28 November 2018

An American rheumatologist working in Christchurch

Global Health Rheumatology

It was a wonderful opportunity.

Having just retired from Mayo Clinic and having always been interested in international medical practice and travel, the chance to work as a consultant rheumatologist at Christchurch Hospital for three months was something I was never going to pass up.

Dr Peter Chapman, a senior rheumatologist in Christchurch was taking a sabbatical at the Mayo Clinic in Rochester, Minnesota, which created not only the opportunity for me to work in his New Zealand city but he also graciously invited us to stay in his home.

That was back in July.

Reflecting on the last few months, I can only say what a remarkable and fully enjoyable experience it has been. So enjoyable in fact, I am extending our stay courtesy of an appointment as visiting William Evans Professor to Otago University, and a further locum in Auckland that will see us staying in New Zealand through to at least April next year.

My wife Herta and I arrived at the start of “winter”. For us, whose concept of winter is being able to walk on frozen lakes and ice fish, it felt more like autumn. Fewer leaves on the trees and longer nights were the only signs we noticed.

Christchurch is a dynamic city, but a city still recovering from the destructive earthquakes of 2010 and 2011. Evidence of the devastation can still be seen in the many condemned and boarded-up buildings and the vacant lots where buildings have been demolished.

It was a unique experience to work in buildings that had postings of “earthquake-prone building” everywhere. Indeed, just outside our office there was a major crack in the wall with a view to the outdoors.

But far from being depressing, it was exciting to see the new construction that was taking place everywhere. Of particular interest, was the building of the new hospital which opens next year, and the new outpatient facility, as well as the planned developments for the medical school, laboratory and research campus.

In terms of practising rheumatology, as you might expect, most of the notable differences related to the health system and processes rather than the clinical medicine, but there were a few surprises.

In Christchurch, the rheumatology practice is hospital-based and supported by the public health system through the local District Health Board. Compared with the larger Mayo Clinic practice which has subspecialty clinics for inflammatory arthritis, myositis, vasculitis and connective tissue diseases, the Christchurch practice is much smaller. However, the practice serves a large catchment area and treats all rheumatological disorders, and there is a great variety of diseases and disease severity to be seen and treated.

The smaller training program supports a single registrar in rheumatology and one in immunology, while at the Mayo there are six rheumatology fellows. 

There are also few clinical trials being conducted at Christchurch, and musculoskeletal ultrasonography has not yet become integrated into the outpatient clinical practice.  But on the plus side, almost all major medical services are available in Christchurch, and I found it very easy to meet and communicate with other providers in the hospital and community. I have a particular interest in CTD-related ILD and could connect with and participate in patient-care conferences with the ILD pulmonary group.

Working in a small country also meant that it was easy to interact with virtually every rheumatologist and rheumatology registrar and many nurses across the country, meeting many of them at the annual NZ Rheumatology Association meeting.

The rheumatology clinics in Christchurch were very busy, with full schedules of follow-up patients every 15 minutes and 45 minutes for new patient evaluations. For many patients in less populated areas on South Island, it is a long trip to see a rheumatologist. Christchurch rheumatology has outreach to the towns of Kaikoura and Greymouth. Working in these clinics provided me with the opportunity to see more of the country and become better acquainted with the people.

I found medical record-keeping was less cumbersome than that which I had been used to in the US. This was, in part because no billing information was needed, which was a nice change but, by the same token, no diagnostic coding was required for outpatient visits.   Without diagnostic coding, it is a challenge to evaluate healthcare outcomes of specific rheumatic diseases. 

One area where diagnostic coding might be useful to help evaluate outcomes is gout, which is much more prevalent among Maori populations. Previous studies have suggested Maori and Pacific Islander populations are less likely to fill prescriptions or attend specialist appointments, which makes poorer outcomes more likely, but without diagnostic coding this will be difficult to prove or to study.

Hospital-based outpatient evaluations including notes from specialty clinics, radiology and laboratory results were integrated into the electronic medical record and available, but in-patient hospital records are still on paper. The system also doesn’t yet access the general practitioner records, or records of specialists in private practice, nor is there electronic delivery of prescriptions directly to pharmacy with corresponding instant capture of medication changes in the medical record. 

This, apparently, will be changing in the coming years as New Zealand works toward integration of its entire medical record system.

There are many well-known major differences between the healthcare systems of New Zealand and the US. But what I found especially appealing, was the right of every New Zealander to health care, a right enshrined in law since 1938.

As a small country with a limited budget and many competing demands for national resources, I was very impressed that all patients could access medical care in an appropriate time frame. Unlike much of the US, in New Zealand, GPs are gatekeepers for patient access to specialists, and they appeared, not only judicious with requests, but also skilled in co-managing these rheumatology patients.

In my experience, GP referrals for rheumatology services always included a summary of the reason for the referral and findings, a refreshing difference to referrals at Mayo, which often include copious documents without a summary.  

In New Zealand, GP visits incur a variable out-of-pocket cost to patients, but specialist visits in the public sector are free. At the hospital-based rheumatology service, medications are available for $5 per prescription for three months. Public hospital inpatient services and outpatient hospital-based infusions are provided without any cost to the patient.

But such accessibility and affordability does not come without compromise. In New Zealand, only five biologics are available through the public funding system.

In addition, access to biologics is much more restricted than in the US. Before a patient is deemed eligible to have a biologic they must have tried a range of medications and combinations of medications (especially including leflunomide, which I heartily dislike).  There is effectively no ability to access biologics for more unusual diseases such as autoinflammatory disorders, although, to be fair, this is also difficult in the US.

However, as a result of these strict prescribing regulations and national contracting, New Zealand proportionally spends about one third of the money on medications than the US. In the US, various laws and practice patterns, a disjointed healthcare “system”, and drug pricing policies have seen costs of medications escalate disproportionately.

And despite spending so much less on medication, New Zealand rates higher than the US across most global measures of health outcomes including mortality and maternal child health. What’s more, and New Zealand healthcare efficiencies have resulted in healthcare costing only about 8% of the GNP as opposed to the 17% spent in the US.

Looking back, there were also a number of differences between the two work environments that were perhaps less expected.

An example was the hospital layout. In the hospital in Christchurch, there are few private rooms on the general medical wards, so patient encounters are likely to be overheard by other patients and their visitors. But apparently this is not seen as a negative, with a study, presented at grand rounds, indicating that most Kiwi patients prefer being in a room with others rather than isolated while in hospital. 

Consequently, wards in the new hospital are being structured in such a way that cleverly allows both privacy and the ability to interact with fellow patients.

Another surprising but very civilised feature of the New Zealand facility is the “right” of salaried employees to their “tea time”.  Tea is provided to all employees by the hospital, and to my amazement, we could order our choice of “trim” or “full” milk delivered fresh to the office each day. 

And then there were the New Zealand people themselves. Through the many patient encounters involved in my clinical work, I gained an insight into the lives of these welcoming and friendly people, once I had learned some new terminology, that is.

New Zealanders are very informal, reflecting, I think, their egalitarian mindset. Even new patients called me by my first name (which would not happen at the Mayo Clinic) and expected me to do the same. 

I quickly learned a Maori patient might greet me with “kia ora”, and a Pakeha with “g’day.”  I’d then ask “How are you going?”, eliciting a number of responses some of which, I found, required interpretation. My farmers might say they were “average,” which was a puzzle to me who thought they were just being modest, until I learned this really means “poorly, fix me.”

Similarly, I’d say: “What’s wrong?” Patient might reply “My knee is stuffed”. I’d think “Huh?, like- swollen, or maybe the guy has had a TKA”, but no, it means he’s about ready for a TKA.

Or, I’d say: “It looks like your LFTs are too high. Maybe it’s your methotrexate, but you might need to cut back on your beer.” Patient would reply “bugger (or more likely, ‘bugga’).” I had to check with the medical student he wasn’t referring to the same bugger found in DH Lawrence novels.

Another patient complained: “I’ve got a crook stomach”. Which had me wondering if his stomach was a thief, but eventually we found the NSAID was the culprit and we got it “sorted”.

Sorted is apparently an all-purpose term. Initially I felt rather like hardware at the iron mongers as I was constantly being sorted by someone or something. But soon I learned the gratification that comes with getting something sorted, just as I learned to feel pleased when a patient reported that they had “come right” after a bad flare of disease.

As has been my experience in medical practices around the world, working in New Zealand has again demonstrated the strong commitment physicians and other healthcare providers have to their patients and their patients’ health. 

I am indebted to my outstanding colleagues-physicians, nurses, administrative staff, and registrars for the opportunity to live this rewarding, eye opening experience which has provided me fresh perspective on the importance of universal health care access.

My wife and I both very much appreciate our time in this beautiful country.

Nga mihi nui,

Eric

Dr Eric L. Matteson,  MPH, works for the Department of Rheumatology, Immunology and Allergy, Christchurch Hospital, Christchurch, New Zealand,  and is Emeritus Consultant and Professor, Division of Rheumatology and Department of Health Sciences Research, Mayo Clinic College of Medicine, Rochester, Minnesota