obstetric and gynecology department on two sub-specialty services: maternal fetal medicine

Transcription

1 Obstetrics and Gynecology in New Zealand Kelsey Simpson, MS4 During my time in New Zealand, I had the opportunity to integrate myself into the obstetric and gynecology department on two sub-specialty services: maternal fetal medicine (MFM) and infertility. While I spent my time in a major medical center like KU, I thoroughly enjoyed experiencing it in another country and the difference between New Zealand s and our own systems. As a student who is very interested in a career in MFM, I was very excited to experience the service from another perspective. The MFM service in Auckland City Hospital is a consultation service. They get referrals for additional anatomy scans, genetic testing, and fetal cardiac echocardiograms. Additionally, their team has internal medicine physician specifically trained in Ob/Gyn co-morbidities that hold a clinic to co-manage their care with their obstetric provider. During my time on this service, I spent 4 days a week rounding with the inpatient team and attending clinics. Every Wednesday, I had the opportunity to be a first assist on cesarean deliveries. This was probably the most significant experience for me because I hadn t had this opportunity previously. It was amazing to go through the steps I have memorized to perform a c-section and actually be the person doing many of them. Prior to coming to New Zealand, I had not gotten the chance to rotate through infertility at KU. Rotating through this service gave me the chance to learn more about the hormonal side of pregnancy and many of the different options for infertility. I learned the United States and New Zealand have very similar protocols for in vitro fertilization (IVF). During my time on this service, I participated in morning ultrasounds for those patients on injections, egg retrievals, embryo replacement, and clinic.

2 For this rotation, I decided to focus my attention on the differences between our healthcare systems. The biggest, and most obvious, was the public healthcare system. Under the subsidized healthcare, all hospital and specialty care is covered for the patient. The general health maintenance and PCP visits have a small fee to see the physician and a $5-10 copay for prescriptions. When talking to many different members of my teams, they believed that one positive of this healthcare system was that it allowed everyone the access to the specialty and hospital care that they needed. Additionally, under this systems, physicians do not order tests as often and unless there are very specific clinical indications. On the negative side, specialty care is limited in many regions of the country and patients tend to not utilize their PCP well due to the cost, even though it is small. Several physicians reported patients showing up to the emergency room for issues that would have been better managed outpatient. Both are not problems dissimilar from our own healthcare system. Additional difference I noted during my time at Auckland City Hospital were: training to become an Ob/Gyn, management of prenatal care, abortion practices and beliefs, and cost of IVF therapy. Training to become an Ob/Gyn was different compared to here in the United States. In the U.S. students typically obtain a four-year undergraduate degree, a four-year medical degree, and a four-year residency. 12 years in total. In New Zealand, students obtain a six-year medical degree with the first three years being bookwork and the last three years being clinical, a two-year house officership requiring at least six months of Ob/Gyn rotations, a four-year core clerkship of core Ob/Gyn material, and a two-year block of specialty Ob/Gyn training. 14 years in total. Despite the shorter time period, I believe our training is more intensive with longer hours in the hospital that make us equally well-trained.

3 Overall, prenatal care is very similar in New Zealand; however, the person managing the prenatal care is different. In New Zealand, pregnant women are assigned to a labor care manager (LCM) immediately upon discovering she is pregnant. In the vast majority of cases, the LCM tends to be a midwife. If a patient requires additional monitoring, they will consult the MFM service. Despite seeing an MFM, the patient will still be managed visit by visit by their assigned midwife. During delivery, a physician is available to support the midwife. Postnatally, midwives oversee all non-complicated patients care. For those being followed by MFM, the midwives will oversee the duration of their hospital stay once the MFM team signs off. Discussion of abortion in New Zealand is much less taboo than in the United States. Overall, there is not much of a pro-life or pro-choice culture, and there is no national religion. Last year, there were 68,000 live births and 12,000 abortions with the majority being first trimester abortions. Elective abortions after the first trimester will be performed, but require documentation of a physical and/or emotional harm to the mother. During my time on the MFM service, there was a patient that was 30 weeks pregnant with an ultrasound showing omphalocele, club feet, and growth restriction. They desired an abortion, and the MFM began the process. Discussing with other members of the team, it is their policy to offer abortion as an option to any women at any gestation with evidence of birth defects. Looking back at my experience at Auckland City Hospital, I think the most shocking discovery was that up to two cycles of IVF is covered under the public healthcare plan. In the United States, IVF costs $12,000 with an additional $3,000 - $5,000 for medications. In New Zealand, a woman undergoes her first cycle of IVF and eggs are harvested and fertilized with sperm a few hours later. At day 5 (or day three if there is an obvious best embryo ), a single

4 embryo is replaced into the uterus. The remaining viable embryos are frozen. Two weeks later, a pregnancy test is done. If the test is negative, a patient will use any remaining embryos. If there are none frozen, the patient will begin her second cycle. If the pregnancy test is positive and the pregnancy continues onto a viable infant, the patient can use the remaining frozen embryos with no additional healthcare costs, but they are not eligible for any additional cycles. Ideally during an IVF cycle, 5 10 egg s will be harvested. 70% of those eggs will successfully be fertilized and grow on to transfer. Only 33% of women have embryos to freeze on day five. During my second week on service, I had the honor of being a part of a pregnancy confirmation ultrasound of a patient who was pregnant on their first IVF cycle. It was amazing to be part of a special moment that was years in the making. I think the most important thing I learned about all these differences is that despite doing things differently, everyone gets to the same end point. Training may be broken down differently, but all become competent physicians. Payment for IVF may be drastically different, but daily a couple struggling with infertility receives the news they are pregnant. Our views and reasons for doing certain things may be different, but at the end of the day we are all trying to do what is best for the patient. This realization will be something I hope to carry on in my training and future career. Culturally, the biggest thing I noticed during my time on the MFM and Infertility service was the work life balance. The majority of physicians worked on both service. In addition to the shorter hours, the average clinic saw 5-8 patients with plenty of time allotted for each patient. Every day, there was time each morning and afternoon to sit down as a team,

5 drink coffee or tea, and chat with each other about things other than medicine. There was a large focus on physical and emotional wellness. Moving forward from our amazing time in New Zealand, I am thankful for the opportunity to have experienced Ob/Gyn in another country. I am thankful I can appreciate that despite differences, there are different ways to go about things to have the same outcome. Additionally, I am very thankful for our training and the things I have learned over the past four years. Despite our shorter training, I believe the intensity and volume at which we train makes us into fantastic physicians that are comparable to those I had the privilege of meeting in New Zealand. I hope I can take a little of the culture I learned throughout my upcoming career stages and remember to take care of myself physically and mentally.