Christchurch Hospital (2 reports)
Tauranga Hospital
Kaeo

Introduction
My elective attachment consisted of a four week attachment to the Dermatology department at Christchurch Hospital in Christchurch in the South Island of New Zealand. I chose dermatology because my forthcoming house job contained a three month section of dermatology and I thought that the elective attachment would prove to be a useful refresher.

Christchurch Hospital
Christchurch Hospital is a modern unit capable of caring for up to 400 patients. It is based primarily on a single site in the centre of Christchurch, with two satellite units further outside the city providing care for women’s health and health care of the elderly. The hospital is also responsible for training a number of medical students from the Otago School of Medicine, some 300km south of Christchurch.

Dermatology
The dermatology department consists of 4 consultants, all of whom are employed on a part time basis. (The remainder of their time being spent in private practice.) The rest of the tearn is structured in a similar to that in Britain, with registrars and house officers. However, there is also a trainee intern post. This is actually occupied by a sixth year medical student who takes responsibility for the day to day running of the ward. This is not a salaried post but the student is eligible for a grant of around £10,000 for the year.

The service is run primarily on an out-patient basis, but there is also a single in-patient ward. Thus, my timetable consisted of daily out-patient clinics in addition to two weekly skin surgery sessions. There were also some specialised clinics that were run once a month, such as paediatric dermatology, that I was also able to attend. There was little opportunity for ward work due to the low number of in-patients. In addition to the clinics I was also expected to attended the weekly teaching sessions for both the trainee interns and fourth year medical students.

In the out-patient clinics the majority of the patient make up was very similar to that in Britain. Most of the cases were those of chronic eczema and psoriasis and the treatment protocols were identical to those I had seen whilst in Nottingham. There was however a significant amount of patients affected by long term sun damage. I saw numerous solar keratoses, benign sebaceous gland hypertrophy and a large number of squamous and basal cell carcinomas. Somewhat surprisingly I did not observe a single melanoma throughout my time in Christchurch. That said, the dermatology department did have a huge number of patients who attend yearly for “mole checks”. Mole mapping, where photographs of suspicious naevi are taken and stored on computer for easy comparison at the next check was being experimented with whilst I was there. The use of the dermatoscope for examination of moles was also commonplace, unlike in the UK.

Summary
My time in Christchurch was both interesting and enjoyable. All the staff I encountered were friendly and approachable and I received some excellent teaching. My clinical experience there should stand me in good stead for my house jobs next year. In addition Christchurch was a great place to stay - very pretty, very safe and with much to do and see. Overall my elective was an experience well worth repeating and 1 would recommend it to any future student.

Matt Wiles, 1999

My experience in Christchurch Hospital was predominantly in Haematology, with the majority of the four weeks spent doing ward rounds in the Bone Marrow Transplant Unit, as well as attending general Haematology clinics. The BMTU is a relatively new ward comprising eight side rooms for neutropenic patients requiring barrier nursing, plus several open ward beds.

The vast majority of the patients here are admitted for bone marrow transplant; which involved stem-cell harvesting and intensive chemotherapy using the CHOP regime, usually following relapses in leukaemia, lymphoma or myeloma. Strict hygiene and full barrier nursing were observed rigorously, especially when dealing with neutropenic patients. Simple hand washing was an absolute requirement for anyone entering the unit.

I participated in the daily 8am ward rounds, which involved having to examine the patients for signs of infection and bleeding. Respiratory complications such as Aspergillus and Pneumocystis infections were not uncommon. However, my responsibilities and experiences were not limited to observing the ‘hand washing’ rule and searching for infection, but also extended to the rarer variants such as hairy-cell leukaemia and CNS presentations of the haematological disorders.

In addition, the weekly grand round was, in my opinion, the epitome of a multidisciplinary team involving the close liaison between haematologists, microbiologists, nurses, social workers, and the laboratory.

Of course, apart from medicine, one must not undermine the enormous physical diversity and spectacular grandeur of New Zealand; of which activities such as bungy-jumping, white-water rafting, jet-boating, hang-gliding, glacier-trekking and tramping all vie for attention!

Li Ching Chew, June 1997

I spent my elective at Tauranga hospital in New Zealand. The town of Tauranga is on the East coast of the North Island in the Bay of Plenty and is approximately 100 km from Auckland.

I worked in the paediatrics department which has approximately 30 beds as well as a special care baby unit. The department is run by 3 consultants - Dr. Fleming, Dr. Lees and Dr. Lourens. I divided my time between ward rounds, clinics, emergency takes and various meetings.

On the ward I encountered a lot of interesting patients, a couple of whom particularly stuck in my mind. One was a 16 year old Maori girl with Rheumatic Fever. Apparently Rheumatic Fever is still prevalent amongst the Maori population, and the reason for this is unknown. Various theories are held by the consultants including the relatively poorer living conditions, immunological differences and perhaps a genetic predisposition to the illness. In the out-patient clinics I also saw several children being followed up after having Rheumatic Fever.

The other patient was an 11 year old Maori girl who was admitted several weeks before my arrival with sudden onset of weakness and tremor. She had been unable to walk, sit up, feed or dress herself unaided since then and the diagnosis remained a mystery. All blood tests, spinal imaging, nerve conduction studies and a CT scan of her head had been negative. The doctors then began to look into the social aspects of her illness and found that she had been through a lot of family stresses recently. She had been brought up by her grandmother but her mother had been trying to get custody of her and to take her to Australia. They agreed that there was possibly a psychological cause for the illness and accepted that conventional medicine may not hold the answer. The grandmother seemed to readily accept this, as in Maori culture ‘spiritual’ forces are considered very powerful. She subsequently took the child out of the ward on several occasions to see a Maori spiritual healer. On his advice, the child’s name was changed to one with a more positive meaning and she seemed immediately to be slightly improved. After several visits to the healer during which she was reassured that she would be staying with her grandmother and that the negative spirits had left with her previous name she was almost back to normal. Her symptoms were definitely not put on consciously by her as they were remarkably constant and often caused her much distress. Such ‘conversion disorders’ were at one time common in our culture but have now been replaced by symptoms of anxiety and depression, however they still occur in the Maori population. Dr. Fleming told me about a similar case he had seen 10 years ago who was still in a wheel chair with no organic cause for his symptoms.

In the special care baby unit I found that things were very much as I had experienced them in England. The only difference being that all babies born in New Zealand are vaccinated against Hepatitis B as it is relatively common, especially in the Maori communities.

Improving the social and health standards of the Maori population is a high priority in New Zealand. Efforts to make the health care system available to Maori people in the paediatrics department included them employing a Maori liaison nurse who goes out into the Maori communities and acts as an interpreter for those who do not speak English. They also hold out-patient clinics specifically aimed at Maori patients in a building decorated in Maori styles, with posters written in the Maori language and with Maorispeaking receptionists etc.

Medical Students in New Zealand have a 6 year course, the 6th year being as a paid intern. The duties of the interns include filling in forms, writing in the notes during ward rounds and doing basic practical procedures such as putting iv cannulas in. Although they find these tasks boring , there is time for them to gain further experience in areas of their choice and having interns does make the job of the House Officers easier.

I thoroughly enjoyed my time in New Zealand, both because I was able to spend more time working in paediatrics and see some very interesting cases and also because I was able to see quite a lot of a very beautiful country.

Diane Astle, 1997

Kaeo is a small town in the very north of New Zealand, chosen as a suitable place to do an elective attachment, because of its unique free health service offered to its residents of Maoris and people of low socioeconomic groups. It serves a vast area sparsely populated yet surrounded by beautiful scenery including secluded bays and harbours, the base for advanced game fishing.

The health service consists of a busy general practice, staffed by three full-time and one part-time GPs, in addition to numerous nurses, administration and receptionists. Clinics occur at 9.00 and 2.00, five days a week for all doctors, and there are community and district nurses available for home visits. A small radiology department, competent only for plain films, assists these clinics. A casualty service is available and there is an ambulance on hand for any call-out emergency. Finally the service also offers a small hospital capable of overnight observation for the not-so-critically ill and longer term geriatric care. As students we were given the responsibility ofjunior doctors clerking the casualty patients first, seeing our own patients in the clinics and carrying out some of the minor surgical procedures performed by GPs; some more successfully than others!

Much of what we experienced was similar to what had already been seen in an English practice, but with certain fundamental differences. Firstly a large percentage of the patients were of Maori origin, so some hereditary diseases were a lot more common. Diabetes (NIDDM) is a big problem with about 70% of the >60 year old affected. Asthma is exceptionally common with the highest incidence over the whole of New Zealand being seen in Kaeo. Glue ear has only recently been noted to be common in Maoris due to the unusually small Eustachian tube giving an explanation for the high rates of teenage delinquency. Hepatitis B is a real problem and most children are now immunised shortly after birth, unfortunately this does not protect those born to infected mothers. Measles is on the increase probably due to the trend against immunisations that is occurring in New Zealand.

There appears to be an awful lot of resentment towards Caucasians by the Maoris (rightly or wrongly) and this can be very difficult to handle. The education of newly diagnosed diabetics or asthmatics is extremely hard, and there is an enormous amount of emphasis on compliance even years after the initial diagnosis.

The funding of New Zealand health system is an interesting topic. It is basically split into two methods; the private and the public. The privately funded system seems greatly advanced, with many insurance companies vying for trade. Each company appears to have its own selection of services and specialities. Unfortunately, even if you have been paying money relentlessly for years to a certain company but that company does not offer heart-by-pass operations, if at the age of 70, you need one you are technically not insured. Most people in New Zealand have private health insurance. The other system is the public system where you will at least receive competent emergency care even if you are asked to make a donation at the end of your treatment. Elective operations, on the other hand, are a different matter. Hernias, ENT operations, plastic surgery operations on the state rarely occur, it is surprisingly common for patients to still be waiting for tonsillectomies and grommets etc twenty years after first being placed on the waiting list. The state system is incredibly underfunded and patients of the lower socioeconomic group suffer because of it.

I enjoyed working at Kaeo very much and found all the New Zealanders very friendly and welcoming; but to work there on a more permanent basis I think I would find very frustrating.

Samantha Digby, 1997