American Elitism: Reflecting on Healthcare Systems from New Zealand
It’s no secret that the American Healthcare System is broken. We may disagree on the solution - but everyone, on both sides of the aisle, agrees that change is needed. It was a challenging decision to enter a system that is so deeply broken. Many of my mentors have warned me about the systemic problems within medicine that contribute to physician burnout and a few even urged me to reconsider applying to medical school. However, throughout the application process and my first year of medical school, when contemplating beginning my career in a system with flaws too numerous to count, I have kept Gandhi’s famous words in the back of my mind: “Be the change you want to see in the world.” If we want to fix a broken system, we need people within that system to see its failings and become leaders in shaping change. If I am worried about entering psychiatry because I think psychiatrists place too much emphasis on medication, the best way to combat this is by becoming a psychiatrist that takes a holistic approach to treatment and publishes research demonstrating the efficacy of a more integrative model of care. Right? Am I ignoring the systemic forces at work pushing psychiatrists and other physicians to rely heavily on medications? Am I naive to believe that I have the power or knowledge to change a system so large and complex? Am I inevitably locking myself into a life of burnout and cynicism by spending my entire career fighting against a deeply broken system?
The last 4 weeks living and working in New Zealand at Auckland Hospital have forced me to think deeply and critically about healthcare systems and medical education. I have always been committed to working in Global Health. But I always pictured myself putting down roots in the US. Now, I’m starting to question that vision.
There is no doubt that the United States is an excellent place to do medical training. I am lucky enough to attend one of the best medical schools in the country and I am confident that I will come out of my training as an incredibly competent physician. But Americans are undeniably elitist and narcissistic - as a nation and as doctors. We pride ourselves on being world leaders in research, technology, and education. But let’s take a look at the numbers. Data from 2016 found that the US spent 17.8% of GDP on health care while other developed countries spent 9.5-12.5%. And unfortunately, this 50% increase in spending is not associated with better outcomes. In fact, life expectancy in the US was the lowest of all 11 countries studied and infant mortality was the highest. Maybe it’s time to start questioning the narrative that the United States is a leader in healthcare and looking to other countries for guidance.
Learning about alternative models of medical education here has also made me start to question the American model. For example, in New Zealand and many parts of Europe, people start medical school after high school. Medical school is 6 years here and includes all of the basic science courses that students in the US take during their undergraduate or post baccalaureate years. This system is more efficient and reduces student debt. However, this model doesn’t hold much appeal for me. I had no idea I wanted to be a doctor when I was 17 and I can’t imagine making such a serious lifelong commitment at such a young age! Anecdotally, it does seem like people here drop out of medical school more frequently than they do in the US. Which is hardly surprising! If I had a nickel for every American college student I know who wanted to be premed until they took organic chemistry, I could get a medical school named after me.
One thing that does appeal to me about the New Zealand model of medical education is that junior doctors here spend at least 2 years working as “House Officers” after medical school before starting residency (here they call it “registrar”). As House Officers, they rotate through different specialties, writing notes and seeing patients under supervision, before applying for registrar in their chosen specialty. I wish we had an option like this in the US. I worry that I, like many medical students, will find myself at the end of MS3 being too excited about too many things and have difficulty making such a huge decision about my career in just a few months. Sure, there are ways to stall applying for residency if you are unsure of what you want to do by MS4, but none of them involve a salary!
Above all else, I’ve noticed that doctors just live better here. Everyone does. We have a work-focused culture in America, especially within medicine. We are one of the only countries in the developed world that has no federal or state statutory minimum paid vacation days or paid public holidays. According to the US Bureau of Labor Statistics, the average number of paid vacation days offered by private employers in the US is 10 days after 1 year of service. In contrast, in New Zealand, employees are entitled to at least 4 weeks of paid annual holiday. Employees are also entitled to 11 paid public holidays. This speaks to a larger cultural difference in how people view work. In America, doctors speak about medicine as a calling, rather than a job. This language, while inspiring, promotes a culture in which doctors are expected to make enormous sacrifices when it comes to work-life balance. This mindset surely plays a meaningful role in the widespread physician burnout in the US.
All of this musing has left me wondering: Am I giving up if I leave my country in search of a better system? Do I have an obligation to stick around and join the fight in my home country? Or, is it in fact an act of self-preservation to find a place where I can prioritize my life outside of work? Where the values of my country’s legal and healthcare system are more in line with my own?