Graduating in absentia,  Cook Islands May 2021

Among the many students graduating from Otago University this year is Dr Vakaola Mafi who is being awarded (in absentia, in the Cook Islands) the Postgraduate Diploma in Rural and Provincial Hospital Medicine https://www.otago.ac.nz/courses/qualifications/pgdiprphp.html

Mafi, as he is known to friends and colleagues is the first Pacific Island Country-based doctor to complete the largely distance-taught diploma. His study was facilitated under an MOU between the Cook Islands Ministry of Health and the University of Otago.

Mafi grew up in Tonga and completed his medical degree at Fiji National University. He moved to the Cook Islands with his wife (who is also a doctor) seven years ago, working as a general medical practitioner both in Aitutaki and Rarotonga.

In 2016, with limited postgraduate clinical training options open to him , he began to study in the Otago Postgraduate Rural programme by distance. Determined to reach his goal, he worked steadily at completing individual papers one at a time, studying in his own time alongside his full time clinical commitments.

Mafi’s achievement is all the more significant in that his final paper was completed entirely virtually due to the Covid pandemic: when he was unable to travel to the 5-day residential in Taranaki, a virtual link-in was created by the rural postgraduate faculty. While far from optimal, the virtual connection ensured his continued access to study.

For Mafi the best aspects of his study have been gaining connections and friendships with rural and GP colleagues in New Zealand and others in the Pacific, gaining a peer group. The biggest gain has been learning relevant evidence-based practice to a NZ standard which he can apply in his daily practice. His thanks go to his family who have supported him throughout .

Register here

Doolan-Noble F, Noller G, Nixon G, Stokes T.  ‘I’m still here, that’s probably the best part’. Lives of those living rurally with an implantable cardioverter defibrillator: a qualitative study. Rural and Remote Health 2021; 21: 5659. https://doi.org/10.22605/RRH5659

This (open access) New Zealand study is the first to consider the lives of those who live rurally following the insertion of an implantable cardioverter device (ICD). Overall, place of residence did not significantly impact the lives of recipients, however, the influence of the care recipient and caregiver dyadic relationship on the recovery journey was an important association identified in the data analysis. The significance of the care recipient and care giver dyad on health, illness appraisal and symptom management has only been acknowledged recently. Health professionals caring for ICD recipients need to consider the health and wellbeing of caregivers who are frequently older and living with their own health conditions.

Abstract

Introduction:  The use of implantable cardioverter defibrillators (ICDs) is increasing in both New Zealand and Australia. Also, both countries are experiencing an ageing of their rural populations. Much of the ICD literature focuses on the experience of those living in urban environments, with little known about the experiences of those living in rural contexts. This study aimed to answer the following questions: ‘Does living rurally impact the ICD recipient experience and that of their partners?’ and ‘Can understanding their experiences inform best practice care for those living rurally with an ICD?’
Methods:  This qualitative study employed purposive sampling and semi-structured interviews to produce rich narrative data. A general inductive approach was then used to analyse data, producing a series of coded themes through an iterative strategy, to generate an understanding of the rural lived experience after ICD implantation. Interpretations and conclusions were tested with participants at a debriefing meeting at the conclusion of the study.
Results: In total 14 ICD recipients and nine partners/carers/whānau (family) were interviewed. One recipient was Māori (indigenous New Zealander) and one female, and overall age range was 57–89 years. The length of time from ICD insertion varied from less than 1 year to 12 years. The final analysis highlighted the substantial role played by partners/carers of recipients. How this recipient–partner/carer dyad managed the post-ICD insertion experience was a major theme in this study. The perennial challenges of advance care planning and ICD deactivation conversation, unmet need for peer support and gaps in the provision of health-related information were all highlighted as challenges to these rural participants. The rural locale, however, posed limited challenges. Loss of a driving licence following receipt of shock therapy was irksome due to the unavailability of public transport but the impediment posed by the device on the practicalities of rural living, such as the need to use power tools and move electric fences, was, for some, more of an issue.
Conclusion:  This is one of the few studies that has considered the influence of rural location on the post-ICD insertion experience of patients and their partners/carers. ICD insertion did not appear to substantially negatively impact on the lives or experiences of rural recipients and their partners/carers. While this study did not set out to explore the role of informal carers who live rurally, the study findings suggest that female partners of rural ICD recipients undertake a significant role in terms of shouldering varying responsibilities including medication management, emotional support and transportation. As the age of ICD recipients increases, so does the age of their partners, therefore, they are also likely to be living with one or more long term conditions. Health professionals need to be aware of this additional burden as research suggests rural informal caregivers are less likely to report associated issues.

Clinical director for Rural GP network and Rural Cohort Manager for Vaccination rollout.

Both jobs require a quite a bit of time in Wellington, but understand that the Clinical Director role can be based from your usual residence.  Both adverts are linked above.

Contact RPGN for more information.

Clinical director Rural Health

The New Zealand Rural General Practice Network is currently seeking a Clinical Director Rural Health for a two year fixed term position.

This is an exciting opportunity to help drive a rural perspective into strategic thinking, planning and advocacy as the Government implements the Health and Disability System Review.

Reporting directly to the Chief Executive, the role can be based in either Wellington or regionally, with the ability to travel regularly.

Please see the full advert for this role attached.

Rural Cohort Manager

This is a reminder about the exciting opportunity available to help drive the rural perspective into the planning, design and roll out of the COVID-19 vaccination programme to rural communities.

Between now and the end of July, the Ministry of Health’s Covid-19 Vaccine and Immunisation Programme Team (CVIP) will be designing and implementing a staged vaccination programme across New Zealand. It is recognised that rural communities have unique challenges and needs, and as such require specialist advice in ensuring that the systems are designed to meet those needs.

The New Zealand Rural General Practice Network is working with the Ministry to identify the right person for this role.

Based in Wellington for three days a week, or travelling regionally to visit stakeholders, the Ministry will cover travel and accommodation to make this position possible for the right person.

The Rural Cohort Manager will be responsible for assisting with the identification of appropriate delivery models and any variations required. The position will also support engagement with DHBs, PHOs and national bodies and provide advice to implementing partners where needed.

This is a flexible position, with the opportunity to be employed by the Ministry through secondment from an existing role, or by fixed term contract.

This position is available immediately so see the full advert for the Rural Cohort Manager role attached and apply today.

Kiuru S, Gutenstein M, Withington S.  Exploratory survey of procedural sedation and analgesia practice in sample of New Zealand rural hospitals: existing guidelines do not support current rural practice. Rural and Remote Health 2021; 21: 6320. https://doi.org/10.22605/RRH6320

A nice open-access paper by Sampsa, Marc and Steve that shows that resources at NZ rural hospitals varies and that current procedural sedation guidelines are not fit-for purpose.

PS09 is currently  under review as rural hospitals are not the only context that the current guidelines do not work. This updated document will likely be re-released end of 2021 as a co-badged document and have a sibling document that defines the skills required for competence to perform procedural sedation.

Abstract

Aim:  Rural hospitals in New Zealand provide broad generalist clinical services, including procedural sedation and analgesia (PSA). This study was designed to explore patterns of procedural sedation use including indications, equipment, medications, logistical and medical staff support available by rural hospitals, and whether current professional guidelines support rural sedation practice.
Methods:  Through the New Zealand Rural Hospital Research Network, 17 rural hospitals were enrolled in an online survey during February 2018. The electronic survey consisted of 31 questions, regarding general information, staffing level and procedural sedation practice. Further questions sought information on clinical documentation and training guidelines.
Results:  Most participating sites represented larger rural hospitals and were distributed equally throughout New Zealand. All performed procedural sedation. The distance of rural hospitals to their referral hospitals varied, with the closest being 65 km and the furthest at 326 km away. This study found that staffing and equipment available for rural procedural sedation varied, with the majority of rural hospitals having access to only one doctor out of hours, and only half having access to two doctors within daytime hours. A majority of the respondents felt that a minimum safe level for procedural sedation in their rural hospital required only a single doctor. Procedural sedation is frequently performed in rural hospitals in New Zealand, with the majority of respondents performing PSA at least once a week or more. Ketamine is the preferred PSA agent. A wide variety of procedures are undertaken including orthopaedic and injury treatments, abscess incision and drainage, and cardioversions. Patient transfer to another centre for the purpose of PSA is infrequent, occurring a few times a month or less for all hospitals.
Conclusion: This exploratory survey of rural hospital PSA practice demonstrated that PSA is a commonly performed procedure for a variety of indications. Staffing, equipment and techniques available for rural PSA vary according to institution. There is no current professional framework that suitably defines minimum standards for rural PSA practice, and specific training resources are limited. Providing procedural sedation and analgesia is an essential rural hospital service which is patient and whānau (Māori-language word for extended family) centred, saves patient transfers, and should be supported by a safe, pragmatic and realistic framework of tools, recommendations and training for rural practitioners.

Register here

Go to the website or email Lucinda

Look forward to seeing you there!

This is the declaration from the recently concluded Rural Wonca conference in Bangladesh. It is a good read, although there are certainly a few discussion points.

17^th World Rural Health Conference

Conference Declaration

Bangladesh 2021

The 17^th World Rural Health Conference hosted, in rural Bangladesh, at the Brahmanbaria Medical College (BMC) by Primary Care and Rural Health Bangladesh, and joined internationally through a virtual conference over four months, has considered how best to ensure that high quality health care is delivered to the almost half the world’s population that live in rural and remote areas. The conference was addressed by experts in rural health from all regions of the world.

The conference heard of the substantial progress of rural health in Bangladesh. We congratulate the government of Bangladesh for tremendous improvement of rural health care by establishing community clinics for every 6000 people throughout Bangladesh.  We also note that this and other measures have improved life expectancy and decreased maternal and infant mortality, and narrowed the urban/rural gap. We acknowledge these achievements make Bangladesh an exemplar in LMIC and demonstrate that country’s commitment to ensure health care of all people. (1)

But there is more to do to build on this in Bangladesh and Worldwide. During this conference we have clarified the key practical elements that can provide short- and long-term change that will bring better services to rural people. We commit ourselves to these through a:

Blueprint for Rural Health

This Blueprint for Rural Health is designed to inform rural communities, academics, and policy makers about how to reach the goal of delivering high quality health care in rural and remote areas most effectively.

Introduction

All Rural communities, and the people who live in them, need to ensure through electoral processes, advocacy and local action, that their voices are heard, and expressly and directly actioned through proactive partnerships with policy makers, health professionals, academic institutions, and health managers.(2)

Rural Healthcare needs

Primary Health Care (PHC) in rural areas should have the characteristics of being both primary in terms of including all first contact care, and comprehensive, local, grounded, and proactive in addressing the health needs of rural communities.

Rural Primary Health care should address all basic healthcare needs, including community care, family practice/general practice, emergency care, preventative care, and public health, and should provide timely access to maternity, surgical, sexual and reproductive, family violence and mental health services. It should be delivered as close as possible to the people thereby ensuring equitable access for all.  Rural services must provide first contact care and have suitable equipment for immediate care including diagnostic imaging and point of care pathology. Preventive health including health promotion, rehabilitative, vaccination, and palliative services should also be included in package of care available at the local primary care level.

Rural PHC should, wherever possible, be enabled and enhanced by, but not substituted by, technology because it cannot fully substitute for emergency and procedural services, it has limited diagnostic capabilities and is not necessarily integrated into the local rural context (such as local referral and retrieval pathways).

Universal Health Care (UHC) is not possible without access to care. It should ensure that resources are not only available but can be accessed conveniently by all rural people irrespective of their background, gender, and financial situation. Emphasis should be placed on engaging with, and understanding the needs and health beliefs of, historically marginalized populations, including indigenous peoples, and respectfully informing them about their health, rights, and responsibilities.   Local health services should be affordable to all.

Primary Health Care in rural areas should be predicated on fit-for-purpose community infrastructure. Education, employment, housing, clean water, sanitation, and sustainable energy are essential to this. Communities should be enabled and resourced to identify and address, and indeed solve, their local health care challenges.

Developing a rural workforce – selection, training. and support

Rural health workforce must be systematically supported and planned, and have clear rural health pathways(3), often termed a rural health pipeline.  Like a pipeline it is important that the are no blockages within, nor leaks from, any of the pipeline elements. A comprehensive, complete, and place-based policy framework is required. Rural WONCA working with the WHO has developed 8 actions required in implementing rural pathways (4)

The key elements to this comprehensive approach are:

Rural health workforce should as much as possible be derived from the local areas that it serves (“grow your own”). It should allow “stepladder” progression of skills attainment and certification. Local health workers must be recognised as teachers by academic institutions utilizing their services for their academic mission, respected for their contextualised knowledge, and supported to develop further their experience and expertise in teaching and stimulating learning.

The community needs to be understood, and the capability of local health workers, and their scope of work established, to identify service gaps or sustainability issues that rural training and development pathways can support.

School students in rural areas should be actively exposed to, selected for, and educated in, and for, health science careers, understanding that students at all stages cannot aspire to a career that is not visible to them. “You cannot be what you cannot see.”

The proportion of students with rural backgrounds in health science courses should at least equal the rural/urban ratio of the society.  Students in rural areas should be provided with access to preparatory courses that enable students to enter health science courses well prepared. Students in health science courses should also have rural immersion that reflects the significance and importance of rural areas.  All students in health science courses should have repeated and/or longitudinal immersion and learning in rural areas, in at least the same proportion to population, to ensure familiarity and comfort with the rural environment.

They should be enabled, sensitised, and expected to provide culturally safe and competent care, both as students and future practitioners. This should involve considering the various determinants that effect well-being and health including culture, education, environment and equitable development.

Prolonged and repeated immersion in rural settings also increases their chance of finding a life partner with similar, rural interests and this contributes significantly to rural recruitment and retention providing that the partners also have a meaningful life and work in the rural environment.  Rural health careers should also be promoted especially to young doctors as a rewarding career where individual clinicians can really make a difference.

Educational institutions have a social obligation to respond better to the health priorities for the benefit of every citizen living in the area they are supposed to serve. They must therefore orient their training, research, and service provision to privilege the underserved population living in rural and remote areas(5) Academic assessment must include examination in and about the rural context.  It has been shown that this learning in rural environments provides a rich, patient-centred and practical learning environment upon which academic learning can be scaffolded.  Rural clinical learning is made more possible now with on-line resources and instruction. It more closely reflects the modern clinical environment with a constant connection to and integration of online learning and resources. Extensive research now confirms that rural clinical education delivers at least equal academic outcomes to urban based coursework and a work-ready workforce.

Rural coursework should ensure community engagement in health improvement initiatives and research guided by communities that foster and enhance rural services.  Local research must be action based, involve academic institutions, proactively assist in health service improvement, and should be guided by the community and its needs. Local communities should be provided with meaningful and local data and data analysis that allows benchmarking and facilitates action by local community and health professionals.  For rural communities, there should be “nothing about us, without us”.

Regional teaching hubs should enhance but not replace the immersive rural experience and learning in smaller, distributed communities.

Rural training at the undergraduate, graduate, and postgraduate levels should be based on curricula that include rural context and include specific curricula for effective rural practice. (e.g. Australian College of Rural and Remote Medicine curriculum(6))

In Family Medicine, training should be aimed at producing Rural Generalist (7) family doctors who provide comprehensive, whole-person and continuous care in rural areas  This is supported by similar initiatives in rural midwifery and nursing(8), and  allied health professions and is applicable in other health professions.

Policy and advocacy

Rural health services should be staffed by generalist/ extensivist staff in all health professions, each working at full scope of their capabilities in teams. The scope of health professionals can be expanded and enhanced by technology including telehealth, but trained health professionals are needed locally.

Policy for rural health should include input from and decisions by rural communities and rural organisations. Rural professional organisations should be encouraged and supported, and should participate in decision making as key informants about rural health. They should be equal partners in this process. Government policies should be assessed in terms of their impact on rural communities (“rural proofed”) to mitigate any deleterious effects of these in rural areas. Government should strengthen coordination among various departments and work towards developing a unified policy to promote rural health. Government policy should promote rural resilience, be responsive, reassuring, and responsible – both clinically and fiscally. It is necessary to evaluate the effect of these policies continuously.

The investment in rural health should ensure a healthy local workforce, short supply chains, a business multiplier effect on local opportunities, opportunities for economic development and opportunities for individual progression and improved opportunities for women in the workforce. (9) They should ensure a sufficient health safety net that enable people to feel confident and safe in rural areas. Private and public health providers should be encouraged to share facilities, resources, and staff. (10) The ageing population in rural areas means both an increase in health care workload and an opportunity to retain and employ a younger workforce to provide this care.

Developing versatile resilient teams by allowing for part time and flexible working patterns, which can particularly benefit healthcare workers with young families or portfolio careers, would enable greater participation.  This could be supported further by developing a wider regional team through collaboration particularly in specialist interest areas and continuing professional education.

While not a solution in themselves, payment incentives do make a difference to recruitment. (11-13). Good management which understands and supports the health needs and services at a local level are vitally important. Working conditions,  lifestyle and other non-monetary factors  can have a multiplier effect,  good or bad, on existing monetary incentives(14).

Successful recruitment requires inter-sectoral investment in training and career promotion, creating a desirable workplace and first creating  and then incentivizing  a pool of workers to make a longer-term commitment to a rural area(15) . These factors are all vital in attracting and retaining young doctors to rural areas.

Challenges

COVID-19

The COVID-19 pandemic has shown the importance of local resources and self-sufficiency during a crisis and provides the rationale for major investment in local rural health service capacity. It has also shown that information communication technology (ICT) can effectively enhance rural health care, education and training, and rural health service delivery.

Climate Change

The changing climate will put further challenges on rural areas – especially arid and coastal zones – making these less habitable or uninhabitable. It will also bring new diseases to some rural areas. These issues must be addressed.

Conclusion

Rural Wonca and the participants in this conference commit to actively adopting these principles and actions and calls on the World Health Organisation (WHO), Governments, Policy makers, Academic institutions and indeed communities in all countries around the world, to honour their commitment to their rural populations by providing fair and targeted health resources and opportunities for their rural people.

1. Sustainable Development Goals Bangladesh Progress Report Government of the People’s Republic of Bangladesh/Bangladesh Planning Commission MoP; 2020.
2. Organization WH. Towards unity for health : challenges and opportunities for partnership in health development : a working paper / Charles Boelen. Geneva: World Health Organization; 2000.
3. Chater A B, OSullivan B. A Checklist for implementing rural pathways to train and support health workers in low and middle income countries. Rural Wonca 2020.
4. Strasser S. Retention of the health workforce in rural and remote areas: a systematic review. WHO 2020.
5. Boelen C, Pearson D, Kaufman A, Rourke J, Woollard R, Marsh DC, et al. Producing a socially accountable medical school: AMEE Guide No. 109. Med Teach. 2016;38(11):1078-91.
6. Rural Generalist Curriculum Australian College of Rural and Remote Medicine 2020.
7. Cairns Consensus Statement on Rural Generalist Medicine. Inaugural World Summit on Rural Generalist Medicine; 2013; Cairns Australian College of Rural and Remote Medicine
8. Rural Nursing and Midwifery Albuquerque Statement Rural Wonca 2019.
9. Global strategy on human resources for health: workforce 2030. Geneva WHO 2016.
10. Strasser R, Strasser, S. Reimagining Primary Health Care Workforce in Rural and Underserved Settings (English)Health, Nutrition, and Population (HNP) Discussion Paper. Washington, D.C.: World Bank Group; 2020.
11. McPake B, Squires A, Mahat A, Araujo E. The economics of health professional education and careers : insights from a literature review. Washington, DC: World Bank Group; 2015. xiii, 70 pages p.
12. McPake B, Edoka I, Scott A, World Bank. Analyzing markets for health workers : insights from labor and health economics. Washington, DC: The World Bank,; 2014. Available from: https://hdl.loc.gov/loc.gdc/gdcebookspublic.2014009118.
13. Soucat ALB, Scheffler RM, World Bank. The labor market for health workers in Africa : a new look at the crisis. Washington, DC: International Bank for Reconstruction and Development/World Bank; 2013. xxiv, 356 pages p.
14. Fixing Labour Market Leakages: Getting more bang for your buck on human resources for health Africa Health Forum The Wolrd Bank 2013.
15. Making it work Framework for Remote Rural Workforce Stability A brief overview European Regional Development Fund; 2019.

Cross post from Kohitanga which is hosted by Robin’s awesome blog over at Islanddocs

The POC testing paper caught my eye.

Hausfater P, Hajage D, Bulsei J, Canavaggio P, Lafourcade A, Paquet AL, Arock M, Durand-Zaleski I, Riou B, Oueidat N. Impact of Point-of-care Testing on Length of Stay of Patients in the Emergency Department: A Cluster-randomized Controlled Study. Acad Emerg Med. 2020 Oct;27(10):974-983. doi: 10.1111/acem.14072. Epub 2020 Jul 27. PMID: 32621374.

This paper attempted to show that POC testing reduces LOS in a busy ED. Ultimately this wasn’t shown to be significantly different but there was overall significant cost savings, which is interesting as POCT is often more expensive. For many of us in rural places, POCT is a necessary part of practicing and in some cases the only way to get timely blood tests. I am a little disappointed the authors didn’t review clinical outcomes in this paper.

Jenn Keys recommends the following podcast – and in particular this episode:

Ep66: Gendered Medicine 1- Heart Disease

Cardiovascular disease is the leading cause of death for women in most of the industrialized world. Women who suffer from this die at significantly higher rates than men because of discrepancies in the quality of care they receive. In this episode we explore the subtle biases that nudge male and female patients down different health pathways.

Finally today from Katelyn Costello a gem:

Toney CM, Games KE, Winkelmann ZK, Eberman LE. Using tuning-fork tests in diagnosing fractures. Journal of athletic training. 2016 Jun;51(6):498-9.

This systematic review looked at 6 studies with a total of 329 patients. Methods for identifying the studies seemed reasonable and without obvious bias. One of the issues however was the variability of fracture types between the studies and lack of “best practice” guidelines on how to perform this test. This unfortunately is not easily corrected for. The results however show that tuning fork testing for fractures has a relatively good (although rather wide ranging) sensitivity of 75% to  92% and a very wide specificity of 18 to 94%. To me the specificity is rather dubious but the sensitivity isn’t too bad. Back to statistical basics from medical school I interpret this as meaning it might be okay to rule out fractures but not so good for confirming them. Does anyone else recall SNOUT and SPIN??? (high sensitivity (SN) rules OUT vs.  high specificity (SP) rules IN).

Personally I’m not sure if I would change my practice away from a combination of the Ottawa rules and clinical concern based on patient and injury factors however possibly in a more remote setting where XR isn’t readily available it is another simple and cost-effective tool for the toolbox?