Medical practice in New Zealand

Cole’s

2011: edited by Ian St George

Published by the Medical Council of New Zealand

Cole’s

Medical practice in New Zealand
2011
10th edition edited by

Ian St George

MD FRACP FRNZCGP DipEd

Published by the Medical Council of New Zealand
Cole’s Medical practice in New Zealand 2011 1

2 Cole’s Medical practice in New Zealand 2011

Editor Ian St George MD FRACP FRNZCGP DipEd Editorial board Michael Thorn BA DPH Philip Pigou LLB DipBusStud. Steven Lillis FRNZCGP MGP DipSportsMed Judith Fyfe LLB Andrew Connolly BHB MB ChB FRACS First published in 1988 by the Medical Protection Society as Medical practice and professional conduct; in 1995 by the Medical Council of New Zealand as Medical practice in New Zealand: a guide to doctors entering practice, and in 1999, 2001, 2003, 2004, 2006, 2007, 2008 and 2009 as Cole’s Medical practice in New Zealand. This revised and updated 10th edition published by the Medical Council of New Zealand, Level 13, 139 Willis St, Wellington 6142. © Medical Council of New Zealand, August 2010. All rights reserved. No part of this publication may be reproduced by any means without permission from the Medical Council of New Zealand. ISBN 978-0-9582792-7-7 Printed by City Print, Wellington
Cover design Rongo M ori are M ori medicines. One is Sophora tetraptera: Kowhai: “All parts of the kowhai including bark, inner bark, flower, leaves and juice can be used as rongoa. There are toxic alkaloids in the tree so careful preparation of rongoa must be observed. Infused bark is drunk for internal ailments and treating cuts, bruises and swelling, as well as colds and sore throats. Boiled and crushed bark is useful for sprains, alleviating broken limbs, bruises, infected skin, wounds and skin diseases. The ashes of the kowhai can be used to treat ringworm .” (http://aoteamoana.co.nz/native/native.html). This 1791 lithograph by Sydenham Edwards is from Curtis’s Botanical magazine; 167: 5. The illustrations of rongo plants here are purely decorative and should not be taken to indicate any opinion by the Medical Council as to their efficacy. They are taken from old New Zealand books of botanical illustration. The moko and other M ori design elements are reproduced with permission from Chamblett Design, Akaroa (www.chamblettdesign.co.nz). All designs are © Chamblett Design 2010.

Cole’s Medical practice in New Zealand 2011 3

Preface to the tenth (2011) edition
This book is primarily for doctors beginning practice in New Zealand–– graduating in New Zealand or educated elsewhere. You are welcome here: our country needs your services and we value your knowledge and skills. A profession is a group that regulates itself, but self and state regulation must run side by side. The public interest must always take precedence over vested interest; competence must be maintained, ethical standards upheld, the regulatory process carried out by competent people, the processes transparent, fair, effective, flexible and responsive. In New Zealand, society permits self regulation by doctors but requires accountability in return, an accountability that doctors acknowledge by good medical practice in terms of demonstrable performance, and maintaining good health and proper conduct. Quality is enhanced by competition among providers only when consumers are knowledgeable about the goods or services they buy. Competition works for bakeries, shoe shops and hairdressers, but it has limited and sometimes perverse results in the professions. Doctors do have special knowledge and skills, and thus inevitably, power, usually greater than that of their patients. Society allows them that power provided they use it for the common good. Doctors therefore have ethical guidelines and legal duties to use power properly, within boundaries that dissuade them from taking advantage of patients sexually, financially or emotionally, by lending spurious authenticity to quack methods, or by allowing their performance to slip. Although doctors are intelligent, well-motivated, self-regulating professionals on the whole, they must also work within sometimes quite austere moral and ethical boundaries defined by their colleagues. The chapters here traverse what may be quite complex law, and they refer to further guidelines and ethical statements made by the Medical Council and other bodies over recent years. The book’s main purpose is to introduce new entrants to medical practice in New Zealand to the main legislative and ethical standards and guidelines. Laws and even ethics change over time. What is permitted now may have been unacceptable not long ago: what can be contemplated now was never imagined longer ago: there is a good deal in here to interest the established New Zealand doctor too. There are gaps and overlaps, of course, but I hope the book will be informative, especially to those entering or reentering medical practice in New Zealand. Ian St George, August 2010

4 Cole’s Medical practice in New Zealand 2011

The aim has been to set down aspects of medical practice in this country that can loosely be regarded as concerned with professional medical conduct and practice.Preface to the first edition Overseas trained doctors entering New Zealand and obtaining registration from the Medical Council will be expected to make themselves familiar with the legal. From time to time publications by the Medical Council. regulatory and professional ethical conduct requirements that are the norm for this country. David Cole. Not only does the text outline various medical professional practices – what should be done – but also what should not be done. tea tree. this text does not deal with this in any depth. and the consequences. effective and desirable practice. by the New Zealand Medical Association and by the Health authorities will update these matters. and other new registrants. these notes have been prepared during 1994 and 1995. In order to assist them. codes or by guidelines but in some instances the essentially dynamic standards are established by accepted practice or from case experience of disciplinary tribunals. If it appears unduly to emphasise aberrations and errors it is because these serve to highlight proper. 1995 M nuka. Leptospermum scoparium. While the basis for medical conduct is essentially ethical in nature. Most of this conduct is established by law. Cole’s Medical practice in New Zealand 2011 5 .

Cultural competence and patient-centred care Jean Hera 5. Kenneth Tong. Pippa MacKay. Nagalingam Rasalingam. Medicine and the Internet Stewart Jessamine 14. The psychiatric patient and the law David Chaplow 9. The organisation of medical services in New Zealand John Adams 3. Pacific peoples in New Zealand Colin Tukuitonga 7. The doctor patient relationship Caroline Corkill 4. David Jansen 6. The medical record Robert Stevens 12. Accident compensation Peter Jansen 11. Catherine Hong 8. M ori and health Peter Jansen. Peter Moller 8 28 34 41 48 61 68 78 85 92 101 111 118 127 6 Cole’s Medical practice in New Zealand 2011 . Informed consent Judith Fyfe. Working with others Rick Acland. The management of clinical investigations Ian St George 13. Andrew Connolly. Barnett Bond 10. Good medical practice: a guide for doctors 2.Contents 1. Asian people in New Zealand Sampson Tse.

Doctors’ health Kate O’Connor. Ian St George 18. Joanna MacDonald 17. The role of the Health and Disability Commissioner and the Code of Rights 198 Ron Paterson 24. Discipline: the Professional Conduct Committee and the Health Practitioners Disciplinary Tribunal 212 Jo Hughson and Kristy McDonald QC Appendix A.15. Orientation of International Medical Graduates 228 Sue Ineson Index 251 Cole’s Medical practice in New Zealand 2011 7 . The doctor who uses complementary and alternative medicine Ian St George 20. Michael Thorn 132 138 148 158 171 175 180 187 23. Maintaining competence Steven Lillis. The pharmaceutical industry and the profession Barnett Bond 21. How medical practice standards are set by legislation: other legislation Steven Lillis. Take our word for it: New Zealand slang expressions 224 Ian St George Appendix C. Doctors in other roles David Rankin 16. The NZMA code of ethics New Zealand Medical Association 19. How medical practice standards are set by legislation: the Health Practitioners Competence Assurance Act David Dunbar 22. Medical Council statements and guidelines 222 Appendix B.

Good medical practice is addressed to doctors. How Good medical practice applies to you Establishing a relationship of trust with your patients Domains of competence Medical care Communication Collaboration Management Scholarship Professionalism Standards set by other agencies Under section 118 of the Health Practitioners Competence Assurance Act 2003 (). establish and maintain good relationships with patients and colleagues. The Council sets standards through discussion with the profession and the public. but is also intended to let the public know what they can expect from doctors. The standards detailed in Good medical practice are those which the public and the profession expect a competent doctor to meet.1 Good medical practice: a guide for doctors Patients are entitled to good doctors. 8 Cole’s Medical practice in New Zealand 2011 . The Council has developed Good medical practice to be the foundation document for those standards. cultural competence and ethical conduct for doctors. Good doctors make the care of patients their first concern. keep their knowledge and skills up to date. the Council is responsible for setting standards of clinical competence. are honest and trustworthy and act with integrity. they are competent.

Protect and promote the health of patients and the public. Provide a good standard of care and practice by: keeping your professional knowledge and skills up to date recognising. To justify your patients’ trust. Respecting patients Treat patients as individuals and respect their dignity by: treating them politely and considerately respecting their right to confidentiality and privacy. Caring for patients Make the care of patients your first concern. Establishing a relationship of trust with your patients Doctors must establish a relationship of trust with each of their patients. Working in partnership with patients Work in partnership with patients by: listening to them and responding to their concerns and preferences giving them the information they want or need in a way they can understand respecting their right to reach decisions with you about their treatment and care supporting them in caring for themselves to improve and maintain their health. It is the responsibility of competent doctors to be familiar with Good medical practice and to follow the guidance it contains. the Council’s Professional Conduct Committees and the Health and Disability Commissioner may use Good medical practice as a standard by which to measure your professional conduct. and sometimes their lives. Cole’s Medical practice in New Zealand 2011 9 . the limits of your competence working with colleagues in ways that best serve patients’ interests. follow the principles outlined below and in the rest of this document.How Good medical practice applies to you The Council expects all doctors registered with the Council to be competent. Patients trust their doctors with their health and well-being. and working within. The Health Practitioners’ Disciplinary Tribunal.

act with integrity by: acting without delay to prevent risk to patients acting without delay if you have good reason to believe that a colleague may be putting patients at risk never discriminating unfairly against patients or colleagues never abusing your patients’ trust in you or the public’s trust of the profession. The public and the profession expect doctors to be competent in the following areas: medical care communication collaboration scholarship professionalism. 10 Cole’s Medical practice in New Zealand 2011 . Remember that you are personally accountable for your professional practice – you must always be prepared to justify your decisions and actions. In the sections that follow. taking account of the patient’s history and his or her views and examining the patient as appropriate providing or arranging investigations or treatment when needed taking suitable and prompt action when needed referring the patient to another practitioner when this is in the patient’s best interests. Good clinical care includes: adequately assessing the patient’s condition. Domains of competence 1. we outline the requirements of each of these competence areas. Medical care Good clinical care – a definition 1 2. 1 See the Council’s statement Non-treating doctors performing medical assessments of patients for third parties. which outlines the specific requirements for non-treating doctors performing medical assessments for other parties.Acting with integrity Be honest and open when working with patients.

Cole’s Medical practice in New Zealand 2011 11 . Usually this will require that you have a face-to-face consultation with the patient or discuss the patient’s treatment with another registered health practitioner who can verify the patient’s physical data and identity.Providing good clinical care 2 3. including repeat prescriptions. 3 See the Council’s statement on Maintenance and retention of patient records. this may mean you are accessible to patients. Keeping records 3 4. You may prescribe drugs or treatment. 4 See the Council’s statements on Improper prescribing practice with respect to addictive drugs and The use of drugs and doping in sport. You may not need a face-to-face consultation if you are prescribing on behalf of a 2 See the Council’s statement Use of the internet and electronic communication for information about providing services electronically or from a distance. You must keep clear and accurate patient records that report:: relevant clinical findings decisions made information given to patients any drugs or other treatment prescribed. or it may mean that you are accessible to colleagues or a triage service provide effective treatments based on the best available evidence make good use of the resources available to you take steps to alleviate pain and distress whether or not a cure is possible respect the patient’s right to seek a second opinion. Make these records at the same time as the events you are recording or as soon as possible afterwards. In providing care you are expected to: recognise and work within the limits of your competence consult and take advice from colleagues when appropriate keep colleagues well informed when sharing the care of patients be readily accessible when you are on duty. Depending on the situation. See the Council’s statement on Safe practice in an environment of resource limitation. only when you: have adequate knowledge of the patient’s health are satisfied that the drugs or treatment are in the patient’s best interests. Prescribing drugs or treatment 4 5.

In an emergency. Providing care to those close to you 5 7. The Council recognises that in some cases providing care to those close to you is unavoidable. Cultural competence 7 9. see the Council’s statement on Best practices when providing care to M ori patients and their wh nau and Best health outcomes for M ori: practice implications. those you work with and family members is inappropriate because of the lack of objectivity and possible discontinuity of care. this may include advising patients on the effects their life choices may have on: their health and wellbeing the outcome of treatments. You should acknowledge: that New Zealand has a culturally diverse population that a doctor’s culture and belief systems influence his or her interactions with patients and accept this may impact on the doctor-patient relationship that a positive patient outcome is achieved when a doctor and patient have mutual respect and understanding. 7 See the Council’s statement on Cultural competence. For example. offer to help. For specific guidance on providing care to M ori patients. Supporting self-care 6. providing care to friends. taking account of your own safety.colleague in the same team who usually practises at the same physical location. your competence. Treating people in emergencies 6 8. in most cases. and the availability of other options for care. Encourage your patients and the public to take an interest in their health and to take action to improve and maintain their health. 5 See the Council’s statement on Providing care to yourself and those close to you. 12 Cole’s Medical practice in New Zealand 2011 . However. 6 See the Council’s statement on A doctor’s duty to help in a medical emergency. You must be aware of cultural diversity and function effectively and respectfully when working with and treating people of all cultural backgrounds. Wherever possible. avoid providing medical care to anyone with whom you have a close personal relationship.

or against a patient’s wishes. in exceptional circumstances. Give patients all information they want or need to know about their condition and its likely progression treatment options. In certain circumstances you may also need to tell your patients about their rights.act/health.nz/ theact/theactthecodedetail. To establish and maintain trust you should: listen to patients. Treating information as confidential 9 12.nz/privacy.Communication The doctor–patient relationship 8 10. Establishing and maintaining trust 11. org. Giving information to patients about their condition 13. including expected risks. 9 See the Council’s Statement on Confidentiality and public safety for information about the requirements of the Health Information Privacy Code. ask for and respect their views about their health. For a copy of the Health Information Privacy Code go to: www. trust and good communication will enable you to work in partnership with your patients to address their individual needs. side effects.org. Make sure you respect: patients’ privacy and dignity the right of patients to be fully involved in decisions about their care the right of patients to seek a second opinion.privacy-code. and respond to their concerns and preferences be readily accessible to patients when you are on duty. costs and benefits. Do your best to ensure the patient understands the information you give 8 For a copy of the Code of Health and Disability Services Consumers’ Rights go to: www. You must familiarise yourself with the: Code of Health and Disability Services Consumers’ Rights Health Information Privacy Code. 14. you feel you should pass on information without a patient’s consent.privacy. Cole’s Medical practice in New Zealand 2011 13 . Be prepared to justify your decision if. Treat all information about patients as confidential.hdc.information. Relationships based on openness.

Your personal beliefs should not affect your advice or treatment. Give information to patients in a form they can understand and. Make sure the patient agrees before you provide treatment or investigate a patient’s condition. make arrangements to meet any language or special communication needs that patients may have. you must also explain the risks. after a patient has died. See the Council’s statement on Cultural competence. for example. You must be considerate to relatives. carers and partners 17. Respect the right of patients to decline to take part in education or research activities. carers. Patients have the right to have one or more support persons of their choice present. 14 Cole’s Medical practice in New Zealand 2011 .them about their condition and its treatment. If you feel your beliefs might affect the advice or treatment you provide. However. 15. 10 See the Health Information Privacy Code and the Council’s statement on Confidentiality and public safety. Follow the guidance outlined in the Health Information Privacy Code. except where safety may be compromised or another patient’s rights unreasonably infringed. You must be satisfied that the patient has sufficient information to enable them to exercise that right. When working with patients under 16 years. you should give information about the patient’s condition and treatment to parents or caregivers only if the following apply: the patient lacks the maturity to understand their condition or what its treatment may involve you judge that you are acting in the young patient’s best interests by informing a parent or caregiver. Involving relatives. Giving information to parents or caregivers 16. Explain the benefits to patients and others of participating in education or research. partners and others close to the patient. Giving information to patients about education and research activities 10 19. you must explain this to patients and tell them about their right to see another doctor. Respect the patient’s right to decline treatment. if necessary. Make sure you are sensitive and responsive in providing information and support. 18. Advising patients about your personal beliefs 20.

You must be prepared to justify your decision. 24. Avoiding discrimination 22. Challenge colleagues if their behaviour does not comply with this guidance. (See the Council’s Statement on advertising. All patients are entitled to care and treatment that meets their clinical needs.Assessing patients’ needs and priorities 21. You must always respect a patient’s wishes expressed in an advance directive. You must not refuse or delay treatment because you believe that a patient’s actions have contributed to their condition. unless the patient is being treated under specific legislation such as the Mental Health (Compulsory Assessment and Treatment) Amendment Act 1992. you should transfer responsibility for the patient to another doctor. It will be expected that investigations or treatment you provide or arrange will be made on the assessment you and the patient make of his or her needs and priorities. Euthanasia is illegal in New Zealand. You should usually tell the patient – in writing if possible – why you have made this decision. If a patient poses a risk to your own health and safety. 11 See the Council’s statement on Ending a doctor-patient relationship Cole’s Medical practice in New Zealand 2011 15 . The information must conform to the requirements of the Fair Trading Act 1986 and the Advertising Standards Authority guidelines. You must also make sure you arrange for the patient’s continuing care and pass on the patient’s records without delay. If you hold a moral objection. Make sure any information you publish or broadcast about your medical services is factual and verifiable. Ending a professional relationship 11 26. Advance directives have legal standing in the Code of Health and Disability Services Consumers’ Rights. In some rare cases. Nor should you unfairly discriminate against patients by allowing your personal views to negatively affect your relationship with them or the treatment you arrange or provide. 25. April 2010). Advertising 27. 23. and on your clinical judgement about the likely effectiveness of the treatment options. you may need to end a professional relationship with a patient. you should take all possible steps to minimise the risk before providing treatment or making suitable arrangements for treatment.

if possible. if appropriate. unless you know that the patient would have objected. You must not put pressure on people to use a service. including an explanation and. constructive and honest response. Patients who have a complaint about the care or treatment they have received have a right to a prompt. and explain fully and without delay to the patient: what has happened the likely short-term and long-term effects. you must not advertise your services by visiting or telephoning prospective patients. You must not falsely claim a high success rate or overstate your qualifications. 29. give this information to the patient’s partner or next of kin. You must not withhold 12 Refer to the Council’s statement on Disclosure of harm. apologise if appropriate. If a patient under your care has suffered serious harm or distress act immediately to put matters right. either in person or through an agent. avoid using titles such as “specialist” that refer to an area of expertise (unless you are registered with the Council in an appropriate vocational scope). When an adult patient has died. When a patient under 16 has died. 34. Advertising and promotional material should not foster unrealistic expectations. Similarly. You should not compare your services with those your colleagues provide.28. 36. explain to the parents or caregivers to the best of your knowledge why and how the patient died. Do not allow a patient’s complaint to prejudice the care or treatment you provide or arrange for that patient. Patients can find medical titles confusing. To reduce confusion. 35. You should express regret at the outcome. for example. 30. by arousing ill-founded fear for their future health. 32. You must cooperate fully with any formal inquiry into the treatment of a patient (although you have the right not to give evidence that may lead to criminal proceedings being taken against you). You must cooperate with any complaints procedure that applies to your work. Claims you make about the quality or outcomes of your services should be evidence based. 31. Dealing with adverse outcomes 12 33. an apology. 16 Cole’s Medical practice in New Zealand 2011 .

37. Most doctors work in teams with a wide variety of health professionals and non-medical health and disability workers. If you are working in a team with other health professionals. 14 See the Council’s online advice Deciding whether to make a competence referral at www. When working in a team: respect the skills and contributions of your colleagues communicate effectively with colleagues both within and outside the team make sure that your patients and colleagues understand your responsibilities in the team and who is responsible for each aspect of patient care participate in regular reviews and audit of the standards and performance of the team. You must also help the coroner when an inquest or inquiry is held into a patient’s death. This procedure helps to ensure that others take over the work you are restricted from doing and that the conditions on your practice are met. Working in teams is likely to become even more common in the future. 39. and advocate for. doctors must act in.relevant information.nz under the heading Publications >>Guidance. the best interests of the patient. In all dealings with team members. offer appropriate advice when needed to help ensure patient safety. You may also need to oversee prescribing by other health professionals in one of the situations described below. see the Council’s statement on Responsibilities of doctors in management and governance. taking steps to remedy any deficiencies support colleagues who have problems with performance. Overseeing prescribing by other health professionals 40. Working in teams 13 38. Cole’s Medical practice in New Zealand 2011 17 . conduct or health 14 share information necessary for the continuing care of the patient. You must tell your employer or colleagues if the Council places restrictions or conditions on your practice because of concerns about your clinical performance. 13 If you are responsible for leading a team.mcnz. Some other health professionals have legal and independent prescribing rights.org. Working in teams does not change your personal accountability for your professional conduct and the care you provide. When other health professionals have prescribing rights 41.

make suitable arrangements for your patients’ medical care. Some teams delegate to non-doctors the responsibility for initiating and/or changing drug therapy. Formal handover is essential. If the non-doctor prescriber is working from standing orders. usually their general practitioner. experience. you need to know the range of specialist services available. General practitioners must take particular care when arranging locum cover. The chain of responsibility must be clear throughout the transfer. When you are going off duty. 43.Standing orders 42. You must be sure that the locum has the qualifications. Going off duty 45. you should insist that time is set aside for the sole purpose of organising appropriate handover. In an environment where doctors work in rotating shifts. Arranging cover Transferring a patient 44. Use effective handover procedures and communicate clearly with colleagues. knowledge and skills to perform the duties he or she will be responsible for. Support your non-doctor colleagues in these situations by: regularly auditing the non-doctor prescriber making yourself available by phone for advice. he or she must remain under the care of one of the two at all times. the more important it is to ensure appropriate communication at the point of transfer. 18 Cole’s Medical practice in New Zealand 2011 . The higher the degree of activity. If you are a general practitioner and refer patients to specialists. When a patient is being transferred between a doctor and another healthcare practitioner. Arranging a locum 46. 48. then the responsibility for the effects of the prescription rests with the doctor who signed the standing order. It is in patients’ best interests for one doctor. The central role of the general practitioner 47. to be: fully informed about patients’ medical care responsible for maintaining continuity of medical care. More and more. other health professionals work in teams with doctors.

17 See the Council’s statement on Confidentiality and the public safety. 15 See the Council’s booklet Induction and supervision for newly registered doctors. this information should be provided in a face-to-face or telephone discussion with the admitting doctor. Many types of care arrangements are possible and patients need to know how information is shared among those who provide their care. Where the transfer is for acute care. you may have seen and treated the patient but not be the patient’s general practitioner. Although you are not responsible for the decisions and actions of those to whom you delegate. The patient may have self-referred or you may have seen the patient on referral from his or her general practitioner or another health professional 55. Make sure you appropriately document all referrals. For example. 16 See the Council’s statement on The maintenance and retention of patient records. Referring involves transferring some or all of the responsibility for the patient’s care. and explain the benefits of. 50. Referring the patient is usually temporary and for a particular purpose. Always pass on complete.16 Sharing information with the patient’s general practitioner 17 54. you remain responsible for your decision to delegate and for the overall management of the patient. Delegating involves asking a colleague to provide treatment or care on your behalf. Referring patients 51. relevant information about patients and the treatment they need.Delegating patient care to colleagues 15 49. 53. Cole’s Medical practice in New Zealand 2011 19 . In all these situations you should seek the patient’s permission to. When you refer a patient. or treatment that is outside your competence. provide all relevant information about the patient’s history and present condition. sharing with the general practitioner information such as: test results details of your opinion any treatment you have started or changed any other information necessary for the patient’s continuing care. 52. such as additional investigation.

When you order a test and expect that the result may mean urgent care is needed.56. Some situations exist in which the general practitioner should be informed even if the patient does not agree (for example where disclosure is necessary to ensure appropriate ongoing care). Do not bully or harass them. your referral must include one of the following: your out-of-hours contact details the contact details of the health practitioner providing after-hours cover. Treat your colleagues fairly and with respect. including doctors and other health professionals. Once you have the patient’s permission to share information. Under the Health Act 1956 you may share information in these situations when the general practitioner is providing ongoing care and has asked for the information. race. You must be readily accessible to colleagues when on duty. 57. or ethnic or national origin culture or lifestyle disability gender or sexual orientation marital or parental status religion or beliefs social or economic status. By law. 18 Colleagues are those you work with. including doctors applying for other jobs. In most situations you should not pass on information if the patient does not agree. 61. provide the general practitioner with this information without delay. You must not allow your professional relationship with colleagues to be affected by their: age colour. Providing your contact details 58. 20 Cole’s Medical practice in New Zealand 2011 . 62. or in the judgement of those treating them. you must not discriminate against colleagues. You must not make malicious or unfounded criticisms of colleagues that may undermine patients’ trust in the care or treatment they receive. 60. Collaboration Working with colleagues 18 59.

appraising and assessing doctors and students 21 66. Making decisions about access to medical care 20 65. 19 Managers and employers of doctors should also see the statement on Responsibilities in management and governance and the statement on Employment of doctors and the Health Practitioners Competence Assurance Act 2003. 20 See the Council’s statement on Safe practice in an environment of resource limitation. Doctors have a responsibility to the community to foster the proper use of resources – in particular by making efforts to use resources efficiently. training. If you are involved in teaching you need to develop the attitudes. which is important for the care of patients now and in the future. Providing objective assessments of performance 68. knowledge. training. Cole’s Medical practice in New Zealand 2011 21 . consistent with good patient care. 22 See the Council’s booklet Induction and supervision for newly registered doctors. Challenge colleagues if their own behaviour does not comply with the guidance in this section. 21 See the Council’s publication Education and supervision for interns. Supervision for newly registered doctors 22 67. make sure you supervise at an appropriate level taking into account the work situation and the level of competence of those being supervised. awareness. skills and practices of a competent teacher.63. Doctors and managers need to work together in a constructive manner to create an environment that encourages good medical practice. Scholarship Teaching. An integral part of professional practice is teaching. appraising and assessing doctors and students. junior colleagues and international medical graduates who are new to practise in New Zealand. including those you have supervised or trained. including locums. Be honest and objective when appraising or assessing the performance of colleagues. Management 19 64. are properly supervised. Make sure that all staff for whom you are responsible and who require supervision. Patients may be put at risk if you describe as competent someone who has not reached or maintained a satisfactory standard of practice. If you are responsible for supervising staff.

and that the research meets all regulatory and ethical requirements accept only payments that a research ethics committee has approved do not allow payments or gifts to influence your conduct 23 do not make unjustified claims for authorship when publishing results report any concerns to an appropriate person or authority. 24 See the Council’s guidelines on What you can expect – the performance assessment and Continuing professional development and recertification. 22 Cole’s Medical practice in New Zealand 2011 . When providing references do so promptly and include all relevant information about your colleagues’ competence.Writing references and reports 69. Use the following guidelines if you are involved in designing. undertaking further training where necessary 24 assess treatments to improve future services contribute to inquiries and sentinel event recognition and reporting. Provide only honest. organising or carrying out research: put the protection of the participants’ interests first act with honesty and integrity make sure that a properly accredited research ethics committee has approved the research protocol. and for improving the health of the population as a whole. In particular: take part in clinical audit. Maintaining and improving your performance 72. justifiable and accurate comments when giving references for. to help reduce risks to patients report suspected drug reactions using the relevant reporting scheme cooperate with legitimate requests for information from organisations 23 See the Council’s statement on Responsibilities in any relationships between doctors and health related commercial organisations. Research is vital for improving care and reducing uncertainty for patients now and in the future. peer review and continuing medical education respond constructively to the outcome of audit. Research 70. 71. or writing reports about. appraisals and performance reviews. colleagues. Work with colleagues and patients to maintain and improve the quality of your work and promote patient safety. performance and conduct.

26 See the Council’s statement on Employment of doctors and the Health Practitioners Competence Assurance Act 2003 (HPCAA). You should also tell the Council about: incompetence disruptive behaviour by another doctor that risks causing harm to patients. you should follow your employer’s procedures or tell an appropriate person. If you are not sure what to do. Professionalism Raising concerns about patient safety Concerns about colleagues 26 74. Your comments about colleagues must be honest. Keep your knowledge and skills up to date throughout your working life: familiarise yourself with relevant guidelines and developments that affect your work take part regularly in educational activities that maintain and further develop your competence and performance observe and keep up to date with all laws and codes of practice relevant to your work. Patient safety comes first at all times. In less serious circumstances. respond constructively. Some of these requirements are outlined in the Council’s statement on Confidentiality and public safety. do your best to find out the facts. Under the Act you must tell the Council if a doctor’s ill-health is adversely affecting patient care. Before taking action. or in situations involving other health professionals. ask an experienced colleague for advice. performance or health.org. Then. 25 Keeping up to date 73.monitoring public health. 77. you may prefer to tell the: medical officer of health chief medical officer chief nursing officer 25 You must comply with the requirements of the Health Information Privacy Code. See also Deciding whether to make a competence referral on our website at www.nz under the heading Competence >>Concerns about competence. Protect patients from risk of harm posed by a colleague’s conduct. 76. 75. 78. If a colleague raises concerns about your practice. if action is necessary.mcnz. Cole’s Medical practice in New Zealand 2011 23 .

You have additional responsibilities if you are involved in management or governance. policies or systems. If you are concerned that patient safety may be at risk from inadequate premises.chief executive appropriate registration authority Health and Disability Commissioner’s office. resources. equipment. You must cooperate fully with any formal inquiry into the treatment of a patient and with any complaints procedure that applies to your work. complete or sign documents or give evidence. If you have agreed or are required to write reports. For example. Disclose to the appropriate authority any information relevant to an investigation into your own or a colleague’s conduct. 85. 28 See the Council’s statement on Medical certification. 29 See the Council’s statement on The responsibilities of doctors in management and governance. Make clear the limits of your knowledge or competence. 82. Writing reports. 30 Refer to the Council’s statement on Providing care to yourself and those close to you. do so without delay. Protect your patients. If you are asked to give evidence or act as a witness in litigation or formal proceedings. Your health 30 84. Cooperating in formal proceedings 81. Concerns about premises. be honest in all your spoken and written statements. In all other cases you should record your concerns and tell the appropriate body. Do not treat yourself. Additional responsibilities for managers 29 83. equipment or other resources. policies and systems 27 79. your colleagues and yourself by: following standard precautions and infection control practices 27 See the Council’s statement on Safe practice in an environment of resource limitation. you must ensure that procedures are in place for raising and responding to concerns. giving evidence and signing documents 28 80. performance or health. put the matter right if possible. 24 Cole’s Medical practice in New Zealand 2011 . Make sure you register with an independent general practitioner so that you have access to objective medical care.

31 Integrity in professional practice 88. Integrity – being honest and trustworthy – is at the heart of medical professionalism. You must inform the Council without delay if. Do not express to your patients your personal beliefs. Ask for and follow their advice about investigations. 32 See the Council’s resource Sexual boundaries in the doctor-patient relationship. Do not rely on your own assessment of the risk you may pose to patients. The committee will help you decide how to change your practice if needed. Do not become involved in any sexual or improper emotional relationship with a patient or someone close to them.undergoing appropriate screening being immunised against common serious communicable diseases where vaccines are available. including political. 86. Cole’s Medical practice in New Zealand 2011 25 . 89. religious or moral beliefs. You must tell the Council’s health committee if you have a condition that may affect your practice. in ways that exploit their vulnerability or that are likely to cause them distress. If you are suspended from working. 31 See The HRANZ joint guidelines for registered health care workers on transmissible major viral infections (a statement developed by the Council with other regulatory bodies). or have restrictions placed on your practice. treatment and changes to your practice that they consider necessary. you must consult a suitably qualified colleague. 87. anywhere in the world: you have been charged with or found guilty of a criminal offence you have been suspended or dismissed from duties by your employer you have resigned for reasons relating to competence another professional body has found against your registration as a result of ‘fitness to practise’ procedures. you must inform without delay: any other organisations for which you undertake medical work any patients you see independently. If you think you have a condition that you could pass on to patients. Make sure that at all times your conduct justifies your patients’ trust in you and the public’s trust in the profession. 91. judgement or performance. 90. 32 92.

gift. Hospitality. 94. Conflicts of interest 96. Do not ask for or accept any inducement.33 In particular. note the following: before taking part in discussions about buying goods or services. note the following: inform patients about your fees and charges before asking for their consent to treatment do not exploit patients’ vulnerability or lack of medical knowledge when making charges for treatment or services do not encourage patients to give. When making recommendations or referrals. The guidelines contained in Good medical practice do not cover all forms of professional practice or discuss all types of misconduct that may bring your registration into question. declare any relevant financial or commercial interest you or your family might have in the purchase make sure funds you manage are used for the purpose for which they were intended and are kept in a separate account from your personal finances declare any relevant financial or commercial interest in goods or services provided by you or another person or entity.Financial and commercial dealings 93. Act in your patients’ best interests when making referrals and providing or arranging treatment or care. In particular. the way you prescribe for. The same applies to offering such inducements to colleagues. insurers and other organisations or individuals. Be honest in financial and commercial dealings with employers. you must declare any relevant financial or commercial interest. 26 Cole’s Medical practice in New Zealand 2011 . lend or bequeath money or gifts that will benefit you do not put pressure on patients or their families to make donations to other people or organisations do not put inappropriate pressure on patients to accept private treatment. or hospitality that may affect. treat or refer patients. gifts and inducements 95. or be thought to affect. You should familiarise yourself with the series of 33 See the Council’s statement Responsibilities in any relationships between doctors and health related commercial organisations. Be honest and open in any financial dealings with patients.

Legislation places further legal obligations on doctors – see chapters 22 and 23 – consult your lawyer if you need advice about your legal obligations. Piripiri. and places obligations on all people and organisations providing health and disability services. 34 For a complete set of Medical Council statements.org. biddybiddy.statements and other publications produced by the Council (see appendix A). go to www. Acaena novae-zelandiae. including doctors (see chapter 23).nz under the heading Publications.34 The Council’s statements expand on points raised in this document. For the most recent versions of the statements. email folder@mcnz.nz or telephone 0800 286 801 extension 793.mcnz. Standards set by other agencies The Code of Health and Disability Services Consumers’ Rights gives rights to consumers. Traditionally the code of ethics for the medical profession in New Zealand is that of the New Zealand Medical Association (see chapter 18). New and updated statements are sent to all doctors with the Council’s newsletter. Cole’s Medical practice in New Zealand 2011 27 . Some statements also cover issues not addressed in this document.org. such as internet medicine and alternative medicine.

Care in public hospitals is free. New Zealand trained doctors have contributed significantly on the international stage over decades. Twenty District Health Boards (DHBs) are largely responsible for dispersing the public funds. including health service provision. general practice visits and pharmaceuticals are subsidised. highlighting the high standard of medical practice. and purchasing required medical and disability services from public hospitals. general practitioners and nongovernment organisations. in spite of the country’s small size. Health service structure Medical Services in New Zealand are primarily delivered through publicly funded services.2 The organisation of medical services in New Zealand John Adams is Chairman of the Medical Council and Dean of the Dunedin School of Medicine. Public funding accounts for about 78 percent of service provision. Health service structure Ministry of Health and National Health Board Changing models of care Registration of medical professionals The Medical Council of New Zealand Workforce Education and postgraduate training Medical liability Drug purchase and prescribing Medical research Doctors’ associations Accidents Organisation of medical services in hospital practice Organisation of medical services in general practice Introduction New Zealand has a proud history of social reform and innovation. 28 Cole’s Medical practice in New Zealand 2011 . There are strong structures in place to protect patient rights and ensure that people receive the highest level of medical care possible within the available resources.

governed by Boards. General practitioners predominantly own their practices. Private hospital services are also full charge to the patient. General practice services are organised into Primary Health Organisations (PHOs). charging patients the full fee for their services. Boards are responsible to the Minister of Health through the Ministry of Health. Most GPs charge most patients a fee for service. there have been clear directions that the number of PHOs around the country is to be reduced. supported by the government. Each Board has a CEO who is responsible for operations and management. or in cases of severe negligence where exemplary damages can be sought. Ministry of Health and National Health Board The Minister of Health has overall responsibility for the health system and the Ministry of Health is principal adviser to the Government on health and Cole’s Medical practice in New Zealand 2011 29 . Doctors are therefore seldom sued. Many senior doctors also work in private settings. and active collaboration and combination between Boards is occurring.The governance of the DHBs lies with a board for each region that is partially elected at local body elections and partly appointed by the Minister of Health. New Zealand has a “no fault” accident compensation scheme which pays for a portion of treatment for accidents in primary care and in some specialist services. although some employment models are emerging. Many have held the view that there are too many Board areas for a country of New Zealand’s size. particularly surgery. Because of this there is only a right to sue in New Zealand for recompense of injuries that fall outside the scheme. by contract. which is passed to general practices and provides varying levels of subsidy for patient visits. The “no fault” scheme includes injury caused by medical treatment. including some DHB primary care services in hard to staff areas. mostly under the terms of national industry employment agreements covering senior doctors (SMOs) and junior doctors (RMOs) separately. Urban areas may also be serviced by Accident and Medical Clinics owned by conglomerates who employ doctors to staff the centres. The Accident Compensation Corporation (ACC) also pays public hospitals bulk amounts for their treatment of accident victims. Medical practitioners who work in public hospitals are employed by the DHBs. Through the DHBs PHOs receive capitated government funding. All patients need to be registered with a practice. Similarly to the moves to merge DHB operations. Several companies provide private health insurance with differing reimbursement plans.

Doctors can practice independently with general registration. general practice had become less well remunerated and less attractive as a specialty. and attract more trainees into general practice. There are initiatives to expand the services delivered by general practitioners and reduce barriers in the primary/secondary interface. workforce. International medical graduates can apply for registration under several pathways according to their planned work arrangements in New Zealand. 30 Cole’s Medical practice in New Zealand 2011 . and prescribes processes for assuring standards of competence. Significant additional funding has reversed this trend. but require a collegial relationship to oversee their work. with reductions in staffing levels and the creation of a National Health Board within its structure. Changing models of care Whilst general practice care had been the foundation of medical care in New Zealand. Both provisional general and vocational registration require a period of supervision. Regulatory Authorities set scopes of practice for each registrant.nz). or qualifications and training that are deemed to be as satisfactory as the Australasian training. purchasing of national services. The National Health Board is responsible for planning analysis and funding. which sets up Regulatory Authorities for each health profession. Registration of medical professionals Registration and regulation of medical practitioners is legislated by the Health Practitioners Competence Assurance Act. There is also a project to redevelop general practitioner training.disability policy. Medical vocational or specialist registration is recognised after the attainment of appropriate Australasian or New Zealand specialist college qualifications.mcnz. and moves are currently underway to further emphasise primary care delivery as the focus of patient care. information strategy and delivery and business services in the Ministry. conduct and fitness to practise.org. The Medical Council of New Zealand (see below) engages with Branch Advisory Bodies to assess whether doctors from overseas applying for vocational registration have equivalent or as satisfactory training as New Zealand trained specialists. Details of registration for international graduates are available on the Council website (www. and is responsible for leading and supporting the sector. until the last decade. performance monitoring. The Ministry is currently undergoing significant changes and restructuring.

refers conduct issues for further assessment if required. at Auckland University and the University of Otago. including redeveloping the general practice training and piloting physician assistants in the New Zealand context. Education and postgraduate training There are two medical schools in New Zealand. The Council registers doctors and issues practising certificates. It is not a disciplinary body. Christchurch and Wellington. A series of recent reports led to the creation of Health Workforce New Zealand as a committee to advise both the Minister of Health and the Director General of Health on a workforce plan and its implementation. Its statutory role is to protect the health and safety of the public in New Zealand by ensuring that doctors are competent and fit to practise. specialist college training programmes and the intern (PGY1) year.The Medical Council of New Zealand The Medical Council of New Zealand (the Council) is the statutory regulatory authority for medical practitioners. The government has recently increased student numbers in both schools. The Council is also responsible for accrediting educational programmes for doctors including medical schools. which has campuses for medical training in Dunedin. and assesses and monitors the health of sick doctors. In practice. All patient complaints in New Zealand are channeled initially through the Health and Disability Commissioner’s Office (see Chapter 23). Workforce Future workforce issues have been a major discussion topic for over a decade. much of the accreditation of medical schools and Australasian colleges is done in collaboration with the Australian Medical Council (AMC). although it manages some complaints to do with professional conduct. There have been several reports indicating the need for concerted action to provide enough doctors in New Zealand as the demands increase with an aging population and changing workforce patterns. deals with issues of competence when they arise and may institute remedial competence programmes. The committee is working quickly and has established a workplan and several initiatives. There are placements for undergraduate students in all major hospitals and increasingly in provincial and rural hospitals. General practices throughout the country are also Cole’s Medical practice in New Zealand 2011 31 .

Indemnity organisations provide legal advice to individual doctors. Indemnity cover is recommended and required by most employers. It is usual for employers to reimburse fees. Medical research New Zealand has an international reputation for the quality of its medical research. research is also performed outside the universities.involved in undergraduate experience and teaching. Increasingly. the Medical Council. Some drugs are only available for prescription by specialists. Funding for medical research is tight. PHARMAC establishes a schedule of subsidised medicines which details the various restrictions and availability of medicines. and purchased from the health providers through the Clinical Training Agency of the Ministry of Health. but available from many sources for good projects. Vocational training is the responsibility of the colleges in association with the employers and the universities. Training in the PGY1 or probationary registration year is managed by the hospitals who are accredited by the Medical Council to provide an adequate supervision and training experience. Specialist qualifications in New Zealand are Fellowships of the specialist colleges. the Health & Disability Commissioner. Medical liability Whilst doctors are rarely sued in New Zealand. there are numerous ways in which their conduct and competence can be investigated including by employers. 32 Cole’s Medical practice in New Zealand 2011 . Both medical schools have established rural programmes. Coroners inquiries. which distributes more than $80M annually of public funds. and yet others require a special authority to be prescribed. All doctors in New Zealand must participate in ongoing education in order to gain their practising certificate. in DHBs and primary care. etc. The predominant purchaser of medical research in New Zealand is the Health Research Council. The Medical Council accredits the CPD programmes of the colleges and audits compliance by doctors. gained after meeting their training and examination requirements. The training programmes are set and supervised by the specialist colleges. Drug purchase and prescribing Medicines are purchased in New Zealand on behalf of the government by a central purchasing agency called PHARMAC.

General practice registrars are employed by general practitioners to provide services as a part of training. gain vocational registration with the Medical Council and are employed as Senior Medical Officers with the DHB. The medical structure of health delivery teams on a service usually consists of a SMO. Smaller special interest associations such as Te Ora (the Maori doctor’s association) and the Pasifika Medical Association cater in addition for the needs of some specific groups of doctors. registrars (residents) come under the auspices of the relevant college. Once in a training programme. Most young doctors complete a second house surgeon year before entering formal training programmes in their chosen specialty. some funding has been made available for house surgeons to experience attachments in general practices. Industrial organisations for senior doctors (Association of Salaried Medical Specialists). Cole’s Medical practice in New Zealand 2011 33 . registrars become fellows of the appropriate college. are responsible for negotiating with health providers for salaried doctors terms and conditions. deals with medico-political issues and generates the Code of Ethics. Organisation of medical services in hospital practice The 6th year of medical school in New Zealand is known as the “Trainee Intern” year. which has Specialist. In recent years. After graduation. registrar. and are supervised by college accredited supervisors.Doctors’ associations The major professional association in New Zealand is the New Zealand Medical Association (NZMA). After fulfilling the required training experience and exams. where they are under the supervision of the general practitioner. house surgeon and possibly trainee intern. the first house surgeon or PGYI year is a probationary registration year with requirements from the Medical Council having to be met before full general registration is approved. where students participate in medical teams in a junior capacity whilst maintaining their student learning. and house surgeons and registrars (Resident Doctor’s Association). Trainee interns also contribute in general practices. General Practitioner and Doctors in Training Councils. The NZMA publishes the New Zealand Medical Journal. Most general practitioners own and run their own practices as small businesses either individually or more commonly in groups. Organisation of medical services in general practice General practitioners in New Zealand are both vocationally registered and generally registered practising under the supervision of a collegial relationship.

124(5):497–504.” Ann Intern Med 1996 Mar 1. Financial matters need to be clear and not used to take advantage of any patient or organisation. Doctor patient relationship The doctor patient relationship is the core of clinical medicine. 36 and will usually result in improved job satisfaction for the doctor. honesty. Respect.” Can Med Assoc J 1995.3 The doctor patient relationship Caroline Corkill is an Invercargill general practitioner and GP Liaison for Southland Hospital. 152: 1423–1433. 34 Cole’s Medical practice in New Zealand 2011 . Second opinions can be useful. she has been a member of the Medical Council and its Education Committee. 36 Stewart MA. An effective relationship will help the patient feel better and be healthier. Sexual relations between a doctor and patient are unacceptable. 35 Kaplan SH et al. “Characteristics of physicians with participatory decision making styles.35. Doctor patient relationship Communication Respect Confidentiality Professional honesty Trust Sexual relations Financial matters Advertising Terminally ill patients Second opinions Ending a relationship Effective doctor patient relationships improve health. communication and trust are important in this relationship. confidentiality. The doctor must have knowledge and skills to practise medicine safely. but the relationship he or she has with each patient will also affect outcomes. Terminating a doctor patient relationship may be necessary but must be done with care. “Effective physician patient communication and health outcomes: a review. Cultural differences can affect the relationship.

277:553–559. The essential ingredients of a good doctor patient relationship are communication. culture. and with someone who is confused or unconscious it may be impossible. laugh and use humour tend to have less formal complaints than those who do not do these things. Cole’s Medical practice in New Zealand 2011 35 . illness and stage of life affect the interaction. friend or relative may facilitate understanding. A good doctor patient relationship will balance the rights and responsibilities of doctor and patient. Communication between people with different languages or expectations can be difficult. Personality type.316:1922–1930. encourage patients to talk. Editorial BMJ 1998. 37 Code of rights for consumers of health and disability services. treatment or advice is being sought and paid for. It is important to get help if communication seems a problem. Sometimes a nurse who understands the medical side of things can communicate this to a patient better than the doctor. Improving doctor patient communication. The Health and Disability Commissioner’s Code of Rights37 (see chapter 23) includes ten rights. 38 Meryn S. from the right to be treated with respect through to a right to complain. Sometimes communication is frustrating. respect. Some groups of doctors have circulated a corresponding list of rights for doctorsand the Medical Council has published You and your doctor which outlines what doctors should expect from patients. 39 Levinson W et al.39 The average time these doctors spend with a patient is longer than those who have a less participatory style. A doctor’s training and what a patient is used to can influence the expectations each has of the relationship. Physician patient communication. confidentiality. JAMA 1997.What makes a good relationship will vary in different situations. Patients today are considered health consumers and want to be active participants in decisions about their health.38 Effective communication is named as one of ten rights of consumers of health and disability services in New Zealand. professional honesty and trust. Some doctors have been trained to deal with illness whereas current emphasis is on patient centred care. Both the doctor and the patient contribute to them but it is the responsibility of the doctor to ensure they are present because he or she is the professional whose diagnosis. Health and Disability Commissioner’s Office 1996. A translator. check understanding.37 Doctors who educate patients about what to expect. Communication has always been important in doctor patient relationships but is becoming increasingly so. The Relationship with malpractice claims among primary care physicians and surgeons.

See also the Council’s Statement on cultural competence. age. The doctor is responsible for keeping the patient’s information confidential unless there is a serious or imminent danger in doing so. or with colleagues. their legal guardians (see chapter 22). social status or perceived economic worth to prejudice the treatment you provide or arrange. Disclosure of harm. 2004. race. or if the disclosure is not done in an open and honest manner. Doctors working in New Zealand will meet patients who have different values and priorities from their own. acknowledges that all medical treatment carries risk and encourages doctors to disclose where a patient has been harmed as the result of their medical care. Respect is necessary in an effective doctor patient relationship. Care should be taken that the relatives involved in these decisions are immediate next of kin or holders of enduring power of attorney with regard to personal health and welfare in the case of adults. decisions may need to involve consultation with relatives of the patient.”40 Cultural competence is the ability to communicate effectively and respectfully with people of other cultures. colour. gender. 36 Cole’s Medical practice in New Zealand 2011 . If the patient is conscious the wise doctor will seek permission to discuss matters with a relative and should establish with the patient which relative is preferred. The Council quotes research that indicates a patient is more likely to complain if a doctor fails to disclose harm to the patient. There is nothing shameful about not knowing the solution to a medical problem.41 40 Good medical practice – a guide for doctors.In cases where the poor communication results from serious illness or injury. Medical Council of New Zealand. It is the doctor’s responsibility to make sure the patient is treated with respect regardless of the patient’s attitude and background. sexuality. A statement by the Medical Council. culture. It is dangerous to fake competence or pretend to know things.35 “You must not allow your views about a patient’s lifestyle. Medical Council of New Zealand. 2003. 41 Disclosure of harm. Professional honesty is about the doctor knowing the limits of his or her own competence and when to refer to someone else for help. Confidentiality and privacy follow when a doctor respects patients. beliefs. Reproduced as the Foreword in this book. An awareness of cultural factors enhances medical practice in New Zealand. It is becoming increasingly important. with its mixed ethnicity and policies of biculturalism. and for children.

2006. explaining sensitive examinations or treatment before carrying them out. Ways of maintaining professional boundaries include asking only relevant personal details when taking a medical history. Signs the professional relationship may be running into danger include arranging nonurgent appointment at odd hours. Doctors need to feel safe too. Cole’s Medical practice in New Zealand 2011 37 . actions or jokes that are sexually demeaning or are embarrassing. In some circumstances another person or institution pays for or subsidises this service. Financial matters Outside the public service the patient usually pays a fee for the service they receive from a doctor. if you think your behaviour or feelings towards a patient are becoming overly familiar or improper. avoiding words. providing privacy with screens for undressing. checking if the patient wants a chaperone present or support person. draping or dressing. Medical Council of New Zealand. keeping discussions and records confidential. discuss this with a trusted friend or colleague. You will need help to re-establish professional boundaries or you may be advised to help the patient find another doctor. the doctor keeping his or her own personal problems private.42 As a doctor. and sometimes asking the patient to allow someone at the doctor’s request. The Medical Council has produced a booklet to help explain what is considered a breach of sexual boundaries. arranging to meet outside work times and places.Trust is essential between a doctor and patient. Sexual relations Sexual relations between a doctor and a current patient are unacceptable. In general these agencies are entitled to check the doctor patient interaction took place. Sexual boundaries in the doctor patient relationship. telling patient intimate details of his/her life especially personal crises. The best protection for both is healthy professional boundaries. sexual desires or practices. A patient who needs to reveal him or herself intimately physically and emotionally to a doctor feels vulnerable. and have access to 42 The importance of clear sexual boundaries in the doctor patient relationship.

although when a doctor significantly discounts fees to a patient. Sometimes a family member pays for a child. Who is going to have access to information from the doctor patient interaction should be sorted out and recorded before the interaction if possible. Similarly the insurance company is entitled to ask for proof the consultation or treatment took place (usually by seeing the receipt). If it is requested after the event the patient’s consent must be sought and gained before information is released to the other party. It is important that patients give consent for this to happen and there is appropriate documentation of this consent. Some people have medical insurance which enables them to claim back part or all of their treatment costs. See also the Council’s Statement on advertising. parent or spouse to see the doctor and then feels they are entitled to information about the consultation. If this is not signed it will not pay. accurate and comply with the Fair Trading Act and with Advertising Standards Complaints Authority guidelines. When doctors charge an organisation for a service provided to a patient there is an ethical obligation not to charge a higher price than they normally charge the patient directly. The Code of Ethics43 (chapter 18) and Good medical practice (chapter 1) recommend doctors provide information about their services in a way that does not put pressure on people to use their services. but they are not entitled to know personal health details. insurance companies and the police. When ACC pays for the consultation it has a form which requests enough information to determine whether it should pay for the services. nor should they use comparisons with services provided by colleagues. Sometimes the medical insurance company pays the doctor directly for the service. that discount need not be applied to the fee for an organisation. Advertising Advertising is increasing in medical and health services.information which has been depersonalised for statistics. In other situations insurance companies or employers pay doctors to examine patients and give the company the information. employers. 43 Code of ethics. This may happen with family members. New Zealand Medical Association. Doctors will differ in what level of advertising they feel comfortable with. 2002 (see chapter 18). but advertisements should be relevant. 38 Cole’s Medical practice in New Zealand 2011 .

patients with other terminal illnesses. While most patients have cancer. When care is more concerned with comfort and quality of life rather than length of life it is called palliative care. There is public debate about euthanasia which is not legal nor supported by medical authorities in New Zealand. Doctors who are part of shared after hours services may make different arrangements for terminally ill patients to minimise disruption to their care. like motor neurone disease. This may be for Symptom control for better control of pain. including pain control. To find out about the hospice in your area visit www. It is often difficult to discuss financial arrangements with terminally ill patients and their families but it is important the patient is informed about what costs they are likely to encounter.hospice. Hospices are for all terminally ill people in need irrespective of their religion.Terminally ill patients The care of terminally ill patients requires good doctor patient relationships. People make requests of friends. It is advisable to remain informed about this debate. Thirty seven hospices come under Hospice New Zealand’s umbrella. Ethical issues surrounding the care of terminally ill patients can be confusing. Hospices can provide effective physical symptom management. age or ability to pay. Some doctors reduce their charges for terminally ill patients and some patients have access to different subsidies. Communication and teamwork are crucial when extended family or wh nau and other health professionals are involved in a patient’s care. The decision to say a person is “not for resuscitation” (NFR) can change as the clinical condition of the patient changes. Cole’s Medical practice in New Zealand 2011 39 . family or doctors not to resuscitate them actively in certain situations. If a doctor is feeling pressured by a patient or family he/she should seek advice or support from colleagues. Advance directives have legal standing in the Code of Health and Disability Services Consumer’s Rights (See chapter 22). In an inpatient unit patients are admitted for a few days or weeks for specialist care. “Living wills” and “Advance directives” can help guide clinicians in their decisions but do not necessarily anticipate the problems which actually arise.. organ failure or HIV/AIDS also receive care. It is important to decide what the patient would want in the given circumstances.org. race. In New Zealand hospices specialise in this. Continuity of care is important in these situations.nz or phone 04 499 0266. nausea or vomiting Respite care short term care to give carers a break Terminal care for patients who are in the final stages of their illness In a hospital mainly for symptom control and pain relief.

Medical Council of New Zealand Statement 2004.45 It is prudent for the doctor to help the patient find a new doctor and transfer the records either directly or via the patient. 45 Guidelines for doctors ending a professional relationship. However.44 In such cases the doctor should usually tell the patient why the relationship is being terminated. Ending a relationship The doctor patient relationship can be terminated by a patient who is moving to another place or who wishes to see another doctor. It can be hard to explain to patients they would be better seeing someone else for a certain problem. October 1997 p 33. Patients sometimes find it difficult to ask for a second opinion so any indication of their wanting this should be taken seriously. or is not happy with what is going on. If doctors want to keep original notes of their own. Discussing the referral tactfully. In situations where there is any possibility of a complaint from the patient it is wise for the doctor to seek advice from his or her defence organisation before ending the relationship. asking why the patient would like to see that other health professional without being judgmental is hard but important.45 Termination of the relationship may be done providing the patient is not acutely in need of immediate care and has been given enough notice to find another doctor. 44 Phipps. 40 Cole’s Medical practice in New Zealand 2011 . In these circumstances the doctor should make a clear note in the file. A patient should be referred for a second opinion when the doctor is outside the limits of his or her competence. whichever is requested by the patient or is most appropriate. if the patient wants to get an opinion from the other person they are entitled to do so. permission should be sought to discuss the case with colleagues. If the patient will not agree to see another doctor.Second opinions A second opinion should be arranged when a patient asks for one. If after the relationship has ended the patient should call on the doctor for help in an emergency the doctor is still obliged to attend. If the patient wants to see someone whose views the doctor does not agree with this can put the doctor in a difficult position. Helping the patient get the second opinion may improve the relationship. The doctor may need to say he or she has different views. A doctor may decide to discontinue seeing a patient only when there is a breakdown in the patient doctor relationship such that the doctor is rendered incompetent to treat the patient. copies must be provided for the patient or new doctor at no cost. New Zealand Doctor. G. and create an opportunity to learn from a colleague.

have always lived here. the health environment often still feels strange and alienating to me even though I know a lot about it. I am aware that it can be far more difficult for patients with less education. social and community work. and I am from the “dominant” culture. I have also personally experienced and heard about many excellent health experiences but somehow the not so good ones are often more prominent in my mind. I feel nervous about what I don’t know and also what I do know from my own past experiences and the stories I have heard from others. for those who feel judged because of how they look.4 Cultural competence and patient-centred care Jean Hera was a lay member of the Medical Council from 2001-2009 and has a background in consumer health issues. It is Cole’s Medical practice in New Zealand 2011 41 . Although I was born in this country. and certainly not on behalf of others in all their diversity. What then is important to myself and other patients in receiving culturally competent patient-centred medical care? This is not an easy question to answer simply. including my rights as a health consumer and how to follow up on any concerns that I may have. act or because of their lifestyle. and for many of those who can no longer speak or act for themselves. for those who don’t have English as a first language or who barely speak English at all. whose culture is far removed from the context they are in. Cultural competence – a consumer perspective Cultural competence – the requirements The Act The Medical Council of New Zealand The Code of Health and Disability Consumers’ Rights Cultural competence and the context of New Zealand society Recognition of the importance of bicultural heritage and development Encountering New Zealand society Is cultural safety a better term for a patient-centred approach? Cultural competence: patient-centred and family-centred approaches Cultural competence – an ongoing journey Cultural competence – a consumer perspective As a patient I feel vulnerable and I find it hard to feel empowered even as a knowledgeable and assertive person.

We patients need you. knowledge and skills that enable you to be nonjudgmental and show us respect and understanding. We also need doctors to engage well and in a culturally competent way with our family and other support people when this is appropriate. and pronounce our name correctly or at least talk with us so that you can learn how to do this. We want you to behave in ways that make us feel safe. It is helpful when you are friendly. to develop a general and interconnected set of attitudes. If it is possible. behaviours. assist us to ask questions and give feedback about any concerns we have.questionable whether I should even attempt to speak on behalf of others. We hope that our doctors are culturally sensitive in all aspects of their work with us. If you manage to achieve this as well it could be very helpful unless you embarrass and undermine us by knowing more about our culture than we do – but then this would not be our lived culture. Cultural competence also needs to extend beyond the patient to apply to interactions with colleagues and others encountered in the health environment to help ensure safe. not just to our face. and to communicate well. Cultural competence involves the heart as well as the intellect. and we want to be listened to. to be approachable. We appreciate it when you show humility and assist us to tell you if there is any cultural need we may have that you are not aware of. However in my roles as a lay member or health consumer representative I am attempting to bring a strong and inclusive (but reasonable) consumer voice. and when we are conscious. We can teach you a lot if you are open to this. If we do not understand you we may find it hard to tell you this and in some cultural contexts even nod as if we do understand. If our requests cannot be accommodated we want you to be honest with us about why this is. Is this too much to ask? 42 Cole’s Medical practice in New Zealand 2011 . however in some cultural contexts we may not want this and we may not find it easy to communicate this to you. If you are not able or are too busy to meet absolutely all these needs we hope you will help to develop and support health systems that can. help us to ensure that any important cultural requirements we have are accommodated. our doctors. As a general rule we want to be active partners in our health care decision making. Therefore I will attempt to do this. General cultural competencies must be recognised as significantly more important than developing a range of cross cultural knowledge about specific ethnicities and cultures. collaborative and supportive health systems are in place around us. We hope that you do not label us as noncompliant or difficult but work to find ways to understand our reality and adapt to this.

for example. Wellington. spiritual and other belief systems. and respectfully. Statement on cultural competence. disability. 48 Medical Council of New Zealand. Cole’s Medical practice in New Zealand 2011 43 . 47 Medical Council of New Zealand. skills and knowledge needed to achieve this. Wellington. 50 Medical Council of New Zealand by M uri Ora Associates. These statements provide guidance to the profession in developing cultural competence both as individual practitioners and in their broader contexts. 49 Medical Council of New Zealand by M uri Ora Associates. lifestyle. These include (but are not limited to) gender. 2003 p87. Statement on best practices when providing care to M ori patients and their wh nau. Cultural competence means a doctor has the attitudes. The definition of cultural competence in the Council’s statement is: “Cultural competence requires an awareness of cultural diversity and the ability to function effectively. 2006. 2010. Wellington.46 The Medical Council of New Zealand After a lengthy consultation process involving the profession and the public. sexual orientation. the Medical Council of New Zealand (the Council) released a general Statement on cultural competence in 200647 alongside a statement on best practices when providing care to M ori patients and their wh nau.Cultural competence – the requirements The Act One of the additional provisions for health regulatory authorities introduced under the Health Practitioners Competence Assurance Act 2003 (the Act) is that of setting the standards of cultural competence to be observed by health practitioners.50 The Council defines culture broadly – extending beyond ethnicity and recognising that patients identify with multiple cultural groupings. Best health outcomes for M ori: practice implications. age and socioeconomic status. Wellington. through practitioner groupings such as the specialist branch advisory bodies. Best health outcomes for Pacific peoples: practice implications. This is included under section 118(i) of the Act. 2006. In 2010 the Council published a resource booklet to assist doctors when providing services to Pasifika patients and their families. A culturally competent doctor will acknowledge 46 Health Practitioners Competence Assurance Act.48 A resource booklet prepared for the Council by M uri Ora Associates on practice implications with M ori patients and their wh nau49 was also released at this time. 2006. when working with and treating people of different cultural backgrounds.

M ori protocols and rituals of encounter have been incorporated into many health workplaces. This bicultural emphasis recognises M ori iwi (tribes) as the indigenous or first nation peoples (tangata whenua). is recognised as the founding document between M ori iwi and the British crown on behalf of the later arrivals. employment. as the later colonisers. beliefs. race. Right Two states that as a consumer you should be free from discrimination on the grounds of age.” The Code of Health and Disability Consumers’ Rights The Code of Health and Disability Consumers’ Rights (the Code)51 includes rights that relate to cultural competence. social and ethnic needs. M ori is an official language in Aotearoa/New Zealand. Treaty of Waitangi and Tikanga 51 New Zealand Code of Health and Disability Consumers’ Rights. 44 Cole’s Medical practice in New Zealand 2011 . That a positive patient outcome is achieved when a doctor and patient have mutual respect and understanding.That New Zealand has a culturally diverse population. values and beliefs. marital or family status. religious. language and manner which you can understand and that a competent interpreter should be available if you need one and if it is reasonably practicable. advisory and cultural services within District Health Boards (DHBs) and Primary Health Organisations (PHOs). That a doctor’s culture and belief systems influence his or her interactions with patients and accepts this may impact on the doctor-patient relationship. Cultural competence and the context of New Zealand society Recognition of the importance of bicultural heritage and development The establishment of cultural awareness and competency concepts and training in Aotearoa/New Zealand has usually incorporated an understanding of our bicultural heritage as a key understanding. the Treaty of Waitangi of 1840. gender. Right One is about being treated with respect and includes the statement that services should take into account your cultural. and the people from the other (originally predominantly British) cultures (tauiwi). Right Five states that information should be given in a form. Te Tiriti o Waitangi. Right Seven includes a statement that you may make decisions about body parts or bodily substances and this is of particular significance to some cultures including M ori. M ori/iwi health services have been established throughout the country as have M ori policy. sexual orientation or disability.

54 Wepa D (ed). is preferable to the term cultural competence.53 54 55 Both terms concern the relationship between 52 Durie M. Cultural safety in Aotearoa New Zealand. Pearson Education New Zealand. The importance of cultural safety”. may manifest differently for people of different cultures in the way symptoms are presented. for example depression. Wellington. April 2008. No 2.52 In addition to learning about M ori culture there are Aotearoa/New Zealand colloquialisms. humour and other shared cultural understandings to make sense of. These and many other aspects influence the make up and expression of New Zealand as a society. 55 Papps E. growing rapidly. Research concerning health disparities for M ori. and the context and processes involved with health care delivery. nurses. “Cultural safety: daring to be different” in Wepa D (ed). Australian and New Zealand Boards and Councils Conference. M ori cultural practices vary between tribal groups and understanding this assists respectful interactions. Aotearoa/New Zealand is increasingly becoming more diverse with the number and range of different ethnicities and cultures increasing and with some groups. are more prominent in certain areas and from 22 separate Pacific nations who have their own distinctive language.M ori training is ongoing and expected in many health workplaces in Aotearoa New Zealand. There are cultural patterns to be aware of. Pearson Education New Zealand. “Managing the cross-cultural consultation. 2005. for example. is important in the ongoing development to assist culturally competent practice with M ori. November 2001. 2005. Encountering New Zealand society There are numerous new challenges for overseas doctors in understanding the peculiarities of New Zealand society. Cultural safety in Aotearoa New Zealand. Significant additional differences are also evident between Pasifika peoples who have been born in Aotearoa/ New Zealand and those who have immigrated. many New Zealand men have a tendency to understate illness and may be reluctant to consult their doctor when unwell. educationalists and doctors assert that kawa whakaruruhau/cultural safety. NZFP. the term introduced by Irihapeti Ramsden and adopted by the nursing profession. Cultural competence and medical practice in New Zealand. and ways to address these. Auckland. Cole’s Medical practice in New Zealand 2011 45 . Is cultural safety a better term for a patient-centred approach? Although similar concepts. 53 Gray B. Auckland. such as Asian immigrants. culture and history. Pasifika communities are scattered throughout. some academics. It is important to recognise that illnesses. Vol 35.

Concepts of both cultural competence and cultural safety also recognise the importance of culturally appropriate and respectful professional relationships with colleagues and staff and the responsibility health professionals have in challenging cultural bias within health care systems where this brings negative impacts for patients. active in their treatment and are assisted to feel safe. It is argued that health consumers are then able to become full partners in health care interactions. 56 Clarke M E. biases. 46 Cole’s Medical practice in New Zealand 2011 . assumptions and expectations you bring and being able to question these while at the same time trying to imagine what it is like in your patients’ situations. It can be argued then that these terms are intertwined. the patient can and should determine what is culturally important to his or her needs. It is therefore argued that cultural safety fits better with a patient-centred stance. review these. having the ability to listen without interrupting and with a willingness and ability to extend your understanding to assist your patients.medscape. Introduction to Cultural Competency. maintain and develop cultural competency. Auckland. Cultural competence: patient-centred and family-centred approaches Patient-centred care places the needs of patients at the centre of health care interactions. Cultural competence involves working effectively with interpreters to enable and improve communication. consider how they might be improved. and develop awareness and knowledge for the future is important. 2005. Pearson Education New Zealand. “Exploring prejudice. That is. It involves engaging with difference. respected and empowered.56 It means being truly “present” with patients. and developing networks with individuals and organisations who can provide expertise to assist in better understandings of patients’ cultural needs. Competency requires safety and safety requires competency.57 The ability to look back on your patient/doctor interactions. A patient-centred approach needs to be central to both. 2008. However the development of culturally safe practice requires health practitioners to establish. Cultural safety in Aotearoa New Zealand.com/viewarticle/573591 57 Spence D.the helper (health professional) and the person being helped (the patient) however cultural competence is frequently described as being more centred on the health professional’s experience while cultural safety centres on the experiences of the patient. www. aware of the values. DeGannes C N. understanding paradox and working towards new possibilities” in Wepa D (ed).

58 There may be a preference for a paternalistic approach where doctors are expected to be the decision-makers. For many cultures and contexts family-centred approaches are important also as it is not possible to consider the patient without the wider unit of their wh nau/family and extended family. The key is being committed to the journey alongside patients. Cultural competence – an ongoing journey Cultural competence is an ongoing journey – there is always more that can be learned. Journal of Medical Ethics. Cole’s Medical practice in New Zealand 2011 47 .This self-reflection (reflective practice) is an important ongoing activity when working for ongoing improvement in cultural and other competencies. “Information disclosure and decision-making: the Middle East versus the Far East and the West. it is important to establish that this is what the patient genuinely wants and that they are not unwillingly being dominated by others. This preference is somewhat at odds in the modern healthcare environment influenced by for example the Code and Good medical practice59 and creates tensions that need careful management. Traversing this can be fraught with tensions and difficulties. Good medical practice. If the cultural context indicates a family-centred approach. their wh nau/families and other support people. and also when appropriate in the wider context of working alongside communities and health consumers to improve both the quality of services and health outcomes. revised 2008. It is important to remember that each patient context is different and assumptions are never helpful. et al. 59 Medical Council of New Zealand. 2008. Vol 34: 225-229. Wellington. Al-Kassimi F. Some families are not a positive environment for patients and may instead be a danger to them. standards for the profession. In some cultures patients and their families may prefer a family-centred approach to care and this can mean family members taking the lead in decision-making. Mokokaue 58 Mobeireek A F.

and ultimately improves overall M ori health status. M ori peoples are essentially a tribal society constructed from small family based units (whanau) organised into sub-tribes (hapu) which contribute to larger tribal entities (iwi). David Jansen (Ngati Raukawa) is a general practitioner in Auckland.5 M ori and health Peter Jansen (Ngati Raukawa) is Senior Medical Advisor with ACC. improves adherence to treatment plans.000 people (at census 2006) with expatriate communities in Australia (estimated 150.000). 48 Cole’s Medical practice in New Zealand 2011 . This chapter recognises that culturally competent practice should include consideration of M ori needs.000) and Britain (estimated 15. comprising some 624. Readers should familiarise themselves with the relevant Medical Council statements on cultural competence and resources to support culturally competent care. Providing culturally competent care for M ori increases the likelihood of M ori engaging with health professionals and health services. Chapters on other ethnic groups and on the principles of culturally competent care are also included in this book. Introduction M ori history and the Treaty The Treaty and health M ori health and inequalities Differential approaches to treatment The impact of culture on health Culture of the doctor M ori concepts and M ori health values M ori language Rongoa and traditional healers Further reading and additional information Introduction M ori are indigenous to New Zealand and a significant proportion of our society. values and preferences across all domains of practice.

describing it as a complete transference of power to the Crown. 1840. also concerns “tino rangatiratanga” or chieftainship. there were an estimated 2. The nearest M ori equivalent to the English term would have been “mana” or “rangatiratanga”. prior to being debated at Waitangi.M ori history and the Treaty Traditional and modern scientific knowledge concur that M ori arrived in Aotearoa/New Zealand from Hawaiki. By 1839. In 1840. in 1840. The second article. However many important chiefs refused to sign the Treaty. the British Government sent out Captain William Hobson to sign a treaty with the M ori chiefs. As a result the British Crown could make no claim on New Zealand without M ori agreement. whalers. fisheries and other properties. the east Polynesian homeland at least 500 years before contact with European explorers. The British Government appointed James Busby as British Resident in 1833 to protect British trading interests and counter the increasing lawlessness amongst traders and settlers. The English version specifically gives M ori control over lands. By contrast. resulting in two documents with different meanings and interpretation. The first article covers sovereignty. but the M ori version implies possession and protection of cultural and social items such as language and villages and promises much broader rights for M ori in regard to possession of existing properties. Over the next eight months. Hobson carried instructions from Lord Normanby of the Colonial Office to secure sovereignty over the independent state of New Zealand. sealers and settlers came to New Zealand.000 M ori living in New Zealand. the M ori version implies a sharing of power and uses the word “kawanatanga”. Both the English and M ori versions of the Treaty contain three articles but the M ori translation differs significantly from the English version. an improvised word which did not mean a transfer of authority from M ori to British hands. an increasing number of traders. but implied the setting up of a government by the British.000 P keh and 150. The English version states that M ori give up “sovereignty” to the British Crown. the Treaty was signed at more than 40 other locations by more than 400 M ori chiefs including some women. forests. at Waitangi in the Bay of Islands by forty-three Northland chiefs. an English missionary. After the late eighteenth century. Consequently. A Declaration of Independence was signed in 1835 by 52 M ori chiefs at the instigation of Busby and later tabled in the British Parliament. After a single day of debate the Treaty was signed on February 6. a treaty was drawn up and translated into M ori by Henry Williams. mainly about the protection of property rights. Cole’s Medical practice in New Zealand 2011 49 .

M ori tribes actively sought missionaries to settle in their areas to acquire these skills. 50 Cole’s Medical practice in New Zealand 2011 . Many of the rights guaranteed to M ori were violated.60 The cultural and political structure of New Zealand in 1840 was still essentially Polynesian. These protests largely fell on deaf ears until the establishment of the Waitangi Tribunal in 1975.Explanations given at the Treaty signings support the conclusion that M ori expected that rangatiratanga would be enhanced not eroded. social and economic disparities continue to exist. 200 cattle. M ori were actively and purposefully organising successful commercial ventures and exporting from their tribal estates to the growing settler communities in New Zealand and New South Wales. the M ori population reached its lowest point. and led to considerable protest from M ori. nearly 2. M ori commercial enterprise prospered. and 1.000 acres in maize. present. the document was ignored in spirit and disregarded materially for many years.000 pigs.000 while migration of non-M ori accelerated. 300 acres in potatoes. However.000 people – had an estimated 3. During this period. despite the promises and protection offered in the Treaty of Waitangi. Claims cannot be made against private organisations or individuals. Auckland: Auckland University Press. The Waitangi Tribunal was established in 1975 to rectify past breaches of the Treaty by the Crown. 5. M ori demonstrated a clear determination to gain the literacy skills of the Europeans. 1991. The manner in which the land was lost was often questionable. Taupo and Rotorua areas) consisting of approximately 8. In 1896. The third article promises M ori the same citizenship rights as British subjects. The Tribunal considers both English and M ori 60 Pool I. In addition they owned some 100 horses. During the twentieth century. Both versions of the Treaty of Waitangi are legitimate as both versions are signed. However. 4 water-powered mills. and all European residents absorbed M ori values to some extent.000 acres of land in wheat. and 43 coastal vessels averaging nearly 20 tonnes each. and projected. For instance in 1857 Te Arawa and Tuwharetoa M ori (connected tribes descended from the Te Arawa canoe and covering the Bay of Plenty.000 acres of kumara. Te iwi M ori: A New Zealand population past. the M ori population has recovered and at over half a million is now larger than ever before. 96 ploughs. estimated at 42. with the Queen or her representative having the power of governorship alongside their sovereignty as chiefs. and M ori lost most of their land through the nineteenth and twentieth centuries.

In many cases. forests and fisheries. Participation – involving M ori at all levels of the planning and delivery of healthcare services.62 The Treaty of Waitangi can be seen to apply to M ori health in numerous ways. loss of language and social disruption. St George. Since its establishment. M ori health in 2004. and Protection – working to ensure that M ori have at least the same level of health as non-M ori. the New Zealand Public Health and Disability Act 2000 recognises the Treaty of Waitangi. compensation can help to address some of the social determinants of health. In this context. In addition. In: Cole’s Medical Practice in New Zealand 2005. values. Cole’s Medical practice in New Zealand 2011 51 . Further.). The Treaty and health The Government has identified three principles derived from the Treaty and relevant to M ori health in key statements and policies. in the M ori version. some of the difficulties of conflicting texts (English and M ori) can be avoided. IM (ed. often including return of land and financial recompense. or precious possessions. Most importantly. 62 Tapsell R. and many others have been settled through direct negotiation between the Crown and claimant tribes. and practices. compensation has been granted.61 The principles are Partnership – working with M ori communities at all levels to develop strategies for the community’s health care. the Treaty ensures that “taonga”. New Zealand Disability Strategy and M ori Health Strategy. and the Royal Commission on Social Policy. In this way. which is vested in the tribal authorities for economic development.versions of the Treaty when making decisions and is also instructed to have regard for the principles of the Treaty rather than the precise words. by requiring District Health Boards to improve the health outcomes of M ori and other population groups. 61 New Zealand Health Strategy. the Waitangi Tribunal has ruled on many claims brought by M ori. In addressing land rights. and safeguarding M ori cultural concepts. health is sometimes considered a taonga. the Treaty should have ensured that M ori retained their land. would be protected and retained.

2006. and lung cancer that are several times those of non-M ori women. BMJ 2003. and M ori die. Brown N. 52 Cole’s Medical practice in New Zealand 2011 . Decades of Disparity: Ethnic mortality trends in New Zealand 1980-1 999. This is compounded by lower rates of diagnosis and lesser access to effective treatment. Wellington: Ministry of Health. Wellington: Ministry of Health. Ethnicity. Lay-Yee R. Blakely T. Ministry of Health.66 M ori infants die more frequently from SIDS and have lower birth weight than non-M ori children. cervical. Harwood M. which contributes to the higher incidence of diabetes (8 percent vs 3 percent) and the younger age at diagnosis (43 years vs 55 years). 64 Blakely T. 2004. Our health. Davis P.67 Avoidable death rates are almost double for M ori than for other New Zealanders. J. koiora roa. Fawcett J. Comparison of M ori and non-M ori patient visits to doctors. Ministry of Health and University of Otago.70 M ori women have rates of breast. Wellington. with M ori accounting for two thirds of the excess male cancer deaths and one quarter of the excess female cancer deaths.69 New Zealand has a higher rate of death from cancer than Australia. eight to ten years earlier. and quality: lessons from New Zealand. McCredie MRE. Tobias M. Pearson JA.115(1153):205-8 71 Ministry of Health. 65 ACC (Te Kaporeihana Awhina Hunga Whara). on average. The health status of indigenous peoples and others. our future.65 . the indigenous population of New Zealand make up approximately 15 percent of the New Zealand population. Hauora pakari. Decades of Disparity: Ethnic mortality trends in New Zealand 1980-1 999. our future. Bonne M. Wellington. koiora roa. 1999 72 Crengle S.68. Hauora pakari. 2003 67 Ministry of Health. Wellington. Tobias M. equity. Robson B. 64 as well as higher rates of illness.327:404–5 69 McPherson K. 2003. 66 Ajwani S. Ministry of Health and University of Otago. yet M ori have the poorest health of any New Zealand group. BMJ 2003. Our health.M ori health and inequalities M ori. Summary guidelines on M ori cultural competencies for providers. The health of New Zealanders. 1999 68 Ring I. M ori have a higher mortality rate than non-M ori63. Cheung J.72 63 Ajwani S. Blakely T. Bonne M. Decades of Disparity II: Socioeconomic Mortality Trends in New Zealand 1981 -1 999.71 There is a higher incidence of obesity in the M ori community (27 percent vs 16 percent). Atkinson. Robson B. Wellington: ACC. NatMedCa Report 6.327:443–4 70 Skegg DCG. McNaughton HK. Public Health Intelligence Occasional Bulletin #25. Tobias M. The health of New Zealanders. 2005. NZMJ 2002 May 10. Comparison of cancer mortality and incidence in New Zealand and Australia.

Scott KM.1. Stith AY. Utilisation of general practitioner services in New Zealand and its relationship with income. No 1: Ethnicity and Resource Use in General Practice in West Auckland Cole’s Medical practice in New Zealand 2011 53 . M ori attitudes to sickness. Nelson AR. 2000.nz/insideout/Forms/Culture_ PreRead. NZMJ 1977.pdf. 79 Analysis of the National Minimum Database over the period 1990–99 by Tukuitonga suggests bias against M ori receiving cardiac revascularisation procedures even though the clinical need is much greater. Presented at RNZCGP Annual Conference.78 Differential approaches to treatment Studies have consistently demonstrated that some doctors treat M ori differently from non-M ori.enigma. and government subsidy. Crampton PR.In summary.75. less effective treatment plans and are referred for secondary or tertiary procedures at lower rates than non-M ori patients.86:483. doctors.bopdhb.77 These negative experiences can also reinforce stereotypes within the practitioner community if a provider does not understand a M ori patient’s dissatisfaction and thus cannot prevent similar experiences with other patients.co. Experience in Practice 1 999. ethnicity. NZFP 2002 Oct. for longer periods.cfm?fuseaction=articledisplay&FeatureID=3 cited as: 31 March 1999 Vol 1.43:296–306. Washington DC: Institute of Medicine . 77 Laveist TA.73. Examples of this include the findings of the 2001–02 National Primary Medical Care Survey (NatMedCa) where it was observed that doctors spent 17 percent less time (2 minutes out of a 12 minute consultation) interviewing M ori than non-M ori patients. Similar evidence of 73 Marwick JC. 2003. demonstrating that culture is an independent determinant of health status. 75 Tipene-Leach David. 78 Jansen P. Ethnicity and resource use in general practice in West Auckland. Once age is taken into account. These disparities in overall M ori health persist even when factors such as poverty. education and location are accounted for. and hospitals. 76 Durie M. 79 Gribben B. but have less access to care and die earlier than P keh .nz/eip/ index. Nuru-Jeter A. ‘M oris: our feelings about the medical profession’ in Primary health care and the community. but obtain fewer diagnostic tests. Online article available at: http://hcro. 1981. Unequal Treatment: Confronting racial and ethnic disparities in health care.29(5):306-18. 74 Smedley BD. Sorenson D. M ori are sicker. Is doctor-patient race concordance associated with greater satisfaction with care? J Health Soc Behav 2002.76. M ori turn up for GP appointments at the same rate as non-M ori.govt.this article is also available at: http://www. Culturally competent health care.74 These lower standards of health lead to suboptimal outcomes for individual M ori and influence the M ori community’s negative perceptions of the health system as a whole. Note .

115(1146):6-9 84 Mauri Ora Associates Ltd. Associations between ethnicity and obstetric intervention in New Zealand. Time trends and seasonal patterns of asthma deaths and hospitalisations among M ori and non-M ori.84 80 McNaughton HK. NZMJ 2002 Jan 25.bias is available for outcomes following stroke80. There is evidence too of the impact of racism on M ori health status. and identified that the remaining differences in self-perceived health status between M ori and non-M ori could be accounted for in terms of self-perceived experiences of racism. Culture of the doctor Like other cultures M ori value highly effective communications with health professionals. beliefs and values. However the impact is that M ori patients are less likely to receive adequate care or adequate and understandable health information.115(1149):101-3 81 Sadler L. The comparability of resource utilisation for Europeans and non-Europeans following stroke in New Zealand. He Ritenga Whakaaroa M ori health experiences of health services. Reid P. These effects appeared to be dose-related: that is the greater the number of experiences of racial discrimination. 54 Cole’s Medical practice in New Zealand 2011 .115(1146):15-7 83 Ellison-Loschmann L. Heart failure: ethnic disparities in morbidity and mortality in New Zealand. NZMJ 2002 Mar 8. NZMJ 2002 Feb 8. the importance of a healthy environment.83 These studies point to unconscious bias by providers rather than frank racism in health service delivery. NZMJ 2002 Jan 25. which impacts both community and individuals. The impact of culture on health Culture plays an important role in health because culture influences behaviours through customs. McCowan L. King R. McPherson KM. the lesser was self-perceived health status. Weatherall M. obstetric intervention81. Taylor WJ. heart failure. Robson BH. Stone P. This will in turn compromise the ability of M ori patients to adhere to treatment recommendations and the effectiveness of any treatments offered. Pearce N.115(1147):36-9 82 Carr J. traditions. In addition. Workman P. Harwood. M. This is demonstrated by the importance placed on tüpuna (ancestors) and whakapapa (genealogical connections over many generations). Purdie GL. In the M ori world view.82 and asthma. Harris et al reviewed the New Zealand Health survey data and made adjustments for socio-demographic factors and deprivation. there is a fundamental belief that understanding and being connected to the past are important for both the present and the future. is incorporated into the world view of many M ori.

mana (reflecting authority. ordinary or safe.34. New Zealand Medical Journal 2002. All things to do with death or the body are tapu. while anything related to cooked food is noa. & Read. 2000. Tapu and noa Although tapu is often described as a state of sacredness. R. For example. Tauwai general practitioners’ talk about M ori health: interpretative repertories. in the case of a patient’s death the wh nau will likely wish to spend 85 McCreanor. M ori concepts and M ori health values M ori beliefs. Thom DH. Azari R. 115(1167). wairua (reflecting spiritual elements and power). 88 Baxter J. acceptability of treatment. Nairn. Doctors may have opportunity to recognise or come into contact with many M ori values. 87 Demystifying Rongoa M ori: Traditional M ori healing.7:48–53. 86 Johnstone. When physicians and patients think alike: patient-centered beliefs and their impact on satisfaction and trust. it also has the more general meaning of being special or restricted.86 It is expected that improved integration of cultural and clinical competence should lead to better outcomes through improvements in communication. 135-145. K. All these problems have been demonstrated in studies of general practitioners85 and psychiatrists in New Zealand. wh naungatanga (relationships interpersonal and familial) and manaakitanga (the duty and obligations of care). Noa is the absence of tapu and denotes the state of being normal. Many M ori feel that keeping tapu items separate from noa items is very important and find it distressing when this division is not observed. unconscious bias and unfounded beliefs about M ori by practitioners contribute to problems in communication between non-M ori doctors and M ori patients. 2002 89 Krupat E. Cole’s Medical practice in New Zealand 2011 55 . Bell RA. including tapu and noa (a pervasive stative dichotomy of restricted and ordinary or normal). City: publishing org. customs and values are often expressed as tikanga. T. Pac Health Dialog 2000. Barriers to health care for M ori with known diabetes. status and control). 89 Crengle S. The development of M ori primary care services. Tikanga M ori describe a guide for living. adherence to treatment plans.87 88 89 and through measurements of doctor performance in delivery of services to M ori . BPAC better medicine NZ 13: 32-36. J. support M ori social systems and reflect M ori knowledge and traditions. New Zealand National Working Group on Diabetes and Te Roopu Rangahau Hauora a Ngai Tahu. 'Psychiatrists' recommendations for improving bicultural training and M ori mental health services: A New Zealand Survey' Australian and New Zealand Journal of Psychiatry. Kravitz RL.However cultural misunderstandings.

The presence of the dead body (t p paku) makes the room tapu. Familial relationships and responsibilities are central to M ori identity and are often expressed in the M ori term wh naungatanga. and until relationships are established may prefer formality. The tangihanga is a coordinated set of formal procedures that recognise the relationships of the deceased with the ancestors and with the living relatives. at their home or at a marae and often returned to their traditional tribal home for burial. and therefore food cannot be brought in. Many M ori recognise very strong imperatives to attend tangihanga of anyone in their extended family and friends. A guest (manuwhiri) has a complementary obligation to accept and receive this hospitality. 56 Cole’s Medical practice in New Zealand 2011 . Death itself however may not be feared so much as the manner and circumstances of dying.time in the room with their loved one. Wh naungatanga M ori culture emphasises familial and community connections to the past and to the present. A person may be grieved over for three or more days. with many M ori preferring to die at home with the attention and support of their family. and will often travel great distances to fulfil their obligations in this regard. This customary value will involve the process of welcoming and caring for visitors to ones home or marae. M ori patients will often bring family members to medical visits and may consult with them before considering or accepting treatment. Tangihanga The rituals and customary practices that surround death are regarded as very important within M ori communities. M ori usually prefer face-to-face interactions with their practitioners. There will of course be wide variation in how strictly such controls are practiced and how observance of the traditional practice might be amended for practical reasons. Manaakitanga The obligations and responsibilities to demonstrate care for your family and for visitors is expressed in the M ori term of manaakitanga. The extended family or wh nau is the basic unit of M ori social organisation. Food (kai) has a central importance in these practices. as well as the provision of food and accommodation. The familial and community obligations to the deceased and the bereaved family are extensive.

allowing or encouraging them to share information with you. Cole’s Medical practice in New Zealand 2011 57 . Let’s introduce ourselves and get to know each other. T n . Ka p hea taku whina i a koe? Ka p hea taku whina i t wh nau? He p hea te nui o te waipiro ka inumia e koe? Ka inu waipiro koe i ia r ? E hia ng r o te wiki e inu 90 Mead. 92 Demystifying Rongo M ori: Traditional M ori Healing.92 Welcome everybody. M ori language There are several general introductory Maori language courses and a small number of dedicated Maori language phrasebooks for the health sector. prayers and incantations (karakia).There are many useful texts that can provide deeper insight into M ori customary practices90. and M ori patients are generally happy to educate a provider who seeks guidance about their preferences.M.91 There are few absolute contraindications to the use of traditional healing techniques alongside western therapies. How can I help you? How can I help your family? How much alcohol do you drink? Do you drink everyday? How many days a week do you Kia ora t tou. me whakam hio atu ko wai r t tou. T n koutou. For M ori this may include consulting people with special skills (t hunga) in herbal preparations (rongo rakau). (2003) Tikanga M ori: Living by M ori Values. 92 Jansen. 2005. Ka mihi atu ki te wh nau. 13 3236. The key then is to maintain open and non-judgemental communication with the patient. Ahuru Press. I would like to acknowledge the family. Huia Publishers. Wellington. However knowing about all the non-prescribed therapy a patient is using will assist the doctor and patient to monitor and adjust medications or to make appropriate choices. Greetings all. massage therapies (mirimiri). Rongo and traditional healers M ori patients may seek assistance from traditional healers like people from other cultural backgrounds. He Pukapuka Reo Hauora M ori. BPAC Better Medicine NZ. H. D. Aotearoa.

he rata ahau. he tautoko hoki i a koe. I am a doctor. I tipu mai ai koe i whea? I kuraina ai koe i whea? He aha t pakeke? E hia tau? 58 Cole’s Medical practice in New Zealand 2011 . he whakarongo ki wangawanga. He aha ng tino take ki u whakaaro? Me p hea taku whina atu? N whea mai koe/koutou? Ko wai t iwi. t papak inga. t hap ? T n . What are the main issues for you? How would you like me to help? Where are you from? What is your tribe. Ko t ku. te toto p rutu r nei ki a koe? He aha u rongo ? Ko Richard ahau. your sub-tribe? Tell me about your marae. k rero mai m t marae.drink alcohol? How many days a week do you drink no alcohol? Do you have pain anywhere? How long have you had that pain? Where did the pain start? What were you doing when the pain started? What makes it worse? What makes it better? Have you been vomiting. Do you have diarrhoea? What is the diagnosis? Does H mi have epilepsy or diabetes? Do you have heart disease or high blood pressure? What medications do you take? My name is Richard. te mate ruriruri r nei ki a H mi? Kua p mai te mate manawa. Where did you grow up? Where did you go to school? How old are you? waipiro ana koe? E hia ng r o te wiki k ore koe e inu waipiro ana? He w hi an kei t tinana e mamae ana? Kua p hea te roa e mamae ana? I t mata mai t n mamae ki hea? I te aha koe i te w i t mata ai te mamae? Ka nui atu te mamae i te aha? Ka whakaeaeatia te mamae ki te aha? I te ruaki koe? I te toroh koe? He aha te whakataunga? Kua p mai te mate huka. your community. My job is to listen to your concerns and support you.

ii. . ng mate r nei o t wh nau. He aha ng rongo e kainga ana e koe? E hia ng w ? hea ka kainga? Ka kai koe i ng rongo mai i te r kau. Tokohia teina/tuakana. This is indicated by the macron over the vowel. K rero mai m m uiui. What medicines do you take? How often? When? Do you use traditional medicines or herbal remedies? Do you have access to a traditional practitioner? Ng Whakahua pronunciation guide Vowel Sounds a e i o u as in as in as in as in as in car. How many brothers and sisters do you have? Tell me about your health. ee. mate. or. . bed eel awe. uu. ng rongo M ori? Ka toro atu koe i t tahi t hunga? Consonants wh pronounced much like “f” (wh pronounced far) ng pronounced like the “ng” in singer (nga sing a) Macrons The vowels may take a short or long form. . The long vowel is pronounced in the same way as the short vowel but the length is extended and has a significant effect on the sound and meaning of a word. Tell me about any illnesses in your family.How many children do you have? Tell me about your family. far Ed. saw chew. . Tell me about any illnesses you have. Knowing the length of each vowel is important in establishing correct pronunciation. . oo. aa. although others occasionally use a double vowel to indicate the long form. moo Tokohia u tamariki? K rero mai m t wh nau. tuahine/t ngane? K rero mai m t hauora. This is the method preferred by the Taura Whiri i to Reo M ori: M ori Language Commission). K rero mai m ng m uiui. Cole’s Medical practice in New Zealand 2011 59 .

Ot huhu Waitemat T n koe T n korua T n koutou O . share breath prayer.te .huhu Wai .used affirmation.t Ng Mihi greetings Hello (literally “there you are”) formal greeting to one person Hello (literally “there you are”) formal greeting to two people Hello (literally “there you are”) formal greeting to three or more people Kia ora Hi (literally “be well. and widely. donation power. sacred physical body song. salutation Kia ora koutou Greetings to you all Kia ora t tou katoa Greetings to us all (inclusive of the speaker) E noho r Goodbye (literally “stay there”) said as one is leaving. health formal welcome language people of the land restricted.ma . Less formal greeting. authority. spiritual dimension family relations relationships house 60 Cole’s Medical practice in New Zealand 2011 . profane wellbeing.t . greetings introductions normal. prestige visitor. reserved. guest greet. invocation gift. to sing spirit. good health”). Haere r Goodbye (literally “go forth”) Glossary hauora hinengaro hongi karakia koha mana manuhiri rnihi mihimihi noa oranga p whiri reo t ngata whenua tapu tinana waiata wairua wh nau wh naunga wh naungatanga whare health psychic dimension press noses. incantation.

worked with WHO in Geneva. Pacific men can expect to live for 73.9 years and Pacific women for 78. The patient may be seen as the victim of family wrongdoing. Ill health is thought to be the result of disharmony between humans and their environment. Demographic characteristics On average. Ministry of Pacific Island Affairs. it had risen to just under 266. In comparison to the total New Zealand population. Mental illness is often thought of as possession by evil spirits. Pacific peoples constitute a predominantly youthful population.9 percent) Pacific people in New Zealand and in 2001 more than 231.1 years lower for women. High population Cole’s Medical practice in New Zealand 2011 61 . Demographic characteristics Socioeconomic circumstances Morbidity and risk factors Mortality patterns Use of health services Caring for the Pacific patient Contacts People from the Pacific Islands have been in New Zealand for over a hundred years.5 percent) were living in the country. Total fertility rate is 3-4 times the rate in the general population. children and young people under 15 years of age compromised 38 percent of the Pacific population compared with 22 percent of the total New Zealand population.3 years lower for men and 4. putting some Pacific ethnic groups among the fastest growing in the country. Like M ori. In 2006.802 (6.000 (4. Pacific men and women have life expectancy at birth lower than the average for New Zealand: 4. and increase of 15 percent since 2001. Adverse socioeconomic circumstances and poor access to health care services put Pacific peoples among groups in New Zealand with the highest health needs.1 years (2006). and is now Chief Executive. In 1991 there were 167.6 Pacific peoples in New Zealand Colin Tukuitonga has been Director of Public Health at the Ministry of Health. The Pacific population is characterised by a high birth rate and low death rate. including those surrounding death and dying. Pacific peoples are very religious and some observers have attributed their apparent apathy to fatalism.000 people. In 2006. Christian doctrine dominates many customs and traditions. which is part of these beliefs. Pacific peoples regard health in a holistic socioecological framework.

although the central role of the family among Pacific communities is also important in determining living arrangements. many do not affiliate with the traditional social and cultural values of their parents. Socioeconomic circumstances Pacific people are over represented at the lower end of the socioeconomic spectrum compared with other New Zealanders.growth is attributed to low utilisation of family planning methods and a strong cultural desire for large families. The majority of the children and young people are born in New Zealand. Pacific peoples remain worse off than other New Zealanders. the unadjusted unemployment rates for Pacific. In March 2010. Overcrowding among Pacific households is more likely to result from economic hardship than from cultural preference. Obesity is more prevalent among Pacific peoples in New Zealand than among Pacific peoples 62 Cole’s Medical practice in New Zealand 2011 . Despite debate about the accuracy of Body Mass Index (BMI) as a measure of obesity in Polynesians. Tongan (19 percent). the median income for Pacific peoples was $20. and other smaller communities. While there has been some improvement in socioeconomic indicators in recent years. Only 4 percent of the Pacific population are aged 65 years and over compared with 12 percent of the national population. The group is highly skewed. the population group consists of several distinct language and cultural entities. The Samoan community is the largest (49 percent) followed by the Cook Islands (22 percent). with 42 percent living in decile 10 areas (most deprived) instead of the expected 10 percent. The Pacific population is mainly concentrated in urban centres of Auckland (67 percent) and Wellington (16 percent). several studies have shown that 75 percent of Pacific people are overweight. While migration was an important contributor to population growth in early years.500 compared with $24. Pacific young people tend to leave school without a formal qualification but the proportion of Pacific people gaining National Certificate of Educational Achievement Level 2 improved significantly between 2005 and 2007. Maori and European people were 14. They were least likely to exercise regularly.400 for other New Zealanders. Morbidity and risk factors Household Health Surveys showed many Pacific people rated their overall health as poor/not so good. A substantial proportion of Pacific peoples claim descent from more than one ethnic group. more than 60 percent of all Pacific people living in New Zealand in 2006 were born here. While there are many similarities among the Pacific peoples in New Zealand. 14. Older people are held in high regard and their care and comfort is extremely important to Pacific families.4 percent.4 percent respectively. Overcrowding and poor quality housing is a major social and public health problem for Pacific families. In 2006.2 percent and 4. Niuean (8 percent). Socioeconomic disadvantage is closely linked with poor health status.

burns and unintentional injuries also exceed national rates. Age specific annual notification rates for rheumatic fever between 1990-1995 for children aged 10-14 years were 77. but they consumed more alcohol at the last occasion. Reported morbidity from coronary heart disease is lower but Cole’s Medical practice in New Zealand 2011 63 . However. Estimated iron deficiency among Pacific children at 36 months is 30 percent compared with 7 percent among European children. The youth suicide rate among Pacific young people is similar to the national average rate.living in their islands of origin. 57 percent of Pacific peoples do not consume alcohol compared with 12 percent of the general population. These childhood problems are consequences of poverty.4 per 100.7 per 100. The Ministry of Health estimates that Pacific males aged 15 years and over have a higher prevalence of cigarette smoking than the males in the total population but female rates are similar.000 for Pacific children. 30. It is also a growing problem among Pacific children and young people in New Zealand. substandard housing and inadequate health care. Young Pacific people generally show morbidity patterns similar to those of other young New Zealanders. Pacific peoples consume alcohol less often than M ori and European. Pacific children have poorer health status than other New Zealand children. Non-communicable diseases are the leading causes of morbidity and mortality in the adult Pacific population. Hospitalisation rates for respiratory conditions. alcohol misuse and sexually transmitted diseases. especially for Type 2 diabetes. Obesity is one of the major causes of morbidity for adult Pacific people. a needs assessment process carried out by Pacific young people in the Auckland region showed that identity concerns. Smoking rates have declined in recent years but remain higher than other New Zealanders. New Zealand has a major public health problem that needs urgent attention and measures currently planned or in place are inadequate.000 for M ori children and 1 per 100.000 for European children. infectious and parasitic diseases. poor self esteem and lack of confidence are important underlying contributors to the observed problems of suicide. The Infant Mortality Rate is 40 percent higher among Pacific population than the all New Zealand average. Hospitalisation rate for asthma is 50 percent higher than the all New Zealand average. Pacific peoples with Type 2 diabetes have the poorest knowledge about the disease and are least likely to be receiving optimum care. The prevalence of Type 2 or non-insulin dependent diabetes mellitus (NIDDM) is 3-4 times the rate of European New Zealanders and complications are common. Pacific children were more likely to fail their hearing test at new entrant level. unwanted teenage pregnancy. The situation is worse for indigenous Maori and Pacific children where 2 in 5 and 2 in 3 are overweight or obese respectively. A school-based survey showed that iron deficiency and anaemia is higher in adolescent Pacific girls. The prevalence of tobacco use among Pacific peoples remains higher than other New Zealanders. Results from the 2002 National Children’s Nutrition Survey showed that nearly 1 in 3 New Zealand children aged 5-14 years are overweight or obese. Type 2 diabetes is the leading cause of end stage renal failure presenting for dialysis at Auckland hospitals.

Large bowel cancer rates increased ten-fold in the same period. Sudden infant death syndrome (SIDS) or cot death in Pacific families was previously reported as low. Mortality patterns Standardised all cause mortality rates for Pacific people are reported to be lower than national rates. However. One study showed that Pacific people were under represented in total psychiatric admissions but were over represented among committed patients. Pacific men have a predisposition to hyperuricaemia and gout. In general. Unintentional injuries are the leading causes of admission to hospital followed by asthma. 64 Cole’s Medical practice in New Zealand 2011 . The difference is more likely to reflect poor access to health information and care rather than inherently more severe disease among Pacific peoples. Pacific peoples suffer the second highest rates of tuberculosis reported in New Zealand. Europeans have a three times higher coronary bypass graft and seven times higher angioplasty rate than Pacific peoples. partly reflecting lower uptake of screening services. For Pacific women. Similarly. incidence of the common cancers is similar to the all New Zealand population average but they tend to present later with advanced invasive disease. Coronary heart disease is the leading cause of death for both men and women with mortality rates midway between those in M ori and European. In spite of similar coronary heart disease hospitalisation rates. and breast and cervical cancer in women. stroke and coronary heart disease. The most common reasons for first admissions to mental health institutions for Pacific men are alcohol and drug abuse followed by schizophrenia. paranoid states and other psychoses are the leading cause of first admissions. reliable community-based information on the prevalence of mental health problems of Pacific people is not readily available. Cervical cancer incidence (and mortality) rates are higher among Pacific women. One study showed that deaths from coronary heart disease among Pacific peoples have not declined in line with national and international trends. The prevalence of hypertension is higher among Pacific peoples compared with other New Zealanders but they are less likely to be on treatment. affective psychoses. The perinatal mortality rate is 34 percent higher than the national rate. The leading sites for cancer in men are lung and prostate.mortality rates are higher compared with European rates. but studies have shown the recording procedures and changes in the definition of ethnicity underestimate the true mortality rate for Pacific people. There is no accurate information on the prevalence of disabilities among Pacific people in New Zealand. a review of cases in Auckland showed that SIDS rate increased fourfold between 1994 and 1995 but the number of SIDS notifications has declined in recent years. Cancer is the second commonest cause of death and cancer death rates increased among Pacific peoples while there was a decline among other New Zealanders between 1980 and 1990.

Other studies have shown that general practitioners rated their rapport with Pacific people as the lowest. Traditional remedies are often used simultaneously with conventional medicines. social. The introduction of Primary Health Care Organisations has seen high enrolment rates by Pacific peoples. Over representation of Pacific peoples in hospital discharge statistics could be attributed to lower primary care utilisation. cultural differences and socioeconomic problems. Doctors should also note that Pacific patients come from distinct language and cultural groups. Admission rates for preventable conditions such as asthma and diabetes are two to three times the national rates. The number of primary care practitioners is generally lower in areas with high Pacific and M ori population densities. These observations are likely to result from delay in seeking care compounded by traditional beliefs about health and illness. but familiarity with the larger Pacific groups is a worthwhile investment. One study has shown that Pacific peoples were more likely not to visit a health professional or to delay seeking care than other New Zealanders. and the general principles outlined here are meant as general guidelines only. Financial. Improving verbal and nonverbal communication is a critical factor as well as other Cole’s Medical practice in New Zealand 2011 65 . Primary care consultation rates are lower for Pacific people than for other New Zealanders. Many Pacific health professionals are aware that Pacific peoples are using traditional remedies in New Zealand. the Pacific patient may present additional challenges such as language difficulties. poor access to primary care providers and preference for hospital services. Caring for the Pacific patient While every patient is unique. Similarly. language and cultural factors are likely to be important barriers but objective information on the relative importance of these factors is not available. It is clearly not possible to be familiar with the customs and traditions of all cultural groups. Simple measures such as greeting the patient in their own language can improve the doctor-patient relationship significantly. and Pacific peoples were least satisfied with doctor’s fees.Use of health services Five-year hospitalisation rates for Pacific people are above the national rates. It provides guidance on Pacific cultures and its impact on health and access to health services. Children of Pacific origin are six times more likely to be admitted with pneumonia than children of other New Zealanders. but the impact on health service utilisation remains unclear. This will increase the complexity of the consultations with Pacific patients and their families. Pacific cultures are dynamic and constantly being redefined. Pacific people with asthma are seen more often in hospital emergency departments and are less likely to be on preventive therapy than other New Zealanders. The Medical Council of New Zealand recently released a valuable resource for health professionals to assist them in their interactions with Pacific peoples. Traditional healers and/or remedies are often brought from the islands for this purpose. Pacific people with diabetes develop more complications as a result of their disease.

Pacific peoples who were born in the islands are more traditional in their approach to health care compared with New Zealand born Pacific people. Statistics New Zealand and 66 Cole’s Medical practice in New Zealand 2011 . Furthermore. older Pacific people value their privacy and this should be respected.relevant issues such as initial contact and protocols. and family involvement is generally useful. social and economic situation. A number of Primary Health Organisations have been established in the main centres owned and operated by Pacific individuals and organisations. Circumcision for cultural reasons is routine in the Pacific islands but is generally harder to obtain in New Zealand without a medical indication. Therefore. however. note that in some cases. Under these circumstances. Some hospitals and commercial organisations provide interpretation and translation services. it may be advisable to check and verify information independently in an appropriate way. Pacific born caregivers gave more importance to traditional beliefs. In Auckland. These beliefs often influence attitudes to illness and care. For example. including family views and practices while New Zealand born caregivers gave more importance to professional advice. and Western biomedical understandings of health and illness. The Ministry of Health. dealing with the elderly and death and dying. Older Pacific people are often accompanied to the consultation by several members of the extended family. it is useful to enquire about telephone ownership and transport options before discharging a sick patient home. The older Pacific patient is often unable to speak in English nor relay a reliable social and clinical history. Contacts There are a number of organisations throughout the country that can help with advice. there are several Pacific owned providers of health care services. Most Pacific patients are deeply religious and regular church goers. The Ministry of Health has a dedicated Pacific health team who plan. fund and monitor health care services for Pacific people. This applies to the clinical situation as well as facilities in the home. While this situation may present some challenges for patient privacy. church ministers can be a useful contributors to the care of selected patients for certain conditions. A study in Christchurch showed that 89 percent felt that circumcision should be performed for cultural and hygiene reasons. A limited number of published studies have shown than in general. it is common practice and one that is generally beneficial for the patient and the family. circumcision was expected and generally well accepted by the boys despite the discomfort from the procedure. a study of infant care practices among several Pacific (and Maori) caregivers in Auckland showed there were similarities across cultural groups and differences were more marked among those born in the Pacific. Doctors should. While these beliefs can present challenges for patient education and care. Another example relates to circumcision of young boys. Some Pacific patients may tell doctors what they think doctors want to hear rather than a true account of the circumstances. Doctors should note that some Pacific people still regard doctors highly and may not provide a complete account of their clinical.

Most of the hospitals in cities where Pacific people live have Cultural Resource Units or Pacific staff who can assist with patient care.Ministry of Pacific Island Affairs websites include a number of useful reference documents about Pacific peoples.9:29-33. Public Health Commission 1994. Soc Sci Med. Afsari M. 2001. Medical Council of New Zealand 2010. Pacific Health Dialog 1997: Vol 4 No. 6. Mitikulena A et al The Health of Pacific Islands People in New Zealand. Bathgate M. 2. Veronica colensoi. Donnell A. Best Outcomes for Pacific Peoples: Practice Implications. Beasly SW. Park J. The Pasifika Medical Association has members in various centres throughout New Zealand who can provide medical advice.53:1135-48. The University of Auckland and the Whitireia Polytechnic host research centres focusing on the health needs of Pacific people. Tukuitonga C and Finau S. Cole’s Medical practice in New Zealand 2011 67 . Abel S.2. Attitudes of Pacific parents to circumcision of boys. Many Pacific community groups exist throughout New Zealand. The Health of Pacific Peoples. Resources 1. Tipene-Leach D et al. 5. Koromiko. 3. New Zealand Ministry of Health 2005. Maoate K et al. 4. Pac Health Dialog 2002. Infant care practices in New Zealand: a cross cultural qualitative study. (Eds) Pacific Peoples in New Zealand.

2 percent) in 2006. Retrieved November 23.govt. M ori and Community Relations at Accident Compensation Corporation. 2007. Kenneth Tong is a former general practitioner in Auckland and Clinical Senior Lecturer at the Department of General Practice and Primary Health Care. 68 Cole’s Medical practice in New Zealand 2011 . Catherine Hong is the National Asian Development Manager.7 Asian people in New Zealand Samson Tse is the former Director for the Asian Health Research and Evaluation Centre at the University of Auckland and now is based at the University of Hong Kong. Nagalingam Rasalingam is the Board Chairman of Refugees As Survivors New Zealand and also the member of Northern Region District Health Boards’ Support Group on Asian Mental health and Addiction Advisory Group. Specific health needs of Asian patients Ways to engage Asian migrant patients Working with interpreters Conclusions The increasingly diverse immigration to New Zealand caught momentum following the changes to legislation in 1987 and 1991 which removed a bias in favour of British and West Europeans who were considered “preferred sources” of migrant population. Asians make up the fourth largest major ethnic group after European. M ori and Other Ethnicity totalling 354.nz/people/default. She is also the President of the Korean Women's Wellness Community Group and Secretary of Auckland Chinese Medical Association.93 The Asian population is expected to grow to almost 15 percent of the national population by 2020. The migrant population of Aotearoa/ New Zealand has increased significantly over recent years. According to the 2006 statistics.htm. from http://www.552 people (9. . at that time accounting for 6 percent of the country’s population. 2000). Between 1997 and 2001 the Asian population increased by 140 percent (Statistics New Zealand. University of Auckland. 93 Statistics New Zealand (2006). QuickStats About Culture and Identity 2006 Census.stats.

211–27. Retrieved October 30... three large-scale reports about the health of Asian New Zealanders were published: Asian Health in Aotearoa: An Analysis of the 2002–2003 New Zealand Health Survey (The Asian Network Inc.nz/journal/119-1244/2277/content. Ameratunga. Filipino. Sri Lankan. 2006. 95 Rasanathan.94 The increase in the Asian population has resulted mainly from large migration gains. Ameratunga and Tse provided a useful summary of the key health issues concerning the Asian New Zealand population. Specific health needs of Asian patients Asians in New Zealand are very diverse in religion. Rasanathan.org. Japanese. (2006). Asian health in New Zealand: Progress and challenges. Many of them born overseas (30-40 percent) and some (15 percent) even do not speak English.nzma. & Tse. Craig. K. A Health Profile of Young Asian New Zealanders who attend Secondary School: Findings from Youth2000 (The Youth2000 project at the University of Auckland) Asian Health Chart Book 2006 (Ministry of Health). (2006). need to be in good health to be allowed to immigrate to a new host country and many have high socioeconomic status in their countries of origin.95 The pattern of 94 Rasanathan.). Chinese (46 percent) and Indian (29 percent) are the major contributors in the increasing trend of Asian population along with populations from other Asian communities (eg. during the past years. D. and because of possible language and cultural barriers between clients and health services and health workers. Ethnicity and Health. The reports indicate that while Asian peoples in New Zealand are relatively healthy overall. & Perkins.. R. This growth will impact on the host population. most migrants. because of its rapidity. and Perkins.. These migrant groups also have high levels of education which are associated with better health status. Cambodian and Thai). S. language.pdf. Craig. particularly the health delivery system. S.For discussion on the use of the term “Asian” please refer to the work by Rasanathan. 11. culture. The novel use of "Asian" as an ethnic category in the New Zealand health sector. education and socioeconomic experiences. New Zealand Medical Journal. K. Korean. Nonetheless. However this positive effect on health gradually disappears with increased length of residency in the new host countries. That is. Cole’s Medical practice in New Zealand 2011 69 . It is therefore difficult to generalise the needs of the Asian population as a whole. 119(1244) (8 pages). from http://www. much of this result is due to the so-called the ‘healthy immigrant effect’.

every Asian must be advised to register themselves and their families with these organisations. M.. Another key issue is cardiovascular disease and diabetes for South Asian people. February). S. Waldegrave. by a health professional. 15 percent of young Chinese New Zealanders reported accessing no healthcare at all which was over three times the rate reported by their European counterparts. In the Youth2000 study.. Asian people in New Zealand are more likely than non-Asian New Zealanders to have tertiary qualifications. or unfair treatment because of ethnicity for example. 97 Asian public health project report. 96 Harris. is seen across most areas for Asian people in New Zealand. Asian Public Health Project Team (2003. particularly in terms of mental health. Primary Health Organisations (PHOs) are playing a pivotal role in New Zealand healthcare system. 1428-1441. M. Stigmatisation and “taboo” of psychiatric illness compound the problem further resulting in a reluctance by Asian patients and their families to seek early intervention or treatment. & Nazroo. According to a local survey conducted by the Asian Public Health Project Team.low levels of healthcare service utilisation for example. R. language barrier. Karlsen. in workplace or when seeking paid employment. Auckland. Racism and health: The relationship between experience of racial discrimination and health in New Zealand. followed by similar levels among Asian (28 percent). primary healthcare and cancer screening. but have higher levels of unemployment.96 M ori reported the highest prevalence of "ever" experiencing any of the forms of racial discrimination (34 percent). Indian people show the highest rates of self-reported diabetes of any ethnic group in New Zealand and they also show high levels of cardiovascular disease. Levels of physical activity and mental health problems particularly in young people remain a concern. underemployment or unemployment. K.. 63(6). Jeffreys. Social Science and Medicine. Unemployment or under-employment are often associated with negative health effects.. Tobias.. (2006). 70 Cole’s Medical practice in New Zealand 2011 . similar to M ori. 1428-1441. J. Recent studies showed that the experience of racism by Asian New Zealanders is rather common.97 Asian patients themselves have identified the following areas as their main health concerns Mental health: depression and psychosomatic illness are frequently seen and have a complex interplay among social isolation (from migration). Racial discrimination included experience of ethnically motivated attack (physical or verbal). particularly for Chinese New Zealanders. Other cultural-social factors are also relevant to the health and wellbeing of Asian New Zealanders such as experiences of racism and difficulties in finding employment.

Family reunification. 99 Ministry of Health (2001). Primary health care plays a significant role as individuals with refugee background have had very limited health care in their respective countries before fleeing to New Zealand.A Handbook for Health Professionals. (2002). Cardiovascular diseases and diabetes: lifestyle changes from Westernisation of diet and the relative lack of physical activities. Asylum seekers – termed as “Convention refugees” those who conform to and satisfy the United Nations convention on refugees.. Indonesian. Conditions prevalent in their respective geographical zones include sickle cell anemia. Wellington: Mental Health Commission. & Cooper. gonorrhoea and syphilis 98 Ho. Au. Mental health issues for Asians in New Zealand: A literature review. Refugee Health Care . Refugees because of premigration traumas and postmigration stressors in adapting to a new culture.. Furthermore. Cole’s Medical practice in New Zealand 2011 71 . C. All in the above are “health screened” for immigration purposes. Mental health needs of older people. the New Zealand Mental Health Commission’s Report on Asian mental health mentioned several specific concerns.Other mental health issues identified in New Zealand include problem gambling and alcohol abuse. a mobile health team employed by Refugees As Survivors (RAS) is already functioning in Auckland and is of great help to individuals and families from refugee background. Wellington. Refugee health: refugees enter New Zealand under three categories Quota refugees – recommended by UNHCR (United Nations High Commission for Refugees) 700 yearly called “mandated refugees’’. Such beliefs may have contributed to the steady rise of the abortion rate among Chinese women in the past decade. Sexual health: Asian women seem reluctant to use safe and reliable contraceptive methods. for example. Bedford. J. E. Another concern is the rapid rise of sexually transmitted illnesses such as chlamydia. S.99 With regard to services for refugee mental health. Abortion is often seen as a de facto form of “contraception” as it is a common practice in many Asian countries. Hepatitis B carrier state and gastrointestinal infections. malaria. some Chinese women believe that the pill will impair their fertility..98 The high mental health needs of women and refugees from smaller ethnic communities for example Vietnamese.

inactive. good health is about having a balanced flow of “Qi” between the “Yin and Yang” organs. 20–27.org. However it is often not the case.101 An example of misunderstanding resulting from differences in health beliefs is the Chinese patient who said. as the patient is trying to say he/she has too much “Yang” in his/her body. Hong Kong Practitioner. active and male like.hk/article/2001/01/20010105. 101 Yu. S. Essential traditional Chinese medicine: Western scientific medicine perspective.C. Contributing factors include ease of international travel and unsafe sexual practices. “Yin” represents cold. & McKenna. Lloyd.pdf]. Ways to engage Asian migrant patients In order to provide practical suggestions to engage Asian migrant patients the following material will be useful for those working with Korean and Chinese patients as examples. Tooth (Eds. “Qi” is the fundamental substance and its movements produce everything that constitutes the universe.L. dark. bright. McKenna & L. “I’ve too much heat in my body. In K. 307-326).).hkcfp.. On an individual level. most doctors would tend to think that the patient is implying that he/she has a fever. negative and female like. When clients are from diverse linguistic and cultural backgrounds.” From a Western medicine perspective. C.100 Appreciate health beliefs Chinese patients in general are rather health conscious even though they appear to be less knowledgeable in human anatomy or the scientific basis behind Western medicine. (2006). Everything in the universe has an element of both “Yin and Yang”. (2001). E. [Available from www. Client education: A practical guide for clinical therapists (pp. Sydney: UNSW Press. The fundamental belief of good health among Chinese people is the ability to maintain a peaceful state of mind and to be in harmony with the surroundings. 72 Cole’s Medical practice in New Zealand 2011 . The concept of “Yin and Yang” describes the dynamic and oscillating relationship of the flow of “Qi” between these two extreme states. It stems from the philosophy that everything in this universe is interrelated and is forever changing with the life force/energy (known as “Qi”) flowing through all matter continuously. K. 23.among Asian patients. It is therefore important to clarify with the patient about his/her 100 Tse. whereas “Yang” represents hot.. Communicable diseases: tuberculosis and chronic hepatitis B infection are particularly common among Asian patients.

Also. and concomitant use of both Chinese and Western medicine is not unusual. Be aware of patients’ expectations The “family doctor” is a rather foreign concept as it is not a common practice in many Asian countries for a patient to have a family doctor. otherwise you will get a “no” answer to questions about medication. and royal jelly as a regular daily supplement. Drugs like antihypertensive and antibiotics were freely available leading to resistance and misuse problems. It is therefore important to seek a full drug taking history especially inquiring about the use of TCM or alternative health supplements. Make sure they come back for repeat prescriptions if necessary. It is more of an issue with Koreans as they have been used to easy access to most medications from their local chemist until a few years ago. Doctors in New Zealand need to emphasise the correct use of medication and check for compliance at each visit. Realise Asian people’s use of medication Noncompliance or miscompliance is an issue with any group of patients. state clearly to the patient the duration of treatment for example two weeks or lifelong. This improves understanding and compliance. Always ask specifically what health supplements they are taking. Chinese and Korean patients will often request injections as they perceive it as a more direct and potent route of delivery with a more rapid onset of action than the oral route. self medication with Chinese medicine and consultation with a Traditional Chinese Medicine (TCM) doctor. It is therefore common for a Chinese patient to ask the health practitioner about food avoidance in times of illness. A perceived imbalance of the “Yin and Yang” forces can be influenced by many factors including dietary intake. it would be best to advise the Chinese patient to seek dietary advice from a TCM doctor or suggest the patient eat whatever he/she feels comfortable or accustomed to. In their own Cole’s Medical practice in New Zealand 2011 73 . calcium supplements. “What do you mean by having too much heat in your body?” Understand health practices Chinese patients often use folk medicine or “tonics” in the early stages of illness. In addition. For those health practitioners who are not familiar with the “Yin and Yang” concept. It is also very common for both Chinese and Koreans to be taking vitamins.concerns by asking something like. propolis. It is helpful to use medication cards with name of medicine and times to be taken on it.

For 74 Cole’s Medical practice in New Zealand 2011 . one has to speak slowly. Many Chinese and Koreans are familiar with the “total body checks” which are performed in many hospitals in South East Asia. Asian patients with limited English will often make appointments through friends or family members. Some Chinese patients are used to doctors who give quick and authoritative diagnosis whereas some are used to asking for tests and medicines that they want. which does not exist here in New Zealand. the practice of patient centred care is crucial in the provision of good medical services. Xrays. so make sure you have the right person’s details. When Asian people come to New Zealand. Medical practitioners may need to explain that in New Zealand. radiology tests and treatment prescription. In addition. they often take on an English name. blood tests. they tend to present to the first available doctor or whoever is the most reputable in treating the condition. so they end up with more than one name. clearly and in short simple English.country. ultrasounds and endoscopy of the gastrointestinal tracts. Offer appointment times that are easy to understand for example. They will often ask for one. Speaking of prescription. concerns and treatment expectations of their illness regardless of their ethnicity. when answering phone calls from Asian patients. we only request blood tests or investigations that we feel are necessary or pertinent to the problem involved. Asian patients are also used to having a one stop shop system of health care where everything is done on the spot such as consultation. In short. Medical consultation in many Asian countries is relatively short in duration and often conducted in a rather “doctor centred” manner. Know your patients’ names and dates of birth Getting this right is tricky. They are used to being investigated extensively with a whole batch of routine blood tests. Walk in without appointment and self referral to specialists is the norm. writing out a prescription. Despite of all the patients’ various expectations. “Two o’clock” not “A quarter to four”. Have effective communication Even simple things such as making an appointment with a general practitioner can be a huge obstacle for some Asian patients with little English. it is important to seek patients’ ideas. This may cause anxiety and frustration for the patient. some expect to be told what to do and expect the doctor to do something concrete for instance. when they are unwell. Repeat and check for understanding. For example. it is important to remember that as a medical practitioner in New Zealand. it is also a foreign practice for Chinese patients to fill a prescription at the chemist.

This results in a possibility of four names for the one person. and try to encourage the patient to speak for himself/herself if at all possible. similar to the wh nau in M ori culture.women. Work with individuals from a refugee background This subgroup of Asian patients has been inadequately treated and needs complex follow up. Patients tend to use the emergency services as their last resort because they have limited understanding of the New Zealand health system or they can’t afford visiting their family doctor. There is no simple solution around such idiosyncrasy but it is important to find the right information. it is further complicated by adopting the Western culture of taking on the husband’s surname. The mental health of refugees needs special care in view of their history of torture. It is recommended that medical practices use the name on the patient’s passport to simplify matters. sensitivity and tact is important when dealing with the psychosocial aspect and sensitive issues like suspected abuses of all patients. Deal with sensitive issues It has been suggested that Confucian teaching which discourages open displays of emotions in order to maintain social and family harmony is contributing to the higher rate of psychosomatic illness among Chinese patients. Referrals to expertise in rehabilitation of these torture trauma Cole’s Medical practice in New Zealand 2011 75 . one according to the solar calendar and the other according to the lunar calendar. Torture methods adopted and the consequence of their sufferings have to be carefully understood for treatment to be successfully pursued. Thus patients are often admitted to hospital acutely with serious presentations. Work with guardians/support persons Some Asian patients are used to having a “guardian” or support person with them in consultations. Beware of the fact that the guardian or support person often speaks on behalf of the patient. Past histories are difficult to ascertain and the lack of interpreters to help the health team can lead to wrong diagnoses. It is appropriate to allow at least one person to accompany the patient into the consultation room. especially if they need help with interpreting. Date of births are also tricky because Koreans and some elderly Chinese people use two birthdays. Regardless of the reason. unnecessary investigations and referrals to tertiary care.

In an ideal situation. 26. and bad luck in Korea. They are faced with putting their trust in a doctor or health professional with a different language and culture to their own. 76 Cole’s Medical practice in New Zealand 2011 . and not spoken too quickly. New Zealand Family Physician. Interpreting big chunks of speech 102 Chan. In reality. Allow more time than other consultations when using an interpreter.. They key is to approach the Asian patient with genuine concern and interest.htm]. friends and family members are frequently used as de facto interpreters for the patient. Sentences should be short. Hence. and indeed feel culturally incompetent of the patient’s health beliefs and practices.. No doctor is expected to be fully competent in the many cultures that exist in New Zealand. 52–56. Introductions/ briefing It is important if the interpreter can be briefed as to the problem . Some may feel uncomfortable when faced with patients with no English skills. Building a good rapport with refugee patients is a useful strategy in addressing their health needs. T. & Tong. as it is more time consuming to consult through an interpreter.rnzcgp. Nonverbal messages of reassurance like smiles and good eye contact along with a clear. red colour is good luck in China. Working with interpreters For the patient this is highly anxiety provoking. Some basic ground rules should be set and agreed on before the consultation begins. Thus it is vital to employ an experienced interpreter who has been trained in medical terminology and concepts. Lloyd. kind tone of voice go a long way. (1999).102 Some doctors will be more experienced than others at adjusting their consultations to the presence of interpreters. especially the many different Asian cultures.This will enhance the quality of the interpretation.nz/NZFP/Issues/Aug99/orchan. in simple English. I. Agreement on type of interpreting In the medical setting. the use of trained interpreters is often not possible because of lack of access and the high cost.org. K. [Available from www. Number four is symbolic of death in both cultures. The use of interpreters by South Auckland GPs. it is recommended that the doctor speaks in one or two sentences followed by interpretation. the doctor might like to find out some do’s and don’ts of the particular Asian culture before the consultation for example.victims are essential.

The doctor should look and talk directly to the patient instead of talking through the interpreter. Interpreters services are being made available to Asian migrants from nonEnglish speaking background at a PHO level. financial situation.(longer than two or three sentences) is less conducive to understanding and flow of conversation or consultation. Maui Cole’s Medical practice in New Zealand 2011 77 . Further enquires can be made at the local practices. slightly out of view from both. Health interpreters play a major role in addressing health needs. Mental health is a challenging area because of the degree of stigma attached to such illness in many Asian cultures resulting in treatment delay and possibly worsening of prognosis. accessibility and affordability are three important criteria in measuring how well Asian people’s health needs are met in New Zealand. The interpreter should be seated in between the doctor and the patient. and have to be considered by health practitioners. Conclusions The cultural beliefs of people’s countries of origin still prevail in their initial settlement period. the doctor. Common diseases listed here need to be considered in the final diagnosis and treatment. Seating arrangements Where possible. the roles family and community play and the barriers to successful resettlement. Availability. This enhances communication. and careful use of these experts is critical in the management of these patients. Efforts must be made to get Asian patients integrated to the health systems in New Zealand and this will require ongoing education for both patients and medical practitioners. The follow up of patients should consider the life styles. patient and the interpreter should be seated in a triangle formation with the doctor and the patient sitting in direct and full view of each other.

“I am depressed doctor. (eg. Up to 30 percent of patients present with such symptoms. Of those who do present to services. “I haven’t been able to sleep properly for ages…”).. assesses and treated to/by secondary (or psychiatric) services. Many presentations will be dealt with in a social context (eg. Up to three percent will be referred. Director of Mental Health and Chief Adviser at the Ministry of Health Wellington. The World Health Organisation (WHO) estimates that one in five persons will present with a mental disorder over their life time. People with presumed mental illness and marked behavioural disturbance may need assessment and treatment under the Mental Health Act (Mental Health [Compulsory Assessment and Treatment] Act 1992). 78 Cole’s Medical practice in New Zealand 2011 .8 The psychiatric patient and the law David Chaplow is a forensic psychiatrist.. counselling by a priest). They will present with a clear psychiatric illness (eg.”) or with symptoms which need explanation. never coming to medical notice. most will be assessed and treated by a general practitioner. Why have an Act? The Mental Health (Compulsory Assessment and Treatment) Act 1992 How is “mental disorder” defined? How do I initiate civil commitment under the Mental Health Act? Issues in civil commitment Known risk to others Guardianship Order (Protection of Personal and Property Rights Act 1988: PPPR Act) Criminal matters Disability Insanity Special patients What happens if you are asked to testify in court? In a typical day a general practitioner will assess and treat people presenting with psychological symptoms and illness.

This chapter defines and discusses mental disorder and practical aspects of using the Act. Section 4 states that the above definition should not apply to the following categories: Cole’s Medical practice in New Zealand 2011 79 . or by disorders of mood or perception or volition or cognition” …and threshold criteria: that their behaviour (a) poses a serious risk of danger to the health or safety of that person or of others. or (b) seriously diminishes the capacity of that person to take care of himself or herself. The Mental Health Act (The Act) protects the mentally disordered person. Why have an Act? Mentally ill patients are vulnerable because of their impaired judgment and autonomy and because of their capacity to harm themselves. means an abnormal state of mind (whether of a continuous or an intermittent nature) characterised by delusions. ensures assessment and treatment and upholds their rights. including giving evidence in court. harm others or to be unable to ensure self-care. There is a core definition: “Mental disorder in relation to any person. Other associated protective legislation includes the Protection of Personal and Property Rights Act 1988 The Mental Health (Compulsory Assessment and Treatment) Act 1992 The Act defines mental disorder specifies Rights and Protections for ‘patients’ and ensures a framework of accountability for their care How is “mental disorder” defined? This is given in sections 2 and 4 of the Act.

others. Disorder of cognition refers to the process of thinking. religious or cultural beliefs. or (b) a person’s sexual preferences.(a) a person’s political. Disorder of mood refers to a pervasive and sustained feeling state. and disinhibited states or in the “frontal lobe syndrome” following a head injury. Abnormal mood states can occur secondarily to other illnesses such as personality disorder and schizophrenia. Continuous or intermittent acknowledges that most mental illnesses and disorders follow a fluctuating course. or (c) a person’s criminal or delinquent behaviour. distinct from people of similar cultural or religious backgrounds. catatonia. or seriously impairs their ability for self-care. as in hypomania. the increased rate of thought in mania and the slowed process of thoughts as seen in depression. judgment and ability to function adaptively. Assessment of risk must encompass the following points: the nature and magnitude of the harm its imminence its frequency circumstances and conditions that increase the likelihood of harm balancing the alleged harm on one hand and the nature of society’s intervention on the other. Disorder of volition is a reference to “will” and may be affected in depressive-stupor. This is why both the “cross-sectional” and the “longitudinal” histories are necessary. or (d) substance abuse. Section 4 exclusion criteria mean that compulsory assessment and treatment should only be applied to those with major mental disturbance. or (e) intellectual handicap. It can be “low” as in depression. The threshold criteria mean that people can only be committed under the Act if their disorder is so severe that it endangers themselves. not 80 Cole’s Medical practice in New Zealand 2011 . The disorder covers the disordered thoughts of the psychotic disorders (such as the disorder of thought form). Disorder of perception include hallucinations and usually occurs in psychotic illness. True depression or hypomania comprise mood states that affect world view. Delusions are defined as fixed false beliefs out of keeping with the patient’s ethnic or religious culture. Abnormal state of mind refers to a qualitatively different presentation. or “high”.

They can request a second opinion from a psychiatrist of their choice. Before the end of five days a patient can be released. a period of five days’ compulsory assessment begins. Patients can appeal their compulsory detention (to the High Court. This is usually in a mental health inpatient unit but could be in the community. The patient’s assessment and treatment fall under the responsibility of a Responsible Clinician (RC). usually a psychiatrist. Both need to complete a Section 8 application certificate (of the Act. A psychiatrist (or a training registrar) will complete the assessment (section 10) stating that there are grounds for suspecting that the person may be mentally disordered (or the contrary).to those who disagree with the state or those whom we dislike or disagree with. Issues in civil commitment Under an inpatient CTO a patient is obliged to take their medication and reside where directed. to the community or to an inpatient unit). This is usually by a member of the public (usually a family member) or by a medical practitioner. often the same clinician as the Director of Clinical Services. At the end of this period the patient must be released or an application made for a Compulsory Treatment Order (CTO). The CTO is usually of 6 months duration and patients must be regularly reviewed by their RC and by a District Inspector (DI). and what type of order should be made (ie. How do I initiate civil commitment under the Mental Health Act? Compulsory assessment is initiated by contacting a Duly Authorised Officer (DAO) at the local District Health Board (DHB).) The DAO reassesses to determine the grounds for further assessment and arranges for a further assessment by a psychiatrist. All services under the Act are the responsibility of the Director of Area Mental Health Services (DAMHS). Cole’s Medical practice in New Zealand 2011 81 . Section 16 of the Act) or to the Mental Health Review Tribunal (MHRT). a lawyer appointed by the Minister of Health. The Judge must determine whether or not the person is mentally disordered. or a further 14-day period of assessment will commence (Section 12). if an order is necessary. This order is made by a Family Court Judge at a hearing arranged for the purpose. informing the patient (section 9). If the assessment finds that the person may be mentally disordered.

the capacity to understand the nature. Application of the act involves the appointment of a “welfare guardian”. Known risk to others Ordinarily the doctor-patient relationship would prevent disclosure of confidential information to a third party. It can be invoked in respect of any persons who “lack. 82 Cole’s Medical practice in New Zealand 2011 . When in doubt you should discuss with a colleague. provision is made in law (Criminal Procedure [Mentally Impaired Persons] Act 2003) in order to assess fitness to stand trial mental status at the time of committal of the alleged crime (“insanity defence”) matters concerning sentencing and disposal. Guardianship Order (Protection of Personal and Property Rights Act 1988: PPPR Act) This provides for people who are impaired in their competence to make certain decisions about their health welfare and property. and to foresee the consequences of. wholly or partly. Criminal matters For those persons before the court for any matter. doctors have a common law and ethical responsibility to warn them of such a risk and take appropriate action. However if there is a known. It provides for the least restrictive orders necessary to address the issues of care and welfare. decisions in respect of matters relating to (his or her) personal care and welfare” (section 6(1)(a)). It can apply to the mentally disordered but more commonly is applies to the care and welfare of the intellectually disabled and/or to those with acquired cognitive impairment (as in head injuries or dementia).The viewpoint of the family and other carers is important and the Act now mandates consultation with the “family” unless there is good clinical reason not to do so or it is not practicable to do so. with your medical defence organisation or with the local DAMHS. serious and imminent risk to a third party.

or didn’t know that their action were morally wrong. For this to occur the jury must hear all of the evidence. Insanity This defence is defined in section 23 Crimes Act and concerns those who …when labouring under natural imbecility or disease of the mind to such an extent as to render him incapable(i) Of understanding the nature and quality of the act or omission. know the plea options and their consequences. Contrary to popular belief only a few people per year are acquitted on the grounds of insanity. including the testimony of defence and crown psychiatrists and be satisfied on the grounds of the balance of probability that the defendant was not only mental ill at the time but either didn’t know what he/she was doing.Disability Natural justice demands that a person understand what he/she is charged with. The statute governing their leaves. Special Patients There are four categories of Special Patient: short-term remandees remand and sentenced prisoners who require assessment and treatment in hospital those who are under disability those who juries assess as “not guilty by reason of insanity”. Cole’s Medical practice in New Zealand 2011 83 . having regard to the commonly accepted standards of right and wrong. or (ii) Of knowing that the act or omission was morally wrong. understand the legal process and be able to work with a lawyer in order to defend him or herself. reviews and release to the community are rigorous and set down in “The Act”. It must be emphasised that the court makes the decision as to insanity with the assistance of the psychiatrist/medical practitioner. The term applies only to the period immediately surrounding the period of commission of the crime.

nz>. Be able to define what words you use. Most doctors feel uncomfortable in court. It is because the evidence needs to be tested and the court need to be sure of the facts upon which it makes its decision. be relaxed and nondefensive. Use plain words. say so. Peters J (Eds) Psychiatry and the Law: clinical and legal issues. The medial witness is in court for two reasons: to assist the court to come to a sound decision to explain complex issues which are often outside the province of the ordinary person. For these reasons it is important to be clear why you are there as a witness.govt. know that you don’t have to “take sides”. will you need to supply a report?) If your professional relationship with the patient may be compromised you are best to request a subpoena. Resources 1. Brookbanks W. Mental Health Law in New Zealand. prepare carefully. As a witness in court you need to know why you are being called how your testimony will be used.moh. Bell S. Brookers. You are also advised to discuss the issue with your medical protection insurer. Don’t give your opinion beyond your expertise. You are there to assist the jury. Wellington 1998. 2. If you don’t know. Chaplow D. 3. Request written instructions as to what role you have. Brookers. and what procedure is required (eg. This makes your obligations (to the court and to the patient) clear. Wellington 1996. Make sure you have your notes. You are not on trial. Brookbanks W. 84 Cole’s Medical practice in New Zealand 2011 . Most general practitioners will be asked to present in court by virtue of having assessed and treated a patient.What happens if you are asked to testify in court? There are three types of witness: witness to fact (when the witness sees or hears something relevant to case) the clinical witness who becomes involved by virtue of the doctor/patient involvement (eg. Ministry of Health Website< www. Nor do you have to prove anything. has made notes about the case) the expert who has special knowledge and experience in a defined area.

enabling them to make an informed choice. benefits and costs of treatments. Andrew Connolly is full-time general surgeon and Head of Department at Counties-Manukau District Health Board. However this informed choice can be made only to the level of comprehension and competence that the patient possesses. The consent form is merely the written acknowledgment of a process that provides the patient with sufficient information in order to make an informed decision about their treatment. Patients will sometimes need time Cole’s Medical practice in New Zealand 2011 85 .9 Informed consent Judith Fyfe is a lawyer with a forensic law practice in Wellington and lay member of the Medical Council of New Zealand since 2009. Barnett Bond is a general practitioner on Waiheke Island and has been a member of the Medical Council. benefits and costs have been quantified to the degree that meaningful information can be given to patients. Informed consent to medical treatment has long been an ethical obligation. Informing and obtaining consent The law When Informed consent is not necessary Who can give consent on behalf of another? Care of Children Act 2004 Ethical dilemmas Informing and obtaining consent Informed consent is more than getting a patient to sign a consent form. and more recently a legal requirement. Most of these risks. It is a fundamental patient right. In the modern world of medical practice much is known about the risks. There can be no suggestion of coercion and the patient must make choices voluntarily. It is a two way communication process between a doctor and patient which results in the patient feeling confident that they have enough information to agree to undergo a specific medical intervention. The process of obtaining informed consent acknowledges the independence of the patient and the fact that that the interaction between the doctor and the patient is for the patient’s benefit. It is therefore necessary to be aware of this level of understanding in your patient.

In such circumstances it is vital to seek collegial support and / or refer the patient to another doctor. the more invasive the procedure. It is reasonable in this circumstance to give an honest answer to this question. In some areas of medical practice. If not. This includes informing the patient of treatment options that might be available outside of the publically funded health service. You 86 Cole’s Medical practice in New Zealand 2011 . the concepts involved in treatment are complex and most consumers will be able to grasp only some of the considerations surrounding the recommended treatment or procedure. You should record this decision. or the more risks it involves. patients can still be unsure about what to do. This is especially true of “alternative therapies” (see chapter 19). They may ask their doctor what he or she would do if he or she were the patient. In this situation.after the consultation to consider matters and possibly discuss these matters with family/wh nau or others who are near to them before they can make a decision. for example. after considering all of the information. The final choice about whether to accept or reject such a recommendation is the patient’s. In these areas of treatment or investigation. the more prudent it is to have the patient sign a consent form. It is not necessary to have a signed consent form for every treatment. and give the patient clear reasons why she recommends one treatment over another. In addition to discussing the risks and benefits of any proposed treatment. then the doctor may need to consider declining to perform the procedure under discussion. However. This does not mean that a practitioner must know of every single possible alternative treatment. In the absence of a signed consent form. it is wise for the doctor to make a specific recommendation based on his or her experience. for every prescription written in general practice. Patients sometimes raise the possibility of a treatment that the doctor does not agree with or does not know about. the patient has the right to know of alternative treatments and their risks and benefits. Sometimes. this would be impractical. but she should know about a range of treatments that her colleagues would judge to be reasonably known by a doctor in her position. you should include an annotation in the patient record that the patient has consented to this treatment. Sometimes patients maintain that they do not want a lot of detail about possible complications from the proposed treatment. the doctor must decide whether or not the patient has in fact received sufficient relevant information to make an informed choice. In addition patients may waive the right to discuss the details of a treatment. In these circumstances the doctor should advise the patient of the evidence base for the respective treatments as far as she knows them.

Particular attention must be paid to explaining the uncertainties and limitations of the screening and implications of false positive and false negative findings for their patient. There are rare occasions when a doctor does not wish to discuss a particular treatment with a patient because that treatment conflicts with the values or beliefs of the doctor. then the consent must be in writing.should do this in every case because it provides evidence that you engaged with the patient in an appropriate discussion. there must be a discussion with your patient about the proposed treatment. and you. This must be explained prior to obtaining consent. (and not a delegated representative) should disclose and discuss with your patient The diagnosis as far as it is known The nature and purpose of the proposed treatment or procedure The risks and benefits of the proposed treatment or procedure Alternatives to this treatment or procedure (regardless of their cost or availability in the New Zealand public health system) The risks and benefits of the alternative treatment or procedure as far as you know them. Other than in extreme emergencies it is also a requirement of the World Health Organisation Patient Safety Checklist to ensure a written and signed consent form is completed prior to any operative procedure. The checklist is likely to be introduced into all New Zealand hospitals. In summary. or there is significant risk of adverse effects to the consumer. An example of this might be termination of pregnancy. during which the patient must be given the opportunity to ask questions and gain a better understanding. Consent should be obtained from the patient if the care or treatment is part of the trainee’s education. In this case the doctor must inform the patient of this conflict and refer the patient forthwith to a doctor who can discuss all the currently recommended and accepted treatment options. Doctors have a special duty of care when enrolling apparently healthy asymptomatic persons in screening programs. and The risks and benefits of not receiving or undergoing a treatment or procedure The patient has the right to Consider the information given Cole’s Medical practice in New Zealand 2011 87 . If a treatment is part of research or is experimental. Where medical trainees are involved in the treatment or care of a patient the patient should be informed about the extent of the involvement of the trainee and the trainee’s experience. or the consumer will be under general anaesthetic.

the Code of Health and Disability Services Consumers’ Rights. and failure to fulfill requirements may be considered as medical misconduct. When informed consent is not necessary There are rare occasions when it is not necessary to get informed consent. The law There are legal requirements for doctors to undertake the informed consent process prior to beginning treatment. The standard for informed consent is that which a reasonable patient might expect rather than what a reasonable doctor might think (Rogers v Whitaker 1992). This can be in the form of an advance directive and must be in writing and is covered by common law. and whether such research requires and has received ethical approval. and 7. change his or her mind and withdraw the consent. especially in Rights 5. The Code says that the patient must also be informed about the estimated time within which a health service will be provided. The Code of Health and Disability Services Consumers’ Rights 1996 (see chapter 23) makes explicit reference to informed consent. The consumer or patient has the right to know the identity and qualifications of the providers of the service. The Code is also explicit that health services can be provided to a consumer. Some of these occasions are covered by statutory provisions which take precedent over the Code. how to obtain an opinion from another provider. 6.Ask for clarification and ask for time to consider the information Consult with family and others Give consent or decline to give consent Waive the right to discuss the details of treatment After having given consent. and the results of the research. General consent may be given by a patient in advance of the knowledge that any treatment will be necessary. It is important that every practitioner working in New Zealand is fully conversant with this Code. All doctors must be familiar. the results of any tests. only if that consumer has made an informed choice and given informed consent. and the results of procedures. Retention and or storage of body parts or bodily substances can be done only with the informed consent of the patient. These situations are detailed in the Medical Council’s statement Legislative requirements about patient rights and 88 Cole’s Medical practice in New Zealand 2011 . Among other things the Code makes it clear that the patient must be informed of any proposed research or teaching associated with their treatment. and comply with.

where they are unconscious. A spouse or next of kin cannot consent to or refuse medical treatment on behalf of an incompetent person unless they hold enduring power of attorney or are their welfare guardian.consent which can be found on its web site. except they do not have the legal ability to refuse consent for lifesaving treatment or medical experimentation. Who can give consent on behalf of another? The only individuals who are entitled to grant consent on behalf of a patient are legal guardians (welfare guardians under the Protection of Personal and Property Rights Act. Only those treatments that are necessary to preserve life or health should be done at this time. Right 7 (4) of the Code specifies other circumstances when it is possible to proceed with treatment without consent. The individual with that authority can make all healthcare decisions. Personal care is the applicable authority in regard to giving consent for health care. then you can provide the key services without consent. or personal care.mcnz. and under the Health Act 1956 to prevent the spread of infectious disease. immediate action must be taken to preserve the life or health of a patient. or both. This section involves a patient’s competence. if they have powers in relation to property. Section 18(1) ( c) of The Protection of Personal and Property Rights Act 1988 specifically forbids the person who has enduring power of attorney from refusing consent “to the administering … of any standard medical treatment or procedure intended to save [the patient’s] life or to prevent serious damage to that person’s health. or have an intellectual disability. www.org. Occasionally. or where they are suffering from dementia. Cole’s Medical practice in New Zealand 2011 89 . but remember that every consumer must be presumed to be competent unless there are reasonable grounds for believing that they are not. a legal opinion should be sought with a view to seeking authority from the High Court. Other examples are the Alcoholism and Drug Addiction Act 1966.nz. when a patient is unable or refuses to consent to treatment. or parents/guardians under the Care of Children Act 2004 or someone with enduring power of attorney). The well known examples are under the Mental Health Compulsory Treatment Act 1992 (see chapter 8).” (see chapter 22) It is important to ask someone who has enduring power of attorney. If. in emergency. The Land Transport Act 1998 and section 16 of the Children and Their Families Act 1989 (see chapter 22). Any procedure that can reasonably be delayed should be delayed until an opportunity can be given for the patient to consent. The common circumstances where a patient is not competent are where they are a young child.

or employers. Section 38 of the Act addresses the issue of obtaining consent for abortion for children (a female of any age has the right to consent to or refuse to consent to any medical or surgical procedure for the purpose of terminating her pregnancy). surgical. Professor Don Evans. It would appear. Doctors should regard court orders against parents as an absolute last resort. and sentenced the parents in the third case to 5 years in prison. People under the age of 16 are not automatically prohibited from consenting to medical. This new Act has changed the way a court order may be sought in cases where the parents or guardians refuse to consent to treatment for children in circumstances where the child’s life is at risk. There are situations where doctors and caregivers may jointly seek a court order for consent. you should read this new legislation and seek advice from the medical protection society. 90 Cole’s Medical practice in New Zealand 2011 . for the time being at least. or sterilisation of a patient who is unable to consent but for whom the family and other carers. that the ability to persuade the court will be the most significant factor in determining outcomes. and all other means to persuade parents should be exhausted first. or dental procedures so judgment is needed in each instance. The way the police and the courts treated these cases was inconsistent and in the first of these cases. New Zealand has had three high profile cases since 2000 when parents withheld consent for medical treatment for their children under circumstances that resulted in all three children dying of their diseases. request the operation to enhance the quality of life or to prevent deterioration in physical or mental health. for example to terminate treatment to allow a patient to die peacefully. It states that all persons over the age of 16 are regarded as adults for the purposes of determining competence to give informed consent.Care of Children Act 2004 This Act came into force on 21 July 2005 and replaced the Guardianship Act 1968. Ethical dilemmas All the issues surrounding consent for the treatment of children have not been settled and doctors will still face dilemmas. the lack of a police prosecution followed intense nationwide public support for the parent’s decision to decline to accept conventional medical treatment. lawyers. It also covers how the consent of children should be obtained for medical procedures and the right of health practitioners to administer blood transfusions to children without consent in certain conditions (to save life being the principal condition). director of Otago University’s Bioethics Centre has stated “There is a huge price to be paid for that last step. If you are likely to find yourself in conflict with a child’s guardian about the treatment of serious life threatening conditions. The courts imposed a suspended sentence on the parents in the second case. In the other two cases the parents were prosecuted. It pretty well destroys any collaboration for the future between parents and health carers”. supported by medical opinion.

that the procedure involved a risk of serious complications. 6 June 2002 5.org/ama/pub/category/4608. Not all issues in informed consent have simple solutions. 2. The patient must be able make an informed choice as to whether they accept and are prepared to run the risk. It can be a matter of what is reasonable under the circumstances and the reasonableness is from the point of view of the patient rather than the doctor. 4. March 2000. www.nz 7. Resources 1.html.legislation. It is advisable to consult with other doctors and professional advisers when you are uncertain. Health and Disability Commissioner. Informed consent. long an ethical obligation. American Medical Association – AMA (legal issues). is in New Zealand a legal requirement. informed consent. New Zealand Government Legislation website. which he or she could readily understand. The test is can the child fully understand the medical treatment proposed and give consent. Rogers v Whitaker (1992) 175 CLR 479 High Court Australia decision affirms that a doctor has a duty to warn a patient of any material risk involved in a proposed treatment. Medical Council of New Zealand. Care of children Act 2004. www. Medical Practitioners Disciplinary Tribunal. 99/54/c. one or more of which if they materialised. Cole’s Medical practice in New Zealand 2011 91 . 3. and that in those circumstances a parent had no power to veto treatment. Information and consent.govt. 1996. The patient should be told in a specific and clear way. Re Stubbs. religion and a dying baby. might result in an extended hospital stay and/or need for further surgery. 2002. A child who is deemed “Gillick competent” is able to prevent parents viewing their medical records. cognizant that the particular patient would express concerns about the risk. The New Zealand Herald.In summary. Current legal authority “consent” decisions Gillick v West Norfolk and Wisbech Area health Authority [1985] 3 All ER 402 (HL) It was held that “parental rights” did not exist other than to safeguard the best interests of a minor (under 16). NZ. Code of health and disability services consumers rights. A risk is considered material if a reasonable person in similar circumstances would attach significance to the risk.amaassn. Informed consent begins with the patient’s first appointment and continues until the procedure is completed. 6. It is one of the cornerstones of good patient care. or should be. Doctor April 2004. or if the doctor is. This is referred to as “Gillick competency”. Science. and recognises that the doctor patient relationship is for the benefit of the patient. In some circumstances a minor could consent to treatment. Campbell J.

employers. New Zealanders who are ordinarily resident may also be covered if they are injured while overseas. The scheme applies to all New Zealand residents and temporary visitors to New Zealand. Levies from workers. Accident claims to ACC Personal injury Mental injury Definition of accident Hearing loss Complex claims Sensitive claims Work related mental injury Treatment injuries Work related gradual process claims Lodging a claim with ACC Entitlements Criminal injuries and self inflicted injuries Time off work – work incapacity certificates Obligations of treatment providers Overview The Accident Compensation Corporation (ACC) has provided comprehensive. vehicle registrations and taxpayers are applied to facilitate the recovery of those injured and to fund the future needs of those injured long-term.10 Accident compensation Peter Jansen is a general practitioner and Senior Medical Adviser for the Accident Compensation Corporation. no-fault cover for people injured from accidental causes since 1974. Once a claim is approved by ACC the injured person may have access to a range of entitlements from treatment and rehabilitation aids. ACC. a crown entity. administers the scheme according to the Accident Compensation Act 2001 (the Act). The right to take legal action for personal injury covered by ACC is removed other than for exemplary damages. to weekly compensation and lump sum compensation. depending on the person’s injury 92 Cole’s Medical practice in New Zealand 2011 .

ACC also contracts for a range of services from elective surgery. Other health providers such as osteopaths and physiotherapists also lodge claims alongside their role in providing treatment or assisting in the rehabilitation of those who are injured. More information on ACC’s performance and monitoring framework is available at www. Accident claims to ACC Most of the approximately 1.nz. Changes to legislation since 1974 mean that the criteria for continuing cover and entitlements on existing claims may vary from that available on new claims. This may not equate to the full cost of treatment so the treatment provider may request a co-payment from the patient. the injured person may be entitled to a range of assistance such as contributions toward the costs of treatment by medical practitioners and other providers.and circumstances. Personal injury is defined in the Act as death Cole’s Medical practice in New Zealand 2011 93 .acc. These contributions are usually claimed by the treating practitioner on the client’s behalf (bulk billing) under the treatment costs regulations which specify the amount ACC will contribute. disease or infection (WRGPDI) treatment provided by or at the direction of a registered health professional (treatment injury). ACC has a network of call centres.co. The information that follows relates to current legislation and new claims. to psychological services and rehabilitation.8 million ACC claims made each year are lodged through general practitioners. the Corporation monitors the delivery of health services. Once a claim has been approved by ACC. To ensure that the health services ACC purchases meet these legislative requirements. Personal injury AC cover is available for “personal injury” that is caused by an accident a work related gradual process. branch offices and specialist units to assess claims and administer entitlements. The legislation also supports good clinical practice – stating that ACC should fund services that are necessary and of the quality required to achieve a return to independence. In general these contracts are intended to meet the full cost of the service and no co-payment can be charged.

the claim will usually be lodged by a medical practitioner or nurse practitioner. bacterium. A mental injury is a clinically significant behavioral. Those definitions include a specific event (or series of events) that involves the application of a force (including gravity) or resistance external to the human body. gas. Specifically excluded by legislation as neither accidents (unless work related) nor personal injuries are 94 Cole’s Medical practice in New Zealand 2011 . or involves the sudden movement of the body to avoid such a force or resistance external to the human body is not a gradual process involves inhalation or oral ingestion of any solid. unless it is as a result of criminal conduct by another person involves a burn or exposure to radiation on a specific occasion (other than exposure to the elements) involves the absorption through the skin of any chemical for a period of not more than one month involves exposure to the elements or to extreme temperatures for a defined period (not exceeding one month).where the exposure results in death or an inability for more than one month to perform an activity in a normal manner. With limited exceptions wear and tear is not covered by ACC. the disorder must be diagnosed by a registered psychiatrist or psychologist. except for inhalation or ingestion of a virus. It does not include emotional effects such as hurt feelings. Definition of accident The definition of an accident is important if claims are to be lodged appropriately. When a mental injury is caused by a physical injury. or protozoan.physical injury damage to dentures or prostheses that replace a part of the human body. Mental Injury Cover is also available for mental injuries that result from a physical injury sexual abuse / assault (sensitive claims) first hand experience of sudden traumatic events in the workplace (WRMI). liquid. However. cognitive or psychological dysfunction. or foreign object on a specific occasion. One example where cover may be available is a work-related gradual process. stress or loss of enjoyment.

Cole’s Medical practice in New Zealand 2011 95 . Complex claims AC legislation describes some claims for cover as “complicated”. For hearing loss claims lodged after 1 July 2010 the person must have suffered at least a 6 percent hearing loss from accidental causes for the claim to be approved. Generally these claims require additional information before ACC can make a cover decision. This is done with the consent of the patient. and ACC may take more time to assess the claim. disease or infection (WRGPDI) personal injuries caused by treatment (before 1 July 2005 this was called medical misadventure) claims that are lodged more than 12 months after the date the personal injury occurred work related mental injuries as a result of witnessing a traumatic event while working (WRMI). These claims are for mental injuries caused by certain criminal acts (sensitive claims) personal injuries caused by work-related gradual process. By responding in a timely fashion and providing all relevant information the patient’s claim can be processed quickly including arranging any expert assessments that are required. Hearing loss Cover for hearing loss may be available where it is a personal injury caused by accident the result of a work related gradual process. When assessing complicated claims ACC may contact treatment providers seeking additional information.any ectoparasitic infestation contraction of a disease through an arthropod as the active vector cardiovascular and cerebrovascular events conditions caused wholly or substantially by the ageing process. disease or infection (WRGPDI) a treatment injury. Nose and Throat specialists are engaged by ACC to assess claims including the apportionment of accidental and non-accidental causes for the loss of hearing. Ear.

Both the underlying disease and other pre-existing diseases are not covered.Sensitive claims Sensitive claims are mental injuries caused by sexual assault or sexual abuse. although a significant worsening of disease might attract cover. Claims approved as sensitive claims have entitlement to the full range of ACC services. Treatment injuries A treatment injury is a physical injury caused as a result of treatment from a registered health professional – but some exclusions apply. There is no requirement to find fault. When a mental injury is caused by sexual assault or abuse. Any information collected is treated as highly confidential and is only seen by the Sensitive Claims Unit staff or the expert independent assessor. sudden traumatic event has been directly experienced. claims for work-related mental injury can also be considered. or heard during the course of their work resulted from an event which could reasonably be expected to cause mental injury in people generally. although in some cases the cause of the injury will be treatment that is inappropriate in the circumstances. Once ACC receives the claim a case manager will contact the client to facilitate the collection of relevant information or to arrange for any ACC-funded assessments that may be required. Also excluded are a necessary part. the person can lodge their claim through either a medical practitioner. providing the injury was first treated on or after this date and the mental injury: was caused by a single. Further information and guidance can be obtained from the Sensitive Claims Unit on 0800 735 566. The events which amount to sexual abuse/assault are included in a list of crimes contained in Schedule 3 of the Act. or the ordinary consequences of treatment (for example hair loss following chemotherapy or radiotherapy burns would be unlikely to be covered) injury caused solely by decisions about allocating health resources 96 Cole’s Medical practice in New Zealand 2011 . seen. nurse practitioner or an ACC-registered counsellor. Sensitive claims are managed by ACC’s Sensitive Claims Unit in a confidential process. although the main treatment offered is counselling or psychotherapy for the mental injury suffered as a consequence of the criminal activity. Work related mental injury Since 1 October 2008.

There are two types of claims under this heading: 1. the client or their employer. The fact that treatment did not achieve the desired result does not in itself constitute a treatment injury. To investigate these claims ACC will collect additional information from the client. namely: there must be a particular property about the person’s work task or work environment which has caused or contributed to the injury the property or environment must not be found to any material extent outside the workplace the risk of suffering the injury must be significantly greater for people who perform that task or work in that environment. or arrange for further Cole’s Medical practice in New Zealand 2011 97 . ACC must report to the Director General of Health and may report to the Medical Council when the investigation of the claim leads to a conclusion there is a risk of harm to the public. This simply involves completing an ACC45 Injury Claim Form and submitting this to ACC. Work related gradual process claims From 1 July 2010 claims for WRGPDI return to the provisions in effect before 1 August 2008. approved and declined are reviewed for reporting of harm.injury caused because a patient unreasonably delayed or refused to give consent for treatment. In most cases the decision takes no more than two days. Other work related gradual process claims that meet the 3-part test. Electronic forms can be submitted from a patient management system or via the web. If more information is needed ACC may contact you as the treatment provider lodging the claim. All claims. The form is available in both paper and electronic format. Lodging a claim with ACC Only registered treatment providers can lodge a claim with ACC. A person is exposed at work to one of the substances or agents listed in Schedule 2 of the ACC Act and then develops the listed occupational diseases. 2. The client may also be assessed by an occupational medicine specialist before a decision is made. their employer and their treatment provider. Examples of treatment injuries could range from a wound infection to operating on the wrong limb. Once the ACC45 information is processed by ACC a decision is made as to whether or not cover is granted or if further investigation is required.

imaging. If cover is declined you and your patient will not receive any payments. treatment and rehabilitation benefits depending on their injury and circumstances. It is important to complete the ACC45 as completely and as accurately as possible. Treatment injury. Each ACC45 has a unique number which is then assigned to that injury. Only a registered medical practitioner or a nurse practitioner can certify work incapacity. The circumstances require that the offence is punishable by a maximum term of imprisonment of 98 Cole’s Medical practice in New Zealand 2011 . public health acute services). work-related gradual process and sensitive claims each have specific processes. Electronic practice management systems will automatically help you assign the correct Read code. Remember to record the Read codes for the patient’s injury on the ACC45. transport. equipment. The completed ACC45 should be posted in the reply paid FastPost envelopes or electronically lodged as soon as possible. For manual forms ACC has produced a quick reference guide to the most commonly used codes. Entitlements Clients who suffer injuries that are covered by the Act may be entitled to a number of financial. The ACC45 also acts as a “sick note” for the client and this part should be filled in as accurately as possible. home-based care. Complicated claims require investigation. elective surgery. Types of assistance include: rehabilitation – treatment (including pharmaceuticals. Where there are multiple injuries record the Read code for each injury. so the Act allows ACC more time to make decisions in some circumstances. consumables and other services aimed at restoring the client to maximum health and independence compensation for lost earnings – clients may be eligible for weekly compensation for earnings lost as a result of their injury death benefits such as funeral grants and payments to dependants an independence allowance for injuries that occurred before 1 April 2002 lump sum compensation for injuries that happened on or after 1 April 2002. Information on these is available from the ACC website. In that event you are entitled to bill the patient for services provided. Once the claim is approved ACC will pay the treatment provider’s invoices and give appropriate entitlements to the client.assessment. Criminal injuries and self inflicted injuries ACC is required to disentitle clients whose injuries are sustained after 1 July 2010 during the course of committing a serious offence.

and the range of tasks they can do now as well as the number of hours the patient can attend work. Special provisions apply to surgery. A certificate that reports on fitness to work (work capacity) helps case managers to negotiate with employers on behalf of the client. This form should be filled in carefully with regard to the person’s work capacity. For that reason it is preferable. All clients should be examined before they are issued with a new medical certificate. and the client is sentenced to a term of imprisonment or home detention. the tasks involved in their job and the alternative tasks they might still be able to do at their work. The patient should be asked relevant questions such as the type of work they do and the tasks involved how long they have been doing that job what their working conditions are like any problems or injuries they had before the accident any concerns or fears they have about returning to work the tasks they are still able to do. with the patient’s consent. Use this information and other findings to estimate the time in which you expect your patient to be fit for normal work. At times it may be appropriate to talk. to the client’s employer. whether that means their usual tasks or alternative duties or limited hours. Some injuries necessitate time off work. In such cases ACC is only permitted to contribute to the cost of treatment. This provision does not apply to those whose injury is the result of a covered mental injury. Time off work – work incapacity certificates Clients who require time off work because of their injury will need a medical certificate from a medical provider. Many clients will return to Cole’s Medical practice in New Zealand 2011 99 . The maximum time off work allowable on the first certificate (usually the ACC45) is fourteen days. to focus on the capacity of the client to undertake work. when completing the forms. and to develop rehabilitation programmes that best suit their needs. From 1 July 2010 similar levels of disentitlement apply to those who commit suicide or a wilfully self-inflicted injury. The certificate used by a registered medical practitioner or nurse practitioner (the only treatment providers who can issue these certificates) is ACC45 for the first visit ACC18 medical certificate if an ACC45 has already been lodged.2 years or more. After that the maximum time off you can certify is thirteen weeks before another certificate is due.

Note: retrospective certification is not good practice. ACC you must register with ACC and maintain relevant practising certificates. ACC has policies and procedures designed to ensure appropriate treatment and rehabilitation. including application forms. I acknowledge the work of Dr Jonathon Fox – who wrote the chapter on ACC in previous editions. including: the Treatment Provider Handbook. and guidelines are available for expected time off related to specific injuries. This chapter is based on his work with updates in line with new legislation and policies introduced since 2007. and Greg Palmer.nz within the “For Providers” section.acc. Mike Mercier of Legal Services.acc. Director of Clinical Services. All treatment must be necessary and appropriate match the quality required be given the appropriate number of times be given at the appropriate time and place normally be provided by your type of treatment provider. is available on line at www. or treat under.co. Resources and where to go for more information ACC has produced several publications to assist you. Obligations of treatment providers Before you can lodge claims for.co. Tangaroa 100 Cole’s Medical practice in New Zealand 2011 . Thanks also to my ACC colleagues for their advice: Dr Kevin Morris.nz and through the Provider helpline: 0800 222 070. Information about registering.work sooner. Acting Communications Manager. This and additional information is available on the ACC website www. Once accepted you can claim and treat under the AC scheme. a comprehensive guide to working with ACC Treatment Profiles which provide a guide to managing individual injuries. Treatment providers are monitored and ACC can investigate if there are any concerns about the treatment being provided.

(O) objective. Purpose and content of the record Legal and ethical obligations Electronic records The Rules of the Health Information Privacy Code Health research Disclosures under other legislation Transfer of patient records to another doctor Purpose and content of the record An important part of a good doctor patient relationship is the keeping of a proper medical record. and what is diagnosed. To fulfil these tasks. the record must be comprehensive and accurate. A good medical record. It is useful to differentiate between what is reported. These different features of a record entry are often abbreviated as (S) subjective. It is also important that the notes can be ascribed to the appropriate patient (so the name. however. It is a tool for management. diagnosis and treatment plans. at an identifiable time and by a recognisable author. signs. Cole’s Medical practice in New Zealand 2011 101 . and has become the primary tool for continuity of care in many practices as well as in hospitals. There is a long established tradition in medicine that the “notes” that form the main part of the record contain something about the patient’s symptoms. what is observed.11 The medical record Robert Stevens is an Auckland barrister and a consultant in the management of personal information and privacy. (Dx) diagnosis and (P) plan. date of birth or other identifying details must be recorded accurately). for communicating with other doctors and health professionals. is important for the health care for a patient and can also be helpful for the doctor if there is any question or complaint about the care of the patient. Time constraints and different styles of consultation may result in records that are not as comprehensive as is desirable.

a special code of practice issued under the Privacy Act adapts the usual rules at the centre of the Privacy Act to health care.Lillenthal suggested 11 “commandments” of medical record keeping. which. would improve practice and protect the doctor in the event of a complaint103 write legibly write the date and time sign legibly do not use ambiguous abbreviations do not alter notes or disguise additions do not use offensive or humorous comments check what you have written look at and deal with. The management of all personal information is covered in New Zealand by the Privacy Act 1993. 130/80. It is called the Health Information Privacy 103 Lillenthal C. Sometimes. if only because such amendments might later raise suspicion of covering up an error in treatment or diagnosis. pulse reg 64/min. Legal and ethical obligations The legal and ethical duties around medical records have nothing to do with ownership of documents. buying Cartia”.5 daily 3/12” and one which says “Repeat meds. incomplete or potentially misleading. 102 Cole’s Medical practice in New Zealand 2011 . Consider the difference between a record on one day which says “Repeat meds Metoprolol 47. if observed. and initial/date reports remember the patient may need your notes understand how patients can get access to your notes if in doubt consult your defence organisation. The earlier entry should never be deleted.5mg daily 3/12. obliterated or changed. Medical Records – the eleven commandments. well. Journal of the Medical Defence Union. Metoprolol 47. the second form shows considerably more of the process the doctor is going through and records important findings for monitoring the patient’s health and the results of the doctor’s interventions. Although not a lot longer. a doctor may feel that it is inaccurate. January 1997. on reviewing an earlier record entry. It is appropriate to augment a record in such cases. Where health information is concerned. making it clear when and by whom the augmentation or annotation was added.

Cole’s Medical practice in New Zealand 2011 103 . so a doctor against whom such a complaint is made will have opportunity to give their side of the matter and. make some offer of redress.nz. where appropriate.org. A good rule of thumb is that there should be no surprises for the individual in how information about them is collected. The HIPC provides rules for health agencies. The HIPC is published with accompanying commentary by the Privacy Commissioner. the commentary is not legally binding. including the HIPC.Code 1994 (HIPC). is used.104 It has the force of law. The published version of the HIPC has an appendix containing extracts from several other applicable statutes. or obtain advice from someone else who is more familiar with the Code. The rules of the HIPC are designed to ensure that people retain a degree of autonomy when others are dealing with health information about them. A brief outline of the twelve rules at the heart of the HIPC is given in this chapter. The Commissioner investigates the complaint and usually looks for a negotiated settlement. but contains a wealth of practical pointers and observations which will answer many a query. on their handling of health information that is about identifiable individuals.privacy. obtainable from the Office of the Privacy Commissioner. a legal case may be taken to the Human Rights Review Tribunal which can make orders and award damages and costs just like a District Court. are enforced by first making a complaint to the Privacy Commissioner. and also includes the incidental information used in conducting the business side of health care such as address and billing details. If there is no settlement after investigation by the Commissioner. but in case of any doubt doctors should refer to the words of the HIPC itself. A copy should be readily available in every medical practice and any other organisation involved in health care in New Zealand. Medical records are very often made and held in electronic 104 Health Information Privacy Code 1994 (reprinted with amendments September 1998). Electronic records The obligations around medical records exist regardless of the form in which they are kept. including doctors working on their own account or for others. “Health information” covers everything from consultation notes through to medical test results. Some other laws are also applicable to medical records. and is passed to others. An individual’s rights under the Privacy Act. Among the more important of these is the Health Act 1956. or at www. and regulations issued under that Act on the retention of medical records. The rules generally reflect good ethical medical practice.

electronic records do require some special care simply because they are easy to access. However. You may be asked to justify having collected individual items of health information. Whilst they are immensely convenient. if scanned copies of images would miss detail of potential significance. there is no need to retain that original. especially if it has come from someone other than the individual concerned. and with what intentions of passing the information to others. is aware of who is doing the collection. you must take all reasonable steps to ensure that the individual is aware that the collection is taking place. Rule 2 – Source of the information Wherever practicable. You will usually be collecting it for care and treatment. and existing paper records converted to electronic media. Many health care agencies find it convenient to communicate these matters by the use of leaflets. It is good practice to record the source from which you have obtained health information.form. The Rules of the Health Information Privacy Code Rule 1 – Purpose of collection You must collect health information only where the information is needed for a lawful purpose. To the extent that an electronic record captures everything which was in the original paper version. You should also see that the individual is told the name and address of the agency which will be keeping the information. If it is practicable to do so. and by notices on the forms which the individual uses to give the information. Thus. and that they have a right of access to it. 104 Cole’s Medical practice in New Zealand 2011 . when sending off certain information in an electronic record. the original films should not be destroyed inside of the normal minimum retention period. Rule 3 – Collection of health information When you collect health information directly from the individual concerned. the practitioner must be alert to the possibility that the transmission will send more of the record than was required or intended. for what purpose. One exception is where the individual has authorised you to collect the information from someone else. and the collection is necessary for that purpose. including the administrative aspects of those activities. copy and transmit. you should collect health information directly from the individual concerned. these steps should be taken before the health information is collected.

Rule 5 – Storage and security Anyone holding health information must take the steps which are reasonable in the circumstances to ensure that it is guarded against loss or unauthorised access and use. on request. There are circumstances in which the request for access may be refused. archive storage. Computers should have passwords. the greater should be the safeguards applied. or by offering inappropriate inducements or threats to obtain it. and records should be accessible only in areas where access is limited to staff. fair. Any doctor making records should do so on the assumption that they may be seen by the individual concerned. the right of access under the Privacy Act Cole’s Medical practice in New Zealand 2011 105 . or destruction of medical records. no matter what the doctor promises. but must remain mindful of its importance to the individual concerned. Amongst other precautions. and in the form that the individual prefers. Medical professionals become used to dealing with very sensitive personal information. for instance. but these are exceptional cases and the only valid reasons for refusal are those set out in the Privacy Act. to health information about them. As with several other rules of the HIPC. Similarly. A request for access must be responded to promptly. and do not intrude unduly on the individual’s personal affairs. all require particular care as to confidentiality. Access should usually be given without charge. this means that the more personal information should not be voiced where others can hear it if those others have no business to know it. giving a misleading impression of the purpose. This means that information should not be collected by. Rule 6 – Right of access Individuals have the right to have access. the test of what steps are “reasonable in the circumstances” calls for a proportional approach – the more sensitive the information.Rule 4 – Means of collecting health information You must collect health information by means which are lawful. However. and the source of the information may ask that the patient is not to be told that the doctor has the information or who gave it. The health agency should verify the individual’s identity before giving the information to them. Transfers. and certainly within twenty working days. care must be taken when transmitting health information by fax or computer transfers to ensure that it goes only to the appropriate recipients. It sometimes happens that a doctor is given information about a patient by someone else.

Given that health information is normally kept for purposes which include future diagnoses and care. A private sector health agency may make a (reasonable) charge for providing copies of X-Ray or similar images. Quite apart from any request. The agency keeping this information may refuse to make the correction if the agency feels that it would not be appropriate to do so. The Privacy Commissioner has power to investigate complaints about charges being made where they should not be made. The steps taken will depend on the use to which the information is to be put: the more important that item of information is in the proposed action. relevant and not misleading. the requesting individual must be advised of the likely charge before it is incurred. but in such a case the agency must if so requested attach a note to the contested information showing the patient’s assertion of the error. complete. 106 Cole’s Medical practice in New Zealand 2011 . if you become aware of an error in health information held you should yourself take steps to correct it. In any case where a charge is proposed and it would exceed $30. Any corrections made should be communicated. Questions of correction are kept to a minimum if the record clearly shows what items of information are opinions rather than facts. Rule 9 – Retention of medical records This HIPC rule states that health information is not to be kept for longer than it is required for those purposes for which it may lawfully be used. Rule 8 – Check before use You must not use health information without first taking reasonable steps to ensure that it is accurate and not misleading. Similarly it may require the payment of a reasonable charge for access by an individual to any health information about herself where substantially the same access has already been given in the previous 12 months. to every other person or agency to which the erroneous information has been previously passed. if practicable. the more rigorous should be the steps to ensure that it is accurate. the rule itself will not often impose a limit on retention.still exists. or charges which are more than is “reasonable”. up to date. and she can make binding rulings on the amount of those charges in any such complaint. Rule 7 – Correction of health information Every individual has the right to request correction of health information about them if they believe it to be wrong. see Clause 6 of the HIPC. so doctors should never give unqualified promises of confidentiality if they receive information about a patient from third parties.

A further group of exceptions applies to allow other disclosures where it is not desirable or practicable to obtain the individual’s authorisation. there are specific regulations – the Health (Retention of Records) Regulations 1996 – requiring that health information relating to an identifiable individual must be retained for a minimum of ten years from the day after the last treatment or care of that individual by the agency holding the information. Rule 11 – Limits on disclosure Disclosures which were anticipated and intended when the information was obtained can proceed as planned. The question often arises as to what to do with health records relating to a patient who has not been seen for very many years. particularly when a sole general practitioner has died or retired. Unless the accuracy of certain health information is being questioned. of which more will be said below. Other disclosures can be made with the authorisation of the individual. and usually are. the most likely form of complaint in relation to retention is that it has not been retained for long enough. The Medical Council’s guideline. Cole’s Medical practice in New Zealand 2011 107 . where the disclosure is for a professionally recognised accreditation or quality assurance programme. Medical records can be. Another permitted exception applies in the area of health research. Examples of this group are where the disclosure is directly related to the purpose for which the information was obtained. is that records are retained for more than ten years. passed on to another doctor as a patient moves from one to another. Doctors in sole practice would do well to make arrangements in advance for their records to be transferred in bulk to another doctor for safe keeping should they cease practice suddenly.Furthermore. and the advice of several colleges. The most commonly encountered exceptions are where the new use is directly related to the original purpose. or where the disclosure is for statistical or approved research programmes (of which more is said below). The rule against disclosure applies to health information about individuals until twenty years after their deaths. and the situation fits into one of the limited exceptions set out in the full rule. Rule 10 – Limits on use Health information obtained for one purpose cannot be used for another purpose unless one of the exceptions to this rule applies. or where the individual has authorised the other use.

which will inquire into any privacy issues apparent in the scope and conduct of the proposed programme and may set limits in those areas. Health information can then be used in. where its recording and use by your agency is for the purpose of making the claims and reports which are required to be indexed by that common identifier. a research programme which has received ethics committee approval. Disclosures under other legislation Disclosure to other health professionals Where another health care professional makes a request for health information in order to provide health or disability services to the individual. this can proceed without the individual’s authorisation if it is not desirable or practicable to obtain that authorisation. The rule does prohibit a health agency using the same identifier (eg. Refusal to provide requested information to another health 108 Cole’s Medical practice in New Zealand 2011 . a driver licence number) given by another body for an unrelated purpose. but nothing will be published in a form that could be expected to identify the individuals covered. and disclosed for. Health research Most health research in New Zealand has to be approved by an official ethics committee. You can use another agency’s unique identifier only where your use of it is part of the purpose for which that identifier was assigned. It should be noted that there is no prohibition on the use or disclosure of statistical information which is not identifiably about any individual. It is not necessary for the doctor acting on such a request to get the individual’s authorisation to make the requested disclosure. this is permitted by section 22F of the Health Act.Rule12 – Unique identifiers Unique identifiers (such as a reference number for a particular patient) can be used where these are assigned by the agency itself and are necessary for the agency’s own purposes. and there are only limited circumstances in which the request for information may be refused. Where information about an identifiable individual is to be disclosed for use in statistical surveys. although one of the few grounds on which disclosure of the information can be refused is if the doctor has reasonable grounds to believe that the individual does not want it so disclosed. but even so any disclosure for the purpose of such a research programme can only go ahead in the absence of the individual’s authorisation if it is not practicable or not desirable to obtain that authorisation. A case in point is the National Health Index number.

who will treat it as if it were a refusal to give access requested by the individual. it means their parent or guardian. in any other case it means a person appearing to be lawfully acting on the individual’s behalf or in their interests (including a welfare guardian or attorney). The request may still be refused if the doctor has good reason to believe that the individual would not want that information to be disclosed to that representative. The bodies which make such requests should make it clear what statutory authority they are relying on. There is a duty on a doctor under the Land Transport Act 1998 to report to the Director of Land Transport Safety any person they know of who is likely to drive a vehicle but whose mental or physical condition makes it unsafe for them to do so. and the statutory provision which might permit or require the doctor to provide that information. Certain protected disclosures There are provisions under the Children Young Persons and their Families Act 1989 which allow and protect the reporting to Police or to a social worker of suspected neglect or abuse of a young person. A doctor can and should ask the requesting body to clarify in writing exactly what information is sought. and supplied by. Section 22F applies to requests.professional. if the individual is a child under the age of 16. where that disclosure seems to be required under section 22F. If the individual is dead. In those cases the legislation allowing or requiring the disclosure will protect the doctor who made the disclosure in good faith from any legal or Cole’s Medical practice in New Zealand 2011 109 . where the matter ought to be dealt with in the usual way under rules 3 and 11 of the HIPC. it does not cover volunteered or routine disclosures. the reason for the request. Disclosures to representatives Section 22F also allows the doctor to meet requests for information from the individual’s “representative” where the individual is under the age of 16 or is for any other reason unable to exercise their own rights. their “representative” is their executor or administrator. such as a report to the individual’s normal general practitioner. Other requested disclosures There are a number of other provisions in legislation under which information can be requested from. concerned. can be referred as a complaint to the Privacy Commissioner. a doctor.

either received directly or through the request of the new doctor.disciplinary action being taken against the doctor on account of that disclosure. and their obligations under the Code apply to all the health information held by the partnership. The agency holding the record should generally wait for a request by the patient or by the new health care provider before transferring the records. Locum doctors may work in. Fuchsia excorticicata 110 Cole’s Medical practice in New Zealand 2011 . that partnership. this allows for agreement on what records are to be transferred and by what means. and as employees of. Kotukutuku. medical defence organisations strongly recommend the doctor keeps a copy. and legal advice should be sought where the partners do not agree on what should happen to the records. Transfer of patient records to another doctor Partnerships of doctors operate as single agencies under the HIPC. A doctor leaving a partnership has no automatic right to remove any records. but at the minimum should consist of a brief factual summary of what records the doctor has along with a note of the present state of the patient’s health. When a patient’s medical records are to be transferred to another doctor. 2001. Maintenance and retention of patient records. Resources 1. and the existence of outstanding accounts is no excuse for refusal or delay. Medical Council. Such transfers must be made at the request of the patient. Transfers should be made promptly on request. The record to be transferred would usually be the whole folder of notes or print out of the electronic file. especially if there has been any suggestion of complaint. 2. The Privacy Commissioner’s enquiry line on 0800 803909.

the failure to manage test results appropriately has the potential to cause harm and there are a number of basic principles that may assist you in protecting your patients. patients have a right to be told by their doctor why the test is recommended and when and how they will be informed of the results If a doctor or medical centre has a standard practice of not notifying normal test results. patients. even if they agree to be notified only of normal test results.12 The management of clinical investigations Ian St George is a Wellington GP and has been an elected member of the Medical Council. The Commissioner’s view The RNZCGP resource Other views Issues Conclusion The management of clinical investigations is a contentious issue in New Zealand practice. and. when results are received by a medical centre. patients must be informed and their consent obtained to nonnotification in such circumstances It must be made clear to patients that they are entitled to be notified of all test results. This is Cole’s Medical practice in New Zealand 2011 111 . and Chair of the International Physician Assessment Coalition. the patient must be informed. However. they are welcome to call the medical centre and check whether their results have been received and what they are In the absence of any other such arrangement being made. There is no clear agreement on the level of responsibility that should be held by doctors. and those conducting the investigations. Chair of its Education Committee. The Commissioner’s view In a paper in New Zealand Doctor the previous Health and Disability Commissioner expressed his view about the key principles that should apply when managing clinical investigations At the time any test is proposed.

especially important if the results raise a clinical concern and need follow up A doctor is responsible for having an efficient system for identifying and following up overdue test results. A review of other cases has identified a number of additional principles which the Commissioner applied when assessing complaints Doctors responsible for reporting test results to the patient should have a system to audit and manage patient test results. This system should not rely on the patient taking the first step in the notification process. However, patients should be able to enquire about their results as a back-up to the notification system Patients should be appropriately informed of the system for notification of test and procedure results, and arranging follow up Where significant pathology is suspected, doctors should ensure that the notification system tracks the request or referral and the outcome, and manages this in an appropriate and timely manner A clear policy should be developed to ensure that staff and colleagues are aware of the system. This policy should cover the role of the test initiator, notifications, locums and follow up. Case 1: The District Court looked at a case involving a patient who presented to a hospital emergency department. The first doctor to assess this patient ordered tests, but neglected to inform a colleague of this before going off duty. The court made a finding of medical error, relying heavily on the advice of an expert adviser who stated, “It is the responsibility of the doctor ordering tests to review, interpret and act on results. When test results are ordered but the doctor goes off duty before the results are known – it is that doctor's responsibility to alert the incoming doctor that there are test results outstanding. Policies vary from one hospital to another on how abnormal laboratory or radiology results are alerted to treating clinician or team.” Case 2: A woman had a slightly painful breast mass that could not be aspirated. She had a history of fibrocystic disease and recurrent breast mass. Her GP was suspicious of “other pathology” and referred her to a hospital radiology department for mammography and ultrasound. She attended the hospital and was told that her GP would inform her of the test results. The GP practice had a policy that patients would be contacted if their results were abnormal, but patients should also contact the practice if they did not hear about their result. The woman was not made aware of this policy. The practice did not receive the report. The woman phoned the practice nine weeks after the mammogram. The practice nurse contacted the radiology

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department and requested the report, but the results were not forwarded and the practice nurse did not follow this up. One month after the first call, the woman rang the practice again. The practice nurse was able to access the results that same day. The Commissioner found that GPs should not be responsible for system failures outside their control, but he also found that tests ordered when a doctor has a reason to suspect a cancer diagnosis do require proactive follow up. The GP was found in breach of Right 4(4) of the Code of Rights, which states that patients must be provided with services in a manner which minimises potential harm to, and optimises the quality of life of, that patient. The previous Commissioner also made his view clear about the patient’s responsibilities. He stated “clearly, GPs are subject to resource constraints (time and money), labs must have efficient systems, and patients have some responsibility for their own health care. But patients who have tests taken should surely be able to look to their primary care provider to follow up results in appropriate cases.” The devil, of course, is in the detail.
The Royal New Zealand College of General Practitioners resource

After considering the Commissioner’s reports and the case heard at the District Court, the RNZCGP developed a resource called Advice on minimising error in patient test result management, which included these principles: General practice is encouraged to develop a system to audit and manage patient test results This system should not rely on the patient taking the first step in the notification process. However, patients should be able to enquire about their results as a backup to the practice's notification system Clear information on the practice's system for notification of test and procedure results should be made available and explained to patients In specific cases, where the GP suspects significant pathology, the practitioner needs to ensure the practice system tracks requests and return of the results to the practice and manages the result in an appropriate and timely manner A clear policy is required covering the test initiator, notifications, locums and follow-up. The resource acknowledged that different organisational structures and procedures among general practices and patient populations made it difficult

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to provide easy solutions to managing patient test results, and identified a number of issues and challenges.
Other views

At a meeting with the different branch advisory bodies (BABs), the Medical Council asked whether guidance on the subject of managing patient test results was needed for the entire profession (and not just GPs). Comments in response to this suggestion included that A statement should not be developed for doctors, but instead Council should look at “how it can help patients to take responsibility for their own health” Good computer systems and software may be the best way to improve outcomes Care should be taken not to put too great a burden on doctors and systems that are already overburdened Provisional and final imaging reports need to be married and differences flagged In hospitals it is often difficult to identify who ordered a test. Doctors should all use a stamp with their name and Council number on it Laboratories should notify high priority results by telephone, as well as by post Test results might be copied to the patient as a matter of course. Issues raised by examples Case 3: A semiurgent radiology referral for barium enema was made for a patient, but no appointment was received seven months after the referral despite the fact the hospital had received the referral. The GP was not aware of this waiting time. Case 4: After a seizure a patient had had a CT head scan one week before seeing a GP. The GP asked that the results be sent to him. Eight days later the GP had not received the results and the patient had another seizure. The GP phoned to find the specialist was on holiday with the results on his desk indicating a brain abscess. Case 5: The Commissioner considered a case where errors resulted in a woman not receiving the cervical screening programme’s recommended follow-up. The programme followed normal recall procedures but the woman did not receive the recall letters as she had moved. He found the GP alone in breach for failure to ensure the patient had a repeat smear.

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As can be seen in the comments made at the BAB meeting, many consider the responsibility and right to follow up test results should remain with the patient. There is a view that practitioners should advise all patients of their right to seek confirmation of test results and how these requests are managed in their practice. This view states that doctors should then be responsible for following up the results only when The patient goes for the ordered test The results are received by the practice or department Failures are within their control. A further problem is that current computer systems for tracking test results may not suffice. A computer system should be able to track individual tests for the results; including when several tests are ordered from one sample, or when the patient did not have the test track tests based on a criterion such as a suspicion of cancer include a follow up function which alerts the doctor when either the patient does not attend a test (or delays attending) or when the results have not been received in a timely manner. In addition, even good systems can fail: an example of this occurred in three weeks during August and September 200l when some GPs did not receive electronic results of x-ray examinations. This anomaly was discovered only from a patient call to one such practice. Clinicians should not be blamed for system failures beyond their control. Practising doctors have signalled a number of other concerns about the principles outlined by the Commissioner, and the cases on which the principles are based. They include Infantilisation of patients by doctors who assume a paternalistic relationship Vicarious liability for employees’ actions The responsibility of GPs who are employees, especially when the practice is owned and governed by other than GPs and the doctors have little control over the systems they are required to use The cost of developing systems to minimise error The term “suspicion of serious pathology” is open to wide interpretation The ongoing fragmentation of health providers and services poses challenges to the provision of continuous care There is some debate about when a referral for a specialist procedure should regarded as a request for “clinical investigation”. For example, should a referral for colonoscopy be included within that definition?

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What are a GP’s responsibilities when results are copied to them from an Accident & Medical Clinic? Conclusion There is a gap between what frontline doctors think is practical and reasonable and what the previous Commissioner, as consumer advocate, believes is proper. The debate has so far largely involved general practice, but all clinical disciplines should consider their position. Nonetheless, despite these debates there are some common principles which most parties can agree on and which you should consider following to ensure patient health and safety: 1. If you request a clinical investigation, you should tell your patient why the clinical investigation is recommended and when and how they will learn the results 2. All the relevant parties should understand their responsibilities clearly 3. If you are responsible for conducting a clinical investigation you are also responsible for ensuring that the results are appropriately communicated to those in charge of conducting follow up and keeping the patient informed 4. If you are responsible for informing the patient, you should Inform the patient of the system for learning test and procedure results, and arranging follow up Ensure that staff and colleagues are aware of this system Inform patients if your standard practice is not to notify normal results and obtain their consent to non-notification If other arrangements have not been made, inform the patient when results are received. This is especially important if the results raise a clinical concern and need follow up 5. Identifying and following up overdue results is an essential, but difficult, office management task. Your system should ensure that test results are tracked successfully. Such a system might be a paper file or computer database that Identifies high risk patients Identifies critical clinical investigations ordered Identifies dates of reports expected Identifies date of expected or booked follow up patient visits. 6. The patient’s medical chart itself might be flagged in some way to aid this tracking process

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then send a letter to the patient advising them of the action they should take If you order investigations it is your responsibility to review. or you have been unable to speak to them directly about test results which raise a clinical concern. and sometimes they do not attend planned follow up appointments The number and intensity of efforts to reach the patient by telephone should be proportional to the severity and urgency of the medical problem. interpret and act on the results. you should alert the incoming doctor that there are results outstanding. 8. you should check the results when you are next on duty. It can sometimes be difficult to contact a patient by telephone. All attempts to contact the patient should be documented If the patient fails to attend an appointment. Hoheria populnea. Further. lacebark. Houhere. Cole’s Medical practice in New Zealand 2011 117 .7. If you go off duty before the results are known.

Over the past ten years information technology has revolutionised the world of business. The internet has decreased the asymmetry of information that existed between doctors and patients and forever changed the nature of the relationship between the two parties by allowing the ideal of informed discussion and consent to emerge for the first time. As with all revolutions increased availability of medical information challenges the status quo and creates a number of threats and opportunities for doctors.13 Medicine and the Internet Stewart Jessamine is the Principal Technical Specialist at Medsafe the agency responsible for monitoring the safety quality and efficacy of medicines in New Zealand. 118 Cole’s Medical practice in New Zealand 2011 . and analyse medical information. The rest of this chapter tries to identify some of these threats and opportunities and aims to provide some guidance on how both you and your patients can determine whether you are in the library or the flea market. Statement on use of the internet and electronic communication . The problem is that it’s almost impossible to tell which of the two you are currently visiting” – Anon. collect. and provided the general public for the first time with the tools needed to find.105 The statement sets out the legal and ethical framework as 105 Medical Council of New Zealand. including the practice of medicine. Searching for evidence in the internet library Continuing medical education and professional development Internet security and medical practice Communicating with patients Prescribing for New Zealand based patients Practising “virtual” medicine Integration of the internet into day to day practice “The internet is the world’s greatest library surrounded by the world’s largest flea market. Wellington. This chapter should be read along with the Medical Council’s “Statement on use of the Internet”. 2006.

In addition. Searching for evidence in the internet library The internet contains a vast number of useful medical information resources. Musacchio RA. such as who has paid for the site to be maintained? In order to make things simpler. and assuring the quality of medical information on the Internet: Caveant lector et viewor – Let the reader and viewer beware. namely Who authored the article? What are their qualifications? Have they disclosed any potential conflicts of interest? Is the article appropriately referenced and are these references from acceptable peer reviewed sources? Where is the article published? Is the journal subject to adequate peer review? Does the website disclose any potential conflicts of interest. Practitioners intending to publish information on the internet should follow the HON Code of conduct when writing and publishing. conjecture and misinformation. JAMA. when searching the internet it is best to stick to mainstream. The availability of electronic copies of a number of the mainstream medical journals makes internet literature review easier. Lundberg GD. the HON Foundation developed databases of health information resources that have been assessed as meeting the requirements of their Code. using these types of questions to form a code of standards for internet health sites. peer reviewed. To determine the value of information you find on the internet. 1997 Apr 16. this 106 Silberg WM. Assessing. Open any internet search engine and type in “medicine” and you will find millions of sites containing medical information.well as the Council’s ethical expectations of medical practitioners who are. Most of these sites are not peer reviewed and are not subject to the publishing and review rules that we expect of evidence based medical information. you therefore have to check each article you review for the basics of quality evidence based medicine. or intend to. As with any form of medical literature review. controlling. evidenced based information resources. 277(15): 1244-5. Cole’s Medical practice in New Zealand 2011 119 .106 This proposal was picked up by the Health on the Net Foundation (HON) and developed into a Code of Conduct. use the internet to deliver services to their patients. Another key information resource is Pubmed. authors such as Silberg et al proposed in 1997. and abstracts of some of the lead articles in these journals can be obtained free of charge from their websites. unfortunately they are hidden amongst a sea of opinion.

nzma. and you can purchase copies of complete articles from the website.org.ox.ch Intelihealth http://intelihealth.gov/medlineplus/ Pubmed http://www.nih.nlm.nz New Zealand best treatments http://www.govt.nz New Zealand Guidelines Group http://www. General Search Engine www.jr2.rnzcgp.com British Medical Journal (BMJ) http://bmj.moh. University of Auckland http://www.govt.medsafe.uk/bandolier/whatnew.co. Since we are all practising medicine in New Zealand.co. local information is essential when we make decisions about patients.google.nz) MEDLINEplus http://www.com Medsafe http://www.besttreatments. as well as a tool for reporting adverse reactions to medicines directly from within the PMS to the Centre for Adverse Reactions Monitoring in Dunedin.org.nih.pharmac. Medsafe (the New Zealand Medicines and Medical Devices Safety Authority) and the Health and Disability Services Commissioner all maintain websites that contain information relevant to medical decision making.hon.ama-assn.co.com The Lancet http://thelancet. The Ministry of Health.nejm.mcnz.org/ New England Journal of Medicine (NEJM) http://content. the New Zealand Guidelines Group. as well as an electronic version of its publication Prescriber Update and information for consumers.ac.govt. These tools include evidence based advice on the management of asthma.html Health on the Net Foundation (HON) http://www.org/ Bandolier Journal http://www. the Medsafe website contains the latest medicines safety and prescribing information for over a thousand of the most commonly used medicines in this country.auckland.medscape.nz 120 Cole’s Medical practice in New Zealand 2011 .ncbi.ac.govt. For example.nzgg. Abstract data can be obtained free from Pubmed. depression and acne.database contains all articles and letters published in over two hundred peer reviewed medical journals from around the world.com Journal of the American Medical Association (JAMA) http://jama.nlm. alternatively you can use Pubmed to identify the key references and then search them out at your local medical school library.nz New Zealand Medical Journal http://www. The following websites are a mix of sites endorsed by the Health on the Net Foundation and websites I have found to be useful: medical librarians are valuable resources for advice about authoritative sites.nz Medical Council of New Zealand http://www.nz/goodfellow/ Royal NZ College of General Practitioners http://www.gov/ Medscape http://www.nz (http://scholar. The Ministry of Health and PHARMAC have also funded the supply of a series of decision support and reporting tools for integration into GP practice management systems.nz/journal/ Goodfellow Unit. PHARMAC.org.nz New Zealand Ministry of Health http://www.nz PHARMAC http://www.

nz Best Practice Advocacy Centre http://www. In addition to information these websites often contain links to other information resources. Due to the lack of infrastructure the same can also be said for telemedicine (a consultation where a specialist interviews and “examines” the patient by video link from a regional hospital).hdc. Despite the reservations many practitioners have about the role of information technology in medical practice. it has also created the means to address the asymmetry between generalist and specialist medical practitioners.nhs.org. such as the Heart Foundation or the Multiple Sclerosis Society.com/cgi-bin/mrwhome/ 106568753/HOME Using a number of these resources as the first points of reference for searching for health information on the internet should keep both you and your patients in the highest quality part of the internet library. Resources to obtain CME points can be found at a number of local sites Cole’s Medical practice in New Zealand 2011 121 .cks.nz Prodigy clinical knowledge summaries http://www. Discussing these rules with your patients and getting them to use them when reviewing internet health sites themselves is a good strategy to empower patients. in reality such initiatives are only just developing and probably have little relevance for day to day medical practice. While telemedicine has tremendous potential for managing patients with common diseases. It is now relatively easy for any doctor to identify and contact specialists anywhere in the world with an interest in a particular medical condition.org. Continuing medical education and professional development Just as the internet has changed the asymmetry of information between doctor and patient. While interaction with these specialists through internet discussion groups has the potential to improve patient outcomes. and chat rooms where patients can discuss subjects such as best treatment options.wiley.library. it isn’t likely that we will be routinely using it in general practice in the near future.bpac.uk/clinical_knowledge/clinical_topics Cochrane medical library http://www3. Useful sources of supplementary information include patient (or disease) oriented websites maintained by national patient organisations. Applying the basic rules for quality evidence based medicine (described above) when reviewing or discussing data obtained from chat rooms and discussion groups should help you sort out the evidence from the opinion.interscience. Unfortunately many patient chat rooms are poorly overseen and in some cases contain a great deal of misleading information. the internet has become an important source of continuing medical education (CME) in New Zealand.Health and Disability Services Commissioner http://www.

nz) sets out the Commissioner’s requirements for data security. eg. The most obvious issues are: how do you determine that the person asking the question is actually the patient named on the email and not some other member of the household who has access to the family computer? what can you do to be assured that any results sent by email will be read by the patient only? and is this information so sensitive it is inappropriate to send it by email? Some subjects and test results are more confidential and sensitive than others. You should seek professional advice if you are not sure about the security of your system or network. obtaining data about patients. Before you embark on any process that involves you. especially if you intend to operate outside of the health intranet. and making claims from funding agencies. you should consider whether the system you are using is secure and able to maintain patient confidentiality and privacy. including patient management systems. The problems of patient privacy. privacy. can be captured (hacked) and read by persons outside of your medical practice. are likely to occur over the next four years. so before deciding to use email routinely as a communication tool with patients. it is worth identifying in advance what data you are comfortable sending to patients and what data or subjects you would only 122 Cole’s Medical practice in New Zealand 2011 . sending or receiving information about patients over the internet. such as blood test results or NHI number. data security and verification of the identity of users of the system have been resolved within the New Zealand health intranet and advances are being made to increase the number of services being delivered electronically.org. Communicating with patients The use of email as a means of communicating with patients significantly increases the problems of confidentiality. Internet security and medical practice The internet offers an opportunity to streamline aspects of the business of medical practice such as sending and receiving patient data. and data security.including the Goodfellow Unit and the Royal New Zealand College of General Practitioners.privacy. The internet is essentially an unsecured network and unless you take adequate precautions. and computer terminals themselves. referrals to specialists. The website of the Privacy Commissioner (http://www. or your practice. the data on your computers. New Zealand is still in the process of developing its IT infrastructure and further information on the proposed national IT plan and significant changes to national and local systems. confidentiality.

If a patient needs a prescription and they are out of your immediate vicinity. internet/telephonic Cole’s Medical practice in New Zealand 2011 123 . especially erectile dysfunction medications. In coming to this decision. email communication must comply with the Code of the Health and Disability Services Consumer’s Rights. You can then discuss your internet information release policy with your patient before seeking their consent to send data to then by email. These are important considerations as a decision to facilitate access by prescribing may expose the medical practitioner to legal liabilities if harmful consequences arise from the patient’s use of the medicine purchased on the internet. As with all other forms of communication with patients. You can also use this opportunity to discuss with them your schedule of charges for responding to questions or requests for comment via email. purchased on the internet are counterfeit products.107 108 107 Federation of State Medical Boards of the United States. so you should avoid this activity. or to write a prescription to allow your patient to obtain a medicine they have decided to buy over the internet. and then if they are able to satisfy themselves that the medicine being imported meets the necessary standards of safety. Prescribers need to consider whether they are prepared to facilitate patient access to a medicine delivered through the uncontrolled route of the internet before writing a prescription on request from a patient. The issue of prescribing to allow a patient to import a medicine purchased over the internet while legal. quality and efficacy of locally available medicines. The current New Zealand legislation does not permit prescriptions to be issued by email. whether the patient actually needs the medicine. a telephone script to a pharmacy followed by faxing. Inc. Report of the Special Committee on Professional Conduct and Ethics: Statement of position.discuss with a patient as part of a consultation. prescribers should consider if the medicine is available in New Zealand. or in fact even that the product actually contains the stated active ingredient. raises a number of ethical and practical questions. It is illegal for a patient to be in possession of a prescription medicine other than that obtained by filling a prescription written by a registered medical practitioner. Prescribing for New Zealand based patients Inevitably you will be asked either to prescribe by email for one of your own patients. The international experience is that most medicines. and sending a written prescription to that pharmacy is required. Prescription medicines purchased over the internet are therefore likely to be stopped at the border and the patient asked for proof that they have a prescription.

the need for a physical examination. Problems such as confirming the identity of the patient requesting advice. also need to be resolved before you should consider embarking on “virtual” medicine . 108 Counterfeit medicines – don’t fake concern. Doctors should only prescribe for patients under their care in circumstances when they have previously seen or examined the patient and the doctor is confident that a physical examination would not add critical information about the management of the patient. Washington.Practising “virtual” medicine Of all the issues raised by the internet the emergence of “virtual” medicine practitioners is the issue of highest concern. 2000. Prescriber Update . have indicated that they are prepared to prosecute doctors involved in virtual medical practice. June 2005 p15-17. and regulatory authorities such as Medsafe. Vol 26 No 1. In addition significant ethical questions about patient safety. Virtual medical practice creates a number of new problems in addition to those identified above for prescribing. prescribing.fsmb. Virtual medicine describes the situation where the entire medical consultation. Internationally medical licensing authorities such as the Medical Council and the Federation of State Medical Boards of America. and the legality of prescribing for patients in another country (where the prescribing doctor is not registered to practise medicine). The Medical Council has developed a Statement on the use of the Internet. often without the knowledge of the patient’s regular medical attendant.org/Policy percent20Documents percent20and percent20White percent20Papers/ internet_use_guidelines.. In addition the Statement clearly says that under the Medicines Act it is illegal for doctors to prescribe medicines for patients unless the patient has had a face to face consultation with the doctor. These services are being supplied by a number of medical practitioners around the world and the quality of the advice offered and the professional standards applied by these doctors vary enormously. 124 Cole’s Medical practice in New Zealand 2011 . professional responsibility and duty of care. including the writing and dispensing of a medicine. takes place over the internet. This statement contains advice on internet security and confidentiality and stresses the need to keep complete electronic records of all consultations. and assessing the validity of the request for the medication all need to be resolved before a consultation can take place. or countersigning. www. Medsafe has already successfully prosecuted a pharmacy that was supplying prescription medicines to consumers in the United States. prescriptions for patients overseas to allow medicines to be dispensed from New Zealand pharmacies. the accuracy of the data presented in any case history. and is investigating several cases where doctors are signing. or another medical practitioner who can verify physical data and patient identity.htm.

You should also check that the terms of your medical practice (malpractice) insurance would cover you for care of patients in other countries. the Medical Council in January 2010 introduced a teleradiology scope of practice designed to allow suitably qualified radiologists located overseas to provide services to New Zealand based health providers.pdf Cole’s Medical practice in New Zealand 2011 125 . Practitioners of virtual medicine are subject to prosecution and disciplinary action in New Zealand for all activities they undertake in their “virtual medical practice” irrespective of the country of residence of their patients. 109 http://www. While authorities have taken a conservative position on New Zealand based practitioners undertaking virtual medicine activities for patients located overseas. as is the creation of a complaints resolution process within the provider’s organisation that will report complaints to the relevant authorities in both countries and will allow these authorities to investigate a complaint.109 The newly introduced scope of practice limits access to radiologists whose qualifications and registration are recognised by the Council and who are employed by a fully credentialled healthcare provider in New Zealand. Oversight of the teleradiology practitioner by the clinical director of the employing organisation is a pre-requisite for inclusion in this scope of practice.org. Before embarking on any scheme to prescribe over the internet you should take legal advice on your potential liabilities in both New Zealand law and in the law of the countries where your patients reside. The controls placed around this scheme which is designed to allow New Zealand healthcare providers to gain access to diagnostic radiology skills located overseas give an indication idea of the range of protective and oversight systems that need to be in place to protect the safety of patients in New Zealand. are examples of how the professions are no longer prepared to tolerate these activities. it is now reasonably clear that virtual medicine practitioners are also likely to be liable for prosecution and action against them in the Courts in the patient’s country of residence. It is an act of hubris if New Zealand based medical practitioners involved in practising virtual medicine in other scopes of practice think that patients in other locations do not deserve the same degree of protection.mcnz. However. and the recent decision by the Pharmacy Council to add a new clause to its Code of Ethics to prohibit pharmacists from selling medicines intended for the treatment of chronic diseases to patients outside of New Zealand.This activity is contrary to best medical and pharmacy practice and the Medical Council’s Statement on use of the Internet.nz/Portals/0/Publications/Gazette-A4.

Creating a website for your practice to inform your patients of your opening and closing times. is a start to establishing this new partnership. Integration of these resources into our medical practice and the provision of patient guidance on how to use them effectively may offer a chance for the interaction between doctors and patients to move beyond the adversarial approach felt by many doctors of today. Rimu.. charges and privacy and email policy. Establishing standards and guidelines for incorporating new technology into medical practice will therefore remain a challenge for doctors and registration bodies. Constructing your website to encourage your patients to use it to obtain information from the evidence based health resources described above should improve the quality of your interaction with patients and go a long way towards ensuring that everyone can come out of the internet revolution a winner. Dacrydium cupressinum. such as the Medical Council. 126 Cole’s Medical practice in New Zealand 2011 . the major impacts are still to be realised at general practice level.Integration of the internet into day to day practice Although we have been living with the information revolution for more than ten years. The pressure for doctors to be better informed and to keep up to date with new developments is steadily increasing as more patients make use of new information resources. Coping with these demands will require a change in how we think about medical education and medical practice. after hours arrangements. for some time. towards an informed and collaborative partnership in the future.

nationality. by making unnecessary or unsustainable comments about them. race. Pippa MacKay is a general practitioner in Christchurch. you must not discriminate against them or let your views of colleagues’ lifestyle. culture. marital status or age prejudice your professional relationship with them You must not undermine patients’ trust in the care or treatment they receive. a previous Director-General of Health. Working in teams A good description of teamwork was made by Dr RA Barker. Peter Moller is a rheumatologist in Christchurch. and a member of the Medical Council. she has been a member of the Medical Council and Chair of the New Zealand Medical Association. geriatrician and rheumatologist: Cole’s Medical practice in New Zealand 2011 127 . sexuality. colour. Working in teams Leading a team Disruptive behaviour Arranging cover General practitioner liaison Delegation and referral Teaching Making assessments and providing references Good health care depends on effective communication between doctors and other health professionals. and has been a member of the Medical Council. beliefs.” Colleagues must always be treated fairly. gender. In accordance with the law. The Health and Disability Services Consumers’ Code of Rights (see chapter 23) makes reference to collaboration in Right 4(5) “Patients have the right to cooperation among providers to ensure quality and continuity of care. or make them doubt a colleague’s knowledge or skills.14 Working with others Rick Acland is a rehabilitation specialist in Christchurch.

Disruptive behaviour is a term used to describe a style of interaction between health professionals. you must take responsibility for ensuring that the team provides safe. status is not granted by virtue of position. Guest editorial. Such behaviour creates turmoil in the workplace. Disruptive behaviour As well as treating patients and colleagues fairly and with courtesy. Regular review/audit of the standards and performance of the team should occur and any deficiencies rectified.. Patient care needs to be properly coordinated and managed and all patients and their relatives need to know who to contact if they have questions or concerns. when not only do the team members work together. 128 Cole’s Medical practice in New Zealand 2011 .. or criticism intended to improve patient care and offered in good faith. but earned by virtue of performance… In any organisation of staff the interests of the patient must be paramount. NZJ Physiotherapy 1975. which continually throws up new ideas and wider horizons to explore. Teamwork involves a clear definition of the role of each member and an acceptance by all the team that each member fulfils his own role better than any other member can.“Teamwork is not just a matter of a group of people meeting together to contribute to different aspects of the patient's care.”110 Working collaboratively within a team does not change your responsibility for your professional conduct and the care that you provide. On the other hand chronic and repetitive inappropriate behaviour that adversely affects the effective functioning of other staff is unacceptable: bullying or intimidation 110 Barker RA. Make sure your leadership skills are adequate for your role as team leader. responsive and accessible service and to treat patient information as confidential. patients and others that is unprofessional and interferes with patient care. efficient and effective care. You must make sure that the whole team understands the need to provide a polite. 5: 3. doctors are expected to behave in a professional manner. Leading a team If you are the team leader. Attending a leadership course is often helpful. An occasional episode of conflict. Nor is it simply a matter of one person unloading some of his burden of work on another. and these are best served by the intellectual stimulation of good teamwork.… In a team. Teamwork reaches its zenith. but they also think together. should not be described as disruptive behaviour.

including handover meetings. abusive or offensive language persistent lateness or delays responding to work calls throwing instruments offensive sarcasm threats of violence. The education of students and the continuing education of all staff may be affected. adequate staff numbers are not maintained. consult the Medical Council statement (Unprofessional behaviour and the health care team. that suitable arrangements are made for your patients’ medical care. These arrangements should include effective handover procedures and clear communication between relevant doctors. The effect on the working environment of this sequence of events also has consequences for educational activities. August 2009). Protecting patient safety. Disruptive behaviour can be caused by a number of factors. Staff morale suffers and this can lead to high staff turnover. Bullying leads to loss of trust and disengagement by those with whom there should be a constructive working relationship. Patients’ safety may be compromised by lack of effective communication when the disruptive individual is avoided and colleagues hesitate to ask for help and avoid making suggestions. health and domestic issues and problems in the work environment. Arranging cover You must be satisfied.sexual harassment racial. Disruptive behaviour impacts adversely on patient care and safety. These include personality and communication skills. when you are off duty. It sometimes develops as an inappropriate assertion of differences in power or status. the morale issues are further compounded. and loss of efficiency. This leads to impairment of the administrative chain. ethnic or sexual slurs loud. the need to use locums. your employer or the Registrar at the Medical Council. rude comments intimidation. retribution or vexatious litigation demands for special treatment passive aggression unwillingness to discuss issues with dependent colleagues in a cordial and respectful manner. Cole’s Medical practice in New Zealand 2011 129 . If you believe one of your colleagues behaves in a disruptive manner. or speak to a trusted colleague. If. and to an adverse effect on the care of individual patients. as a result.

You are still responsible for the overall management of the patient. When you refer a patient. and responsible for maintaining. If this is not the case. usually a general practitioner. to be fully informed about. doctor. usually a general practitioner. which falls outside your competence or knowledge. Adequate and appropriate information about the patient and the treatment needed must be conveyed. and accountable to a statutory body. that adequate and timely information is given to the patient’s general practitioner to ensure safe and appropriate on going care. If you are a general practitioner and refer patients to specialist services. provide the results of the 130 Cole’s Medical practice in New Zealand 2011 . If patients object to disclosure of any information. Patients should be informed about how information is shared amongst those providing their care. The person to whom you delegate must be competent to carry out the procedure or therapy involved. you should know the range of services available to your patients. knowledge and skills to perform the duties for which they will be responsible. retain overall responsibility for the management of the patient. Specialists who have seen or treated a patient should. Delegation and referral Delegation involves asking a nurse. you should be satisfied that the health care worker you refer to is educated and qualified for the task. Referral involves transferring all or some of the responsibility for the patient’s care. you must satisfy yourself that the doctors who stand in for you have the qualifications. you must respect their wishes. continuity of a patient’s medical care. such as additional investigation. It is important when a patient is discharged from specialist or hospital care. General practitioner liaison It is in patients’ best interests for one doctor. A deputising service doctor is accountable to the Medical Council for the care of patients while on duty. you should provide all relevant information about their history and current condition. experience. Usually you will refer patients to another registered medical practitioner. care or treatment.If you are a general practitioner or private specialist. The patient must be fully informed about the delegation. usually temporarily and for a particular purpose. and that you or another registered medical practitioner. unless the patient objects. medical student or other health care worker to provide treatment or care on your behalf.

but you must not disclose anything unless the patient agrees. Wellington. You must also make sure that students and junior colleagues are properly supervised. you must develop the skills. Taniwha Cole’s Medical practice in New Zealand 2011 131 . Making assessments and providing references You must be honest and objective when appraising or assessing the performance of any doctor. you should encourage patients to allow information to be passed to their general practitioner. or writing reports about colleagues. 2. 3. including those you have supervised or trained. Code of Ethics. If sensitive information is involved. you must keep the general practitioner informed. New Zealand Code of Health and Disability Consumers’ Rights (see chapter 23). the treatment provided and any other information required for the continuing care of the patient. New Zealand Medical Association. Patients may be put at risk if you describe as competent someone who has not reached or maintained a satisfactory standard of practice. All relevant information that has any bearing on your colleague’s competence. If you are a specialist and accept a patient without referral from their general practitioner. Good medical practice –a guide for doctors. Remember. If you have particular responsibilities for teaching. Wellington. performance and conduct should be provided. Only honest and justifiable comments should be given in references for. 2008 (see chapter 19). Medical Council of New Zealand. the reference may be disclosed by its recipient to your colleague.investigations. attitudes and practices of a competent teacher. Teaching All doctors have a duty to share information and promote education of colleagues and students. Resourcces 1. 2003 (based on the General Medical Council’s Good medical practice). provided you have the patient’s consent.

Doctors as leaders and managers Notifying poor performance Disagreement about clinical decisions Providing opinions about patients or other doctors Working in a resource constrained environment111 Doctors in advisory roles Expert witness Doctors as leaders and managers Doctors are increasingly involved in both leadership and management roles. risk and clinical outcome of decisions. Webb C.112 “Starting from isolated pockets of excellence and innovation. 111 Statement on safe practice in an environment of resource limitation Medical Council of New Zealand 2008 112 Kotter J P (1990) A force for change: how leadership differs from management. 113 Mountford J. Youth and Family. while the role of medical management is to provide stability. strategy. consistency. 132 Cole’s Medical practice in New Zealand 2011 . But it is an essential road for both clinicians and their patients. behaviour change and effective clinical processes. In making day to day management decisions the clinical leader is applying their medical knowledge to assess the impact. It is the role of the medical leader to apply clinical medicine to the development of policy. clinical leadership still has a long road to travel. When Clinicians Lead McKinsey & Co.” 113 It is the clinical skills and knowledge inherent in medical training that separate clinical leaders from health service executives. He has worked in senior roles in the Child. The purpose of clinical leadership is to bring about movement and constructive change. Work and Income and Accident Compensation Corporation.. service design. London: Collier Macmillan. Feb 2009. order and efficiency. The clinical leader is uniquely responsible for ensuring patient safety and monitoring both service and individual outcomes.15 Doctors in other roles David Rankin is past president of the Royal Australasian College of Medical Administrators.

and work within an organisational culture and communicate the impact of change to executives and senior managers. facilitating transformation. encouraging improvement and innovation. managing resources. making decisions and evaluating impact. Improving services – ensuring patient safety. continuing personal development and acting with integrity. In order to effectively achieve these competencies requires an understanding of health service organisation organisational change management healthcare law healthcare finance. Working with others – developing networks. Clinician leaders need to be able to develop a cohesive team. These include: Demonstrating personal qualities – developing self awareness. applying knowledge and evidence. building & maintaining relationships. encouraging contribution and working within teams. The clinician leader bridges the cultural divide between clinicians and managers.To be an effective clinical leader requires a different set of skills from those required to be a good clinician. managing people and managing performance. The degree of competence in each of these areas that a clinical leader needs to have developed depends on their level of leadership responsibility. work across disciplines. Clinician Patient focused Clinical outcomes Patient safety Clinician performance Risk of harm to the patient Patient need Evidence based practice New technology Patient satisfaction Manager Service oriented Fiscal outcomes Risk and assurance Organisation performance Media and reputational risk Ministerial priorities High performing peer organisations Facility maintenance Data collection and reporting The NHS Medical Leadership Competency Framework defines five key areas of competency required to be an effective clinical leader. managing yourself. and Cole’s Medical practice in New Zealand 2011 133 . Setting direction – identifying the contexts for change. Managing services – planning. critically evaluating.

The Royal Australasian College of Medical Administrator (RACMA) is the recognised body which trains and certifies doctors as competent in the vocational scope of practice of medical administration.115 As an employee the clinical leader has a duty to work within their organisational governance structures. This poor practice may relate to doctors working within the organisation or who are providing a service to patients of the organisation. www. Medical administration is defined as Administration or management utilising the medical and clinical knowledge. A medical practitioner has a mandatory requirement to report to the Registrar of the Medical Council another medical practitioner who they believe is not fit to practise medicine because of some mental or physical condition.org. This may include administering or managing a hospital or other health service. 114 Bristol Royal Infirmary Inquiry. or developing health operational policy. or planning or purchasing health services. Every clinical leader should clarify their organisation’s expectations and processes around their reporting of fellow employee’s and other colleagues performance to the Medical Council. the clinical leader often becomes aware of performance issues amongst their colleagues. even when that clinical leader is not in active clinical practice114.bristol-inquiry. Clinical leaders may become aware of poor practice when undertaking their audit or advisory role. and capable of affecting the health and safety of the public or any person. Notifying poor performance In effectively fulfilling their clinical governance role. Medical administration does not involve diagnosing or treating patients.uk/final_report 115 Responsibilities of doctors in management and governance.statistical methods and analysis. The Medical Council recognises medical administration as a vocational scope of practice. skill. and judgement of a registered medical practitioner. Medical Council of New Zealand 2001 134 Cole’s Medical practice in New Zealand 2011 . The enquiry into clinical issues at the Bristol Royal Infirmary highlighted that the clinical leader has a responsibility to identify and report failing performance. July 2001.

Medical Council of New Zealand 2008. Where their concerns are not adequately addressed they may raise the issue with the Director General of Health. lead to serious harm or constitutes serious wrongdoing. This can be a particularly vexing dilemma for the clinical leader who is asked to provide advice on the marginal benefit of two competing priorities. Serious wrongdoings may include inappropriate use of public funds. or the Medical Council.Disagreement about clinical decisions When a clinical leader becomes concerned about a decision that an organisation has made and believes that it will compromise patient outcomes. Working in a resource constrained environment117 The New Zealand government allocates a defined amount of money for the provision of health services each year. and acts or omissions that constitute serious risk to public safety or constitute an offence. It is strongly advised that they seek legal advice before raising the issue with an external party or the media. 117 Statement on safe practice in an environment of resource limitation. Providing opinions about patients or other doctors A clinical leader may be asked to provide an opinion on the adequacy or appropriateness of another doctor’s report. The clinical leader must put their concerns in writing and ensure they are addressed to the appropriate person. This opinion is usually based solely on information recorded in the patient’s file. the non-treating doctor should either refrain from providing an opinion or note the need for further information in their report. gross negligence or mismanagement by a public official. Cole’s Medical practice in New Zealand 2011 135 . they must follow the procedures outlined in the Protected Disclosures Act 2000. Medical Council of New Zealand 2003. Where the doctor follows these procedures they have the right of complete confidentiality. the Health and Disability Commissioner. The non-treating doctor must ensure they have access to all the necessary information and that they can provide an opinion based on the information to hand. 116 Non-Treating Doctors Performing Medical Assessments of Patients for Third Parties. The distribution of this money has to balance the needs of the population with the needs of the individual patient. 116 Where additional information or a clinical examination is required.

the medical practitioner should determine if they are invited as an individual with a desired set of clinical skills or as the representative of an organisation or industry body. In such cases it is helpful to indicate when advice will be forthcoming. doctors should use evidence from research and audit to inform their decisions and advice on the best use of the resources that are available within their organisation. This discussion should be documented. Prioritisation systems should be fair. Amongst other things they currently preclude the payment of locum fees to a practitioner who is required to be absent from their practice. DHBs or NGOs. Where they are engaged as a representative they should ensure they have a mandate from the nominating body before preferring an opinion or providing endorsement to a planned strategy or process. 136 Cole’s Medical practice in New Zealand 2011 . they should be informed what the preferred treatment involves and what the available options are. It is good practice to distribute an agenda and briefing papers well in advance of a meeting to allow representatives to seek advice from the nominating body on issues that are to be discussed. Where a patient is unable to access the preferred treatment due to funding constraints. Such decisions are both funding decisions and medical decisions. Cabinet Guidelines set out a framework for government agencies engaging expert advisors.Clinical leaders will also be asked to provide advice on whether certain expensive procedures are medically necessary or appropriate. Failure to do so compromises the value of the meeting. Where inadequate time has been allowed for consultation or consideration of an issue. When invited to serve on a committee. consistent. the doctor may need to withhold their advice. the clinical leader has a responsibility to ensure that appropriate arrangements are in place to optimise the discharged patient’s recovery. evidence-based and transparent. Doctors have a responsibility to ensure that the process of assigning priority is appropriate and that patients referred to a service with limited resources are adequately assessed and consistently receive treatment in accordance with the clinical priority criteria. Doctors in advisory roles Doctors are often engaged to serve on advisory committees to government agencies. If a patient is discharged or transferred early to allow a sicker patient to take the bed. In all roles. systematic.

Metrosideros excelsa. When giving evidence as an expert witness. Pohutukawa. be it to a court. 118 High Court Rules [Schedule 4] Code Of Conduct For Expert Witness. These rules note that the expert witness has an overriding duty to impartially assist the Court on relevant matters within the expert's area of expertise. give the reasoning behind their opinions The expert witness must also clearly indicate any provisos that would make their evidence incomplete or inaccurate. They should also describe any examinations.Expert witness The High Court118 publishes a set of rules to guide expert witnesses. This should include any literature or other material they have used in forming their opinions. the doctor should: clearly state their qualifications as an expert and indicate how the evidence they provide lies within their area of expertise. When these were undertaken by a third party. insurance company or medical review panel. they should provide the qualifications of the person who carried out the tests or examinations. or other investigations which helped them reach their conclusions. The expert witness must not act as an advocate for the party who engaged them. These provide a sound basis for any doctor who is providing an expert opinion. tests. July 2002 Cole’s Medical practice in New Zealand 2011 137 . They also need to make it clear if they have been unable to reach an opinion because of insufficient research or data or for any other reason. provide the facts and assumptions on which their opinions are based.

The incidence of these disorders in doctors is comparable to that in the general population and in some cases considerably higher (eg. London: BMA. The British Medical Association’s working group on the misuse of alcohol and other drugs reported in 1998 that. suicide. infectious diseases. 120 British Medical Association. radiation. Being a patient Being a doctor’s doctor Maintaining good health The law: fitness to practise The Council’s Health Committee Infection with transmissible major viral infections Conclusion As doctors we are constantly exposed to stresses and hazards that can impair our relationships and ourselves: working long hours. Joanna MacDonald is a psychiatrist and senior lecturer at the Wellington School of Medicine: she was a member of the Council’s Health Committee from 2002 to 2008. an elected member and Deputy Chairperson of the Medical Council and Chairperson of its Health Committee. Sept: 9–14. fatigue. The misuse of alcohol and other drugs by doctors. fear of complaints and litigation.119 consequences of mistakes. A report of the working group on the misuse of alcohol and other drugs. secondary traumatic stress. and its Chairperson for 6 years. In addition we are vulnerable to the same physical and psychological disorders as the rest of the community. noxious chemicals. 138 Cole’s Medical practice in New Zealand 2011 . about one in 15 doctors in the UK may suffer from some form of dependence on alcohol or other drugs. 1998. in a lifetime.120 119 Huggard P. consumer demands. demands of external bodies (including the Council and colleges). debt. liver cirrhosis and accidents). Secondary traumatic stress. sleep deprivation. New Ethicals 2003.16 Doctors’ health Kate O’Connor is a radiologist in Auckland.

We often fail our colleagues by not confronting them when it is clear they are sick and impaired. The health and health practices of doctors and their families. New Zealand Medical Journal 1999. 27.5 percent had not had recommended cervical screening. Of women.121 Some factors that make it difficult for a doctor to become a patient are a sense of being indispensable fear of moving from a position of power in the medical system to a position of powerlessness fear of breaches of confidentiality or of being recognised in the waiting room fear of having a serious condition shame or embarrassment particularly with respect to substance abuse or sexual issues a misperception that we lack time to see to our own health needs reluctance to impose on a busy colleague a belief we should be able to heal ourselves our ready access to a wide range of medication financial pressures to maintain high levels of income shame at having “let myself down”. 121 Richards JG. A survey of the health practices of New Zealand general practitioners found that only 71 percent claimed to have their own family doctor and only 10.9 percent said that they visited their doctor for regular checkups.112:96–99. especially in shortage specialties and small practices misplaced loyalty–the “he/she has always been a good bloke/woman” phenomenon judgmental attitudes denial that there is a problem. and also your family and the profession at large a fear of disciplinary action and deregistration. Cole’s Medical practice in New Zealand 2011 139 .Being a patient Doctors are often poor at seeking help and attending to their own health needs. Some of the reasons for this failure include the “there but for the grace of God go I” syndrome lack of knowledge of the notification process and the consequences of notification fear of the reaction. especially if the doctor is in a position of power anxiety about increasing our already overburdened workload.

you should make a formal appointment in your rooms. history as you would with any patient. and if necessary challenging. You may need to discuss whether the doctor is comfortable to wait in the waiting room or elsewhere and whether an appointment at a quieter time of day would be easier. You will need to explore the doctor’s fears and look for any other issues. It is important not to make assumptions eg. payment and your expectations of each other (including how to address each other) should be clarified. At the first appointment issues of confidentiality. suggests a six step consultation model when seeing a colleague as a patient. Exploring thoughts and feelings–at this stage you may need to reaffirm confidentiality and the difficulty of being a patient. You will need to clarify what he or she thinks is the diagnosis then take the history and examine the patient to establish the diagnosis for yourself. Dr Hilton Koppe who works in the area of doctors’ wellbeing.Being a doctor’s doctor Being a doctor to a colleague can be challenging for a number of reasons. notes. that the doctor would tell you of symptoms without your needing to ask specifically. These include fear of being seen as inadequate fear of offending a colleague role confusion hierarchy difficulties if you disagree with your doctor patient’s self diagnosis identifying with the doctor patient boundary issues difficulties saying “no” to a colleague issues of privacy and confidentiality difficulties challenging a colleague particularly with respect to lifestyle issues. Connection–as part of the process of agreeing to see a colleague. The principles are those used in any consultation–the key issue being to retain these principles and your usual professionalism in this unusual encounter. rather than accepting that diagnosis. It is particularly important to be aware of the dangers of self disclosure and identification or collusion. 140 Cole’s Medical practice in New Zealand 2011 . Information gathering–you will need to walk the tightrope of acknowledging your colleague’s knowledge while taking a thorough. Keep the focus on the doctor who is here as a patient and avoid discussing mutual patients or experiences.

In recent years this has been increased further by administrative and reporting pressures as well as by the exponential rise in knowledge and literature in all medical fields. 123 Chew-Graham CA. Each doctor must find his or her own solutions but some simple guidelines are establish good health habits early set aside time each day to maintain your own fitness and health. and agree on how to book the next appointment. This may begin during medical student years and then persist into vocational practice. coupled with the subtly induced ethos of “doctors must always cope” can be a very toxic mixture. 'I wouldn't want it on my CV or their records': medical students' experiences of help-seeking for mental health problems.Education–Again you will need to walk a tightrope between assuming your colleague has specific knowledge. Acknowledge his or her fear if relevant. Medical Education 2005. Safety net–you should give clear instructions about follow up and after hours contact.122 and an earlier study showed that at that stage of their careers. Doctors should be informed about stress management and how to stay healthy despite these demands.37:873–880.123 The practice of medicine can place huge physical and emotional demands on practitioners. Cole’s Medical practice in New Zealand 2011 141 . Joneborg N. Medical Education 2003. Runeson B. and causing offence by imparting that knowledge.9 percent (significantly higher that the general population). and to pursue other interests outside of medicine 122 Dahlin M. removal of sutures. As with any patient it will be important to negotiate the choice of treatment. Sadly this is not often the case with respect to our own health and we often fall into unhealthy work patterns. so you will explain it as you would to any patient. It can help to explain that hearing information about yourself is different from giving it to others. Check that everything has been dealt with and reinforce your commitment to them. Increasing pressures. Maintaining good health Medical practitioners are in the vanguard of illness prevention and health promotion and should lead by example. and admit the limits of your own knowledge. Ask whether the doctor patient wishes to receive copies of test results and negotiate about minor procedures eg. A recent study found that the prevalence of depressive symptoms among medical students was 12. Closure–is just as important as starting the consultation.39(6):594–604. medical students were reluctant to seek help if stressed or distressed. Stress and depression among medical students: a crosssectional study.

because of a mental or physical condition. both real and imaginary. Isolation is not always geographic and can occur even in the biggest cities plan holidays and recreation and make sure work does not intrude on them remind yourself often that you are “responsible to” your patients. he or she is not able to perform the functions required for the practice of medicine”. isolated doctors. which prevent help seeking behaviour have your own general practitioner – someone who is comfortable treating doctors avoid corridor consultations about your own health if you are feeling stressed consider contacting support groups from your professional body. The law: fitness to practise The Council states. women doctors. a peer support group. which may mean from time to time organising somebody else to care for them) when ill health strikes seek help early (as you would like your patients to) consider income protection so financial pressures are not a consideration in preventing you from taking sick leave if it is necessary consider planning for your retirement so you do not feel you have to keep working for financial reasons. These functions would include the ability to make safe judgments the ability to demonstrate the level of skill and knowledge required for safe practice behaving appropriately not risking infecting patients with whom the doctor comes in contact not acting in ways that impact adversely on patient safety. wellness and coping skills in the undergraduate programme. “A doctor is not fit to practise if. and attend meetings regularly. (Responsible to your patients to provide the best care you can for them. improvement in working conditions for those in training and a greater recognition and assistance for some groups with particular stresses: rural. 142 Cole’s Medical practice in New Zealand 2011 . the older doctor. Join professional bodies. The future is perhaps a little rosier with a greater emphasis on promoting health. not “responsible for” them.deal with your own reluctance to seek help and identify the barriers. College or insurer you should not prescribe for yourself as you lose the benefit of objective care and insidious illness may ensue when you visit your GP leave your “medical mantle” at the surgery door do not become isolated.

There is a mandatory requirement for registered health practitioners. their employers. personal and professional stress and situational crises. Any person making a notification is protected from civil or disciplinary proceedings unless the person acts in bad faith. The Council’s Health Committee Cole’s Medical practice in New Zealand 2011 143 . Part 3 section 45 sets out the steps that must be taken when there is reason to believe a doctor is unable to perform the functions required for the practice of medicine because of some mental or physical condition. The Health Practitioners Competence Assurance Act (the Act) provides for notification of any mental or physical condition affecting a doctor’s fitness to practise medicine. and between. Disruptive behaviours may indicate a health and/or competence problem. People considering making a notification are entitled to seek medical advice to assist them in forming an opinion and must state whether such advice has been obtained when giving notice to the Registrar. all registered health practitioners and their professions. Persons in charge of health professional education programmes (eg. Medical disorders head injury neurological diseases malignancy eyesight and hearing difficulties communicable diseases. These provisions extend across. medical officers of health and persons in charge of a hospital or other organisation that provides health services to notify the Council Registrar promptly in writing.The most common disorders that impair doctors’ ability to practise are Psychiatric disorders substance use. deans of medical schools) are similarly required to give written notice to the Registrar if students who are completing a course would be unable to perform such functions. abuse and dependence (both alcohol and drugs) mood disorders–bipolar disorder and severe depression dementias eating disorders anxiety disorders adjustment disorders. so it is important to make a notification rather than attributing the behaviour to “personality”.

The doctor is also entitled to make written submissions. If necessary. However. which considers the notification and its potential implications. An important aim of the Health Committee is to keep the doctor working. Failure to attend for such an examination may mean the Council suspends the doctor’s registration. If appropriate. duties. including one public member. a report might be requested from the doctor’s general practitioner and other treating specialists. contacts the doctor. or alter a doctor’s scope of practice in ways it considers appropriate. to ensure public safety while an expert examination is arranged. The doctor receives a copy of the report. and then the health manager. there is provision to suspend a doctor’s practising certificate temporarily. 144 Cole’s Medical practice in New Zealand 2011 . The examination is by a specialist relevant to the suspected (health) condition. except for those relating to registration. The Health Committee is comprised of at least four members of the Council. the doctor will usually be invited to attend a meeting of the Health Committee to discuss the report and implications. with a support person if desired. the notice is passed to the Health Committee. If the circumstances warrant.The Council’s Health Committee is currently authorised by the Council to exercise the functions. If the examining doctor’s report indicates that a mental or physical condition is affecting the doctor’s ability to practise. The Council’s health manager is responsible for the functioning of the Health Committee and keeps close liaison with the committee chairperson. and powers contained in sections 45-51 of Part 3 of the Act. Usually the notice is discussed immediately by the chairperson of the Health Committee and the health manager. and pending a full review. The Act gives the Committee. any initial limitations are reviewed in light of the report. If an examination has been arranged and the examining doctor’s report received. and to be represented. the power to order a doctor to attend a medical examination at the Council’s expense. acting under the Council’s delegation. Sometimes the doctor may be asked to make an agreement which limits his or her practice of medicine in particular ways. the Council can impose restrictions on a doctor’s scope of practice. How the Health Committee deals with notifications When the Council Registrar receives notification of the possible impairment of a doctor or graduand. this course of action is rarely required. and the Council would consult with the doctor about the specialist.

Doctor required to stop work to obtain treatment or enable / facilitate recovery Health Committee considers doctor's fitness to practise Unfit to practise (irreversible condition) Fit to practise if participating in a monitoring programme Fit to practise under low level review by Health Committee Fit to practise. the Health Committee usually decides on one or more of the following ask the doctor to sign a voluntary agreement conform to appropriate restrictions on practice to ensure public safety in light of his or her condition Cole’s Medical practice in New Zealand 2011 145 .Steps taken when a health notification is received Notification received Doctor required to withdraw from practice Yes Doctor appears unfit to practise No Doctor continues working Health status clarified by: * treating doctor * independent assessment by a Health Committee nominated doctor Unfit to practise. No involvement of Health Committee required If the doctor’s ability to practise is affected by a mental or physical condition.

and also ensure the health and safety of the public are protected. therapists and agencies who may be involved in the doctor’s treatment programme. if all is going well. the doctor may be monitored by an annual exchange of letters and then. When the situation has stabilised and the doctor’s recovery is firmly established. current state. There may be provision for each to communicate with the Health Committee if problems arise eg. provision for a key person in the doctor’s workplace to be aware of the condition some monitoring by the Health Committee for example where the problem has involved abuse of drugs. non-compliance or relapse where relevant. random urinalysis testing will also form part of the agreement restricted access to prescription drugs and medicines prohibition on self prescribing regular assessment of progress by a Health Committee nominated doctor. the workload eg. supervision of the doctor’s practice treatment to be undertaken and the names of the treating doctors. Doctors monitored by the Health Committee may meet with members of the committee at intervals to discuss their progress. In doing this. hours of work. A typical voluntary agreement may include limiting the doctor’s scope of practice such as the place or places of work. 146 Cole’s Medical practice in New Zealand 2011 . the types of work to be undertaken. It should be stressed that the Health Committee does not become involved in treatment decisions directly but ensures the appropriate treatment is taking place and the doctor’s health is maintained at the most satisfactory level possible. the doctor is finally discharged from Health Committee monitoring. while the doctor attends a rehabilitation or treatment programme. with some indication as to the frequency of consultation.undertake specific treatment or counselling according to the advice in the examining doctor’s report recommend to the Council that conditions be placed on the doctor’s scope of practice or that registration is suspended eg. the Health Committee’s intention is to help the doctor to regain and maintain health so that he or she can continue to practise. subject to appropriate limitations. The doctor chooses his or her own treating team. The voluntary agreement is underpinned by the acknowledgment that conditions may be placed on the doctor’s practice if the agreement is breached in any material way. and to make changes to the voluntary agreement.

other health professionals. Conclusion “Physician heal thyself” is not a policy the Medical Council endorses. The Council website: www. 2. not punitive. DHAS 1997. Infection with transmissible major viral infections (TMVIs) As with any illness that may pose a risk to patients. Resources 1. in students’ training doctors should be tested if they may have been exposed to the viruses doctors should advise patients who may have been exposed to be tested doctors who perform exposure prone procedures have a responsibility to know their HBV. The process is intended to be rehabilitative.This process has been designed to separate matters of impairment from matters of professional misconduct and discipline. This is best achieved by early notification and early intervention. with the Medical Council. Doctors are a valuable asset. Health Committee via health manager phone 04 384 7635 or 0800 286 801. has. developed guidelines for all health care providers.nz. Cole’s Medical practice in New Zealand 2011 147 .org. by itself. they may be infected with any of the viruses must seek advice and then act on it–a doctor should not continue practising based on her or his own assessment. or think. In Sickness and in health: a handbook for medical practitioners. The assumption is that with treatment of the impairment a doctor should be able to return to the medical workforce. HCV and HIV status and notify the Council if they are infected being infected does not. it is preferable if the Council can reserve the use of these powers and assist doctors to continue to work as appropriate and recover from their illnesses. While the HPCCA gives the Medical Council powers to restrict doctors’ practice when necessary to protect public safety. their partners and their families. hepatitis C and Human Immunodeficiency Virus) must take all necessary steps to minimise the possibility of transmission. doctors who are–or may be–infected with one of the transmissible major viral infections (hepatitis B. Key points are learning and awareness must start early. We must take responsibility for maintaining our own health as much as is possible and seek professional help when we are ill. justify either refusing registration of the doctor or limiting their practice–such decisions are always case by case doctors who know.mcnz. Editors: John O’Hagan and John Richards. 3. HRANZ.

The principal purpose of the Health Practitioners Competence Assurance Act 2003 (the Act) is “to protect the health and safety of members of the public by providing for mechanisms to ensure that health practitioners are competent and fit to practise their professions”. Regular practice reviews Reading list Error in medical practice Error is common Causes of error Preventing error Clinical governance Responding to error Conclusion Assessing doctors performance when concerns have been raised Responsive assessment The assessment process Remedial education What performance assessments are not Regular practice reviews Although no one would negate the importance of lifelong learning.17 Maintaining competence Steven Lillis is a general practitioner in Hamilton. The Council currently requires all doctors to participate in approved continuing professional development (CPD) activities in order to recertify. with its emphasis on continuing medical 148 Cole’s Medical practice in New Zealand 2011 . and Chair of the International Physician Assessment Coalition. Chair of the Education Advisory Group for the Royal New Zealand College of General practitioners and Medical Adviser for the Medical Council of New Zealand. Chair of its Education Committee. Ian St George is a Wellington GP and has been an elected member of the Medical Council. but there is disquiet that the currently practised CPD. there has been considerable debate as to how to ensure that useful learning occurs.

. E. Regular practice reviews offer a solution to many of the problems inherent in delivering good education for practising doctors. 296(9). Van Harrison. M. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review..124 A body of research on educational effectiveness has revealed the following: Of marginal value Formal CME meetings or conferences Didactic sessions Self assessment of educational needs Large group teaching Cross-discipline teaching sessions Self assessment What works well Interactive programs between practitioners and educators Comparison between optimal and actual care Academic detailing Outreach programs Providing learners with access to their own data Teaching integrated with clinical practice Multifaceted approach to education Individualised educational initiatives The task of good education is to understand where learning needs exist and meet those needs in the most effective and efficient way. Traditional CME employed planning models that were devised 50 years ago. The outcome should be either a positive change in physician behaviour or better patient outcomes and preferably the change should be measurable. R. A. The effectiveness of such methods has been substantially questioned and it is generally accepted that such techniques have little to offer modern complex professional practice. K. E. Cole’s Medical practice in New Zealand 2011 149 . 1094-1102. Fordis. Mazmanian.. CPD comes somewhat closer to the needs of doctors but is generally deficient in its ability to understand learning deficits.. and therefore cannot “ensure” doctors are competent. (2006). Alongside these limitations is increasing awareness of the dangers inherent in self assessment of learning need where inadvertent self deception can colour objectivity. does not necessarily identify or improve underperformance. L.. D. the assessment of need is undertaken on the 124 Davis. P. Thorpe. JAMA. & Perrier.education.

Jama 1995. Understanding Doctors' Performance. Bmj 2004. J Contin Educ Health Prof 2007. Portnoy B. J Contin Educ Health Prof 2007. Int J Technol Assess Health Care 2005. Lapsys FX. Does CME work? An analysis of the effect of educational activities on physician performance or health care outcomes. Perrier L. Coomarasamy A. Khan KS. Tian J. Oxman AD. J Contin Educ Health Prof 2007. Gold RS. O'Brien MA. workshops. Changing physician performance.real work of the doctor rather than a theoretical construct. Impact of formal continuing medical education: do conferences. Accuracy of physician self-assessment compared with observed measures of competence: a systematic review. Effects of continuing medical education on improving physician clinical care and patient health: a review of systematic reviews. Brown CA. It will be formative (designed to assist learning) rather than summative (designed to test minimum standards).28(1):21-39.27(1):42-8. Mansouri M. Taylor-Vaisey A. Forsyth RA. Sohn W. Foster JP. The Medical Council envisages a system of regular practice reviews being part of continuing professional development.274(9):700-5. Chakraborti C. McAvoy P. rounds. Int J Psychiatry Med 1998. The Branch Advisory Bodies rather than the Medical Council will administer the scheme to ensure that it is in line with professional need in various disciplines.27(1):6-15. Jama 2007. Van Harrison R. Freemantle N. Influence of remedial professional development programs for poorly performing physicians. A meta-analysis of continuing medical education effectiveness. Bass EB. Ismail AI. Davis DA. Cost effectiveness of continuing professional development in health care: a critical review of the evidence. Efficacy of educational interventions targeting primary care providers' practice behaviors: an overview of published systematic reviews. Thomson MA. the process is individualised and the assessment is objective. J Public Health Dent 2004.282(9):867-74. Davis DA.21(3):380-5. Effectiveness of teaching quality improvement to clinicians: a systematic review. Wolf FM. Boonyasai RT. Clark VA.22(4):214-21. Mazmanian PE. Feldman LS. What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review. Oxford: Radcliffe. Windish DM. Hutchinson A. Thorpe KE. 2006.298(9):1023-37. Cauffman JG. Lockyer J.27(1):16-27 150 Cole’s Medical practice in New Zealand 2011 . Martin KJ.329(7473):1017. Randomised controlled trials of continuing medical education: what makes them most effective? J Contin Educ Health Prof 2002. Further information on the effectiveness of educational methods can be found in the reading list below. Bloom BS. and other traditional continuing education activities change physician behavior or health care outcomes? Jama 1999. A systematic review of the effect of continuing medical education strategies. There will be a focus on developing the concepts to ensure they are acceptable and feasible to the profession. Gingras ME. Fordis M. Mazmanian P. Rubin HR. Bmj 2002. Atkinson NL. Regular practice reviews embody many of the most effective methods of educating doctors. Jama 2006. A systematic review of evaluation in formal continuing medical education. Belfield CR. Field SJ. Davis D.296(9):1094-102. Gagnon R. et al.64(3):164-72. Tellez M. Cox J. Goulet F. King J. Davis D. Haynes RB.324(7338):652-5.

. P. U271. Humility Reconsidered.A.A. as it is probable that the next slice in the series will prevent the error. Reason describes the “Swiss cheese” concept of error. 129 Davis. 1999.. Adverse events in New Zealand public hospitals I: occurrence and impact... 324(6): p. A further study based on Australian hospitals revealed similar statistics. 127 Thomas. The presence of a hole in one slice doesn’t necessarily cause an error. Results of the Harvard Medical Practice Study I. et al.A. J. Well trained professionals. R. 370-6. et al.Error in medical practice “On one hand. 126 Brennan..000 people die each year as a result of medical error in the U. L. An individual may be at the sharp end of this failure but should not be blamed for its defects. T. N Engl J Med.Z.R. S.127 The results indicated that somewhere between 44. Runbin. Two research papers highlighted the extent of the problem by quantifying the number of patient deaths caused by error in the U. E. cause and prevention of medical error have attracted considerable interest in both the public and professional domains.J.128 New Zealand data suggest 13 percent of hospital admissions are associated with an adverse event and 15 percent of these adverse events are associated with permanent disability or death. p. University publishing Group: Hagerstown. et al. Cole’s Medical practice in New Zealand 2011 151 . 255-64. 128 Wilson. Inquiry... The Quality in Australian Health Care Study. This fundamental paradox creates the moral challenge of accepting our fallibility and at the same time struggling against it.S. et al. in Margin of Error. Med J Aust. 125 Andre. Editor. 2000. Maryland. 458-71. 2002. 163(9): p. 1991.129 All practising doctors are aware of error in their day to day work.126. Causes of error A useful concept is to look at error as a failing of processes and systems. mistakes are inevitable. 1995. 59 .M.. 115(1167): p. When holes in successive slices line up momentarily. guidelines and computerisation all can be considered defensive layers against error and can be likened to individual slices of Swiss cheese. Incidence of adverse events and negligence in hospitalised patients.”125 Error is common The incidence. 36(3): p. mostly intact but with some holes. error occurs. On the other hand they are to be avoided…. N Z Med J.000 and 98..S. procedures. High technology systems such as medicine have many defensive layers.72. Costs of medical injuries in Utah and Colorado.

1311-6.134 Medical culture has proved quite resistant to change. there is constant interaction between humans and technology. S. 280(15): p.. 132 Britt. Lau.131. 16(5): p.W. and S. 134 Hargreaves. 320(7237): p. a common underlying theme to the continued high prevalence of medical error. 325-34. 330(7491): p. P. Failure of medicine as a profession and health care as an industry to recognise the negative effect of dealing with error by “naming. confidential reporting systems and developing a culture of safety. BMJ. 231-8. The attributes of medical event-reporting systems: experience with a prototype medical event-reporting system for transfusion medicine. and C... Better systems for safe prescribing can have significant impact on the rate of prescribing error. J Gen Intern Med. Clancy. Evidence on interventions to reduce medical errors: an overview and recommendations for future research. 2005. 152 Cole’s Medical practice in New Zealand 2011 . blaming the individual rather than the process. J. D.. 2000. 136 Barach. et al. 1998. Reporting and preventing medical mishaps: lessons from nonmedical near miss reporting systems.D. 1996. Effect of computerised physician order entry and a team intervention on prevention of serious medication errors. Small. Arch Pathol Lab Med. collecting data on “near misses”. 135 Stryer. the processes are complex and the end result of error can be catastrophic in human and resource costs for both those receiving the service and those providing it.135 Many other industries face similar work environments as medicine where real time decisions have to be made. blaming and shaming” the person involved in the mistake has led to disappointing results in reducing error rates. Aust Fam Physician. 326(7384): p. et al..B. 759-63. D. collecting information on “near misses” – events that could easily have led to an adverse outcome if not discovered – allows better understanding of what 130 Ioannidis. BMJ. However. 1998. 2003. 1609-10. Clinical incidents in general practice. 2001... 553-4. 131 Bates.133 There is. 25(10): p. J. et al. and J. Patients' safety. BMJ. Common themes that emerge from these industries as to methods of reducing error include systematic reporting systems. says chief medical officer. 300. "Weak" safety culture behind errors. JAMA. 133 Battles.130 Prescription errors are a common and serious cause of error in both hospital and community based medical practice.136 Not all error results in an adverse outcome. Prescription errors.P.Preventing error The study of error in medicine would indicate that solutions range from the very simple to the complex. H. 122(3): p. however.132 Utilising error reporting systems to understand better what has gone wrong has also shown effective in reducing error.

Cole’s Medical practice in New Zealand 2011 153 . W. 138 Cunningham. depression and reduced enjoyment of the practice of medicine. 7(4): p. 139 Goldberg. 39(3): p..137.139 137 Christensen. U972. and P.M.M. Dunn. 2004.138 However. Most doctors who are involved in patient care where error has occurred are significantly affected by it. J Gen Intern Med. W.. The heart of darkness: the impact of perceived mistakes on physicians.F. R. This in turn requires a culture in medicine that encourages and supports open communication and recognises that it is a defective system and not an individual that is responsible for the vast majority of errors that occur.” A more concise way of thinking about it is “Taking responsibility for clinical outcomes at a locality level. Coping with medical mistakes and errors in judgment.. 1992. guilt.processes are deficient and how to fix them. et al. Levinson.” The five components are clear lines of accountability for the overall quality of clinical care at practice level a comprehensive programme of quality improvement systems in each practice supporting and applying evidence-based practice clear policies aimed at managing risk procedures to identify and remedy poor performance integrated into practices Responding to error It is an inevitable part of professional practice that all doctors will make mistakes and that some of these mistakes will result in patient harm. the importance of effective emotional support during a time of professional crisis is also being recognised. Reactions include anger. N Z Med J. Clinical governance The National Health Committee defines clinical governance as. Ann Emerg Med. particularly if the error results in harm to the patient and formal complaint. The immediate and long-term impact on New Zealand doctors who receive patient complaints. 287-92. The key to collecting information on things that go wrong is effective communication. “A framework through which New Zealand health sector organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish. J.. 424-31. 2002. 117(1198): p. shame.

Lessons from plaintiff depositions. understanding of what has happened and reassurances that the “system” has been fixed so that the error will not happen again. 141 Witman. D. The majority of patients who have suffered from medical error want disclosure of error. 156(22): p. 1996. A. and S. the threat to ones own sense of professional competence and the desire to avoid compromising a legal situation. It is an important step in the process of recovery for both the patient and the doctor concerned. Not all litigation and complaint is occasioned by medical error and only a small proportion of error results in complaint. Arch Intern Med. the institution in which a doctor is employed should be notified at the earliest opportunity should error occur and the appropriate indemnity insurance company notified. The doctor-patient relationship and malpractice. 142 Soleimani. 2565-9. An American study looking at why a decision to pursue litigation was made by patients suggested that failure of communication was a crucial factor in the majority of cases. Clearly.. F. Once such notification has occurred. truthful explanations.141 Failure to meet these expectations is more likely to result in the patient seeking such explanations through legal and disciplinary processes. 1994. H. Park.B. Learning from mistakes in New Zealand hospitals: what else do we need besides "no-fault"? N Z Med J. 154 Cole’s Medical practice in New Zealand 2011 . if working as an employee..M. the error should be disclosed. Hardin..B.Communication would seem to be a strong predictor of the outcome of medical error. Disclosure may lessen the likelihood of formal complaint and allows a transparent process of understanding what went wrong and how to prevent it from happening again. 2006.. A 2006 study undertaken in New Zealand reported that 86 percent of hospital doctors surveyed believed that disclosure of error to patients would decrease the likelihood of a complaint being filed against them. How do patients want physicians to handle mistakes? A survey of internal medicine patients in an academic setting. 1365-70.140 Good communication between doctor and patient is crucial should error occur. et al. Arch Intern Med. fear of complaint. 154(12): p. It empowers patients as they have both understanding and involvement whereas nondisclosure disempowers patients.B. Acknowledging and apologising for the error places the incident in an interpersonal framework rather than the impersonal and distant hierarchy of an institution. A common question asked when error occurs is “Should I apologise?” The uncertainty as to what to do is usually driven by fear of disclosure to the patient and colleagues. 119(1239).142 140 Beckman.

the Council has to consider “whether… the practitioner’s practice… meets the required standard of competence”. The form of the assessment is at the Council’s discretion. and a decision then made at the Council on whether to proceed to a performance assessment. the doctor’s scope of practice may be restricted. Errors are to be avoided. patients and others. at any time… review the competence of a practitioner… whether or not there is reason to believe the practitioner’s competence may be deficient”. If the doctor fails to meet that standard the Council must order further assessment. Like many things in medicine. physical and financial cost for both the patient and the doctor involved. and on receipt of an unsatisfactory explanation in the doctor’s response. but until now the Council has assessed a doctor’s performance only after receiving a complaint or concern. the learning that can be found in them is invaluable in ensuring they don’t happen again. a response is sought from the doctor. Responsive assessment Currently the Council assesses doctors’ performance on receipt of a concern about the doctor. Cole’s Medical practice in New Zealand 2011 155 . effective communication and transparency can lessen the emotional. a remedial education programme or conditions on the doctor’s practice. Assessing doctors performance when concerns have been raised The Council “may. effective communication is the key to improving outcomes. Health Practitioners Disciplinary Tribunal. or registration suspended pending the assessment. When they occur. In conducting the assessment. from the Accident Compensation Corporation. the Health and Disability Commissioner. On receipt the concern is reviewed by the medical adviser and others. The opportunity for learning should not be overlooked. Complaints Assessment Committees. If there is apprehension that the doctor poses a serious risk.Conclusion Developing a culture of safety in medicine requires effective communication and trust among team members and acknowledgement of the failure of processes rather then individuals as the cause of the majority of errors in medicine. If and when error occurs. The concern and the doctor’s response are reviewed again. Concerns are received from colleagues. counselling. and if the concern appears proper.

Terms of reference state the domains of performance (medical expertise. Assessments are usually done at the doctor’s workplace. activities. practitioners’ association. practice systems review. but generally an educational supervisor is appointed to help the doctor plan appropriate educational activities. The clinical supervisor must be vocationally registered. supervision and reporting are detailed. or branch advisory body. nominated by employer. hospital. scholarship. management. closing interview. professionalism) to be assessed and the tools to be used. its objectives. case based oral. review of oversight or recertification requirements. Special kits of these tools have been developed for assessments of alternative medicine practitioners. disruptive doctors and doctors whose sexual boundary knowledge or behaviour has raised concerns. and a range of tools appropriate for the domain of practice to be assessed may be employed. work at the same site. and refined for New Zealand use. The assessment itself takes a day to two days. they agree not to practise in the clinical areas where their performance was deficient. Remedial education If performance is rated low. who has an opportunity to write submissions or be heard. initial interview. and a clinical supervisor may be appointed to oversee the doctor’s clinical practice. teamwork. though some doctors prefer to accept restrictions on their practice – ie. and name the assessors – one lay person and two medical assessors. records review. These tools have been developed from international assessment experience. audit of procedures. and be able to meet the doctor regularly to review clinical cases. 156 Cole’s Medical practice in New Zealand 2011 . The programme is approved and ordered by the Council.The assessment process The Council informs the doctor. They include peer and patient questionnaires. review of addictive drug prescribing. and must be available to meet regularly and help the doctor meet the requirements of the programme. educationally able. observing consultations. and the performance assessment committee writes a detailed report to the Council on its findings. usually from the same discipline – who form the performance assessment committee. The programme may take any form the Council decides. remedial education in the form of a performance improvement plan may be required. communication. There are penalties for noncompliance. outcomes. almost invariably a follow up review is ordered after the period of education. The educational supervisor must be vocationally registered.

and an individual’s error may be quite understandable in the circumstances. If a deficit is found. Everybody makes mistakes. Porakai. Cole’s Medical practice in New Zealand 2011 157 . the error signals poor performance. It is not a surrogate for discipline. and the remedies do not include punishment or apologies. The assessment process is about considering concerns about a doctor’s performance. error will lead to performance assessment only when. educational management is prescribed. pigeonwood. Nor is the assessment process about the conduct of doctors: it has nothing to do with discipline. Hedecarya arborea. and the outcome reassessed. The complainant is not involved after the initial expression of concern. in the opinion of the Council. If distracters or health issues affecting the performance of an otherwise competent doctor are detected. or investigating a specific complaint.What performance assessments are not The Council’s performance assessment procedures are not about systems failures in organisations. looking for distracters or health issues and making an educational diagnosis. these will be taken into account.

It revises the code of ethics and provides guidelines endorsed by the Council of the New Zealand Medical Association (NZMA). All treatments should be subject to the same standards in respect of the rigour with which they are subjected to scientific testing and the ethics applicable to their use). The medical profession has a social contract with its community. The moral basis for practice has its expression through what is commonly termed medical ethics. (This principle involves consideration of risks versus benefits from particular procedures. non-maleficence. This document represents a further stage in that evolutionary process. and recognition of their autonomy. to this end. (The NZMA recognises no distinction.) Justice incorporates notions of equity and of the fair distribution 158 Cole’s Medical practice in New Zealand 2011 . between conventional and alternative medicine when practised by a registered medical practitioner. and is therefore well established. Integral to an ethical basis for professional practice is the overriding acceptance of an obligation to patients. Its knowledge and consciousness must be directed to these ends. in terms of accountability.18 The New Zealand Medical Association code of ethics Preliminary statement The profession of medicine has a duty to maintain and improve the health of the people and reduce the impact of disease. The basis of the moral framework for medical practice has been developed gradually over several thousand years. This document does not purport to set out rigid. Non-maleficence implies a duty to do no harm. Beneficence requires a doctor to achieve the best possible outcome for an individual patient. In return for the trust patients and the community place in doctors. (The NZMA strongly favours retention of the word "patient" because it reflects accurately the nature of the relationship between a doctor and the person seeking help). Autonomy recognises the rights of patients to make decisions for themselves. beneficence. immutable rules. Standard treatises on medical ethics cite four moral principles: autonomy. PO Box 156. comment and feedback is invited (Comments should be sent to: New Zealand Medical Association. Wellington). ethical codes are produced to guide the profession and protect patients. and justice. The Code will be reviewed at regular intervals and. whereas guidelines for professional behaviour must reflect the changing social and cultural environment in which doctors practise. while recognising resource constraints.

Faced with this complex and changing situation. there is also an increasingly wide recognition of the principle of partnership . Many commercial concepts. namely. The concept of accountability.of resources. doctors are experiencing difficulty in balancing the requirements of their primary obligation to individual patients and families with their responsibilities to the wider community. The ethical issues related to this are at present being defined and the present code cannot encapsulate any established pattern). Cole’s Medical practice in New Zealand 2011 159 . are challenging aspects of medical organisation and professional practice. profession and society. In today’s world. Changes in the context of medical practice are reflected in new sections on Medical Responsibilities in Prioritising Care and on Medicine and Industrial Action to address the exquisite dilemmas that doctors find themselves in as participants in the tension between the welfare of the individual patient and the good of all other patients. The NZMA urges members and all doctors to follow the standards set out below. The patenting of inventions based on an individual's thinking and research is becoming widespread. and different cultures as an important aspect of the ethos of professional practice. the New Zealand Medical Association affirms its adherence to certain ethical principles. including that of intellectual property and that of contracting with various funding bodies.between doctor and patient. experience and judgement with others. The concept of the autonomy of doctors also needs to be considered. Some ethicists are beginning to argue for a fifth principle. (The concept of intellectual property and its protection is relatively recent. In New Zealand today. Increasingly. An increasing number of statutory and commercial organisations interact with doctors in relation to issues of accountability. although this principle has always been tempered with common sense and recognition of the duty to act within the limits of one's own capabilities. doctors have an increased ethical responsibility to participate in reviewing formally their own and others’ work to maintain standards of practice. The Association accepts responsibility for delineating standards of ethical behaviour expected of doctors in New Zealand and has consulted widely in the development of this Code. as applied to the medical profession. needs to encompass a widening set of relationships and contexts. Patients have a legal right (under the Health and Disability Commissioner’s Code of Patient Rights) to services that comply with ethical standards such as this Code of Ethics. sharing their skills. the duty of doctors in some circumstances to recognise the need to work in collaborative groups.

including those who may not be engaged directly in clinical practice. Accept a responsibility to assist in the protection and improvement of the health of the community. 5. will acknowledge and accept the following Principles of Ethical Behaviour: 1. Strive to improve your knowledge and skills so that the best possible advice and treatment can be offered to the patient.Principles All medical practitioners. no set of guidelines can cover all situations. The following set of recommendations is designed to convey an overall pattern of professional behaviour consistent with the principles set out above in the Code of Ethics. Protect the patient's private information throughout his/her lifetime and following death. prevention and treatment of disease. 11. including its traditions. Practise the science and art of medicine to the best of your ability with moral integrity. and the increasing difficulties brought about by the need for rationing of resources and direct intervention of third-party providers of funding. 10. Responsibilities to the patient 1. 12. 3. compassion and respect for human dignity. whether it be physical. Exploitation of any patient. 9. in the ways that best serve the interests of the patient. 7. 2. Honour the profession. 6. and its principles. values. Respect the rights. Adhere to the scientific basis for medical practice while acknowledging the limits of current knowledge. 160 Cole’s Medical practice in New Zealand 2011 . Accept a responsibility to advocate for adequate resourcing of medical services and assist in maximising equitable access to them across the community. autonomy and freedom of choice of the patient. Recommendations Given the complexities of doctor-patient relationships. Consider the health and well being of the patient to be your first priority. 8. 4. Accept a responsibility for maintaining the standards of the profession. unless there are overriding considerations in terms of public interest or patient safety. Doctors should ensure that all conduct in the practice of their profession is above reproach. Avoid exploiting the patient in any manner. Recognise your own limitations and the special skills of others in the diagnosis.

sexual. 7. Doctors should seek to improve their standards of medical care through continuing self-education and thoughtful interaction with appropriate colleagues. 4. whether seen urgently or unexpectedly. Doctors should ensure that every patient receives appropriate available investigation into their complaint or condition. and should assure themselves that appropriate arrangements are Cole’s Medical practice in New Zealand 2011 161 . doctors may withdraw from or decline to provide care as long as an alternative source of care is available and that the appropriate avenue for securing this is known to the patient. to refuse to care for a particular patient. In any situation which is not an emergency. The NZMA considers that a sexual relationship with a current patient is unethical and that. Doctors. are involved in relationships in which there is a potential or actual imbalance of power. Where a doctor does withdraw care from a patient. The NZMA is mindful of Medical Council policy in relation to sexual relationships with present and former patients or their family members.2. particularly where exploitation of patient vulnerability occurs. It is acknowledged that in some cases the patient-doctor relationship may be brief. 8. like a number of other professionals. in most instances. Doctors have the right. Doctors should ensure that information is recorded accurately and is securely maintained. Doctors should ensure that continuity of care is available to all patients. and expects doctors to be familiar with this. Any complaints about a sexual relationship with a former patient therefore need to be considered on an individual basis before being considered as unethical. emotional. In such circumstances and where the sexual relationship has developed from social contact away from the professional environment. or within a long-term contractual setting. minor in nature. or financial. except in an emergency. reasonable notice should be given and an orderly transfer of care facilitated. 6. is unacceptable and the trust embodied in the doctor-patient relationship must be respected. Sexual relationships between doctors and their patients or students fall within this category. sexual relations with a former patient would be regarded as unethical. When a patient is accepted for care. or in the distant past. 3. impropriety would not necessarily be inferred. including adequate collation of information for optimal management. doctors should render medical service to that person without discrimination (as defined by the Human Rights Act). 5. with due regard to the challenges of the modern electronic era.

if possible. the range of possible solutions. when indicated. recommend to patients that additional opinions and services be obtained.9. 16. Where the assessment occurs in the context of a treating relationship. informing patients of these. Doctors should recognise the right of patients to choose their doctors freely. the doctor should have a basis for confidence in the competence of that practitioner. within the limits of their capacities. In making a referral to another health professional. and costs. risks. Patients should be made aware in advance. including the risk of serious harm to another person. 14. in understanding the nature of their problems. doctors should seek guidance from colleagues or an appropriate ethics committee. available to cover absence from practice or hours off duty. 11. as well as the likely benefits. Doctors should accept the right of a patient to be referred for further management in situations where there is a moral or clinical disagreement about the most appropriate course to take. this must ordinarily be respected. 15. doctors should communicate with colleagues who are involved in the care of the same patient. Doctors should ensure that patients are involved. Where a patient expressly limits possession of particular information to one practitioner. and should assist them in making informed choices. the purpose of the assessment and the limits of confidentiality. Doctors should ensure that patients are promptly informed of any adverse event or error that occurred during care for which the doctor has individual or direct overall responsibility. 10. the patient should be made aware that the doctor is ethically obliged to provide a 162 Cole’s Medical practice in New Zealand 2011 . where there are limits to the confidentiality which can be provided. the patient must be clearly informed of who the third party is. 12. so far as practical. When appropriate. Where a doctor is performing an assessment on behalf of a third party. and divulge it only with the permission of the patient or in those unusual circumstances when it is clearly in the patient's best interests or there is an overriding public good. and accept a patient's right to request other opinions. Doctors should keep in confidence information derived from a patient. 13. Doctors should recognise their own professional limitations and. This communication should respect patient confidentiality and be confined to necessary information. Patients should be made aware of this information sharing which enables the delivery of good quality medical care. or from a colleague regarding a patient. If there is any doubt.

treatment applied with the primary aim of relieving patient distress is ethically acceptable. In such inevitable terminal situations. doctors should consider any previously expressed preferences from the patient. In the case of conflicts concerning management. In relation to transplantation and requests for organ donation. guardian or other appropriate person. 24. They should recognise their responsibilities to the donor of organs that will be transplanted by disclosing fully to the donor or relatives the intent and purpose of the procedure. doctors should consult widely within the profession and. 17. even when it may have the secondary effect of shortening life. Doctors should recommend only those diagnostic or screening procedures which seem necessary to assist in the care of the patient and only that treatment which seems necessary for the well being of the patient. 22. the wishes of the family. which may include recourse to the courts for determination. and consult colleagues before making management decisions. the risks of the donation procedures must be fully explained. and in the process of dying. Doctors should be prepared to discuss and contribute to the content of advance directives and give effect to them. When it is necessary to divulge confidential patient information without patient consent this must be done only to the proper authorities. Doctors should be aware of statutory provisions and the codes of the Privacy Commissioner. with ethicists and legal authorities. Doctors should ensure that the Cole’s Medical practice in New Zealand 2011 163 . and the requirements of the Medical Council of New Zealand. 21. 18. if indicated. When requested or when need is apparent. In the case of a living donor. chronic illness. 25. doctors should provide patients with information required to enable them to receive benefits to which they may be entitled. 20. doctors should accept that when death of the brain has occurred. Doctors should bear in mind always the obligation of preserving life wherever possible and justifiable. ageing. Doctors should accept that autonomy of patients remains important in childhood. and a record kept of when reporting occurred and its significance. the cellular life of the body may be supported if some parts of the body might be used to prolong or improve the health of others.complete and professional report. When patients are not capable of making an informed choice or giving informed consent. while allowing death to occur with dignity and comfort when it appears to be inevitable. 23. 19. the Human Rights Commissioner and the Health and Disability Commissioner.

Doctors should accept a share of the profession's responsibility toward society in matters relating to the health and safety of the public. 28. Where doctors are working within a health 164 Cole’s Medical practice in New Zealand 2011 . health promotion and education.determination of death of any donor patient is made by doctors who are in no way concerned with the transplant procedure or associated with the proposed recipient in a way that might exert any influence upon any decisions made. 30. 29. 34. Doctors have an obligation to draw the attention of relevant bodies to inadequate or unsafe services. and legislation affecting the health or well being of the community. Disruption of such a relationship should. 33. When appropriate doctors should make available to colleagues. 27. Doctors have a responsibility to participate in reviewing their own practice and that of others. 31. Doctors should seek guidance and assistance from colleagues and professional or healthcare organisations whenever they are unable to function in a competent. Doctors should recognise that the doctor/patient relationship has a value and should not be disturbed without compelling reasons. In normal circumstances. 35. a report or summary of their findings and treatment relating to that patient. 36. Doctors have a responsibility to assist colleagues when they are unwell or under stress. Doctors have a general responsibility for the safety of patients and should therefore take appropriate steps to ensure unsafe or unethical practices on the part of colleagues are curtailed and/or reported to relevant authorities without delay. safe and ethical manner. wherever possible. Professional responsibilities 26. with the knowledge of the patient. be discussed in advance with an independent colleague. Doctors have both a right and a responsibility to maintain their own health and well being at a standard that ensures that they are fit to practise. information about colleagues divulged as a part of quality assurance exercises (including peer groups) should remain confidential. 32. Doctors should avoid impugning the reputations of colleagues. doctors have a responsibility to behave cooperatively and respectfully towards team members. When working in a team environment. When approached in this way doctors should provide or facilitate such assistance.

Advances and innovative approaches to medical practice should be subject to review and promulgation through professional channels (including ethics committees) and medical scientific literature. 40. rather than the trade or commercial name. commissions. vaccines and specific ingredients. Doctors should accept that their professional reputation must be based upon their ability. Doctors should certify or give in evidence only that which has been personally verified when they are testifying as to circumstances of fact. 43. Doctors should advertise professional services or make professional announcements only in circumstances where the primary purpose of any notification is factual presentation of information reasonably needed by any person wishing to make an informed decision about the appropriateness and availability of services that may meet his or her medical needs. and that evidence should be clearly outlined. the doctor has a duty to assist the body impartially on relevant matters and to confine such opinion within their area of expertise. technical skills and integrity. 38. In presenting any personal opinion contrary to a generally held viewpoint of the profession. in arriving at just decisions. If endorsing a product. whatever the offence of which the victim of such procedures is suspected. Doctors should not countenance. or have a financial or other interest in.37. Any such announcement or advertisement must be demonstrably true in all Cole’s Medical practice in New Zealand 2011 165 . doctors must indicate that such is the case. and consult with colleagues before speaking publicly. doctors should use only the proper chemical name for drugs. commercial organisations or products. service they should first raise issues in respect of that service through appropriate channels. 39. including the organisation responsible for the service. their interest must be declared. generally accepted opinions when presenting scientific knowledge. inhuman. 41. Any endorsement should be based on specific independent scientific evidence. and disciplinary bodies. condone or participate in the practice of torture or other forms of cruel. or degrading procedures. When doctors are acting as agents for. Doctors should not allow their standing as medical practitioners to be used inappropriately in the endorsement of commercial products. Doctors should recognise the responsibility to assist courts. Doctors should accept responsibility for providing the public with carefully considered. Doctors should not use secret remedies. accused or guilty. 42. and present information fairly. commissioners. When doctors are providing expert opinions.

All studies involving patients should be subject to the scrutiny of an appropriately constituted ethics committee which must be independent of the investigator and the sponsor. There must be a robust mechanism for curtailing the trial should at any stage the treatment group be demonstrated (by adequate statistical methods) to be different from the placebo group. 47. Doctors should be assured that the planning and conduct of any particular study is such that it minimises the risk of harm to participants. equipment or policy. even if an established therapy is available for a certain condition. 44. 46. There must be an assessment of predictable risks and burdens in comparison with foreseeable benefits to the participants or to others. doctors should assure themselves that the particular investigation is justified in the light of previous research and knowledge. diagnostic or therapeutic method.respects and contain no testimonial material or endorsement of clinical skills. 166 Cole’s Medical practice in New Zealand 2011 . When comparing active treatments. in accordance with a reasonable body of medical opinion. Any proposed study should reasonably be expected to provide the answers to the questions raised. Qualifications not recognised by appropriate New Zealand statutory bodies should not be quoted. advice should be sought from relevant professional organisations. and any kind of undue influence. diagnostic or therapeutic method is being investigated for a minor condition and the patients who receive placebo will not be subject to any additional risk of serious or irreversible harm. or where a prophylactic. Doctors must not allow gifts to influence clinical judgement. under the following circumstances: the established treatment has never been demonstrated to be effective by evidence-based criteria. In all cases of doubt. the control group should receive the best currently available and accepted treatment. hospitality or gratuity which could be interpreted as an inducement to use or endorse any product. Before initiating or participating in any clinical research. A placebo-controlled trial may be ethically acceptable. or where for compelling and scientifically sound methodological reasons its use is necessary to determine the efficacy or safety of a prophylactic. Research 45. Doctors should exercise careful judgement before accepting any gift.

48. Patient consent for participating in clinical research (or permission of those authorised to act on their behalf) should be obtained in writing only after a full written explanation of the purpose of that research has been made, and any foreseeable health hazards outlined. Opportunity must be given for questioning and withdrawal at any time. When indicated, an explanation of the theory and justification for double-blind procedures should be given. Acceptance or refusal to participate in a clinical study must never interfere with the doctor-patient relationship or access to appropriate treatment. No degree of coercion is acceptable. 49. Boundaries between formalised clinical research and various types of innovation have become blurred to an increasing extent. Doctors retain the right to recommend, and any patient has the right to receive, any new drug or treatment which, in the doctor's considered judgement, offers hope of saving life, re-establishing health or alleviating suffering. Doctors are advised to document carefully the basis for any such decisions and also record the patient's perception and basis for a decision. In all such cases the doctors must fully inform the patient about the drug or treatment, including the fact that such treatment is new or unorthodox, if that is so. 50. In situations where a doctor is undertaking an innovative or unusual treatment on his or her own initiative, he or she should consult suitably qualified colleagues before discussing it with, or offering it to, patients. Doctors should carefully consider whether such treatments should be subject to formal research protocols. 51. It is the duty of doctors to ensure that the first communication of research results be through recognised scientific channels, including journals and meetings of professional bodies, to ensure appropriate peer review. Participants in the research should also be informed of the results as soon as is practicable after completion. 52. Doctors should not participate in clinical research involving control by the funder over the release of information or results, and must retain the right to publish or otherwise release any findings they have made. Doctors involved as principals in research should not participate if they do not have access to the base data. Negative as well as positive results should be published or otherwise made publicly available. Any dispute or ethical issue which may arise in respect of the research should be considered openly, eg, by consultation with the appropriate ethics committee.

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Teaching 53. Clinical teaching is the basis on which sound clinical practice is based. It is the duty of doctors to share information and promote education within the profession. Education of colleagues and medical students should be regarded as an ethical responsibility for all doctors. 54. Teaching involving direct patient contact should be undertaken with sensitivity, compassion, respect for privacy, and, whenever possible, with the consent of the patient, guardian or appropriate agent. Particular sensitivity is required when patients are disabled or disempowered, eg, children. If teaching involves a patient in a permanent vegetative state, the teacher should, if at all possible, consult with a nursing or medical colleague and a relative before commencing the session. 55. Wherever possible, patients should be given sufficient information on the form and content of the teaching, and adequate time for consideration, before consenting or declining to participate in clinical teaching. Refusal by a patient to participate in a study or teaching session must not interfere with other aspects of the doctor-patient relationship or access to appropriate treatment. 56. Patients’ understanding of, or perspective on, their medical problems may be influenced by involvement in clinical teaching. Doctors should be sensitive to this possibility and ensure that information is provided in an unbiased manner, and that any questions receive adequate answers. It may be appropriate for the doctor to return later to address these issues. Medicine and commerce 57. Commercial interests of an employer, health provider, or doctor must not interfere with the free exercise of clinical judgement in determining the best ways of meeting the needs of individual patients or the community, nor with the capacities of individual doctors to cooperate with other health providers in the interests of their patients, nor compromise standards of care or autonomy of patients in order to meet financial or commercial targets. 58. Where potential conflict arises between the best interests of particular patients and commercial or rationing prerogatives, doctors have a duty to explain the issues and dilemmas to their patients. Doctors should state quite clearly what their intentions are and why they advocate particular patterns of diagnosis, treatment, referral or resource use. Commercial arrangements that have the potential to impinge on the patient’s care should be declared to the patient.

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59. Doctors who provide capital towards health services in the private sector are entitled to expect a reasonable return on investment. Where there may be a conflict of interests, the circumstances should be disclosed and open to scrutiny. 60. Like all professionals, doctors have the right to fair recompense for the use of their skills and experience. However, motives of profit must not be permitted to influence clinical judgement. 61. Doctors should insist that any contracts into which they enter, including those involving patients, be written in clear language such that all parties have a clear understanding of the intentions and rules. 62. Doctors who find themselves in a potentially controversial contractual or commercial situation should seek the advice of a suitable colleague or organisation. Medical responsibilities in prioritising care 63. Doctors have a primary responsibility to the individual patient, but also a concurrent responsibility to all other patients and the community. Doctors therefore have an ethical responsibility to manage available resources equitably and efficiently. 64. Rationing of resources must be open to public scrutiny and points of conflict identified and presented in a rational, non-biased manner to the public. 65. Patients must be able to trust their doctor to deal with their needs fairly and honestly. Doctors should, within reason, provide adequate information to their patients about their assessment and available treatments, including those not readily available. 66. In an environment of resource constraint, priorities need to be assigned to achieve the wisest use of limited resources. Doctors have a duty to work with others in developing rules to set priorities. Doctors also have a duty to abide by such rules, provided the rules conform to ethical principles. The rules should be just, open, valid, and reliable. Medicine and industrial action 67. It is recognised that certain extreme circumstances may lead to consideration of industrial action by doctors. Such action is not always unethical, even if it compromises care to individual patients, which is contrary to one of the ethical principles. However, a decision to take industrial action must be based on a reasonable expectation that the desired outcome will result in improved patient care and safety. A doctor’s primary duty is to their patient, but the secondary duty to all
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other patients may mean that action has to be considered. In the case of industrial action, doctors should take care to minimise any detrimental effect on patient care. Services to preserve life and prevent permanent disability must always be provided. Self interest alone by individuals or the profession is not an ethical basis on which to take action. This code will undergo major review by May 2013. However, minor changes may be introduced before then in response to further alterations in the environment in which medicine is practised. To this end, the NZMA welcomes feedback and comment on this code at any time.

Ngau, Lepidium oleraceum, Cook’s scurvy grass.

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19

The doctor who uses complementary and alternative medicine

Ian St George is a Wellington GP and has been an elected member of the Medical Council, Chair of its Education Committee, and Chair of the International Physician Assessment Coalition.
The “homeopathic clause” The evidence base Standards Complaints and concerns

A government committee established to investigate alternative health practices in New Zealand (the Ministerial Advisory Committee on Complementary and Alternative Health) adopted American guidelines to classify the various therapies into five groups 1. long established systems such as naturopathy, homeopathy, oriental medicine, Ayervedic and other traditional practices; 2. mind body therapies such as meditation and hypnosis; 3. “biological based” therapies such as herbalism, special diets and orthomolecular treatments; 4. manipulative therapies such as osteopathy and chiropractic; 5. “energy” therapies such as reiki, qi gong and therapeutic touch. The “homeopathic clause” The Health Practitioners Competence Assurance Act 2003 (section 100 [4]) states “No person may be found guilty of a disciplinary offence … merely because that person has adopted and practised any theory of medicine or healing if, in doing so, the person has acted honestly and in good faith”. This has been colloquially called “the homeopathic clause”, and has been interpreted as tacit approval of the practice of forms of complementary and alternative medicine (CAM) by registered medical practitioners in New Zealand. That is a risky interpretation: the Medical Practitioners Disciplinary Tribunal stated (Decision 237/02/89D)
Cole’s Medical practice in New Zealand 2011 171

nor the use of performance procedures to assess the performance of a doctor practising CAM. speculation and testimonials do not substitute for evidence. The evidence base The New England Journal of Medicine stated. that the patient is not harmed by withholding the standard therapy. that the unproved treatment is safe. The clause does not preclude prosecutions for substandard medical practice or dishonesty. There is only medicine that has been adequately tested and medicine that has not. A doctor who chooses to recommend an unproved treatment ahead of one with proved effectiveness (or one that is regarded as orthodox) must be prepared to argue. This applies equally to unorthodox diagnoses as it does to treatments. Any registered medical practitioner who embarks on a mode of investigation or treatment of patients that is not based on evidence of effectiveness must also apply the standards that would be applied to orthodox methods.” The important distinction is between evidence based medicine and unproved medicine. medicine that works and medicine that may or may not work. for instance the Medical Practitioners Disciplinary Tribunal stated (Decision 237/02/89D): “…the Tribunal wishes to record that Dr X did not provide any meaningful explanation of the condition of ‘electromagnetic sensitivity’ or any credible reason for having diagnosed (the patient) as having it. In other words the doctor must be expected to apply the same standards (and the same critical appraisal skills) that would be applied to orthodox methods. That requires a history and examination sufficient to make or confirm a generally recognised diagnosis.“Whilst section 109(4) recognises that a practitioner is not to be found guilty ‘merely’ because he has adopted or practised a theory of medicine or healing.” Standards Patients who consult doctors who practise CAM methods state they do so “to get the best of both worlds”. with evidence. Alternative treatments should be subjected to scientific testing no less rigorous than that required for conventional treatments. … But assertions. “There cannot be two kinds of medicine – conventional and alternative. and that the patient is fully informed and consents. investigations using generally accepted tests 172 Cole’s Medical practice in New Zealand 2011 . it does not follow that his adoption and practice of any theory of medicine or healing is by itself a sufficient answer”.

is there any suggestion of exploitation?).” Furthermore. Patients must be told the likely effectiveness of a given therapy according to published and accepted information. It will also consider whether the methodology promoted for diagnosis is reliable. there is a reasonable expectation that the treatment will result in a favorable outcome compared with placebo. not subjected only to the doctor’s individual beliefs. Cole’s Medical practice in New Zealand 2011 173 . The informed consent issue has been traversed by the Tribunal – “… Dr X did convey misleading information to give (the patient) the impression PMRT had a scientific validity it did not have…. act according to the fundamental values of the profession. informed consent has been adequately documented in the medical record. the practitioner is excessively compensated for the service (ie. laser management and spiritual healing without explaining to her the conventional options and without advising her of the risks.pertinent to the patient’s complaint. his claim to use this diagnostic technique (which he claimed was extensively used overseas) ahead of his peers in New Zealand. the authoritative manner in which he gave his successive diagnoses. and c. and recording all of the above in accordance with sound practice. the risk/benefit ratio for any treatment is acceptable. It also requires the doctor to demonstrate current knowledge and skills in their specialty. Some examples are a. homeopathic drops. In the case of CAM practices it will particularly consider questions relating to the preceding paragraphs. benefits and efficacy of his nonconventional treatment compared with conventional treatment. he prescribed “treatment … in the form of homeopathic paraquat injections. the treatment is extrapolated from reliable scientific evidence or is supported by a credible scientific rationale. advising the patient of the orthodox treatment options. his use of pseudoscientific language. a diagnosis that reasonable doctors would make. the Medical Council will apply the standards that have been developed for reviewing the competence of any practitioner. their risks. benefits and efficacy. provide sufficient information to allow patients to make informed choices without misrepresenting information or opinion. as reflected by current knowledge. b.” Complaints and concerns In assessing complaints or concerns related to the practice of a doctor who has adopted or advocated CAM investigations or treatments.

Angell M. Policy statement: Model guidelines for the use of complementary and alternative therapies in medical practice. 3. and should certainly read the decision at www. Washington. alternative medicine. that a registered medical practitioner cannot discharge his or her obligation to treat the patient to the acceptable and recognised standard simply by claiming the particular treatment was “alternative or complementary” medicine. the usual domains of competence are assessed. Federation of State Medical Boards of the United States.fsmb.In assessing the performance of a doctor practising CAM. Resources 1. Kassirer JP. In other words. (www. Doctors considering undertaking CAM practices should also be aware of the robust approach the Medical Practitioners Disciplinary Tribunal has taken.org). 2. 339:839–41. Inc. The Tribunal said. the support of the majority of practitioners. there is an onus on that practitioner to inform the patient not only of the nature of the alternative treatment offered but also the extent to which that is consistent with conventional theories of medicine and has. (www. ______________________________________________________________ 174 Cole’s Medical practice in New Zealand 2011 .pdf.mpdt. among other things.org.mcnz. it is difficult to escape the conclusion that the patient derives considerable assurance from the fact that the practitioner is so registered.org. although the critical appraisal skills of doctors who can convince themselves about the claims of some fringe therapies may be of concern. they are more readily exploited. As such. Alternative Medicine – the risks of untested and unregulated remedies. the health of the doctor and the presence of distracters preventing good performance will be assessed. the Council will not attempt to evaluate the alternative therapy itself. rather than the principles of alternative practice.nz/decisionsorders/decisions/0289dfindings. It follows. Where such remedies are offered by a registered medical practitioner. Statement on complementary and. N Eng J Med 1998.nz/standards/guidanceresources/#mostr). 2001. The faith which such persons place in practitioners offering alternative remedies largely depends on the credibility with which such practitioners present themselves. Medical Council of New Zealand. As in any assessment of a doctor’s performance. therefore. The Tribunal recognises that persons who suffer from chronic complaints or conditions for which no simple cure is available are often willing to undergo any treatment which is proffered as a cure. or does not have. April 1999 (revised March 2005). Where a registered medical practitioner practises “alternative or complementary” medicine. There will be parity of assessment standards whether the physician is using conventional medical practices or CAM.

The relationship between the pharmaceutical industry and the medical profession has been the target of severe criticism in recent years.” Many medical colleges worldwide have also responded to public criticism and have written clear codes for their members. For example. it contains the following: “Information directed to consumers should be accurate. in the section on Direct to Consumer advertising. Some doctors also act as advisers to the industry. There is a growing public demand for greater transparency with respect to the medical profession's relationship with industry. Between 2008 and 2010 the American Psychiatric Association (APA) has reduced.20 Prescribing Research Summary The pharmaceutical industry and the profession Barnett Bond is a general practitioner on Waiheke Island and has been a member of the Medical Council. balanced. Some progress has been made by both the profession and the industry over the last decade in acknowledging the inherent risks in their mutual relationship. The Royal Australasian College of Physicians (RACP) has had a code of conduct for its members since 1994 but it does not go as far as Cole’s Medical practice in New Zealand 2011 175 . In New Zealand the Researched Medicines Industry (RMI) is a voluntary organisation but has as members all the large pharmaceutical companies. Doctors can also be involved in the design and execution of clinical drug trials for pharmaceutical companies. The RMI has published a code of ethics which covers many aspects of the Industry’s interactions with the profession. Doctors interact with the pharmaceutical industry in a number of ways. The most obvious is when a doctor writes a prescription. Sometimes research facilities are funded by the industry. although not all have done so. not misleading and due consideration should be given to the role of the health care provider. In other situations doctors may be the recipients of benefits of one kind or another which enable them to progress their research. and from 2011 will eliminate all industry sponsored symposia at its annual meeting.

Thus there are advertisements in medical journals. To do this they need to have the highest possible volume sales for their products. In 2008 the largest 5 companies had combined global sales of more than 0. incentives offered to doctors to prescribe specific agents and in New Zealand and the USA. Doctors should keep in mind that the handful of leading pharmaceutical companies are among the largest global entities in the world. Commercial realities dictate that a pharmaceutical company will do considerable work to persuade doctors that a) drug therapy is superior to nondrug therapy. Sitting uncomfortably alongside this fact reactions to drugs are estimated to cause 100.000 deaths per year in the United States and are the 5th leading cause of death. Changing doctors’ prescribing behavior is not easy. In the most affluent countries in the world the prescribing of pharmaceuticals is tightly regulated and the “sales” are determined almost exclusively by the medical profession. direct to consumer advertising. and other publications.6 trillion US dollars. However it does give guidance to its members about where the boundaries for ethical behaviours are in this arena. direct to doctor mailings. Terfenadine and rofecoxib (Vioxx) are two recent examples of widely prescribed drugs that caused serious morbidity and death. or nondrug therapy. Pharmaceutical companies’ research has shown them that sustained effort and expenditure on a number of fronts is necessary to effect change. How certain is the diagnosis? What is the natural history of the disease? What are the available options for altering this natural history? And finally what is the best choice of an appropriate drug. Doctors should exercise good judgment and not look to a company for impartial critical education about any product it sells.the APA. and b) a particular agent (theirs) is superior to all other agents. Prescribing There are a number of steps that should precede the writing of a prescription. It is this last step that the pharmaceutical industry has an intense interest in influencing. Direct to consumer advertising has an intense focus on these two issues. Pharmaceutical company personnel will arrange GP access to specialists who will endorse prescriptions for restricted drugs. and are among the most profitable companies year on year. Advertisements for drugs for mild to moderate depression do not allude to the studies showing that regular physical exercise is as effective an antidepressant for many (not all) patients as tricyclics and SSRIs. Pharmaceutical companies are commercial entities and are motivated to be profitable. “Detailing” by company representatives is 176 Cole’s Medical practice in New Zealand 2011 .

resulting in a prescription that is not the best treatment for the patient. One area of very high risk is where pharmaceutical companies seek to be involved in the production of continuing education material for doctors. and allows biased or incomplete trial data to influence prescribing. In addition. From this data most pharmaceutical companies can demonstrate the effectiveness of a particular sales representative. Doctors need to recognise that. There are a number of objective studies that show that the pharmaceutical industry is successful in influencing doctors’ prescribing. The pharmaceutical industry does not share this view and has data to prove it. Finally the “medicalisation” of conditions formerly viewed as lifestyle or behavioral matters and the expansion of existing diagnostic criteria to make Cole’s Medical practice in New Zealand 2011 177 . as are sponsored medical education sessions. in ways that are not beneficial to patients. This will occur if the doctor allows the relationship with a pharmaceutical company to influence prescribing. Considering the level of investment and cost it takes for a new drug to be brought to market. Relationships between health care professionals and industry can lead to confusion about goals and clouding of judgment about what is an appropriate course of action. they are susceptible to marketing and should actively seek unsponsored objective education about new drugs so that patient care is not compromised. Many doctors claim that their relationships with the pharmaceutical industry do not influence their prescribing at all. pharmaceutical companies themselves track sales (ie. then best patient care will be compromised. Both health care decision making and the conduct of research have been profoundly affected by these influences. it is not surprising that pharmaceutical companies promote their products with the most effective marketing tools available. (Many employers now seek to ensure that doctors are not unduly influenced by gifts). like other consumers. and the relationship between sales (prescriptions written) and the currency of the most recent visit by a representative to medical practices in each location. Drug promotion is a sophisticated commercial activity with the intention of overtly and covertly altering doctors’ thinking. prescriptions written) figures on a regional and area basis. and sponsorship of medical conferences.common. If a doctor fails to manage successfully the inherent conflicts of interest which arise from these interactions with the industry. or allows the clinical trial data the pharmaceutical company has presented to be the sole source of education.

and future employment with the pharmaceutical company may be lost. The recent proposed expansion of the DSM–IV criteria for ADHD and the influence that the industry is exerting to promote these proposed changes is a case in point. then the results of their research will be seen as neither reliable nor impartial. unless these risks are managed properly. considering the likely benefits. There are documented cases where patient care has been compromised (including death) by the implementation of the results of such research. Others should be allowed to determine whether the apparent conflicts are potential or real. The doctor must take steps to separate the conflicts by withdrawing from or curtailing certain activities and by delegating these functions to others. as a result of which future financial rewards.increasing numbers of patients eligible for drug therapy. and the long term effects of current drug therapy are unknown. are areas where the pharmaceutical industry takes a keen interest. whether the risks to which the patients are exposed are reasonable. Doctors who are researchers need to be aware that. At the trial design stage. A doctor involved in research must declare apparent conflicts of interest to the ethics committee which is involved in approving the trial. The 178 Cole’s Medical practice in New Zealand 2011 . whether the study design is appropriate. There is clear ambiguity in the advantage to those currently (and those who will be) diagnosed. and whether patients will be able to consent freely with appropriate levels of informed consent. the doctor must consider whether the proposed study sets out to answer questions which are sufficiently important to justify the study. doctors who are researchers can have a direct financial interest in the design or the conduct or the outcome of a clinical trial individual researchers are increasingly becoming involved with the commercialisation of their own work individual researchers sometimes retain the intellectual property to their own work financial compensation for doctors who are investigators in clinical trials sometimes appears to be at a level that is not commensurate with the work performed researchers sometimes stand to gain in nonprofit ways from the results of clinical drug trials researchers sometimes have to make a decision about whether to publish unfavorable results. Research There are number of areas of potential conflict of interest for doctors here.

doctor must communicate these decisions to fellow researchers and to the participants in the research.
Summary

In spite of widely held notions by doctors of immunity to their influences, the activities of the pharmaceutical industry do affect the behaviour of doctors in ways that are not always conducive to providing the best patient care. Unless these risks are managed appropriately doctors will be breaching ethical and sometimes legal boundaries. The Code of Health and Disability Services Consumers’ Rights makes specific reference to patients who are subject to research (Right 9). When considering whether or not to interact with the pharmaceutical industry doctors should ask themselves on each occasion “Might there arise a conflict of interest in this activity which could compromise my ability to provide impartial and best quality patient care?”
Resources

1. NEJM October 28 2004 – Doctors and drug companies 2. Good Medical Practice – A Guide for doctors. Medical Council of New Zealand. 3. Royal Australasian College of Physicians website 4. American Psychiatric Association – Code of Conduct

Puka, Meryta sinclairii.

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21

How medical practice standards are set by legislation: the Health Practitioners Competence Assurance Act

David Dunbar is the Registrar of the Medical Council.
Registration and practising certificates Scopes of practice

General scope of practice Vocational scope of practice Special purpose scope of practice
Professional Standards

Competence, and performance Conduct Suspension or imposition of conditions Health Practitioners Disciplinary Tribunal (HPDT) The regulation of health professionals in New Zealand is governed by the Health Practitioners Competence Assurance Act 2003 (the Act). The principal purpose of the Act is to protect the health and safety of the public by establishing mechanisms to ensure that health practitioners are competent and fit to practise medicine. This provides the framework for the policies, procedures and standards applied by the Medical Council of New Zealand (Council) to the regulation of doctors. The intention of the Act is to increase consistency, transparency and efficiency in the regulation of health professionals. Each mechanism established by Council is based on the principles of natural justice, with Council striving to balance the desire for increased regulation and accountability of health professionals, with the desire to maintain professional autonomy. The Act details a number of important functions that Council is required to perform, including but not limited to

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determining scopes of practice and qualifications required for registration registering doctors in a scope of practice requiring doctors to demonstrate competence at registration and maintenance of competence when applying for a practising certificate conducting competence reviews (performance assessments) and requiring programmes for up-skilling or retraining of doctors who are not practising at the required standard receiving notifications of any mental or physical conditions affecting the fitness of a doctor to practise medicine (referred by Council to its Health Committee where necessary for expert assessment and follow up) setting standards of cultural and clinical competence, and ethical conduct accrediting branch advisory bodies143, medical schools and intern runs.
Registration

Under the Act, Council is required to define what falls within “the practice of medicine” in New Zealand in terms of one or more “scopes of practice”. These “scopes of practice”, determined by Council, define aspects of the practice of medicine and the health services that a doctor may provide within the scopes. Under the Act, each doctor must be competent and fit to practise, and hold a relevant qualification “prescribed”144 by Council, and practise within a scope of practice. These prescribed qualifications will vary between the different scopes of practice. In many cases, a “prescribed” qualification will be an identified medical degree, or fellowship of a medical college, but in some cases the Council will require a combination of a medical degree, and additional training, or approved experience. In such cases, the medical practitioner will be required to meet all these requirements before he or she will be recognised as holding the “prescribed” qualification. Thus, to qualify for registration within a specific scope of practice, a doctor must: have a relevant prescribed qualification for that scope of practice be competent to practise in that scope of practice be fit to practise.
143 The branch advisory body is an accredited Council agent, drawn from a relevant medical college that provides a training programme and the New Zealand approved postgraduate qualification. 144 Section 12(2) of the HPCAA lists the aspects that may form part of a prescribed qualification, which include training, educational qualification and experience. Cole’s Medical practice in New Zealand 2011 181

In assessing an application, Council may consider placing one or more conditions on a person’s scope of practice. In the context of registration, a condition does not suggest an identified competence, conduct or health concern. Rather, its use is to facilitate registration. That is, it enables a doctor to be registered in a practise context that best corresponds to the areas that the doctor has previously worked in, or been formally assessed in. Conditions may also record a requirement for a period of supervision in a specified position or identify an examination that must be passed to enable the removal of any limitations on the doctor’s registration. Once a doctor is registered, their authorised scope of practice is entered on the publicly-available medical register, along with any conditions. Practising certificates A doctor must hold a practising certificate to work in New Zealand. The practising certificate is valid for a period of time, up to one year and is issued in cycles. The certificate records the doctor’s registered scope(s) of practice, place of work, supervision requirements and conditions (if applicable).
Scopes of practice

General scope of practice (and provisional general scope of practice) New Zealand and Australian medical graduates who have completed their internships in New Zealand or Australia are eligible for registration in a general scope of practice. International medical graduates who apply for registration within New Zealand in a general scope of practice must first be eligible or become registered in a provisional general scope of practice. This allows Council to determine whether a doctor is able to work at the required standard required in the New Zealand health system. Doctors registered in a provisional general scope of practice are required to work satisfactorily under supervision in an approved position or positions for 6-12 consecutive months to qualify for registration in a general scope of practice. Once the doctor has satisfied Council that all conditions have been met under their provisional general scope of practice, they can then apply for registration within a general scope of practice. Vocational scopes of practice (and provisional vocational scopes of practice) The vocational scopes of practice are the scopes for specialised medical practice. There are currently 35 different scopes of practice in the vocational

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pathway. Each scope has an associated accredited postgraduate training programme and postgraduate qualification145. International medical graduates who hold a postgraduate qualification and wish to apply for registration within a vocational scope practice, must first be eligible or become registered within a provisional vocational scope of practice146. Council seeks advice from the branch advisory bodies when determining whether the doctor has training, qualifications and experience equivalent to or as satisfactory as that of a New Zealand trainee, and Council considers this advice in making its final decision. Special purpose scopes of practice The Council provides special purpose scopes of practice for short-term registration. All of these pathways are limited in duration and are for defined purposes. They provide registration options for doctors wishing to teach, train, conduct research, work as a locum specialist, assist in an emergency or pandemic scenario in New Zealand or provide teleradiology in New Zealand. Doctors may work as a postgraduate trainee registered in a special purpose scope of practice for a maximum of 2 years. This pathway to registration is specifically designed to allow International Medical Graduates to work in New Zealand and gain skills and experience that they can take back to their country of origin. Therefore, time registered in a special purpose scope of practice as a postgraduate trainee will not be counted toward gaining registration in any other scope of practice. Recertification To maintain the right to be issued with a practising certificate, the doctor must meet ongoing recertification requirements. For the general scope of practice, this is achieved by maintaining a collegial relationship (they also have other Continuing Professional Development (CPD) requirements including clinical audit, peer review and CME). Within a vocational scope of practice, doctors must participate in an approved recertification programme.

145 Council has a system of accrediting and reaccrediting the postgraduate training and recertification programmes associated with each vocational scope 146 See 3 Cole’s Medical practice in New Zealand 2011 183

following the assessment. A competence review (also known as a performance assessment) is a broad based assessment of how the doctor is practising and is intended to be educative. or the matter has been resolved by the Commissioner. speedy and efficient resolution of complaints. This means the ability to practise well is not enough. The DP reviews the case and makes an independent decision on whether or not to take any further action 184 Cole’s Medical practice in New Zealand 2011 .Professional Standards Competence and performance The Act permits the Council to review the competence of a doctor to practise medicine at any time. whether or not there is a reason to believe the doctor may be deficient. Conduct The Act enables the Council to appoint a Professional Conduct Committee (PCC) to investigate a complaint or investigate the circumstances of offences committed by doctors. he may refer the provider to the DP. Council has reason to believe that the doctor does not meet the required standard of competence. or the Director of Proceedings148 will not be considering or proceeding with the matter. Any complaints Council receives must first be referred to the Health and Disability Commissioner (the Commissioner)147 and may not be referred to a PCC until the Commissioner informs Council that: the matter is not being investigated by the Commissioner. however. to promote the rights of the health and disability services consumers and facilitate the fair. simple. the assessment also needs to show whether the doctor is actually practising well. Council must make one or more of the following orders: that the doctor undertakes a competence programme that conditions be placed on the doctor’s scope of practice that the doctor sits an examination or assessment that the doctor is counselled or assisted by a named person. Commonly. When the Commissioner has found a breach of consumer rights. 148 The Director of Proceedings (DP) is a lawyer appointed under the Health and Disability Commissioner Act. 147 The Office of the Health and Disability Commissioner was created under the Health and Disability Commissioner Act 1994. The Act refers to “competence” (ability) and “standard” of competence (performance). If. such reviews follow formal notification to Council of potential competence concerns.

Conduct Council may also place an interim suspension on a practising certificate or place conditions on a doctor’s scope of practice. Competence Where a doctor’s competence is being or has been reviewed. or scope of practice (including placing conditions on their scope of practice). or impose conditions on a doctor’s scope of practice. After considering a case the PCC may make a number of recommendations to Council. For other matters. for an interim period. independent of Council. and in some cases referral to the police. Council has powers in more serious cases to suspend a doctor’s right to practise. where Council believes on Cole’s Medical practice in New Zealand 2011 185 . make its own determinations. Council will first propose its decision and give the doctor the opportunity to provide submissions and be heard by Council before finalising any proposed interim suspension or conditions. However. These include laying a charge before the Health Practitioners Disciplinary Tribunal (HPDT). depending on whether the core concern relates to matters of competence or conduct. alternatively. in either situation. The processes differ. Interim suspension or imposition of conditions In association with a review of a doctor’s competence or conduct. The PCC may. including recommending that Council review a doctor’s competence or fitness to practise. The condition or suspension will remain in effect until the performance assessment is completed or the doctor has passed an examination or assessment required by Council. Council may propose conditions or suspension.If a doctor is convicted of an offence punishable by imprisonment for a term of 3 months or more. the Council will be notified and is required under the Act to refer the matter to the PCC for an investigation (regardless of the actual sentence ordered by the Court). Council has residual power to refer the matter to a PCC if the Council considers that information in its possession raises one or more questions about the appropriateness of the conduct of the safety of the doctor’s practice. and Council considers it has reasonable grounds for believing the doctor poses a risk of serious harm to the public by practising below the required standard of competence. Council adheres to natural justice principles and the specific provisions in the Act.

The High Court decision is final and can only be appealed to the Court of Appeal on points of law.reasonable grounds that a conduct issue casts doubt on the appropriateness of the doctor’s conduct in their professional capacity. Cyathodes acerosa. The main purpose of the HPDT is to protect the health and safety of the public from incompetent and improper conduct by doctors by ensuring that doctors conform to standards reasonably expected from them. suspension for a period of up to 3 years. 186 Cole’s Medical practice in New Zealand 2011 . and a fine not exceeding NZ$30. Health Practitioners Disciplinary Tribunal (HPDT) The HPDT hears and determines charges brought by the Director of Proceedings from the Commissioner or a PCC. Should the doctor be found guilty then the gravity of the doctor’s offence is reflected in the nature of the penalty imposed by the HPDT.000. Mingimingi. The Act does not always require that a matter be before a PCC before action can be taken. imposition of conditions. Penalties could include the cancellation of a doctor’s registration. The Act can charge a doctor with ‘professional misconduct’. Decisions of the HPDT may be appealed to the High Court. Council may also consider imposing an interim suspension or conditions when a doctor is alleged to have engaged in conduct that is relevant to a pending criminal proceeding or is being investigated by the Commissioner.

Prescribing medicines Good prescribing practice Drugs of abuse Standing Orders Crimes Act 1961 Withdrawal of care and euthanasia Public health Cervical screening Contraception sterilisation and abortion The Medicines Act Assisted human reproduction Advance directives and enduring powers of attorney Fitness to drive motor vehicles Reporting of suspected child abuse Deaths and medical certificates of causes of death Introduction Medicine is a risky business. Chair of the Education Advisory Group for the Royal New Zealand College of General practitioners and Medical Adviser for the Medical Council of New Zealand. Many of these laws have a direct impact on the way you practise medicine. It is important that you have a basic understanding of these laws before they have an impact on your practice. governments usually like to enact laws. Steven Lillis is a general practitioner in Hamilton. Cole’s Medical practice in New Zealand 2011 187 .22 How medical practice standards are set by legislation: other legislation Michael Thorn is the Medical Council of New Zealand's senior policy adviser and researcher. Some grant you protections and powers. He has previously worked for the Office of the Health and Disability Commissioner and the Wellington Regional Public Health Service. and where there is risk. and others place limits on what you can do.

Refer to Good prescribing practice for a discussion on how “under the care” should be interpreted.151 Good prescribing practice152 The issuing of prescriptions for prescription medicines is legally restricted.149 This chapter aims to provide a brief overview of aspects of the law not discussed elsewhere in this book and discuss how they apply to your practice. ask a colleague or an adviser from your indemnity insurer. Prescribing drugs of abuse.nz. Central Region (04) 496 2437 or Southern Region (03) 474 8074 151 These are Good prescribing practice.govt. If you are unsure about something.Other chapters in this book deal with specific areas of medical law in detail. prescribing.150 The Council has also issued a portfolio of statements on Good prescribing practice which outlines its expectations within the context of these laws. is responsible for monitoring and administration of medicines and controlled drugs and staff can provide you with advice on the legislation and your responsibilities. Prescribing medicines The Medicines Act 1981. storage. the Misuse of Drugs Act 1975 and the Medicines Regulations 1984 provide controls over the manufacture. In particular. 188 Cole’s Medical practice in New Zealand 2011 . and Prescribing performance enhancing medicines in sport. 152 For more information.legislation. Medicines Control. and the Council requires that you only prescribe “within the limits of your competence”. a regulatory team within the Ministry of Health. you should be aware that while a doctor can generally prescribe from the full range of approved medicines. 150 Telephone: Northern Region (09) 580 9088.153 he or she is only permitted to prescribe for a patient “under his or her care”. Regulation 39. The Council also provides a variety of statements. The Acts and regulations mentioned below can all be read online at www. dispensing and advertising of medicines. Much of the law is complex and this chapter is unlikely to answer all of your questions. 149 Refer to Appendix A. 153 Although there are often separate subsidy requirements which must be met. refer to the Council’s statement on Good prescribing practice. 154 Medicines Regulations 1984.154 Other prescribers (such as midwives) are generally only permitted to prescribe a limited range of medicines. which discuss how aspects of the law apply in particular situations.

missing information or illegibility can have serious consequences. go to www. Mistakes. It is not permissible to issue prescriptions by email or other electronic means. Regulation 41. the total amount to be dispensed. the name and strength of the medicine.158 Approved medicines and their uses are outlined in MIMS New Ethicals. but only in cases where a medicine is needed urgently. Cole’s Medical practice in New Zealand 2011 189 . Regulation 40. the date. “Class A” controlled drugs are very high risk (for example cocaine. 158 Medicines Regulations 1984.The Regulations require that your prescriptions be “legibly and indelibly printed” and include: your signature (not a facsimile or stamp).mims. and the period of treatment. 159 Subscription details are available from www.nz/regulatory/unapproved. the name and address of the person for whom the prescription is given (and date of birth if they are a child). 156 Misuse of Drugs Regulations 1977.155 Prescriptions for some controlled drugs must be written on a proscribed form and require additional information. the number of occasions on which it may be supplied.nz or 0508 464 676.156 You should also ensure that your prescriptions include all the information needed for appropriate dispensing and compliance with subsidy requirements. refer to the Council’s statement on Prescribing drugs of abuse. In such cases the original prescription must be forwarded to the pharmacist within 7 days.co. If you prescribe an unapproved medicine (or a medicine for a purpose for which it has not been approved) you are required to pass certain details relating to the supply of that medicine to the Director-General of Health. refer to the Council’s statement on Good prescribing practice. the interval between each date of supply.157 It is wise to avoid using any abbreviations that could be misunderstood. 157 For more information.medsafe. dose and frequency (and method of delivery in some cases).asp 161 For more information. 160 For more information and to download a notification form. heroin and methamphetamine) and these are almost unprescribable.159 and you should keep a copy on hand. and further classifies these according to the risk of harm they pose.govt. while “Class 155 Medicines Regulations 1984. Faxed or telephone prescriptions are permitted. morphine and pethidine. Regulation 29. your address.160 Drugs of abuse161 The Misuse of Drugs Act classifies some medicines as “controlled drugs”. “Class B” controlled drugs (high risk) include methadone.

You are also required to keep “Class A” and “Class B” controlled drugs and your controlled drug prescription pad in a secure cupboard or compartment. See the Council’s statements on Good prescribing practice and Prescribing drugs of abuse for more information. diazepam and temazepam. administer or supply controlled drugs for the purpose of treating dependency. If you have any doubts about the appropriateness of a request for drugs. prescription medicines. 163 Telephone: Northern Region (09) 580 9088. 190 Cole’s Medical practice in New Zealand 2011 . excessive or reckless prescribing.162 If you prescribe drugs that have the potential for abuse you should make sure you are aware of any restricted persons living in your area. Under section 24 of the Misuse of Drugs Act only authorised persons (or persons working for an authorised facility) are permitted to prescribe. 164 “Inappropriate prescribing” can include indiscriminate.163 Section 48 of the Medicines Act 1981 empowers the Medical Council to inquire into the prescribing of any doctor to consider and determine whether he or she is prescribing inappropriately. especially controlled drugs. In particular you should be aware that it is illegal to prescribe controlled drugs to any person deemed a “restricted person” by a Medical Officer of Health. Regulation 37 and Schedule 1. It is usually also against the law. Lists of restricted persons are maintained through prescriber updates and peer review processes. If you hold or dispense controlled drugs then you are required to keep a controlled drugs register. or specific classes of. Central Region (04) 496 2437 or Southern Region (03) 474 8074.165 Standing orders The requirements for initiating and using standing orders are set out in the Medicines (Standing Order) Regulations 2002. If you delegate the dispensing of medicines to a nondoctor colleague by means of standing orders then you need to make 162 Misuse of Drugs Regulations 1977.164 If the Council has concerns then it can recommend to the Minister of Health that a doctor be prohibited from prescribing all. Inappropriate prescribing of drugs of abuse is unacceptable. both clinically and ethically.C” controlled drugs (moderate risk) include codeine. 165 Misuse of Drugs Regulations 1977. These only allow medicines to be administered or supplied to patients by way of a standing order if certain conditions are met. Regulation 25. it is wise to discuss your concerns with an advisor from Medicines Control. which is of metal or concrete construction.

Section 11. the law also recognises a distinction between “active killing” and merely allowing someone to die by the withdrawal of life support. This section applies if the performance of the operation was reasonable. having regard to the patient's state at the time and to all the circumstances of the case. Under the New Zealand Bill of Rights Act 1990 withdrawal of care necessary to keep someone alive is also permitted if the patient refuses it.171 166 Refer to the Medicines (Standing Order) Regulations 2002. Although not defined. Section 61 171 New Zealand Bill of Rights Act 1990. Regulation 8. 168 Medicines (Standing Order) Regulations 2002.168 Crimes Act 1961 The Crimes Act 1961 provides you with a degree of protection from prosecution and also specifies what is expected of you under certain circumstances.167 and you must also countersign the charted treatment or record and put in place a process to monitor and review the correct operation of the standing order. Cole’s Medical practice in New Zealand 2011 191 . skill and care. However. Section 155 170 Crimes Act 1961.169 If you perform a surgical operation with reasonable care and skill upon any person for that person’s benefit then the Act provides you with protection from criminal responsibility. Regulation 5.170 This means you cannot be charged with a crime such as manslaughter if something goes wrong. 167 Please also refer to the Ministry of Health’s Guidelines for the development and operation of standing orders. The common law also contains “Good Samaritan” principles which may protect you from legal action if you perform a procedure in an emergency. 169 Crimes Act 1961.yourself familiar with these conditions. The New Zealand Court of Appeal has upheld the withdrawal of treatment in circumstances where the court was satisfied that treatment was futile and merely prolonging death. “necessaries of life” could include medical and hospital treatment.166 If you sign a standing order then the responsibility for the effects of the prescription rests with you. Under this section you are required to supply a sick person in your charge with the necessaries of life. Withdrawal of care and euthanasia Section 151 of the Crimes Act places legal duties on any person “who has charge of any other person… unable to provide himself with the necessaries of life”. The Act imposes a legal duty on those who “undertake… to administer surgical or medical treatment” to have and to use reasonable knowledge.

172 Clause 23 of the NZMA Code of Ethics advises you to bear in mind always the obligation of preserving life wherever possible and justifiable. Euthanasia. In 2001 a doctor was convicted of manslaughter of his mother who was nearing the end of her life. refused to accept nourishment needed to keep her alive. Public health The Health Act 1956 is intended to improve.172 When a medical or surgical treatment is not for the patient’s benefit or where it is not “reasonable”. such as ensuring the safety of drinking water and giving certain officials the power to quarantine ships or aircraft. is illegal. Under the Tuberculosis Act 1949 you must also notify your local Medical Officer of Health of cases of tuberculosis. If the notifiable disease is infectious. while allowing death to occur with dignity and comfort when it appears to be inevitable. promote and protect the public health. treatment applied with the primary aim of relieving patient distress is ethically acceptable. It covers a range of issues. The list of diseases and infectious diseases which must be notified are set out in Schedule 1 and Schedule 2 of the Act. In such treatment situations. 192 Cole’s Medical practice in New Zealand 2011 . The local authority must also be informed in some cases. ensured that she was well informed about the consequences of her decision and documented these discussions. the provision of treatment when the primary aim is to assist a patient to die. It also outlines the statutory duties and responsibilities of Medical Officers of Health and sets out when and how doctors must notify infectious and notifiable diseases. He injected her with a cocktail of drugs in significant quantities that she might die and he also strangled her. even when it may have the secondary effect of shortening life. Section 74 states that if a doctor has a reason to believe that a patient is suffering from a notifiable disease then he or she must advise their local Medical Officer of Health.In a recent incident a severely physically disabled patient. Mrs Margaret Pope. then a patient death may result in a conviction for murder (if deliberate) or manslaughter. In this case Mrs Pope’s carers made sure that they offered her treatment every day. then the doctor must also “inform the occupier of the premises and every person nursing or in immediate attendance on the patient of the infectious nature of the disease and the precautions to be taken”.

but may withdraw at any time. If this is the woman’s first screening test or you are performing a colposcopic procedure. who has access to information on the programme’s register.175 173 Health (National Cervical Screening Programme) Amendment Act 2004. Section 16. Sterilisation and Abortion The Contraception. Part 3. prohibits some unacceptable procedures (such as sex selection of human embryos) and prohibits commercial transactions relating to human reproduction. Sterilisation and Abortion Act 1977 and section 174 of the Health Practitioners Competence Assurance Act 2003 outline the duties of doctors in respect of reproductive health services. For colposcopic procedures you must also tell the woman that she will be automatically enrolled on the programme. 174 Human Assisted Reproductive Technology Act 2004. and how that information might be used.174 The Act also establishes an information-keeping regime to allow people born from donated embryos or donated cells to find out about their genetic origins. you must also tell her about the importance of having regular screening tests. or perform a colposcopic procedure. Section 112ZB of the Act also states that you must make health information and specimens available to a screening programme evaluator. It is the Council’s wish to publish a statement to assist doctors to comply with this complex area of law. 175 Human Assisted Reproductive Technology Act 2004. the objectives of the screening programme. Contraception. but in the interim you may wish to refer directly to the legislation or seek advice from a colleague. Assisted human reproduction The Human Assisted Reproductive Technology Act 2004 regulates assisted reproductive procedures. Cole’s Medical practice in New Zealand 2011 193 . Sections 112L and 112M.Cervical screening The Health (National Cervical Screening Programme) Amendment Act 2004 established a national cervical screening programme intended to reduce the incidence and mortality of cervical cancer. Organisations that wish to perform assisted reproductive procedures or conduct research into reproduction are required to first obtain the written approval of a specially designated ethics committee. but the evaluator is bound by strict confidentiality rules to ensure that the patient’s privacy is protected. Under the Act173 you must tell a woman about the screening programme whenever you take a specimen from her for the purpose of a screening test.

176 Refer to Chapter 22 177 Code of Health and Disability Services Consumers’ Rights.Advance directives and enduring powers of attorney Advance directives and enduring powers of attorney are methods that patients can use to ensure that their treatment wishes are met. but section 18(1)(c) of the Act specifically forbids the attorney from refusing consent “to the administering… of any standard medical treatment or procedure intended to save (the patient’s) life or to prevent serious damage to that person’s health. and the validity of an advance directive under common law is currently unclear.” If you are concerned that an attorney has made a decision which is not in the patient’s interest. You should also be satisfied that the patient intended the advance directive to apply to the current situation and that they reviewed the advance directive recently. The person who holds this “enduring power of attorney” should generally be treated as the patient for most information and consent purposes. and b) that is intended to be effective only when he or she is not competent. Clause 4. even after they are no longer able to communicate those wishes to you. In some countries there is specific legislation setting out requirements that need to be followed and met before such a directive is legally valid. 194 Cole’s Medical practice in New Zealand 2011 . The Protection of Personal and Property Rights Act 1988 allows a patient formally to nominate someone else to make healthcare decisions on his or her behalf should he or she become mentally incapable. there are some steps that it would be prudent for you to take before acting in accordance with a patient’s advance directive or living will. Right 7(5) of the Code of Health and Disability Services Consumers’ Rights176 says that “every consumer may use an advance directive in accordance with the common law”. There is no equivalent legislation in New Zealand.”177 This means that a person can make an advance choice about receiving or refusing services. An advance directive is also sometimes referred to as a living will. then section 103 empowers you to ask a court to review that decision. You should ensure that the advance directive was made without undue influence and that the patient was competent and fully informed about the consequences of their decisions. The Code goes on to define an advance directive as “a written or oral directive a) by which a consumer makes a choice about a future health care procedure. Although the law is not clear.

When assessing such a driver and completing a certificate. Part 7 and Part 13.nz/resources/medical-aspects/docs/medical-aspects. 179 Land Transport Act 1998. and you believe or know that the patient is continuing to drive despite this advice.Fitness to drive motor vehicles The Land Transport Act 1998 requires you to report to the Chief Medical Adviser of the New Zealand Transport Agency when in your judgement a patient is not medically fit to drive. You do not need to seek authorisation from a child or parent before making this disclosure and section 16 provides you with protection from civil.govt. Reporting of suspected child abuse Reporting of suspected child abuse is not mandatory. Cole’s Medical practice in New Zealand 2011 195 . and their Families Act 1989 allows you to report ill treatment or neglect of children and young persons to the Police or a social worker. At some point you might be called upon to take a blood specimen for evidential purposes from a person who is suspected of an offence relating to alcohol or drug involved driving. drivers over the age of 75 and bus drivers) are required to regularly obtain a medical certificate to state that they are medically fit to drive a motor vehicle. However the Council strongly recommends that you report such cases as part of your responsibility to the child.nzta. you are required to consider the information contained in the booklet entitled Medical aspects of fitness to drive. criminal or disciplinary proceedings for doing so (although this protection does not apply if the disclosure is made in bad faith). or when an enforcement officer asks you to.179 When taking a blood sample you must be satisfied that doing so would not be prejudicial to the person’s proper care or treatment and must tell him or her (unless they are unconscious) that the blood specimen is being taken for evidential purposes. Young Persons. and you have advised the patient not to drive. Some drivers (for example.178 You can download a copy of this booklet from http://www. Sections 72 and 73. Section 15 of the Children. The Act allows you to take a blood sample without a person’s consent if they present as a result of a motor vehicle accident. 178 Land Transport (Driver Licensing) Rule 1999.pdf.

Section 46B(3).Deaths and medical certificates of causes of death The requirements for the issuing of a “Medical certificate of causes of death” are outlined in the Burial and Cremation Act 1964. For further information you should refer to the booklet A guide to certifying causes of death. or 24 hours or a longer period has passed since the death and the doctor who last attended the person during the illness has not completed a certificate.nsf/pagesns/216. In such cases you should record the condition which you believe is most likely to have initiated the train of morbid events leading to the death.181 In such situations you are required to consider the patient’s medical records and the circumstances of their death. 182 Burial and Cremation Act 1964. If you were not the last doctor to attend the patient during the illness you may only complete the certificate if you are satisfied that the death was a result of the illness and the doctor who last attended the person during the illness is unavailable.nz/moh. Often it can be a combination of a number of serious conditions that leads to the death of the person. 181 Burial and Cremation Act 1964. This Act states that a doctor attending a patient who dies as a result of an illness must sign such a certificate “immediately after the doctor learns of the death”. Marriages and Relationships Registration Office. and to examine the body before completing a certificate. Section 46B(8).nzhis. 196 Cole’s Medical practice in New Zealand 2011 .180 Urgency is often important in such situations.182 You should be as precise and specific as possible when completing a certificate of causes of death. Deaths. but is also used in the national cause of death statistics that are reported to the World Health Organisation. Section 46B(2).govt. and the doctor who last attended the person during the illness is unlikely to be able to complete a certificate within 24 hours after the death. This can be downloaded from http://www. The information you provide not only appears on the official death certificate issued by the Births. because the body cannot be released for burial or cremation until you have issued the certificate. or less than 24 hours have passed since the death. 180 Burial and Cremation Act 1964. You should pay particular attention when specifying the underlying cause of death.

Moko 183 Coroners Act 2006. dental or similar operation or procedure death occurs while a person was affected by an anaesthetic or the result of the administration of the anaesthetic death occurs while the woman was giving birth. unnatural or violent death occurs during or apparently as a result of some medical. suicide. or that appears to have been the result of the pregnancy or giving birth death occurs in certain types of institutions or custody.There are some circumstances when you should not issue a certificate. and in some situations might require you to complete a written report. or treatment facilities for mental illness or alcohol or drug addiction. including police or prison custody. The number for this service is (04) 910 4482. Cole’s Medical practice in New Zealand 2011 197 .183 If you are uncertain about your obligations in these circumstances or how to go about completing a report then you can contact a coroner directly and a 24-hour phone service has been set-up to facilitate this. The coroner might then contact you. surgical. These circumstances are outlined in section 13 of the Coroners Act 2006 and include when death appears to be without known cause. Section 40. Once you have notified the Police they will usually make some enquiries and then notify a coroner. and must instead report a death to the Police.

The Code confers legal rights on those who use health and disability services in New Zealand (consumers) and places corresponding responsibilities on providers of those services. and increase the interface with other agencies. simple.23 The role of the Health and Disability Commissioner and the Code of Rights Ron Paterson was New Zealand’s Health and Disability Commissioner from March 2000 until March 2010. The Code of Rights Complaints resolution No action Provider resolution Advocacy Mediation Investigations Relationships with other organisations Options where there is a breach of the Code Proceedings The Human Rights Review Tribunal Conclusion The Health and Disability Commissioner (the Commissioner) is an independent ombudsman set up to promote and protect the rights of consumers who use health and disability services. and efficient resolution of complaints relating to infringement of those rights. The Health and Disability Commissioner Act 1994 was amended in 2004 to address a number of problems with the complaints system. speedy. 198 Cole’s Medical practice in New Zealand 2011 . and facilitate the fair. The Commissioner enforces a Code of Health and Disability Services Consumers’ Rights (the Code). which came into effect in September 2004. give the Commissioner greater flexibility to resolve complaints. streamline complaints mechanisms. The amendments.

including benefits. No one should discriminate against consumers. and any other relevant circumstances. hospitals. paid and unpaid services. and costs. nurses. This may require the services of an interpreter. 5. independent lives. Consumers should have any treatment explained to them. risks. Consumers should always be treated with respect. alternatives. 6. 4. and individuals. and dentists. and comply with the duties” in the Code. In summary. It is a defence for a provider to show that he or she took “reasonable actions in the circumstances to give effect to the rights. and are free to change their mind. the provider’s resource constraints. Consumers should be treated with reasonable care and skill and receive well coordinated services. 2. such as doctors. and the Code does not extend to funding decisions or confer entitlement to any particular service. The Code covers all registered health professionals. and even people who care for family members with a disability. or take advantage of them. The rights set out in the Code are not comprehensive. The Commissioner can consider systems issues as well as individual actions. and have any questions answered honestly. Nor are the rights absolute. Cole’s Medical practice in New Zealand 2011 199 . pressure them into anything. “The circumstances” are defined to include the consumer’s clinical circumstances. the right to patient confidentiality is affirmed in separate privacy legislation (see chapter 11 on medical records). and in addition brings a level of accountability to other providers such as naturopaths. 1. 7. Application of the Code is very wide and includes public and private services. Services should help consumers to live dignified. caregivers. 8. Service providers should listen to consumers and give them information in a way they can understand and that makes them comfortable to ask questions if they don’t understand.The Code of Rights The Code became law on 1 July 1996 as a regulation under the Health and Disability Commissioner Act 1994 (the HDC Act). Consumers can have a support person with them at most times. The Code does not override duties or obligations established in other legislation. 3. For example. Consumers can make their own decisions about treatment. there are ten rights.

184 and should make it available to patients. Medical Law in New Zealand (2006). a family member. or 184 For fuller analysis.). chapter 2 in Skegg and Paterson (eds. or even another provider) may complain to the Commissioner alleging that any action of a provider is or appears to be in breach of the Code. Complaints resolution Any person (the consumer.). The HDC Act supports resolution of complaints at the lowest appropriate level. All these rights apply if consumers are asked to take part in research or teaching. This may occur where. A full copy can be obtained from the Commissioner’s website (www. and the Medical Council must refer all patient care complaints about doctors to the Commissioner. is appropriate. for example the length of time that has elapsed between the incident and the making of the complaint is such that an investigation is no longer practicable or desirable the subject matter of the complaint is trivial the complaint is frivolous or vexatious the consumer does not want action to be taken there is an adequate remedy which it would be reasonable for the complainant to exercise. 10. Consumers have a right to make a complaint and have it taken seriously.hdc.9.org. 185 For fuller analysis. if any. see “The Code of Patients’ Rights”. No action The Commissioner may. All doctors should be familiar with the Code. see “Assessment and Investigation of Complaints”. decide to take no action on a complaint if he or she considers that any action is unnecessary or inappropriate.nz) or by phoning 0800 11 22 33. at his or her discretion.185 On receipt of a complaint. chapter 22 in Skegg and Paterson (eds. The Commissioner is responsible for ensuring that each complaint about health care and disability services providers is dealt with appropriately. the Commissioner is required to make a preliminary assessment of the complaint to decide what course of action. Complaints made to an advocate that remain unresolved after advocacy assistance must be referred to the Commissioner. Medical Law in New Zealand (2006). 200 Cole’s Medical practice in New Zealand 2011 .

providing her with a copy of the Action Plan and explaining some of the specific initiatives being developed in the Emergency Department. a number of the recommended changes had been implemented and the majority were in process. Following its completion she contacted the Commissioner. and sepsis secondary to cellulitis/gangrene of her right leg. and the dates for completion. On arrival. which clearly set out the recommendations and changes needed. The Action Plan showed that seven months after completion of the review. and an HDC investigation is unlikely to shed further light on the matter. indicating that she needed to be seen by a doctor within 30 minutes.10am with a history of right leg pain and a fall at her home that morning. and any recommendations of the review have been implemented. She was admitted to the Intensive Care Unit and managed for multi-organ failure until a decision was made to withdraw treatment nine days later. arrived at a public hospital Emergency Department by ambulance at 10.the matter has been fully investigated and reviewed. Following Mrs A’s death. On receipt of Ms B’s enquiry. Mrs A’s daughter. The review was headed by a senior nursing consultant and an emergency medicine consultant from separate District Health Boards. These included an electronic patient management system and structural changes to the layout of the department. was involved in the external review. The District Health Board responded promptly and in detail. how the changes would take place. Mrs A was not reviewed by a doctor until 4pm that afternoon. the District Health Board commissioned an external review to determine whether the care and treatment provided to her in the Emergency Department met an acceptable standard. According to the records. The Commissioner wrote to Ms B. and made a number of recommendations designed to improve the systems and processes in the Emergency Department. Case study Mrs A. Ms B. confusion. who was responsible for them. renal failure. providing an “Action Plan”. the Commissioner wrote to the District Health Board requesting specific advice on the actions it had taken to give effect to the recommendations. on examination Mrs A had hypotension. an insulin dependent diabetic who also had low grade non Hodgkin’s lymphoma. concerned whether the recommended changes had been implemented. Mrs A was immediately triaged and allocated a triage code 3. The review concluded that the care and treatment provided to Mrs A did not meet an acceptable standard. Ms B advised the Commissioner that she was very happy with the outcome and hoped that Cole’s Medical practice in New Zealand 2011 201 .

The Commissioner’s file was closed without need for any further action. 202 Cole’s Medical practice in New Zealand 2011 . The Commissioner may refer a complaint to the provider for resolution if the complaint does not raise public safety issues and can be appropriately resolved by the provider. and the willingness of the District Health Board to implement the recommendations. Due to the quality of the external review. and independent oversight is maintained. The patient complained of her “year of hell”. The Commissioner may take further action if not satisfied with the reported outcome. met with the patient. This complaint would have been difficult and lengthy to investigate. looked into it. and sets out minimum requirements for keeping consumers informed about the progress of their complaint. This enables the Commissioner to review the outcome of referrals to ensure the matter is adequately resolved. All referrals to a provider are accompanied by reporting requirements back to the Commissioner. and with Ms C’s agreement. all within one District Health Board. and the outcome would probably not have been so positive. a potentially serious complaint was resolved without formal investigation. the District Health Board took over the complaint. After discussion with the District Health Board’s chief executive officer. In some cases.the situation that had contributed to her mother’s death would be unlikely to occur again. Consumers are entitled to the assistance of a support person or an independent advocate when making a complaint. The Code requires that providers have a complaints procedure. Provider resolution Often the quickest and most satisfactory way of dealing with grievances is for the consumer to deal directly with the provider. any compliance issues are addressed. She acknowledged that taken in isolation the matters she complained of could appear trivial. but in total they had had a serious effect on her health. the provider may not have been aware of the complaint and may be well motivated to resolve the complaint directly with the consumer. Case study The Commissioner received a complaint relating to Ms C’s care over a year or more by providers from many disciplines. and achieved a speedy resolution which satisfied Ms C. She reported the positive outcome to the Commissioner before the District Health Board had reported back.

but she agreed to do so. They assist consumers to resolve complaints at an early stage and encourage self advocacy as well as providing more support as needed. Mrs D decided to seek a second Cole’s Medical practice in New Zealand 2011 203 . Advocates do not make decisions on whether there has been a breach of the Code.nz. Rather. Case study Mrs D was provided with verbal and written information about advocacy and the Code after relaying the following information: on a number of occasions she and her doctor had discussed the probability that she would need to start an antihypertensive. The advocacy service can be contacted by freephone on 0800 555 050. The majority of complaints referred to advocacy are successfully resolved. Advocates must refer any unresolved complaints to the Commissioner and may also report on any matter concerning the rights of consumers that they consider should be brought to the Commissioner’s attention. yet again. their role is to give consumers information about their rights. who advised that it is not the pharmacy’s normal practice to provide such information about the medication. to be high.org. The nationwide health and disability service is provided by an independent national advocacy trust through a contractual arrangement with the Director of Advocacy. free fax on 0800 2787 7678 or at advocacy@hdc. They again discussed her reluctance to commence the treatment. At a consultation her blood pressure was noted. Most complaints that advocates handle are received directly rather than via the Commissioner. often by face to face meetings with providers. providing free education sessions to consumers and providers. Mrs D was told the name of the medication being prescribed and she asked about possible side effects. Mrs D then requested the same information from the dispensing pharmacist. and the doctor advised that it was now time to start the treatment. Advocates promote awareness of the Code and HDC Act.Advocacy Free independent advocacy services are available throughout New Zealand. As a result of her concerns and discussions with the advocate. Mrs D was very disturbed about not being able to get the information and contacted the local advocate to reaffirm her rights. and to support them to make decisions and take action to attempt to resolve the complaint. The doctor told her she would know if she experienced any and she should return if she did. but in some cases the Commissioner may decide that a complaint made to his office should be referred to an advocate to enable the parties to resolve the matter.

Four days later he deteriorated markedly. Within the hour her doctor had telephoned her. this is not necessary. He was reassessed and discharged home with pain relief and treatment for a urinary tract infection. All statements made during mediation are confidential. Although the parties may have a lawyer present. However. She reported back to the advocate that the meeting had gone well and she had received the information she required. increased abdominal and back pain. his main complaint was abdominal and back pain. explore options for resolution of the complaint. and asked to meet with her later the same day.opinion from a specialist. the Commissioner will decide what (if any) further action to take. Case study Mr E was admitted to a hospital Emergency Department after injuring himself in a car accident that morning. Mr E continued to complain of intermittent back pain. The parties meet across the table. with or without support persons. a further Xray and CT imaging taken a few days later indicated a fractured spine. The doctor apologised for the distress caused and assured her that he would support her in obtaining a second opinion. and find their own solutions to the dispute. but Mrs D felt able to proceed alone. Mediation is often a very effective way of resolving complaints. Mr E’s condition deteriorated and he was readmitted to the Emergency Department at 10pm with pain in the kidney region and symptoms of shock. An impartial mediator assists the parties to define the issues in dispute. 204 Cole’s Medical practice in New Zealand 2011 . but another Xray showed no fracture. If a complaint is not resolved by mediation. having recognised her distress. He was admitted to Intensive Care and received treatment for a contusion of the small bowel. Mrs D’s advocate offered to support her. Mr E experienced increasing heaviness in his legs and subsequently developed paraplegia. and weakening of his legs. On assessment. and if a deed of settlement is signed it is a full and final settlement of the issue. with disorientation. to discuss their concerns. Xrays of his back and neck showed no fractures. Mediation The Commissioner may call a mediation conference at any stage. and contacted her GP’s nurse to organise a referral letter. and provides an opportunity for the parties to agree to a fair outcome with minimum delay and cost. and he was discharged around 5pm.

Providers are informed of the investigation. the matter was considered appropriate for mediation. such as the Medical Council. and that the knowledge would be applied for the benefit of all patients. are not appropriate for low level resolution and proceed to a formal investigation. and asked to respond to the complaint within 15 working days. such as those involving allegations of serious professional misconduct. In its letter of apology. the care Mr E received was satisfactory. The Commissioner commenced an investigation and. The family and the District Health Board were provided with a copy of the expert advice prior to the mediation conference. compassionate care. complex systems issues. The advisor stated that this was an exceptionally complex case. the Board commented that the mediation was a learning experience for all involved. Mr E’s fracture was not displaced at the time of initial Xray investigation and was therefore hidden from view. As Mr E’s family was M ori. are notified of any investigation. sexual impropriety. Cole’s Medical practice in New Zealand 2011 205 . the Commissioner engaged a M ori mediator with knowledge of cultural issues. The Commissioner may commence an investigation in response to a complaint or on the Commissioner’s own initiative. This included a written apology by the Board to Mr E and his wh nau. The investigation process is independent and impartial. nursing care. to guide them in their discussions. which left Mr E paralysed.This serious complaint concerned the standard of care Mr E received at the hospital. The complaint also concerned pain management. or public safety issues. as well as the instigation of a process to restore his mana. given a copy of the letter of complaint. and enables the Commissioner to form an opinion whether there has been a breach of the Code. overall. referred the matter for expert orthopaedic advice. Investigations Some complaints. and the unresolved communication concerns. after reviewing the hospital’s response. The mediation conference resulted in a successful outcome. and communication. Registration authorities. and that Mr E had received good management and well documented. The provider’s response is very important as it helps the Commissioner to decide whether to refer the matter to advocacy or mediation. The primary issue was the failure of hospital medical staff to diagnose the fracture. In light of the expert clinical advice. The advisor considered that.

Relationships with other organisations Complaints may be referred to other agencies or persons involved in the health and disability sector. a complaint of a breach of patient confidentiality will be referred to the Privacy Commissioner. or to the complainant (if there is a provisional finding of no breach of the Code). and sometimes seeks further expert advice. The Commissioner also has a duty to report any public safety issues to the appropriate body or person. The Commissioner is required to cooperate and share information with a number of other agencies and persons. so that relevant information can be analysed and acted upon to identify public safety concerns. and concerns about inappropriate prescribing may be referred to Medsafe. the Commissioner may contact ACC if it appears that the consumer may be entitled to compensation. before issuing a final report. and so that duplication can be minimised. The Commissioner has wide discretion to refer a matter to an appropriate person or authority. A simple investigation usually takes six to twelve months. and the advisers are named in the Commissioner’s report. or to give false or misleading information. For example. and to require the production of relevant documents. 206 Cole’s Medical practice in New Zealand 2011 . It is an offence to obstruct or hinder the Commissioner or any other person in the exercise of their powers under the HDC Act. These reports are usually published in an anonymised form on the HDC website. expert independent clinical advice is obtained to assist the Commissioner to form an opinion. Most investigations end in a written report from the Commissioner to the parties. nominate expert advisers. a complex investigation may take twelve to eighteen months. The Commissioner considers responses to the provisional report. the Commissioner sends a provisional report to the provider (if it contains adverse comment about the provider). such as the Royal New Zealand College of General Practitioners. This includes the ability to summon witnesses. and a complaint of discrimination will usually be referred to the Human Rights Commission.Where the appropriate standard of care is in issue. For example. Before forming a final opinion. Working with other agencies is an important part of promoting and protecting the rights of consumers. The HDC Act gives the Commissioner wide powers to gather relevant information. to take evidence under oath. Relevant professional groups.

but occasionally may recommend that a provider refund money paid for substandard services.hdc.org. Mrs A. It had been agreed between Mrs A. the anaesthetist arranged to transfer Mrs A from theatre to a busy orthopaedic ward. The Commissioner uses individual complaints to promote wider systemic improvements. The Commissioner is empowered to name individual providers publicly. or implement appropriate systems to prevent a recurrence. and HDU staff were unaware of the intention to transfer Mrs A to HDU postoperatively. Usually. and her surgeon prior to surgery that the operation would take place in the local public hospital rather than a private hospital. who had significant comorbidities. As no HDU bed was available. the Commissioner’s final report makes some recommendations. and a bed was not available in the appropriate surgical ward. the Commissioner investigated complaints involving deficiencies in the coordination of care (including handover) and supervision. Copies of the report may also be sent to the Minister of Health. following the operation. Mrs A was also nursed in a standard-sized hospital bed. Case study A man complained about the care his 55-year-old wife. funders. The anaesthetist failed to inform the surgeon (who was shocked to find out after Mrs A’s death that this had occurred). review his or her practice in the light of the Commissioner’s report. the Medical Council may be asked to consider the need for a performance assessment. it was found that no HDU bed had been booked. or any other appropriate agency. However. For example. the Commissioner may recommend that the provider offer the consumer a written apology.Options where there is a breach of the Code Where an investigation reveals a breach of the Code. In the cases below. The Commissioner’s opinion is reported to the relevant registration authority and. in the case of a doctor. undertake further education. The Commissioner cannot order compensation. where the provider poses a risk of harm to the public). the Commissioner has a number of options. received following surgery for breast cancer in a public hospital.nz) in an anonymised form. and will do so in exceptional circumstances (eg. which Cole’s Medical practice in New Zealand 2011 207 . because she required a high dependency unit (HDU) bed. Reports with significant educational value are distributed to the appropriate colleges and posted on the Commissioner’s website (www.

and clinical staff did not properly coordinate their care. 208 Cole’s Medical practice in New Zealand 2011 . Case study The Commissioner was alerted to concern about failed tubal ligation procedures undertaken by Dr Roman Hasil in 2005-06.hdc. Dr A was responsible for Dr Hasil’s regulatory and clinical supervision when he was the Clinical Director and Head of Department. A larger bed had not been arranged as a result of poor communication. This case highlights the importance of the cooperation of a large team of clinical and non-clinical staff in the management of a patient in hospital.186 In light of these events. the Board extensively reviewed and made changes to various hospital systems and staff guidelines.org. One aspect of the inquiry involved determining whether Dr A’s supervision of Dr Hasil was adequate. but did not document the instructions.nz. Mrs A’s postoperative care was jeopardised because monitoring equipment was unsuitable or was not functioning. given her special needs. 4(2) and 4(5) of the Code. The Commissioner found that the District Health Board breached Rights 4(1). supplemental oxygen and regular observations”). from first assessment until discharge from hospital. www. 186 See Opinion 06HDC19538 (Health and Disability Commissioner. and the ward was inadequately staffed to provide Mrs A with appropriate care. A hospital must have adequate systems in place to ensure that a patient’s care is assessed. and the steps taken by Whanganui DHB to ensure that Dr Hasil was competent to practise. planned and delivered appropriately. The only guidance given to nursing staff was to perform half-hourly clinical observations until Mrs A was “stable”. 12 March 2008). The Commissioner initiated an inquiry into the standard of care provided by Dr Hasil at Wanganui Hospital. Mrs A died the evening after surgery. The anaesthetist said he gave “clear instructions” to nurses for Mrs A’s care on the ward (“the need for pulse oximetry monitoring. The numerous failings in the care provided to Mrs A were caused by poor planning of a scheduled operation for a patient with significant risk factors. The team is responsible for ensuring that the care provided to a patient is of an appropriate standard.was unsuitable given her size. The Commissioner found that Mrs A did not receive postoperative care of an appropriate standard.

188 Health Practitioners Competence Assurance Act 2003.187 Regulatory supervision is supervision provided at the request of the Medical Council for doctors who are provisionally registered. 190. “Supervisory Responsibility of Specialists” (2002) 10 Journal of Law and Medicine 187. Dr Hasil’s CV indicated that he had more than 20 years’ experience in obstetrics and gynaecology and he had been working in a comparable health system for a number of years. a senior doctor of a registrar or medical officer. then less over time.188 Clinical supervision is the more familiar type of supervision in medicine where a more senior doctor supervises a more junior doctor within a clinical team (eg. a registrar of a house surgeon).189 A basic principle of clinical supervision is that the supervisor may delegate care to the supervisee where he or she has good reason to believe that they are competent to carry out the delegated tasks. A critical issue in cases involving clinical supervision is whether the supervisor acted reasonably in relying on the supervisee acting in the role assigned. This duty is recognised at common law. such as international medical graduates newly registered in New Zealand. Dr A should have increased the frequency and regularity of his meetings with Dr Hasil. This contact was largely limited to informal discussions rather than formal meetings or routine peer review. Dr A took appropriate steps to familiarise himself with Dr Hasil’s practice. frequently at first. It was only when Dr A took over the review of a number of Dr Hasil’s patients (during his leave) 14 months later that he realised the extent of Dr Hasil’s deficiencies. At the outset.A supervisor has a duty to provide supervision with reasonable care and skill and in accordance with professional standards. Cole’s Medical practice in New Zealand 2011 209 . under Dr A’s supervision. 189 R Paterson and M van Wyk. In deciding this issue. Dr A had significant concerns about the safety of Dr Hasil’s practice. 187 McKenzie v Medical Practitioners Disciplinary Tribunal [2004] NZAR 47 (HC). section 23. to assist the specialists. Dr A directly observed Dr Hasil for a few weeks and considered that he was competent to provide obstetric and gynaecology services independently. paras 24– 25. Dr A conceded that with hindsight his supervision was not adequate and failed to promptly identify the extent of Dr Hasil’s shortcomings. The Medical Council may require that the supervisor assess and report on the performance of the supervised doctor. Dr Hasil was employed as a medical officer. several factors are considered. including the supervisee’s experience and the supervisor’s knowledge of their skills and experience. Dr A met with Dr Hasil on an “ad hoc” basis to discuss his clinical practice. which he reported to the DHB.

The Director of Proceedings may take proceedings before the Human Rights Review Tribunal and/or the Health Practitioners Disciplinary Tribunal. he should have alerted management and the Medical Council that he could not fulfill his supervisory responsibilities.nz/publications/other-reports.hdc. An aggrieved person may bring proceedings before the Human Rights Review Tribunal where the Commissioner.and routinely reviewed cases with him to be satisfied that he was practising safely. was aware of concerns about Dr Hasil. but did not consider that he was unsafe. decides not to refer the matter to the Director of Proceedings. or where the Director of Proceedings decides not to take proceedings. Dr A took reasonable actions to supervise Dr Hasil. including a declaration that the provider’s action is in breach of the Code an order restraining the provider from continuing or repeating the breach 190 See Whanganui Inquiry Report (Health and Disability Commissioner. or may decide to take no further action. but given what he knew at the time. having found a breach of the Code. the Commissioner must give the provider an opportunity to comment on the proposed referral. to decide whether legal proceedings will be issued against the providers concerned. the Commissioner may refer a matter to the independent Director of Proceedings. the Tribunal has the power to award a number of remedies. that was an error of judgement. The functions of the Health Practitioners Disciplinary Tribunal are outlined in chapter 24. Proceedings Following a finding of a breach of the Code. Dr A followed up concerns with Dr Hasil and remained satisfied that he was performing to an acceptable standard.org.190 This case demonstrates that effective clinical supervision is critical for safe health care. February 2008). 210 Cole’s Medical practice in New Zealand 2011 . If this was not feasible. A system based on delegation without supervision and responsibility will not work to the benefit of the patients and the community. http://www. The Commissioner must also have regard to the wishes of the consumer and complainant and the public interest (including any public health or safety issues). In hindsight. Before referring a matter. The Commissioner concluded that Dr A. The Human Rights Review Tribunal Where proceedings are brought before the Human Rights Review Tribunal.

an order that the provider perform any specified acts with a view to redressing any loss or damage suffered by the consumer as a result of the breach damages of up to $200. and any other relief the Tribunal thinks fit. While the Tribunal has found two doctors to have breached the Code.000 (including damages awarded in respect of loss suffered. no award of damages has been made. loss of dignity. Conclusion The Commissioner promotes resolution of individual complaints and systemic improvements in health care. injury to the feelings of the consumer. Rehabilitation. and any action that was in flagrant disregard of the consumer’s rights). The Commissioner’s focus is on resolution. and Compensation Act 2001. Cole’s Medical practice in New Zealand 2011 211 . expenses reasonably incurred. no damages other than punitive damages (where the provider’s action was in flagrant disregard of the consumer’s rights) may be awarded. humiliation. However. an important limitation is that where a person has suffered personal injury covered by the Injury Prevention. protection and learning.

Professional Conduct Committees Membership Process Recommendations and determinations Health Practitioners Disciplinary Tribunal Function Membership Procedures Charges Interim suspension Public hearings Procedures Findings Who sets the standard? Penalties Appeals Part 4 of the Health Practitioners Competence Assurance Act 2003 (the Act) sets out the complaints procedures which apply to doctors and establishes the Health Practitioners Disciplinary Tribunal (the Tribunal) which hears and determines disciplinary charges brought against doctors (and other health professionals).24 Discipline: the Professional Conduct Committee and the Health Practitioners Disciplinary Tribunal Jo Hughson is a Wellington barrister with experience in professional disciplinary proceedings and medicolegal matters. to protect the public and the profession from persons who 212 Cole’s Medical practice in New Zealand 2011 . Kristy McDonald QC is a Wellington barrister with extensive experience in professional disciplinary and medicolegal matters. One of the principal purposes of the complaints and disciplinary process is public protection.

A charge brought by the Director of Proceedings goes directly to the Tribunal and bypasses the PCC process.are unfit to practise. one of the doctors on the PCC practises in the same vocational scope of medicine or a similar vocational scope as that in which the doctor being investigated practises. if while a matter is under consideration by a PCC. the Council thinks a further matter concerning that doctor should form part of the PCC’s consideration. In addition. then it may refer those questions to a PCC. This ensures there is an appropriate mix of general medical knowledge and specialised knowledge on the committee. One member coordinates the investigation process and presides at PCC meetings. The Medical Council must refer all complaints it receives to the Commissioner. The Commissioner has the power to refer complaints back to the Medical Council and if a complaint is referred back then the Council must promptly assess the complaint. it may refer the further matter to the committee. The Medical Council may decide to refer the matter to a Professional Conduct Committee (PCC) for investigation. if the Medical Council considers information in its possession raises questions about the conduct or the safety of a doctor’s practice. Professional Conduct Committees PCCs deal with complaints referred from the Commissioner and with referrals after convictions in a court of law. Further. Another purpose is to enable the profession to ensure the conduct of its members conforms to the standards generally expected of them. general practice). Both the doctor and the complainant are advised of the intended composition of a PCC and have an opportunity to request changes in membership. Two are doctors and one is a lay person. The Commissioner must notify the Medical Council of any investigation under the HDC Act that directly involves a doctor and the Medical Council may take no action while the matter is under investigation by the Commissioner. where possible. Complaints about doctors may be made to the Medical Council or the Health and Disability Commissioner (the Commissioner). and consider what action should be taken in response. Membership PCCs comprise three members appointed by the Medical Council. Cole’s Medical practice in New Zealand 2011 213 . The other doctor is usually selected from a more general area (for example. Usually. This member is usually known as the Convenor.

000. The PCC has the power to call for information or documents from any person and in the event of refusal or failure without reasonable excuse to comply with a request for information (or knowingly or recklessly providing false or misleading information). Process The PCC may investigate however it sees fit. Care is taken to ensure the parties are informed about the progress of the investigation and that the investigation is carried out fairly and in accordance with natural justice principles. 214 Cole’s Medical practice in New Zealand 2011 . information or matter that in its opinion. In respect of patients. consent is normally obtained in writing before the PCC obtains medical records. any person in association with whom the doctor practises. neither the legal assessor nor the investigator may be present during any deliberations of the PCC. the doctor’s employer. friend or counsellor) to a PCC meeting. The PCC has wide powers to receive evidence and may receive any statement. It is also entitled to appoint an investigator to collect information and to investigate complaints. and evidence. family or whanau member. procedure. The PCC may hear oral evidence and receive written statements and submissions from any or all of the following persons: the doctor. However. The PCC must give the doctor who is under investigation a reasonable opportunity to present evidence about each matter that is the subject of the PCC’s investigation. that person is liable to a fine not exceeding $10. The PCC usually appoints a legal assessor to advise it on matters of law. The PCC usually gives the complainant and the doctor an opportunity to meet with the Committee in person. may assist it to deal effectively with its investigation (even if the evidence would not be admissible in a court of law). This is important particularly if the complainant is disabled or if the complaint concerns sensitive issues like sexual impropriety. Recommendations and determinations The PCC’s role is to determine whether the issues it has investigated are matters of competence or discipline and then to recommend and/or determine an appropriate course of action.If there are multiple complainants involving one doctor the same PCC generally deals with all the complaints. the complainant and any clinical experts. Complainants may bring a support person (patient advocate. document.

If the PCC decides the complaint or conviction should be considered by the Tribunal it must frame an appropriate charge and lay it before the Tribunal in writing. If the complaint has not been successfully resolved by agreement. the complainant). and/or refer the subject matter of the investigation to the Police. and/or review the doctor’s fitness to practise medicine. the PCC must promptly decide whether it should lay a charge against the doctor before the Tribunal. or whether to make any recommendations to the Medical Council about the doctor. or a complaint should be submitted to conciliation. It is not the responsibility of the PCC to reach a view on the guilt of the practitioner if the matter is considered to be a disciplinary matter. The PCC must make its recommendations and/or determination within 14 days after the completion of its investigation. or whether no further steps should be taken in relation to the complaint. and the reasons on which they are based. the chairperson of the Tribunal is required to convene a hearing of the Tribunal to consider the charge as soon as reasonably practicable. The Medical Council must “promptly” consider any recommendations. Cole’s Medical practice in New Zealand 2011 215 . and/or review the doctor’s scope of practice. and the doctor concerned (and in the case of a complaint. a disciplinary charge should be brought against the doctor before the Tribunal. and/or counsel the doctor. Written notice of any recommendations and/or determination. Health Practitioners Disciplinary Tribunal Function The Tribunal’s principal function is to hear and determine charges brought against doctors (and other health professionals) by the Director of Proceedings or by a PCC. it must appoint an independent conciliator to help those concerned to resolve the complaint by agreement. The PCC may also make one of the following “determinations”: that no further steps be taken in relation to the complaint or conviction. If the PCC determines the complaint should be the subject of conciliation.The PCC may recommend the Medical Council should assess the doctor’s performance. If the PCC determines to lay a disciplinary charge then the Tribunal will determine the outcome and whether or not the established conduct is professional misconduct. must be given to the Registrar of the Medical Council. Where a charge is laid against a doctor before the Tribunal.

Procedures The Tribunal controls its own procedures in accordance with the Act. In most cases the hearing dates are rescheduled once the availability of the parties and their counsel has been ascertained at a Directions Conference. doctors). and on the Medical Council. For each hearing the Tribunal must comprise a legal chair and four other persons selected by the chair or deputy from the panel. one or more legal deputies and a panel of doctors and laypersons. or acting in contempt are offences punishable by fine. A provisional hearing date is set between 20 and 60 working days from the date of the notice. The Tribunal does not have to give notice to the doctor that it intends to make such an order but it must advise the doctor of the order once it has been made. Public hearings Although the Tribunal has the power to restrict publication and hold hearings in private. three of whom must be professional peers of the doctor (ie. The panel is maintained by the Minister of Health. to suspend the doctor or impose conditions on his or her practice if the Tribunal is satisfied it is necessary or desirable to protect the health or safety of the public. and has wide powers to summon witnesses and records. On occasions hearings are adjourned. Doctors can be heard personally or they may be (and usually are) represented by a lawyer. One member must be a lay person. The Tribunal must also serve a copy of the order on the doctor’s employer. Any application for revocation has to be heard within 10 working days after it is received by the Tribunal. the emphasis is on public hearings.Membership The Tribunal has a legal chairperson. Charges The Tribunal must notify the doctor in writing of the charge and provide enough particulars to inform the doctor clearly of the substance of the allegations against him/her. Refusing to attend or to cooperate. The Tribunal can make various 216 Cole’s Medical practice in New Zealand 2011 . Once a doctor has been notified of a charge they must advise the Tribunal within 10 working days whether or not they wish to be heard by the Tribunal. the reasons for it. and their right to apply for variation or revocation of the order. Interim suspension The Tribunal has the power pending the hearing of a charge.

Witnesses are given special protection if their evidence relates to a sexual matter.orders restricting the public nature of the hearing including ordering that the whole or part of the hearing be heard in private and suppressing the publication of the name or particulars of any person. whether or not it would be admissible as evidence in a court of law. including the doctor. The Tribunal may restrict publication of any evidence relating to the sexual acts. The Tribunal may receive as evidence any statement. 7/Med04/03P). Witnesses usually read out their evidence from a written statement. if the complainant is 16 years or older and applies to the Tribunal for an order and the Tribunal is satisfied the complainant understands the nature and effect of the application the Tribunal must make an order. or relates to another matter that may require the witness to give intimate or distressing evidence. In sexual cases no person may publish the name of the complainant or any particulars likely to lead to the complainant’s identification. Applications for name suppression are usually supported by affidavit evidence of the reasons why an order is sought and the Tribunal is required to balance the respective interests of the doctor. unless the complainant is 16 years or older and the Tribunal makes an order permitting the publication. if necessary (Tribunal Decision No. Procedures The Tribunal can regulate its own procedures. or matter that may help it deal effectively with the matters before it. They are then cross examined by opposing legal counsel and questioned by members of the Tribunal. information. any person the witness chooses. The hearings are either heard in the Tribunal’s hearing rooms in Wellington or in the closest major centre to the events in suitable conference venues where there are facilities for hearing and waiting rooms. Only certain people may be present during evidence of this nature including a journalist. Each party must be given a fair opportunity to put their evidence and call relevant witnesses. The witness may object to the presence of a person of the doctor’s choice. If the Tribunal makes a privacy order any person can apply for it to be revoked. Cole’s Medical practice in New Zealand 2011 217 . including representatives of the media. Applications for private hearings are rarely granted. and any person the doctor chooses. The evidence is recorded by a stenographer. However. The Tribunal has the power to order that a witness be permitted to give their evidence from behind a screen. however the procedures must accord with the rules of natural justice. the complainant and the public interest before exercising its discretion. document.

The first step involves an objective assessment of whether the doctor’s acts or omissions in relation to their practice can reasonably be regarded as constituting malpractice or negligence. The Tribunal has to be satisfied to the civil standard of proof (“on the balance of probabilities” rather than “beyond reasonable doubt”) that a doctor is guilty of the charge. Medicines.The prosecution has the burden of proving the charge. or Has been convicted of an offence that reflects adversely on his or her fitness to practise (convictions for offences against relevant health acts including Contraception. the Injury Prevention. or Has failed to observe any conditions included in his or her scope of practice. or Has performed a health service without being permitted to perform that service by his or her scope of practice. and Misuse of Drugs. It must prove the doctor’s guilt. The civil standard of proof is applied flexibly depending on the seriousness of the allegations (Z v Dental CAC ([2008] NZSC 55). The charge of professional misconduct has been part of New Zealand’s medical disciplinary regime for many years. Sterilisation and Abortion. or Has breached a penalty order of the Tribunal. or otherwise meets the standard of having brought or was likely to bring discredit to the profession. Findings The Tribunal may find that the doctor Has been guilty of professional misconduct because of an act or omission that amounted to malpractice or negligence in relation to the doctor’s registered scope of practice when the conduct occurred. A two step process is involved in testing what constitutes professional misconduct under the Act. Coroners. or Has been guilty of professional misconduct because of an act or omission that has brought or was likely to bring discredit to the medical profession. or Has practised his or her profession while not holding a current practising certificate. The second step (often referred to as “threshold”) involves the Tribunal being satisfied the doctor’s acts or omissions require a disciplinary sanction for the purposes of protecting the public or maintaining professional standards or punishing 218 Cole’s Medical practice in New Zealand 2011 . or for an offence punishable by a term of three months imprisonment or longer). Rehabilitation and Compensation.

11/96. Who sets the standard? Whether or not there has been a breach of the appropriate standards is generally measured against the standards of a responsible body of the doctor’s peers (Maynard v West Midlands Regional Health Authority [1985] 1 All ER 635). The Tribunal’s deliberations now rely on both public as well as professional opinion. could reasonably conclude that the reputation and good standing of the profession was lowered by the behaviour of the doctor concerned. The Tribunal posts its decision on its website (www. It… is an objective test judged by the standards of the profession: Ongley v Medical Council of New Zealand [1984] 4 NZAR.org. The test recognises that not all acts or omissions which constitute a failure to adhere to the standards expected of a medical practitioner will constitute professional misconduct. Elias J).nz). Auckland. Negligence generally involves breach of a doctor’s duty in their professional setting.” However. illegal or unethical conduct or neglect of professional duty (improper professional conduct). Malpractice involves immoral. and it is that mix of opinion which sets the standard. when assessing a doctor’s conduct the Tribunal cannot lose sight of the fact that the Tribunal’s role is partly one of setting standards (including the expectation that professional standards should not be permitted to lag) and that in some cases patient interests and community expectations may require the Tribunal to be critical of the usual standards of the profession (B v The Medical Council of New Zealand (Unreported. Bringing discredit to the profession involves bringing harm to the reputation of the profession and involves an objective assessment of whether reasonable members of the public.hpdt. M 2390/91. The Tribunal usually issues a fully reasoned written decision once it has determined the charge.” (p16). 369.the doctor (that is. In Tizard v Medical Council of New Zealand (Full Court. Cole’s Medical practice in New Zealand 2011 219 . 374. 10 December 1992) the Full Court stated: “ ‘Professional misconduct’ is behaviour in a professional capacity which would reasonably be regarded by a practitioner’s colleagues as constituting unprofessional conduct. that the conduct was sufficiently serious to justify the imposition of a sanction). informed and with knowledge of all the factual circumstances. High Court.

Auckland. to attend a course of treatment or therapy for alcohol or drug abuse (the doctor must consent to these). Before determining to cancel a doctor’s registration the Tribunal must consider the alternatives available to it short of doing that. and when reconsidering.000. the penalties imposed by the Tribunal stay in force pending the outcome of an appeal.Penalties The penalties available to the Tribunal if a doctor is found guilty are cancellation of the doctor’s registration. After cancelling the doctor’s registration. the PCC (for its investigation and the prosecution) the Tribunal (hearing costs). and any other condition designed to address the matter that gave rise to the cancellation of the doctor’s registration. a condition requiring the doctor to undertake a specified course of education or training. CIV 2007-404-1818 Lang J. the High Court may direct the Tribunal to reconsider the whole or any part of its decision or order. which may be appealed to the Court of Appeal. The Tribunal cannot impose a fine in dealing with an offence for which the doctor has been convicted by a court. There is no power to order costs to be paid to a doctor acquitted of a charge. 220 Cole’s Medical practice in New Zealand 2011 . the imposition of conditions on practice for up to three years. including the Commissioner. If the Tribunal decides to order that the doctor’s registration be cancelled it must explain why the lesser options have not been adopted in the circumstances of the case (Patel v PCC (High Court. suspension of the doctor for up to three years. the Tribunal must take the Court’s reasons into account and give effect to the Court’s directions. censure. The conditions may include any or all of the following. In all other cases the full range of penalties (including cancellation of registration) is available. Appeals Appeals must be filed within 20 working days from the date of the Tribunal’s decision. Instead of determining an appeal. a fine of up to $30. 13 August 2007). whose decision is final on all matters except points of law. counselling or therapy. Unless a Court orders otherwise. the Tribunal may impose one or more conditions which the doctor must satisfy before applying for registration again. to undergo a medical examination and treatment or psychological or psychiatric examination. The Tribunal has no power to award compensation or costs to a complainant. and the payment of costs and expenses incurred by other parties. Appeals against decisions of the Tribunal are to the High Court.

D-G Health. The High Court must form its own assessment of the merits of the case. ACC. NFA Advocacy. Auckland. Health care provider. The complaints and discipline processes Complaint to Medical Council (HPCAA) Medical Council Competence. Conciliation. Mediation Investigation Complaint to HDC (HDCA) Referral after conviction etc No breach Breach of the Code Professional Conduct Committee Recommendations Director of Proceedings Health Practitioners Disciplinary Tribunal Human Rights Review Tribunal No further action Cole’s Medical practice in New Zealand 2011 221 . the High Court must act on its own view. If the High Court is of a different view of the merits from the Tribunal and is therefore of the opinion that the Tribunal’s decision is wrong. having regard to the expertise of the Tribunal members who heard the charge but not approaching that expertise with undue deference. Privacy Comm. Counsel. Nicholls & Co Inc v Stichting Lodestar [2007] NZSC 103 (see Harman v Director of Proceedings (High Court. 13 October 2009. Duffy J)). Auckland CIV-2009-404-000951.. following the approach outlined in Austin. The appellant bears the onus of satisfying the appeal court that it should differ from the decision under appeal. CIV 2007-404-3732) and more recently Dr G v Director of Proceedings (High Court. Health.Appeals are conducted by way of a rehearing on the record of the Tribunal.

org. but the Health Practitioners Disciplinary Tribunal. Core guidance Good medical practice. Some statements also cover issues not addressed in this book. standards for the profession (July 2008) Administrative practice Statement of safe practice in an environment of resource limitation (October 2005) Responsibilities of doctors in management and governance (September 2004) Statement on employment of doctors and the Health Practitioners Competence Assurance Act 2003 (December 2005) Non-treating doctors performing medical assessments of patients for third parties (June 2003) General subjects Disclosure of harm (August 2008) Responsibilities in any relations between doctors and health related commercial organisations (June 2008) The doctor’s duty to help in a medical emergency (August 2006) Medical certification (December 2007) The maintenance and retention of patient records (August 2008) 222 Cole’s Medical practice in New Zealand 2011 .nz where they can be found under Publications / Good medical practice.A Medical Council statements and guidelines You should familiarise yourself with the following statements produced by the Council. the Council and the Health and Disability Commissioner may also use them as a standard by which to measure your conduct. You can obtain a full copy of the statements by sending an email to mthorn@mcnz. These statements expand on points raised in Good medical practice (refer to chapter 1) and elsewhere in this book. such as resource limitation and cosmetic procedures. The purpose of the statements is to provide advice to doctors.nz or can download them from www.mcnz.org.

April 2010 Prescribing performance enhancing medicines in sport.nz Sexual boundaries in the patient-doctor relationship.org. Protecting patient safety (August 2009) Statement on advertising (April 2010) Prescribing Good prescribing practice. April 2010 Health HRANZ Joint guidelines for registered health care workers on transmissible major viral infections (November 2005) Statement on providing care to yourself and those close to you (June 2007) Cultural competence Statement on cultural competence (August 2006) Statement on best practices when providing care to M ori patients and their wh nau (August 2006) Other Council publications The following may also provide useful guidance and advice and are available from the Council’s office. Some are also available on the Council’s website www. a guide for doctors (October 2006) Best health outcomes for Maori: Practice implications (February 2007) Best health outcomes for Pacific peoples: Practice implications (April 2010) Continuing professional development and recertification (June 2010) Cole’s Medical practice in New Zealand 2011 223 .mcnz. April 2010 Prescribing drugs of abuse.Statement on use of the internet and electronic communication (June 2006) Statement on complementary and alternative medicine (March 2005) Confidentiality and the public safety (April 2002) Information and consent (April 2002) Legislative requirements about patient rights and consent (October 2005) Ending a doctor-patient relationship (March 2004) When another person is present during a consultation (March 2004) Statement on cosmetic procedures (August 2008) Unprofessional behaviour and the health care team.

as “he fell arse over tit”. Be warned. often referring to a stranger: “Seems a decent bloke”. small child. anus. a guide for patients (October 2006) You and your doctor. anklebiter: infant. as Q: “How are you feeling now?” A: “A box of birds”. arse: buttocks. guidance and advice for patients (October 2006) What to expect from your doctor when you have a cosmetic procedure (June 2008) _____________________________________________________________ B Take our word for it: NZ slang expressions Ian St George is a Wellington GP and has been an elected member of the Medical Council. a guide to how the Council manages doctors with health conditions (December 2004) Education and supervision for interns (October 2006) Supervision for international medical graduates (November 2009) Induction and supervision of newly registered doctors (May 2007) What you can expect. many of these words and expressions are considered vulgar. arse over tit: head over heels. Chair of its Education Committee. as “Dole bludger”. butt. toddler. box of birds: well. however: don’t try these at home. beaut: great. rude or offensive: do not use them until you are sure you will not offend.Doctor’s health. bludge: to sponge off other people or the government. they may use slang words that you do not understand. Bob’s your uncle: it’s all fixed. and Chair of the International Physician Assessment Coalition. as “I put the ointment on. and Bob’s your uncle”. When Kiwis (New Zealanders) talk. 224 Cole’s Medical practice in New Zealand 2011 . Here are a few that may be used in a medical context. as “I’ve been feeling beaut”. The performance assessment (November 2005) The importance of clear sexual boundaries in the patient-doctor relationship. well. kid. bonk: (= bang) to have sex with. bloke: usually a man. rear end.

brilliant: excellent. unwell (but to “go crook” may mean to complain or tell off). buggered: exhausted. dreaded lurgy: alternative name for the flu. ding: a small dent in a vehicle. butt. cheers: goodbye. cotton buds: Q tips. chemist: pharmacy. as “Just thinking about the operation gives me the colly wobbles”. any febrile illness. southpaw. duvet: quilt. income support for the unemployed. as Q: “Are you any better?” A: “No. cheerio: good bye (also a small red sausage). Like “croaked”. or “thanks”. bum: buttocks. chuffed: pleased. a head cold. dunny: toilet.braces: suspenders. wonderful – or even OK. brassed off: disappointed. bust a gut: make an intense effort. As a verb. for keeping beer and food cold. “That’s choice!” chook: chicken. unreliable. drug store. as “The knee’s a bit dodgy”. colly wobbles: a feeling of nausea usually associated with nervousness. carpenter. kicked the bucket. bugger all”. dummy: pacifier. choc-a-block (chocker): full to overflowing. woollen button-up-the-front jersey. means to bludge. bun in the oven: pregnant. cardie: cardigan. crook: sick. chunder: vomit. bugger all: not much. carked: died. cot: child’s bed. choice: used when something is desirable. eg. any hit on the body. bathroom. satisfactory. thanks. usually polystyrene insulated box. dressing gown: bathrobe. chippy: builder. as “Her knee took a bit of a ding early in the game”. chilly bin: sealable. dole: unemployment benefit. corker: very good. girl. great. rear end. annoyed. lavatory. dodgy: bad. spoiled. chips: french fries. Cole’s Medical practice in New Zealand 2011 225 . cackhanded: left handed. very little. Like Australian “eskie”.

greetings. eg. fanny does not mean buttocks! a warning to Americans. as “Give it heaps”. urine. john: lavatory. fagged out: see knackered. football: rugby. not a problem.eh: often used at the end of sentences whether or not expecting a response to a statement which is not a question. certainly. french letter (frenchie. pike out: to give up when the going gets tough. kia ora: hello. fag: cigarette. frog. 226 Cole’s Medical practice in New Zealand 2011 . hottie: hot water bottle. nappy: diaper. half pai (half pie): sort of. rubber): condom. “get away from it all”. excellent. fanny: “fanny” refers to female genitalia.” (origin: the “knacker’s yard” is where surplus farm animals were sent to be slaughtered). as Q: “How has your sore knee been?” A: “Good as gold”. pack a sad: become morose.” or “The fridge packed a sad”. heaps: a lot. or well. croak. cark it. toilet. loo: bathroom. “He packed a sad and went to bed. kapai: fine. good as gold: a good job well done. jersey: sweater. jumper: woollen sweater. means to push it to the limit. “I took all the pills. kick the bucket: die. face cloth: flannel: wash cloth. rooted. as “I’m knackered. fagged out. only half pai”. knackered: tired or broken. (“Take the piss” = tease). hard yakka: hard labouring work. ill humoured. piker: one who gives up easily. moody. nana: female grandparent. no worries: not a problem. broken. piss: beer. go bush: become reclusive. as Q: “Are you feeling any better?” A: “Well. an affirmative answer. full on: intense.” A: “No worries!” off (his) face: completely drunk. not completely. hunky dory: everything’s fine. joey. kai: food. as “My life is hunky dory now”. yes. eg. stuffed. as Q: “Thanks for your help. sexually available potential partner. eh”.

As “you’re being a sook” or “just a big sook”. pong: bad smell. feeling sexy. stuffed: really tired. right as rain: OK. ‘What. or behaving over cautiously. round the bend: going crazy. plastered: drunk. spit the dummy: to throw a tantrum or get mad. it’ll be OK (may disguise some deficiencies). inebriated. as “I’ll just take a shufti at that”. PMT: premenstrual tension. she’ll be right: not a problem. suss: to figure out. as “I’ll give him a ring”. One of the boys said. as “I’m really pissed off!” pissing down: raining heavily. plaster: see sticking plaster. piss-up: social gathering with alcohol.” Cole’s Medical practice in New Zealand 2011 227 . Q: “How would you rate the service?” A: “Sweet as. pushing up daisies: dead and buried. also used for sickness certificate. A small dinghy. prang: minor vehicle smash. sticking plaster: band aid. for sputum – but also for strawberries in the S. packing a sad. An American woman visitor: “My first time in New Zealand I said I liked to root for the football team. pottle: small container (eg. rooted: feeling tired. sickie: as “Throw a sickie”. stroller. fart about.piss around: waste time or effort in a futile manner. “Giz a squiz” ask for a look at something. pissed: drunk. snotty: condescending. perfect. ring: phone somebody. pissed off: angry. squiz: as “Have a squiz” to take a look at something.Is. meaning “I’ll have a look at that”. sook: someone timid. to take time off work. snooty.) pram: baby carriage. shufti: a look. snarky: mixture of sarcastic and nasty. singlet: undershirt. sprog: a child. root: to have sex. randy: horny. or ill humoured. the whole team?’”. spew: to throw up. sweet as: really good.

http://homepages. sprogged.html.vuw.ac. a consultant in the health regulatory sector. They were written by Sue Ineson.chemistry. take aways: New Zealand term for “take outs” or food “to go”. zit: acne lesion. grizzle. yonks: forever. 228 Cole’s Medical practice in New Zealand 2011 . in the family way. 4.ihug. the tatas: anxiety. 3. a long time. as “I feel wicked after a week off work”. with a bun in the oven.nz/~sarah/content/slang. underpants: undershorts. wicked: energetic. often when speaking to a child.co. get snotty.nz/international/studentlife/glossary_nz.html. well. 2.ta: thank you. she was for some years chief executive of the Medical Council. www.co. etc. References This material was gleaned from several general websites on New Zealand colloquial words. wobbly (pack a wobbly): become angry. as “I haven’t been right for yonks”. whinge: complain. zambuck: St John Ambulance officer.html. tata: goodbye. www2.htm#quite_nice. ______________________________________________________________ C Orientation of International Medical Graduates The following information will be published as three seperate resources by the Medical Council in 2010.nz. tinned food: canned food. undies.com/NZ/Culture/NZDic. ages.nz/kiwi. as “I’ve got a dose of the trots”. 1. grundies. Introduction The New Zealand health system relies on the contribution of international medical graduates (IMG) or overseas trained doctors to ensure it functions. trots: diarrhoea. www. Prêt á manger. up the duff: pregnant.

Thus the term IMG does not accurately portray the reality of many doctors working in New Zealand. this covers a huge range of doctors including those that have lived in New Zealand for many years and even gained a further qualification in this country. Internationally Trained Physician. Previously the Council used the term “Overseas Trained Doctor” (OTD). For instance it is common for a doctor to have been born in one country and qualified in another. but moved to IMG as this was the term used internationally.192 The definition used in New Zealand is wider than that used in many similar jurisdictions overseas. A citizen of another country who studied overseas and is practising in New Zealand. Foreign Trained Doctor. A New Zealand citizen or permanent resident who studied medicine overseas before immigrating to New Zealand. and some redefine the status of the doctor once the doctor has obtained postgraduate qualifications in the country. It says nothing about the doctor’s ethnicity. and may have even done postgraduate study in their chosen specialty in New Zealand It says nothing about the doctor’s current situation. 192 Alternative terms to IMG are a Foreign Medical Graduate. some for a short overseas experience and others may have lived in New Zealand for many years. Cole’s Medical practice in New Zealand 2011 229 . for example some may be here for locum positions. Who are IMGs? The current definition of an IMGs is very wide.Over the last two years the Medical Council has been working to develop advice both for international graduates themselves wanting to work in New Zealand and for those helping them settle in this country. a Foreign Trained Physician. some are 191 An IMG is defined as a doctor who obtained their primary medical degree from outside New Zealand.193 So in New Zealand an IMG may be A New Zealand-born resident who went overseas to study medicine. Some countries count as local graduates those in similar areas such as in the European Economic Union or the United States and Canada (Fletcher. It says nothing about the doctor’s acculturation to the New Zealand health system as the doctor may have lived here a few months or many years.191 The term IMG is not always understood and different terms are used in other countries. culture or country of birth. 193 Some jurisdictions redefine the status of the doctor after a period in the country. Internationally Educated Health Professional and Internationally Trained Medical Doctor. Foreign Medical Doctor. 2008).

In addition. Others have New Zealand partners and many have raised their families in this country. 230 Cole’s Medical practice in New Zealand 2011 . for others the expertise they have can only be applied in other larger countries and for others they have decided to call another country their home. many of whom travel and work extensively in other countries. the more likely the doctor will be able to contribute and get satisfaction from their job. The reason why the Medical Council and other employers have been studying why doctors come to New Zealand and what makes them stay is so these doctors can be given the right type of support. In medicine some overseas experience is valuable and often necessary to complete training. What we do know is that IMGs are a diverse group. Others are here because they actively chose to live and work in New Zealand. The way IMGs are defined is important because categorising a doctor based on where they obtained their first medical qualification does not give an accurate view of the many and varied situations and contributions of IMGs. One thing we do know is that without IMGs the New Zealand health systems could not function. have had to adjust to living in different countries and dealing with different cultures and different ways of practising medicine. It also impacts on these doctors’ perceptions of New Zealand and it does not encourage acculturation. some are refugees and New Zealand offered them a home and others came because of their spouse’s job is in this country. the more likely they are to remain in New Zealand. Why is understanding medical migration to and from New Zealand important? Young New Zealanders have always travelled (approximately one million of them currently live overseas) and doctors are no exception.New Zealand citizens. Most importantly it does not value the contribution to the New Zealand health system of the doctors we call IMGs. after a certain time in this country most IMGs are indistinguishable from New Zealand graduates (who are also varied ethnically and culturally). It does not say anything about the importance of the global flow of ideas and expertise so necessary in medicine. others are New Zealand residents. Therefore even if New Zealand increases the number of doctors graduating here it will continue to need and benefit from the expertise of doctors who trained overseas. The more they and their families can be helped to settle into this country and into a New Zealand health practice.

It is not a good use of resources if the doctor (or their family) has an incorrect expectation of life and work in New Zealand and leaves after only a few weeks in the position. Doctors planning to come to New Zealand do need to be realistic.Research has shown that broadly speaking doctors who come to New Zealand usually fit into one of three groups. If not. how can a doctor from another country be helped to settle in New Zealand? In terms of orientation to medical practice in New Zealand the needs of an IMGs depends on their own experiences and the countries where they have worked. and who after the expense and disruption of moving need to “make a go of it”. These doctors may only stay for a period but may come back several times if they have had a good experience. settling a whole family can be harder. both they and their families may undergo a disruption. especially if the doctor moves into a small community. who come for a more relaxed way of practising and for a different lifestyle. For this group. An employer or colleague might ask. especially for doctors with families. even if there are problems. who may not stay – though feedback from some of them indicates a good New Zealand practice experience may bring them back later in their career. Feedback from doctors noted that the Medical Council should be transparent about the reality of practice in New Zealand the standards of registration issues of resettlement. and Council and employers’ work to assist them register is wasted. As there is not one “group” of IMGs. Cole’s Medical practice in New Zealand 2011 231 . Differing countries of origin and/or countries of recent practice and personal expectations mean that doctors entering New Zealand have different expectations of the settlement process: the enclosed immigration readiness checklist – Is practice in New Zealand for you? – is included so doctors intending to come to New Zealand can make their own “reality check” before planning to relocate. there is not one solution to ensure better orientation and acculturation. Doctors from over 90 countries are currently working in New Zealand. who often have families or links in New Zealand. The “adventurers”: usually younger doctors wanting to see the world. Therefore it is useful to give the doctor enough information so they can “be in charge” of their own orientation and assess what they need to know and when they need to know it. The following Orientation Guidelines and the Orientation Topic Checklist are designed to assist the process. Those who are near retirement: “the empty nesters”. Those wanting to try out a “new life”.

consider whether it is a good idea first to come for a short period or holiday or for a locum position.immigration.Immigration readiness checklist If you are a doctor contemplating coming to this country (or an employer helping a doctor to decide whether New Zealand is the right place for them) the following “readiness check list” may be helpful. As a doctor you do need to ensure coming to New Zealand is the right move for you.nz/nzopportunities/aboutnz/ http://www.govt. Council may ask you to sit an English test and/or an examination of your medical skills and knowledge.nz/migrant/settlementpack/ 2. Helpful websites are http://www. 232 Cole’s Medical practice in New Zealand 2011 . While it may be tempting for a prospective employer to recruit a doctor. culture. Can you practise in New Zealand? The Medical Council of New Zealand is the body responsible for the regulation of doctors who work in New Zealand.immigration. lifestyle will met you and your family’s needs. They will want to ensure themselves that you are fit for registration. This means that you are able to communicate effectively have not been convicted in a court of a matter that may reflect adversely on your fitness to practise do not have a mental or physical condition that may impair your ability to practise have not been (or are not currently) under investigation for professional disciplinary proceedings that reflect adversely on your fitness to practise are not subject to an order from any disciplinary tribunal have the qualifications that are required to be able to practise in New Zealand are competent to practise in New Zealand. Are you planning on coming to New Zealand for the short term or the long term? If you are thinking of making a permanent move to New Zealand. unless the “fit” is right it is unlikely it will be a long term solution to your recruitment issues. Is practice in New Zealand for you? 1. to ensure the country. To ensure you met the requirements.govt. The Council sets requirements to ensure those who practise in New Zealand meet the standards.

If you enjoy fishing. or skiing.immigration. hiking. If you have come from and enjoy the lifestyle in a large European or Asian city consider the wider implications of moving to a more remote part of rural New Zealand. consider the impact of on your family of where you take a job. Are you bringing your family? If so.nz/nzopportunities/lifestyle http://www. Some people can feel very isolated in rural environments.govt. then New Zealand may be the place for you.nz/Default. while others find it much easier to integrate into a small welcoming rural community while it is probably easier for you to find work in a small town. music and culture can be more limited variety in shopping might not be what you expect.nz/Registration/SelfAssessmentforRegistration/tabid/70 /Default. if you like space and want to own your own house and land then New Zealand will hold many opportunities.govt. Do think about where you have come from and where you are going.mcnz. Similarly. http://www. If you have older children and intend moving to a rural area then it is likely that your children will have to travel to attend high school or a tertiary education facility consider your family’s social needs when deciding between urban and rural working environments. have you thought about settling the children and the education opportunities in the area you are going to? Resettlement research tells us that older children may settle less easily than younger children.mcnz. Keep in mind that options to enjoy art. Have you looked at the differences in living standards and living styles? New Zealand is a country where people enjoy and participate in sporting and outdoor activities.immigration. The Medical Council’s website includes a tool which allows you to assess whether you meet the Council’s requirements for registration: http://www. sailing.Once you are registered you may apply for a practising certificate.org.aspx The website also includes detail on the various registration policies: http://www. Each year the Council will expect you to renew your APC.org.aspx?tabid=106 3. keep in mind that it is likely to be much harder for your partner to find work Cole’s Medical practice in New Zealand 2011 233 .nz/nzopportunities/aboutnz/ 4.

careers. http://www. For example there are differences in the work environment.nz/ for listings of urban jobs in medicine. you may find settlement more difficult. A good recruitment agency may help you to find a job. http://www. and will also help coordinate the other matters relating to resettlement. be aware that there will be differences in the way medicine is practised.nzmedics.nz/home_page. be sure to explore registration within a vocational scope (specialist registration). Practice in New Zealand may be different Even if you come from a country that seems similar to New Zealand. 7.com for listings of rural locum GP jobs.html for information on careers for your children or partner http://www2. and some doctors have reported that they found it hard to establish relationships in a small community where some people see them as something of an outsider If you are leaving behind a large close family or elderly parents. even towards those in positions of responsibility or seniority 234 Cole’s Medical practice in New Zealand 2011 .nz/districthealthboards 6. your application for residency with Immigration New Zealand and a job offer. These sites may be helpful: http://www2.nz/education_training_info.govt.html for information on education and training for older children 5.co. New Zealanders have an informal approach to others.nzlocums.careers. There can sometimes be a kernel of truth in this saying.govt. If you are a specialist with a postgraduate qualification. District Health Boards are the organisations that run government funded hospitals and their websites have a lot of information about hospital jobs and some give excellent information on living in the area: http://www. Where do you want to work and how can you find out about work? There are a number of helpful websites that provide information about jobs and where they are located.govt.moh. Do you intend making the move permanent? If you wish to come permanently to New Zealand you will need to coordinate approval of your registration with the Medical Council of New Zealand.New Zealanders often joke that ‘everyone knows everyone’ here. These processes take time – so they need to be started as soon as possible.

especially those working in general practice or family practice the information technology systems and electronic databases may not be as advanced as they are used to some doctors find that when working in the New Zealand system particularly in primary care that they have to complete a higher amount of paper work and forms New Zealand referral systems can be quite different.drs. Remember settlement is a process It is estimated that most people take fifteen to twenty-four months to settle in a new country.nieuwzeelandforum. As a doctor in New Zealand you need to understand and work within priority setting systems New Zealand is a small country. but on the other hand the cost of living can be lower for some doctors.doctors. There are a number of chat groups available for doctors and other immigrants who are considering moving to New Zealand: http://www.net.nl 8. with a small and broadly scattered population and therefore has more need of generalists. nurses and allied health workers work together in collegial teams with little hierarchy there are differences in salary. The settlement process often involves both high moments – when you will feel very positive about the shift – and low moments – when you will feel homesick for the life and places you have left behind. Cole’s Medical practice in New Zealand 2011 235 . Contact between general practitioners and hospital specialists can be more limited there are waiting lists for some patient procedures at major public hospitals. In New Zealand salaries are not as high as in other countries.uk or http://www.

The Council has developed a check list called Is practice in New Zealand for you? which may help doctors to set realistic expectations. If the doctor is relocating for some years he or she is likely to want to be assured before leaving that he or she can gain permanent residency. and the practicalities of settling a family here.For employers: Orientation guidelines for employers and supervisors of IMGs Differences in medical cultures do exist around the world. It should occur on multiple levels and at multiple times. Orientation of doctors who are new to New Zealand should not be treated as a one-off event. The Medical Council has developed online resources to help you to meet international medical graduates’ (IMGs) information needs. 1. and you cannot be by their side to meet those information needs every hour of the day. Orientation is a process. not a one-off event Doctors who are new to New Zealand will need your help to get used to our systems. The new doctor will need to access different information at different times. It can also be very useful to provide an immigrating doctor with the contact details of another IMG who has been through the resettlement process and who can answer questions and provide advice. One of the key aspects of providing a good orientation experience is to make sure that the doctor knows how to find information when it is needed. For this 236 Cole’s Medical practice in New Zealand 2011 . There is no one way to induct and orientate new staff. 2. Employing a doctor from overseas Making sure that a doctor has realistic expectations is the key to making his or her experience in New Zealand a good one. the reality of New Zealand medical practice. Good orientation and support will ensure that newly registered doctors do not experience difficulty understanding and learning their adopted medical culture in New Zealand. processes and culture. The better the orientation and settlement process the quicker the doctor will be able to contribute effectively to your service. Orientation and induction should be adapted to fit your organisation’s culture and the needs of the individual doctor. and ensuring that resettlement occurs with minimal disruption. Before a doctor leaves his or her home country you should make sure that he or she has some understanding of life in New Zealand.

reason you should put the doctor in touch with Immigration New Zealand as early as possible in the process. For example.govt.uk/. Provide the doctor with links to http://www. When advertising you should consider the needs of both the doctor and the service.nz/migrant/settlementpack/ – which outlines different “settlement packs”. Ensure certainty of outcome If doctors are relocating to New Zealand it is important to give them certainty around certain key issues as soon as possible. 3.nieuwzeelandforum. and to help him or her to learn about the experiences of others and find out about life in New Zealand.nz/nzopportunities/williqualify/ – this has information about residency options in New Zealand. ensure that his or her registration with the Council is organised and that Immigration New Zealand requirements are met. but these can be wasteful and expensive when the service or practice actually needs a longer term solution. http://www.nl and http://www. Such websites can provide the doctor with a useful place to ask questions. then they are more likely stay for longer.immigration.govt. 4.net. Short term employment contracts may meet an immediate service need. organised in relation to the way the person wishes to enter New Zealand and how long they intend to stay. if your advertising focuses on the exciting outdoor experiences available in your region then you may attract a good locum.govt.newzealandnow. Research indicates that if a doctor is coming to New Zealand to join family or a partner. but this is unlikely to be a suitable approach when seeking a full time long term placement. Not all IMGs have the same needs In recruiting a doctor from overseas for your practice or service. There are a number of overseas sites which enable those settling in New Zealand to discuss their settlement experiences. or has had a previous period of work in New Zealand. http://www. Once you have established that the doctor is suitable for the role and fit for the position. it is important to consider what motivated that individual to come to New Zealand and to assess whether these motivations are compatible with your longer term service or practice needs. Doctors come to New Zealand for different reasons and via different recruitment strategies.immigration.doctors.nz/ – this has a huge an amount of information about coming to New Zealand. These include http://www. For registration purposes it is particularly important to Cole’s Medical practice in New Zealand 2011 237 .

Make the doctor’s arrival in New Zealand a welcoming one. and make all those other arrangements which need to be made. Touches like meeting the doctor at the airport. Remember that many New Zealanders are relatively used to long flights. to ensure that the doctor has time to help the rest of his or her family settle. 5. Good orientation is an investment to adjust Good orientation strategies should be seen as an investment in the future – the better the doctor settles the less likely it is that the service or practice will be looking for a replacement employee in six months’ time. A pre-arrival pack might include a general resource on practice in New Zealand (such as the Medical Council’s book. and that this person has an overview of the organisation. the relevant department and specialty. orientation processes and information. and give them time to adjust to their new environment. Try and ensure that one person is in charge of coordinating the orientation process. assisting with the practical arrangements of the settlement process. but most people from overseas have no idea what it is like to fly for 12–24 hours. organise housing. can make a huge difference. Face to face contact is important as it gives a doctor a feel for the culture of your service. Try and organise a gradual introduction to the work place and work routines. Cole’s Medical Practice in New Zealand) and the Settlement Support guide for your part of the country. Then supply the doctor with a contract of employment and give precise details on start dates and your expectations. making contact with the partner and family. If this is not possible. and can ensure the doctor gets all the information they need. Give the doctor a few days to adjust to New Zealand time and to settle the family. IMGs have told the Council that it can be useful to be provided with packs of information before they leave for New Zealand. The easiest way to help a doctor to acculturate to life in New Zealand is to have him or her spend time with New Zealanders. organise to introduce the doctor to Settlement Support in your area. 238 Cole’s Medical practice in New Zealand 2011 . and organising a social occasion so the new doctor can meet other New Zealanders. Do not underestimate the importance of the personal approach and how much a helping hand in the first few days will be appreciated.make sure that the doctor is on the right registration pathway and that he or she will be able to meet the requirements for registration within a general or vocational scope.

Include a clear and easy to follow table of contents. This is often an effective way to demonstrate common workplace practices. make sure that you coordinate your orientation processes with theirs – so that the doctor does not get overloaded. CMO. Peter Spurgeon. As a paper on enhancing engagement in medical leadership notes. It is therefore important that you indicate what parts of the orientation programme or manual are the most important and ensure the doctor has an understanding of these sections. with guidance on where to go to find the detail. but doctors might find it easier to flip through a folder. Julie Dent and Kirsten Armit. Use these meetings to listen to doctors’ ideas for the service and to set out organisational expectations”. clinical head or practice partners. what should be read and what is background information for future reference. While it is important to have an orientation programme and induction manual. It can be more useful to simply summarise information in the manual. or get duplicate or conflicting information. In discussions with IMGs it was noted that differences in approach to medical practice can be addressed by good orientation.194 6. Organise a greeting from the CEO. You can make your orientation manual web based. Most new doctors to New Zealand will appreciate some time to observe or “shadow” another doctor. 194 Can doctors influence organisational performance Enhancing Engagement in Medical Leadership by Patricia Hamilton. or have gaps where vital information is missed. leaders should clearly “signal interest in doctors by seeing all doctors as part of an induction programme in their first week and again for one to one meetings two to three months after appointment when they have had an opportunity to form views about the service. Cole’s Medical practice in New Zealand 2011 239 . A hard copy can also be taken home and read and be referred to over the following days and months. it is also likely that in his or her first few days the doctor will be overloaded with information. good supervision and buddying. Large volumes of text can be off putting. If you are using a recruitment agency.Having one person coordinating the process should also help to ensure that the doctor does not get overloaded with information in the first few days. Starting work Identify the key information that the doctor needs to know straight away. Ideally this should take place during the orientation and induction period before the doctor takes on any clinical responsibilities. John Clark. Put resources in the induction manual in order of importance – what must be read.

The doctor’s direct supervisor’s initial aim should be to ensure that the doctor can access information and materials as he or she needs them. Make sure the doctor has a copy of his or her job description and terms and conditions of employment. Follow up Over the next few months stay in touch with the doctor. so concentrate on providing practical material. It is important to give the doctor a copy of the orientation plan you have agreed with Council. Consider introducing one of the following for each new doctor: A “buddy” for a more senior doctor. so they are aware of the employer’s and the Council’s requirements.If you are running an induction programme. invite those doctors who did not attend last time. and introduce the doctor to social networks – such as churches or sports clubs. Make sure that both you and the doctor are confident before assigning any after-hours. 8. and outline where the doctor fits in. The Council’s web portal provides a wide range of links to internal and external resources. and check whether he or she needs you to clarify any aspect of these documents. Put the doctor in charge of the orientation process The Council’s Orientation Topic Checklist may help you to ensure that all the doctor’s needs are met. 9. but it can also help the doctor identify what he or she needs to know and allow them to drive their own orientation. The supervisor should also provide the doctor with an overview of the whole service and the department. 240 Cole’s Medical practice in New Zealand 2011 . Often people learn more from these sessions after they have been working on the job for a while. Ensure that any issues with settling in or the standard of practice are brought to your attention. 7. Provide practical material The more relevant the information is to a doctor’s actual work the better it will be received. The supervisor should then concentrate on helping the doctor settle into his or her work within the service. and act on these concerns before they become a problem. The best strategies to promote ongoing communication have the added benefit of encouraging doctors to stay in your service. to ensure that doctors can access a lot of information by themselves. and a copy of any supervision agreement. on-call or sole practice responsibilities. This is a person who can give collegial support in the first days and months.

Troubleshooting Language and communication – IMGs have advised that a list of New Zealand slang words. The Council has developed an Orientation Topic Checklist which tries to highlight what your orientation programme should cover. The Council’s Orientation and Induction Topic Checklist and web portal provide links to New Zealand language resources that you might find useful. Keep in mind that New Zealanders tend to speak very fast compared to other English speakers. Too often new resources are produced without considering what else is available. This can also help doctors to build up contacts and experience. Do not reinvent the wheel Before you develop a recruitment or orientation resource. It is Cole’s Medical practice in New Zealand 2011 241 . Use other agencies Organisations such as ACC. Invite them to come and speak to your staff. The mentor’s role is to help the doctor identify any concerns. review what others are using. HDC and the Privacy Commission provide information and services to help introduce doctors to their systems.A “mentor” for a more junior doctor. GP practices or other facilities so they can become familiar with all services in the region. 11. review training options and develop their career pathway. that communication often involves more than just language – different cultures use different nonverbal cues and may have different mores relating to touch and body space. This is a senior doctor who makes contact in the first week. Encourage and enable doctors to travel to nearby hospitals. Most doctors have a high level of English before they enter New Zealand but if accent or communication is a problem after the first 1–3 months the doctor should be encouraged to attend a communication or speech course. translations and pronunciations of common M ori words and explanations of acronyms would have been useful when they started work. and then at the third and sixth month. Make sure that others involved in providing orientation and induction are aware of this and have some understanding of how to communicate effectively with someone from a different culture. and Cole’s medical practice in New Zealand includes a list of common slang words. 10. Remember. 12. or provide doctors with the tools to obtain information directly from them. both in the health sector and from other agencies such as Immigration New Zealand.

asp. Discussing cases with this colleague may assist the doctor to appreciate the “New Zealand way”. This video is based on the UK version of Good Medical Practice – and this outlines similar expectations to those published by the Medical Council of New Zealand.. and how and when to involve whanau in a consultation. H. Council statements and Cole’s Medical Practice in New Zealand all contain excellent information and are available in hard copy or on the Council’s website.gmc-uk. as some doctors have reported that they found the informality of interactions between nurses and doctors in New Zealand a surprise and a difficult thing to adjust to. New Zealand medical practice expectations –the Medical Council’s resources are sometimes not used or known. 2009). http://www. You might refer doctors to a video on the General Medical Council’s website.mcnz. http://www. Good Medical Practice. It can be very easy for such a doctor to get off on the wrong foot with nurses.a spx.org/guidance/good_medical_practice. New Zealand cultural issues – IMGs often come from multicultural societies and most doctors are used to considering cultural issues in their practice. To understand M ori health disparities and how to deliver effective health care to M ori patients. As noted above it is recommended that a new doctor shadow an experienced colleague for a while. You need to discuss these issues in a clear and open fashion. Consulting styles – an honest and open discussion with a senior practitioner may help if the new doctor’s consulting style is different to local practice. which is intended to outline ethical expectations in the UK. Doctors from very different societies can also struggle to adapt to New Zealand attitudes towards women and some of our ethical practices. However they are unlikely to have encountered M ori culture before and do need practical information relating to M ori tikanga and cultural mores. such as the treatment of patients near the end of life. and for this to cause ongoing problems. even for a doctor from a comparable health system. The organisation of the health systems in New Zealand – can be confusing.particularly important to discuss cross cultural communication with nursing staff.nz/Publications/Goodmedicalpractice/tabid/293/Default. the approach to patient centred care. Understanding the principles of the Treaty of Waitangi may be easier after the doctor has spent some time in New Zealand. the importance of informed consent. Research in the United Kingdom shows that some doctors from other jurisdictions take time to adapt to new ethical expectations (Slowther A.org. Such doctors often make 242 Cole’s Medical practice in New Zealand 2011 .

Some doctors find difficulty entering smaller more closed New Zealand communities and may need your help to make contacts and develop a social network. Personal and social support at work and in the wider community – IMGs have noted that New Zealanders are usually friendly and the life style here is more relaxed.org.nz ________________ For employers: Orientation Topic Checklist – what should your department or organisation cover?195 Where can you find resources to help you? The Council encourages the sharing of information and resources to ensure that not every organisation has to “reinvent the wheel” when it comes to orientation and induction. 195 Orientation is the term used to describe the processes and programmes needed to enable an IMG to familiarise themselves with working and settling in New Zealand. Medical knowledge and clinical skills . You need to explain these organisational issues if they impact on the doctor’s area of work. Celebrate diversity in the workplace so all staff value the perspectives doctors from other countries bring to New Zealand. The Clinical Education and Training Unit (CETU) runs a Ready for work programmes for doctors who are struggling with adapting to practise in New Zealand. Cole’s Medical practice in New Zealand 2011 243 .mcnz.the mistake of assuming that things here will be similar to their home country. The Medical Council of New Zealand is constructing a one stop web portal for all information to assist a doctor to enter and practise in New Zealand: http://www. access to diagnostic tests. waiting lists. and referral timelines are often very different. The mix of public and private funding in health.If the doctor is having real difficulty adapting to New Zealand practice. the division of services between DHBs and PHOs. It is a process that goes beyond an initial induction to the workplace and may take several weeks or months. provide support earlier rather than later. For those from more formal societies this may take some getting used to. while organisations such as ACC and PHARMAC are essentially unique.

Introduce the doctor to other staff and their roles. giving the organisation wide view and matters that directly impact of the new doctor. so the doctor gets a sense of where his or her workplace fits into the whole.General principles There is no one way to induct and orientate new staff. That might include printing a modified copy for the new doctor so that they can drive their own orientation and induction programme and tailor it to their particular needs. Have an organisational chart with brief information on the organisational structure: Board Committees The management team Have a ‘must know’ contacts list with phone and email details. Not all the ideas will be relevant to your situation. Provide a map of the facility or area where the doctor will work. Adapt this checklist for your own purposes. the services it delivers in the local area. 244 Cole’s Medical practice in New Zealand 2011 . and structures and people in the service is a useful start. Including the names and photos of those that new doctors may need to contact in an orientation pack is useful. At the organisational level. At the department and specialty level. Many people can be overwhelmed by information and names. Information that will be useful at the organisational level What should you be covering? Introduction to the organisation. Cover organisational and service level plans. A welcome and orientation to the organisation as a whole. It might also be helpful to provide photos with names and brief notes about those the doctor will meet in the first few days. This Orientation Topic Checklist is intended to give departments and practices ideas on what could be provided in orientation sessions and orientation manuals. Do a tour of the entire site. Orientation should be adapted to fit your organisation’s culture and the needs of the individual doctor. as would be brief notes on the backgrounds of the people in his or her immediate team. and find it easier to remember faces. Orientation for the doctor has various stages: At the practice level.

Getting across the ‘need to know’ information Ensure the doctor is aware of any requirements for health screening before the he or she starts work. such as profile of the practice or department. Cover medical indemnity issues. Make sure he or she knows how to reach after hours contacts. Give information of the way the specialty operates. Human resource information Give roster information and expectations for on call. sick leave and study leave. Document any supervision requirements and ensure that the supervision plan has been lodged with the Medical Council and give the doctor a copy. how to get cross cover. Face-to-face orientation Face-to-face orientation may not be able to cover all the issues and all learning necessary – but it can be great for giving a feeling of the “culture of the service”. Give details on how credentialing works in your organisation. how to swap with someone else. Demonstrate equipment. and how the on-call system works. Give a list outlining the services to which patients should be referred. Outline your expectations on nurse / doctor communication and the team environment. including. Orientation to the practice at the department or practice level Set up a network of staff working in same area of work or in the same geographic area. allowances. Kiwi-saver and health insurance. Give information on pay. pay and what to do if there is something wrong. Explain the procedures to be followed during a fire or earthquake. and how doctors will be reimbursed in the case of a call-out. especially emergency and resuscitation equipment. type of disease conditions and the main referral agencies. Provide information on security and advice on personal protection. leave. Provide information on support mechanisms such as Employer Assistance Programmes and how to access and where to go if there are concerns about doctor’s health issues. how to use pagers. Cole’s Medical practice in New Zealand 2011 245 . Check the doctor’s knowledge of CPR and resuscitation guidelines. Give information on time sheets. Provide guidelines to superannuation. Ensure that the doctor understands the Medical Council’s registration processes and how to apply for an annual practising certificate.

Discuss triage systems. Detail expectations regarding patient notes. Discuss how to access allied health services – such as physiotherapy. Cover death certification. Detail discharge guidelines. For example: the prevalence of illnesses such as meningitis. and access and prescribing for controlled drugs. Provide information on when and how to access interpreters. access to medicines. Discuss the detail required in discharge summaries. 246 Cole’s Medical practice in New Zealand 2011 . OT and dieticians. Discuss the requirements relating to adverse events and incident reporting. Discuss the use of restraints. special authorities. Discuss how to manage challenging behaviour. prescribing and how to write a script. Provide information on referral systems and waiting lists. records and confidentiality. diabetes and asthma responding to suspected child abuse expectations relating to requests for contraception or abortion responding to suspected drug and alcohol abuse immunisation and child health cervical screening. Discuss. Outline any New Zealand specific disease patterns or issues which might be relevant. Outline your expectations and any limits to a doctor’s clinical responsibility and the lines of accountability. Discuss how to admit a patient. Outline the processes to be followed and legal obligations when a patient presents with a notifiable disease. Talk about handovers at the end of a shift and what to do if called after hours.Starting work at the practice level Give an over view of how the ward / service functions. Discuss recalls.

Information relating to the patient Discuss patient expectations of the doctor. Discuss the role of the patient in determining his or her healthcare. Cover informed consent -the Council has published a statement on Informed consent http://www.mcnz.org.nz/Resources/Standardsandguidelines/tabid/293/Default.aspx Provide a copy of the Health and Disability Commissioner’s Code of Patients Rights, The Nationwide Health and Disability Advocacy service may be able to supply a speaker to talk to your services about their role. Discuss intimate examinations and when and how chaperones should be used. Discuss the doctor-patient relationship, and boundary issues The Council publishes a booklet for doctors on Sexual boundaries in the doctor-patient relationship http://www.mcnz.org.nz/Resources/Standardsandguidelines/tabid/293/Default.aspx. Family advisors. Give information about consumer advocates, family advisors and chaplains. Provide information about patient meals and how to organise. Discuss how patients can give feedback and what they should do if they have a complaint. Clinical practice information needs to cover Provide information on infection control and sterilisation. Provide information on advanced life support. Provide an overview of laboratory testing. Outline expectations for theatre. Provide an overview of the Emergency Department. Provide an overview of Outpatients. Provide an overview of ICU. Provide an overview of Radiology. Provide information about your pandemic plan. Pandemic planning. Organisational policies and guidelines Make sure that it is easy for a new doctor to find organisational policies and guidelines when he or she needs them. Make sure that the doctor is aware of any house rules and where to they find them.

Cole’s Medical practice in New Zealand 2011 247

Provide an overview of in-house legal procedures. Quality assurance Discuss how quality assurance works in the hospital or practice. Provide information on your risk management programme. Explain how to access Standards New Zealand information. What is the complaints policy? Where to access useful Standards New Zealand information. Health system and IT information Demonstrate how to access and use the IT system. Explain the document management systems. Detail coding and statistics collection. Health services information Give an overview of health services and health funding, including information on ACC and PHARMAC. Explain Health Benefits and claiming. Explain the pharmaceutical schedule and prescribing, including: minimal requirements for legally acceptable prescribing appropriate use of controlled drug forms monitoring processes for effectiveness, safety and cost. Cultural awareness Treaty of Waitangi resources: Compass PHO and Northland DHB have protocol guidelines. The State Services Commission has a Treaty of Waitangi pack with lots of background. The Human Rights Commission and Internal Affairs have information. Cultural competence: ACC has a booklet – The M ori Patient in your Practice –Guidelines on M ori Competencies for Providers. Mauriora does training in this area. Standards New Zealand has recognition of M ori values and beliefs, and recognition and respect for the individual’s culture, value and beliefs.

248 Cole’s Medical practice in New Zealand 2011

The Royal New Zealand College of General Practitioners has guidelines on cultural competence. The Medical Council has guidelines on cultural competence, including Best

health

outcomes for Pacific peoples: Practice implications.
Maori contacts that work with the service. Communication If language may be an issue, provide information on language services.ESOL home tutors have a programme to assist overseas settlers improve their English – it is free to those who have permanent residence or New Zealand citizenship. Discuss the expectations when communicating with children and expectation for consent when working with children. Any particular programmes at the service Discuss any smoking cessation policies and expectations of staff in relation to your smokefree policy. Discuss any screening programmes available. Discuss any immunisation protocols. Professional development should cover Outline the Medical Council’s expectations for recertification and how Continuing Professional Development should be documented. Explain how and when grand rounds occur. Outline other meetings which doctors can attend. Document any useful e-journals. Advise of the resources available in the library. Advise of any journal clubs the doctor can access Provide information about medicine and the law; including the role of the HDC, requirements of the Mental Health Act, and ACC requirements. Cole’s medical practice in New Zealand includes several chapters on the law and medical practice. http://www.mcnz.org.nz/Publications/Reportsandpublications/tabid/82/ctl/Edit/mid/476/w ww.mcnz.org.nz/Publications/Reportsandpublications/ColesMedicalPracticeinNewZeala nd/tabid/261/Default.aspx Discuss the requirements of the Health Information Privacy Code 1994. A copy of the Health Information Privacy Code which incorporates a very helpful plain English commentary can be downloaded from the Privacy Commissioner’s website. http://www.privacy.org.nz/health-information-privacy-code-1994-with-commentary-link/ Provide information on professional indemnity insurance.

Cole’s Medical practice in New Zealand 2011 249

Discuss clinical governance. Provide information on any available mentoring programmes. Discuss the ethical standards which doctors are expected to meet in New Zealand. The Council also publishes a range of statements on specific topics, such as sexual boundaries with patients; internet medicine; and informed consent. http://www.mcnz.org.nz/Resources/Standardsandguidelines/tabid/293/Default.aspx The General Medical Council has an online video which outlines ethical expectations in the United Kingdom and these expectations and similar to those outlined in Good medical practice. http://www.gmc-uk.org/guidance/good_medical_practice.asp Outline the support systems that the doctor can access if he or she is finding it hard to adjust to practise in New Zealand. Useful references New Zealand slang words in health. The Medical Council’s Cole’s Book has a list in an appendix M ori words in common usage - the New Zealand History website has a list of “the 100 M ori words every New Zealander should know” http://www.nzhistory.net.nz/culture/tereo-100words. Medical terms in New Zealand. ’ Drugs used in New Zealand- these is an in-depth information is available online from MIMS and in hard-copy in MIMS New Ethicals www.mims.co.nz Standards New Zealand standards framework.

Evaluate your orientation programme or process every 2–3 years so you can improve it!

250 Cole’s Medical practice in New Zealand 2011

Index
A
abdominal and back pains 204 abortions 71, 90, 187, 193, 218, 246 see also Contraception Sterilisation and Abortion Act (1977) abuses 71, 75, 94, 96, 109, 187, 190, 195, 246 alcohol 71, 246 child 195, 246 drug 64, 80, 139, 143, 146, 187–90, 220, 223, 246 sexual 94, 96 ACC see Accident Compensation Corporation Accident and Medical Clinics 29, 116 Accident Compensation Act (2001) 92 Accident Compensation Corporation 29, 38, 48, 52, 68, 92–100, 155, 221, 241, 243, 248–9 application papers 98 approval of claims 98 contributions 93 entitlements 92–3, 96, 98, 199 'no fault' scheme 29 Injury Claim Forms 97 Sensitive Claims Unit 96 accidents 28–9, 94, 138 accountability 17, 79, 153, 158–9, 180, 199, 246 accreditation 31, 107 see also Medical Schools' accreditation acculturation 229–31 'Action Plan' 201 addiction 68, 89, 197 addictive drugs 11, 156 administering of entitlements 92–3, 96, 98, 199 advance directives 15, 39, 163, 187, 194 advertising 15–16, 34, 38, 175–6, 188, 223, 237 Advertising Standards Complaints Authority 38 advocacy service providers 198, 203, 205, 221 affidavit evidence 217 age, issues surrounding 20, 36, 39, 43–4, 53, 61, 63, 78, 90, 109, 195, 228 agencies 8, 27, 32, 37, 104, 106–8, 110, 118, 146, 198, 206, 241 agents, use of 16, 97, 165, 176 alcohol 57, 63–4, 138, 143, 195, 197, 220, 227 abuses caused by 71, 246 misuse of 63, 138 Alcoholism and Drug Addiction Act (1966) 89 allegations of misconduct 205, 216, 218 alternative health practices 171 alternative medicines 27, 86, 156, 158, 171, 174, 223 alternative therapies 86, 174 AMA see American Medical Association AMC see Australian Medical Council Cole’s Medical practice in New Zealand 2011 251

53–4. medical licensing 124 authorship claims 22 autonomy. 91. 179. 80 patient-centered 55 sensitivity regarding 14. 144. 78–9. 42. 20. 166. 63–5. 142. 168 availability of careers 141. 174. 219. 22. 120. 87. 112–13. 89. 231. 139. 234 awareness of biases 46. 162. 149–50. 44. 156–7 assessments compulsory 80–1 needs and priorities 15. 246 beliefs cultural 77. 245 Aotearoa New Zealand 44–6. 248 traditional 65–6 beneficence. 81. 71. 79. 246 asymptomatic patients 87 attorney. enduring powers of 36. 48 APA see American Psychiatric Association APCs see Annual Practising Certificate Asian community 68–71 Cambodians 69 Chinese 69–75 engaging with 68 ‘healthy immigrant effect’ 69 Indians 69–70 Koreans 73–5 mental health needs 70 Public Health Project Team 70 Vietnamese 71 Asian Health Chart Book 69 Asian Health Research and Evaluation Centre 68 assessment processes 63. importance of 54 Annual Practising Certificate 31–2. 25. principles of 158 autonomy of patients 163. 54. 25. 179 anaesthetics 197 anaesthetists 207–8 ancestors (t puna). 83. 148. 218. 61. 176. 194 Auckland Chinese Medical Association 68 audits (standards and performance) 17. 180–3.American Medical Association 69. 98. 156. 120 American Psychiatric Association 175–6. 54. 136. 144. 147. 128. 155–6. principles of 158 252 Cole’s Medical practice in New Zealand 2011 . 200 Association of Salaried Medical Specialists 33 asthma 54. 37. 21. 66. 36. 184–5. ethical 15. 68 B BABs see Branch Advisory Bodies behaviour. 169. 185. 233. 156 Australian and New Zealand Journal of Psychiatry 55 Australian Medical Council 31 authorities. 158–60. 134. 127. 31.

183 breaches 37. 61. 90. 19. 184. 208 tertiary 75 Care of Children Act (2004) 85. 95 care 12–13. 122. awareness of 46. 139. 90 Centre for Adverse Reactions Monitoring 120 certificates 99–100. 201–2. 221 Code of Health and Disability Services Consumers’ Rights (1996 ) 198. 128. 87. 94 CAM see complementary and alternative medicine Cambodian community 69 cancer 39. 219 standard of care 206–7. 79. 52–3. 210. 168. 68 bicultural heritage 41. 240 biases.benefits 13–14. 14. 205 continuing 15. 39. 166. 152 bullying and intimidation 128–9 Burial and Cremation Act (1964) 196 burns 63. 161 patient-centred 19. 208 postoperative 208 providing of 11–12. 181. 205. 20. 223 specialist 39 standards of 9. 39–40. 82. 85–7. 219. 231. 74–5. 91. 56. 65. 89–91 careers. 114–15. 52. 64. 203 complaints regarding 210–11. 199 carers 9. 53–4. 16. 246 CETU see Clinical Education and Training Unit charges. 41. 82. 163. disciplinary 212. 207–8 acute 19 appropriate ongoing 20. 191–2. 208 compassionate 142. 74. 193. 17. 115. availability of 141. 15–20. 44 biculturalism 36 births 61. 142. 64–6. 187. 28. 205–6. 104–7. 196–7. 43. 234 caregivers 14. 130. 189. 114. 175. 195–7 cervical cancer. 150. 131. 229 blood samples 195 blood tests 58. 215 Cole’s Medical practice in New Zealand 2011 253 C . 210. 26. 203 blood transfusions 90 BMI see Body Mass Index BMJ see British Medical Journal Body Mass Index 62 bowel cancer rates 64 Branch Advisory Bodies 30. 127–30. screening for 64. 55–6. 20. 127. 101. 150. 158. 115 cardiac procedures 53 cardiovascular diseases 70–1. 39. 113–14. 43. 173. 120. 230. 191. 101. 161–3. 66. 210 British Medical Association 138 British Medical Journal 52.

209 clinical research 166–7 clinical supervision 208–9 clinicians 81. 26. 115. 127. 54–5. 158–9. 91. 180–1. 153–6. 143 communications 10. 15. 88–9. 175. 77. 125. 107. 116 clinical leaders 132–6 clinical practices 149. abuse 109. 50. 123. 173–4 with Accident Compensation Corporation 92–5. 179. 210–11 Code of Patients' Rights 35. 138. 195. 141. 181 cultural 46. 194. medical 32–3. 187. 36. 249 compensation issues 51. 129. 40. 191. 39. 38. 39. 132–3. 100. 149–50. 103. 41. 112. 159. 88. 233–4. 150 CME see continuing medical education co-payments 93 Code of Ethics 27. 173–4. 246 children 36. 95–8. 209 communicable diseases 25. 90. 178 Clinical Education and Training Unit 243 clinical examinations 135 clinical investigations 115–16 management of 111. 194. 207 commercial organisations 22. 249 fake 36 patient's 89 professional 154–5 254 Cole’s Medical practice in New Zealand 2011 . 131. 249 Children Young Persons and Their Families Act (1989) 89. 205. 19. 44. 222 Committee on Professional Conduct and Ethics 123 common law 82. 165. 21–5. 159. 198–9. 195 Chinese community 69–75 Chinese medicine 72–3 chiropractic therapy 171 choices 14. 33. 58. 127. 205–8. 13. 98. 184–5 clinical 8. 88. 109. 218 competence 9–12. 27. 85. 89–90. 52. 92. 82. 162. 46–7. 158–60. 46. 34–5. 195. 91. 168. 55. 173 legislation 194 circumcision 66–7 cirrhosis of the liver 138 claims 49–51. 202–3. 168. 175 Code of Health and Disability Services Consumers’ Rights (1996 ) 13. 247 colleges.chemotherapy 96 child. 81. 198–200. 85. 156. 61–3. 160. 142. 66. 30–2. 160. 133. 65. 163. 241. 113. 130. 225 Code of Health and Disability Services Consumers’ Rights (1996 ) 194 food 225 informed 85–6. 181. 92–3. 108 evidence based 16 falsifying success rates 16 medical insurance 38 'Class A' controlled drugs 189–90 clients. 74. certificates for ACC 100 clinical drug trials 175. 97. 206.

184–6. 122. 95. 65–6. 33. 106–7. 87–91. 211 mechanisms for solving 198 patient's 16. 202–3. 73–7. 223 consents. 213–15. 214. 153–4 individual 207. 220 clinical 39 imposition of 180. 210. 13–14. 203. 177–80. 38. 184 standards of 155. 124. 146. 134. 71. 63–4. 202. 78–9 compulsory assessments 80–1 Compulsory Treatment Orders 81 conditions 13–15. 124. 121. 116. 131. 58. 221 Cook Islands community 62 coronary heart disease 25. 30. 82. 220 irreversible 145 minor 166 particular medical 121 patient's 10. 42. 23. 175–7. 198 formal 35. 153 coroner. 112. 223 Compulsory Assessment and Treatments 15. 19. 119. 103. 206–7. 220 complaints 16. 22. 121. 183 contraception 71. 86. 197. 90. 181. 193.reviews measuring 181. 150. 187. 198–200. 205 unresolved 203 Complaints Assessment Committees 155 complementary and alternative medicines 171–4. 183 Continuing Professional Development Programmes 32. 220. 184–6. 142–5. 162. 17. 101–3. 38. 87. 36. 163. 25. 87–9. 25. 221 chronic 174 efficient resolution of 184. 137. 190–1. 160. role of 17. 35–6. 178–9 consents 26. 95. 218 Cole’s Medical practice in New Zealand 2011 255 . 108. 65–6. 40. 161. 34–6. 157. 148–50. 109–10. 184–5 competence programmes 31. 118. 246 Contraception Sterilisation and Abortion Act (1977) 193 convictions 192. 166. 128. 141. 198. 111. 154–5. 200. 218–19 conferences 149–50 confidentiality 9. 215. 80. 32. 116. 213. 121. 123–4. 123. 101. 173. 167. 53. 168. 194. 213. 223. 206 Continuing Medical Education 22. 194. 218. 173 policies for 248 procedures for 16. 185–6. 182. 139–40. 203 consumer demands 138 consumer health issues 41 consumers 27. 184. granting of 85. 32. 212 resolution of 125. 120. 204 serious 202. 85. 24. 74. 178. 232 respiratory 63 conduct 17. 217. 14 physical 109. 210–11. 44. 200. 146. 136. 19. 218. 90. 105–6. 97. 54. 206. 89–90 consultations 11. 246 conflicts 87. 198. 212–15. 169. 184 complainants 157. 202–6. 31. 247 perspectives 41 rights of 35.

220 disability services 27–8. 90. 223. 93–4. manner of handling 20. 143 anxiety 143 D 256 Cole’s Medical practice in New Zealand 2011 . iron 63 depression 45. 36. 48. 143. 207 deficiencies. development of 8. evidence-based 166 CTO see Compulsory Treatment Order cultural competence. 55. 93. 198. 238. 158. 54. 70–1. 115. 39–40. 246 Director of Area Mental Health Services 81 Director of Proceedings 184. 149 DAOs see Duly Authorised Officers death 52. 206 diseases 63–5. 154. 210. 150. 61. 246 parasitic 63 pre-existing 96 transmitted 63 disorders 79–80. 65. 192. 68–9. 249 cultural issues 205. 229–30. 130. 191 criteria. 107. 141. 85. 241 customs and traditions 54–5. 176 DHBs see District Health Boards diabetes 52. 101. 151. 94. 213. 103. 82. 65 DAMHS see Director of Area Mental Health Services dangers (personal relationships) 37. 64. 201. 121. 153. 217 CPDPs see Continuing Professional Development programmes credentialed healthcare providers 125 Cremation Act (1964) 196 Crimes Act (1961) 83. 127. 235. 215 disclosure. 54. 187. 220–1 court orders 90 courts of law 213–14. 187. 236. 95 chronic 125 coronary 63–4 fibrocystic 112 motor neurone 39 neurological 143 notifiable 192. 160. 41–5. 192 cardiovascular 70–1. 35.Coroners Act (2006) 197 correction of health information 106 see also health informartion costs 13. 79. 248 Council Registrar 143–4 counterfeit medicines 123–4 Court of Appeal 186. 107–10. 120. 80. 140. 70. 159. 52. 199. 204. 55–6. 47. 83. 176. 63. 87. 36. 163. 70. 43–6. 93. 196–7. 195 discrimination. 76. 186. 215. 203 disciplinary charges 212. 176. 108. 220. 95–6. 161. 153. 242 cultural misunderstandings 54 cultural safety 45–6 cultures 35–6. 47–8. 177. 232–3. 162. 66. 76. racial 44. 138. 58.

146. 168. responsibilities of 17. 18. 224. 178. 219–20. industrial actions 159. 154 employers. 128. 166. 201–2. 110. 131. 32. 70. 250 abuse of 187–90. responsibilities for 110. 224. 177. 192. 223. 209. 232 doctors. 94. 208–9. 115. 176. 43. 209. new 40. 247 employees. 117. 25. 163. 236. 32–3. 55. 176–7. 32. 129–31. 69. 131. 28. 190 restricted 176 Duly Authorised Officers 81 duties 11. 81. 128. 44. 247 doctors. 21. 157 doctors. 65. 91. 234 efficacy of medicines 118. 144. 127–9. 156. 52. 82. 28. 223 addictive 11. 204. 139. 247 doctors. 217 recognition of 26 District Health Boards 28–9. 44–6. 242 doctor-patient relationships 12–13. deputising services 130 doctors. 199. 167–9. 158–9. 173 electronic records 104 electronic results 115 Emergency Departments 201. registered 19. 154. 138. 16. 149. 34–5. 31. 172. 236 doctors. 35. 136. 129. 23. 121. 15. 181–2. 97–9. 174. 220. 92. 220. 186. 155–7. 73. 44. 91. 246 drug promotions 177 drugs 11. 214 doctors. 238. 143 psychological 138 psychotic 80 disputes 167. 80. 144. 168. 240 Cole’s Medical practice in New Zealand 2011 257 E . 101. 25–6. 33. 160–1. 85. 38. 37–8. 65. 123. non-Mãori 54 doctors. 156 distress 11. 146. 90. 240–1 doctors. 39–40. 240 employment. 141. 134. 126. 143. 187–90. 191. 143. 195. 21. 177 prescribed 11. 192. 184. 205. 13. 167. 218. 167–8. senior 29. 207. 234. 124. women 142 DP see Director of Proceedings drug abuse 64. 42. 190.eating 143 mental 78–9 mood (bipolar) 79–80. competencies 8–9. 129. 222. 143. 156 'Class A' controlled 189–90 controlled 188–90. 156. 164. 169–70 doctors. 51. 204. 209 eating disorders 143 education 14. 21–5. 244. 134. 165. performance 17. 246 new 167. 238. 240. 204 disruptive behaviour 23. ill-health 23 doctors. 230–2. 55. 236. requirements for 21. 177. 243 doctor-patient interactions 12. 21. regulation of 180. 242. 180. 161. 223. 225. 109. 44. 177. 112. 25. 37.

47. 26. 157. 61. 74. 148. 97. 61–2. 217. 42–3. 166. 144. 199 environment 18. 66 large 62 Family Courts 81 258 Cole’s Medical practice in New Zealand 2011 . 47. 79. 184–5. 152. 199–200. 249 entitlements. 165–7. 245 errors 102. 165. 169–70 constraints surrounding the 132. 178. 236–8 bereaved 56 extended 39. 118–21. 98. 52–4. 79. 62. 192 Ethics Committee 22. 24. 172. 222 rural 233 equipment 24. 159. 244 authorised 190 tertiary education 233 Fair Trading Act (1986) 15. 132. 87. 205. 179. 137. 24. 74. 56–9. 158–60. 241. 241. 70–1. 53. 210 disclosure of 154 individual's 157 minimising of 113.enduring power of attorney 36. 158–60. 68–70. administering of 92–3. 45. 66. 42–3. 38–9. 21. 131. 128. 229 European patients 50. 49–50. 69. 194 engaging of Asian migrant patients 68 English language issues 41. 168–9 ethics 33. 126. 54. 151–5. 232. 172. 214 exploitation of patients 160–1. 133. 96. 182. 135 resource limitations of 11. 37. 217 examinations clinical 135 intimate 247 physical 124 psychiatric 220 x-ray 115 examinations for academic qualifications 137. 156. 193 ethnic groups 48. 106. 230–3. 173 F facilities 66. 42. 108. 201. 65–6. 38 families 12. 70 euthanasia 192 evidence based medicine 16–17. 214. 98. 89. 153. 115 reduction of 152 serious medication 152 ethical behaviour 15. 38. 150. 74. 125. 54. 219. 63–4. 162. 139. 250 ethical issues 159 ethical practices 242 ethical responsibilities 82. 112–15. 176. 68. involvement of 77. 246 ethical expectations 119. 76. 21. 70 ethnicity of patients 36. 232 expert witnesses 137 experts. 123. 144. 81–2. 83–4. 56. 135. 64. 21. 242. 142. 162.

232 food 55–6. 142–3. 89. 74. 65 fevers 72 fevers. 71. 101–3. 213. 29. 177 'Gillick competency' 91 Good Medical Practice . 184. 65. 37–8. 134. 225–6. 175–6 gifts 22. 247–9 guilt. 113. 24. 28. 130–1. 78. 201. 147. 138.'family doctors' 73. 200. 153–4 fractures 204–5 'frontal lobe syndrome' 80 funding 30. 77. 218. 234 guardians 75. 187. 142 fitness and health 30. 91. 51. issues surrounding 25. 105. 141. 89 Guardianship Act (1968) 90 Guardianship Orders 78. 174 fees and charges 26. 35. 31–2. 55. 48. 224. 99. 135. 29. 108. 166. rheumatic 63 financial dealings 26. 152. 143 Health (National Cervical Screening Programme) Amendment Act (2004) 193 Health and Disability Commissioner 9. 165. capitated government 29 funding agencies 122 funding bodies 159 funding constraints 136 G gastrointestinal infections 71. 195. 24. 186–7. 222. 242 inadequate 63 interactions 46 limited 71 outcomes 150 providers 110. 33–4. 75. 215. 181. 40. 49. 214. 160. 39. 74 general anaesthetics 87 general practitioners 18–20. 159. 52./Commissioner HDUs see High Dependency Units head injuries 80. 82. 32–3. 151. 112–15. 220–2 health care 53. 245. 175 services 61. 228 forensic psychiatrists 78 formal complaints 35. 92–3. 21. 171–2. 186. 217–19 gynaecologists 209 HDC see Health and Disability Commission. 142. 100. 155. 66.A Guide for doctors 179 governance issues 17. 147. 150. 222 governments 29. 139. 55. 30. 158. 85. 145. 185. 153. 66 Cole’s Medical practice in New Zealand 2011 259 H . 82. 139 Federation of State Medical Boards of America 123–4. 163. 206. 31. 160. 82 guidelines for medical practice 27. 243 funding. 74. 198. 126. 26. 53. 211 effective 53.

136–7. 185–6. 112. 193. 153 see also coronary heart diseases hepatitis B 71–2. 215 health providers 32–3. 143. 248 Accident Compensation Corporation 29. 109–10. 30. 134–5. 108. 196. 175–9 Health Research Council 32 health service executives 132 health services 38. 249 health intranet 122 Health on the Net Foundation 119–20 Health Practitioners Competence Assurance Act 8. 199. 54. 98. 88. 209. 219–21 High Dependency Units 207 HIPC see Health Information Privacy Code (1994) 'homeopathic clause' 171. 61. 62–3. 21. 53. 181 'health consumers' 35. 171. 23. 169. 181. 164. 204. 166 hospitals 32. 151–2. 121. 143. 45. 210. 28. 247 heart diseases 25. 32. 127–8. 218. 48. 212. 236. 221–2 Health Practitioners Disciplinary Tribunal 155. 210 reproductive 193 rural 31–2. 99. 248–9 fundeding of 86 mental 55 public 23. 102–8. 162. 215. 149. 164. 147 hepatitis C 147 herbal remedies 57. 133. 168 health research 14. 38. 87. 93. 65. 87. 184–6. 146. 83.teams 129. 48. 221–2 health professionals 8. 166–7. 51–2. 43. 17–18. 121. 48. 212. 144–7. 223 workers 130 Health Committee 138. 180. 208 hours of work 37. 22. 89. 209 Household Health Surveys 62 HPCAA see Health Practitioners Competence Assurance Act HPDT see Health Practitioners Disciplinary Tribunal 260 Cole’s Medical practice in New Zealand 2011 . 46–7 health funding 248 health information 54. 147. 137. 180. 23. 64. 114. 101. 173 HON see Health on the Net Foundation Hospice New Zealand 39 hospices 39 hospitality 26. 152. 69. 101. 56. 64. 103–6. 36. 70. 101. 242 health workers 69 Health Workforce New Zealand 31 health workplaces 44–5 healthcare organisations 70. 142. 233–4 health status 52–4. 41. 246 house surgeons 33. 101. 192. 77. 243. 20. 58. 53. 39. 42. 241. 205. 52. 92–100. 71. 54. 42. 150. 180–1. 61–3. 193 Health Information Privacy Code (1994) 13–14. 41–2. 209. 186. 159. 54. 110. 63–4. 156. 115. 143–4. 107–8. 155. 134. 148. 187. 93. 74–5. 67–8. 67. 23. 66–7. 238. 65. 59 High Court of Australia 91 High Court of New Zealand 81. 221. 212. 69 health supplements 73 health systems 29. 103. 87–8. 68.

90–1. 82. 242. 162 need to know 245 resources 119. 198. 126 sensitive 131 sharing 11. 45. 88. 77–8. 88. 235 written 203 informed choices 85–6. 246 IMGs see International Medical Graduates) Immigration New Zealand 234. 81 insanity 78. 138. 119–22. 221 hypomania 80 I illnesses 35. 163. 243 statistical 108 strategy 30 supplementary 121 technology 121. 236. 192 information 13–17. 19–20. 173 Indian community 69–70 inducements and gifts 22. 130–1. 26. 121 community-based 64 confidential 82. 193 Human Rights Act (1993) 161 Human Rights Commission 206. 248 Human Rights Review Tribunal 103. and Compensation Act 2001 211 inpatients 39. 121. 96–100. 249 insurance companies 38. 82–3 insurance. 173. 173 informed consent process 85. 159. 73–4. 19. 163. 234. 162. 147 imprisonment 99. 36. 241 impairments 129. 211 physical 94. 135. 210. 51. 138. 161–5. 96 Injury Claim Forms 97 Injury Prevention. 211 head 80. 137 Cole’s Medical practice in New Zealand 2011 261 . 218 independent scientific evidence 165. 80. 91. 105. Rehabilitation. 147. medical indemnity 245. 95–100. 203–4. 178. 65–6. 196.HPDT see Health Practitioners Disciplinary Tribunal human anatomy 72 Human Immunodeficiency Virus 147 human reproduction 187. 98 personal 92–5. 85–8. 39. 237. 147. 143 patient's 92. 59. 38. 188–90. 223 infectious diseases 89. 185. 103–9. 213– 14. 247. 166. 250 injuries 29. 177 Induction and Supervision for Newly Registered Doctors 19 Infant Mortality Rate 63 infections 25. 238–50 asymmetry of 118.

108–9. 154. 24–5. 191. 148. doctor and patient 12. 83. 218–19 mana 49. 85. 183. 126. 199 liability 28. 97–8. 120. 126 literature review 119 use of 11. 110. 93–4. 241. 44–6. 214 iron deficiencies 63 JKL juries 83–4 justice. 172. 130–1. 55–6 262 Cole’s Medical practice in New Zealand 2011 . 42. 27. 228–31. 180. 118–19. 200. 76. 74–5. 213–15. 109. 224 internet medicine 27. 238 involvement of experts 77. 75–7. 209. 187–8. 124 health sites 119. 194. 184. 220–1 complex 206 formal 202. 49. 223 use of libraries 118–19. 236–9. 137. 129. 121 integration with daiIy practice 118. 205–7. 121 interpreters 44. 115 litigation 24. 194 locums 18. 216 laypersons 215 legal duties 191 legislation 15. 205 particular 166 investigators 166. 178. 103. 81. 209 lawyers 27. 232. 44. 120. 19. 121–6. 126. common 82. 35. 112–13. 101. 199 intimate examinations 247 investigations 10. 35. 183. 177. 65. 51. 121. 15. 224. 237 M macrons. 37–8. 234. principles of 158 Korean community 73–5 Korean Women's Wellness Community Group 68 Land Transport Act (1998) 89. 86. 69. 177. 214 investments 169. 161. 138. 128. 32. 241–3 International Physician Assessment Coalition 111. 158. 85. medical protection 84 integration of internet with daiIy practice 118.insurers. 126 integrity 25. 249 law. 250 data security 118. 164. 68. 193–4. 88. 90. 65. 21. 154 liver cirrhosis 138 'Living Wills' 39. 160 see also moral integrity Intensive Care Units 201 interactions. 111. explanation for 59 malpractice 125. 46. 204. 229. 171. 242 International Medical Graduates) 21. 136. 195 languages and language services 14.

214 medical research 32 medical schools 31–3. 204–5. 93–4. 18. 160. 28. 117. 144. 124. 180–1. 181. 124–7. 158–60. 81. 48–57. 156. 207 Medical Council of New Zealand 8–12. 196. 158–9. 250 M ori values 56 marae 56. 209. 143. 45. 195–6 medical colleges 32–3. 68. 21–5. Health Committee 138. 144 medical errors 112. 209 medical problems 36. 221 medical care 10. 239 medical practitioners 30–1. 139. 32. 103. 36. 134. 43–5. 110. 139. 138. erectile dysfunction 123 medicines 28. 168–70. 118–20. 30–7. 147. 77. 28. 151–3. 36. 158 medical indemnity insurance 245. 181 Medical Schools' accreditation 31. 81. 148. 30. 70. 85. 240–3 Medical Council of New Zealand. 190 Medicines Regulations (1984) 188 Cole’s Medical practice in New Zealand 2011 263 . 63–5. 160–1 medical students 130. 209 medical practice in New Zealand 28. 161 medical certificates 99. 175. 213–16. 177. 123–4. 213– 14. 228–34. 73–4. 123–4. 191. 180–90. 107. 141. 158. 118. 32. 155–8. 221–4. 33. 125–6. 192. 119. 115 medical librarians 120 medical licensing authorities 124 medical migration 230 medical misadventure 95 Medical Officer of Health 24. 105–6. 143. 141–4. 89–91. 155. 203 medications. 74. 146–8. 173. 58 MCNZ see Medical Council of New Zealand mediation 198. 218 medical professionals 25. 136. 172. 205. 36. 223 counterfeit 123–4 theory of 171–2 Medicines Act (1981) 124. 187–8. 14–17. 168 medical treatments 29. 165. 181. 43. 74. 176 Medical Law in New Zealand 200 Medical liabilities 28. 190.manaakitanga (duty and obligation of care) 55–6 M ori (iwi) health services 44 M ori Language Commission 59 M ori people 12. 134–5. 219 Medical Practitioners Disciplinary Tribunal 91. 187–91. 34. 248. 121–2. 107 medical services 15. 30 medical record keeping 102 medical records 91. 175–6. 171. 28. 85–6. 96. 187. 151. 86. 174. 223. 61. 174. 174. 21. 142. 171–2. 75. 151–2. 231. 129. 194 medications 57–8. 73. 230 alternative 27. 165. 249 see also professional indemnity insurance Medical journals 119–20. 168 medical procedures 90 medical profession 27. 53. 101–3. 242. 27–8. 154 medical ethics 47. 199.

90 alcohol and drug abuse 71. 218–19 NEJM see New England Journal of Medicine neurological diseases 143 New England Journal of Medicine 120. 243 Misuse of Drugs Act (1975) 188–90 Misuse of Drugs Regulations (1977) 189–90 moral integrity 25. 139. 188. 191 misconduct allegations 205. 127. 66–7. 81. 114.medico-political issues 33 medicolegal matters 212 Medsafe 118. 131. 215 Ministerial Advisory Committee on Complementary and Alternative Health 171 Ministry of Health 28–9. 31. 216. 151. 78–9. 246 inpatient units 81 institutions 64 issues for Asians 71 women and refugees 71 Mental Health (Compulsory Assessment and Treatment) Amendment Act (1992) 15. 220–1 New Zealand Disability Strategy and Mãori Health Strategy 51 New Zealand Doctor 40. 71. 151–4. 172. 120. 33. 120. 249 Mental Health Commission 71 Mental Health Compulsory Treatment Act (1992) 89 Mental Health Law in New Zealand 84 Mental Health Review Tribunal 81 mental injuries 92. 96. 158–9. 179 New Zealand Bill of Rights Act (1990) 191 New Zealand Code of Health and Disability 44. 63. 52. 157. 94. 75. 124. 32. 190. 218 mistakes. 131 New Zealand Court of Appeal 186. 69. 158. 38. consequences of 138. 94–6 MHRT see Mental Health Review Tribunal Minister of Health 29. 160 mortality rates 64–5 N National Cervical Screening Programme 64. 189. 61. 207. 193. 191. 246 National Health Board 30 National Health Committee 153 National Health Index 108 National Primary Medical Care Survey (2001-2002) 53 national rates (mortality) 64–5 Nationwide Health and Disability Advocacy Service 247 negligence 29. 111 New Zealand Family Physician 76 New Zealand Guidelines Group 120 New Zealand Medical Association 27. 187. 161. 206 mental health 70–1. 170 New Zealand Medical Journal 33 New Zealand Mental Health Commission 71 New Zealand Ministry of Health see Ministry of Health 264 Cole’s Medical practice in New Zealand 2011 . 79. 81.

164. 189 nurses 35. 81. 103. 250 Orientation Topic Checklist 240 orthomolecular treatments 171 osteopathy 171 overweight problems 62–3 see also obesity P Pacific community 43. 119. 208. 158. 243–5. 154. 246 notification. 116. 40. 55–6. 85. 245 NZMA see New Zealand Medical Association O obesity 52. 91. 181. 130. 242. 199 ethical 38. 121. 45. 157. 13. 60 non-doctor prescribers 18 non-insulin dependent diabetes mellitus 63 non-maleficence. 101–2 legal 27. 246 treatment providers 100 obstetrics 53–4. 84. 58. principles of 158 notifiable diseases 192. 139. 165. 184. 209 opinions 19. 106. early and formal systems 111–13. 239–41. 174. 147. 62–3 obligations 27. 45. 223 caring requirements 65–7 Cook Islanders 62 customs and traditions 61 demographic characteristics 61 health services 65 morbidity and risk factors 62–4 mortality patterns 64 Niueans 62 obesity 52.New Zealand Public Health and Disability Act (2000) 51 New Zealand Transport Agency 195 NIDDM see non-insulin dependent diabetes mellitus Niuean community 62 noa 55. 88. 199. 62–3 population mix 61 Samoans 62 socioeconomic circumstances 61 Tongans 62 Pacific Health Team (Department of Heath) 66 pain 11. 39. 204 Cole’s Medical practice in New Zealand 2011 265 . 84. 40. 61–7. 110. 197. 236. 214 personal 165 professional 219 second 11. 135–7. 208. 173. 204 oral evidence 214 Orientation of International Medical Graduates 228 orientation programmes 231. 165. 143. 204–6. 235. 143–5. 162.

170. 176 pharmacists 123–5. 188.partnerships of doctors 9. 184. 169. 101. 150. 105 Privacy Commissioner 103. 138–41. 163. 153 patient confidentiality 122. 132. 109–16. 18. 67. 78. 248 personal injuries 92–5. 140. 209. 190 prescriptions 11. 184–6. 71. 128. 113. 20. non-doctors 18 prescription medicines 123–4. 153. 44. 101. 19. 134. 51. 155–7. 152. 180. 36. 77. 25. 159 Pasifika Medical Association 33 Pasifika patients 43. 110. 61. 125. 101. 165. 86. 123–4. 122. 35. 243 principles of beneficence 158 principles of justice 158 Privacy Act (1993) 102–3. 211 Pharmac 32. 66. 127. 11. 73–4. 179. 131. 68. 65–6. 199–208. 222 patients fears and concerns 99. 225 Pharmacy Council 125 PHOs see Primary Health Organisations physical examinations 124 physical injuries 94. 177–8 patient chat rooms 121 patient complaints 31. 220 PCC see Professional Conduct Committee peer review processes 190 performance. 21–5. 98 patient's symptoms 45. 70–1. 243. 13. 191–2 patient's history 10. 154 psychiatric 64. 147. 148. 228 prescribers. 175–7. 206 patient consent 163 patient deaths 151. 32. 207. 78 patient's benefits 85. 189. 174. 54. 181. 30. 150. 55. 220–1 266 Cole’s Medical practice in New Zealand 2011 . 159. 139. 203. 128–30. 152–4. 44. 155–7. doctor's 17. 87. 23. 53. 204 payments 22. 174. 45 pathology 112–13 patient care 8–9. 184. 199. 191 primary care delivery 29–30. 44. 96 physicians 34–5. 140. 120. 163. 70. 212–15. 32. 192 Primary Health Organisations 29. 55. 248 pharmaceutical companies 175–8 pharmaceutical industry 175–9 pharmaceuticals 28. 106. 210–11. 19 patient's injuries 92. 172. 21. 224 personal beliefs (sensitivity regarding) 14. 188–9. 214 performance assessments 22. 184–5. 229 pregnancies 225. 106. 65–6. 136. 134. 98. 191. 86. 192 patient-doctor relationship 40 patient records 11. 17. 110. 153. 249 privacy issues 108 privacy legislation 199 privacy orders 217 Professional Conduct Committee 9.

97. 127. 100. 184–5. 184. 41. 232 racial discrimination 44. 70. 247 rangatiratanga ('mana') 49 RAS see Refugees As Survivors rates 52–3. 93. 49–50. 88. 166. 87. 70. 147. 64. 78 psychiatrists 55. 63–4. 70 RACMA see Royal Australasian College of Medical Administrators RACP see Royal Australasian College of Physicians radiation 94. 22–5. 138 forensic 78 psychological disorders 138 psychological services 93 psychological symptoms 78 public health 23. 61–3. 192. 130. 82. 229–30. 112. 98. human 187. 36. 150. 203 consumer's 211 patient's 14 risks 10. 35. 88. 160. 198–200. 207 Pubmed (database) 119–20 QR qualifications 16. 194 providers 52–4. 44. 81. 79. 210 public hospitals 28–9. 82. 162–3. 219–20 reproduction. 80. 119. 88. 138 radiology 112. doctor's 144. 27. 125. 161. 194. 70. 51–2. 198–200. 193 Researched Medicines Industry 175 Responsible Clinicians 81 resuscitation equipment 245 reviews 34. 83.professional indemnity insurance 249 Protection of Personal and Property Rights Act (1988) 78-9. 125. 71 registration. 109. 151. 137. 61. 85–7. 89. 66. 184. 127. 210–11. 201–2. 46. 119. 178–9 including expected 13 inherent 175 managing 153 Cole’s Medical practice in New Zealand 2011 267 . 18. 56. 144. 78 psychiatric patients 64. 186. 117. 90–1. 113. 14–15. 205–7. 131–2. 183. 206 racism 54. 191. 67. 152 cancer death 64 RC see Responsible Clinicians recognition of distress 26 Refugees As Survivors 68. 155–6. 18. 187. 150. 30. 173–4. 182. 166. 113. 54. 214–15 external 201–2 systematic 149–50 rheumatic fever 63 rights 13. 248 credentialed healthcare 125 primary care 65. 78. 202–3. 165. 181. 150 psychiatric examinations 220 psychiatric illnesses 70.

132–6. 19. 152. supporting of 12. 249 social workers 109. 193–4. 119–25. 148. 135. 164 public 13–14. 193. 218 screening programmes 64. 139. 23. 236–41. 64 supervision (newly registered doctors) 19. 50.material 91 moderate 190 patient safety 133 serious 79. 205–6. 233–4 safety 12. 26–30. 156. 202. 174 slang expressions 224–7 smoking 63. 169. 146–7. 88–9. 79–80 S 268 Cole’s Medical practice in New Zealand 2011 . 40. 171. 79–80 self medication 73 Sensitive Claims Unit 96 services 15–16. 116. Dr Ian 111. 224 Standards New Zealand 248. 134. 243–9 services. 79. 134. 146. 33. 21. 123. 155 rituals 44. 243 SIDS see Sudden Infant Death Syndrome skills 8–9. 207–10. 159–60. 43–4 sharing patient's information 11. 64–6. 19. 152. 166. 134 Royal Australasian College of Physicians 175. 143 Sudden Infant Death Syndrome 51. 146. 182. 46. 173 scope of practice 108. 125. 135. 164–5. 180–3. 223 safety issues 210 salaried doctors terms 33 Samoan community 62 scientific evidence 165. 143. 250 Statistics New Zealand 66. 33. 187. 160. 81. 53–5. 42–3. 204 self-care. 31. 155 of patients 18. 130–1. 166. 133–4. 68 substance abuse 80. 14–15. 159. 43–4. 148. 13. 142. 21. psychological 93 sexual abuse 94. 249 second opinions 11. 185–6 cultural 41. 124–5. 169. 197–200. 195. 93. 142. 96 sexual orientation 20. 37–9. 162. 191. 217 rural working environments 31–2. 141. 164. 209 skills. critical appraisal of 172. 56 RMI see Researched Medicines Industry rongoã (traditional healers) 57–8 routine blood tests 74. 137. 23. 121. 224 supporting of self-care 12. 132–3. 179 Royal New Zealand College of General Practice 249 Royal New Zealand College of General Practitioners 122. 45–6. 122 Royal Australasian College of Medical Administrators 132. 206 rules 101–9. 144. 34. 22–4. 17–18. 195 St George. 127. 129. 185.

154 TMVIs see transmissible major viral infections Tongan community 62 torture 75. 112. 19–20. 88. 181. 168. 165 'total body checks' 74 Traditional Mãori Healing 55. 242 Cole’s Medical practice in New Zealand 2011 269 . 185–6. 142. 147. 220 therapy. 141 managing patients resulting from 114 normal 111 overdue 112 reporting 112 tracking 115 tests 20. 125. 65 trainee interns 33 trainees. 182–3. patient's 45. 248 training programmes 32–3. 130–1. 110 transmissible major viral infections 25.surgeons 35. 172–4. 228–30. 201. 85–93. 88. 118. 181 transfer of patient records 101. non-drug 176 threats 105. 172. 115–17. 210. 101. 35–8. 171. 154. 112–16. 14–16. 220. 70. 53–6. 95–8. 208. 32. 171. 131. 122. 99. 207 surgery 29. 75. 78. 77–81. postgraduate 183 training 21–2. 248 computer 115 efficient 112–13 event-reporting 152 failures of 113. 150–1. 122. 166. 30. 32–3. 142. 183. 204 symptoms. 127–8. 127. 156 telemedicine 121 tensions 47. psychological 78 systems 24. 111–12. 127–8. 74. 191–2. 137. 91. 133. 174 therapy. 159 terminally ill patients 34. 91. 207–8 suspension 180. 234. 39 test results 19. 44. 61. 232 therapy 130. 244 teamwork 39. 111–15. 105. alternative 86. 145–7. 24–6. 223 transplantations 163–4 treatment 9–12. 201. 140. 147. 115 T tangata whenua 44 tangihanga 56 taonga (precious possessions) 51 tapu and noa 55 Te Ora 33 teaching 21. 227. 241. 147. 235–6. 17–18. 219 'Swiss cheese' concept 151 symptoms. 57 traditions and customs 54–5. 163–4. 166–8. 200 teams 12. 219.

25. 146. 61. 99 delays to 15 emergency 12. 55. 155. 169 tüpuna (ancestors). 142. 20. 85. 75. 129. 205. 121–6. 13. 242 WHO see World Health Organisation women 49. 176 use of internet 11. 180. 178 trust 9–10. 55.appropriate 100. 223. 76. 167–8 charted 191 cost of 38. 97. 182 Waitangi Tribunal 44. 214. 49–50 Wellington School of Medicine 138 whakapapa (lineage or genealogy) 54 wh nau 12. 161. 213. 242. 34–5. 93. benefits ('dole') 224–5 universities 32 unjustified authorship claims 22 unprofessional conduct 219 use of agents 16. 238 vocational training 32. 53. 166. 134. 196 Xrays 74. 223 Vietnamese community 71 vocational scopes of practice 134. fitness to stand 82. importance of 54 UVWXYZ unemployment 70. 139. 52. 95–7 lifesaving 89 orthomolecular 171 particular 87. 59–60. 245 facilities for 197 of injuries 93. 204–5 Yin and Yang 72–3 young New Zealanders 63. 47–8. 101 recommended 86 surgical 192 unproven 172 Treatment Profiles 100 Treatment Provider Handbook 100 treatment providers 92–3. 39. 37. 174 plans for 48. 127. 97. 99–100 Treaty of Waitangi 44. 40. 191. 87. 84. 234. 71. 118–19. 68. 165. 89. 48–51. 43. 242 women doctors 142 World Health Organisation 78. 75. 248 triage service 11 trial. 182–3. 55–7. 64. 183. 161. 230 270 Cole’s Medical practice in New Zealand 2011 .

promoting good medical practice Te tiaki te iwi whānui me te whakatairanga pai te mahi e pā ana ki te taha rongoa ISBN 978-0-9582792-7-7 .The Medical Council of New Zealand Protecting the public.