex raincoat and hat and took a walk in the forest. This is a very easy level walk along both banks of a stream, that comes out in a grassy flat up above. Just as I got to the open area, it began to pour- so I stopped under the trees and just waited it out for about 20 minutes. I was rewarded for standing still by having a bellbird come look me over, about 4 feet away, and start singing his song. It was great, because mostly you hear them but never see them. The rain let up for a bit, and I walked through the meadow, over and back down the stream. Halfway down it began to pour again- but in the dense bush you hardly notice it. I got back to the car after an hour's pleasant walk with just sounds of birdsong, wind and falling water for company.

On the way back down, a lone sheep was in the road, having jumped the fence and being too dumb to find the way back in. (One of my Quincy patients told me once that "sheep were her proof of the existence of God, as no animal so dumb could survive without God watching over it.") The rain was pouring again, but as I came down the road further a young farmer was coming up on his 4-wheeler, typical "Southern Man" type, as they call it here, with rain slicker, hat and 2 very wet sheep dogs balancing on the back. I waved him over.
"There's a sheep loose on the road back up there- I don't know if it matters much" I yelled at him.
"Hmm," he said. "Could be one of mine, how far back was it?"
"About 1/2 a kilometer, just after the hill that's being mined."
"Hmm...... Lovely day out here, isn't it?" he said, looking around at the pounding rain, "I'm sure it will find its way home eventually".
"Yeah, I guess. Its beautiful out here though in the rain." I said, "I was up walking in the hills, and there was no one else up there".
[Looking out at the rain.] "Well there wouldn't be now, would there?. But when you're alone up there you're either the King or Mad I guess."
"Well, Mad probably fits me best", I said.
He grinned, waved goodbye, and gunned his 4-wheeler off, in a direction away from the sheep.

Contrast yesterday's walk with today's trip to Queenstown. This was a lovely drive, up the Oreti river valley, 150 km. We went mostly to explore the area. Liz wanted to shop a bit, as she's realized that she has no warm clothes. Her dream is to find a cheap sheepskin coat. I wanted to get the lay of the land, see the place, and maybe do a short walk. We spent most of the afternoon there. It is a very pretty resort town, in a beautiful setting. The sky and lake really ARE that blue color, and the rain cleared off on our drive up, so we had perfect weather. The mountains are beyond human scale. However, I just am not excited about drinking cappucino and watching the lake and the people jet-boating and paragliding over it. And you won't catch me bungy-jumping this trip. I visited the DOC office and looked in a few shops with the girls. Prices were as-expected for a high end resort town. Liz wanted to shop some more, so Vicki and I drove up the lake and did an hour's hike up the terrace to Lake Dispute and back. Beautiful day, but not nearly as peaceful as the trees, alone in the rain. My opinion of Queenstown: resort not really my cup of tea, great place to make plans to go somewhere else (like the backcountry or Fiordland, etc.). But with lots of fresh air, sunshine and blue lake and clouds, certainly one of the world's most stunning places for scenery and setting.