Dr. Rob Woods is a well known Emergency Physician and program director for the FRCPC Emergency Medicine Program at the University of Saskatchewan, who recently practiced emergency medicine in New Zealand on a one-year sabbatical. Here, he provides us some with answers to many questions he has been getting, insights into the country, lifestyle and medicine from abroad.
Why did you go to New Zealand?
We also thought it would be great for our family to experience living and travelling in a different part of the world, and well, we live in Saskatchewan. I’ve grown up here and to me it is home, prairie landscape, lots of sunshine and 8 months of winter, what more could you ask for right? No matter how much you love this province, you will ask yourself why you live in Sask when it’s minus 30 degrees outside in January! That was motivation number one, to explore a different part of the world with warmer weather. We chose New Zealand because everyone we knew who had gone there loved it. We planned it during a year when our kids were not yet in high school but were old enough to participate in outdoor adventures as a family.
What is a sabbatical? How easy was it to get a job and how long did it take to set up?
Ultimately, the purpose of the trip was purely for family adventure, but we did have to pay the bills so finding work was necessary. We had to first obtain Visa’s in order to work in New Zealand for more than nine months. Initially, we looked for work for my wife (a Pediatrician), thinking I could fairly easily pick up casual work. However, it turned out there were not many jobs in Pediatrics, but fortunately there were a reasonable number of EM jobs. Our kids are in French Immersion in Canada, and we had hoped to continue their education in French. We applied to the two French Immersion school in Auckland and were accepted into Birkdale North, on the North Shore.
The next task was finding work, as luck would have it, there were positions available at both Waitemata District Health Board (North Shore Auckland) and Auckland City Hospital (downtown Auckland). Given the proximity to the school and our desire to have one car, I applied to Waitemata, had a skype interview and was accepted for a one year maternity leave position. I had initially hoped to work part time to maximize travel, but understandably it is difficult to get a health district to sponsor you for a work Visa from overseas for a part-time job, so I accepted a full-time position in their EDs. This was ~ 6 months before our planned departure date and was just enough time to get all the paperwork sorted.
After signing a contract, I had to apply to the Medical Council of New Zealand to get my credentials accepted. This was definitely the rate limiting step, and certainly has been the case anytime I have travelled out of province or out of country for work in the past. During the 4-5 months while we were waiting for my application to be processed, we got to work on the Essential Skills Work Visa application. First criterion is that you need to be younger than 55. So, for those of you thinking about doing this when you retire, think again. The application required a criminal record check, medicals for all of my family, photos, proof of my relationship with my wife and of course a copy of my registration with the Medical Council of New Zealand. We had everything together 6 weeks before our flights were booked. Thankfully, there was only a minor hiccup with the Visa application and we had passports with precious Visa’s in them 4 days before our departure…what a relief. If you have any medical issues, add a couple extra months lead time for Visa delays.
What were some of the first things you noticed?
We arrived in early August after enjoying some beautiful Saskatchewan summer weather and arrived in the middle of New Zealand ‘winter’. We love Air New Zealand! They have the friendliest staff and the most hilarious safety videos. If you travel with your kids we highly recommend the SkyCouch option so you can get some sleep on the 14-hour flight. When we arrived, it was +14 with occasional showers. They have no idea what winter is! The first thing we noticed was the ocean and the scenery. Waitemata provided a hotel room and a rental car for the first few weeks until we found our place to live. That initial hotel and the apartment we ended up renting were right beside Takapuna Beach. We spent many hours walking up and down it amongst all the dogs playing in the sand, climbing on the Pohutukawa trees, staring out at Rangitoto Island and the beautiful sunrises. Mission beautiful scenery…accomplished!
Driving on the wrong side of the road is a challenge. It was probably 4 months before I stopped clicking the ‘windscreen’ wiper when I wanted to signal and was comfortable navigating round-a-bouts. Just getting to the grocery store and finding groceries took a lot of cognitive energy the first few days. Central heating was one thing that we were immediately missing from back home! They use space heaters to heat their houses in the winter and their houses have minimal insulation. So if it is 14 degrees outside, it is maybe 15 degrees inside! We Canadians did not think we would struggle with their winter, but it was toques and socks in bed at night until late September when the weather started to warm up.
We had a laugh at the language differences. ‘Bring your togs and jandals to the beach’ (bathing suit and flip flops) and ‘You’re going to need your ‘gumboots’ (rainboots). Our favourite is how many words were given a cute ‘ies’ on the end: sunglasses (sunnies), kindergarten (kindy), university (uni), relatives (rellies), hundred dollars (hundy), wetsuit (wetty) and my favourite, sideburns (sideys).
How was school for the kids?
The kids went to school at Birkdale North, with the school year running from February to December, so we arrived a little over half-way through the year. Most of the children in the French Immersion stream were from primarily French speaking families who had moved to NZ for work, so we met children from France, Switzerland and Belgium. The teachers commented that our children ‘spoke very good English’…! As a result, the level of French being taught was well above what our kids were used to back in Canada. The kids had to spend extra time getting their French caught up the first couple of months we were there. After Christmas our son attended Takapuna Normal Intermediate School. We were very impressed with both schools, the kids had amazing experiences and made some wonderful friends who they still keep in touch with. It would have been nice to have had skype and facetime when I was a kid, pen pals are a thing of the past.
How was day to day life in Auckland?
By far the worst thing was traffic! Getting across the harbour bridge to travel south of Auckland had to be timed. My wife spent many hours in the car each day getting the kids to and from school and activities. Luckily for me, North Shore Hospital was only 2 km from our apartment, so I was able to walk or bike to work. The second hospital was ~ 27km from the apartment in West Auckland, so I biked and used it as an opportunity to exercise on day shifts, and tried to arrange my afternoon shifts on weekends at that site so I could use the car.
Auckland is also quite expensive. Gas, groceries, rent and going out to eat were roughly double what we were used to back home. Oh, and my income was a little over half of what I was used to making in Canada, so we had to be more careful with our spending, but man was it worth it! We quickly saw why Auckland is ranked one of the top most livable cities in the world on a consistent basis.
It was so easy to be outside and active in Auckland. I joined a great triathlon club and my wife joined a morning cycling group. Early morning exercise is a lot easier to motivate yourself to do when you know the weather is almost always nice. I will miss my morning swims in the outdoor pool at Birkenhead watching the sunrise as our sessions would come to an end, and cycling to North Head in Devonport watching the sun shine onto downtown. There was a real fitness culture in New Zealand. The best example was Beach Series, where every Tuesday evening in the summer at Takapuna Beach there was a Paddleboard, Swim or Beach Run race you could enter, and everything was kid friendly. If you did a little driving, you could find a series like this pretty much every day of the week somewhere in Auckland.
Where did you travel?
We went away probably every second weekend and every school holiday plus a bit more. Auckland is an amazing city in its own right. We went to the zoo, the aquarium (multiple times), and tons of reserves, many of which had interactive farms. Living in Auckland was a great launch point for seeing the North Island. We took many day trips to islands in the Hauraki gulf, the many reserves along the East coast bays, the blacksand beaches on the West coast, and hikes in the Waitakere Ranges. With weekend trips we went to Rotorua, Taupo, New Plymouth, Raglan, Mount Maunganui, and several to the Cormandel peninsula. During our extended trips we did a tour of Northland including Cape Reinga, Bay of Islands and Tane Mahuta (the 3rd largest tree in the world), a road trip to the South Island in Picton and Blenheim, and a flight to the South Island in and around Queenstown.
What did you first notice at work?
I started work with Waitemata District Health Board a week after I arrived. I was given 4 buddy shifts, a computer orientation and general orientation to start off. The first thing I noticed was the focus on Maori culture. It was made clear that the health outcomes of Maori people were not at the same level as the rest of New Zealand, and it was crucial that we closed this gap. Additionally, it was made clear that achieving equal outcomes did not necessarily mean equal resources. All of the health care facilities are blessed by Maori spiritual leaders so that Maori people can feel safe accessing care. There were specific programs and staff for Maori mental health, addictions and social work to try and close the gap. This focus seems to have found traction through the re-signing of the Treaty of Waitangi, and incorporating the principles of the treaty into health care.
It made me reflect a lot on how we approach Indigenous Health in Canada. I participated in an on-line course offered by the College of Medicine at the University of Saskatchewan while we were there. The role of practitioners in Indigenous wellness was an incredibly valuable learning experience, helping me become more aware of Canada’s Indigenous history and my own biases. It was about 30 hours of time invested over a term, well worth it if you are wanting learning more about Indigenous health.
New Zealand was very upstream in its thinking about illness prevention. You couldn’t walk by an elevator without a sign saying something like ‘Warning…using the stairs may cause buns of steel’. Further to that, every patient seen in the ED was screened for smoking and offered resources for smoking cessation. New Zealand has set a target to be ‘Smoke Free’ by 2025, hoping to have less that 5% of the population smoking at that time. It was very easy as a physician to participate in this counselling as the resource page automatically printed when you printed a discharge summary. Waitemata even instituted a smoke free policy on all of their grounds, and won an appeal in the courts to uphold the ban.
Waitemata ED was particularly focused on bundles, or as we would refer to them here as pathways. They had a pathway for everything! The one I was most impressed with was the Suspected NOF Fracture Bundle, (NOF for the Canadians refers to neck of femur). The nurses would order an Xray, put the procedure ‘trolley’ in the room and ask a physician or clinical nurse specialist to administer a Fascia Iliaca Block. Everything you needed to do the block was in a package in the procedure trolley, including a diagram with landmarks and description of the procedure for a quick refresher if you hadn’t done it in a while. Almost every physician in the group was involved in creating, updating, auditing and reporting back to the group about a bundle. It was a very impressive model for Quality Improvement that engaged all of the staff.
You are probably asking how did they get everyone to help out with a care pathway? I asked the same thing. The answer is PAID NON-CLINICAL TIME. Full time physicians were scheduled for 3 x 10 hour clinical shifts and 1 x 10 non-clinical shift every week. That’s right, 25% of your time was for non-clinical work! We had our teaching and departmental meeting on Tuesday afternoons. Unless you were working on a Tuesday, you had your non-clinical day on Tuesday. You spent the morning working on your assigned QI, research, education duties, then the afternoon in teaching and meetings. This is in stark contrast to back home where most of our non-clinical time is unpaid unless you hold a formal leadership role, and even then, the role rarely pays anywhere near what clinical work pays.
Was the medicine the same?
The types of problems and the way they were treated were very similar. Patients used some classic kiwi language to describe their symptoms. They weren’t hot or tired or dizzy, they were hot as, dizzy as, tired as, sick as. Despite my best attempts to introduce myself as ‘Dr Woods’ patients would spot my first name on my name tag and politely say ‘Thanks Rob’ as I left the room. After about a week, I went with the flow and haven’t changed since I’ve been back in Canada.
Some of the drug names were different. The most important one was that Epinephrine was Adrenaline, and during my first code, I got some strange looks when I asked for 1mg of Epi. They had a couple of drugs I wish we had back in Canada: IV Paracetamol and Rectal Diclofenac. They provided great pain relief and avoided opioids in a tremendous number of patients. They did not have a few drugs, most notably Procainamide, so I had to cardiovert my Atrial Fibrillation patients electrically. I was considered ‘aggressive’ in my management of these patients, and it was one of the few conditions where there was a significant practice difference between Canada and New Zealand.
I saw some interesting infectious disease cases. Varicella vaccinations are relatively new in NZ, so I would regularly see cases of chicken pox. Sadly, Maori and Pacific Island Children are more susceptible to Rheumatic Fever, so we would see the occasional new case of it, and would often see teenagers and young adults with heart failure or valvular complications from this disease. The government had a campaign to ensure people got their sore throats treated to try and reduce the incidence of this disease. Quite a different approach to North America where we are at the point where we question whether or not we even use antibiotics for confirmed group A strep. It was quite common to see a case of Dengue or Typhoid from people travelling in the Pacific Islands and other nearby destinations. I saw my first case of Leptospirosis, and will never forget what conjunctival suffae looks like.
I also had to learn a bit of ‘Kiwi doctor terms’. When you got your work done for a patient it was ‘all sorted’, when a patient was healthy they were ‘fit and well’ and a patient that had no neurologic deficits had ‘no neurology’. Nobody had diarrhea and vomiting, they had ‘Ds and Vs’. When someone was critically ill they were ‘crook’ or ‘crook as’ and if they were seriously injured they were ‘munted’.
Was overcrowding just as bad as here?
Quite the contrary. The Ministry of Health initiated a 6-hour target for patients leaving the ED several years ago. 95% of ED patients needed to be discharged or admitted within 6 hours of registration…and they were above the target!?!? This was a HUGE change for me. I saw all of my patients IN A BED. When I called an admitting service to see a patient, THE PATIENT WAS TAKEN OUT OF THE ED! It was surreal. Seeing St. John’s volunteers walking around offering patients and their ‘Whanau’ (Maori for family plus other social supports) a cup of tea with no hallways beds it didn’t even feel like you were in an Emergency Department anymore. So how did they do it?
Well, the initiative came from the top, and health boards were held accountable to the targets. That meant administrators collected data, reported it weekly and actively worked on strategies when problems arose. In order to make this a reality, you need a separate ‘Consultant ED’ which was referred to as the Assessment and Diagnostic Unit (ADU), which was similar in size to the ED and located in close proximity to the ED. Once they left the ED and were in the ADU, they were considered admitted and the clock stopped. It changed the way I practiced a bit as it is difficult to reliably assess a complex patient requiring advanced imaging to make a diagnosis.
Patients with suspected appendicitis, diverticulitis, bowel obstruction, cholecystitis or ovarian pathology often need a CT or ultrasound to make a diagnosis. These patients would be referred to the appropriate specialist and finish their work-up in the ADU. They could be sent home or admitted to the ward from there. From a selfish ED doc point of view, it made the job a little less interesting as I did not work up my patients as much, so I did not find out the actual diagnosis in as many patients, but if you were a patient, your care was efficient! Additionally, the ED had an OBS unit where we could ‘admit’ patients who needed longer for their care, but were almost certainly going home. Most commonly these were patients with renal colic, an overdose, intoxication +/- psychiatric complaints and older patients with functional decline as they often needed resources that were only available during daytime hours.
For the skeptics, you can see there is a small potential for gaming the numbers. Patients who are close to the time limit can be ‘admitted’ to the observation unit and then subsequently discharged to meet the target. I can tell you it was extremely rare for this to happen. With a low threshold for admission and no real barriers to admission, I felt I did not have to hone my ‘are they safe to go home’ skills as much. Overall, the intervention has reduced length of stay and mortality in the ED, although quality of care markers in the ED do not seem to have changed much.
Staff were less concerned with patients seen per hour, but more on ‘dwell time’, which was the time from signing up for a patient to the time you either discharged or admitted the patient. You would see a couple patients and then results would start coming back on patient one. In Canada I would keep seeing more patients and then make some decisions on disposition for patients after a couple hours. I couldn’t get away with it in NZ…the nurses wouldn’t let me. As soon as investigations were back everyone wanted to know ‘what was the plan?’ The target was the culture. I would decide the disposition for the patient and move on right? Wrong! I had to finish all documentation and print it out for the patient before they left the ED or were transferred to the ADU. I told one of the Registrars that I finish most of my charting at the end of my shift in Canada. They asked how the patient got the record of their ED visit, and I said they didn’t. They quipped back, ‘that doesn’t sound like very good care!’ I had no comeback, I saw fewer patients, documented in a timelier fashion and made quicker decisions about disposition and patients efficiently navigated the system.
In Canada, this is an initiative pushed at the ED level, and less so at a system level. As such, CAEP’s position statement on ED overcrowding looks mostly at measurement to advocate for the problem, and metrics for physician productivity (time to initial assessment). In-patient beds or access block are the main problem, and our ED approach tends to be to admitted as few patients as possible. Additionally, ED physicians are paid very well, so we match their work hours to patient demand to maximize their productivity, resulting in the same problem with different approaches.
The staffing for a shift was a mix of skillsets. There were ED Consultants, MOSSs (Medical Officer of Special Scale), ED Registrars, House Officers, and Clinical Nurse Specialists. A MOSS is a physician who has not completed residency training, but has lots of experience in that field. We would have 5 or 6 providers on the day shift and evening shift, and 3 or 4 providers on the night shift. Having the care pathways was quite useful with this mixed skillset for standardizing practice. We mostly had common start times with formal handover at 0800, 1600 and 2400. This was very unusual for me as we have staggered start times where I work in Saskatoon, and you hit the ground running when you walk through the door. It was great to have the handover for staff bonding and clarification of staffing and protocols. The downside is meeting patient demand in surges during the early afternoon and early evening.
What was medical education like?
The biggest difference I noticed was the structure of education. Post-graduate training was not under the jurisdiction of a University, but rather the hospital. In this way, the hospital oversaw both academics AND quality of health care delivery. It made things a lot simpler for allocating extra roles and tasks through non-clinical time. In Canada it always seems Universities and hospitals are competing for resources because of similar end goals but different agendas.
After completion of medical school, graduates apply for House Officer positions. They complete 6 month ‘jobs’ in 3 month clinical ‘runs’. Trainees usually complete 2-3 years of house officer runs before applying to residency. Applying to residency is very different than Canada. You apply for a 1 year contract job with 6 month rotations. At the end of the year, if you decide you don’t like the specialty you can switch. Registrars had to complete approximately 8-10 work-based assessments during each 6 months of clinical experience. After the year was up, registrars could switch sites and often did.
For me, the structure of training lost its intimacy a bit compared to Canada where you train in one institution for your entire residency. Faculty feel quite invested in their trainees and spend a lot of time with mentorship. Even with medical students and off-service residents, we staff them as add-on personnel to shifts. There is more of a buddy relationship on developing their knowledge and skills. The structure in Australasia made training posts seem more focused on learning on the job and less like an apprenticeship. In the end, the consultants I worked with who trained in this system were excellent. Goes to show you that there are many ways to accomplish the same goal.
Would you recommend it to others?
Absolutely! Just writing this post makes me nostalgic for an ocean swim, a family hike or all the wonderful people we met on our journey. Working somewhere else gives you a great perspective on how care can be delivered in a different way. It also makes you appreciate what you have back home. Sometimes you can be frustrated by your own place of work, but you realize nobody has it totally figured out, and there are always unintended consequences to changes that you think will fix all of our problems. Most importantly it gave our family an adventure of a lifetime, and made me realize I was working too much back in Canada. I am doing my best to keep exercise and family time a high priority so that work does not overwhelm my life. Our kids were a great age for this type of trip and they will never forget the adventure.