'I was overjoyed to move from the US health system to NZ's. But then I could see the cracks' (2025)

Comment: I arrived in New Zealand in 2022, fresh from the trauma and heartbreak of caring for patients through the American Covid nightmare. The wounds on my soul and conscience were still raw, but, more than healing, I came in search of hope.

The pandemic had, with great efficiency, stripped away the facade that the US healthcare system was the most advanced in the world. The grotesque reality underneath the mask was a system that profits from disease and has no incentive to make anyone well. “I still love the practice of medicine,” I wrote to my students and trainees and colleagues at the time, “it’s just that we get to do so little of it.”

American doctors are increasingly data entry clerks, spending their days entering patient information in a way that nominally cares for the person who needs it, but mostly serves to extract as much money from each encounter as possible. I could feel my clinical practice warping to match the system.

In my open letter, I wrote “I am going because I want to experience the practice of medicine within a system that guarantees access to care and is built around health rather than profits.” I wondered what I might learn from this change in focus.

My early days in New Zealand brought exactly the learning and growth and reinvigoration I had hoped for. Instead of hours fighting over what would be covered by insurance and adding detail to my notes to enable “upcoding”, I simply did what I could to help the patient feel better. The only question to consider was, what is in the patient’s best interest?

It was incredibly freeing. It was also challenging. In a small provincial hospital with few other specialists in house to call on and our referral centre only accessible by flight, I found myself practising the full scope of general medicine like never before. I read every day, reviewing the cardiology and neurology and pulmonology and all the other subjects I had learned in medical school that had atrophied from underuse. Most extraordinary of all, I had the time for this learning, having shed the yoke of over-documentation.

I sometimes imagine I arrived in New Zealand in my adolescence as a doctor – if not in a larval state, at least pupal. And I can remember the cases that forged the metamorphosis into the doctor I am today – the first time I treated a myocardial infarction with clot-dissolving medicine or pharmacologically sped up a patient’s heart rhythm to end a persistent arrhythmia that threatened to stop her heart completely.

But as I grew clinically, the cracks became more obvious. The reason I had never used the clot-dissolving medicine for a heart attack before is that, in the US, that patient would have had the standard procedure – angiography – within an hour. Our patients require a transfer by air for that procedure, and for the less urgent form of heart attack called an NSTEMI often wait more than a week for that transfer. In the US, waiting longer than 24 hours would be considered sub-standard care, and even New Zealand expects it to occur within 72 hours.

But our tertiary centre, like every other hospital in New Zealand, is understaffed, underfunded, and overcrowded. My colleagues there are usually courteous and friendly, but you can almost hear them trying to find a reason not to transfer our patient because they simply don’t have the capacity. And it has only got worse with time. In 2016 we met that 72-hour target 70 percent of the time, but in 2023 that number fell to 24 percent.

Meanwhile, the staffing at my small hospital has dwindled. There is a constant churn of short-term doctors, coming for six months, a year, maybe two years, then moving on. We rely on locums to fill gaps, but it’s hard to develop the collaborative relationships needed for excellent patient care with high turnover, not to mention developing services to meet the changing health needs of an ageing population.

But there is no time for service development and, as far as I can tell, no strategic planning for how our health system should be structured in two or five or 10 years to best promote the health of our community. We are too busy putting out fires, trying to repair the plane as we’re flying it. With fewer colleagues and growing demands on our time, all we can do is scramble every day in the hope that today is not the day when something slips and one of our patients is harmed.

After years of understaffing brought multiple departments to the brink of collapse, our group of senior medical officers wrote a letter to the leadership of Health New Zealand/Te Whatu Ora and the Minister of Health calling for immediate action. This was in August 2024.

In the 32 weeks since then, we have received visits from multiple regional and national leaders in Health NZ and held regular recruitment meetings, 14 in all on this topic. There is little else to show for our efforts.

Why has it been so difficult to improve the staffing here? It has always been hard to recruit to this rugged, isolated corner of the country that many Kiwis undervalue. Though pay is supposed to be level across the country, we know from acquaintances that other centres offer higher reimbursement and other enticements. And compared with big brother Australia, doctor’s pay in New Zealand is roughly a 40 percent pay cut. No wonder New Zealand is an estimated 1800 senior medical officers short (25 percent of the needed workforce), and our hospital is at over 35 percent SMO vacancy.

On top of those disadvantages, we have been saddled with an ineffective and entirely unreliable recruitment apparatus. There are endless examples of unscheduled interviews, successful candidates who didn’t receive their job offers for weeks or even months, new hires who weren’t able to start because no one completed their medical registration or visa paperwork. The people tasked with this recruiting work are well-intentioned but inexperienced with disorganised management and are woefully understaffed to address the staffing crisis.

The result is multiple departments that are nearing collapse. We have one part-time radiologist. There have been days when operating theatres couldn’t run because of a lack of anaesthetists. In my department of general medicine, we will soon be staffing four inpatient teams and a 24/7 on-call service with only two permanent doctors and whatever short-term doctors we are able to bring in. The demands of trying to recruit and piece together this increasingly fragile service eats into the clinical work and learning and growth I came here for – and still love.

But this has been – and still could be – a great place to work. Many of our doctors did part of their training here and came back to stay when they finished because the clinical practice is rewarding and it is an easy place to live and raise a family. My kids are thriving here in ways I never imagined when we moved. And despite our limited resources, we still manage to provide some amazing life-preserving care for an appreciative community – our neighbours and family and friends.

This is why I have stayed – I care about this community and my colleagues and the doctors in training with whom I have the privilege to learn. But the work of caring for this community will only remain fulfilling if I have the colleagues I need to provide the excellent care my patients deserve. Inaction from Health NZ leadership and the Ministry of Health have left us in critical condition, with services likely to close this year without urgent intervention.

The response so far has been to stick to the party line of “back to budget” and reshuffle the organisational leadership chart. But there has been no sign of the promised reinvestment in the frontline services, and I have fewer colleagues at my side than I did a year ago.

The reality is adequate staffing will require more than cutting budgets and “back-office bloat”. Many of the “back-office” staff who have been cut or not replaced or never hired would relieve the growing administrative burden on me and my colleagues and allow us to get back to the clinical work we love. More importantly, no plans have addressed the massive exodus of doctors overseas or introduced adequate incentives to bring them back home.

The country must decide what kind of health system it wants – an atrophied, substandard patchwork that hobbles the economy with preventable death and illness, or a robust and reliable system that enables wellbeing for the good of us all.

I have stayed for now because I still hope that Kiwis will rally in support of the latter, and enable me to continue to do the sacred work that I love as a guest in this land.