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For the past five years, says Gisborne surgeon Torben Iversen, his hospital has been about 40 per cent short of doctors.
Until recently, he was the only permanent staffer in his department, obstetrics and gynaecology. Locums, or temporary doctors employed on a casual or contract basis, have helped plug the gaps.
"For several months I was alone all by myself, but now we have a second person. We have one long-term locum who is going to be with us for another six months, and we have another six-month locum coming in. So in terms of having bodies on the ground we are up to what we are allocated," said Gisborne Hospital's co-clinical director of obstetrics and gynaecology.
The scenario at Gisborne is one repeated in countless regional hospitals throughout the country. And over the years, overseas-trained doctors such as the Danish-born, American-trained Dr Iversen have become the backbone of the medical workforce of provincial New Zealand.
But not all stay.
"People come here and they stay here for a couple of years, and then they get their vocational registration and they run off either to a bigger centre or to Australia, where they can make twice as much money as they can here. So we have a very high turnover of staff," Dr Iversen said.
Doctor shortages used to be a provincial New Zealand problem. Smaller centres - particularly towns that cannot sustain private hospitals and offer doctors a balance between the lucrative private sector and the more challenging cases of the public sector - felt the pinch the worst.
Not any longer.
Now even hospitals in Auckland are facing a shortage of doctors. In May, vacancy rates for house officers - junior doctors in their early post-graduate years - at Auckland public hospitals ranged between 18 and 23 per cent.
A report by the Association of District Health Boards predicts this will worsen to between 40 and 50 per cent by the fourth quarter of this year, "and these numbers are mirrored in some hospitals throughout New Zealand".
Historically, the vacancy rate has been around 2 to 3 per cent.
Dr Stephen Child, Auckland DHB's director of clinical training, says demand has simply outstripped supply. Since 2002, junior doctor positions nationally have expanded by around 14 per cent while the workforce has grown by only 1 per cent.
New house-officer applications, which remained essentially static until 2004, have also taken a big hit from a marked drop in applications from overseas-trained doctors.
In 2004, 229 sat the Medical Council's licensing exam. Last year, the figure was 41.
Dr Child said Australia was enticing many who would have otherwise come here. If they enter an area deemed to be in special need, they can bypass the Australian licensing exam altogether - although these rules could now be tightened after an Australian-based Indian doctor, Mohammed Haneef, was linked to last month's UK terrorism bids.
"Partly the demand has increased because the volume of patients coming to hospital has increased,"Dr Child said. "Partly the demand has increased because the junior doctor contract has given them more leave, for example. If there's more leave, then you need to hire more people to cover the people who go on leave."
Junior doctors - the group traditionally worked the hardest - have enjoyed better working conditions such as reduced hours and a rostering structure that stipulates minimum numbers working in a department at any one time.
These hard-fought gains for better work-life balance by their union have arguably led to increased staff retention.
But they also mean more doctors are needed to do the same amount of work.
Dr Child calls the rostering structure "rigid".
"You must have a minimum of eight doctors to run a 24/7 roster. Whether you need eight doctors on the day or not, you have to have eight."
The Medical Council's chairman, Professor John Campbell, said an ageing population was exacting a toll on hospital services.
That, coupled with a reduction in working time and a drive for doctors to go into narrower and narrower bands of specialisation, meant that demand for more doctors was likely to grow.
The new generation of physicians also has different expectations.
Professor Campbell said that while the number of medical graduates leaving the country had remained constant - around a quarter leave within three years of graduating- many are increasingly seeking only part-time work.
The new GPs the country desperately needs are also put off by the idea of having to run a business as well as being a doctor.
An increasingly female workforce also poses a challenge, as women work on average fewer hours per week than men.
The Medical Council's 2004 medical workforce survey found women worked an average of 40.9 hours a week, while men worked 48.5. Among doctors aged 35 to 39, the difference was the greatest, with men working on average 14 hours more a week than women.
All this points to a shortage that many - like Dr Child - predict will only get worse.
"Generation Y doesn't want to work 65 hours a week for the rest of their lives any more. Generation Y - I gently suggest this - is more selfish rather than selfless."
But Generation Y, and X, have had to grapple with something doctors generations earlier have not had to contend with - student debt.
The average medical student graduates with a debt of $65,000. More than 90 per cent have some debt, with 24 per cent owing more than $88,000.
The cost of a year's study at Auckland medical school is now around $11,000.
Anna Dare, vice-president of the Medical Students' Association, said debt was a generational phenomenon.
"As yet our workforce has not seen the full effects of a generation of doctors graduating with debt to the tune of tens of thousands of dollars."
She predicts more doctors heading overseas or into better paying specialist jobs with "serious consequences for the structure of New Zealand's health workforce in the future".
A study published in the Medical Journal last year found 65 per cent of first-year house officers intended to leave the country within three years of graduating. About 55 per cent have considered leaving, specifically because of student debt.
Debt is perhaps a driver behind what Dr Child calls "a locum market".
"It's not good for continuity of care for the patients, it's not good for the education and supervision of the individual house officer, and it's not good for the team morale when the faces are changing within the medical team."
Gisborne's Dr Iversen has worked with many locums in his time at Tairawhiti DHB.
"Locums, as godsend as they are for being on the ground and being able to take the calls, don't provide the continuity of care that either the patients need or that the department needs."
Obtaining and retaining full-time staff were still the best options.
"When you have a shortage like this, patients don't get the care they need," Dr Iversen said. "All you're doing, if you're as underpowered as we are, is really just stamping out the acute fires. Patients who have more chronic or interlinked but nevertheless debilitating problems get left on the backburner because we don't have the capacity to see them."
Arrivals from abroad speak of mixed local response
When Bhavani Peddinti came to New Zealand in 1985 as a junior doctor, he recalls a wariness about an Indian slotting into the hospital system.
But it never reached what Dr Peddinti, now the clinical head of Middlemore Hospital's emergency care centre, would call racism or discrimination.
"When I first arrived we were a unique breed because they hadn't actually seen overseas doctors being taken on before in fairly large numbers. Doctors from India were a novelty.
"Of course there is the unknown factor. Is this guy really a quality doctor? You have to work your way through it."
Dr Peddinti and other overseas-trained doctors faced this to a greater degree than those trained locally. "People need to realise that it's reasonable for the people, both patients and staff, to be wary of your qualifications if you are not from NZ. But I think it's our job to prove it. We have to overcome those barriers."
Dr Peddinti, 47, defines himself as a New Zealand doctor because he has worked in the country for so long. His postgraduate qualification is with the Australasian College for Emergency Medicine. But officialdom still deems him an "international medical graduate" because his first medical degree is from India.
Delightful Memories
Dr Amber Moazzam, a Middlemore plastic surgeon whose medical degree is from Pakistan and postgraduate qualifications are from Ireland and Britain, recalls a "delightful" experience after his arrival in New Zealand two years ago as a specialist.
"Maybe that's because it's more of a senior position. My training was in the UK and that was a bit different all right.
"I wouldn't categorise it as racism. It was difficult for an overseas graduate going through their training system. Maybe in comparison with a local trainee or graduate they may get more opportunities than international [medical graduates]."
Supportive Environment
Dr Shameem Safih, clinical director of Waikato Hospital's emergency department and, like Dr Peddinti, a college fellow, recalls a very supportive environment when he came as a junior doctor to New Zealand from Fiji after that country's first coup in 1987.
"Now and then there was a little bit of discrimination from patients during the early phase of the career. That does happen when people in the emergency department are uninhibited, drunk, disturbed or using drugs, then they would get abusive. The staff stood up for me; it was fantastic.
"A lot depends on your approach and your ability to communicate with patients.Maybe right in the beginning they sensed I was new and I was a bit uncertain ...
"I think once you understand what our rights as practitioners are, as well as patients' rights, and respect each other, we have no problems."
