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Hello, I'm Norman Swan.
Welcome to this Rural Health Education Foundation program
which is a special interview on maldistribution around the community
in terms of the health workforce.
And to talk about it is Professor Des Gorman,
who's Dean of Medicine at the University of Auckland,
has worked in Australia and knows Australia well.
Has particular interest in Maori health, being a Maori physician himself.
And we're talking about the gap. Des, welcome to the program.
Thank you, Norman.
You're doing better with the gap in New Zealand than we are?
Everything's relative, of course. I'm reminded of that aphorism about
'In the land of the blind, the one-eyed man is king.'
So perhaps we are one-eyed Indigenous health deliverers
in the land of the blind.
We're doing better, but, having said that,
we are hardly meeting the challenge.
NORMAN: It's about nine years in difference?
It is, which, between Indigenous New Zealanders and pakeha, that's right,
which is a greater gap than between whites and American Indigenous peoples.
So we don't take that as a particularly outstanding achievement.
Now, why do you think that is, because the reason you think that is,
it should be said that you're Maori yourself,
why you think that is,
because a lot of doctors, pharmacists, primary healthcare practitioners
who are watching this, clinicians who are watching this,
will say, 'It's all up to housing, finance, economics, employment.
We've got very little role to play here.'
But from the perspective of a Maori physician,
also a Maori health educator,
what is the role for people watching us converse?
I think you're right. By the way, they are right.
Housing may have a greater bearing on referral to hospital
than acuity of illness, but, putting that aside,
we have a maldistributed workforce in New Zealand, as you do in Australia.
15% of New Zealanders are Maori.
About 2.5% of the health workforce is Maori.
Two out of every three rural doctors are trained overseas.
There's a major cultural disconnect
between the communities that these doctors serve
and the communities that the doctors originate from.
I'll give you some examples for that.
Very subtle differences in philosophies, understandings, concepts
can end up with very major differences in health understandings.
Some of the barriers to health access are actually quite subtle.
Can you give me a tangible example?
Yeah, I can give you an example from my own family.
One of my aunties died of lung cancer.
The first issue is that Maoris smoke two to three times more
than pakeha and New Zealanders.
Of course, the pakeha perspective in that regard
is 'We need another white, middle-class health awareness campaign.'
- 'Don't smoke.' - Exactly.
As if Maori don't know they shouldn't smoke.
Or 'Don't eat McDonald's and run around the block.'
It beggars belief to think that Maori don't know.
And the same would go for Aboriginal people.
Absolutely. See, you can intelligently articulate,
'Yes, it's a good idea not to eat McDonald's and run around the block,'
but on Saturday, when there's a funeral, I go to the tangi.
I'll know exactly how important the person is who's died by the food.
I can look around the room and say, 'That's the most important person here'
by the nature of the food served to that particular person.
And it's the deculturation of food
and the models of health and health perceptions that matter.
I'll give you another example before I get back to Sally.
I haven't forgotten Sally.
We were offered a lot of money to look at skin cancer awareness
and outdoor workers.
This money was offered to us by the Cancer Society.
Their idea was that they'd have a slip, slop, slap campaign
to encourage people who work outdoors to avoid non-melanoma skin cancer,
which is a good idea, isn't it?
And they asked what I thought, would I be interested in the money?
I said, 'No, it's a complete waste of time.'
The person you're trying to influence will go to the pub tonight,
excuse my language - get pissed and drive home drunk.
He'll go home with a woman he hasn't met before, have sex without a ***.
He'll drive to work the next day, still hung-over,
he and his mates will smoke a couple of joints on the way to the forestry site
and then he'll climb a tree with a running chainsaw.
- What's a bit of sun? - Precisely!
You imagine that and your white, middle-class intention
where you rush up the tree...
'Put on some factor 30, if you can just stop the chainsaw for a moment.'
So health-at-risk perceptions - we keep taking a white, middle-class view
of what health-risk perceptions are and what health-risk behaviours are
and assume that if we articulate them in our idiom
that these will be understandable to anybody else.
The first thing about Sally is that she smokes.
Whatever the idiom is of the anti-smoking campaigners,
it's not a Maori idiom.
The second thing is she doesn't present to anyone
until she has very advanced disease.
And I said to her, 'You silly old ***.
What are you doing here in the far north getting this sick
before you went and saw somebody?'
She said, 'Well, Desi...' She's treating me like I'm a five-year-old.
- You will always be a five-year-old. - Absolutely.
Breathtakingly stupid, hence you've got to speak slowly to me.
She said, 'How could I possibly go to the nearest town
and take my blouse off in front of those men?'
Because there were two doctors in Kaitaia - one Indian, one South African.
For her, the idea of visiting either an Indian or South African doctor
and taking her blouse off was just a barrier too far.
In that case, we had two issues -
one was the nature of the anti-smoking campaign,
which has had little traction on the Maori.
The second thing is, to her, the barrier of going to see men
from such a dissimilar culture to her
meant that she was not going to go into that situation.
What can you do? So here's the practical outcome.
So I understand cultural sensitivity.
The reality is you've done better than us in terms of training Maori doctors
than we have in training Aboriginal and Torres Strait Islander
doctors and health professionals.
But it's only a little bit better.
There'll never be enough to go round.
For the next 20 years, we are going to be dependent on international graduates
at the very minimum in rural areas,
particularly in Aboriginal communities.
So is it just a barrier too far? We've just gotta accept it?
Or can an Indian-trained doctor change his or her ways
in a way that will help?
Clearly, this is an issue which doesn't lend itself to a simple answer.
Very clearly, the long-term solutions are to have
the communities of doctors bearing a striking resemblance
to the communities they serve. That's a no-brainer.
- It's also a huge task. - Yes. It's also a long-term task.
In our situation, and I know this is true in Australia,
the problem isn't my willingness to train Maori doctors,
the problem is my ability to recruit from secondary school.
And the failings are occurring a long time before.
And if I take Maori graduates, I'm robbing Peter to pay Paul,
'cause I'm taking... Probably the most important community in Maoridom
is primary school teachers, not doctors.
The last thing I should be doing is depleting those reserves.
What you're talking about is the task of a generation.
It is. So let's come back to the immediate task.
The first thing I think is that we need to incentivise
the most culturally appropriate people to move into the communities
where they are going to be best put to task.
At the moment, I think we have a very significant economically driven
malalignment of resource and need.
We don't incentivise generalism, we don't incentivise rural generalism,
we don't incentivise urban generalism.
We may have a range of affirmation programs in place
through medical schools,
but, at the end of the day, the drivers are to procedural
or what I call 'partialist' practice.
New Zealand's far worse than Australia.
We are essentially the most reliant country in the OECD
on overseas-trained doctors.
Unfortunately, two out of every three rural doctors in New Zealand
are overseas-trained doctors.
So we've actually maldistributed within that again.
And there's the fundamental problem.
And it may be something as simple, for example, as...
But it's not necessarily guaranteed that a pakeha doctor
trained in Auckland, Wellington or Dunedin
is necessarily any better than somebody who comes from South Africa.
Somebody from South Africa might be better off
because they've worked in black communities.
I'm not sure that's true. We have taken Indigenous health
and made it an across-curriculum domain.
In the old days, we'd have a week of Maori health,
and what that did, it said, 'This is not really mainstream.
This is something you do one week in six years.
It's almost showcasing.'
I'm now saying the Indigenous health domain
has to be part of all the teaching we do at every level that we do it.
The Maori word's 'kaupapa', which means 'concepts and philosophies'.
If you don't understand someone's concepts and philosophies,
you'll have a lot of trouble interpreting their disease
and their perception of that disease,
particularly where it lends itself to preventive medicine.
If we're to make a big difference in Maori health
it'll be around the major threats of obesity, diabetes and heart disease,
which are really in the preventive domain.
That's where you need to understand kaupapa intimately.
Interestingly, if you're going to change behaviour
which lends itself to diabetes,
it probably has more to do with sociologists than anthropologists.
Given the reality in Australia and in New Zealand
that there's a shortage of doctors, nurses
and all other health professionals,
and you're not necessarily getting Indigenously trained doctors,
whether they be black or white,
is it really the job of doctors here that we're talking about?
In part it is, Norman, but...
We have to understand the limit medicine has in this regard.
For example, we just had a major program looking at preventing diabetes,
which was, essentially, to put it crudely,
'Run around the block, don't eat McDonald's' which...
It was as puerile as it sounds.
That should have been led by sociologists and anthropologists,
'cause the real issues were the cultural underpinnings of those behaviours.
They wouldn't have designed it that way?
No, it was designed by doctors and led by doctors.
That was a situation where we were trying the medical solution
to what was not a medical problem.
Coming back to the question you asked, that with a shortage of doctors
and a shortfall of doctors to meet Indigenous health needs,
there has to be an incentivisation for the doctors trained
who are contextually relevant to work in those practices.
It's the obligation, I believe, of Australian medical schools
to do two things - one, to have an affirmation program
they don't apologise for.
- To attract Indigenous students? - Exactly.
The second is to make sure that every student who leaves there
sees Indigenous health and health concepts of Indigenous people
as an integral part of everything they learn throughout that process.
I think there are three domains in medical education.
One is the bit they were obsessed with in your day and mine -
for those of us who are dinosaurs, it was around information.
That's transferred now to information use and problem-solving,
that we've been fixated with that domain.
The other two domains are professionalism
and career choice.
Too much in medical education we've been obsessed with the first bit
and not enough with what sort of models are we putting in place
to address the second bit - the whole professionalism domain,
which is around communication and it's around ethics
and it's around reality, and that's where Indigenous health sits.
And in career choice, how do we incentivise people
to take up career choices which quite deliberately
have Indigenous health as a major stream.
The first way to do that is to ensure that
everyone teaching throughout a whole medical curriculum
has Indigenous health as an obligation,
not as something you should tick off on a box
or have some special occasion to do.
What about those people who are already graduated?
They're out there working, whether or not they graduated in Dublin, Delhi
or Johannesburg.
What about them, whether they be pharmacists, nurses or doctors?
You know as well as I do that some people have intrinsic ability
and sensitivity to pick up cultural themes and become very, very good
at understanding the differences between their perspectives
and the perspectives of their patient populations.
That's more likely to occur when you have a reasonably intimate relationship
between the practitioner and their communities.
It's not going to occur where there's shift work
or multiple practitioner practices.
It's not going to occur where the people you try to address are marginalised
and don't gain access to the practice.
You say it's not going to occur where you have multi-practitioner practices?
It's less likely to occur when there's a lack of intimacy.
You mean multi-partner practices where you don't see the same patient
all the time and they have to organise things accordingly.
Yes. To some extent, to understand Indigenous kaupapa
by assimilation or by osmosis requires exposure.
It also requires that the person being exposed, the doctor,
has the ability to be sentient.
That'll work for some graduates and it won't work for others.
There are real barriers for overseas-trained doctors,
particularly those whose first language is not English.
For example, I saw a patient last week in a clinic that I ran,
and I said to him, 'Are you still having those funny turns?'
And his response to me was, 'Not really'.
As an English speaker predominantly, I heard him say yes.
If I'm a non-English speaker, I'd have heard him say no.
So sometimes even very subtle differences in language
can send you down paths.
So I think the non-New Zealand trained doctor,
the non-Australian trained doctor,
first has to get the local language,
second, has to then understand the local concepts and philosophies.
I'm not saying it's impossible for an overseas-trained doctor
to provide a health service to Indigenous peoples,
in fact, quite the opposite. I'm saying it's difficult,
when the way you're learning is by trial and error.
What structures are you putting up in New Zealand
to help the existing workforce?
Good question.
We have an affirmation program in place for Maori civics students
and also for underprivileged students.
I'm talking now about the existing workforce.
I see what you mean. Uh...
We are trying to build into continuing medical education as much as we can,
the sorts of discussion we're having now.
In fact, the response we get from most practitioners
is very much the perspective you presented,
which is, 'Listen, how do I do this? I'm here already. I'm doing OK.'
People find it quite offensive when you say,
'You're malaligned to your community.
You don't understand the kaupapa of the people you're treating.'
For example, the young Maori boy who you told the family is schizophrenic -
you'll never see them again,
because they believe he's possessed by his grandfather.
Because you didn't articulate that, because you didn't understand that,
you'll never see them again.
You think he's going to take that major tranquiliser -
it's gonna be in the rubbish bin on the way home,
because you never understood the perspective of that family.
When we do this, we've found that, in an abstract sense,
there's not a lot of traction, but when we inculcate Indigenous health
into CME, the way to do it is by stories.
I wrote an editorial for IMJ, and I thought, 'I can do this conceptually
or I can just do it by stories.'
You told a story where you got thumped after a decision you made
as a naval medical officer.
Yes, well, in fact, there was a mismatch
between our perspective of mental health and Maori mental health.
'Maori doctor, heal thyself' is the moral of this story.
I tell you what - I need to learn to duck better,
'cause this old lady hit me with a stick and she didn't miss.
The story was I was in the New Zealand Navy.
I was in the Australian Navy originally, but in the New Zealand Navy at the time.
This young Maori sailor had gone quite mad.
He was taking his commands from the ship's plumbing, not the captain,
which is a problem on any ship,
the plumbing not being particularly good at giving sensible commands.
So the idea was we'd survey him in the navy
and that proceeded along normal lines.
Of course, we called a meeting to let his family know
and one of the first things that overseas-trained doctors
really are taken aback by, because the whole family turns up -
the whole family, grandmothers, the whole lot.
- They turned up. - You've got 20 people in the room.
Absolutely, and I articulated the navy perspective...
Because you were discharging him under medical grounds.
Right, and there was the classic case in point.
The old grandmother knew that her grandchild, called a mokopuna,
was possessed by the spirits of his grandfather.
Now, I should've known better.
'Cause if I said at the beginning,
'I understand that this is a blessed boy,
I understand that this is a special boy,
I understand that this boy is one of your hopes for this whanau,
because his grandfather lives through him.
But unfortunately, this is incompatible with what we want him to do.
So we aren't able to employ your special boy.'
Because I presented in a schizophrenic idiom,
she hit me with a stick, and she didn't miss!
I'm actually not saying that those of us
who have been raised in Maori communities
or trained in Maori idiom get it right, but at least I knew what went wrong.
There's been interesting research in the Northern Territory
which shows that even Aboriginal health workers
can get it as wrong as non-Indigenous health workers
because of mismatch in language.
So what about the mid-level trained Indigenous health worker?
You have them in New Zealand, the Maori health workers.
We have Aboriginal health workers.
I'm going to sort of say the unsayable -
do they provide a useful role or are we still being doctor-dependent here?
Uh, that's a very good question, again.
One of the things I think we need to do...
A conversation for a different day, perhaps.
..is when we identify just what it is that doctors do,
we need to identify on the basis of that clear delineation of doctor roles
as what other sorts of health providers we want and need.
The idea of a community health worker,
although we usually use some pejorative term
like 'doctor boy' or 'physician's assistant' or 'barefoot doctor'...
- Or nurse practitioner. - Absolutely.
Nurse practitioner's a classic case of failed workforce substitution,
because of the politics of it.
NORMAN: Not necessarily in Australia, though.
No, in fact, there's good models in New Zealand too,
but right now we should have an incredibly strong
nurse practitioner community,
but the question I'd put to you is not 'Does it work?'
but 'Why hasn't it been on a much broader base
and why isn't it providing a whole range of procedural services
to free doctors up to problem-solve?'
You're suggesting medical dominance has got in the way?
I'm suggesting that even the nursing council's got in the way
by making it time-punitive.
And they also had the model back to front.
Instead of the doctor being at the front door solving the problem
for nurse clinics, it was nurses at the front door.
Even the model was back to front.
But the community health worker - we have two views of that.
One is that it can serve an immediate purpose
and provide an articulation between a malaligned medical community
and a community of need.
The other thing is it acts as a bridging program
for young Maori or young Australian Aboriginals
who don't have strong interest generally in health services.
So it's like a transition to other more advanced professional work?
To a different professional... that's right.
The view that we have of it is sort of a common year of health sciences,
which provides knowledge of human biology, human disease,
epidemiology, public health,
then a year of modular training along specific lines.
For example, you might train someone in drug and alcohol or *** health
or you might train them in obesity and diabetes.
The beauty of this is you can readapt and reconfigure
the health provider community as you need.
As the change needs, you come back and do that module.
Then so what that model lends itself to
is recognising that health system planning
will always be wrong.
But also it's an awful lot of work.
You've recognised this in your writing, that a doctor doesn't need to do
and a doctor could actually become much more of a consultant,
even at the general practice level, and allow others to do tasks,
even ones that are perhaps highly remunerated at the moment,
such as colonoscopy and cataract surgery.
Couldn't agree more.
It's interesting to me that when you meet
with deans of Australian medical schools
or deans of UK medical schools and elsewhere,
that the debate around what a medical school is and what it should be doing
seems to be a debate within that medical school,
not with its community.
I think most medical schools have lost track of
just what their social contract is.
And the issue around the doctor of the future is this -
how or why would any society spend several million dollars
to train someone who it takes 15 years to train
to sclerose varicose veins? Does that make any sense?
If you take the Fred Hollows experience in cataract surgery,
you could take it further and say, 'Why would you spend $3 million
and 16 years training someone to be an ophthalmologist
to do cataract surgery?'
Then you begin to say... Take it the other way round, you say,
'Well, what does justify the training that we invest in being a doctor?'
When you wander outside the cognitive realm, the answer is 'not much'.
So if you were taking an economic perspective of the doctor of the future,
a socioeconomic perspective,
you'd probably argue that once you get beyond patient differentiation,
care planning, care oversight,
that it becomes very difficult to justify a lot of our current roles.
Why are you questioning the community health worker?
Presumably, even now, before you define...
They are a solution to significant...
I'm not challenging them. They are exactly what we need.
I'm a strong advocate of community health workers.
The reason why most of these models have failed
is they haven't begun with an employment model.
What generally happens is a group of well-intentioned people
put together a health worker project, train people
and then try and find employment for them.
- You haven't defined the need before. - No.
Where it works is where some health-employment authority says
'We want people to do this.' And then go to an educator and say,
'This is not a philosophic debate for you.
- We need people who can do the...' - Teach them to do this or that.
'Please train someone for this purpose.'
I think that, far from depreciating the roles of community health workers,
I think the future lies in active workforce substitution.
At the moment, it's passive - your profession and my profession
are giving away the things that we feel don't reflect on us well for status
or the things which we don't make money out of.
That's not the way to do this. We should be saying,
'Workforce substitution has to be active.
What are the things that doctors need to be doing
by virtue of their training and their knowledge?'
If a pharmacist or rural nurse is watching this,
they're thinking, 'Here's another ***
who's doctor-focused, doctor-centric, thinking a doctor should rule the world.
It's not worked up till now, why should it work in the future?
Doctors aren't trained to rule the world.
Surely we should be moving away from that.'
Yep. The criticism is always on medical chauvinism
when you argue, 'We need a doctor-first health-planning cycle.'
But health systems and, in fact, I think -
remember that the GPs of today are the apothecaries of the 19th century -
and I see, in the future, the nurse practitioner
occupying an incredibly important, if not majority role in primary care.
Of course, nurses don't want to be run by doctors.
They say, 'We're independent practitioners.'
They have different skill sets.
The hierarchical thing and the thing underpinned with feminist debate
is a sad thing, because it's distracted the debate from where it needs to be.
The debate's not around who runs what, but what skill sets people have.
Most health systems have as their key role
the differentiation of a patient's problem.
That's where things either go well or badly.
For example, a breathless person walks in to see you and me,
and that breathless person is differentiated into asthma or pneumonia
or heart failure or pulmonary embolism
or hyperventilation syndrome or whatever.
That differentiating role is the most demanding, challenging role
in the health service.
If we get that role wrong, then everything goes wrong.
If that role is properly resourced,
then we can end up with all sorts of outcome
and cost efficiencies flowing on.
To me, that is the role of the doctor.
It's that differentiating role which justifies...
- Diagnosis management planning. - Absolutely.
Training the right people to manage the condition from there on,
which might be the doctor or somebody else.
Likely somebody else. The point about this doctor-first policy
is until we have this debate and have it with maturity
about just what doctors do in the future,
until we have that debate and have a very clear idea
of the social contract we have in terms of the scope of a doctor's practice,
if doctors in 2020 are going to be doing cataract and varicose veins operations,
we'll need a hell of a lot of them and not much of anything else.
If, on the other hand, we're to say,
'No society can tolerate using a 747 to deliver the milk.'
If they say, 'No, if you train 747s, use them to fly between continents.'
If that's the case, then our aligned health workforce
will have to be very large and very heavily differentiated.
So my doctor-first planning cycle is not born of medical chauvinism -
it's born of pragmatism, because until we know
what that expensive part of the health system's gonna do,
then just what is the scope and what is the number and range?
It lends itself to the complaint of medical chauvinism,
but the outcome's quite the opposite.
Finally, you talked several times about incentives.
Describe what those incentives are - is it just more money?
As Aneurin Bevan would say, 'Stuff their mouths with gold'?
(Laughs) Yeah. It is fair to say at the moment
there's an economic malalignment driver. That's true.
That you can earn a million bucks a year as a knee surgeon
but not as a cognitive general physician.
Precisely. So there are economic drivers.
I think the major issue there is status, actually.
I'm trying to work out why so few of our graduates want to do primary care,
when, in fact, to me, it's... I'm not a general practitioner.
As a physician, I look at my general practice colleagues in awe,
given the nature of their practice and the demands on them.
Why is it that our students are disinterested?
The answer is status.
Remuneration is one of the contributors to status.
But status is more than just money -
status is the standing you have amongst your professional colleagues,
the standing you have amongst your community.
It's to do with the range and scope of things you do,
it's to do with what you think the value you add into the health system.
So for me, remuneration is a step towards
the realignment of utility and need,
but it needs to come with a deliberate perspective of status.
It's not something we actually debate in medicine,
because we're frightened of appearing arrogant.
You can't buy... You've got to earn it, haven't you?
No, I think status comes from the perspective of a professional group
which has clear career progression, clear training,
appropriate levels of remuneration
and a sense that what's being done within that disciplinary group
makes a difference.
I think what we've seen in the last 25-30 years
is an undermining and undervaluing of the generalists,
and particularly the general practitioners.
Added to that, there's the economic incentive
to get into being an expert in the left anterior descending coronary artery.
But when the decision comes as to whether you're going to practise
in Wellington or in rural New Zealand,
it's often the partner saying,
'Where will our children go to school?' as much as the status.
What can you do about that?
It's a very good question.
Maldistributions do exist in demographic terms as well as cultural, ethnic
and disciplinary terms.
And interestingly, schooling has probably as big an effect
on where doctors end up working as they do elsewhere.
The solution may come from this next generation of graduates,
who I do not believe will be singular in their discipline
or in their work location, as we were.
We entered a system which was siloed
in terms of our discipline and where we ended up practising.
I'm sure this generation, from what they tell me,
will probably change career three or four times.
What we have to try and make for them is that a period of rural practice...
So it might be five or six years and then they move on?
It at least provides an effective health workforce in areas of need,
bearing in mind that New Zealand doesn't have anything like
the rural health issues that Australia does.
Rurality in Australia is a very major issue,
but that may be counterproductive.
By that, I mean rurality in New Zealand doesn't lend itself
to the wonderful breadth of practice that rurality in Australia does.
So a provincial New Zealand doctor
may have a lot of the downside of a rural Australian doctor
without the upside.
Procedural work and things like that.
And also a standing in the community
where they are viewed as being someone very, very special.
Professor Des Gorman, thank you for joining us.
You're welcome, Norman.
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