RACP — Could you tell me a bit about your background, career, area of medicine, and what you are currently doing?

Rod Nicholson (RN) — Sure, I come from a medical background, as my dad was a gastroenterologist, but I wasn't keen to work in the hospital environment and wanted to be out in the community, so I did general practice. After that, I was doing locums as I didn't want to settle into a practice, and I ended up getting a job as a civilian working with the army out at Whenuapai in Hobsonville, Auckland. I was there for five years, and during that time, Professor Des Gorman was with the Navy and was running the occupational medicine training programme. Each month, on a Friday afternoon, all the defence doctors would go over to the Navy hospital and do the training.  

Initially, I had no idea what Occupational Medicine was, and it took a little while to work it out, but by the end of it, I was hooked and it seemed to be the right fit for me. I spent a few years in Wellington and then moved back to Auckland and set up my own practice as a solo occupational medicine specialist on Green Lane Road, where we lease the building to Proactive, another organisation that has occupational health nurses. 

You mentioned your dad was a doctor. Did you have an interest in medicine early on?

RN — Yes, my dad was a gastroenterologist at Auckland Hospital. He would bring home specimen jars, which would be in the car, and I would be looking at these specimens and slides, which wouldn’t be allowed these days of course. Plus, we had a lot of medical-related information coming through the mail, so we'd get all these pens, calendars and things. I was exposed to medicine early on and it was something I was very familiar with. In high school, I had toyed with the idea of becoming a pilot, and in my final year I considered joining the Air Force, which then was primarily an all-male institution, or going to university in Otago. I thought, okay, Otago wins.  

So, I went to Otago Medical School, and I guess, at that time, I didn't really have any other idea about what I wanted to do, but medicine was something I was familiar with, so medicine became the default – but it's worked out fine. Actually, later on, I ended up getting my pilot's license and had a share in a plane at Whenuapai air base when I was working out there. So, it was quite funny how things had gone a full circle and I had ended up doing the pilot thing anyway. So, in retrospect, I think I'm happy that I went down this track rather than sitting in a cockpit for hours.

I wasn't particularly attracted to working in the hospital, and I felt like I'd be happier out in the community, and that's why I initially went down the general practice route. Plus, I enjoyed the patients and enjoyed spending time with them. I didn’t want to do 10–15 minute appointments all day and feel like the life was being sucked out of me. Occupational medicine has a nice balance, because you still get that patient contact, where you can spend a good hour with the patient, and you have a lot of variation because you've seen people with all sorts of medical conditions. There is no on-call work, just office hours, nothing's really acute. You don’t have weekend work, and you can pick and choose your hours, so it's a nice work life balance. 

How about you, Richard?

Richard Seemann (RS) — I think there's some parallels when I listen to Rod’s story. My mother was a general practitioner, and she ended up with a major fatigue syndrome and was off work for about two years. She worked back in the day when you could see close to 100 patients a day. This was in the '60s, and I wasn't initially attracted to doing medicine. I was looking at doing something in the sciences, maybe biochemistry, but then the professor of biochemistry told me that all the excitement is in human biochemistry, and I should go and do a medical degree, so that's what I did. We lived into Dunedin, so I went to  Otago University.

My route to  medicine was also not direct. I was interested in internal medicine, so I did the RACP training, became a geriatrician, and then worked as a geriatrician for a number of years at Palmerston North Hospital. We had a good rehab centre there led by Dr Peter Disler, who was one of the first professors of rehab medicine in Australia. I found out that I could do conjoint training in rehab medicine, and so that's what I did. But there wasn't any particular job for me there, so then I ended up in Auckland working for ABI rehab where I have been for 26 years now. A lot of the focus for ABI is on brain injury, and my area of specialty is brain injury, traumatic brain injury primarily, where I've focused on concussion. 

Could you expand a little bit on what your respective areas of medicine are?

RN — Well, occupational and environmental medicine, in simple terms, is about the effect of work on someone's health and how a person's health impacts on their work. So, for example, if you're a healthy person working in an unhealthy work environment, which historically was working in the mines or in factories where you're exposed to dust and fumes and chemicals, it’s how that impacts people's health. But nowadays, it's more about people who've got an injury or some sort of illness or disease, such as diabetes, and how that impacts their ability to do their job. A lot of my work is injury related ACC type stuff, where people have sustained an injury that's causing long term impairment or disability, and considering how that impacts their ability to do their pre-injury job. Also, whether they can go back to their job, or whether they need to look at something different.

The environmental side of it is similar, but we probably don't do so much of the environmental stuff. It's how your environment impacts your health, like climate change, for instance, or the change in temperature, how that's going to impact people. But it might also be something like a factory that's pumping out fumes or chemicals, and how that impacts a local community. Or other problems like lead in the water or asbestos, that's probably quite a relatively common one. Asbestos in older buildings is an issue, and the University of Auckland, and Auckland Hospital have had those issues. 

It sounds like your work almost crosses over a little bit with the kind of work that Richard does. But you’re also putting people into various kinds of treatment, looking at the environment, and making recommendations about that kind of thing.

RN — That's right. With the injuries, we're involved with rehabilitation, rehab plans and management. Some of our work involves going to factories and industries, assessing the workplace, looking at ways that they can improve things, how they can manage their hazards and risks, and monitoring people. 

So, would conditions like accelerated silicosis be a good example of that?

RN — Yes, that's a good example. I enjoy interacting with a variety of environments and worksite visits, because you can go all over the place, to all sorts of industries and factories, and that's one of the enjoyable aspects. I also like going around and giving talks, such as the asbestos one, for instance, where you've got a room full of hospital workers and you're talking about the potential risk of asbestos, and there's usually someone in the crowd who's quite upset by the whole thing and dealing with that.

The work life balance often comes up and was mentioned in an interview we did with Dr So Young Kim on rehabilitation medicine?

RS — If you're looking at the medical specialties in general, I think our main point of difference is that we work in a multidisciplinary environment so the focus is the multidisciplinary team, and you're also working with a lot with therapists. Unlike some areas of medicine, you don't do a lot of diagnostic work, as in general teams, you've got the diagnosis made for you, and then you're dealing with long term effects for that person.

Here in New Zealand, we don't do the paediatric side of things, but in America, they are trained in both paediatrics right through to geriatric care. Just like Rod, we're seeing more of the older population coming through with chronic disease, including more accumulated effects of various problems that you need to deal with. So, the rehab issues become very complex as you're dealing with persistent, long-term disability, and trying to rehabilitate as much as possible, or to accommodate the disability that a person has, with equipment or notifications.

I don't do a lot of work outside of this clinic, but I occasionally do home visits, particularly to people who are very disabled as it's hard to get people in sometimes. But we do have that sort of option as well, going out and seeing people in the community. Most rehab in New Zealand tends to be focused on neurological rehabilitation, but certainly in other places, like Australia and the United States, rehab can cover numerous areas like musculoskeletal rehab, and chronic pain. We've got one rehab physician who's doing conjoint training with pain medicine here in New Zealand, and it's quite common in other places to do conjoint training. Some people are doing cardiac and pulmonary rehabilitation as well.

You mentioned neurological. Does that include rehabilitation for stroke patients?

RS — In the public hospital system, it’s very much about stroke, but ABI is a privately owned company, so our funding source is primarily through ACC, so we have in-patient services and considerable work with concussion. 

So, for training in your respective areas, is that quite specific to New Zealand? I mean, in terms of whether you can do, for example, rehabilitation training?

RS — Yes, it's very specific and we have our own training programme. We have a curriculum and an exam system that is different from the normal college sub-specialties, so we're people who are trained in rehab medicine and not trained as physicians, which causes a bit of difficulty, particularly with the overseas trained physicians that want to come to New Zealand. We're not there primarily to diagnose, but to provide direction for a multidisciplinary rehab programme. 

And is it primarily places like Auckland where the training can take place?

RS — Yes, well, this has been a problem, it's very Auckland centric. We would like to have people being able to rotate around the country and maybe work in smaller centres, but because we've still got the remnants of the DHB system it's very difficult to set that up. Ideally, we would have a system with a national training scheme and then rotate around. 

How many funded training posts do you have?

RS — I think it's a total of nine at the moment, with about six or seven registrars, but most of them are here in Auckland, primarily funded through Auckland Council. They're all kind of regional training programs, so all of the medical registrar posts are all funded in rotations amongst the three DHBs in Auckland, and then ABI sits outside that as a private company, but we still have rotations. You’ve got people in the hospital dealing with the rehab wards, you've got Middlemore and Auckland City Hospital, and the spinal unit in Otara, and then ABI.

How about the training for occupational medicine?

RN — Traditionally, it's been a matter of people finding their own job, finding their own work, and then joining the training programme. So, it’s about working in a job that's considered to satisfy the requirements. For example, the Defence Force is a big employer of military doctors in New Zealand. 

RS — How do you rotate them?

RN — We don't traditionally rotate, even though the College would like us to. We look at what the current job provides in terms of covering the competencies, and then maybe a trainee can spend a bit of time on their afternoon off going and working somewhere, either paid or voluntary to get further exposure. We've approached ACC and Health New Zealand, to see if we can get some registrar posts. ACC is getting close, but we haven’t had the same progress with Health New Zealand.

RS — But aren’t there occupational medicine positions within the DHB?

RS — Yes, there's Occ Med units at Auckland Middlemore, but they can only come in as an employee, not as a registrar.

So, you need to get the position first and then set up the training?

RN — That's right, it’s sort of back to front. For me, I was working with the military, so that meant that I could join the training programme and do the training. But it is a bit complex, as you don't necessarily have a supervisor there with you. You might be working on your own and you've got to get a supervisor who's based somewhere else. For example, I was training a registrar a couple of years ago, but I wasn't employing her. She had to generate her own work so I could pass her, but she basically had to create that job herself, and then I could act as a supervisor. So that's why people that tend to join up in the training programme used to be military doctors or GPs who have had some contact with some industry. They might be looking after the local factory or whatever down the road, and they get an interest in occupational medicine, so they do a diploma, and then they can continue on. Otago University has a diploma, so we've had a number of GPs who've trained that way.  

But because we're not in the hospital, we're not visible, and people don't know about us. Most other doctors don't know who we are, and the general public don't either. I have looked at ways of trying to raise our profile, but it is difficult. Also, since Des Gorman moved on from the military, the military now promotes GP training, so their doctors go through the GP training programme and they're more useful that way.

How about with rehab, Richard?

RS — We're in significantly better shape, but even so, Health NZ data predictions show that the numbers will gradually go down, so that is concerning to me. On a national basis, most doctors that register in New Zealand are trained overseas, so my philosophy is that we must accept overseas doctors, and we must make it easier. This was one of my major considerations in joining the Overseas Trained Physicians Committee at the College.

In terms of the training programme, we're probably reducing by one to two specialists a year from our current training programme with about six to eight registrars. So, I think it's probably not as good as I'd like it to be, but it's not unhealthy. Also, I'm wanting to support people who are coming to this country with good qualifications, and recently I supported a German rehab specialist to get here and work in Wellington. I want to make sure that we're providing a welcome to these doctors. 

So, especially given the size of your membership base, how are you finding things at a Faculty level?

RN — I think, because we are a small Faculty, everyone knows each other, so we can just easily contact each other. For example, if we're short of someone, we think, okay, who would be good for that role, and then we could approach them directly, have a conversation, and ask whether they’d be interested in taking it on. Whereas perhaps in a large division, such as adult medicine or paediatrics, they might not as they probably don't know everyone. So, I think that being small has its benefits as you tend to know everyone.

RS — Yeah, I think it's a major issue within the College as a whole. My impression is that during the COVID lockdowns, we lost a lot of engagement. Certainly in Australia, many committees have disappeared even though they've got over 800 rehabilitation Fellows. In New South Wales, all the committees just disappeared with COVID, and we've had to rebuild. It's only this year that we’ve managed to get a full committee.

RN — Yes, I noticed that in a recent email. It had the results of the election for President-elect and various other reps. There was a lot of empty vacant positions, and no interest from New Zealand at all.

We’ve got a lot of work to do to try and promote your respective areas and to find the specific spaces to do this. We should have more information about occupational environmental medicine and rehabilitation medicine. It should all be out there.

RS — Rod, you've got a harder way to sell it. But what we found, though, is we've recruited when we've had house surgeon posts. I mean that's how I ended up doing it as well, from geriatrics, because I was exposed to the rehab service there.

RN — I recently contacted the Waikato Medical School and spoke with them. I ended up applying and getting accepted as an honorary clinical lecturer, but my angle is to get the medical students' placements within occupational medicine. So have them attending the clinics in the central North Island, so that they're getting exposed to occupational medicine. Then they’ll know about it, and hopefully that will feed through later on, when they’re interested in potentially training in that area. Whereas in the other two medical schools, they're largely hospital trained, so they don't get exposed.

It does seem like this often requires direct contact, that nudge from a personal contact. But it looks like there's some good synergies between occupational medicine and rehabilitation.

RS — Yes, we do operate in similar ways. I can even see the potential for trainees to do some kind of conjoint training between both. This also brings up the possibility of trying to encourage people to do more sort of regional training as well.

Could this be something we look at in terms of CPD, i.e. having some conjoint events?

RN — We've got one in Hawkes Bay in August. It's called ANZOM, Australian New Zealand Society of Occupational Medicine. We run our local conference each year, and occasionally we have a combined one with Australia, usually over a weekend. The first day is worksite visits, and the second day is lectures and talks.

RS — We have an annual Rehab symposium just for members of the Aotearoa NZ Faculty. We could maybe do something conjointly in New Zealand, but we also have RMSANZ – an annual conference which runs for four days. It's primarily for physicians and we usually get about 250 to 300 physicians and probably about 100 allied health practitioners attending. So, there might be opportunities to do something conjointly, or through the College. I think we have done this in the past with RACP Congress. I feel we've done something with occupational medicine in the past.

RN — Yes, we have. I know one year there was a combined meeting in Australia. So, with Congress now gone, maybe we have the opportunity to look at conjoint events.

How do you deliver your work in rural and regional spaces?

RN — A lot of us do clinics in the provinces. I go to Palmerston North, Whanganui, and Gisborne, every two or three months, and do clinics, and that's largely ACC work. We do have some of the occupational medicine doctors who are based in the provinces, like Tauranga, Rotorua and Nelson. Otherwise, it might be left up to a GP with an interest in occupational medicine. Or maybe if it were a big enough company, they'd fly someone down for the day.

RS — And for rehab medicine, I mean if you look regionally, it's largely done by geriatricians. We had one rehab position in Hamilton, and he retired and was replaced by a stroke physician. They advertised for people in Whangarei but didn’t get anyone, and Palmerston North doesn't have a rehab position in the hospital anymore. ABI's trying to address that because we like to try and do rehab as close as possible to the person's home. We've got rehab centres in Wellington, Hamilton, Auckland, and Whangarei, but it's definitely an issue. We do some telehealth rehab as a response to that, for example with people in Kaitaia. Therapists have got quite creative with telehealth, especially during the COVID era. It would be nice to see rehab positions working in other regions though. But the other thing is, if you rotate in Auckland, you've got six rehab training posts here. They don’t want to leave when they finish, and they all want to work here. They don't want to go and work in Tauranga, for example.

Can any of this be addressed with an increase in generalism to support your areas?

RS — It doesn't work in rehab because we're not trained as physicians, and I assume this is the same for you, Rod. It needs to be developed as a strategy, at least at a super-regional level, or if not a national level, to try and figure out what to do.

Thanks so much for your time today.