Training Docs Down-under

The great themes of fiction are love and death.

Death is always a theme in medicine.

So too, I would argue, in its many spirits,

Is love.

And one of those spirits is resistance

To inhumanity, and injustice.

Love and death.

How lucky we are.

- Samuel Shem, author The House of God

Medical training in New Zealand is very different from training in the U.S. In New Zealand, I have been very fortunate to work with an amazing group of Junior Doctors and Registrars. While I am responsible for their instruction and oversight, I have been learning as much from them as they have from me.

I will attempt to make sense of the system from which they arrived and in which I now work. Since I can't really take pictures at work, I have included a selection of bird pics.

Common Raven (Corvus corax) - Yosemite Nat'l Park, April 2016

Training in the U.S.

The typical trajectory for medical training in the U.S. is four years of college/university, followed by four years of medical school, then 3-5 years of residency plus or minus additional fellowship training. I have known a handful of doctors who earned their undergraduate degree in some other discipline, but most people pursue a degree in one of the basic sciences. They identify themselves early on as "pre-med" and set about choosing coursework that will take them down that path. In the Spring of their Junior year, they sit for the Medical College Admission Test (MCAT) as the first step in a long medical school application process. There are some notable exceptions to this pathway that combine undergraduate and medical training into a 6-, 7-, or 8- year baccalaureate/MD program, combined MD/PhD programs, and people like me who came to medicine as a second career, but these represent a small minority.

The application process for medical school takes about a year starting with the AMCAS application. This is an electronic application used by most of the 140+ allopathic (MD) medical schools in the U.S. The selection process for granting interviews at each school varies, but it is usually based on some combination of undergraduate GPA, MCAT score, letters of recommendation, extra-curricular activities, and personal statements.

AMCAS applications can be submitted in June and are usually due August through October, though some schools will accept applications later. Interviews start in September and can run as late as February or March. Medical school classes start in August. In 2016 53,042 applicants submitted 830,016 applications for 21,030 medical school slots.

Red-headed Woodpecker (Melanerpes erythrocephalus) - Myrtle Beach SC, June 2012

Medical school is 4 years, generally divided into 2 years of pre-clinical classes followed by 2 years of clinical training. The first two years focus on normal and abnormal (disease) anatomy and physiology. Between the 2nd and 3rd year of training, med students take the first in a series of medical licensing exams. The 3rd and 4th years are devoted to direct patient care (though some schools do include limited patient involvement in the first year or two).

During their 3rd year, med students are expected to identify the specialty they want to pursue. They go through another nerve-wracking year of essay writing, applications, and interviews trying to secure a spot for their residency training. The process is stressful and expensive. During that third year, while learning to take care of patients on the wards and studying for each clinical rotation, they are also studying for the second round of medical licensing exams.

Blue Jay (Cyanocitta cristata) - Myrtle Beach SC, June 2012

One of the worst and most stressful periods in the lives of many U.S. medical students is the time leading up to "The Match". Applications for specialty medical training are due early in Year 4. The next several months are spent continuing inpatient medical training, and waiting to hear from residencies to which they submitted an application. Interview offers are made and students have to find the time and financing to travel to as many as possible. Once the interview period is completed, generally in January or February, students submit to the National Resident Matching Program (NRMP) a rank-list for the residencies at which they interviewed. The residency programs also submit a rank list. Residencies typically get several hundred applications and interview 100-150 med students for a dozen or fewer slots. Students may travel to only one or two interviews, but 10-15 is not unheard of.

The NRMP claims their algorithms are designed to ensure that students match as high up on their rank list as possible and residency programs fill their openings with their highest ranked students, all while ensuring that the maximum number of students are matched to some program somewhere. Of course, the algorithm isn't published and there is a lot of grumbling from both students and residency programs. Every medical student in the country finds out on the same day and time whether or not they matched to a program but not which program they matched to.

Red-bellied Woodpecker (Melanerpes carolinus) - Myrtle Beach SC, June 2012

Those students who don't match spend the next day in a "Scramble" calling every program with unmatched openings and doing telephone interviews on the spot trying to find a job. Two days later, amid much pomp, and tears of joy or frustration, medical students find out where in the country they are going to spend the most critical years of their medical education. There is no changing their placement and there is no recourse.

Once a residency position is secured, the life of a U.S. medical resident is fairly well regimented. Regardless if they are training to be a psychiatrist, family medicine physician, surgeon, emergency medicine physician, or some other specialist their course is predetermined. Residents follow a prescribed set of rotations and training segments. Residents in any given discipline will perform similar duties and functions, pre-approved and accredited, no matter where they train. The ultimate goal is board certification and the chance to establish a career. Board certification isn't always necessary to hang a shingle and start treating patients, but without it options are limited.

Eastern Bluebird (Sialia sialis) - Myrtle Beach SC, June 2012

Physicians trained in the U.S. therefore have nearly identical training when compared to their peers, regardless of where they went to medical school and where they did their residency training. Certain programs may be more rigorous, have greater exposure to research or some other sub-focus, or they may provide a small advantage in some other way; however, the basic requirements and pathway to attain them are determined by the ACGME and colleges (Medicine, Surgery, Psychiatry, Family Medicine, etc). Accredited residency training programs must adhere to these standards. (To my friends who trained at Harvard, Johns Hopkins, Wash U, Cleveland Clinic, Duke, etc ... I do recognize that your training was different, and elite, but the basic requirements were the same.)

Medical training in the U.K., while taking a slightly different pathway, is equally regimented. This is one of several reasons that we see so many U.K. trained junior doctors ("house officers") here in New Zealand where the pathway provides a little more variability.

Kotuku (Ardea modesta) - St Clair NZ, December 2016

Training in New Zealand

During their high school years, NZ students write (sit for) a series of standardized exams called the National Certificate of Educational Achievement (NCEA) Levels 1-3. The Level 2 scores appear to be the most important for entrance into an undergraduate (university) degree program.

In their first University year, students interested in a medical career must complete 8 required courses and write the Undergraduate Medical and Health Sciences Admissions Test (UMAT). There are two universities with medical faculty and they oversee 4 schools of medicine (a 5th has been proposed but does not yet exist). Admission to one of the two medical universities is based on first year university GPA, UMAT scores, and an interview. Not all eligible students are granted interviews ... in any given year, there are approximately twice as many applicants as there are interview slots. Students who aren't accepted along this "Overlapping Year One" track can go on and complete their undergraduate degree and re-apply as a "Graduate". They can only apply once as an Overlapping Year One candidate, and they can only ever apply to medical school twice regardless of the entry category.

Yellowhammer (Emberiza citrinella caliginosa) - St Clair NZ, December 2016

With Year 1 (the university "overlapping" year) behind them, NZ medical students have an additional 5 years of medical school training for a total of 6 years. The two years of pre-clinical training (Yr 2-3) are similar to U.S. medical school didactic training. This is followed by 3 years (Yr 4-6) of clinical training. Examinations are held at the end of the second, third, and fifth years. Year 6 students are called "Trainee Interns" and, the best I can tell, have a role similar to 3rd and 4th year medical students in the U.S.

After successful completion of their T.I. year, NZ medical graduates then move on to their "pre-vocational" training. In this new role, their official title is Resident Medical Officers (RMOs) but they are known as "House Officers" or "House Surgeons". Potential RMOs apply for positions within a given District Health Board for two years of general medical training. They do a variety of clinical rotations, each lasting 3 months. The equivalent training in the U.S. would be a two-year intern or transitional stint. In the U.S., the Intern would then be expected to continue on to specialist training, but in NZ they can essentially stay in this position indefinitely.

Kaka (Nestor meridionalis) - Orokonui Ecosanctuary NZ, December 2016

After at least 2 years of being a House Officer, they can apply for training in their preferred specialty. In the U.S., specialty training is chosen and applied for as a medical student and the Intern year is typically integrated into the overall program. Occasionally, residency training programs require that trainees do a "transitional" year at another institution before matriculating into the residency program. In NZ, the area of medicine for preferred specialty training isn't identified by the trainee until their RMO years. Instead of sending out a blanket application to several programs like in the U.S., potential residency trainees apply directly to the training program. For example, we have two trainees now who have asked us to sponsor their Emergency Medicine training, one of whom we suggested needed at least another year of RMO training before we would consider accepting them for training in our group.

Specialist training programs are 4-6 years depending on specialty. Once accepted for advanced training, the trainees are known as "Registrars". They continue to work in the hospital doing rotations of various duration. Interestingly, they don't stay with the same program for the entire 4-6 years. For example, our group has openings for up to 9 EM Registrars at any one time but we are only accredited to provide 12 months of training. Registrars must therefore complete their training elsewhere. The flip side of that is that we do take on Registrars who started their training at other hospitals. At the end of their Registrar training, they sit for qualification exams before becoming Consultant Specialists. Again, while the training is 4-6 years, the timeline is open. We have a "registrar" in our program who has been in this position for 12 years and has never gone on to sit for his exams.

Kakianau (Cygnus atratus) - Palmerston North NZ, November 2016

Consultant and RMO Unions

Consultant Specialists can choose to be members of a professional union, the Association of Salaried Medical Specialists (ASMS). From the ASMS website, this is how they see their role ...

1. Professional and Policy
In this role the ASMS:

• Promotes the right of equal access for all New Zealanders to high quality health services;

• Articulates our members' professional concerns and interests to the Government and its various agencies, employers and the public at large;

• Liaises with the Medical Protection Society to ensure effective representation for members facing disciplinary proceedings in clinical matters which may affect their employment;

• On the basis of our own experience and research we contribute to and promote informed public debate on matters relating to the provision of high quality health services to all New Zealanders.

2. As a union of health professions (Industrial)
We will advise and represent members in respect of their employment agreements. Our primary roles are to:

• provide advice to salaried doctors and dentists who receive a job offer from a New Zealand employer;

• negotiate collective employment agreements with employers. This includes a national collective agreement "the MECA" covering employment of senior medical and dental staff in all district health boards; ensures minimum terms and conditions for more than 4,000 doctors and dentists, representing more than 90% of this workforce;

• improve employment conditions for our members;

• support workplace empowerment and clinical leadership

We also advise members in respect of their individual employment rights and entitlemens and may represent them when those rights and entitlements are threatened. We will also review offers of employment made to members. The ASMS unashamedly promotes collective employment agreements through which we have achieved major advances for members.

RMOs can also choose to belong to a union, the New Zealand Resident Doctors' Association (NZRDA). Their mission ...

The RDA is the only organisation in New Zealand solely representing the interests of RMOs (RMO means Resident Medical Officer and includes trainee interns, house surgeons, senior house officers, and registrars). Our main purpose is to look after and to promote the interests of our members. This includes taking care of doctors' rights and your interests at work, with the health sector and in the wider community. The philosophy of the NZRDA is based on community, support and union principles such as democratic structure and quality service delivery to members. 

In short, the RDA supports RMOs, pursues RMO's interests and negotiates and enforces RMOs terms and conditions of employment. We provide advocacy advice and support for workforce issues that may arise including those related to compliance and enforcement of your employment agreement.

Torea (Haematopus unicolor) - Aramoana NZ, December 2016

For the past 6 years, I have worked nights only. I like the night shift for a whole lot of reasons, not least of which is that I actually get to see my family more than I would working days. I generally get up around 4 or 5 pm and have dinner with Kari and Little H. As they start getting ready for bed, I head off to work. I work through the night, and if I am lucky I get out as scheduled to make it home in time to kiss Little H as she heads off to school. Kari and I spend some time alone, have coffee and breakfast, and she heads off to work as I tuck myself in for the day.

Working in New Zealand, I have been on a more typical Emergency Dept schedule of shifts, working a mix of days and evenings. Over here, I haven't had to work any overnight shifts, though I do occasionally have to be on call overnight for issues the Registrars can't handle or need a Consultant to approve. In the past 4 months, I have worked no night shifts ... until last week.

The RMO's went on strike last week. Nationally, outpatient clinics, surgical cases, and many inpatient services were cancelled during the 3 day strike. Emergency Departments, here as in the U.S., are open 24/7/365. Like the post office, neither snow nor rain nor heat nor gloom of night (nor RMO industrial action) stays these couriers from the swift completion of their appointed rounds. The ED was staffed by consultant specialists and those RMOs who either were not union members or who chose to work despite the strike. I worked a total of 29 hours spread over three nights. It was a familiar rhythm, and one I enjoyed, but as the inevitable creep of time overtakes me I found night-shifts a little more difficult and a little harder from which to recover.

Kereru (Hemiphaga novaeseelandiae) - Totara Reserve NZ, January 2017

Things don't happen for a reason.

Things happen and then we give them a reason.

Right now, RMOs can work up to 12 days in a row and up to 7 nights in a row. They are asking for a maximum of 10 days in a row and 4 nights in a row. Sounds reasonable to me ... physical and mental fatigue is one of the largest factors in patient care mistakes. There are some finer points on both sides of the debate that I disagree with, but I trust that an equitable solution will be reached.

I spent three nights working while the RMOs went on strike to fight for better working hours and better working conditions, and a day later I marched. This past Saturday, January 21st, was our wedding anniversary. Kari's anniversary request was that Little H and I walk with her during the Women's March on Washington - Wellington.

My strong woman

Just so you don't think I am a total cad, we did have an amazing Anniversary dinner at Logan Brown in Wellington ...

Prosecco to start the evening

We live in a world where women are disproportionately affected by domestic violence and sexual violence. They are more likely to suffer from poverty. They are more likely to be affected by a lack of education, unemployment, under-employment, and a lack of opportunity. Women's rights are human rights. The failure of many to recognize or acknowledge this just contributes to the problem.

I marched because right now Little H thinks she can do and be anything in this world, and because of this belief, she can. Unfortunately, some day that light will dim. Too often she will be judged by the size of her tits or her ass, by how "sweet" or pretty she is, and not by her intelligence or the content of her character. If she does raise her voice and fight for what is right, she will be labelled "angry", "bitch", "strident", "cold", or worse.

I marched because I can, and in both the U.S. and abroad, many could not. I marched to lend my voice to the chorus of others, and to raise my voice for those who were too afraid to.

I marched.




May the Force be with you, and with her ...