RACP — Kia ora, Michelle, thanks for being available to chat. You were recently in Wellington on a course, is that correct?
Michelle Downie — Kia ora, yes. I attended the Otago University Health Law Intensive course, which was of particular interest to me now that I’m in an Associate Chief Medical Officer role. One of the topics I was interested in was workplace safety and risk. With the pressure everyone works under in hospitals, I think there’s an unprecedented amount of psychosocial risk, and that's something I'm struggling with. You see things you’d like to quantify and address to better protect staff, but we're operating in a resource-constrained environment. If you start looking, you quickly uncover issues right across the hospital and then question what you can realistically do about them.
How do you divide your time between your Associate CMO role and clinical practice?
Yes. Our Chief Medical Officer is also in the regional role, and she oversees 5 CMOs in the district, and still does part of the Tauranga CMO role, but it's too much for one person. I work half-time as Associate CMO and half-time clinically, split between General Medicine and Endocrinology, although General Medicine has the stronger pull because of the unrelenting acute demand. I think having that split is good, but it can get tricky in hospitals when the same workforce is trying to meet competing targets. Most people doing general medicine are dual trained, so there is competing pressure to drive people through our ED’s in reasonable timeframes, as well as meet targets for first specialist appointments.
How are things going at Tauranga Hospital?
It’s similar to everywhere. What’s unusual is that Tauranga is still a regional hospital, but our population is getting close to that of some tertiary hospitals. Generally, I’d say that like much of the health system, we've struggled to keep pace with demand while working within limited resources, and a constant challenge is balancing advocacy for more funding with finding new ways to make the best use of what we already have. From a CMO perspective, that means looking across the whole system and making difficult decisions about priorities and resource allocation. Stroke services are a good example. During the day we have specialist stroke physicians, but out-of-hours those responsibilities fall to general physicians. That creates challenges and raises questions about whether we should expand specialist services, collaborate more across the region, or further upskill general physicians. Underpinning all of this is the fact that it’s best for patients when they can access care closer to home. That's the tension when you're thinking about tertiary hospitals or regional services.
Health New Zealand is implementing a model that has a focus on generalism, GPs and allied health in the regions. How do you see that working out in the future?
Having a mixed general and specialist workforce is the most cost-effective way to look after patients. I think it’s generally accepted that we need more general physicians, particularly outside the major centres. The other issue being recognised is that with the ageing population, patients are increasingly presenting with multiple conditions rather than a single problem. Diabetes, kidney disease, cardiovascular disease, obesity - all these things come as a package, not as a single organ system.
The breakdown in our primary care sector is also having a massive influence on hospital medicine. Increased presentations to the emergency departments means that EDs are becoming overwhelmed, and high proportions of people are being referred for inpatient admissions because we're just not able to turn people away from the ED. There are such huge numbers.
General Medicine is also where many of our most vulnerable patients end up. There are social complexities, mental health issues, drug and alcohol abuse, and intellectual disability. All those things are disproportionately represented in general medicine. General physicians deal with medical and social complexity, mental health issues and multiple comorbidities all at once, so we need a workforce that can manage complexity across the whole patient, not just one organ system. Single-organ specialists are experts in their specific areas, but someone needs to bring all those perspectives together and help patients make decisions that align with their values and priorities. That’s the art of General Medicine. Often there isn't a perfect evidence-based answer, so understanding what matters most to the patient becomes incredibly important.
“General physicians deal with medical and social complexity, mental health issues and multiple comorbidities all at once, so we need a workforce that can manage complexity across the whole patient, not just one organ system.”
For those who haven't worked or trained in general medicine for a long time, asking them to take responsibility for that complexity and the balancing of it all is a little unfair and very stressful for them, because that's not their area of expertise. It also leads to inefficiency and confusion for patients, getting consults from three single organ doctors who are each advocating for what they think the right thing is for that patient.
All this means is that General Medicine has become incredibly demanding, and that’s why I think the mixed model of general and specialists contributing to care is the best model. Likewise, as an individual, always working in general medicine with big in-patient loads, making so many complex decisions 365 days a year is hard. I think that having a mix, or doing a stint in General Medicine, then doing something different is more sustainable.
There’s been a lot of discussion about elevating the profile of General Medicine. What are your thoughts?
It’s something IMSANZ has been discussing for years. One of the biggest challenges is that many patients don't actually know what a general physician is. If we want to raise the profile of General Medicine, we need to be better at explaining what we do and probably use more modern platforms and bite-sized content to do it.
How do we get more trainees interested in General Medicine?
The first thing they need is role models, that’s the most powerful thing. Trainees in their first couple of years need to see people who are doing that job well and be inspired by it. For that, you need to have a healthy workforce who are well looked after, are still passionate and engaged in their jobs and not burnt out. We need to demonstrate that this is a job that can be rewarding and fulfilling, and demonstrate how to do it sustainably throughout their career. There is a high on-call and out-of-hours burden, particularly in regional and remote hospitals, which you can manage when you're younger, but it gets harder as the years go on. More sustainable models of care might involve people having regular breaks from ward work, maybe stepping in and out of general medicine and combining it with outpatient work, research, or another specialty.
“The first thing they need is role models, that’s the most powerful thing.”
Another important part of how we get people to think about training and general medicine is bringing them into our community from the time they're registrars. A lot of the work we do with IMSANZ is getting people to feel like they're part of a community of practice. We've pushed quite hard, and we had 80 or 90 trainees at our IMSANZ conference. We encourage them to join our meetings and make connections with other general physicians, exposing them to the specialty while making them feel they belong.
You recently finished your term as President of IMSANZ. Looking back, what stands out?
Yeah, it was actually quite nice handing one of my many hats to someone else. I joined the IMSANZ Council in 2012 and have spent 14 years on the Council and Board, including the last two as President, so I've seen a lot of changes to how IMSANZ operates. I guess the biggest difference was that we recognised the importance of training board members in governance a few years ago, rather than them simply learning by following what others were doing. IMSANZ now requires all Board members to complete the Institute of Directors and Company Directors training, so they learn about governance and what being on a board involves. That has been transformative and now the society has a board that's trained in governance and understands what its job is, not just a group of interested people who are meeting regularly.
We've also spent the last few years developing clear strategies, goals and priorities, and holding ourselves accountable for delivering them. That focus has strengthened the organisation and prompted us to think carefully about the value we offer and why people choose to be members of IMSANZ, particularly in Australia where membership costs are often paid personally rather than reimbursed by employers.
We've strengthened our conferences and educational programmes, built an online learning hub, grown our research network, and supported research demonstrating the value of general physicians, particularly in peri-operative care. We've also developed our own recognition pathway and are launching an IMSANZ Fellowship (FIMSANZ) - a standalone IMSANZ post-nominal, similar to those offered by other specialty societies. To be eligible, members must be an RACP Fellow working in general medicine for at least five years, be nominated by a peer, and demonstrate a significant contribution to general medicine through areas such as leadership, teaching, research, or service development. It's a recognition of people's contribution to general medicine. We want to provide meaningful value, build a strong professional community, and encourage more physicians working in general medicine to become part of it. We've still got a way to go but have definitely made some good ground.
You’re also involved in College exams, how long have you been doing that?
This is my 11th year writing questions on the Item Writing Panel. I’ve written general medicine questions and endocrinology questions, and now I do the deputy Chair role. It's probably been the most rewarding committee I've been involved with in terms of my own learning and development.
Three times a year, around 18 of us meet in Sydney to debate and decide on exam questions. The process has evolved over the years, particularly with the emergence of AI. It’s interesting because, where we once relied on textbooks, journals and resources like ‘UpToDate’ to fact-check the questions we write, AI is now becoming part of that process. Trainees are using it as a learning tool and it also makes people ask what the point of a written exam is if we can just ask AI these days. So that's an interesting reflection as well.
We also recognise that the exam is a major source of stress for trainees, so there's been a focus on providing more support, including education sessions on what to expect and greater access to sample questions. Around 80% of people pass, but the raw score that people pass with is around 55%. That's really challenging for someone who possibly hasn't done an exam like that since medical school when they probably got 90% right. One of the toughest skills to hone is to write the questions so they're just hard enough, but not too hard, as that is the point where we get the greatest discrimination between candidates.
Being on the exam writing panel is a great activity. It’s challenging work, but it's one of the roles I'm most reluctant to give up. It keeps my knowledge current across a broad range of specialties, and there’s a good bit of humour and collegiality in there. Every meeting teaches me something new, while also reminding me how glad I am that I never have to sit the exam again myself.
It’s a very different learning experience these days now that we’ve got everything at our fingertips. How much do you use AI in your day-to-day work?
Clinically, we've started using AI scribes to support patient assessments and admissions. We're still learning how best to use them, but they can save time, improve patient flow, and produce clearer, more detailed documentation than handwritten notes. You just have to watch out for inaccuracies and be conscious of the security.
The other thing is you never know it all, right? Almost every day there’s something you can’t quite remember, so AI has been good for that, and it's quite a good teaching tool. We’ll often have a consultant, a registrar, and a house surgeon all look something up and then talk about it together.
That’s what makes General Medicine interesting. Every day on a ward round is an intellectual or procedural challenge. There’s that sweet spot when you're being challenged just enough that it's forever interesting. We just have to make sure we don’t make people too busy and worn out for it to be enjoyable.
One last question about Research - what advice would you give trainees tackling research projects?
Start early and ask for help. One thing that happens repeatedly is that it's often the one thing that stands in the way of someone getting their fellowship. People can also find it quite overwhelming. They might have completed all their training requirements but can't get their fellowship or move into a consultant role because the research project isn’t signed off. That can be very disruptive and frustrating.
“Don't leave it until the last minute, and don't do it alone. Find a mentor early, connect with experienced researchers, and link into projects that are already underway.”
So, don't leave it until the last minute, and don't do it alone. Find a mentor early, connect with experienced researchers, and link into projects that are already underway. Professional societies, including IMSANZ through its research network, can provide mentoring, workshops and practical support. But you've just got to get on with it. Find somebody who can help you almost as soon as you start your advanced training.