Plain, please

Yesterday marked another adventure in Doc Jenn's encounters with the Kiwis. Once again I packed up my day pack and joined a few members of the Alpine Club for a hike up Mt. Egmont. This time we were headed to one of the old hut sites. Department of Conservation, or DOC as it's more commonly known, manages all government land in the country. Much like the national park system for us in the states. To facilitate locals and visitors alike to utilize the recreational land, DOC maintains several huts across the country. They don't amount to much more then four walls of corrugated aluminum with a few bunk beds inside, but it sure beats sleeping in the rain. Unfortunately, like all government agencies, DOC had to make cuts in spending, and that meant removing some of the huts across the country, including the Mangahume Hut we were hiking to on Saturday. Initially the plan was to camp overnight on the old hut site, but due to inclement weather (ie pouring rain and blustering winds) they elected to stay in the shelter of another existing hut on the mountain. Prior to heading out, I had elected to hike the whole trip in one day. It meant 7 1/2 hours of hard hiking, at the price of very sore buttocks and legs and a water-logged left foot, but the hot shower felt fabulous when I got home. The 'adventure' part of this trip originates from the lack of established trail down to this old hut site. This meant some of the male members on the trip got to play with their GPS toys, running us all over the mountain side in the low-visibility mist until we succeeded in finding our destination. If this sounds very Lord of the Rings-esque, you would be correct. Let me tell you, though, the scenes in that movie do not even come close to bringing justice to the beauty of walking through the land yourself.

After safely making the solo journey back to my car, all I could think about was food. I had a great desire for my mother's wonderful clam sauce, loaded with dripping butter and garlic, on a bed of spaghetti. Unfortunately, clams are not native to New Zealand, nor has the average kiwi heard of clams as I found out when I went hunting for them in the grocery store. What I did find was a variety of other canned seafood, in particular tuna and salmon. All different varieties for your choosing: smoked, seasoned with lemon and pepper, dill and chives, spicy curry. Any flavor you'd like, except plain. Okay, there were a few token cans packed in oil or water, hidden on the back of the shelf, covered in dust. In general, everything was flavored. This goes for most other processed foods as well. A walk down the potato chip aisle reveals the usual flavored suspects of sour cream and onion and barbecue, but then on closer inspection you'll find chicken with herbs, liver and onion, and even lamb with mint flavored varieties. But your basic run of the mill plain with a little salt? Not present. I don't understand. Kiwis like their processed food flavored. All I want is plain, please.

Adventures in abseiling

When I arrived in New Zealand, I yearned for a way to meet new people and explore the countryside. Some of the locals warned me that the terrain could be quite unforgiving and dangerous, with weather changing within minutes, making solo journeys obsolete. So when I heard about the Alpine Club, I jumped at the chance to join. It's a very laid back group composed of people from all different types of employment and varying in age from 18 to 60. Trips are planned almost every weekend, usually consisting of hiking the regional Taranaki countryside, but occasionally venturing into the middle of the island and even down to the south island. They are the group that guided me up Mt. Egmont twice, granting me the pictures you've all been perusing. However, hiking isn't the sole activity of the club. This past weekend we broke from the norm and went abseiling. Now for those who don't know what abseiling is (admittedly, I being one of them until I looked up the word), it's simply rappelling. And it's fabulous fun. When else do you get to descend down a sheer cliff face, reenacting scenes from Mission Impossible? Unfortunately, our group was quite large, including some high school kids from the Adventure Club, limiting our descents to two. The second, displayed in the pictures, was about 40-45 meters high and quite thrilling. I played my best Tom Cruise stunt double part, pushing myself away from the wall, narrowly missing a collision with the log below. Oops.
Yet, while the descent was not as technically difficult as you might think, the ascent was a different story. Having recently rained, the ground up the canyon wall was rather slick and moist, causing plant grip-holds to easily uproot, bathing us all in mud on the way up. Oh well, that's the price you pay for fun.

Distance sucks

There are no two ways about it. This is a great country, but sometimes its isolation and water locked state really get to me. In the states if you want to change your mood you can drive across the state line and become a temporary Arizonian, Idahoan, or even Canadian if you so desire. Here, if you run across the border all you hit is water. Vast amounts of water. And if something happens to a friend or family member I feel crippled, unable to share in their joy or sorrow.

The reality of my isolation became glaringly apparent today when I received some disheartening news about a close friend of mine. Someone who has been with me through a lot of my most difficult growing pains: med school, residency, fellowship, even failed dates and relationships. You can imagine my heartache when I got her email. All I wanted to do was run to be by her side. Again, water everywhere. While my swimming skills are decent, I knew they wouldn't be up for a trans-Pacific crossing. So I did the next best thing, rush to look at the web fares. Then this nagging voice spoke up in my head, something I like to call my rational mind. As much as I care about my friend and want to be there to support her, I have obligations here. I've developed a family of patients who rely on me, expect me to be here, even invite me to their houses for tea. How will they feel when I'm not here on Monday morning to help them out? I realize I care almost as much about this temporary family as I do my own friends and family in the states. But never you fret my stateside compadres, I will be back, even if I have to swim to get there. For as much as a temporary family can ease the pain, it can never take the place of the real thing. In the interim I will assist in the economic gains of the telecommunications company and call as much as I can, realizing that support comes in all forms.

Rigor Mortis

One of the downsides of being a doctor is death. Namely, pronouncing someone dead. This was a privilege I was granted as an intern working in a mainly geriatric hospital. It takes on a whole different realm when you're the GP in a small town practice. Maori have some very distinct cultural practices when it comes to death. Once a body is identified and pronounced, the kaumatua (elders) will come in to bless the body, usually at the site of passing. During this time a death certificate is filled out releasing the body to the family. That's where I come in as the GP. Quite often the family want this done as quickly as possible so they can begin preparing the body. What this really means is that I can be called upon day or night to fill out a death certificate.

Imagine my surprise when a call was put through to my consultation room from a police officer informing me that one of my patients had died and did I have any information on next of kin. Unfortunately, the patient was new to the clinic and we didn't have all the details. This meant I had to identify the body. It was the middle of the afternoon and I couldn't leave. The next thing I know, I look out my window and see the funeral director's car pull into the parking lot and a police officer hop out and start walking toward the clinic door. I jump out of my chair, apologize to the patient with whom I was in the middle of a consult, and walk outside. The police officer then shows me the passport of my patient and hands me a form to sign declaring the patient deceased. At the same time, the funeral director opens the back end of the car and unzips the body bag so I can guarantee this is the right person and confirm lack of life. Suddenly two kaumatua appear, seemingly out of nowhere, to bless the body. In the middle of the carpark! (I later learned this was a big no-no.) Meanwhile (this is the middle of the afternoon, mind you), other live patients are walking through the carpark into the clinic.

Oh, but it doesn't end there. It was my impression when the police officer and funeral director left that they would bring back the death certificate for me to fill out. Oh, no. Apparently we have the certificates in our office and I was to fill one out and send it over to the funeral home. Unfortunately, no one told me that. Again, you can imagine my surprise when I got a frantic call from my office manager at 7pm asking if I'd filled out the death certificate. Uh, no. I was waiting for it to show up at the office. The next call I received was from the funeral director asking if I could go over to the office, find the certificate amongst the disorganization of paperwork, fill it out, and bring it over to him. Excuse me? By now it's almost 8:30 and the last thing I want to do is rifle through a bunch of paperwork looking for a certificate that I'm pretty sure I'm not going to find. Have you actually gotten in touch with the next of kin? Well, no. Do you really need me to fill out the death certificate before you embalm the body? Well, no. Okay then, I'll fill it out in the morning.

I can only imagine how this scenario will play out at two in the morning.

Surf's up!

One of the added benefits of living in a country that is mainly Christian is that they observe religious holidays with extended time. Easter is not just a weekend here, they also take off Good Friday and "Easter Monday". There's actually a law that forbids shops from being open on Good Friday unless it relates to the sale of "necessary" items or for tourists purposes. You can see how the lines get blurred with that one. All this really meant for me was...four day weekend! So in classic style, I packed up some clothes, threw them in the car, grabbed a coworker, and hit the road. Destination: Raglan. This is a small arts and crafts town on the west coast. It's become quite a tourist spot and retreat for some of New Zealand's more affluent, reflected in the sky-rocketing housing market with properties going from NZ$200,000 up to NZ$1 million. However, it got its origins as a renowned surfer's haven with a world famous left-hand break. Put these two ideals together and you can see how the town has become quite eclectic, with people of all socioeconomic classes co-inhabitating. Given its tourist appeal, it's also become a hotbed for foreign work visas. We met a German, an Irish, and a Japanese student all in the same night. The plethora of foreigners astounded my NZ native coworker, something I didn't think about twice having come from the American melting pot.

While this up and coming resort town resembled so many I've visited in the states, there was just something different about it that I couldn't quite pinpoint. It was made glaringly apparent to me while touring the coast line by kayak on Sunday. There was actually still a coastline. It hadn't been overcome by house upon house, occupying every square inch of beach front. New Zealand is very particular in this way, they like to maintain their landscape. There are often property restrictions on how close homes can be built to the waterfront, ie not within view from the water. It's a beautiful juxtaposition of country landscape with modernization. You see it everywhere you go. Even along the highways and in the towns, farms will abut subdivisions, drawing the eye through flocks of sheep into rows of quaint bungalows. It's the kind of assimilation that makes New Zealand so beautiful to tour and relaxed to live in.

Ramp it up, baby

Yesterday ended the two doctor reign at Ruanui Health Centre. A sad day in my eyes. As I watched the short term locum drive off into the sunset (cue dramatic music), I realized that I was once again left on my own. Admittedly, the past ten days have been wonderful: less hectic, more time to spend with patients, a colleague with whom to discuss difficult cases. Ideal in every way.

I awoke this morning (clouds looming overhead) and psyched myself up for my already fully booked schedule of patients every 10-15 minutes. A potential catastrophe considering it's a four day weekend here, and today's Thursday equals a typical Friday. Meaning there would be more patients that would walk in and need to be seen. The irony is that as I looked at my schedule for the day, I realized that I actually knew these patients already. In just a short time I had become familiar with them. As each one came into my office I was able to talk to them, not as a patient, but as a person, almost as a friend. What could have turned out to be a very arduous day, ended up being quite enjoyable. I guess that's what continuity is all about.

And Bob's your uncle

Okay, I admit that part of the reason I chose to come to New Zealand was because English is their first language. Medicine is hard enough to practice without having to throw a whole new language into the mix. What I didn't figure was that American English is not exactly the same as New Zealand English. Yes, there is the occasional Maori work thrown into the mix that complicates the communication with patients, but it's more the basic English that really gets me. Let me give you a little lesson in English, the New Zealand way...

Tea = Dinner. Do not make the mistake of showing up at someone's house having already eaten, thinking that all you'll actually get it the drink "tea". You then have to appear rude when refusing their feast because you're already full.

Smoker = morning break from work, not one who actually smokes. I can't tell you how many times I counseled patients about the dangers of smoking, when all they were doing was eating a mid-morning snack.

Gumboot = condom. I don't really want to know the explanation for this one. Yes, it is also the footwear for the industrial employee. You might imagine where I could get caught in a delicate situation on this one.

Wee = tiny. In fact I'm not sure the word tiny actually exists in common communication here. I got the biggest laugh when I sent a little stuffed kiwi to a friend, and the label actually read "wee kiwi".

Good on ya = ??? Even the natives couldn't explain this one to me. Loosely translated, I think it's "Good for you."

Ta = thank you. Although "cheers" can also mean "thank you", or "I'll talk to you later", or "That sounds good", or even just "okay". It's really a multipurpose sort of word.

Every day I add another word to the vocabulary. Today's word? Ute. I was talking with a friend this morning, and she kept going on about this "Ute" that she and her partner (ie common law husband) were going to buy. I kept nodding and listening. Finally I got the sense to ask what she was talking about. She said, "You know, the thing we were riding in when we went water skiing." Oh, the trailer for the boat. No the "utility" vehicle we were using to tow the boat.

Ah...and "there you have it".

Assimilation

It's a funny thing living in a small town. The first month I was here, I walked around wondering if people looked at me as the new foreigner in town. The second month I was here, I walked around town almost hoping no one would recognize me. Now in the third month, there's no doubting that I will be recognized. The reality of this hit home a few weekends ago when I was shopping in the center of town and I heard someone say, "Hi, Doc." Being a third generation physician in my family, I often don't pay attention when someone recognizes a doctor, always assuming they're talking to my father. This time, I looked up and saw one of my patients. There was no denying this person was talking to me. A few blocks later the same thing happened again. I knew at that moment I was now a part of this community.

This became ever more apparent this past Thursday when the clinic decided to go out for dinner. The idea was local pub food, then karaoke at the White Hart Hotel. Now if this sounds a little shady, you would be correct. I went along begrudgingly. A quick look up at the performer, a patient of mine. A glance around the room realized that half the patrons were patients of mine. I sat in the corner hoping no one would recognize me. My attempts failed. All too soon I felt an arm around my shoulder. I looked back and a woman exclaimed, "It's great to see my doctor off call and relaxing." No doubt, I was truly a part of this community.

How r u 2day?

Cell phone texting is such an interesting phenomenon. I realize that I'm a little behind getting on board with this technological innovation. Granted, I probably had one of the original cell phones that Sprint ever made (circa 2000) while living in Seattle and thus did not having this capability. Now that I have it, I'm totally addicted. I will fully admit it. I text friends on almost a daily basis. It's such a great way for me to communicate with people on the other side of the Pacific, especially considering Vodafone doesn't charge me for this endeavor.

The interesting part, is that it's the main mode of communication here. If you want to meet someone for tea, a "cuppa", or even just to catch up, you don't call them, you text them. Voice to voice communication has gone by the wayside. While the convenience of texting gives you the leisure of responding (or not) when you desire, sometimes it just seems too impersonal. It's as if you're saying, "I really need to talk to you, but I can't be bothered to talk to you."

There's so much more to communication then the words: intonation, facial expression, body language. Things you just can't capture in a text. So while I will continue to support my texting addiction, voice will forever be my favorite mode of communication.

Apathy meets Aggravation

I used to complain about the American medical system. Now that I've experienced working within a socialized medical system, I won't complain anymore. It's not a complaint about the patients. In fact, quite the opposite. They are a lovely group to work with, not very demanding, use to waiting six months to see a specialist, a year to have surgery. They don't know any different system. They continue on, in what I like to call their stably sick situation, riding a fine line between death spiral and life maintenance.

No, it is not the patients. It is the system. As a GP here, I'm meant to be the gatekeeper, keeping these patients stable, referring them on when necessary, being their advocate every step of the way. As the gatekeeper, I often find the gates are closed. I can't prescribe the medicines I want, either because they're not available or because they need specialist consent for dispensing, and I can't order the tests I need. It's really the simple things that bother me. After all, I used to teach residents that 90% of diagnoses can be made by history and physical exam alone (boy, am I biting my tongue on those words everyday).

As an example, let's discuss medications for a moment, antibiotics in particular. I'm limited to about twelve I can prescribe, unless I can some how track down a specialist, talk to him on the phone, fax him the information about the drug and clinical situation, and get him to fax back the approval. Granted, the specialists are always willing to help, but I could spend all day on the phone just for one patient. Advocacy has its limits.

Radiology is a totally different story. General xray spans the extent of my ordering, but only on a Monday, Wednesday, or Friday when the radiology tech is actually at the local hospital. Ultrasound, I don't think so. CT or MRI? You've got to be kidding. I had a lady come into the office in the midst of an acute stroke. She waited a week to get a carotid ultrasound, only because I sent her through the emergency department. Not because I could actually order the scan myself. Stably sick.

Thus, I continue on, laughing with the patients, appreciating that they don't understand my frustrations. Knowing that not everything can be American.

Help is on the way...maybe

For those who have listened to me perseverate about my working situation for the last three months, you are free to stop reading at this point. For those who have not had this pleasure, let me give you some background. I arrived in New Zealand on 8 January, excited about the prospect of working in a different country, in a different medical system, and in a rural setting. My contract was for a year in a small town, one of two General Practitioners in a community based clinic. Perfect, I thought. I had asked a collegue about the area, spoken to some of the nurses and the CEO of the Tahua, and thought everything seemed fine. One never really knows what they're getting into when embarking on an adventure like this, that's part of the risk you take. It can also be part of the fun.

I officially started working on 16 January. It was an easy schedule at first, 30 minute patient visits, giving me the ability to get to know the patient population, perhaps practice a little holistic medicine. Everyone was very friendly, helpful, and eager for me to be there. The other GP was another locum from South Africa, a common country from which to transplant to New Zealand I learned. Two days into starting the other GP called in sick one morning, the first inkling I had that things were not to be so peachy. I was left with my schedule of patients for the day and fitting in a few of his as well. Don't worry, I thought, things will be fine. A week later the other GP didn't show up for work again. No one had heard anything and he was unreachable by phone. I learned that his father was quite ill and he had traveled back to South Africa to be with him. Completely understandable. A week went by, then another, then another, and no one had heard from him. In the interim, I was left as the sole practitioner for the clinic with a panel of 2600 to 2800 patients. To say that things were a little busy would be only a slight understatement. At the same time all this was going on, the Head Nurse informed me of her resignation, effective at the end of February. Breathe, Jenn, breathe. At this point I had been ticking along in the clinic with the help of some occasional locums who came in to help 3 days a week. All in all, it wasn't that bad. My partner arrived back in the country, but only to inform the clinic that he felt he needed to move back to South Africa to be closer to his father. Okay, I thought, I've been handling it this far, I can keep going. Surely they'll get someone else in to help on a more permanent basis. During this time, the only other nurse who had been working at the clinic longterm decided the work evironment was to unsettling and also decided to resign. This left me, an occasional locum, and two practice nurses, neither of whom had been working in the clinic for long, to see the patients.

They say that which doesn't kill you makes you stronger. At this point I must have been a stone wall of fortitude. Imagine my gratitude when more permanent help showed up on the clinic doorstep today. My thoughts about ease of workload and perhaps even a holiday came rushing to the surface of my mind. Unfortunately, these thoughts were quickly crushed when I realized he was not going to be here for a month as I'd thought, but only 10 days. Sigh. Someday, I'll get the more permanent help I desire. In the meantime, perhaps I'll climb up on my stone wall and look out on a country which I hope to visit more of in the future.

Winds of change

I never really understood the concept of maritime weather, nor what it meant to have a southerly, northerly, southwesterly, etc., until I lived in New Zealand. Weather changes at the drop of a hat here. As they say, "If you don't like the weather, wait 30 minutes and it will change." I can never plan my day based on what I see out my window in the morning. Inevitably by midday it will change. I never leave my flat without a raincoat, several layers of clothing on, including a t-shirt, and my sunglasses.

To give a prime example, lets discuss this weekend. Saturday, I awoke to glorious sunshine and calm air. It afforded an outing to the local lake for an afternoon of water skiing. This morning I awoke to blustering winds, pouring rain, and cooler temperatures. Only slightly different then the day before. While you might think it would deter myself and some other locals from hiking, no, we continued on, despite getting soaked through. You just learn to live with it.

A long way from home

I decided, after viewing several friend's blogs over the last few days, that this was the prime way to keep in touch with everyone on the wrong side of the Pacific. In other words, I'm getting tired of writing to all of you individually. As time goes, I will publish the pictures everyone keeps asking about and tell you about the daily trials of living in a foreign country away from everyone I know.

Stay tuned...