Geographical Narcissism

Wednesday, September 9th, 2020 | Rory | No Comments

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

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: 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.

Please click here to let us know what you think!

Exploration of rural physician’s lived experience

Friday, September 4th, 2020 | Rory | 1 Comment

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

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.

Please click here to let us know what you think!

Call to action: American Heart and Stroke association on rural health

Friday, February 21st, 2020 | Rory | No Comments

Harrington RA, Califf RM, Balamurugan A, Brown N, Benjamin RM, Braund WE, Hipp J, Konig M, Sanchez E, Joynt Maddox KE. Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association. Circulation.:CIR–0000000000000753.

Open Access

An interesting read from American Heart and Stroke Associations. Key points below – some of which will sound familiar, although in a vastly different health and political (thank goodness) environment!

  • There is no single definition of rural in the United States.
  • Rural population: older, lower population growth, more impoverished, less ethnic diverse, but higher percentage of indigenous populations (living close to or on their homelands)
  • Health outcomes significantly worse (and worsening) cf. urban areas
    • 40% higher prevalence heart disease
    • 30% increased stroke
    • higher maternal mortality rates

y axis = deaths; rural = orange line

  • Hospital care is increasing more difficult and further away (10.5miles cf. 4.4 miles)
    • Worsening as hospitals close (>100 rural hospitals closed since 2010; especially if state did not extend Affordable Health Care act (Obama Care))
  • Harder to access ambulance services
  • Some evidence of worse cardiovascular outcomes in rural v urban hospitals (evidence in NZ coming soon)

“In addition, it is hard to measure and track outcomes of rural hospitals for many conditions because volumes are often sufficiently low so as to preclude any conclusions from being drawn about performance for any individual site.”

  • Patient satisfaction higher cf. urban hospitals’
  • 9% of US physicians practice in rural area (despite 20% of population)
    • 77% of rural areas = Primary Care Health Professional Shortage Areas

Solutions

  • Supply of clinicians need to be addressed
  • Rural specific team based care models
  • Scope of Practice Laws facilitate rural workforce development
  • Telehealth and digitally enabled health care
  • Rural-specific care delivery sites
  • Regionalisation fo care
  • Sustainable funding
  • Flexible payment models
  • Improvement health insurance coverage
  • Broader economic development in rural areas
  • Research!

“The AHA is committed to leveraging our reach and assets and to working with strategic partners to develop solutions to improve rural health in America.”

Abstract

Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association’s pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association’s commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.

 

Thanks to Mayanna Lund (Cardiologist @ Middlemore Hospital) for passing on this paper 

Broken? Postgraduate medical education

Tuesday, January 21st, 2020 | Rory | No Comments

Hutten-Czapski P. The ‘Brokenness’ of postgraduate medical education. Can J Rural Med [serial online] 2020 [cited 2020 Jan 21];25:3–4. Available (open access) from: http://www.cjrm.ca/text.asp?2020/25/1/3/273540

Seem familiar?

“There is a disconnection in all Canadian postgraduate programmes, from both the medical school mission and community needs’ standpoint.”

A nice editorial that outlines issues familiar to us in NZ. The lack of a coordinated pathway (? is there a better term ?) to rural generalist practice. We eagerly await the results of the survey into the first 10 years of the rural hospital medicine training programme, but this programme only addresses one aspect of rural practice – what about rural general practice? what about rurally based academics?

“Not surprisingly, a longitudinal residency that takes place entirely, or mostly, in rural generalist settings (typically between 4000 and 30,000 population and 150–1000 km distant from a city of over 100,000) is associated with rural practice at an odds ratio of 3.9.”

The Orange Declaration

Monday, October 21st, 2019 | Rory | No Comments

Perkins D, Farmer J, Salvador‐Carulla L, Dalton H, Luscombe G. The Orange Declaration on rural and remote mental health. Aust. J. Rural Health. 2019;00:1–6. https://doi. org/10.1111/ajr.12560

Open Access: https://onlinelibrary.wiley.com/doi/full/10.1111/ajr.12560

Contribution by Dr. Fiona Doolan-Noble

The Orange Declaration on rural and remote health evolved out of a meeting in Orange, New South Wales in October 2018 between mental health researchers and service providers from New South Wales, Victoria, the Australian Capital Territory and Western Australia to examine the issue of rural mental health and well‐being. Following the meeting five iterations of the document were developed, with participants agreeing upon a consensus statement that outlined ten problems related to current models of rural mental health and well‐being and ten potential solutions to the problems.

Reading the paper the identified problems and associated solutions could easily be applied to any health and social care service. As the authors highlight this is driven by the association and relationship between the challenges associated with provision of services in rural areas- geographical, demographic, social, economic and environmental. All of which are not addressed satisfactorily by the current mix of services, the distribution of the health and social care workforce, nor the associated skill mix within those workforces.

Sadly what is missing from the Declaration is any mention of the need to prioritise addressing the crisis in Aboriginal and Torres Strait Islander mental health and well-being.

The publication of the Declaration is a useful way to start a conversation about rural mental health and well-being and as a strategy for bringing the varied organisations and academic institutions working in the space together. However, it is to be hoped that any funding secured will be used in the first instance to co-develop programmes and interventions that are culturally appropriate for rural Aboriginal and Torres Strait Islander people.

 

“4 TEN PROBLEMS

Ten problems related to current models of rural mental health and well‐being were identified. They are as follows:

  1. Rural communities are different from cities and are not homogenous: they are distinctive, each with different local assets and challenges. Community contexts can change rapidly due to economic instability, dependence on particular leaders or natural disasters. One‐size‐fits‐all service models that cannot adapt to time, place and context are therefore inappropriate.
  2. The rural mental health system is not working: Indicators of rural health and illness suggest that current service models are failing, not fit for service or overly stretched; this situation has been recognised in the public imagination, the media and in political debate.
  3. Top‐down service models are based on urban assumptions: Rural service models in Australia are based on large region‐wide analyses of service activity data, with relatively little evidence of community co‐design or co‐production. People in rural communities can draw on available local evidence and participate effectively in service design. This requires providing them with appropriate data so that they can partner with local providers and commissioners. An example of these productive partnerships is the rural and remote Aboriginal Community Controlled Health Services that provide integrated and locally managed services which have achieved notable health gains.
  4. Services are not based on needs: Emerging evidence suggests that service provision does not always map to population need, nor does spending necessarily achieve better mental health outcomes. This suggests that the available services are failing to provide what is needed and could be due to demand exceeding supply, service fragmentation, challenges in service navigation or services not reaching vulnerable rural clients.
  5. The current forms of public financing are misaligned disproportionately rewarding outreach, telehealth and city‐centric models at the expense of the local public, private and NGO services from medical, allied health, nursing, peer and care partners. Short‐term funding constraints such as 12‐month contracts offered by Primary Health Networks discourage providers from making investments in rural and remote communities.
  6. Fragmentation and competition hinder sustainable, robust service provision: With a large number of service providers in small communities competing for short‐term contracts, addressing different performance targets and often based elsewhere; the role, past performance and track record of services can be highly confusing and their work uncoordinated. Navigating fragmented services increases transaction costs is a challenge for both clients and for health practitioners.
  7. Structural inequity in mental health service provision is amplified in rural areas: While there are rural residents with acute mental health needs, many of the current gaps in rural mental health might lie in areas of awareness, acceptability, prevention, mental health literacy and social connectedness. An over‐emphasis on specialist and hospital services neglects the first‐line “self‐care” that community members could provide for themselves.
  8. The rural mental health workforce cannot be a miniature version of that found in large cities. Its location, skills, scope of practice, supervision, support and development are all problematic. Mental health jobs are very demanding, responses are needed around the clock, personal and professional boundaries are hard to maintain in small communities and burnout is common.
  9. While telehealth and online services should augment mental health services for all clients whether rural or urban, people with mental health challenges often need to speak in person with a health professional, and on some occasions, very quickly. Rural residents need a range of appropriate options to cater for the different situations in their lives.
  10. Data sets are incomplete, disjointed and limited: many different and incompatible data sets are gathered and there is little data‐sharing or linkage. It is therefore complex to analyse service data and find out which services are associated with improvements in access or health outcomes in which communities.

5 TEN SOLUTIONS

Ten solutions are proposed for rural mental health and well‐being that together would benefit from robust testing and evaluation. They are as follows:

  1. Whole‐of‐community, place‐based approaches are promising: These approaches are established in many countries and place‐based planning is increasingly popular in Australia. Resources and toolkits have been developed by organisations such as the World Health Organisation (WHO). The WHO model has been shown to be successful in an international systematic review but has not yet been trialled in Australia.
  2. New service models tailored to context must be considered: There are numerous innovative models, methods and ideas being tested at a community level that could be scalable. These models need to be tested at a larger scale using appropriate investigative methodologies. Ideally, much of this research would be conceived and conducted by rurally based researchers and partnerships, helping to build rural research capacity. Moreover, these new ways of working (different models) are likely to require new skills in health care providers and new organisational arrangements, which will also require development.
  3. Co‐designed bottom‐up processes should be pursued in collaboration with state and federal partners: Involving place‐based communities in collaborative co‐design can help to build local partnerships, awareness and generate appropriate solutions. These are beginning to be tested using rigorous methodologies. Such approaches can build empowerment, capacity, resilience, social connection and empathy in diverse cultures. Local partnerships are best placed to plan models about how to care for people in crisis locally who could be at serious risk if they cannot access timely assistance.
  4. Holistic and integrated care models need testing: Many rural communities and primary health services have already given‐up on one‐size‐fits‐all centrally imposed models. Many new non‐clinical, community‐based roles are emerging, including service navigators, connectors, peer supporters and outreach workers who can visit isolated‐community members, provide navigation and support. Such workers can provide a cost‐effective source of local prevention, connection and support. However, models engaging lay personnel to complement health and community services would benefit from large‐scale testing.
  5. New better‐aligned funding models are needed: New funding models that reward collaboration provide rural residents and service providers with choices and referral options, enable clinical supervision and professional mentorship need to be developed, modelled and tested.
  6. Whole of community approaches are needed, not pilot studies: These should be co‐designed with rural communities and tested over longer time periods (at least 3‐5 years). Incremental design and improvement is a much better model with a clear recognition that one size will not fit all and that those without personal experience of living in rural communities might not be the best source of wisdom.
  7. Prevention and early intervention must be considered: Local providers and community leaders suggest that prevention is a largely neglected strategy. Building local strategies to address social connection, transport accessibility, mental health literacy and stigma reduction is a fundamental step. Further research summarising and exploring effective and ineffective approaches at the community level would help identify locally relevant strategies.
  8. New rural workforce models are needed: To address specific rural mental health workforce challenges “grow‐your‐own” and “skills escalation” strategies appear promising. These approaches seek to identify existing local practitioners and residents with the potential to become future health and community service workers, peer supporters or volunteer navigators. These strategies require local incentives to encourage staff to work at the top of their scope of practice; “task‐shifting” to non‐clinical or community roles; effective supervision and governance structures. Workers involved could include personnel from the health sector in general, alcohol and other drugs workers, social care, police, social workers and finance/banking workers.
  9. Digital technology contributes now and can do more as part of new systems: Digital and telehealth services continue to play an important role in extending services to rural communities, but they are not a panacea and people might also need immediate face‐to‐face help or specialist advice and care. Understanding the place and value of online, digital and telehealth offerings is a significant research gap. Social media such as Facebook pages that are created and maintained by local practitioner‐community member collaboratives might be useful for people isolated by distance, culture, poverty, negative relationships or lack of connection. The use of online sources of care and support is partly dependent on increased access and expanded bandwidth.
  10. Enhance data collection, monitoring, linkage, analysis and planning: To address the issues of service fragmentation, gaps, duplication and lack of information sharing, there needs to be a substantial investment in better data collection, monitoring and evaluation to enable services to assess outcomes in a timely manner, thereby facilitating responsive service improvement activities.”

CRASH into a post – get tranexamic acid. Or not?

Friday, October 18th, 2019 | Rory | No Comments

The CRASH–3 trial collaborators. Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH–3): a randomised, placebo-controlled trial.Lancet. 2019

EZ-PROXY link

A follow-on from the CRASH2 trial (tranexamic acid (TXA) in trauma), this large randomised placebo-control multi-centre study looked at Traumatic Brain Injury (TBI). 1g of TXA was infused over 10minutes followed by a 1g over 8 hours or placebo within 3 hours of injury. The primary outcome was death in hospital related to the head injury within 28 days.

Although the authors conclude that TXA reduced head injury related death this conclusion has come under fire on the internet. In all head injured patients the confidence interval for the risk reduction includes 1. However, in the mild-moderate injured patient (GCS 9–15) there was a clear reduction in head injury related death (RR 0.78 – 0.64–0.95). Also importantly the risk of VTE and other complications – including stroke – was similar in both treatment and placebo groups

Many authors (urban based ED docs) are hesitant to give TXA in the isolated head injured patient, like they are in post-partum haemorrhage on the basis of the results of the WOMAN trial1 but I see TXA as a really important drug – when there is little else you can do. It might be effective and save a life and it is unlikely to do any harm! Give it and give it early!

 

Give it early…

Would like to hear what you think or disagree in the Comments.

There are lots of blogs discussing this trial and will let them go into the nitty gritty of Evidence Based Medicine.

Abstract

Background

Tranexamic acid reduces surgical bleeding and decreases mortality in patients with traumatic extracranial bleeding. Intracranial bleeding is common after traumatic brain injury (TBI) and can cause brain herniation and death. We aimed to assess the effects of tranexamic acid in patients with TBI.

Methods

This randomised, placebo-controlled trial was done in 175 hospitals in 29 countries. Adults with TBI who were within 3 h of injury, had a Glasgow Coma Scale (GCS) score of 12 or lower or any intracranial bleeding on CT scan, and no major extracranial bleeding were eligible. The time window for eligibility was originally 8 h but in 2016 the protocol was changed to limit recruitment to patients within 3 h of injury. This change was made blind to the trial data, in response to external evidence suggesting that delayed treatment is unlikely to be effective. We randomly assigned (1:1) patients to receive tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Patients were assigned by selecting a numbered treatment pack from a box containing eight packs that were identical apart from the pack number. Patients, caregivers, and those assessing outcomes were masked to allocation. The primary outcome was head injury-related death in hospital within 28 days of injury in patients treated within 3 h of injury. We prespecified a sensitivity analysis that excluded patients with a GCS score of 3 and those with bilateral unreactive pupils at baseline. All analyses were done by intention to treat. This trial was registered with ISRCTN (ISRCTN15088122), ClinicalTrials.gov (NCT01402882), EudraCT (2011–003669–14), and the Pan African Clinical Trial Registry (PACTR20121000441277).

Results

Between July 20, 2012, and Jan 31, 2019, we randomly allocated 12 737 patients with TBI to receive tranexamic acid (6406 [50·3%] or placebo [6331 [49·7%], of whom 9202 (72·2%) patients were treated within 3 h of injury. Among patients treated within 3 h of injury, the risk of head injury-related death was 18·5% in the tranexamic acid group versus 19·8% in the placebo group (855 vs 892 events; risk ratio [RR] 0·94 [95% CI 0·86–1·02]). In the prespecified sensitivity analysis that excluded patients with a GCS score of 3 or bilateral unreactive pupils at baseline, the risk of head injury-related death was 12·5% in the tranexamic acid group versus 14·0% in the placebo group (485 vs 525 events; RR 0·89 [95% CI 0·80–1·00]). The risk of head injury-related death reduced with tranexamic acid in patients with mild-to-moderate head injury (RR 0·78 [95% CI 0·64–0·95]) but not in patients with severe head injury (0·99 [95% CI 0·91–1·07]; p value for heterogeneity 0·030). Early treatment was more effective than was later treatment in patients with mild and moderate head injury (p=0·005) but time to treatment had no obvious effect in patients with severe head injury (p=0·73). The risk of vascular occlusive events was similar in the tranexamic acid and placebo groups (RR 0·98 (0·74–1·28). The risk of seizures was also similar between groups (1·09 [95% CI 0·90–1·33]).

Interpretation

Our results show that tranexamic acid is safe in patients with TBI and that treatment within 3 h of injury reduces head injury-related death. Patients should be treated as soon as possible after injury.

Funding

National Institute for Health Research Health Technology Assessment, JP Moulton Charitable Trust, Department of Health and Social Care, Department for International Development, Global Challenges Research Fund, Medical Research Council, and Wellcome Trust (Joint Global Health Trials scheme).


  1. Shakur H, Elbourne D, Gülmezoglu M, Alfirevic Z, Ronsmans C, Allen E, Roberts I. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010 Dec;11(1):40.

Avoid the urban box

Saturday, November 17th, 2018 | Rory | No Comments

 

Rural – avoid the urban box

Don’t Try to Fit Rural Health Into an Urban Box

https://www.rwjf.org/en/blog/2018/11/dont-try-to-fit-rural-health-into-an-urban-box.html#
Mellissa Bosworth

a practical and obvious perspective from the USA;

  1. Support local leaders and customised solutions
  2. Design for both community and individual
  3. Celebrate older generations
  4. Take the long view
  5. Respect and build on rural strengths

contributed by Dr. Fiona Dolan-Noble, senior Research Fellow, rural health, Department of GP and rural health, University of Otago