Why Am I Here?

    While on a recent site seeing trip with visiting family, I had some extra time to contemplate life.  The boat slowly motored out to Hole in the Rock/Motukokako Island at the end of Cape Brett on the southern boundary of the Bay of Islands, leaving plenty of time for introspection.  Maybe it was the somber cloudy day.  Maybe it was the proximity of another passing year in my own life.  Possibly it was the seasoned words of the lovely 92 year old lady, my patient on the previous day, whose sharp Irish/Kiwi wit polished by a childhood French finishing school, that had left me contemplative.  "Multus Annos Domini" was her own self diagnosis, as her sharp mind remained well ahead of the failings of her body.  The years passing by, purpose still present, but body unable.  Most likely it was my wife, who reminded me as we got out of bed this morning, that by life expectancy, "Your life may be more than half done!"  (Thanks for the birthday wishes, honey).

     Life itself is a purpose for being here on this earth.  Each day lived is a chance to feel, breath, experience, share, love, and cherish life itself.  For some, end of life comes too soon, for others it comes too slowly, but the reality is that none of us get out of this life alive.  Purpose is simply found by living each one of our days to its fullest.

   If you would have asked me 20 years ago when I was a freshmen U of Minnesota medical student if I was planning on practicing medicine in a foreign country for an extended period of time, my answer would have been no.  Mostly because I would not have considered "God's Country" of Montana a foreign place, but instead my home state that I still miss.  Once again the joy of life and living with purpose that can lead us directions beyond our wildest dreams.

     So with kind regards to Nietzsche and Kierkegaard, instead of asking, "Why am I here?", I will change the question to "Where have all the Kiwi doctors gone?"    Recent media attention in New Zealand, both written and televised, have drawn attention to the ongoing crisis in New Zealand's health care system.  The emigration of New Zealand trained doctors has resulted in a shortage of available physicians to provide necessary medical services throughout the country.  With a country this beautiful, why would anyone want to leave?  Everything is so green....
    Not green enough according to statistics from the NZ Resident Doctor's Association.  The salary disparity for house officer (intern) and registrar (resident or fellowship) level physicians between New Zealand and Australia is one of the first reasons listed for the migration of NZ medical students.  Even with factoring in the recently strengthened NZ dollar, the disparity ranges per year from $7,000 AUS$ ($6,900 US$, thank goodness for our weak economy, as my NZ$ goes further) for first year medical trainees, to as much as $32,000 AUS$ per year for fellowship trainees.  That money easily buys a few plane tickets over the Tasman for visits with the family.  
   Once those physicians leave, it is less likely they will return.  Money potentially being a motivator again, as salary disparity between Australia and NZ consultant level physicians indicate a range of 7% to 30% difference of income depending on specialty.  Data from the Auckland graduating class of 1999 indicates that 46% of the class permanently practices outside of New Zealand, with the majority of them having ceased their registration (license to practice) in NZ.  Similar to the US, physicians in training are more likely to settle in the region in which they have trained.  A losing situation for New Zealand.

    That is where a physician such as myself fits in.  Nearly 41% of physicians practicing in New Zealand are international medical graduates (Damn foreign doctor has an accent and I can't understand him!), compared to 21-25% in the US.  The system does not suffer though, and in some cases benefits.  The majority of foreign trained physicians who choose to permanently relocate to practice in New Zealand tend to be from other Commonwealth nations (UK, India) or Asia.  US trained physicians tend to only stay for a short period of time.  A statement more about our tax structure in the US than the quality of medical care that is provided in New Zealand.  Uncle Sam gets a piece of US citizens wherever we live, whereas citizens from other countries who relocate to New Zealand, are only expected to pay taxes in New Zealand. 
     Despite the challenge of double taxation, and potentially a lesser income, I found another reason for our prolonged stay here in New Zealand.  Interestingly the letter quoted below was handed to me on my first day of orientation with NZ Locums. It is written for new enrollees in the Medical Protection Society (malpractice insurance) when they start practice in New Zealand.  
    
    "Most days, most people will make a mistake, normally small and inconsequential ones that are never discovered or result in no harm, although occasionally they will be serious or embarrassing.  The point is that everyone makes mistakes but most people are fortunate enough not to be a doctor who can be formally investigated two, three, possibly four or even five times over, concerning the same incident.  It is a fact that adverse events will happen.  Everything should be done to try to minimise those avoidable errors but there must be an acceptance that some will occur - it is how we react to these events that is vital.
     My fear is that if doctors continue to believe that they are under sustained attack and fear the stress of prolonged investigation for one or two mistakes in a career, then many of those who are the most caring and conscientious will decide to leave the profession early or, even worse, decide not to train in medicine in the first place.  Can you imagine the uproar if members of other professions could expect to be investigated at some stage in their career?
     The move towards the harder-nosed, thick skinned, more money-oriented doctor has already happened in the USA and has perhaps started elsewhere.  If it gathers pace, then it will be to the detriment of society as a whole."

    Matthew O'Brien, General Manager Asia Pacific
    Medical Protection Society of New Zealand. 

   The erosion of the hole in the rock at Motokukako Island started thousands of years ago.  It started with a few cracks, enlarged to crevices by wind and wave, and eventually resulted in the hole in the rock institution that stabilizes the island.  The practice of medicine and health care in the US is our island for safety.  With the recent passage of major health care legislation that contained no meaningful malpractice reform, the cracks in the US health care system have gone far beyond crevices and become holes in an institution that is necessary to support a successful nation. 
    I am practicing in a country where more and more US physicians are coming to work permanently.  The ER group at Whangarei hospital is nearly all Americans.  Up and down Northland, many of the GP practices have one or two full time American trained physicians.  One excellent young US physician with whom I oriented in Wellington has opted to stay for a full two years.  Two former US colleagues are on their way here to work for an extended period of time.  Makes me wonder when people in the US will need to look through the hole in the rock, and contemplate "Where have all of our American doctors gone?"