Auckland-based ICU doctor Ivor Popovich offers an insider's view of the health system in his new book, A Dim Prognosis.
Hospital bullies, mismanaged priorities, disparities between public and private health care – Auckland-based Dr Ivor Popovich is not holding back. He speaks to Kim Knight about his new book detailing a health system in crisis.
“The skin crackled slightly as it separated.”
Seven pages in, and the reader is right there with registrar Ivor Popovich as the intensive care unit (ICU) he is working in fills with patients injured in the Whakaari/White Island volcanic explosion.
They’ve been transferred to Auckland from Whakatāne Hospital and Popovich is placing a central line to deliver crucial medication and intravenous fluids.
The scene is clinical, urgent and graphic.
Popovich begins a mantra he’ll repeat over and over – ultrasound, needle, wire, dilator, line, sutures. He describes spots of cherry-red burn on a patient coated in ash so toxic it disintegrates the surgical team’s gloves and explains that when burn scars wrap around a person’s limbs, they can cut off the blood supply. He can smell his own breath and sweat under a mask and inside a sterile gown. Patients keep arriving, unidentified beyond their room numbers.
“It was,” he writes, “An ICU full of ash-covered, mummified identical siblings.”
As far as first chapters go, it’s gripping. But to the casual reader with no personal connection to the December 2019 eruption, the most terrifying sentences are, perhaps, the least action-packed.
Popovich – at the time a junior doctor entering the third year of his chosen speciality – is tasked with determining what blood tests and procedures the injured may have already had. What drugs had they been given? How much fluid had they already received? Did they have a CT scan at another hospital?
He writes: “I sat at a tiny desk flicking through pages of photocopied documents written in chicken-scratch, trying to figure out who had had what. A unified electronic system would have made this child’s play, but we didn’t have that (and still don’t) ...
“It was all a goddam mess. A job that would have taken 15 minutes with good technology instead took several valuable hours.”
Popovich’s book is called A Dim Prognosis. It describes a health system in crisis and offers one doctor’s view on how to fix it.
Who should read it?
“Everybody,” says the now 32-year-old intensive care fellow at Middlemore Hospital. He told his colleagues about the book only three weeks ago. It started with a desire to write about being a med student, but what, he wondered, would be his point of difference?
Every second day, he saw media interviews with people complaining about hospital wait times – patients had died before they could be seen – and he knew that, in the 10 years since he’d begun his own training, things had become objectively worse.
“What is it going to look like in another 10 years? It’s quite a scary thought ... Let’s go through the specifics of what are the problems. What is it actually like on the ground? That was what spurred me to go into the book from that point of view.”
This interview was scheduled for 4.30pm or maybe 5pm or maybe 6pm. It would depend really, on how long handover took, and what kind of day it had been in the ICU at Middlemore, the country’s largest public hospital, situated in the South Auckland suburb of Ōtāhuhu.
Ultimately, Popovich would only be 20 minutes late. Giraffe-tall and good-looking (true story – at the shoot for his book cover, the photographer suggested he submit pictures to a modelling agency), he is quieter and more deliberate than his fast-paced narrative suggests.
His family came to New Zealand from Croatia when he was 2 years old.
“There was a war going on, and it was very easy to get a visa, and New Zealand had this kind of mystical reputation. Overseas streets paved with gold. We were immigrants. Not refugees, technically – though, I guess, practically.”
His grandfather had been a nurse in then Yugoslavia, working in villages where payment might have been cake or brandy. His uncle was, until recently, an oncologist. Growing up, Popovich’s overarching memory is that his uncle’s work made him late to events.
At Northcote College, when he listened to older students ponder how hard it was to get into medicine – the exams and required pass rates – Popovich thought “that sounds really terrible”.
Becoming a doctor was never the plan. It was his parents who suggested that, since he was good at science and not too bad with people, he reconsider.
“I went into it pretty blind to be honest, but it worked out okay ... Despite all of the things I describe in the book and the frustrations, I still very much enjoy my job.”
Those frustrations are distilled into a short but damning list at the end of his book. They include: Not enough registrars, specialists, nurses, wards, operating theatres and clinics to deal with an ageing and increasingly unwell population. A bottleneck of registrars who can’t transition to specialities because there are not enough places available. Under-resourced community-based health services – including hospices – that prevent hospitals from focusing on the very sickest. And the ongoing issue of high-quality care concentrated in the private sector at the expense of the public system.
If it’s nothing you haven’t already heard (or experienced), Popovich’s commentary and many supporting anecdotes are illuminating.
Ever wondered why you can’t get in to see your GP for a fortnight? Why it takes six hours longer than you’d like for a hospital discharge? Why one elderly patient is eight months into a public system wait for a heart scan that would have revealed they needed a valve replacement to stop the dizzy spells that eventually led to black outs and a bone fracture – and another has health insurance that rapidly provided for an echocardiogram, CT angiogram, treadmill test and a holter monitor when they developed an arrhythmia?
“Getting all those tests in the public system would take ... well, somewhere between 10 and 150 years,” Popovich tells the latter, and it is not immediately clear that he is joking.
A Dim Prognosis offers his insider’s opinion on what might be going wrong - from the apparent lack of IT solutions, to the oft-debated shortage of medical staff at every level.
For example, Popovich notes that, on average, only one-third of applicants to surgical programmes are accepted annually. He also notes that the most competitive specialities offer the most scope for private – and well-reimbursed – work. He carefully reports that investigations have revealed no evidence of anti-competitive practices at Australasian specialist medical colleges.
But he also alleges a conversation overheard during his compulsory anaesthesia training. Three surgeons are discussing junior doctors who want to advance into orthopaedics. Popovich writes that they express a hope that “they keep the numbers similar to last year ... there’s been a lot of new trainees coming through recently. Gotta protect the patch!”
Popovich tells the Herald that two factors determine the number of specialist training spots: the Government, and the medical colleges themselves.
“How that all plays out, how much each one has an influence, is a bit unclear. I think both of them are important factors ... we need more transparency about what the process is, so we know where the problem is. If the problem is the Government not funding enough positions, then we know that’s what we need to push for.”
Is he concerned about collegial reaction to A Dim Prognosis? Consider, for example, another of his bullet points: “Doctors need to lose the mobster mentality that keeps bullies and sociopaths in positions of power within the medical profession.”
Care to elaborate?
“Yeah ...” he says. “Maybe that was one of the phrases that sounded good at the time, but I maybe could have reworded?”
Still, “that was in the context of describing some individuals with bad behaviour. I make the point that in any area, there is always people like this and what allows it to keep happening is the people around them who say, ‘well, that’s just the way they are’ ... ‘we might work together, and maybe it’s easier for me to just let him or her do his thing’. But the thing that allows these things to happen is that everybody around who is nice and normal, letting these things fly.
“The standard you walk past is the standard you accept,” says Popovich. “Even if you’re ready to call out bad behaviour, if you’re in a position where it’s a hierarchy and you’re not empowered to do it, and you don’t feel safe to do it, then that’s also an issue.”
Hospitals are not easy places to work. He met his wife, Sarah, a nurse, on the job. He plays keyboards in a work band. The Bootleggers perform covers from the 1980s and 90s, rock, pop and blues at Christmas and retirement parties (his current favourite song is Van Morrison’s Moondance, because it has a nice keyboard solo).
Popovich chose intensive care as his speciality because he perceived the work as interesting and varied, albeit with fewer opportunities to move into the more lucrative private sector. He acknowledges big egos gravitate to medicine – but those same egos also work up to 70 hours a week and 14-hour shifts.
In this environment, he writes, you can become a miserable misanthrope or convince yourself you are more important and skilled and special. Or both.
“There are moments where stress can overwhelm and get too much and you find yourself behaving in a way that you didn’t think you would,” Popovich says.
“The 100th request and a busy night shift, and I just shout at the nurse and throw a piece of paper at her and then come crawling back in the morning and saying sorry. You do find yourself behaving in ways that you didn’t want yourself to. There’s those kinds of episodes, but then there’s sustained patterns of behaviour and people who actually don’t reflect and don’t apologise.”
His book contains stories of gobsmacking racism and, more generally, senior doctors who “get up to all kinds of seedy things” – sexual harassment, corruption and drug use. Others are just “terrifyingly bad” at their jobs, or won’t condone fallibility.
Popovich is a house officer on rounds when he loses focus and offers an “ummm, let me think,” followed by a guess. Later, his superior tells him that, right or wrong, he must sound confident, because “patients don’t like an unsure doctor”.
Honesty, says Popovich, is another thing the health system could do with a dose of.
“People do want, and like it, if you come out and say, ‘Well, I know this is the problem and I know this is the answer’, rather than umming and aahing. But eventually you’ll get burned by doing that, because eventually you will be wrong.
“There are some days when what you can do for patients is just provide some comfort or reassurance or even, in a situation where you can’t fix the problem, provide someone with a good death or a good experience of death.”
New Zealand hospitals have a total of 304 ICU beds, or 5.7 for every 100,000 population. The observed ICU mortality rate is, according to the Australian and New Zealand Intensive Care Society, 7.3% (Australia has 2446 beds – nine for every 100,000 people – and a comparative mortality rate of 5.1%).
Dying is part of living, and it is definitely part of doctoring.
Things you learn reading A Dim Prognosis: People might gloss over why they have a gunshot wound. At any moment, a brain aneurysm could kill you. Only one in 10 recipients is saved by CPR. If you can find the right people to drive you, you might not have to spend the final hours of your life in an ICU bed.
“I think a lot of people struggle to talk about death and don’t really want to think about it until they really have to,” says Popovich.
He separates his medical colleagues into three categories.
“Those who let everything in, and they just become a mess, because they get too emotionally worn down.
“People who block everything out, and they just kind of turn into jerks.
“And most of us, who let the stuff in, but dull it by using some humour and having moments with colleagues and friends where you can actually just openly talk about stuff.”
Early in his career, Popovich was told the job he trained for was not the job he would end up doing. That realisation has sunk in ever deeper as he has progressed through the ranks.
There was a fast and basic understanding that many patients are in hospital not because they are very unwell and waiting to get better, but because there is nowhere else to send them.
“You go to medical school and you think, well, ‘there’s going to be a problem and I’m going to fix it, I’m going to make someone better’, and then you go into this scenario where you’re dealing with all these patients who really shouldn’t be in hospital, but they can’t go anywhere else.
“They get cooped up in bed. They get weaker and frailer because they’re not moving, they get infections from other people in hospital ...”
More funding is the most obvious solution to a health system crisis.
“We’re perhaps not willing to admit just how much. There is a direct phrase where I say in capital letters A LOT OF MONEY. I don’t think we’re ready to admit just how much extra resource we need to put into the system just to keep it where it is. From a politician’s point of view or a manager’s point of view, the outlook is they’re managing a budget and they need to get back in the black ... That way of thinking is almost antithetical to what really needs to happen.”
New Zealand, he points out, is a first-world country. There is money.
“It is,” he writes, “a question of priorities.”
In August, Popovich fully qualifies as an intensive care specialist. Right now, he’s in what he calls a “transition” role. He suspects he will be criticised for expressing his opinions; for being a 32-year-old upstart with only a decade in the system.
“At every step, there’s an ‘oh, there’s another thing I need to be good at’. I was never trained in how to be diplomatic or how to negotiate with people, but that ends up being an increasing part of your job.”
A pause.
“Some people are definitely not negotiators.”
A Dim Prognosis: Our health system in crisis – and a doctor’s view on how to fix it by Ivor Popovich (Allen & Unwin NZ, $37.99)
Kim Knight joined the New Zealand Herald in 2016. She is a senior journalist on the lifestyle desk and recipient of the Gordon McLauchlan Journalism Award at the 2025 Voyager Media Awards.
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