MacDoctor

I see Paul Henry is in trouble again. This time over suggesting that foreign doctors aren’t as good as those trained in New Zealand. I suspect he makes stupid comments like this deliberately, because he knows they are good for ratings. As a foreign-trained doctor myself, I find it hard to take offense at Henry’s remark, simply because I have zero regard for his opinion. However, the topic is interesting because I have heard many patient reiterating the same sentiments, blissfully unaware that I am South-African-trained  (because I am originally an ex-Brit and do not have much of a South African accent).

Like all prejudices, there are some elements of truth in the belief (it is very hard to believe in something demonstrably completely false). There are some countries whose medical training regimes are significantly less robust than New Zealand’s. However, Medical Council place sufficient numbers of hurdles in the way of these doctors being registered, that they either do not register as doctors, or they bring themselves up to New Zealand standards. There are also a number of medical training regimes overseas that have very different emphases than the New Zealand one. For instance, both the US and the Indian systems produce specialists at a relatively early stage in the training process, making it difficult for these doctors to perform as non-specialists while they await registration in their speciality (often a lengthy process requiring rewriting exams). Note that specialists find it very difficult to perform as generalists if they have been specialists for more than 5-10 years, anyway.

Once a doctor is registered to practice here then there is also the question of adaptation to New Zealand ways. This usually extends far beyond language barriers. There is a lack of familiarity with the New Zealand Medical system, that can take a year or so to overcome. There is a lack of familiarity with New Zealand cultural differences which may take much, much longer. For instance, the South African sense of humour tends to be fairly bluff. I have seen a number of New Zealand patients walk away from a consultation mortally offended, simply because the doctor has been overly direct with them ( you eat like a bird? What kind of bird are we talking about? An ostrich?). At the other end of the spectrum, Asian doctors tend to be overly technical and oblique in their explanations to patients because they do not want to give offense. Neither of these tendencies detract from the doctors skills, but they do sometimes produce dissatisfied patients.

Of course, what people sometimes forget is that there are some areas where foreign-trained doctors are actually better than New-Zealand-trained ones. The most obvious example of this is the ability of most South African doctors to handle major trauma. Experience counts in such situation and there is no doubt that South African doctors experience far more major trauma than New Zealand doctors (the same is true for US emergency doctors who have worked in city trauma units). Rural areas love South African doctors, because they can usually do almost any procedure imaginable and are highly autonomous. This, of course, gets SA doctors into trouble with the HDC and, occasionally, medical council, disproportionately often. A cursory glance at these complaints will show that the vast bulk are extremely minor, bearing out that these doctors are “as good as Kiwi ones” but, perhaps, not as cautious.

New Zealand is very reliant on foreign-trained doctors. This is not likely to change any time soon. By the time they have passed through the registration system, there is no doubt that these doctors are every bit as good as their kiwi-trained counterparts. But they are not the same and probably never will be the same. This is only a problem if we let xenophobia dictate our choice of doctor.

Any comment by Len Brown on the use of taxpayer money has to be treated with a great deal of reserve. However, you would have thought that the man could perform some elementary arithmetic when it came to rates. Instead, Mr. Brown accuses John Banks of keeping rates down by supplementing Auckland City’s income with bus lane fines.

Well apart from the elementary mistake of crediting Banks with keeping rates down, thereby validating the general impression that Banks is more fiscally prudent, Brown makes a ludicrous accusation that simply can’t be possible – a simple look at the figures tells you this:

Number of (ratepaying) dwellings in 2006 = 160,000

Bus Lane Fines YTD June = $6.2 million

Reduction in rates $38.75 per annum.

Note this assumes that all the fines for bus lane infringement are an evil revenue-collection ploy by Banks (i.e. that they have no enforcement value at all) – this is clearly nonsense too.

It seems that Ludicrous Len finds it difficult to make it through a week without some foolish statement or another.

And he can’t do maths for toffee..

PS. I don’t normally blog on the antics of Mr. Brown, but Whale Oil is in court today and I thought I’d help him out. Good luck Whale..

The CTU are running a series of videos on YouTube featuring young workers who have been dismissed under the 90-day probation legislation. The first caused a bit of a furor in that the young lady featured was also a Labour party activist.

She is certainly an articulate young woman. I note that at no time did Ms. Kelly attempt to ask the employer’s viewpoint on this matter. The second video is in a similar vein:

Notice how they are called “unfair dismissal” stories, despite the fact that both dismissals are perfectly legal under the current law. In other words, there is no attempt to actually assess the effect of the law. Each story is simply an emotional ploy rather than a rational argument. The ploy is enhanced by using young women – a male ex-con or a cocky young man would not have had nearly as much of an impact. While I have some sympathy for these young women (which was the intention), the reality is that the world is a tough place where you are going to get plenty of rejection. Your only solution is to try again.

While the discussion over these videos appears to have revolved around the possible political affiliations of these two young women, neither of these videos address the challenge that John Key issued to the CTU. Produce examples of where the 90-day probation law is being abused. There is no evidence here of employers systematically hiring and firing workers within the 90-day limit to circumvent the employments act. There is no evidence of workers being forced to accept unfavorable or dangerous working conditions because of the threat of easy dismissal. There is not even any evidence of employers unreasonably refusing entrance to union officials.

All we have here is two videos of young people being given an employment opportunity and then being dismissed at the end of their trial. This is EXACTLY how the 90-day probation is supposed to work. You can’t even read too much into the fact that they were dismissed near the end of their trials. Any reasonable employer would make sure the the employee was given as long an opportunity as possible to settle in.

If I was John Key, I would ring up Helen Kelly and thank her for providing such good evidence that the 90-day probation period was working well.

Updated:

It turns out that the woman in the second video has had her dismissal overturned. This is because the 90-day probation law was applied incorrectly because it is only for new employees. Again, all this shows is that the current set up is working extremely well and that the 90-day probation law cannot be used as a “get out of jail free” card in order to circumvent the employment act. This is exactly as intended.

I reiterate: Unless Helen Kelly can demonstrate that an employer is systematically hiring and firing new employees under the 90-day probation law in order to circumvent employee’s rights, then she and the CTU should shut up. Citing cases where the law is working as intended or has been misapplied is not supporting her case.

There is a bizarre story in the Herald today about a woman who is apparently starving to death on her benefit because it is not enough? I say bizarre, because, unlike the “journalist” responsible for this article, I can do arithmetic. Firstly, the reason given for this lady to be in such dire straits is:

“she has not been able to eat properly since the Government tightened access to training subsidies for beneficiaries last year.”

Except that the article tells us that her subsidy was $98 a week and her current shortfall is $151 per week. I assume this indicates that this lady has been living beyond her limited means for much longer than last year. I also have grave doubts that this entire weight loss story is due to reduced food consumption. Recall I have been a doctor in Africa – I am very aware of exactly how little food you need to eat in order to maintain your weight .

I’m not going to sift through her budget as depicted in the paper, except to note that she can’t really afford a car and could save at least $90 per week ditching it. A simple move to Waterview or Mount Albert, where rents are fairly similar, would put her within walking distance of  Unitec. Just a thought. It seems that she has made little or no attempt to adjust her lifestyle and simply expects the government to address her budget shortfall.

But the real silliness in this article lies in the proposal that being given $517 a week is somehow starving this woman to death, like an inmate of Auschwitz. This is an absurd contention. Let’s do a little calculation. Labour have been campaigning on raising the minimum wage to $15.00 per hour. Working 40 hours a week on this minimum wage would bring in $600 per week. Less Tax of $103 per week leaves $497 – or $20 per week less than “Sara” is getting. Thus Labour’s “living wage” is less than this woman’s “starvation” wage.

I am uncomfortably aware, as I write this, that I earn vastly more than this lady. Some may say that this disqualifies me from posting about this, but I disagree. I know a number of people in my church who have little more to live on than $500 a week and they seem to make do. I am humbled by their ingenuity. I also think it an affront to them that their hard earned wages supplement people on benefits, and yet those people insist that they need more.

When will it be enough?

Spam Journalism: The spurious use of sensational headlines to add spice to an otherwise pointless article

This piece of ecological spam even comes with pictures!

Volcano collapse underlines threat of tsunami

“A huge undersea volcano not far from the coast has dramatically reduced in size after partly collapsing more than 100 metres toward the ocean floor.

“National Institute of Water and Atmospheric Research scientists found that a volcanic cone on Rumble III, 200km northeast of Auckland, had crumbled. The volcano’s highest point had dropped 90m further below the Pacific Ocean, and in some places the volcano had slipped as much as 120m.

“Marine geologist Richard Wysoczanski said the collapse was caused by an eruption some time in the last two years.”

So far, so dramatic. Although you can already see that only a small part of the volcano “collapsed” 120m. As the volcano is 1200m tall, it seems unlikely that it has “dramatically” reduced in size. In fact the size reduction was so dramatic it took NIWA 2 years to notice. And they only appeared to notice because they were doing a routine survey. In fact, the landslide (seaslide?) was completely innocuous (except perhaps to a  few fish in the immediate vicinity). Nevertheless, that does not stop the Marine geologist, Richard Wysoczanski, from a good bit of scare-mongering:

““There’s no doubt some of these slips can cause tsunami. This one was quite small, but it sits right on top of a much older, larger structure which would’ve probably sent a tsunami towards New Zealand. It’s pointing [southwest] – right towards us.”

How big a tsunami? No one knows.

When might we expect this collapse? No one knows.

Is the older, larger structure unstable? No one knows.

Additional knowledge added to our knowledge of risks of tsunamis? Diddly squat.

And the picture at the top is one of a Tongan sea volcano…

Sigh.

I thought I might start a new series today, partly inspired by Labour’s release of yet another taxpayer-funded pile of nonsense and partly by Pete Hodgson’s series of posts aptly named “Silly Ideas” (Apt because his posts are indeed very silly…). Since Labour and their left-wing blogging friends seem always ready to misinform, I thought it only right and proper to set the record straight.

As the unofficial Labour Party blog site (AKA the “Standard”) is spending some time ranting about the supposed inept economic management of National this past fortnight, I have decided we may as well start there. Their contention is that National is without an economic plan, by which they mean, of course, “without an economic plan that matches ours”. In fact, to all intents and purposes, National’s economic plan for weathering the economic crisis (which is not yet over) is to sit tight and do nothing – except whittle away at a bloated civil service. This is not an entirely unreasonable plan. One may wish for a little more slash and burn in some areas, but one quite appreciates that New Zealanders are now addicted to their state services and can only be weaned off them gently.

In contrast, Labour’s “plan” (not yet actually articulated, I may add) is based almost entirely on two complete fabrications. The first is that breathtaking bald-faced lie often articulated by Mr. Goff – the one that runs “Labour left the economy in good shape”.

Strange, I seem to recall that almost the last official words of the previous government’s minister of spending finance was “we’ve spent it all…”

The economy inherited by National was not, of course, “in good shape”. The economy inherited by National had already moved into recession a full two quarters before the global collapse. Although Cullen had paid down debt and bought some head-room for borrowing, this was by no means being “in good shape”. This is more like having a bit of room on your credit card for emergencies. Having the country go into recession early means that the recession was initially due to intrinsic factors – namely excessive government spending and taxation – rather than the external crisis. National has elected to tackle only the intrinsic factors of the recession and use borrowing to soften the blow of state service cuts, rather than fruitlessly attempt to generate jobs through massive government spending. Which brings me to the second myth. Governments can create jobs through spending. This is not true.

Governments do not create jobs.

Sure – a government spending millions of dollars in an area will create a mini boom and increased employment. Unfortunately, the only way it can do this is with taxpayer dollars. These are the very same taxpayer dollars that would have stimulated the economy elsewhere and created more employment in those places. Of course, the government may decide to borrow money to fund those “new jobs”. These are still taxpayer dollars. By spending borrowed dollars, the government is forgoing the opportunity to reduce taxation and allow the economy to generate jobs naturally. It is also borrowing against future tax dollars thereby ensuring less jobs in the economy of the future.

Finally, a government might choose to simply print money, Obama-style. This devalues the money supply, essentially trading the future value of capital for a few immediate jobs. Without capital, economic recovery is impossible. And the temptation to print more money and push the problem into the future is overwhelming…

If governments do not create jobs, it might be argued that they are better at deciding which jobs should be created than the market. Unfortunately the state has never been demonstrated to be able to pick winners. Typically, state job-creation revolves around expensive capital projects like broadband and roading. The jobs created are project-specific, temporary and favour predominantly one industry. Market-based job creation is widely based and fluid. If the state project is not worth the value of the forgone opportunities to create market-based jobs, then the net result is always less jobs than before, particularly when the project ends.

And just to dispel one final myth – that governments can pick winners, we have this priceless quote from the inimitable Pete Hodgson on the Cullen fund:

“Suspend payments into the “Cullen fund” – that’s the fund that helps pre-pay superannuation for when all the baby boomers retire in the next twenty years, and therefore makes national super sustainable.

“Justify that decision on the basis that the global economic downturn means that the government is fresh out of cash, and would need to borrow.

“Quietly overlook the fact that the share market was really low at the time and that that is precisely when smart people buy.

“Forgo a huge profit opportunity for the “Cullen fund” as a result, leaving the future of national super uncertain, yet again. [emphasis mine]”

Ah, no, Pete. Smart people do not buy at the low end of the market. Smart people buy at any time when they can reasonably predict the direction of flow of the price of stock – up or down. They are very skilled at it. Unlike governments. Smart people most certainly do not borrow money to play the stock exchange. Only very, very stupid people do that.

Very. Very. Very. Very. Stupid.

Additional

In case you think I am being too hard on Labour, Stuart Nash very obligingly provides solid proof that Labour think that spending your money produces growth and jobs (but you spending your own money, by implication does not – go figure). Whatever the merits or demerits of income splitting as a method of reducing taxation, can there be any doubt that less taxation is a good thing?

Dear Mr. Ryall

I hear you are occasionally dropping in to emergency departments unannounced and talking to patients. This is excellent news. Under no circumstances should you continue to sound defensive about this in any way. After all, exactly who is the hospital service for, if not the patients accessing it? How can it be bad that the minister of health is actually taking time to collect some genuine patients views on the service, rather than the sanitized things that cross your ministerial desk?

As a one-time Clinical Director of an emergency department, I applaud your taking the time to see how it is for real patients in real waiting rooms. I know you are far too intelligent to drive health policy from anecdotal evidence gathered in this way, but it can certainly help you get a feel for where current policy may be failing people. Policy may come from taking a larger view of the situation than the narrow concerns of a single patient, but it never hurts to look past the cold factual information and see where people really are.

While Ms. King may think that the trials of individuals are nothing in the grand scheme of things, I am most happy to see that you do not. The concern for how individuals perceive things is what sets National apart from Labour, despite the Labour-lite feel of some of your policies. The fact that you are willing to get this information first-hand is what make you one of the better ministers in the current government.

It is important that you don’t blow this by being unnecessarily apologetic about something that you are undoubtedly doing right.

A final word of advice when you next go on one of your unannounced field trips. Look beyond waiting times and length of stays in EDs. These things are certainly important but they are not the only concerns of patients. Look for the more dehumanizing aspects of ED care. By this I do not mean “cultural sensitivity” and the like. I am talking about the small courtesies of life. Look for the way the worried and those in silent pain are handled. Look for the way the ones who make the most nuisance of themselves are rewarded by prompt service. Look for the anxiety on people’s faces as their wait lengthens. Note how seldom, if at all, patients are informed about the length of their wait. Look at the attitude of the receptionists and the triage nurse.

Once inside the treatment areas, note the lack of interest nurses and doctors take in “routine” patients. Note how seldom patients are informed of their progress. Note the lack of opportunity patients are given to ask questions. Note the almost complete disregard to their privacy.

These things are not said to criticise my colleagues; you won’t find all these things in any one department anyway. I say them because they are things that need fixing. They are endemic throughout hospitals, not merely in the emergency department.

You can fix them, Mr. Ryall, but it will take a great deal more effort than some kiwihost-style courses and some sensitivity training. The dehumanization of medicine started with the socialization of it. It is the very fact that it is a public health service that removes it so far from true customer service. Essentially, your people all work for the government, rather than the patient, to some greater or lesser extent. They may deny this, but deep in their hearts, they know it is true.

Does the patient have a choice of doctor? No. Does the patient have a choice of what service is supplied? No. Does the patient have a choice in how the service is supplied? No. Does the patient have a choice of hospitals? No. Does the patient have a say in their treatment choices? Yes, but it is usually “take it or leave it”. Every aspect of their treatment is dictated by the needs of public health, not the patient’s wishes.

I have had to allocate resources as a hospital doctor, and now as a GP, for too long not to know that all that I do is constrained by your Ministry, Mr Ryall. I am therefore the servant of the public health system rather than in the service of my patient.

Yes waiting times are indeed important. But sometimes we need to remember that faster is not necessarily better.

Sincerely

MacDoctor.

Apparently, Hone Harawira thinks I am a “boorish redneck”. I have no particular objection to Mr. Harawira’s opinion, partly because I am supremely indifferent to it and partly because I make it no secret that I consider him an ill-mannered racist trougher. So we are possibly even. Maybe.

Harawira reminds me of an old Afrikaaner who once told me: “I’m not a racist – I just don’t like bloody kaffirs.” Every time he opens his mouth to deny his racism, he makes it more and more clear that racist is exactly what he is. Someone who pre-judges people based solely on their skin colour. Unlike the old Afrikaaner, however, Harawira is not only in denial,  he slips into the time-honoured defense of politicians (particularly socialist ones) the world over – that is; the automatic use of denigration to make your opponents looks small.

You see this technique used whenever negative maori statistics are brought up. The mere mention of the horrifically high rates of domestic violence and child abuse in the Maori population brings out useful words like racist and bigot and phrases like maori-bashing (and Bomber’s sarcastic Maaaaaaori) that immediately stifle all debate on the issue, despite these things being facts rather than opinions. In this case, Harawira is attempting to deflect the charge of racism by suggesting that only racist rednecks are making it – that he is being judged excessively because he is Maori. The implication being that a Pakeha making the same sort of statement would be judged less harshly. Interestingly, exactly the opposite is true. We have a recent example of what happens when a white person makes comments of a similar tenor  - Andy Haden comments on quotas of “darkies”. Judging from the furor around those remarks, I would say that the stirring around Harawira is positively beneficent in comparison. In fact, it is only Harawira’s insistence on repeatedly bringing it up and defending himself that is keeping it in the media.

Strangely, I don’t have a problem with Joris de Bres’ lackadaisical response to Harawira’s remarks. The last thing I want is some heavy-handed “Hate Speech” commissioner attempting to define what is acceptable speech or not. This should be left to the opinions of the public, who are quite capable of spotting Harawira’s racism for themselves. Further hate speech legislation and the pontifications of Mr. de Bres only serve the purposes of those attempting to stifle debate and denigrate their opposition. This sort of justification is politically dangerous.

The problem with this demonisation of your opposition is that it is addictive. If you get away with it once, the chances are high you will try it again and again with equal success. The chances are that you will try it with all of your faults and all of your mistakes. Eventually, you may manage to exonerate yourself from all responsibilities as a reasonable human being and place yourself in a position where you can get away with anything. For an example of how this works look no further than Robert Mugabe – all of his excesses and murderous ways are excused by the spectre of colonialism hanging over his opponents.

The question is: Do Hone Harawira and the Maori party really want to model themselves on the methods of this man?

Yesterday’s Herald contained a sad story about a young man who had been seen by the local mental health team, diagnosed him as potentially psychotic and prescribed an anti-psychotic. His counsellor later told him to stop taking the anti-psychotic and continue with counseling. He subsequently committed suicide.

“A young man committed suicide after his counsellor told him by text message not to take his medication, provided he was undergoing regular counselling.

“Acting Health and Disability Commissioner Rae Lamb, in a finding issued today, said the case highlighted the importance of consulting other health professionals working with a person, the dangers of providing advice by text message, and the risks associated with “no suicide” contracts.”

Now there is a limited amount of information in this article. The HDC report is here. But the newspaper piece makes it sound as though the counsellor in question had been a little sloppy in her duty to her patient. Instead, buried in the HDC report, there is evidence of a serious ethical breach:

“It is my opinion that [Ms C's] provision of advice about medication prescribed by the primary clinical team fell short of what I would expect of a qualified and ethical counsellor and that to do so without discussion with that team breached her professional duty to collaborate with other health providers and uphold the values of responsible caring, as well as breaching the principles of promoting safety and avoiding harm.

“I consider that this would provoke severe professional disapproval. [emphasis mine]”

Though these are strong words, the breach of ethics here is far more serious than this. This counsellor advised (or, at least colluded with) a patient to stop their medication without knowing either the diagnosis of the medical team, nor the name of the medication. Worse, this person has no ability to prescribe medication and only a lay understanding of their use and purpose.

Now I know that patients take advice all the time from people with no clue at all about the drug or the disease. It drives doctors quite wild to prescribe a medicine only to have a patient tell you (usually when they return, feeling no better) that their aunt Mabel advised them that the medicine you prescribed was useless/bad/evil/not as good as rubbing with juju beads… But it should be emphasised that friends and relatives do not purport to have medical authority in any way. Their advice is purely anecdotal and you take it on that basis.

My concern with this case is that there is a definite therapeutic relationship between this unfortunate young man and his counsellor. The young man would certainly have given weight to his counsellor’s opinion as a professional clinical opinion. To me it seems clear that the counsellor stepped well outside her competency almost to the extent of fraudulent representation. She may not have claimed she was a doctor, or “as good as” a doctor, but she certainly implied that her opinion counted for more than the professional mental health team’s.

Whilst I appreciate the work that most counsellors and psychotherapists do is soundly professional, within their discipline, I have noticed that some seem to assume roles that are dangerously medical, or worse – anti-medical. This is a recipe for precisely this kind of disastrous result. I do not try to provide psychotherapy for my patients. I have no expertise in this at all. Psychotherapists and counsellors should not interfere in medical matters without seeking the opinion of the doctor involved.

Dear Mr. Sharples

I judge from your recent remarks that you are not aware of the definition of the word racist. In the interests of helping you understand your colleague Hone Harawira, I thought I might help you out:

 

racism

“Pronunciation:/ˈreɪsɪz(ə)m/
noun [mass noun]

“the belief that all members of each race possess characteristics, abilities, or qualities specific to that race , especially so as to distinguish it as inferior or superior to another race or races

• prejudice, discrimination, or antagonism directed against someone of a different race based on such a belief:

In case you are still puzzled, let me spell it out for you.

Hone Harawira is a racist.

If you think what he said was…

 
• Amusing
 
• Normal
• “Just a view point”
 
• Justifiable

…then that makes you a racist as well. Trust me on this. I’m ex-South African. I can spot a racist remark from 10,000 paces.

Now that I have appraised you of the reality, I trust that you will roundly condemn your racist colleague, Mr Harawira. Failure to do so will lead me to the inescapable conclusion that the Maori party is not merely ethnic in nature, but ardently racist. Should this be the case, I will be actively campaigning for you to be voted out of parliament in the next election. The last thing the Maori people need are representatives who are blinkered bigots. Racism has a nasty habit of spreading.

Your views would probably be welcome in Zimbabwe. Go there.

Yours Sincerely

MacDoctor