New Zealand postgraduate medical training by distance for Pacific Island country-based general practitioners: a qualitative study

Wednesday, April 27th, 2022 | claly44p | No Comments

Blattner K et al. Journal of Primary Health Care 2022; 14(1): 74–79.

Open Access https://doi.org/10.1071/HC21090

“Enrolling at the University of Otago distance-taught Rural Postgraduate programme allowed me the flexibility to study, work, and not have to relocate my young family to NZ. The registration process was simple and the content of the papers were applicable to the Cook Islands context especially the challenges faced in rural/remote settings with very little resources. It created a career pathway for upskilling which formed an important academic component for the Cook Islands GP Fellowship Programme which I’ve been blessed as a recipient.” Dr Teariki Puni

This study explores student experiences of the now established partnership between the University of Otago rural postgraduate programme and Pacific Island country-based doctors. While successful in meeting clinical relevance and professional connections, there needs to be better access to University resources and academic support akin to those based on campus. The lead author, Kati Blattner, is a tremendous advocate and support for these students who have achieved highly. See previous posts:  https://blogs.otago.ac.nz/rural/congratulations-mafi/  and  https://blogs.otago.ac.nz/rural/new-cook-island-gps/ and https://blogs.otago.ac.nz/rural/cooks-islands-doctor-upskills-with-otago-diploma/

Abstract

Introduction. New Zealand health training institutions have an important role in supporting health workforce training programmes in the Pacific Region. Aim. To explore the experience of Pacific Island country-based doctors from the Cook Islands, Niue, and Samoa, studying in New Zealand’s University of Otago distance-taught Rural Postgraduate programme. Methods. Document analysis (16 documents) was undertaken. Eight semi-structured interviews were conducted with Pacific Island country-based students. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately, followed by a process to converge and corroborate findings. Results. For Pacific Island countries with no previous option for formal general practice training, access to a recognised academic programme represented a milestone. Immediate clinical relevance and applicability of a generalist medical curriculum with rural remote emphasis, delivered mainly at a distance, was identified as a major strength. Although technologies posed some issues, these were generally easily solved. The main challenges identified related to the provision of academic and other support. Traditional university support services and resources were campus focused and not always easily accessed by this group of students who cross educational pedagogies, health systems and national borders to study in a New Zealand programme. Study for individuals worked best when it was part of a recognised and supported Pacific in-country training pathway. Discussion. The University of Otago’s Rural Postgraduate programme is accessible, relevant and achievable for Pacific Island country-based doctors. The programme offers a partial solution for training in general practice for the Pacific region. Student experience could be improved by tailoring and strengthening support services and ensuring their effective delivery.

College drives improvements for rural registrars

Monday, April 11th, 2022 | claly44p | No Comments

Registrars in the first year of the General Practice Education Programme (GPEP) who choose to relocate and work in a rural community will now benefit from a sensible accommodation allowance thanks to College negotiations with the Ministry of Health.

From 1 April 2022, registrars living within 30 kilometres of a rural practice in which they work will receive $350 a week towards accommodation.

The College proactively approached the Ministry to substantially increase the existing allowance as a way to make working in rural locations more attractive to registrars. The approach, and ask, was recently ratified by the Resident Doctor’s Association (RDA) members.

 

Rural matters

About 20 percent of College-employed GPEP year 1 registrars do one rural attachment a year. Encouraging registrars to live closer to their rural practice means better understanding the culture and community they work in but also ensuring the health and safety of our people by cutting down long commutes at the start and end of busy days.

Encouraging our registrars to work in rural communities helps address some of the shortfall in some of New Zealand’s most remote locations, that really benefit from community doctors. We know more registrars would like the opportunity to work in rural communities but the financial barriers hinder many in making the move.

 

Eligibility

Any College-employed GPEP year 1 registrar who relocates to live within 30 kilometres of the rural practice they are attached to is eligible. With College pre-agreement it may also be possible in future to remain in a single rural practice for the whole of a first GPEP year.

Rural (or urban) practices wanting to sign up to become a teaching practice can do that on the College website.

 

Our voice is important for making change

The College is constantly advocating to make improvements to the workforce and conditions for registrars and Fellows. We do this through relationships, surveys to the membership, meetings with politicians, media messages, and direct advocacy to the Ministry of Health.

 

We believe this initiative will entice more GPEP year 1 registrars to live and work rurally and that will benefit both our members and our rural communities.

Nāku noa, nā

Lynne Hayman

Chief Executive

A prospective multi-centre study assessing the safety and effectiveness following the implementation of an accelerated chest pain pathway using point-of-care troponin for use in New Zealand rural hospital and primary care settings

Wednesday, April 6th, 2022 | claly44p | No Comments

Rory Miller, Garry Nixon, John W. Pickering, Tim Stokes, Robin M. Turner, Joanna Young, Marc Gutenstein, Michelle Smith, Tim Norman, Antony Watson, Peter George, Gerald Devlin, Stephen Du Toit, Martin Than. A prospective multi-centre study assessing the safety and effectiveness following the implementation of an accelerated chest pain pathway using point-of-care troponin for use in New Zealand rural hospital and primary care settings, European Heart Journal. Acute Cardiovascular Care, 2022; 

OPEN ACCESS https://doi.org/10.1093/ehjacc/zuac037

It’s great to see a significant piece of rural clinical research from NZ published in an international journal. I know many of you contributed to this study.

This has important clinical implications. We now know that we don’t disadvantage our patients when using point of care troponins, as long as we use them as part of the Rural Accelerated Chest Pain Pathway. We also have a clearly defined group of chest pain patients we can assess without admitting to hospital. If the DHBs (or what follows them) can get the funding streams right, there is the potential to manage many of these patients in rural GP, resulting in savings to both patients and the health system.

Well done Rory. This is excellent work!

Doing without the residential component of a blended postgraduate rural medical programme during the 2020 COVID-19 pandemic in New Zealand: student perspectives

Wednesday, January 12th, 2022 | claly44p | No Comments

Katharina Blattner, Rory Miller, Mark Smith & Janine Lander (2022) 

Education for Primary Care, DOI: 10.1080/14739879.2021.2011626

To link to this article: https://doi.org/10.1080/14739879.2021.2011626  

In a post-COVID19 era we have all experienced a move into the virtual environment especially for ongoing education/professional development and will relate to this study’s findings.

ABSTRACT 

Aim: Rural-targeted postgraduate medical training is a key factor associated with entering rural practice. Rural health professionals often experience geographical and professional isolation, which can impact their training and education. In New Zealand, during the 2020 COVID-19 pandemic, an established distance postgraduate rural medical programme replaced its in-person residentials with virtual workshops. This study aimed to gain insights into the student experience of the virtual workshops, with emphasis on exploring the effects of the absence of an in-person component. 

Method: Qualitative exploratory design. All students who had completed a semester one 2020 University of Otago rural postgraduate module were invited by email to participate. Fifteen semi-structured interviews were conducted by video-conference. A thematic analysis was conducted using a general inductive approach. 

Results: Three themes captured the main issues. 1. Making sure everyone is in the same boat: the key roles of an in-person component were identified as consolidation of learning, benchmarking and connectedness. 2. Learning but not connecting: virtual workshops were well facilitated, allowed continuation of study and the convenience of staying home, however connectedness faded. 3. We’ve got to keep a human touch in a digital age: looking beyond the pandemic, opportunities for streamlining virtual content were identified, however there was concern around diminished communication and cultural aspects of learning and the absent connection with rural health services and communities. 

Conclusion: A virtual workshop is valuable in the COVID-19 environment but does not replace an in-person component of a distance postgraduate training programme for rural medicine 

If you would like the full text please contact katharina.blattner@otago.ac.nz

Exploring the response to the COVID-19 pandemic at the rural hospital–base hospital interface: experiences of New Zealand rural hospital doctors

Friday, November 12th, 2021 | claly44p | No Comments

Just in case you missed the highlight in today’s NZMJ!

Exploring the response to the COVID-19 pandemic at the rural hospital–base hospital interface: experiences of New Zealand rural hospital doctors

Garry Nixon, Katharina Blattner, Stephen Withington, Rory Miller, Tim Stokes. NZMJ 12 November 2021, Vol 134 No 1545

The study found that during the first L4 lock-down that communication and processes linking rural hosptials to base hospitals were disrupted. DHB support for rural hosptials varied widely and an established local leadership facilitiated an effective local response. Equity concerns persist regarding transfer, especially those who are critically unwell.

The paper is open access and can be found at:

https://journal.nzma.org.nz/journal-articles/exploring-the-response-to-the-covid-19-pandemic-at-the-rural-hospital-base-hospital-interface-experiences-of-new-zealand-rural-hospital-doctors-open-access

Along with a couple of media interviews!

https://www.rnz.co.nz/news/national/455546/study-highlights-dangerous-disconnect-rural-hospital-face-as-spectre-of-covid-19-looms

https://www.iheart.com/podcast/211-newstalk-zb-early-edition-25086386/?keyid%5B0%5D=Early%20Edition%20with%20Kate%20Hawkesby&pname=podcast_profile&sc=widget_share

 

Abstract

Aim

The COVID-19 pandemic stress-tested health systems globally and accentuated pre-existing health inequities. There is little understanding of the impact that the 2020 pandemic preparations had on New Zealand’s rural hospitals. This study explores rural hospital doctors’ experiences of the COVID-19 pandemic, with an emphasis on the rural hospital–base hospital interface.

Method

Seventeen semi-structured interviews were conducted with rural hospital doctors across New Zealand. A thematic analysis using a framework-guided rapid analysis method was undertaken.

Results

The regular communication channels and processes linking rural hospitals to their urban base hospitals were disrupted as the pandemic began. Established local leadership facilitated a rural hospital’s ability to make an effective local response. District health board (DHB) support for their rural hospitals varied widely and largely reflected the status of the pre-pandemic relationship. DHB understanding of rural hospital facilities and processes was considered to be poor. Ongoing uncertainty around managing and transferring acutely unwell patients with COVID-19 remained. Equity concerns centred on access to advanced care.

Conclusion

The experience of the COVID-19 pandemic has highlighted the resilience of rural hospitals as well as the challenges they face in operating at the margins of the healthcare system.

 

 

“No better or worse off”: Mycoplasma bovis, farmers and bureaucracy

Monday, October 25th, 2021 | claly44p | No Comments

Chrystal Jaye, Geoff Noller, Mark Bryan, Fiona Doolan-Noble (2021) “No better or worse off”: Mycoplasma bovis, farmers and bureaucracy. Journal of Rural Studies, Volume 88, Pages 40-49, ISSN 0743-0167,

https://doi.org/10.1016/j.jrurstud.2021.10.007.

This paper uses Habermas’ theory of lifeworld and system to dissect the collision that happened on farms during the management of the incursion between farming values of stock welfare and practical and relational forms of knowledge; and policy, regulation, compliance and technical instrumental forms of knowledge.

Abstract:

The 2017 outbreak of Mycoplasma bovis in New Zealand deeply impacted rural communities, particularly cattle farmers. In 2018, the Ministry for Primary Industries (MPI) implemented an eradication programme that involved herd testing, stock culls, restriction of stock movements, decontamination of affected farms, and compensation to farmers for losses associated with the eradication programme. New Zealand news media reported widely on the emotional trauma experienced by affected farmers and MPI was criticised for poor management of the outbreak. We interviewed nineteen farmers and farming couples affected by M. bovis in Southern New Zealand to gain insight into their experiences of the outbreak. In this paper, we present the findings pertaining to one dominant thematic: that of farmers’ interactions with the bureaucracy associated with the management of the outbreak. The farm appeared to quite literally represent a site of collision between farming values of stock welfare and practical and relational forms of knowledge; and policy, regulation, compliance and technical instrumental forms of knowledge. For these reasons, Habermas’ theory of lifeworld and system presented itself as a particularly salient framework for interpreting our data. Participants experienced the eradication programme as intrusive, impractical, and inhumane; while their situated local knowledge and pragmatism were ignored in favour of adherence to wasteful and inefficient bureaucratic processes that while compliant with policy, made no sense to the farmers. We suggest that biosecurity threats such as M. bovis might be more effectively managed when the bureaucracy is attentive to the rural lifeworld and responsive to the situated knowledge of farmers.

 

Does it matter where you have your STEMI?

Tuesday, November 3rd, 2020 | Rory | No Comments

Lee S, Miller R, Lee M, White H, Kerr A. Outcomes after ST-elevation myocardial infarction presentation to hospitals with or without a routine primary percutaneous coronary intervention service (ANZACS-QI 46). The New Zealand Medical Journal. 2020 Oct 30;133(1524):64-81.

Link – NZMJ articles become open access after 6 months.

 

Commentary from Associate Professor Garry Nixon

Why no difference? There should be a difference!

As expected STEMI patients who present to rural and provincial hospitals are older,  more likely to be Māori and have on average lower socioeconomic status (because our patient populations are). They also get fibrinolytics – a second rate substitute for primary PCI. You’d expect, even with the best will in the world, that there would a measurable difference in outcomes, with patients presenting to urban PCI centres doing better . That this study failed to demonstrate this is, to say the least, surprising.

The authors attribute this to the adoption of the pharmaco-invasive strategy and the implementation of current strategies including the out-of-hospital STEMI pathway (which includes the ‘appropriate bypass of non-intervention hospitals’). But the study period (2011-2016) predates the NZ out-of-hospital STEMI pathway and we were practicing a Rescue PCI strategy targeted at patients who failed to reperfuse back then. This is evidenced by the small percentage of rural patients getting angiography within 24 hours (about 25%; a pharmacoinvasive strategy = PCI within 24hrs of fibrinolysis). And these results are not the result of hospital bypass, the basis of the study groups was hospital of initial contact. The results are however a lot better than studies done in the 1990s that demonstrated much poorer outcomes for provincial AMI patients.  My guess is the key here is good communication between peripheral centres and base hospital cardiology units, and that was becoming well established by 2011 in NZ; and all parties should aim to keep building these networks.

I have to thank the whole ANZACS QI team. Its great to see a major NZ research unit looking seriously at rural outcomes. In large part that’s due to the work of the 2nd author. Well done to him.


Abstract:

AIM: Primary percutaneous coronary intervention (PCI) is the optimal reperfusion strategy to manage ST-elevation myocardial infarction (STEMI). Where timely primary PCI cannot be achieved, an initial pharmacological reperfusion strategy is recommended with subsequent transfer to a PCI-capable hospital. The study aim was to assess STEMI outcomes according to the interventional capability of the New Zealand hospital to which patients initially present.

METHODS: Nine thousand four hundred and eighty-eight New Zealand patients, aged 20–79 years, admitted with STEMI to a public hospital were identified. Patients were categorised into three groups— metropolitan hospitals with all-hours access to primary PCI (routine primary PCI cohort), metropolitan hospitals without routine access to PCI, and rural hospitals. The primary outcome was all-cause mortality. Secondary outcomes were major adverse cardiac events (MACE) and major bleeding.

RESULTS: Invasive coronary angiography was more frequent in the routine primary PCI cohort compared to metropolitan hospitals without routine access to PCI and rural hospitals (90.6 vs 83.0 vs 85.0% respectively; p<0.001) and occurred more commonly on the day of admission (78.9 vs 28.7 vs 25.7% respectively; p<0.001). There were no differences in multivariable adjusted all-cause mortality, MACE or major bleeding between patients admitted to any of the hospital groupings.

CONCLUSION: Outcomes after STEMI in New Zealand are similar regardless of the interventional capability of the hospital where they first present.

Technology-facilitated care coordination in rural areas: What is needed?

Monday, July 6th, 2020 | Rory | No Comments

Gill E, Dykes PC, Rudin RS, Storm M, McGrath K, Bates DW. Technology-facilitated care coordination in rural areas: What is needed? International Journal of Medical Informatics. 2020 May;137:104102.

 

Comments by the lead author – Dr. Emily Gill from Opōtiki

Take-away

People who live in rural areas have poorer health than their urban counterparts, and for those with multiple, complex medical needs, this is impacted by health IT systems.  This research suggests US rural settings may contend with more unaffiliated electronic health records (EHRs a.k.a. PMSs), than urban settings.  The equivalent in NZ is that rural areas that border between DHBs are more likely to see patients from outside their own DHB, and this poses challenges of accessing and exchanging electronic information (e.g., electronic referrals) with unaffiliated DHBs.  Policy regulations should require that health information be exchanged between all health services, from pharmacy to private hospital to allied health providers, in a way that is ‘useable’ (e.g., user-friendly; without the need to login to multiple other platforms).  An important way to evaluate whether health IT systems are improving health is to focus on care coordination activities: for patients who see multiple health providers due to their complex, chronic needs, how easily can the patient and all the health providers involved access and know pertinent health information, especially when changes are occurring frequently? 

More details:

To provide coordinated care, health information needs to be frequently transferred across settings such as primary care clinics, acute care hospitals, and community health services. The U.S. government made a major financial investment in health information technology with the aim of improving improve care coordination and provided incentives for healthcare organizations to electronically exchange information in a more efficient and accurate process.  Given the increased health needs of the rural population, this research project sought to understand the experiences of healthcare providers in exchanging information during or in response to a transfer of care.

 

The interviews and surveys conducted through this research described numerous gaps between the necessary care coordination activities for patients with complex needs and the capacity for technology to facilitate the process. Healthcare professionals described low confidence in the integrity of the information they receive, and the effort required to gather needed information, including challenges with arranging real-time communication with other providers caring for the same patient.  Providers described care plans, a potentially useful tool in care coordination, as being regulated to such an extent that they are not used in routine decision making. In exchanging information between organizations using different Electronic Health Records (EHRs), most systems could not automatically incorporate the new information into the existing patient record. This lack of interoperability explains the large quantities of information the providers described faxing and scanning in.  Finally, rural healthcare professionals described the compounding impact of poverty on coordinating care for their patients. Not having transportation to specialist appointments; being geographically located between multiple larger health systems, which amplifies the number of external EHR systems in use; and the lack of access to specialty services all accentuate the challenges of information exchange during care transitions.

Both the U.S. and New Zealand should continue to focus on policy that drives the development of technology standards for how health information is exchanged.  In addition to promoting EHR systems that can receive and incorporate information automatically, standards should guide the usability of digital health data, and how it is aggregated across settings to create useful longitudinal care plans. Policy in both countries should encourage further research to define meaningful measures of how coordination technology tools impact population health.

Dealing with chest pain – a pathway protocol.

Friday, July 3rd, 2020 | Rory | No Comments

Miller R, Young J, Nixon G, Pickering JW, Stokes T, Turner R, et al. Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations. Journal of Primary Health Care. 2020;12(2):129.
open access link

The study protocol for an observational study examining the safety a novel chest pain pathway that uses point-of-care troponin.

Chest pain pathway’s are used throughout the country but largely rely on laboratory based troponin assays, which are not available for a considerable proportion of the rural population.[1] This will be the first large study that examines a rural and/or primary care population.

Enrolment has been more difficult (and slower) than anticipated, but in more than 300 low risk patients (and preliminary analysis), there have been no missed Major Adverse Cardiac Events in the first 30 days after presentation. This is in line with other chest pain pathways that use the new high-sensitivity assays.

very preliminary analysis of the primary end-point 

If you have access to point-of-care troponin and aren’t involved as a study site then please get in touch with me, and if you are already contributing – thank you!! and think of entering patients with chest pain into the data collection tool!

 


  1. Miller R, Stokes T, Nixon G. Point-of-care troponin use in New Zealand rural hospitals: a national survey. New Zealand Medical Journal. 2019;132(1493):13.  ↩

People falling over in the South.

Tuesday, May 26th, 2020 | Rory | No Comments

Merrett A, Keys J, Crane C, Gwynne-Jones D. Non-resident orthopaedic admissions to Dunedin Hospital 1997 to 2017 and Southland Hospital 2011 to 2017. The New Zealand Medical Journal (Online). 2020 May 8;133(1514):41-5.

An interesting audit of orthopaedic injuries in the far South published in a recent NZMJ. One of the authors is the current Chair of the Division of Rural Hospital Medicine (Jennifer Keys). The authors found that overseas visitors cost the DHB a lot of extra money when they fall off or over things. It would be interesting to examine the extra workload these injuries have on the rural health services closer to the ‘action’.

Suspect on balance the tourist dollars in far outweigh any extra health costs incurred – as I think we are finding out!

Abstract

Aim

The purpose of this study is to audit the numbers of non-residents requiring orthopaedic admission to Dunedin and Southland Hospitals and determine the effects of increasing tourist numbers on healthcare resources.

Method

All non-resident orthopaedic admissions to Dunedin Hospital from January 2005 to December 2017 and Invercargill Hospital from January 2011 to December 2017 were analysed with respect to country of residence, mechanism of injury, primary diagnosis and case weights consumed. The results were combined with figures from 1997–2004 to give a 21-year series for Dunedin Hospital.

Results

There has been a significant increase in the number of admissions and case weights (CW) over the past 21 years at Dunedin Hospital (p<0.001). The most common mechanisms of injury were snow sports at Dunedin Hospital and falls for Southland Hospital. Between 2011 and 2017 there were on average 50 non-resident admissions per year (92.9 CW/year) to Dunedin Hospital and 74 admissions (120.7 CW/year) in Southland.

Conclusion

Increasing tourist numbers have resulted in an increase number of orthopaedic admissions to Dunedin Hospital over the last two decades although it remains a small proportion of the total workload. Southland Hospital is relatively more affected. These patients represent an annual cost in excess of $1,000,000 to Southern DHB.

 

Rider unknown. Too much hair for Garry…

image credit: http://www.pinkbike.com/news/Fails-for-Your-Friday-July20-2012.html