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Hospitalist Down Under


 

antipodes (n.): 1. two points diametrically opposite on the globe; 2. a nickname for New Zealand.

With that definition in mind, this hospitalist decided to seek a working sabbatical—not so much over dissatisfaction with my job back home, but to see how the other side lives with nationalized healthcare. Of course, moving to the beach in undeniably beautiful New Zealand never hurts, either. When it comes to government involvement and healthcare, the U.S. is in a distinct minority globally; New Zealand’s healthcare delivery system, while not diametrically opposite, offers some fascinating differences.

Last July, my wife and I, along with our two young boys, relocated to Ohope Beach, a quaint resort community on the northeast coast of New Zealand about 100 miles south of the nation's largest and most well-known city, Auckland. I am now six months into a year’s assignment at Whakatane Hospital.

I do not claim to be an expert on the comparative aspects of national healthcare systems, and some of my observations are directly related to my move from an urban to a rural setting. Still, the differences between the health systems in New Zealand and the U.S. are striking. Compared to Americans, New Zealanders spend less money on healthcare, their medications cost a third of what ours do, they undergo less testing, and they spend less time in the ICU, yet they live longer. Additionally, the public sector pays for the health insurance of every single New Zealand resident.

Ohope Beach (above) is known as New Zealand’s best beach, and Pohutukawa are known as the nation’s native Christmas tree because of their bright red flowers that bloom during the Christmas season, which also is the summer season in the Southern Hemisphere.

Ohope Beach (above) is known as New Zealand’s best beach, and Pohutukawa are known as the nation’s native Christmas tree because of their bright red flowers that bloom during the Christmas season, which also is the summer season in the Southern Hemisphere.

Let’s dispense with a few dry facts:

  • Healthcare spending as a percentage of GDP: in the U.S., 16%; in New Zealand, 8%;1
  • Per capita spending on healthcare in U.S. dollars: $7,500 for Americans; $2,700 for New Zealanders;
  • Percent of healthcare spending by public sector: U.S., 45%; New Zealand, 80%1;
  • Average life expectancy in the U.S.: 78.2 years (38th in the world); average in New Zealand: 80.2 years (13th in the world);2 and
  • World ranking in infant mortality: U.S., 33rd; New Zealand, 27th.2

How are those figures possible? Does New Zealand employ death panels? No. Is there something in the water (e.g. statins and ACEs)? No. Is everyone a non-GMO, fair-trade, shade-grown, sustainably harvested vegan monk triathlete? Hmm.

Anyway, here are a few observations—from a hospitalist’s point of view.

Hospitalist by Another Name

My job title here at 100-bed Whakatane Hospital is “consultant physician.” The term “hospitalist” is not common, but it is exactly the job the consultant physician performs. Inpatient ward rounds make up the majority of the consultant’s role, and the only outpatient responsibility is a twice-weekly clinic to see patients referred from primary-care physicians (still called GPs here) for clinical questions. Because it’s a public hospital, we have house officers and junior physicians as well. Roughly, that means that the consultant examines the patient and formulates the plan, the junior physician does the new intake, and the house officer does all the writing.

As for the team, it’s a bit like working at the United Nations. So far, I have met physicians from New Zealand, Australia, Ireland, Sri Lanka, Spain, Jordan, Iraq, the United Kingdom, India, Zambia, South Africa, and, of course, America. Thank goodness we—and the patients—all speak varying degrees of English. It’s certainly a bit odd to find yourself misunderstood by someone else speaking your (and their) native tongue.

The work schedule is quite reasonable, or, as I have come to call it, “civilized.” It is a 40-hour workweek, 8 a.m. to 4 p.m. daily, with at least 12 hours of each week dedicated to nonclinical time in the form of reading, research, and teaching. The daily patient census per team is about 12, and the call (or “take”) ratio is about 1:4. With no nights and rare weekends, the whole experience is a welcome change of pace. For the Kiwis, this pace is perfectly accepted and expected, with little pressure to work harder, longer, or faster. Teatime is 10 in the morning, and breaking for a cuppa is just part of the job.

In switching from the private sector to the public sector, I braced myself for a significant cut in pay. As it turns out, the compensation is actually quite reasonable when matched to the schedule. Based on the current exchange rate of $1 USD equal to $0.75 NZD, the annual salary is about $165,000 USD. You also receive six weeks of vacation, two weeks of CME leave, and a $12,000 CME allowance. All in all, it’s a nice package. (Unfortunately, the pay in Australia is higher, and many Kiwi physicians choose to practice over there.) The resulting shortage of locally educated and trained physicians in New Zealand explains the ongoing need for overseas physicians.

Whakatane Hospital could use some upgrades, but the local residents are grateful for the care they receive.

Whakatane Hospital could use some upgrades, but the local residents are grateful for the care they receive.

Fewer Resources, So Choose Wisely

The hospital is part of a larger network called a district health board (DHB). The DHBs receive government funding based on population, then must decide how to spend the money. For that reason, there are only a few hospitals that include subspecialties. Smaller sites, such as Whakatane, have no subspecialists at all.

That also means we have no MRI machine, no cardiac catheter lab, no echocardiography, no hemodialysis. So, to do one of these procedures, it involves speaking to a specialist at a tertiary site and requesting a transfer, which, in turn, forces you to explain and justify your request. All of a sudden, the history and the physical exam regain their proper importance rather than being subverted to ordering a confirmatory imaging study or specialist consultation. It’s much different than back home, where the indication to perform coronary angiography can be the presence of a cardiologist and a groin in the same room.

In addition, the community GPs cannot order such testing as exercise treadmills or CT scans without going through a consultant first. Although this inevitably leads to delays, it also means some thought is introduced into the process.

Dialysis is another example. In New Zealand, more than 40% of patients receive peritoneal dialysis, and many of those who get hemodialysis do so at home. The average cost per patient per year is $25,000. By contrast, 93% of U.S. dialysis patients are on hemodialysis at a cost of $67,000 per patient per year.3 The outcomes for the two treatments are generally accepted to be the same; one just costs a whole lot more.

Time for tea? New Zealand physicians and hospital staff break for “a cuppa” at 10 a.m. each day.

Time for tea? New Zealand physicians and hospital staff break for “a cuppa” at 10 a.m. each day.

This Is the Only Formulary

U.S. physicians are all too familiar with MRSA, VRE, C. diff, and their ilk. Soon we may have to deal with NDM-1. Over and over again, we hear about how we should curtail our antibiotic use, yet little is actually done. New Zealand has strict antibiotic guidelines in accordance with a patient’s diagnosis. Ordering antibiotics outside the protocol is not accepted, unless you can convince the infectious-disease physician otherwise. It is an eminently reasonable practice that has simply never gained broad acceptance in America. What is the result of the New Zealand practice mandate? The hospital where I work has experienced only rare MRSA cases (9% of all S. aureus vs. 35% in the U.S.), no VRE, and zero cases of C. diff in the past nine months.

New Zealand has one drug-purchasing entity: Pharmac. The entity negotiates prices with suppliers and writes the formulary. If a drug is not on the national formulary, it is not available. Period.

Most drugs are fully subsidized; some drugs are partially subsidized. If it is available and subsidized, a 90-day prescription costs $3. All in all, Kiwi pharmaceutical costs are about 30% of the costs in the U.S. The choices are fewer, yet patients still receive appropriate pharmacologic treatment.

Every hospitalist has worked with an electronic health record (EHR) in one form or another, but one of the most frustrating things in the States is the lack of interface between EHR in different health systems. Such disconnect leads to an extraordinary amount of effort not to duplicate tests for patients who frequent more than one hospital. Often, these patients are high consumers of healthcare at baseline, and duplicating tests only makes it worse.

New Zealand has one computer system that allows the GPs and the hospitalists to view all the labs and imaging results together, in the same system. No matter who orders the test, it all comes back to the same place. It might seem small, but it makes a tremendous difference to the management of the patient. One could argue that defensive medicine is good practice, but we’ve all seen the extra study get ordered somewhere along the line. I won’t get into the details of malpractice insurance (the editors said stop at 2,000 words, and I could go on for 200,000), but back home in Colorado, I paid about $20,000 a year for malpractice insurance. Here, it’s $1,200.

New Zealand has a no-fault compensation system in which injured patients apply for government-funded compensation and thus give up the right to litigation. Most claims are processed within weeks, and all decisions are final within nine months. The patients here know that they have recourse for a bad outcome, and the physicians practice in a manner according to clinical judgment, rather than trying to avoid being sued.

The front desk at 100-bed Whakatane District Hospital. The main entrance signage is in English and the indigenous language, Te Reo Maori. Both are “official” languages.

The front desk at 100-bed Whakatane District Hospital. The main entrance signage is in English and the indigenous language, Te Reo Maori. Both are “official” languages.

Confusion and Delay

You might get the sense that practicing medicine in New Zealand has been a refreshing change of pace, and you would be right. My physical exam skills (what was left of them) are starting to return. I think long and hard before ordering an imaging study or requesting consultation. I order antibiotics according to the guidelines. I only prescribe medicines that are on the formulary. The care given to the patients by the staff and the knowledge exhibited by our physicians are quite good.

Still, this system is by no means perfect. The delays in care can be excruciating in both the urgent and routine settings. For example, my first patient on my first day of work had an acute myocardial infarction. The ED physician admitted him to the hospital at midnight, but no one on our team had met the patient when I arrived for work the next day. At 8 a.m., he had dynamic EKG changes, a positive troponin, ongoing chest pain, and a systolic BP of about 90 mm/HG. Back home, I never would have met the man, as he would have gone pretty much straight to the cath lab—with the cardiologists—within 60 minutes, even at midnight. Here, we had to call the hospital that does interventions, arrange a bed (hoping one was available), then put him in an ambulance for a four-hour drive on a two-lane road to receive a stent for his 100% coronary lesion.

The average wait for transfer for acute coronary angiography is about five days. The average wait for routine outpatient echocardiography is two years. Yes, two years.

Ultimately, the right thing gets done, but sometimes way too slowly. Thus, there is a smaller, parallel private insurance system, but people view it as optional and only use it when they want to speed up the schedule.

A Few Things I Have No Answer For

I have yet to admit someone with alcohol withdrawal—this in a country with a higher per capita alcohol consumption. I have yet to order a PCA pump for a medical patient. Low-back pain is managed by surgery, and a pneumothorax goes to the medical service. There is no Pyxis equivalent, just an open cupboard in the ICU where the meds are kept. There is no separate page for physician orders; the staff is expected to read the notes. In an old physical plant such as Whakatane, there are no private bathrooms for patients—it’s down the hall. Oh, and it’s four patients to a room, with no television, no Internet, and no telephone. There are plans for a new hospital in a few years’ time.

Culturally, the patients and their families are more accepting of the fragile nature of old age, with a strong desire to avoid unnecessary interventions at the end of life. There is a robust community hospice program that helps patients remain comfortable at home. As a local colleague of mine explains, the Kiwis are uniformly grateful for the care they receive, even if it means sharing a room with another patient (or three).

Kingsley Logan, MD, consultant physician and medicine chairman, at the ICU nurses’ station at Whakatane Hospital.

Kingsley Logan, MD, consultant physician and medicine chairman, at the ICU nurses’ station at Whakatane Hospital.

Final Observations

Healthcare delivery in New Zealand is different from what we see in the U.S. Obviously, the vast majority of healthcare delivered in New Zealand is through the public sector. No matter which direction U.S. healthcare reform goes next, it’s highly improbable it will ever resemble New Zealand’s system.

One quote that resonates comes from the medical practice handbook, which is given to all newly registered physicians in New Zealand: “Doctors have a responsibility to the community to foster the proper use of resources—in particular, by making efforts to use resources efficiently, consistent with good patient care.”4 It’s sound advice.

Changes are coming, and hospitalists everywhere are in a unique position to gain knowledge and lead the change. In the U.S. or in New Zealand, as a hospitalist or a physician consultant, medicine is a fascinating field of practice.

I hope you enjoyed reading about one hospitalist’s observations from New Zealand. Time for tea. TH

M-A Williams has been a practicing hospitalist in Denver since 1999. He worked with the same company (Inpatient Services, which then merged with Sound Physicians) for 11 years until departing for New Zealand. He is a member of Team Hospitalist.

References

  1. Organisation for Economic Cooperation and Development website. Available at: www.oecd.org. Accessed Dec. 31, 2010.
  2. The United Nations Statistical Division website. Available at: http://unstats.un.org/unsd/default.htm. Accessed Jan. 4, 2011.
  3. Ashton T, Marshall RM. The organization and financing of dialysis and kidney transplantation services in New Zealand. Int J Healthcare Finance and Econ. 2007;7:233-252.
  4. Cole’s Medical Practice in New Zealand (2009). Ed., Ian St. George. Medical Council of New Zealand: Wellington:18.

New Zealand Fast Facts

Digging for tuatua (clams) on Ohope Beach in summer. They usually are<br />
</p><p>harvested when there is a very low tide.

Digging for tuatua (clams) on Ohope Beach in summer. They usually are harvested when there is a very low tide.

Demographics

  • New Zealand pop.: 4.3 million
  • Capital: Wellington
  • Largest city: Auckland, 1.4 million pop.
  • Whakatane District pop.: 32,814
  • Ohope Beach pop.: 2,760

Information

  • Whakatane District in the Bay of Plenty features 34 miles of sandy beaches.
  • Ohope Beach is a popular vacation spot. White Island, an active volcano offshore, is a world-renowned tourism attraction.
  • The kiwi, NZ’s national emblem, is a flightless bird with hair-like feathers and a long, slender bill, which it uses to pull worms and insects out of the ground.
  • New Zealanders often refer to themselves as Kiwis, and the term is also used as a short form for the famous kiwi fruit. The NZ dollar is referred to as the kiwi.
  • Whakatane summer temperatures average in the 80s, and winter months in the 50s. The district records New Zealand’s high temperature about 55 days a year.
  • New Zealand’s seasons are the reverse of the Northern Hemisphere.

Health Stats

  • Spending as a percentage of GDP: 8%
  • Per capita spending on healthcare: $2,700
  • Average life expectancy: 80.2 years (13th in the world)

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