I walk to work in the morning. I love this. I have always disliked being in a car, and being able to walk to work is a wonderful thing. It is about three-quarters of a mile, and takes me about 15 minutes. I leave a little before eight. We are in winter, pretty far south, so morning has only just dawned for us. It is crisp and chilly. Some mornings the fog is so thick I can only see a few yards ahead, and I can only see the ghostly trees as they loom, darkly, just in front of me. I cross train tracks, past the yellow sign with the picture of the train that always reminds me of a scorpion, tensing, ready to sting.
It is a large, new-feeling office, with a big front desk, and an open waiting area that has a place for kids to play. To the right are the Doctor’s Offices, and I have my Office, which makes me feel important. When my patients start arriving, I am notified via the computer system, and when I am ready to see them I go and summon them from the waiting room to my office. There is no medical assistant to gather them into an exam room, check their blood pressure and temperature, make sure that their medications are correctly listed in the computer – there is just me, and my desk, and an examination table at one end of the room. If I don’t choose to spend the few minutes it takes to take their blood pressure, their blood pressure is not recorded. If I don’t choose to take their temperature or ask them about their medications, these things are not done. And there is no one to get upset about it.
In the United States, there are a lot of boxes to tick before an insurance company will pay a doctor. You have to have a certain amount of information in the History section. You have to do a Medication Reconciliation, where someone (generally a medical assistant) sits with a patient and asks them “Are you still taking the lisinopril?” and the patient replies, “Is that the little brown one for my heart? Or the big pink one? I’m on some medicine that starts with P, I think. Or maybe B.” You have to record a certain number of Examination Findings, including things like blood pressure, and whether their heart is beating regularly or irregularly. You have to give a Diagnosis (and the scarier and more precise, the better, because you might get more money from the insurance companies that way), and you have to explain why the patient definitely doesn’t have Appendicitis or Diverticulitis or a Myocardial Infarction or a Malignancy, because if this is the one-in-a-million person who has cancer and the only symptom of their cancer is some pain in their left fourth toe, the lawyers might come after you someday if you don’t explain in your notes why you feel that their fourth toe pain isn’t cancer, and justify why you are not ordering the MRI that the patient feels is very necessary. We call this CYA medicine.
They don’t have CYA medicine in New Zealand, and they don’t write notes for either lawyers or insurance companies, which is strange to me. Doctors notes are usually only a few words. Sometimes they use abbreviations I don’t know. Sometimes they use New Zealand words that I can usually figure out from context. For one patient I saw, the previous note said, “A bit chesty at the moment.” This was just about the whole history.
I have been trained in the United States. I can always feel the lawyers’ hot breath on the back of my neck. I hear them whispering in my ear, “That didn’t look like a melanoma, but what if it was an atypical-looking melanoma?” or “You didn’t check that patient’s blood pressure. They were here for something else, yes, but what if their blood pressure was sky-high and they have a stroke tomorrow?” or “what if that baby DOES have a bacterial infection and needs antibiotics and you just told the mom that it was viral infection?” So my notes are long and detailed, explaining what the patient said, and why I chose to do what I chose to do, and that I told the patient to come back if they got a fever or if they couldn’t breathe or were vomiting uncontrollably. A New Zealand doctor doesn’t need to write this. A New Zealand doctor says to him or herself, “of COURSE a patient is going to come back and see me if they are vomiting uncontrollably. It goes without saying. Why waste my time writing it?”
In any case, this is how my visits go: I go and summon the patient from the waiting room, and bring them to my Office. I sit at my desk, my computer on one side (as a young doctor, I need my computer. But I am also able to turn away and look at you and listen with my full attention). I introduce myself and ask the patient where they live. They tell me and I usually admit I have no idea where that is (unless they live in Darfield). I often add that I’m the new doctor and then they say, “Where are you from?” (I feel like the accent should give it away… but then, I guess I can’t distinguish other people’s accents so I shouldn’t assume they know mine).
“The States,” I say.
“Where?” they always ask.
“Connecticut,” I used to say. Now, after too many blank looks, I say, “The northeast part. Near Boston and New York.” I figure they’ll probably at least have heard of one of those cities.
“Ah,” they’ll say knowingly. We then discuss how long I am here for – I wait for the disappointment as they find out I’m yet another doctor who is going to stay for a short time and then leave again, probably never to return – and then we discuss where in Darfield I’m living and how I like it.
“It’s so cute!” I say. “With the main street, and everything walkable. It’s such a cute little town!”
If they’ve lived in Darfield all their life, they’ll often look at me with a look of mingled skepticism and loss of all respect for my judgment. They will attempt to find something positive to say, but settle for lukewarm. If they haven’t lived in Darfield all their life, they will agree wholeheartedly.
Then, because the time is ticking, I ask the patient what they are here for.
“Oh, I’m just here for my repeats,” they always say. They don’t do refills in New Zealand, they do repeats. And patients have to come every 3 months to get their repeats. That’s the rule.
“Oh, okay,” I say – relieved that, finally, THIS visit will take only the 15 minutes I’m allotted. “Anything else?”
“Oh… just a couple of other little things,” they always say, with a winning smile. Then my heart sinks. As it is sinking they launch into a brief summary of their knee pain, and their 3 years of sinus congestion, and that pain they sometimes get in this particular part of their chest. I can feel the lawyer hiss disapprovingly into my ear as I look at their knee (which always looks fine) and tell them it’s probably just arthritis, and they should do stretches and walking and tylenol as needed. What if it’s not? he asks. What if it’s something else? What if it’s something terrible? It will be diagnosed later, and it will be too late, and you will have missed it! And you will be a TERRIBLE DOCTOR! I stare at their knee and ask him, What else could it be? But he just hisses irritably again and so I launch into a halfhearted questioning about when the pain started (“A wee while ago”) and what makes the pain worse (they are never sure) and whether they’ve ever collapsed (no, but almost!), and then I check the ligaments and the meniscii and the joint lines and everything is all fine. And so I Counsel them extensively, and then I realize that I am out of time, and I haven’t even asked them about their congestion or their chest pain or why they need refills of the strange medicines they are on. I haven’t even had time to launch into my spiel on why I will refuse to refill their Ambien (or the New Zealand equivalent, which everyone is on), or my spiel on weaning off the strong heartburn medications (they are all on heartburn medication too, even people who don’t have heartburn).
So I generally am running behind. But the patients are generally pleasant, which makes it much easier. I haven’t had to argue with anyone demanding antibiotics for their runny noses, which is refreshing. I get along particularly well with the moms (or I should say, the “mums”) and their babies (or “bubs”). The mums come in and tell me about their bubs, who are acting “grizzly” or “whinging” or are “a bit chesty”. I am sympathetic and then I always manage to let drop, casually, that I have children of my own. This is true but a calculated move. I then tell them my children’s ages, and you can see a little relief cross their faces, a little more trust, a little more of a ready smile – and of course more honesty. A woman admitted with some embarrassment that she was breastfeeding her 9-month-old in the middle of the night. “Oh no!” I said. “Still?” She looked sad and embarrassed, and talked about how she was trying to get him to stop, and she had been down to one feed per night but it was so hard, she just didn’t like to hear him cry, and then we were silent for a few moments while I was examining her bub, and then I said, “And everyone you know is giving you advice on how to get him to sleep, right?” I said. “Everyone thinks they know better than you how to get your baby to sleep, and they’re telling you what you should and shouldn’t do, aren’t they?” She looked surprised and a little relieved and nodded. I told her that my seven-month-old used to sleep through the night but had stopped recently, and I would do anything to get sleep, and we both talked about how easy it is for other people to say “just let them cry” – people who lying in bed, staring at the ceiling, listening to the misery in the crib next to the bed. She admitted that she knew she should move her bub into another room but… but… “But if he wakes up in the night and you have to go to him-” I started; “I don’t have to fully wake up to pick him up and feed him!” she finished, relieved that I understood where she was coming from. “I know!” I agreed. “I haven’t gotten my bubs into another room, either.”
I’m not sure if this makes the mums trust my doctoring skills any more, but they certainly trust that I will take their concerns more seriously, and not brush them off. Sometimes they ask me what I do as a mum in certain situations – which makes me a little uncomfortable, because the truth is that Mary Beth the mum does things quite differently from Dr Van Siclen. But I’m honest when they ask.
Overall, I have been surprised at how similar doctoring in New Zealand is to doctoring in the United States. The same types of questions, generally; the same maladies, the same discussions. I’ve had some very sick patients and a lot of not-very-sick patients; some challenging social situations that I would love to write about but can’t, because of patient privacy; lots of bubs, and young people, and some elderly people – I just got into an animated discussion last week about why I wasn’t going to refill an Ambien-equivalent prescription for a lady in her 90s. She just needed it sometimes when she went visiting people. I imagined her, in a strange house, popping an Ambien and then sleepwalking into a strange living room, tripping over strange furniture, and cracking her head open while simultaneously breaking her hip. The lawyer was shaking his head but I just looked at her, bemused. I love being able to see different ages and different complaints. I love not knowing what might walk through the door – although it’s sort of like getting onto a ride at a carnival; it might be terrifying when you’re on it, and it’s too late to get off.
At the end of the day, Peter usually drops off the car for me (even though I tell him he doesn’t have to) and I have my 3-minute drive home. I walk in the door, and there is always, always the sound of screaming children. Sometimes it is happy screaming, sometimes it is not, but it envelops me the instant I appear in the doorway and I have to switch, abruptly, from Dr Van Siclen back to a mum.