Kia ora,

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.

These are archived here.

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Delay to surgery: #NOF

Hansen, S, Liu, S, D’Souza, R, Miller, R. Time to surgery for fractured neck of femur in the Waikato District Health Board: Comparison between rural and metropolitan hospitals between 2017 and 2019. Aust. J. Rural Health. 2020; 00: 13.

A pre-publication open-access version can be found by clicking here.

This is a short report by a couple of fifth year medical students and a rural hospital medicine registrar who were on attachment at Thames Hospital. They found that there is an average of a 29 hour delay to surgery for those that presented to a rural hospital compared to patient’s that presented to Waikato Hospital, with 13% fewer patients receiving surgery within the Aus/NZ guideline of 48 hours. There was a trend towards higher mortality at 40 and 120 days for those that presented to rural hospitals.

Further work is required exploring the reasons for this delay (the transfer took on 7 hours on average – so 22 hours to make up somewhere), which would be ideal for a research elective for a Trainee Intern. Would also be interesting to see what is happening in other regions around the country.

Awesome to see this report published, with a lot of the mahi done during Level 4 lockdown!



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Webinar - Heart Failure

Welcome to the next Rural Doctor CME webinar – an update on Heart Failure with Associate Professor Garry Nixon and Dr Rory Miller.  Our webinars are brought to you by the University of Otago Rural Postgraduate Programme and the Division of Rural Hospital Medicine.

Previous webinars and podcasts can be found at the Leaning on Fenceposts blog.

To register for this webinar click here.


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Elliott, B.M., Witcomb Cahill, H. and Harmston, C. (2019), Paediatric appendicitis: increased disease severity and complication rates in rural children. ANZ Journal of Surgery, 89: 1126-1132. doi:10.1111/ans.15328

This Northland based study shows that children with appendicitis who lived in rural areas (see below) had increased odds (over double) more severe disease, more complications and more unexpected readmissions. Māori patients had a higher perforation rate.

The authors used the StatsNZ definition and we may see different results once an appropriate classification system is sorted. But thy including driving time in their model, which was significant so suspect the results will hold.

I understand there are more general surgical based metro-rural comparisons planned by this group of registrars. Great stuff.



Appendicitis is the most common surgical emergency affecting children. Rurality has been shown to be a predictor of worse surgical outcomes in patients with acute appendicitis compared to urban residents. There are no previously published studies investigating this in Australasia.


A 10‐year retrospective study of all patients aged ≤16 years who underwent an acute appendicectomy in Northland, New Zealand, was conducted. The cohort was identified by searching the hospital database for theatre events and admission diagnoses coded as appendicitis. Primary outcome of interest was the difference in the American Association for the Surgery of Trauma (AAST) anatomical severity grading of appendicitis and the Clavien–Dindo complication rate. The role of ethnicity was also examined.


A total of 470 children underwent appendicectomy during this period. On multivariate analysis, increased AAST grade was twice as likely in rural patients (odds ratio 2.04). Post‐operatively, rural patients had higher Clavien–Dindo complication grade (P = 0.001), longer median length of stay and increased rates of intra‐abdominal collection (19% versus 4%; P = 0.018), 30‐day readmission (19% versus 4%; P = 0.020) and perforation (27% versus 19%; P = 0.031). Māori children had increased perforation rates (28.9% versus 19.0%; P = 0.014) but ethnicity was not found to be independently associated with increasing AAST grade.


Accounting for ethnicity, socio‐economic deprivation and age, we implicate rural patient status as being associated with increasing severity and complicated paediatric appendicitis. This work adds to the evolving description of inequities in rural health outcomes. Further prospective studies are needed to confirm these findings at a national level.

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Geographical Narcissism

Fors, M. (2018, May 28). Geographical Narcissism in Psychotherapy: Countermapping Urban Assumptions About Power, Space, and Time. Psychoanalytic Psychology. Advance online publication.

Open access

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:


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.

Please click here to let us know what you think!

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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

Open access

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


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.

Please click here to let us know what you think!

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