Transcript
Announcer:
This is ReachMD. The following episode in the series, Spotlight on Locum Tenens, in partnership with Locumstory.com
Dr. Johnson:
Locum tenens have come a long way since their beginning as doctors traveling across the western frontier. Fast forward to today and these physicians still travel to see patients, but now their frontier isn’t just the Wild West; it’s the entire world. Welcome to Spotlight on Locum Tenens on ReachMD. I’m Dr. Shira Johnson, and joining me today is Dr. Brian Smith, an internist who is currently working as a locum tenens physician. Dr. Smith, welcome to the program.
Dr. Smith:
Thank you very much. I appreciate it, Shira. It’s good to be here.
Dr. Johnson:
So, to start, tell us a bit about your background and how you came to the decision to be a locum tenens physician.
Dr. Smith:
I’ve been a hospitalist. I’m a board-certified internist. I’ve been practicing since 1994. I’ve been a hospitalist for about 18 of those years. I’ve worked in a number of states in the U.S., most recently in Florida. Let’s see, Washington, Nevada, Alabama. I trained in Alabama, went to school in S. Dakota, did my medical school training in S. Dakota, and I’m originallyfrom the Pittsburgh area.
Dr. Johnson:
So, that’s pretty interesting. You’ve been all over.
Dr. Smith:
Yes, I kinda have. Travel’s not really something which is unfamiliar to me. How I came to New Zealand—well, one of the things I was kind of looking at was where would I be able to practice internal medicine where my credentials would essentially laterally transfer. So, I was looking for a place where I could practice internal medicine, somewhere English-speaking, because my foreign language skills are a little spotty, so I was really looking for a place that had a public health system, kind of a socialized medical system, because I really always wanted to work in that environment just to see what it’s like. New Zealand has always been someplace where it’s a little exotic, and it’s definitely different, or I imagined it would be different from practicing in, say, Europe or Canada, so I basically convinced my family to pack up, and we came down here, and a year and a half later here I am.
Dr. Johnson:
Did you have a lot of options when you were choosing your assignment, and were there other additional circumstances why you picked New Zealand as opposed to anywhere else? You mentioned socialized medicine and speaking English.
Dr. Smith:
Yes, I was thinking potentially Australia. Some of the options that I had in Australia were more geared towards sort of a general practitioner-type of scenario. I love hospital-based medicine, so my main reason for picking this assignment was to be able to practice hospital-based medicine. Additionally, I also love teaching, and so I have a team of residents—they call them registrars here—residents which I can work with, and so it’s kind of a great scenario here. I’ve got the teaching aspect. I’ve got the inpatient medical aspect. It happens that I actually moved into both an administrative role as well as the clinical role that I have. I was down here about 2 or 3 months when I was offered the Clinical Directorship, which is essentially the person in charge of medicine for the health district here. New Zealand’s broken up into about 17, I believe, 17 health districts, and so I’m in charge of medical services for that entire district, so both outpatient and inpatient, but that’s just administratively. Anyway, I took on a pretty huge administrative role as well as a clinical one.
Dr. Johnson:
Well, being an internist to patients in another culture is not without its challenges. Would you like to share a few examples with our audience?
Dr. Smith:
Yes, challenges, it’s a little different with regard to actually getting things done. New Zealand is… As far as its practice techniques and some of the services, from a practice technique standpoint, a pure hospitalist model, as I am used to in the States, is relatively foreign to them. What they use primarily here is sort of a hybrid inpatient/outpatient type of arrangement, which is sort of similar to where we were about 15 years ago in the States. That has been a bit of a challenge. I’ve actually been working on a sort of an American-style hospitalist program. I’ve tried bringing that to my health district, and it’s been reasonably successful, but it has been a challenge. It’s difficult to try and explain to a Kiwi what actually an internist is because they don’t really have that type of role here. They have general practitioners, which are essentially like a family practice doctor, and then they have specialty medicine services, like gastroenterology, cardiology, endocrinology, etc. But in terms of an internist, a person who practices internal medicine within the hospital, it’s somewhat different as far as their concept of what internal medicine is, so that’s been a bit of a challenge. There are challenges just with living in New Zealand (laughter). It’s definitely different from the United StatesThere’s good things there, but it’s unusual. They don’t know how to make pizza here.
Dr. Johnson:
(Laughter) I had the same problem in London, I understand, but I understand it’s gotten better now, but yes. Are there differences in resources or what’s allocated for you and your practice in New Zealand compared to the States?
Dr. Smith:
Yes, there really are. Because it’s essentially capital which drives the healthcare services in the States, we look for things that are cost-efficient and so forth. Here in New Zealand, cost is not really the focus; it’s more resource-driven. If you’re working in the States, you’re basically working to see how you can stretch your dollar. Here there are limited number of resources and so, therefore—not necessarily dollars, but there’s a limited number of resources, so here it’s how can we deliver the most care to the most people, and so every clinical decision is sort of colored by that. You have to look at: Is what I am doing going to be efficient for the majority of the people that you’re servicing? So, yes, there’s a bit of a focus difference, and there are some things that I’m used to in the United States that I just don’t have here. That’s actually been one of my goals is to actually try and bring this to New Zealand, using my health district as sort of a prototype. Again, it’s been fairly spotty with regard to success. I’m trying to introduce the use of a certain lab test. It’s a point-of-care procalcitonin test which helps to guide antibiotic use, because we have virtually no antimicrobial resistance here yet. We’re using penicillin to treat, -, most gram-positive infections. There is very, very little… Well, MRSA is almost unheard here. Drug-resistant Klebsiella almost—doesn’t exist. So, I’m trying to stave off the antimicrobial resistance for the next, I don’t know, 10, 15, 20 years if I can by improving antimicrobial stewardship here. So, it’s a little goal, but I’m trying.
Dr. Johnson:
That’s really interesting, actually. And I understand in New Zealand they are more into “prove that it works,” or “evidence-based medicine,” and there has to be a reason to institute a particular therapy. So, some of that may be resources, but can you talk a little bit more about that?
Dr. Smith:
New Zealand—and I don’t say this in a bad way—but New Zealand is very insular. I think it’s more kind of a nationalist mindset that it doesn’t really look at itself as being an offshoot of Great Britain, although it’s a commonwealth here. And everybody associates Australia with New Zealand, but Australia is, in fact, geographically extremely far away from New Zealand, but it looks at itself as its own entity. And in some cases, the practices and techniques that are adopted in the rest of the world are looked at with a bit of skepticism unless they’ve been practiced or proven or adopted here in New Zealand. For instance, the research from the procalcitonin test, there are reams of data that support its use in certain clinical entities, and there’s certainly a great deal of usefulness in trying to keep antimicrobial use down, but that research is looked at with skepticism because it’s never been done here before; or simple things like stool guaiac tests are just simply not used here. Why? Because they’ve just never been a common practice. So, even though there’s data everywhere else in the world, you have to kind of reproduce that data here in New Zealand for Kiwis to accept it, so that’s been a bit of a challenge, and that’s actually one of the… The research that I’m doing is effectively just duplication of research that’s already been done time and time again in the States, in Europe, etc.
Dr. Johnson:
For those just joining us, you’re listening to The Spotlight on Locum Tenens on ReachMD. I’m Dr. Shira Johnson, and today I’m speaking with Dr. Brian Smith about his experience traveling across the world as a locum tenens physician.
We spoke earlier, Brian, about the different medical practices and healthcare systems in the United States and New Zealand, but let’s switch gears a bit, because as I understand it, you’re actually conducting some pretty interesting research yourself right now.
Dr. Smith:
I’m trying to do research to gain acceptance for the use of point-of-care procalcitonin testing in the decision to start antibiotics in lower respiratory tract infections and COPD exacerbations and also in using it as a tool to make clinical decisions on the duration of antimicrobial therapy. I’m also working on introducing an American-style hospitalist model to New Zealand, because as we learned in the States, it’s massively more efficient with regard to delivery of care than the old model that we had, and which is essentially the model that has been present here in New Zealand for decades. So, my research actually takes kind of 2 different bends. I’m looking at both clinical research and, also, I’m working on introduction of practice techniques in order to improve allocation of resources.
Dr. Johnson:
So, when you complete this research, then will it be published in New Zealand journals or something locally, and is that the way you hope to gain acceptance, or is it through hospital panels and protocols?
Dr. Smith:
My goal is to actually use our healthcare district as a prototype to have other healthcare districts, the larger ones, the ones in, say, Wellington or Christchurch or Auckland, to have them take a look at it and say, “Hey, actually, we can do more with less if we use a hospitalist model as opposed to our traditional hybrid of inpatient/outpatient models.” So, from the administrative standpoint, I’m actually more interested in sort of leading by example than I am of actually publishing, but yes, I do plan on publishing the clinical research I’m doing.
Dr. Johnson:
And how is your work being received?
Dr. Smith:
With a great deal of skepticism, and it has taken me the better part of a year to kind of bring people along with me. With the administrative model, the administrative work that I’ve done, I’ve revamped the way we practice here in this hospital in very small ways, and those small ways have paid big dividends with regard to our length of stays, our cost-per-patient. So, because I’ve shown that there’s been large improvements with small changes, I have fairly good cooperation among my colleagues to come along with me and go a little further. It does take some wedeling and coercing, but people are buying into it,which is nice. People in New Zealand are extremely nice. You just have to be completely stereotyping. There is kind of a general kindness to the people that I work with, and that’s been sort of a real boon towards doing the things that I want to do, so I’m grateful for that.
Dr. Johnson:
So, that sounds really mutually beneficial. What about you and your family? How is working as a locum tenens benefited your family, taking them to this far-off country and cultural changes? How does that feel? What’s happened for you?
Dr. Smith:
Yes, that was actually one of the reasons why I wanted to do this at this point in my career. I wanted to expose my family to a different culture. And I’ve got 2 kids, 14 and 16 years old, and they’re of an age when they would appreciate the fact that they’re in a different world. We’ve been able to travel to Australia. We’ve traveled to Fiji. They’ve seen things that their contemporaries in the States will never have seen. I’m giving them an experience which I’m sure is going to last for a really long time, so that’s been a huge benefit as far as I’m concerned. My wife loves it here. It is a genuinely physically beautiful place. She’s made a great number of friends here, and so this has been just a very good experience for all of us.
Dr. Johnson:
So, you’ve given us a lot of information, and it’s very intriguing. Do you have any other final thoughts to share with our audience or maybe for any other physicians out there who might find this an interesting career path? How would they get started, or what would you like to say to them?
Dr. Smith:
Well, I originally went through a staffing company which set me up in a locum position. That turned into a permanent contract. But the locum tenens job which I had for a year prior to my contract being converted to a local contract, that is a great way if physicians are looking at a way of changing your perspective. I know it becomes a little grinding, working in the same system all the time, and sometimes we get disillusioned and we have a tendency to start working by rote, but coming here has kind of changed my perspective on a lot of things: on how medicine is practiced, on how to relate to patients. So, if anybody out there is looking to kind of shake things up and have a bit of an adventure, this is a great way to do it. I have colleagues that have been here that are doing locum assignments in other places. I have a colleague that is doing a locum assignment in Bermuda, for instance, and all of us are kind of doing it because we like seeing the world from a different angle. So, that would be my advice. If you have the opportunity to do so, take this time in your career to do it and do it for a year and see how you like it.
Dr. Johnson:
This has been a great look into locum tenens assignments on an international level, and I’d really like to thank you, Brian, for sharing this experience with us. It was just great having you on the program today.
Dr. Smith:
Thank you, Shira; it was really nice talking to you.
Announcer:
You’ve been listening to Spotlight on Locum Tenens. To download this program or others from the series, please visit ReachMD.com/LocumTenens. This series is produced in partnership with locumstory.com. Thank you for listening.
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