I’ve wrapped up my second month of clinical shifts, including a string of nights, and wanted to highlight some of the practice differences here in Gisborne that many of you have been asking me about.
Warning: this is another more technical post, I hope it’s also interesting to the non-medical followers.
For starters, the quality and training of both the nurses, consultants, and my ED colleagues has been phenomenal. There is a genuine collegial relationship between departments here; as an example, we meet weekly with the orthopedic group to review films and discuss cases. Imagine a dozen attending physicians, half orthopedists and half EM physicians, sitting around in jeans on a Thursday morning reviewing x-rays, and you can begin to understand the type of hospital environment we have here in Gisborne. The radiologists are readily available to discuss cases as well, and have state-of-the-art imaging equipment that compares favorably to what we have in the states. We spend weekend nights with the hospitalists and other consultants. Our kids all go to school together; it’s that type of shop.
But the hospital here in Gisborne is different. To be clear, there are less resources (translation: people) available here than most places I’ve worked in the States (the one notable exception being Cottage Hospital in Nantucket MA). Any shortfall that we may have here however, in speciality or after-hours coverage, is made up for by consultants who are more than happy to share the load. As is already the case with emergency physicians everywhere, our general surgeons and hospitalists are expected to manage a wide variety of disease states and medical procedures. Everyone does their part. Case in point: orthopedic and other “specialty” surgeons admit their own patients here, which almost never happens in the States (my hospitalist friends in Richmond are likely submitting Visa applications now). All this to say, the hospital staff collectively makes this place work and delivers great care.
The biggest difference I’ve found working here is the use of ancillary testing; in particular with CT scanning and its associated ionizing radiation risks which is taken quite seriously here in NZ. (https://www.health.harvard.edu/cancer/radiation-risk-from-medical-imaging)
In the United States, the introduction of new medical technology in the last 30 years has led to fundamental changes in practice. Here in Gisborne, we have the same technology but are much more deliberate about its use. The system tolerates much more diagnostic uncertainty than we do in the US. There is not the same ‘rush to know’ that we see in American EDs. I’m not certain how this came to be. Perhaps it’s reflective of a broader cultural difference between the States and NZ. I’m certain financial factors play a role. Regardless, it’s a real phenomenon. It’s a more rational approach from a doctor’s perspective; physicians are expected to use their clinical gestalt to determine who really requires advanced testing.
So how does this play out in practice?
Here is an example: I had a young guy with abdominal pain last week who I couldn’t quite sort out with the information I obtained in the first few hours of his care. He seemed alright, but I wasn’t certain he was ok to go home safely – at 1AM, no less. He was subjectively in too much pain to go home and come back in the morning for a recheck, the wait-and-see approach. As opposed to ordering a CAT scan (the “donut of truth” as we often refer to it in the US,) I called a general surgeon, who was more than happy to admit him overnight for observation. This would almost never happen in the United States, as the surgeon, on call from home, would most certainly be uncomfortable taking responsibility for this patient without additional testing. The risk of a bad outcome and the resulting liability is simply too great in the US for this type of approach.
Here in Gisborne, this type of practice is commonplace. It’s dependent on a great deal of trust between physicians. It’s definitively old school, but it works. And the same approach is employed at all hours of the day, not just at night when less resources are available. In the case above, by morning the patient’s pain had largely gone away. It was clear that his problem was nothing dangerous, and he went home happy.
Whether it’s better or worse care is certainly debatable. The NZ approach in this case saves the patient from unnecessary testing and the radiation exposure of a CAT scan. It is likely a more cost-effective approach as well, especially when you factor in all the additional testing that often follows the first diagnostic test. (As a reference point, New Zealand spends about 9.5% of its GDP on healthcare, compared to 18% in the United States, with more favorable clinical outcomes by most traditional healthcare metrics).
Not insignificant – the NZ approach allows physicians the ability to make full use of their clinical experience to direct care. There’s a lack of urgency for the sake of urgency that I’ve grown accustomed to in US hospitals. To be fair, patients with non-acute complaints often wait longer than what I’m accustomed to seeing (and personally comfortable with) in the States. But the wait here most often seems acceptable to all involved. I had a guy wait several hours for an ear wax problem during a particularly busy shift last week; he thanked me profusely for flushing it out for him and allowing him to hear again.
So why is medicine practiced differently in the US?
One answer is the difference in terms of liability risk. Successful malpractice suits against doctors in New Zealand do occur, but they are exceedingly uncommon when compared to the States. But it’s more than just the risk of medical malpractice suits that drive physician behavior. It’s how physicians are trained. It’s managing patient expectations. Tort reform in the United States would likely help allow this type of practice to return to the US, and I’ve heard from physicians working in states with real protection from frivolous lawsuits (Texas for example) that it does change things for the better. But it’s more than that.
My conscientious ED colleagues here in New Zealand still feel the same internal responsibility to work hard and advocate for their patients. But they don’t have the same external pressures to diagnose everyone within a pre-specified time of arrival with absolute certainty. They are largely immune to externally derived quality measures, and patient satisfaction surveys as far as I can tell do not exist here.
So what’s the end result?
Physicians are expected to have great clinical skills. In return, they are given the autonomy to practice medicine and make decisions in the best interest of patients within the confines of the health system in place. Like everywhere in the world, including the US, medical resources have limits, and often have to be rationed. Here, it is the physicians that make these decisions. Short-term “social admissions”, whether it be for a frail elderly patient or a young child with suboptimal support at home, are largely accepted outcomes and in keeping with the hospital’s mission.
It’s a rational medical system – and similar to much of what we’ve encountered in New Zealand, common sense and decency rule the day.