Burned Out? Try Rebooting with a Year Abroad

Published on April 18, 2016
Is it ever too late to make radical lifestyle adjustments? A middle-aged American EP left his medical practice in Texas and moved his family for 18 months to practice medicine, life, and leisure—Kiwi style. Here’s what they learned.

The author’s daughter surveys the scenery during a family cycling outing in New Zealand. Taking a “gap year” can revitalize clinical skills and restore life and work priorities.

I will always remember the fork in the road for me: my 50th birthday celebration and a poignant question from my 12-year-old daughter. While on a family holiday in Mexico with an emergency physician friend from Melbourne, we talked about his plans for the remainder of a three-week holiday to the US. Kate, my daughter, looked at me and said, “Dad, why can’t you have a job like Al’s?”

At that moment it became quite clear to me that I could have a job like my friend’s. As an EP in Australia, it seemed Al had a good work-life balance, plenty of holiday time, protected non-clinical time, and staffing that made for a less stressful work environment than my 2.5–3.5 sick patients per hour in the US. My career and my family’s direction were forever changed in that moment of clarity. Within 12 months, I left my practice in Texas, where I was a partner, and took a position at the Mid Central District Health Board (DHB) in Palmerston North, New Zealand for 18 months. I would like to share a bit on how I got there and what I learned on my extended gap year.

Why Make a Change?

A gap year is a break in education common in many parts of the world. It typically entails a year of life experience prior to starting university, or a break during rigorous training programs, like in medicine.

I am a product of the US medical education system. I attended medical school in San Antonio, Texas, and did an emergency medicine residency at Indiana University. Like so many other trainees, I went straight to my first attending job after residency in Indiana. During my training, the prospect of taking a gap year was never on the radar for me. I’d taken a circuitous course to my medical career, which began in my early thirties after a career in public service as a police officer and firefighter/paramedic in Dallas, Texas, and I was eager to get on with my new career.

When I looked up again at age 50, I’d been hard at it as an attending emergency medicine specialist for 10 years. I was a much better and more experienced clinician by then, but I did not think I would fare well for another 10 years at the pace I was going. Like many of my ED colleagues, I was constantly asked to work miracles (we can sort out the most complex medical and social nightmares in a four-hour length of stay) with diminished resources, and increasing pressure from hospital administrators, regulators, and other clinicians. We have to make all this happen with no mistakes and are expected to achieve 95th percentile patient satisfaction scores. The work we do and the pressures of our practice—with limited control of our work environment—take a toll. After my epiphany (thank you, Kates), I went to work deciding how and when to make a move.

Where To Go?

I investigated several options, including changing to jobs with a slower pace here in the US, doing a fellowship, or working abroad. I settled on an experience abroad. I’d always been interested in how healthcare systems in different countries compare with the US system, and decided to search for a position in New Zealand.

New Zealand, a remote island gem in the South Pacific, seemed to be the best fit for us. I had young children, ages 12 and 13, and a graduating senior heading off to university the year we left for NZ. I really wanted an international experience for my younger children, but was cognizant of the strain a move would put on them, and I wanted to choose a geographical location that was English-speaking and had a good educational track record. NZ has a population of 4.5 million (smaller than greater Houston, Texas metro area), a good public education system, and very friendly folks to call neighbors.

The healthcare system in NZ is publicly-funded, and there is universal care available at no cost to all NZ citizens. The public healthcare budget is divided between 20 District Health Boards (DHBs) that provide care and hospital services for the communities they serve. All of the doctors in the DHBs are employees and paid a set salary and benefits depending on experience. There are no fees for service, no patient satisfaction scores, and few if any lawsuits in the public hospital system. NZ has a robust network of private General Practitioners who provide outpatient health care and refer patients for inpatient services to the respective DHBs as needed.

How to Get a Position?

There are many routes to a physician job in NZ. Start with making connections. EM is a relatively small specialty worldwide, and that’s certainly true in NZ. There are 198 current fellows of the Australasian College of Emergency Medicine NZ (FACEMs). This qualification is similar to the American Board of Emergency Medicine standard and can be challenged by certified ED doctors from the US for reciprocal recognition. There are many US-trained EPs working in Australasia, and it doesn’t take much work to find a connection and start enquiring about opportunities.

In my case, a classmate from my residency in Indiana had taken a position with the Mid Central District Health Board in Palmerston North and was happy to share his experience. I traveled to Palmerston North to interview and tour, and I got an ED consultant position at Mid Central starting in July 2014.

Work Life

Medicine is universal; it’s done the same way in Australasia and North America. We use the same sets of clinical decision rules, same diagnostic tests, and same therapies. The main difference is availability of resources and pressure to have everything sorted out prior to patients being admitted to hospital. There is an emphasis on clinical diagnosis, and I found it very refreshing to get back to using my skills as a clinician and working in a system where this is an accepted standard. I was quite fond of telling our registrars (equivalent to residents in the US system) that time is on our side, and we used repeat exams/observation in lieu of CT scans to sort out some of these patients where the diagnosis was not quite clear. We certainly ordered CT scans and other testing in NZ, but there is less pressure to use imaging or other expensive testing to rule in/out a diagnosis when observation and repeat exams will accomplish the same outcome.

My department in NZ has an annual census of 45,000 patients, and was staffed by eight senior medical officers known as consultants/attendings, and 16 junior medical officers of various levels of training. The ED at Palmerston North Hospital is an ACEM approved training site for EM registrars. We also supervised junior medical officers (RMOs) and training interns (first year medical students). It’s fair to say that NZ has its share of frustrations just like any ED on the planet. You will not escape chronic pain patients, personality disorders, snotty colleagues, or administrative frustration. Our department was at times under resourced, understaffed, and overwhelmed with patient load and acuity, but, alas, that is our specialty! We are the ones who are experts at sorting through a mountain of chief complaints in austere conditions with limited data—and making decisions! I’m pleased to say you will find these same competencies in NZ departments.

Work-Life Balance

This was a foreign concept for me, as I fear it is for many of my US colleagues.

Kiwis have a different view on the work-life balance, and they enjoy their leisure time and holidays. The average annual paid time off for a consultant is 10 weeks. This, along with protected non-clinical time in most contracts, makes for a very attractive lifestyle that most US doctors find quite sustainable. When I spoke with our trainees in Palmerston North about the workload and lifestyle in the US, they were stunned that anyone would work under such adverse conditions. Doctors in NZ take time to sit down for dinner, a shock for those of us from the US who rarely take time for a bathroom break, and absolutely never leave the department for a meal break. Many of the trainees in NZ take time off during their specialty training to travel or take interesting jobs not directly related to their specialty. The juniors seem to be in less of a rush to complete their specialty training, and the contracts for junior doctors in NZ come with favorable amounts of paid holiday and dedicated CME time to support this.

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