Welcome to the rural research blog – brought to you by the Section of Rural Health.
The postcards from the edge series has come to an end. However, if you have something to contribute then please be in touch.
Feel free to comment on any post to start a discussion.
You can sign up by clicking the ‘follow’ button that appears to the left of the screen. You will receive an email once a new post is published. We won’t use your email address for any other purpose.
Geographical Narcissism
Fors, M. (2018, May 28). Geographical Narcissism in Psychotherapy: Countermapping Urban Assumptions About Power, Space, and Time. Psychoanalytic Psychology. Advance online publication. http://dx.doi.org/10.1037/pap0000179
From time to time, I circulate articles to a wide network of individuals around the world who are involved or have an interest in rural health and rural practice. This article is the one that triggered the most responses with comments that it resonates with their own rural experience. The author, Malin Fors, a psychotherapist in Hammerfest, a small community in the far north of Norway is involved in teaching University of Tromso medical and nursing students based in Finnmark county. In the article, she relates her own experience to the rural geography and psychology literature, as well as psychoanalysis. Essentially, the message is that the cities see their rural communities as existing for the aggrandisement of the cities. This is geographical narcissism.
Comment from Professor Roger Strasser – Professor of rural health at the University of Waikato
Saul Steinberg’s March 29, 1976 “View of the World from Ninth Avenue” cover of The New Yorker – image credit: https://en.wikipedia.org/wiki/View_of_the_World_from_9th_Avenue
Abstract:
In the field of psychotherapy there is a subtle, often unconscious, devaluation of rural knowledge, conventions, and subjectivity, and a belief that urban reality is definitive. Through metaphors from geography and cartography and via psychoanalytic theory on privilege, I formulate urbanity as a seldom-addressed privilege and consider implications of the misrepresentation or absence of the rural world on the “map” of psychotherapy. I countermap urban biases on power, space, and time and explore consequences of frame, self-disclosure, ethics, and interpretations as I investigate urban valuing of specialized expertise over wisdom, urban disconnection from weather and distance, urban colonizing behavior, the dumping of incompetent professionals into rural areas, and the urban sense of entitlement to anonymity.
Rural post-graduate society:
We are still seeking feedback on developing a voluntary post-graduate rural society that will help fund exisiting CME activities that are free to access and allow development of future activities.
Exploration of rural physician's lived experience
Konkin J, Grave L, Cockburn E, et al. Exploration of rural physicians’ lived experience of practising outside their usual scope of practice to provide access to essential medical care (clinical courage): an international phenomenological study. BMJ Open2020;10:e037705. doi:10.1136/bmjopen-2020-037705
A hermeneutic phenomenological study (look it up or read the methods) undertaken by a group of prominent rural health leaders, most of them well known to a us in Aotearoa. This qualitative study uses interviews with rural doctors to explore a fundamental part of rural medicine, practicing outside your comfort zone aka ‘clinical courage’. The investigators identified a number of features of clinical courage:
the commitment to deliver the care your community needs;
accepting uncertainty;
understanding and making the most of the resources at hand (limited as they are);
consciously testing and understanding your limits;
once you have decided that ‘its needs done’ and ‘you are the best person available to do it’, having the confidence to get on and act;
the importance of supportive rural colleagues in maintaining clinical courage.
The themes will resonate strongly with those working rurally and form a useful insight for those involved in educating the rural workforce.
Comment kindly from Associate Professor Garry Nixon
ABSTRACT
Objectives: Rural doctors describe consistent pressure to provide extended care beyond the limits of their formal training in order to meet the needs of the patients and communities they serve. This study explored the lived experience of rural doctors when they practise outside their usual scope of practice to provide medical care for people who would otherwise not have access to essential clinical services.
Design: A hermeneutic phenomenological study.
Setting: An international rural medicine conference.
Participants: All doctors attending the conference who practised medicine in rural/remote areas in a predominantly English-speaking community were eligible to participate; 27 doctors were recruited.
Interventions: Semi-structured interviews were conducted. The transcripts were initially read and analysed by individual researchers before they were read aloud to the group to explore meanings more fully. Two researchers then reviewed the transcripts to develop the results section which was then rechecked by the broader group.
Primary outcome measure: An understanding of the lived experiences of clinical courage.
Results: Participants provided in-depth descriptions of experiences we have termed clinical courage. This phenomenon included the following features: Standing up to serve anybody and everybody in the community; Accepting uncertainty and persistently seeking to prepare; Deliberately understanding and marshalling resources in the context; Humbly seeking to know one’s own limits; Clearing the cognitive hurdle when something needs to be done for your patient; Collegial support to stand up again.
Conclusion: This study elucidated six features of the phenomenon of clinical courage through the narratives of the lived experience of rural generalist doctors.
Rural post-graduate society:
We are still seeking feedback on developing a voluntary post-graduate rural society that will help fund exisiting CME activities that are free to access and allow development of future activities.
Rural Postgraduate Society: an idea
The Division of Rural Hospital Medicine and Uni. Otago are considering setting up a postgraduate society and we are keen to get feedback on the idea.
Why do we need a rural postgraduate society?
The Division and the University have been running CME targeted at the educational needs of rural clinicians (and delivered by rural clinicians who understand those needs). Some of these, such as the RiSC courses and the annual CME workshop, have a fee associated with them, but as many as possible are free and open to everyone. This includes the articles on Leaning on Fence Posts, the webinars and the podcasts. These have proven very popular. Leaning on Fence Posts get up to 100 visits per week and average webinar attendance is around 60 people. We need to find other ways of resourcing these activities if we and to ensure sustainability and see them grow.
Some of us have good access to CME funds but there is big variation in our ability to pay for CME. A postgraduate society could be a way of those with CME allowances (who maybe are having second thoughts about European cardiology conferences) to use some of it to support home grown open access CME for ourselves and the whole rural health professionals community.
How would a rural postgraduate society work?
Membership would be entirely voluntary. It would be a non profit making society governed by its members and would support the current CME activities and grow new ones. Members would likely be offered a discount course fees but the majority of the funds would be used for open access CME.
Recruiting and retaining
Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects
Ogden J, Preston S, Partanen RL, Ostini R, Coxeter P. Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects. Med J Aust. 2020;1–9.
Why is this paper important?
It brings together the evidence in a formal systematic review and meta-analysis. It only includes papers that look at place of work after completion of postgraduate training. It does not include softer outcomes like intention to practice rurally, undertaking an intern or early PGY/registrar job in a rural area.
Does is provide any new information?
Not really. It just reinforces what we know about the 3 proven strategies.
That is:
1) taking students from a rural background,
2) prolonged (and ideally repeated) undergraduate attachments in rural areas and
3) targeted postgraduate training in rural communities.
All these increase the uptake of rural careers – and combining the strategies works even better.
Are there any surprises?
Not really. There were not a lot of eligible studies, and none from NZ (someone needs to do one).
Many thanks to Associate Professor Garry Nixon and Katelyn Costello for their comments.
Abstract
Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas.
Study design: Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas.
Data sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature.
Data synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle–Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12–3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48–2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80–7.46; eight studies).
Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce.
Protocol registration: PROSPERO, CRD42017074943 (updated 1 February 2018).
COVID in rural US
Pro G, Hubach R, Wheeler D, Camplain R, Haberstroh S, Giano Z, Camplain C, Baldwin JA. Differences in US COVID-19 case rates and case fatality rates across the urban–rural continuum. Rural and Remote Health 2020; 20: 6074. https://doi.org/10.22605/RRH6074
This short letter published in Rural and Remote Health (Open access) shows that using a ranking score in the US up to April 2020; while there were fewer cases, the mortality was increased compared to metropolitan areas of the US.
The authors acknowledge issues with testing capabilities skewing the data, and we can only assume that things are getting worse given the US’ COVID trajectory.
Fortunately in NZ we don’t have nearly enough data to draw any conclusions (even if we could) but the important message from the paper is equally valid in a NZ context:
“The US and international responses to the COVID-19 pandemic must include plans for strengthening rural health systems, most notably in the form of improving access to treatment for severe cases.”
Worth noting that Doctors Without Borders was deployed in the US to help in rural areas with high proportion of indigenous peoples – the first time the aid organisation has had to be deployed. Gives some further perspective, if any more was needed, on the state of healthcare in the states.