Planning for Retirement

Give a child a fish, and he will eat for a day.

  
     Teach a child to fish, and she may feed the world.

    Show a child how to fly fish, and maybe when I am old, he will drive me to the nearest river, park me in my wheelchair near my favorite fishing hole, give me a wee dram of scotch and a good cigar, and say have a good day, Dad!

      Retirement plans in sight.  Joel trying out his Christmas present on the school grounds.  Enjoying the last bit of summer/Christmas holiday before the school year begins here next week.

Ninety Mile Beach and Patient Expectations

Cape Reinga Lighthouse

   Since arrival in New Zealand, I have been trying to surmise what is different about providing primary and emergency health care to New Zealand residents as opposed to Americans.  No, the anatomy is not different, or at least I have not found the usual orifices in unusual places in the Southern Hemisphere.  As I go through my daily list of 27 patients, I realize at the end of the day that despite the same medical challenges, something is different about the attitude of the New Zealand patients approach to their medical care. 
      Talking with colleagues in the US before leaving for NZ, I did receive a few trite answers about what might be different in patient care, but I wanted to experience it myself. Now that we have been here into the new year, it is time to put my own answer into writing.  So how does a medical system that spends one-half to two-thirds less per capita, based on gross domestic product statistics compared to the United States, obtain things like lower infant mortality, longer life expectancy, and better access to care? How does a health care system where there are definitely fewer bells and whistles (and fewer grand piano players in the  hospital entry foyer,  oops, there isn't really an entry foyer either) outrank the USA on a number of desirable health outcome statistics?
     The summary I was looking for was found not in the exam rooms of Broadway Health or Bay of Islands Hospital, but in the sage advice of a holiday house owner in Ahipara, the town at the beginning of Ninety Mile Beach.  We, (Kim, the kids, and Karen and Tracy, two of Kim's classmates from physiotherapy school in Holland) had stopped overnight in Ahipara on our triangular tour of Northland from the Hokianga Harbor, to Cape Reinga and back to Kerikeri.  Paul Steele (check out www.holidayhouses.co.nz/properties/1979.asp) the owner of the beach front home at which we stayed, and a retired dentist from Wellington, took me aside as we were preparing to start our drive from Ahipara to the Cape.

Cape Marie Van Diemen
Immediately west of Cape Reinga

      Paul had sized up our situation.  Americans for sure by our accent (he even introduced us to his neighbor, a former resident of Sun Valley, ID.  Idaho is a small state, but didn't know him.).  Middle aged bloke traveling with three beautiful women and two children (bloke's a bit crazy?).

Tracy, Kim and Karen

  Automobile suitable for some Northland locals and a beach run (check out the pictures of our wheels known as  "Beastie Babe" and the trailer "Beastie's Behind").  Seeing that we met all the requirements he was ready to give us his advice for travel.

Beastie Babe and Beastie's Behind at the end of Te Paki Stream and the beginning of Ninety Mile Beach

      "First, I wouldn't recommend what you are planning on doing." (Wait, we had not even discussed what we were planning on doing, other than vague plans for driving the tar sealed road safely up to the Cape and back.)  "I would recommend just going into Kaitia and jumping on one of the bus tours."  (Bus tour, our ignorance.  We did not even investigate a bus tour option).  Then he showed me the answer I had been looking for about the joy in life and blunt approach to their health care that I had appreciated from so many patients.  Paul, with a sudden sparkle in his eye and a devilish grin, unfolded a map in front of me and said, "I would drive up the main road to the Cape, then when you get back to TePaki Stream, put that car in 4 wheel drive and gun it down the center of the stream.  Maybe take a look around the first corner on foot before you go in, but otherwise don't stop driving hard until you get to the beach. If you bog down a bit, just gun it.  I have checked the tides for you and you should be all good.  Otherwise, just don't drive too close to the ocean and too close to the sides of the stream, where you can end up in a soft sand hole.  You will come out alright at Waipapakauri Road."
   Once we made our drive on the tar sealed road all the way to the Cape, with a stop at the Kauri Kingdom(spectacular kauri tree woodwork) and a brief test drive of Beastie on the white sands or Rarawa (Jetson's Astro pronounced that one) Beach we made our way back to Te Paki Stream Road.

Rarawa Beach.  Yes we had most of it to ourselves!

 As Joel and McKeely tried some sand boarding on the dunes above TePaki, I walked around the first corner and had a look to the beach (couldn't see it as there were alot more corners in the stream before Ninety Mile Beach).  Suddenly Paul's words, my experience with patient expectations in two different countries, and the metaphor of an equitable health care system all came together.
    I stood in shallow stream water on solidly packed platform of sand that shifted only slowly and slightly with my steps.  New Zealand people needing medical care, like much of the rest of the sane (not US) industrialized world, start with a secure platform of single party payer (usually government) health care.  Compare that to the current US system which would look more like a boulder strewn river.   Great if you can cling to one of those insurance rocks (did you see that Big Blue Boulder), but the water is deep and fast moving (drown your family in bankruptcy) if you lose your job or are denied insurance.  If you can hold your breath long enough in the US system (lose all your finances first), you may get caught by the bottom level small rocks of Medicaid.  The smooth secure platform of guaranteed health care for all, allows New Zealanders to have far less anxiety as a starting point about what their diagnosis may be when they arrive in need of medical care.

    The kids had finished sand boarding when I returned, so we loaded back into Beastie.  Continuing the metaphor, I would consider Beastie as the health care providers in New Zealand.  Solid, reliable, a few dings, but utilitarian and dependable for everyones need.  In the US, the providers probably win this part of the metaphor, so think of Beastie in the US as a full size Ford F-350 4X4 with all the upgrades to help you crash through the boulder strewn stream.  Just like myself, and many of the other providers in New Zealand, as I discussed in my previous post, Beastie is an import!  In the US though, even the best providers get caught drowning with you beneath the boulders of the bureaucracy of insurance boulders.
     I started Beastie up, put her in 4-wheel drive and off we went.  Like anyone with a medical condition, going around the first corner in the stream is a blind corner, and everyone inside of Beastie had a little anxiety.  In the US, our recent health care reform debate convinced us of all kinds of fears around that first corner in a diagnosis.  A single party payer system will cause us to "lose your choice and independence", or "death squads lurking", or "government cronies will decide the care you receive".  Beastie rolled into the stream with the sand firmly supporting us, and I added a little speed for Beastie to get around the first corner.  Instead of additional dangers, we found exactly what people living with a single party payer health system in New Zealand have found:  wide open pathways to maintaining our health (the stream widened through the sand dunes), independent choices ( the stream split around soft sand islands in the stream, and we could chose either side), and security (we made it safely to the wide driving path on Ninety Mile Beach!).
     That is what I have found with patient expectations here in New Zealand.  People have independence with confidence that the system will provide for them when in need.  They understand that if their diagnosis warrants it, they will receive the care they need immediately, and wait with appropriate patience if their diagnosis is less critical or life altering.  They understand their choice that they can buy up to additional private insurance which gives them access to faster, but not better medical care.  They come in with the security that whatever the diagnosis, their family will not be devastated by an additional financial ruin.  They know that if something with their care goes wrong they will have financial support (ACC and WINZ programs). They often question me how our country can have a system that seems so unfair from their point of view.  Peaks and valleys they refer to it.  Hence  the boulders in the stream analogy.
    Our traveling group proved that such a system of single party payer health care could work from coast to coast in the US.  One-quarter the way down the actual 55 miles of driving Ninety Mile Beach, Karen, who is from Long Island in New York City took over Beasties wheel.  She safely guided Beastie the rest of the way to the Lake Ngatu turnoff to return to the tar sealed road.  From Oregon to New York state we enjoyed the drive on the solid sand beneath us.
      As we made our way back to the main road, we all had a sparkle in our eye and a grin on our face, much like Paul's.  Thrilled by the beautiful scenery along Ninety Mile Beach and joy in overcoming a fear unknown.  Maybe we should approach our solution to the health care problem in much the same way.  Overcome our fears of a single party payer health care system.  Wouldn't it be nice to not fear financial devastation anytime you need medical care?  Come on, jump on board Beastie, and we will go for a ride! 

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?"

Happy Thanksgiving from NZ!

   Normally it would be a morning stumble out of bed to stuff the turkey so that it could be put in the oven and ready for us to dive into a large turkey dinner later in the day.   This year it was a Thanksgiving Thursday stumble out of bed for a 5am departure with friends for a fish and dive in the Bay.  Strapping on dive gear on a balmy day is a far cry from watching leaves (or snow) fall outside while we digest our meals and watch football inside.  But a new kind of abundance was found today.  Kingfish, scallops and crays (lobster).  Plenty of things for which to be thankful this year and every year.
    We wish you all a Happy Thanksgiving!
     

Mullet is Gone. Replaced by a Whale.

   He missed the dinner and camping overnight on his school outing, but I don't think it bothered him.  The smile on his face tells the tale.  Outfished his dad and a near record for the boat.  Schnappa season is on in the Bay.  This is only the second snapper he has caught since being here in NZ.  Right in our new backyard.

21lb Snapper

The Ski Bum and the Single Parent.

   "Daddy, I heard you say the F-word!"

    Mt. Ruapehu, an active volcano on the North Island last blew its top with a major eruption in 1995-1996.  Since then it has had a few smaller eruptions most recently in 2008.  It is also home to two of the major ski fields on the North Island, Turoa and the other one of which I am still working out the pronunciation.  Our neighbor, a mechanical engineer who has been relaxing between jobs (living on the money he made in Aussie) has a ski home there. He has piqued my interest (lucky bastard) with his reports of the ski trips he has taken over the winter months.  His complaints of feeling "shattered" after some hard days snowboarding and the seven hour drive back to Kerikeri have garnered my deepest sympathy (Please get a job).  Why didn't I get to go? Oh, yeah. This is a WORKING sabbatical.

    It is mid October, and I am still trying to wrap my head around this southern hemisphere living.  Usually this is the time of year where the changing leaves and mountain valley rainfall find me nursing my shin wounds from a recent backcountry bushwhack...no..fishing trip while watching the snow reports tally the snowfall at the higher altitudes.  This year the calendar reads the proper dates, but instead of snowfall, I am enjoying the fragrance of orange blossoms while checking the ocean and beach temps. 
    A couple of weeks ago while sharing a beer in our backyard with our neighbor as he pulled his recently caught Waipapa Inlet mullet out of his bait net (Yeah, between ski trips, relaxing mechanical engineers drink beer and fish.  Did I mention the two college female exchange students, one Chilean, one German, neither language hard on the eyes, who are staying with his family?) a ski plan was hatched.  He reminded me that October 23-25 is Labour Day weekend in New Zealand.  The ski fields at Ruapehu were currently getting fresh snow from a southerly storm and another southerly was expected the week before the holiday.   "The ski fields will stay open 'til mid-November with this snow base. Bro,you oughta go."

     Hmm... Saturday morning clinic then drive seven hours.  Ski Sunday.  Hmmm...  I have hiked for seven hours just to make a few ski turns.  Lots of ski gear shipped over here sitting around waiting to be used.  Hmmm.  Day to drive back on Monday.  See more of this beautiful country....I'm in!
      Did I mention that Kim was going to be back in the US during that time.  Due to her amazing (some of my in-laws are following this blog) family, that has bonded together through some very difficult circumstances that I will discuss in a future post, Kim needed to go back to the US for a visit.  I was signed up for two weeks of single parenthood, (As opposed to the life sentence of double parenthood?) from October 11-26.

     Convincing the kids to go was a no brainer.  I have been grooming them as co-conspirators in getting mom back up onto the ski mountain since they were old enough to enjoy the snow.  Yeah, Kim was getting to be a pretty good powder skier, and even headed towards the bumps.  But ever since one slipped past the goalie and became a Joel bump, her skiing days have never been the same.  I am still scarred by my one and only solo attempt to get her back up on the mountain postpartum.  Hence my reason for looking for help from the kids.  Their joy of skiing has been infectious and we have had mom out a few times the last couple of years.  So when I told McKeely that I would take her skiing the week after her birthday, she was all in.  So was Joel.

    Now the part that would take some brains and organization:  Getting through the two weeks before the ski trip.  With a good after school program that the kids loved, generous colleagues at work who volunteered to cover our late acute clinic, and a day off per week to reload the groceries, the majority of the two weeks cruised by without much problem.  I would say I was the king of the daddy domain (it's good to be king when the queen is gone).   As king, I even was able to host a birthday party that included five little princess friends of my princess McKeely.  Thank goodness for an associate queen mum who stood in to help.  No way could I have combed that much candy (pinata malfunction) out of one little princesses hair!



  
     But then there was the full moon Friday before we were to leave for skiing.  The morning was going great before work.  Had the dishwasher nearly loaded.  Ten minutes early too.  Kids lunches packed and homework checked.  I am the domestic king!  Then the largest glass of spilled milk and Milo I have ever seen occurred.  It was also the first time I properly pronounced the name of the other ski area on Mt. Ruapehu.  Somehow as Joel was picking it up to drink, the glass opted to hit the counter ledge, twist out of his hand and spray ,with a couple bounces, the entire volume of milk onto nearly every cabinet front in the kitchen, onto Joel's pants, and the front of the refrigerator.
   So now we were five minutes late heading up the driveway.  Pleasantly drop the kids at school (Bye, get out.  Now!), and race to clinic.  Back to a normal day until the call from school at noon.  Seems that the one holer loo per classroom was not enough for the number of kids with post lunch gastrocolic reflex.  Kid number three in line could not control number one and "needs a fresh pair, so would it be OK for a teacher to walk your child home for a change of undies?"  Bummer.  "Sure that is fine, I am a half hour away."  What was that ski area name?  Thank goodness for some wonderful teachers at the school.
   A little late getting out of work, so the kids were the last ones at the after school program.  No big deal, as it is a holiday weekend, and next week, Kim will be back home for the after school routine.  That is when the volcano blew.  It started with a simple small voice.  "Daddy what are nits?"  Clinically, I have known it was only a matter of time before this happened.  Seems the nice moist warm environment in this part of New Zealand is ideal for the spread of head lice among school children.  Clinic nursing staff have since entertained me with stories of the number of times they have had to treat their children over the years.  At this moment though, I was not being entertained.  "Daddy, my head has been itching for the the past three days too." says the older of my precious children.   A rapid search through each child's scalp, which revealed plenty of crawling parasites, and I suddenly found myself an expert in pronouncing that second ski area name.
    A load of bedding into the washer, a drive back to the clinic to pick up a bottle of malathion, a stop at the store for a nit comb and additional conditioner (works great to loosen the nits for combing) and the battle was on.  By 2pm the next day, thanks to additional help from our unbelievable find of a babysitter, (yes, she rewashed bedding and combed the kids hair, while I finished Broadway's Saturday clinic) we were still able to depart for the ski field.  Hair and scalp hygiene much improved.  I packed the two remaining parasites (the ones that could have only been removed with a preemptive vasectomy on my part) into the car and headed south.

  
     The ski trip was wonderful, as the pictures show.  Turoa ski field treated us well.  It was definitely spring skiing, but the beauty of a snow covered volcano surrounded by the lush greenery of New Zealand more than made up for the quality of snow.  Mt. Taranaki, another volcano near the west coast of the island, even made an appearance on the sunny horizon.   Smiles all around erased some of the difficulties of the preceding weeks.

      As I sit and write this in a Taupo hotel room, kids worn out from the day, already tucked in bed, I do have some remorse for erupting in front of them.  Daily stress can catch up to us, and sometimes blow up to cause damage.  Fortunately, our children are at an age where they are highly inquisitive about the handling of emotional situations.  We had some great talks about words, communication, joy, anger, sadness, and losing a loved one during our drive to the mountain.  As parents and children, we are each growing up a little more each day.  Maybe as a dad I didn't handle full moon Friday as well as I should.

    
     While the sun sets across Lake Taupo with Mt. Ruapehu on the far horizon there is one thing I do know for sure. When they ask to go skiing again, thanks to my outburst, they will at least know how to properly pronounce the name of the other ski area at Mt. Ruapehu.
    "Dad, when can we go skiing at Whakapapa?"
     That's the story of the F-word in our house.  (Read the June 27 post for proper Maori pronunciation help.)          
  
  
               

Cathedral and Train, The Coromandel Part II

   After leaving Hotwater Beach and enjoying a lunch, not spaghetti on toast, at Cook's Beach, we considered our options for additional sightseeing on our way to our overnight destination in Whitianga.  The kids were begging to head to the hotel, as they knew it had a swimming pool.  The weather was not the best, and for some reason the statement made by an Aussie travel mate years ago, while traveling in Europe on a Contiki Tour bus, ran through my mind.
   "Ah, Jeez**!  Not another !%$ D$#% Cathedral!"

   That Aussie bloke uttered his religious observance as our bus pulled up in front of another institution in central Europe.  After several days in a row that involved stopping at a cathedral for a look around, he had had his fill.  Despite the inspired architecture, I too had to admit that they all started looking the same after awhile.

      With Cathedral Cove only a few minutes drive from Cook's Beach, I was hopeful that our family would have a better tolerance before we headed off to the hotel.  We were not disappointed.  Nothing like God's own carving with the help of Mother Nature, to provide beauty and inspiration. I have put in the video, mainly for a feel of the ocean ambiance while you view the pictures.  

   Fortunately the lunch had rejuvenated us, and it was an easy hike along the coast to the Cove.  The heavy ceiling of rain clouds intensified the reverence we felt for this site.  As we hiked back to the car for our final drive of the day to Whitianga, visiting Cathedral Cove was a wonderful way to finish our day enjoying nature. 

    After our overnight in Whitianga, blessed by another ocean front sunrise, we drove across the peninsula to Coromandel Town.  Formerly a gold mining town and port city in which surrounding Kauri trees were harvested for use as ship masts, this town now thrives on the gold from tourists pockets.  It also is famous for its Coromandel Mussels which are farmed in the bays near town. 

     We opted to take on the Driving Creek Railway, a narrow gage railway on private property that travels up into the native bushland.  In 1975 Barry Brickell, a schoolteacher who decided he did not want to teach school anymore, started a pottery workshop on land he obtained fairly cheap after it had been harvested of all its native Kauri trees.  He also was a railway enthusiast and decided that a railway would be the best all-weather transport to bring clay from the surrounding hills on his property to his workshop.  In 1990 the train was safely upgraded to carry people to the top of the property.  



The Snake Train



The potter's work

     





     As we wound our way to the Eyefull Tower at the top of the hill, 465 meters higher than we started, I came to a realization.  It takes a whole lot of wine to build a railroad!  Even though the tunnels and some other major structures were built with pottery tiles, all of the corner terracing of the rail bed was done with empty wine bottles buried neck first in the ground.  Maybe the potter needed to get on the wagon and not on the train!

The view from the top.  Whanganui Island.