We’ve talked about religion, how about politics?

Last year, I tried to “give up” politics for Lent.  I am admittedly addicted to politics.  It’s like a dangerous drug, for me.  It makes me angry, crazy, and depressed, and yet once I get going I cannot stop.  It’s interesting, though, since coming to New Zealand, I’ve almost adapted the attitude of an outsider when it comes to American politics.  I almost hate to admit it, but I feel relieved that I’m here, far away from the insanity.  However, if all I’m doing is running away from one crazy system, then I’m not really experiencing the culture where I am now.  What would be the point of that?

With that in mind, I’ve decided to do a little research into the New Zealand political system and compare similarities and differences with US politics.  I’ve been working on this post, now, for over a week and so far, the best I can do is, in the words of a friend I was talking to yesterday, sound like I’m studying for a citizenship exam!

So, I’ll try to be brief about the boring stuff.  New Zealand is a Constitutional Monarchy, which means that Queen Elizabeth, II, is the Head of State of the “Realm” of New Zealand.  It is also Parliamentary Democracy with proportional representation.  Effectively, this means that there are multiple (more than 3) parties in the game and the number of seats each party has in Parliament is proportional to the number of votes the party’s candidates (and the party itself) get.  The leader of the majority party is the Prime Minister.  Currently, this is John Key, and he is a member of the National Party.  You can read all about this on Wikipedia.

New Zealand is not divided into states or provinces but is governed in its entirety by the Parliament.  Regional and territorial issues are managed by a variety of boards and councils, including District Health Boards which manage the delivery of healthcare to the people in their particular region.

The rest of this post is more observational than factual.  First off, the idea of “proportional representation” is quite appealing to me.  It lessens the probability that one party can essentially “take over” and assert its agenda to the exclusion of all other voices.  Instead of a “winner take all” system where a party has to have a winning candidate in a certain district in order to get a seat in government, New Zealand has a system where a political party only has to get 5% of the vote to have a seat in Parliament.  Mind you, in reading through the list of parties, it seems that they are all some version of the progressive/liberal/moderate/socially conservative/fiscally conservative spectrum.  On the “far left” are those who want to the government to take care of all of the social needs of its citizens and raising taxes is a good thing to do to achieve that. On the “far right” are the people who want to rein in government spending, want lower taxes, AND, in some cases have a fairly conservative social agenda.  HOWEVER, these are people that would be seen as “moderates” in the US.  The “National” party which is currently in power seems, to me, to be fairly moderate, although it is criticised for wanting to gut social programmes and for giving tax cuts to wealthy corporations and being too beholden to special interest lobbies?  Sound familiar?  Only the scale is much different.  When I read/hear these things, I shake my head and say, “If you ONLY knew.”

RELIGION, POLITICS AND “MORAL” ISSUES

One notable thing about the “socially conservative” agenda is that there is not the vitriolic rhetoric you hear in the US. First off, most people aren’t really all that concerned about what the RELIGION of the candidate is.  Of course, Christians might tend to vote for a Christian, if they thought that person would do a good job of representing their values and interests as Christians. The same goes for people of any other religion or, for that matter, culture, ethnicity, sexual orientation, or gender.  But it doesn’t become a subject that’s open to scrutiny in the question of “can this person do the job they are being elected to do?”  Second, the two biggest “litmus test” issues for conservative candidates in the US are, still, abortion and same-sex marriage.  Now, don’t even get me started on how ridiculous it is to debate these things when the gap between rich and poor is growing at a stunning rate, when children in one of the wealthiest countries in the world are starving, when people are going bankrupt because they can’t pay their medical bills.  In New Zealand, same-sex marriage is not legal and there is some debate and discussion going on about it.  However, no one is trying to amend the (non-existent) constitution to deny that right to gay people.  In fact, sexual orientation is listed in all the non-discrimination policies that I’ve ever read here. So, how does that work?  How can gay people be free of discrimination but not be able to “get married?” Well, for one thing, New Zealand DOES allow all couples to have a Civil Union which basically is legally identical to marriage.  I don’t quite get the difference, actually, since couples in a Civil Union (straight or gay) have the same access to medical decision making, inheritance, tax breaks and other benefits that married people do.  In any case, it is, for the most part, a non-issue. 

Similarly, there have been some efforts to outlaw abortion.  Briefly, groups like “Operation Rescue” came over and staged protests.  However, attempts to actually ban abortion entirely have repeatedly failed in Parliament and the issue seems to have died down and all but gone away in the political arena.  Abortion is legal in New Zealand but there are reasonable (in my opinion) restrictions.  It can only be performed if two doctors (one of whom must be an OB/GYN specialist) agree that it must be done to protect the life and/or health (physical or mental) of the woman.  It’s the “mental health” part that is invoked in most cases.  I know there are efforts, such as government subsidised contraception and family planning programmes, to try to reduce the need for abortion.  This is something I need to research a bit more, however.  I know there are abortion providers in the area but I have never seen people carrying signs with pictures of dead babies and to my knowledge, abortion providers do not go to work wearing bullet-proof vests. (But then, guns are a whole other issue.  I just found out the other day that the police are not armed!)

WHAT DO THEY CARE ABOUT?

So, with 2 of the issues that take up so much of the time of American politicians virtually out of the way, what do lawmakers have to do all day?  Well, they decide on how to spend money for things like healthcare and care for new parents and young children.  They decide on how much to spend on infrastructure and supporting business.  I’m sure they waste time on things that tax payers don’t think are important.  But if they waste too much time on those things, guess what? They get voted out! 

WORK, INCOME AND POVERTY

It is, of course, very complex to try to define poverty and then quantify it.  To make matters worse, comparing the US to NZ is extremely difficult because the two countries define poverty differently and, remember, the US is a REALLY big place with a lot of variation in income, employment, and cost of living.  New Zealand has a minimum wage of $13.50 per hour.  The NZ dollar is worth about US$0.85 but that still puts it at around US$11.45.  The US minimum wage is $7.25 per hour.  Some states have a higher minimum wage but many do not.  The minimum wage in the US is, almost universally, not enough to live on.  It seems to be designed to keep people in poverty while allowing businesses to thrive.  A worker making minimum wage in the US and working 40 hour weeks would earn about $15,000 per year.  When I went to the Bureau of Labor Statistics website I found that the workers in the lowest paying jobs in the US (burger-flippers, dishwashers, etc) had a median income in about the $18,000 range, just barely above minimum wage. On the other hand, a similar list for New Zealand had the lowest payed workers, including wait staff, baristas, caregivers, and fast food workers, making something in the $31-32,000 per year range.   Both lists had doctors at the top, with American anaesthesiologists making well over $250,000 per year and New Zealand doctors as a group making around $143,000 per year.  The bottom line is, if you have a full time job in New Zealand, you will be making more at the bottom and less at the top than you will in the US BUT that means that the gap is much smaller and those at the bottom have a chance of actually making a LIVING wage.  The median hourly pay in NZ is $20.  Incidentally, the spread of housing costs is similar between the two countries depending on the area and there are certainly some areas in New Zealand where housing prices are too high for the wages people are earning in those areas.  There are poor and homeless people in New Zealand and there are NGOs as well as government programmes aimed at helping them.  A lot of the recent poverty and homelessness can be attributed to the disastrous earthquakes in Christchurch.  They are still rebuilding from that, and facing huge insurance issues and increases in premiums.  However, today, someone told me that his homeowners’ insurance premium had skyrocketed all the way up to $600 per year!  It’s all relative, I guess.

ENVIRONMENT AND CLIMATE CHANGE

It seems to me that this is not up for debate in New Zealand.  We are responsible for our environment and keeping our planet healthy and happy.  Full stop.  Again, this is an area I need to research more, but my observation is that people fairly readily accept the taxes on carbon emissions (such as petrol, or gasoline) and the recent start of government subsidised kerbside (the kiwi spelling of “curbside”) recycling pick up has been widely embraced by just about everyone in town.  I’m sure there are debates on how, exactly, to allocate resources to ensure cleaner air and water and what government’s role should be in that effort.  But the facts are the facts and the kiwis simply cannot understand how supposedly intelligent, educated Americans can deny those facts. 

THE INSANITY OF IT ALL!

Some of the assertions I have made here are backed up by facts and others are wild speculation based on what I see and hear and experience.  My overall impression of life in New Zealand, so far, is that there is a lot less of the “shared psychosis” that I see in America, whereby people jump on a bandwagon for a cause, no matter how lame that cause might be, and can’t let go.  The economic picture, while certainly scary for a lot of people in NZ, is even more dire in the US with the huge gap between rich and poor widening rather than shrinking.  Healthcare is in danger in NZ because the government has subsidised so much and costs are going up. However it seems that there is a saner approach to fiscal responsibility, with a party that sticks to this policy agenda rather than getting distracted by micro-managing people’s personal lives. If American politicians could buckle down and get the work done instead of spending all their time trying to get re-elected and worrying about how they can next niggle in people’s lives, imagine what they could get done?!

In a coming post, I want to get into more detail about one of my big social justice concerns:  Human Trafficking.  But that will require still more research so it might take awhile.  It's much easier for me to just rattle off my thoughts than to actually sit down and wrangle with facts.  But that's important, too, and so wrangle I will. 

From the doctor's perspective

I started to summarise a bit about the NZ Health system in this post.  But I've been thinking a lot about how I might describe MY experience working in it for a few weeks.  Of course, it's only been a few weeks, though I've seen LOADS of patients already.  This is a very busy practise.

The first thing I've noticed is how overall, I am much more relaxed and able to enjoy the encounters with the patients I am, compared to previous jobs I've had.  I recall the words of Ray Anton, the CEO of Clutha Health First, during my phone interview.  He said, "we want your brain to be focussed on taking care of patients, not all that other stuff."  "All that other stuff" is the stuff that has threatened to make me leave clinical practise entirely.  "Stuff" like diagnosis coding, procedure coding, E&M coding, worrying about whether the patient can afford a medication or a visit or a procedure and fighting with them to come in once a year to get their prescriptions renewed.  "Stuff" like documenting to support the coding and documenting to satisfy the lawyers of potentially litigious patients.  I spend so much less time documenting now.  And yet, I document sufficiently (there are some here who don't, for sure).  The subsidies for primary care are on a capitation basis so it really doesn't matter the complexity of the visit. The patient's copay is almost always the same.  So I'm not worried about how many "bullet points" I need to justify billing for what I know I did.  Instead of spending a couple of hours at the end of the day dictating notes or filling in templates in the EHR, I am usually done with the note as soon as I've done seeing the patient.  I look up a diagnosis that seems to fit in the EHR and I put it in.  The only extra "coding" work comes when it's an accident case, and then it's coded on time (so if there's a cast or a dressing change or whatnot that takes longer, it gets billed for more).  Granted, my learning curve is still quite steep with all the different forms, drug names, etc that I'm required to look up or go ask the nurses about every 15 minutes.  But everyone is VERY patient with me.  It seems they are grateful that I'm here and don't mind answering my incessant questions.

As for litigation, it is virtually impossible to sue a doctor.  I think I mentioned that before. It's virtually impossible to sue anyone!  I think in SOME cases that can go too far and there are doctors who get lazy.  In fact, even in other areas, it seems, there could be a bit more concern for safety. A colleague (who is a kiwi but just moved back from years in Canada) told me he was hiking and there was a sign on the track that warned of some loose ground, holes, or something.  He thought MAYBE these pitfalls might be marked but they weren't.  Whoever put up the signed figured that was sufficient warning, even though there might be unexpected holes or loose rock on a track that someone might fall into without knowing they're there.  When they say "at your own risk" they really mean it!

Anyway, the majority of my time is spent actually listening to and examining patients, figuring out what they need and finding a way to provide it.  It's the last bit that is slowing me down at the moment because it requires a lot of learning about the system, what's available in the clinic or the hospital, what can be done urgently in Dunedin, and whom to refer to and how to do it.  I spend a lot of time looking up drug names in the drug book.  I'm working making a list of important numbers, as well as units conversions because it's sometimes hard to work out quickly whether someone's cholesterol levels REALLY are in an acceptable range.

One interesting thing is that patients are required (and expect) to come in every 3 months for prescription refills if they are on chronic meds.  They don't fuss about it AND it give us ample opportunities to catch any problems early and review whether they have good BP control, etc.  Occasionally a doctor will make an exception and let a patient call in for refills but patients know those are exceptions and don't push for those exceptions.  So, although people will come with lists, if you are seeing them every 3 months, the lists are usually much shorter.

I am going to stop there because my lunch break is over and I wanted to post some of these thoughts before I lose them.  I think it's a pretty good introduction to how things are going from my perspective.  Of course, there will be more!  Cheers!

More thisses and thats

I'm having a hard time compiling my thoughts into a coherent written form.  There is so much that is new and interesting and I'm just trying to figure it all out.  I'm still having a hard time coping with the change in seasons, including the daylight, the weather, and the fact that we are starting to give influenza vaccines for the upcoming winter season.  It's all a bit disorienting.

I've had a couple of days of work in which I've seen some patients and started figuring out the nuances of the healthcare system here.  I've also met the students with whom I will be working this year.  They are a select group of 5th year medical students (in a 6 year programme) who are doing all of their clinical rotations (or attachments) in a rural community. I am to be the coordinator of this particular site (Balclutha).  They are four very bright and motivated students who are meant to be responsible for their own curriculum.  Of course, right off, I feel like I'm in a bit over my head.  Afterall, this is a new country, a new curriculum, a new job...what makes me think I can do something like this?  Well, I guess that's the point...I DON'T but clearly someone does and, as I posted here, I am just following the directions and the path laid out in front of me.

I'll try to summarise my understanding of how the New Zealand Healthcare system works.  First off, there is a Minister of Health and a Ministry of Health which allocate government funds to various aspects of healthcare.  Generally speaking, there are District Health Boards and local Primary Health Organisations.  Primary care is the basis of all health care here and, as my colleagues at The Robert Graham Center for Policy Studies in Family Medicine and Primary Care have elucidated, communities and societies which are centered around PRIMARY healthcare are healthier societies with better outcomes and more efficient, cost-effective healthcare.  The Primary Health Organisations provide government subsidised care to their members.  The members are people who are eligible for the government benefits who enroll in that PHO.  They can then receive care from any General Practice doctor in that PHO at a discounted fee.  Now, when I say "discounted," I'm talking about a fee for an average consultation (say, 15 minutes) that FULL PRICE would cost about $50, far less than a similar consultation/visit in the US.  The interesting thing, though, is that doctors in the PHO are often in private practise.  They set their own fees and they get paid by a combination of government money allocated to the PHO (on a sort of capitation system) and patient co-pays.  Other services, such as hospitalisation, nursing home care, home health care, physiotherapy/rehab, etc are also government subsidised to varying degrees.  They are also VERY well coordinated by the GP(s)...very much like a Patient Centered Medical Home.

In addition to PHOs, which are funded by the government (through taxes) and the Ministry of Health and District Health Boards, there is a separate Accident Compensation scheme.  This is funded by petrol taxes, automobile registration taxes, and income and sales taxes.  It covers ANYONE in New Zealand, whether visting, traveling through, or permanent resident or citizen, who gets injured in an accident.  The definition of such an injury is fairly strict; it has to include a definite time and place and event that caused it.  However, if that happens, all the funds for treating that injury come out of a separate pot and the fees are 100% subsidised.

Then there is private insurance.  Anyone who needs specialty care has two options:  go through the public system, which often requires long waits to see a specialist for non-emergent problems, or go through the private system.  Many employers provide insurance and many people have their own insurance, but almost half of New Zealanders have no health insurance other than what they are entitled to through public subsidies.  So, there is a two-tiered system. The wealthy and well-insured can get their knee scoped faster than the others.  However, the key word is "faster."  Everyone who needs it will get their knee scoped or their gall bladder removed, it's just that some will wait longer than others.

I think the sticking point when it comes down to trying to garner support from the average American for such a system is the definition of "emergency."  Today I saw someone who had a problem that could have threatened the viability of an important body part.  I phoned up the surgical resident in Dunedin (about an hour's drive away) and he was VERY polite and told me to send the patient up right away.  I printed out a note from the electronic record and sent the patient to the hospital.  If he needs surgery, he will get it immediately.  HOWEVER, if a person has a gallstone, for example, this USUALLY does not have to be handled emergently.  There are signs and symptoms to indicate when it becomes an emergency but absent those, a strict low fat diet is usually sufficient to keep the symptoms under control until surgery can be done.  No, a person will not "die waiting" for their procedures.  If the problem becomes life-threatening, they move to the head of the line and get right in.  If they die, in the meantime, it's likely from something else that had nothing to do with the problem they were waiting to have fixed.

So, that's the basic idea.  In addition, I've made a few other interesting observations.  First, people do not expect antibiotics for their colds!  Yes, they still come to the doctor for colds but they are more than happy to be told it's nothing more serious and that they don't need antibiotics.  Second, people are not allowed to sue doctors.  That, of course, would NEVER go over in the US.  Patients who are injured through "medical misadventures" (I LOVE that term) are covered under the Accident Compensation plan.  They have all of their medical bills covered and, I believe, their lost income as well.  Doctors may be disciplined by the Medical Council and have their licences or practising certificates suspended for their "misadventures."  Doctors don't "get away" with irresponsible practises and patients get well compensated for their injuries. However, you don't have people getting wealthy from malpractise suits and you don't have doctors afraid to practise good, rational medicine because of fear of lawsuits.  It means that the doctor-patient relationship can be one of mutual trust, rather than suspicion.

Another interesting observation is about tests, especially screening tests.  Screening for things like cervical, breast, and colon cancer are done according to rational evidence-based guidelines.  Did you know that in most cases, it is not necessary to have a pap smear EVERY year?  And the breast cancer screening?  Don't get me started on that one!  It would seem that, at least at my clinic, there is an ongoing effort to use the technology available to track appropriate screening indicators and health outcomes.  It appears to me that they do better than many practises I've been involved with in the US.  BUT they don't do it by over-testing.  So, while we are busy trying to get people to have mammograms, blood tests, and CT scans they don't need, they are actually getting people in for smoking cessation, nutritional education, and cardiovascular risk screening and finding that it actually makes a difference.

One last thought before I put this post and myself to bed for the night.  Healthcare providers in New Zealand are almost universally committed to working to erase disparities in access and outcomes.  As in most other countries, the indigenous people (the Maori) have higher mortality rates from preventable causes, such as diabetes, hypertension, and heart disease.  There are programmes that EVERYONE has bought into to work to eliminate these disparities.  It's fascinating.  I've spent a lot of time listening to discussions about WHETHER there are health disparities along racial and ethnic lines in the US, as well as philosophical discussions about WHY these disparities exist and WHETHER we have an obligation to try to eliminate them.  While we're still arguing about these questions, New Zealanders are actually tackling the problem.

I don't want to imply that this is a perfect system.  I don't think such a thing exists.  AND, as I describe the New Zealand healthcare system, I note many places where Americans just simply would not accept such conditions.  However, the system seems to work pretty well for most people.  I will be interested to see, over the coming months, what the problems and pitfalls are and how they get solved.

Meanwhile, I am enjoying Hokey Pokey icecream, a flavour which I will describe in a future post.