RACP — Could you tell us a bit about your career, how did it all start, your specialisation, and also about what you are up to these days? 

Mark Lane — So basically, I got to med school but had no idea what I wanted to do. Then as a house officer, met up and worked with a really good medical registrar, Rafiq Ali, who just passed away last year and was a good friend and colleague for 50 years. He made medicine look absolutely fantastic, so I decided I'd become a physician.

Once you have passed basic training, in part two advanced training in general medicine, you cycle through specialties. I was looking through what specialties were available and did cardiology, endocrinology, and chest medicine. Gastroenterology was fun, you can do procedure and still be a physician, so that directed me towards doing this. 

So, I trained as a general physician with an interest in gastroenterology. Technically, according to the Medical Council of New Zealand, and the College, I'm not a gastroenterologist, I'm actually a gen-med physician with a sub-specialisation in gastroenterology. But nevertheless, during my training, I did  a year in gastroenterology, which would be sufficient for your sub-specialty. Then I did another year post FRACP in Auckland as a clinical fellow, followed by another year in Auckland as a research fellow, all in gastroenterology. Following this I went to the United Kingdom and worked for two years in an inflammatory bowel disease unit there. So really, I had five years of training in gastroenterology.

After this I came back to New Zealand from Birmingham, around 1987/88. I went to Middlemore, where I worked as a general physician/gastroenterologist, and then around 1990 a job came up at Auckland Hospital, so I came back to work there as the full-time gastroenterologist.

Was this when you started working with the College?

Around that time is probably when I started my engagement with the College because I was supervising trainees. I am always amazed that when I look at the gastroenterologists in New Zealand, so many of them have been a trainee of mine at some stage. 

I was involved in the Special Advisory Committee, maybe now called the ATC, for gastroenterology for about 15 years and was Chair for about six years. This took me through to about the early 2000’s and then I got contacted by the NZ College President at the time, to join the then called Specialties Board in New Zealand, where basically twice a year all of the specialties had a meeting at the College, with all the society presidents, and  I ended up chairing that for a couple of years.

Not long after this there was a reorganisation of the College, and the Divisions came into existence, with Adult Medicine and Paediatric and Child Health Divisions, and basically the specialty boards were discontinued. So, at that point in time, I stopped working with the College.

Then around 2010 I stepped down as Head of Department at Auckland Hospital, and I realised I would have time up my sleeve so I rang up the College and asked if they had any jobs I could help out with – that literally was the conversation!  It turned out the Chair of the New Zealand Adult Medicine Division had to step down for various reasons, and would I be interested in chairing it? I asked what did this job involve, and they said, oh, it’s just one face-to-face meeting a year in Wellington. What they didn't tell me was that because I was Chair of that committee, I was also automatically on the Australian Adult Medicine Division Committee, which had two face-to-face meetings and two teleconferences as well, plus I would be on the New Zealand Committee, which also had a face-to-face meeting and two teleconferences a year. But in addition to this, because I was a New Zealand Division chair,  I was also on the Executive Committee of the overall Adult Medicine Division as well, which also had four teleconferences a year. So, in the end, I think I had six face-to-face meetings a year, with four in Wellington, two in Sydney and about twelve teleconferences!  I did not do my due diligence when I offered to do work for the College!

What dates covered your tenure as a New Zealand President?

I must admit I am a little unclear of the dates now, I think I chaired the New Zealand Adult Medicine Division from 2010 to 2014,  was NZ President-elect from 2012-2014, and NZ President from 2014-2016.

I did all those jobs because no one else stepped up. The only election I've ever had to do in the College was the one for President of the College. Every other one, I just basically walked in and took on a job that people didn't want to do. It was all tap on the shoulder stuff, and the previous President or other people would tap someone on the shoulder. I moved into the NZ President role after Dr Johan Morreau, who tapped me on the shoulder to do it. In those days the NZ President, and the NZ President-elect, we're both on the Board. At that time, the College Board was quite big with about 20 people. So, I was on the College Board from 2012.

By 2015/16 I had been on the Board for four years and had enjoyed the work and the interaction with staff and fellow Board members and thought I could continue to contribute, so I put myself forward for the election for RACP President-elect, and much to my surprise, I won.

You were RACP President between 2016 and 2018?

 I was RACP President from 2018 to 2020. I was President-elect from 2016 to 2018. I had Jonathan Christiansen with me as the other New Zealander on the Board while I was President-elect . And when I became RACP President, Jeff Brown was on the Board with me. They were both fantastic supports for me personally and for the College in general while they were on the Board.

2018, the year I became President, was an interesting one because that was when the first major exam failure occurred.

What's your take on what happened with that exam failure?

There were a number of things that contributed to it, but the key failure point was just simply that they did not do the beta testing well enough.

What happened was they tested the exam, but they did not test two things. They gave it an environmental check, but they did not test it properly across multiple sites in different time zones, and they did not allow for people having to log out for lunch and then logging back in. Those were the major failure points, and that's what crashed it. If those issues had been tested and the issues addressed, the online exam may well have succeeded. We did however have a backup plan available in case the exam failed. We had a paper exam ready to go and were able to set this up and have all trainees sit a paper exam ten days later.

At the time the Board view was that  there was no way we were going to go with these providers again, the reputational damage to the College was immense. However, in retrospect I wonder if it would have been a smarter move to have stuck with them. They were one of the largest exam providers in the United States with a long history of providing online exams. They acknowledged it was their error and they immediately refunded all of the exam fees to our trainees for the exam, which I believe came to about  $5,000,000.  They had already done the vast majority of the prep work and fixing it may well have been much easier than restarting from scratch which is what we did.

We then went back to a paper exam. Four years later the College again tried to do an online exam and it failed, again.

Then with COVID that ended your presidency, right?

More correctly COVID appeared during the last months of my presidency and defined much of what was happening at that time, but it did not end it.

My exit from the College was underwhelming. It was right at the beginning of COVID in March 2020. I was sitting in a College Council meeting in Sydney at 2pm and I got a text message from the hospital saying that due to the pandemic all further overseas travel for senior staff  was cancelled. So, at 4pm, I walked across the road to head office in Macquarie Street, walked in the door, and said hey guys, Health NZ says that I'm not allowed to come back again because of COVID, so I think this is goodbye. I walked out the door and climbed on my 5pm train to the airport.

I had a few more teleconferences, but I haven't shown my face in the College office since then, and I haven't even seen my photo up on the wall. It was the most low-key exit from the College ever.

The handover ceremony for me to hand the presidency  to John Wilson was basically me sitting in an office in Auckland with a camera on me, and John Wilson was sitting in an office in Melbourne with a camera on him. My daughter, a College member, took my president's gown off and handed me a membership gown back again, and somebody in Melbourne put a president's gown onto John and gave him a hat, that was it. Then all the email traffic dropped from about 50 a day to zero immediately.

So fast forward from that, what are you currently doing?

I am semi-retired. So basically, I retired from the public sector in 2022, but the hospital calls me back to do occasional locums. I have a couple of days a week of private practice, and then, occasionally, I go to other parts of the country and do locums, which is why I might be looking at Palmerston North at some stage, I’ll probably give them a call tomorrow. About a year ago I did quite a lot of work up in Whangarei Hospital, supporting their ERCP service. So largely it's just procedural work now. Nice, simple stuff for a gastroenterologist, push the tubes, just like riding a bike.

Our former NZ President, Stephen Inns, used to talk about the time it takes to develop the skill required for endoscopy work.

Yeah, I know Stephen, and yes, there's an interesting psychology of complex things we do. If you sit down and think about driving a car, you know, driving cars is actually an enormously complex task, and not only in terms of controlling all the things in the car, it's also your awareness and responsiveness to what's going on in and around the car. How many times are you driving around the road and you're braking before you even think about why you're braking? Ultimately you do it without thinking about it. To be a good endoscopist takes years of training and ongoing practice, and even then there are huge performance differences between endoscopists. To go back to the car analogy – we are not all able to be F1 drivers, some of us are just happy to drive the family car!

Doctors train to be doctors, not teachers, yet these are roles we get put into. In gastro, we actually have programmes called Train the Trainers, which is actually to teach people how to train. We think that teaching is just part of our skill set, but it is not, and we need to be trained to do it.

The current crisis in the College highlights another deficiency in our training, namely leadership and in particular governance. Members taking up leadership roles in the College need specific training in these areas

So, there is a much broader skillset required to be a doctor than most people think about?

Entry criteria for med school must take into account what makes a “good” doctor not just what is needed to pass the medical school course. What makes a good gastroenterologist is different to what makes a good surgeon, to what makes a good radiologist, to what makes a good histopathologist, to what makes a good primary care doctor. I am sure the leaders in our medical schools are quite aware of these issues, but many of these skills are learned and acquired over the many years we work post medical school.

In the age of AI, vast amounts information is at our fingertips, however you need to ask the right questions. But the new doctor is going to be about working out what the question is and then communicating the answers to the patient that they wish and need.

What's your thoughts about the state of gastroenterology around New Zealand, you will be well aware of what has happened at Palmerston North hospital?

I think Palmerston North is in desperate need of more gastroenterologists but can’t get any applicants, which is not unusual in rural NZ.

First issue is that there is a limited capacity to train new gastroenterologists. We've got enough people who want to become gastroenterologists, as gastroenterology is a great specialty to work in and it has become very popular. Most training occurs in larger centres, as smaller ones do not have the required number of supervisors to get accredited. The training pipeline cannot currently meet the demands.

The popularity of gastroenterology in part relates to the procedural work. When I trained, procedural work was a smaller part of our work, but it's grown and grown and grown. But now with the bowel cancer screening programme, your average gastroenterologist is spending probably 40 to 50 per cent of their time doing endoscopy, and we still cannot meet the demand even in main centres. The main centres can absorb every gastroenterologist we train leaving the Palmerston North’s without any gastro services.

New gastroenterologists don't feel attracted to working in small centres peripherally. In the big centres you’re members of big teams, with colorectal surgical backups sitting right next door, intensive care is right next door. The lifestyle issues outside of medicine make the main centres more attractive as well. 

The same applies to overseas trained doctors who take up a post in a regional or rural unit  when first arriving, but once they get full registration with the MCNZ take up a post in a main centre. I have observed this occurring a number of times when doing VPAs for the Medical Council.

Can we increase the capacity to train?

The requirements from the College for a training site to be accredited requires a certain number of gastroenterologists to be on site for training, but there's a limited number of centres that can do that. I think that we need to build some more flexibility into those requirements. I mean, if you consider Whangarei, I think it's got three gastroenterologists at the moment, but three or four years ago they only had one, and a lot of surgeons, so they couldn't do training, in fact, I'm not sure they even can now [Whangarei currently does not have accreditation for gastroenterology training]. We need some more flexible ways of supervising training built into our accreditation criteria, e.g. remote supervision with teleconferences, or even using surgeon endoscopists as accredited supervisors are a couple of thoughts.

What about the Gen Med or dual training aspect this?

Yes, when I was supervising trainees all the way through the 80s and 90s, even to the early 2000s, I always encouraged gastro trainees to do dual training. I told them you can't guarantee that you're going to get a gastro job, so you need to keep the general medicine training. It was a mistake, as every single one of them could get a full-time gastro job. They didn't need to dual train, as they could just be absorbed by gastroenterology everywhere around the country. So, while I understand the philosophy of the dual trained person, why train as a general physician with an interest in gastro when you can go straight into a full time gastroenterology job the moment they finish gastro training. Plus, the training will only take three to four years rather than five to six as a dual trained physician.

This is pretty much reflected in current retention statistics for NZ trainees.

Yes, that’s right. If you come to a main centre and you pick up an eight-tenths job there, then you can spend your two-tenths doing private work. You get the lifestyle you want and a significant financial benefit with the private practice. You can't do that in regional and rural settings.

Can we flip the model and get people to do it the other way around? I feel that this requires a lot of altruism in a sense, but that is not so evident these days.

Yes, it probably does require a degree of altruism to work in a rural/regional setting.  The lifestyle issues and significant financial negatives seen accompanying working there are difficult to overcome. I am unconvinced that level of altruism exists these days.

Mind you many of RACP members do unpaid work for the College. The College relies on volunteerism, in other words altruism, so maybe I am being a little harsh in that judgement!

What do people get out of providing that sort of service to the College. Is there a value in it that you see?

You're asking the wrong person, you should ask my daughter who is one of many members doing College work. She has been very active in running RACP exams in and sits on a training committee. I'm sitting there thinking, why, when you have seen the impact that your father’s work for the College has had on him, and the family, would you do this?  

Another colleague of mine, her father was a GP, and she's a gastroenterologist, made the comment that people who come from medical families are possibly more likely to have that altruistic understanding of what a medical lifestyle is about, because they have watched dad or mum living it.

Personally, I have done a lot of governance and leadership stuff most of the way through my career. It's been my thing and I have generally enjoyed doing it, which is why I did it.

Do you have any interests outside of medicine? You know, hobbies or anything like that?

Yes, I just finished building a lovely new house up north on the Whangaroa Harbour, where  family settled  in 1870. So, I've got my roots up there and hope to spend more time up there. So, I've got lots things to do, family and kids fishing, tramping etc as well as home maintenance, lots of little stuff.

It sounds like you're in a nice space, sort of tapering off and doing a bit of this and bit of that, but you still have a high level of stimulation and interest in gastroenterology.

Honestly, it's going to be a sad day when I finally walk out the door. Currently I work about 40 per cent of my time, but there's got to be a point where it’s time to stop and it's very close. I've got plenty of things to keep me busy. We are a ridiculously close-knit family with nieces, nephews and cousins in and out of our home all the time. I see all my kids almost every day, even though they're now in their 40s. I see my grandchildren every day and see nieces and nephews most days for week.

I try to keep myself fit. I walk home from work, which is about 10 kilometres away several times a week.