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 best not quite there yet…

Tuesday, November 19th, 2019 | Rory | No Comments

Hutten‐Czapski P. Is Northern Ontario School of Medicine there yet? Can J Rural Med 2019;24:103‐4.

Full text available at the CJRM website

This editorial is in the latest edition of the Canadian Journal of Rural Medicine. The Northern Ontario School of Medicine is considered the gold standard in rural medical education. But it appears that rural communities in Northern Ontario are still more likely to see medical students than the finished product, and most of the graduates are still headed to the cities; albeit the provincial cities in Northern Ontario.

This tells us what we already know. It’s not easy, and it’s important not to confuse workforce success in provincial centres with success in rural areas.

I am however sure we still have much to learn from NOSM.

Thanks to Assoc. Prof Nixon for the commentary

1’s and 0’s of wisdom: Don’t be afraid

Monday, November 4th, 2019 | Rory | 2 Comments

Gutenstein M. Daring to be wise: We are black boxes, and artificial intelligence will be the solution. Emergency Medicine Australasia. 2019 Oct;31(5):891–2. EZProxy link

A very well written and thoughtful piece on the future of emergency medicine in a technologically advanced age. There are many similarities between emergency and rural medicine – e.g. just substitute overwhelming patient and time pressure with (professional and geographic) isolation and workforce shortages – and the technology is and will have a very positive effect on the care of our patients – if we let it. I don’t think we will lose our jobs, we will work differently – hopefully more enabled, with more compassion and more satisfaction (and more time at the beach?)

Abstract

Emergency physicians seek wisdom through personal resilience, deliberate reasoning, clinical consensus and reflective practice. However, there is a limit to how useful psychological training, clinical guidelines and audit initiatives can be in the face of inherent human fallibility, increasing system complexity and escalating demand. Wisdom may be more easily attained through the careful design of new technology and this should be a priority for the emergency medicine community.

Marc is a convener of GENA 723 Trauma and Emergency Medicine in Rural Settings and the Rural Inter-professional Simulation Course. You can find out about both these courses at the Rural Postgraduate Page

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.

The golden hour – unachievable for a chunk of NZ – a problem?

Thursday, October 3rd, 2019 | Rory | No Comments

Geographical and population disparities in timely access to prehospital and advanced level emergency care in New Zealand

Lilley R, Graaf B, Kool B, Davie G, Reid P, Dicker B, Civil I, Ameratunga S & Branas C. (2019). Geographical and population disparities in timely access to prehospital and advanced level emergency care in New Zealand: a cross-sectional study. BMJ Open. 9.

Open Access https://bmjopen.bmj.com/content/9/7/e026026

 

This is a very interesting study that shows that 16% of NZ doesn’t have access to an ‘advanced-level’ hospital within a hour. They have used a novel approach to identifying this population. With regards to trauma care this is a significant finding and something to consider for rural NZ, especially with planning emergency service networks. The average time the ambulance spends responding, travelling to and on the scene (even scoop and run) seems short based on practical experience in areas staffed by volunteer crews that are often 30 minutes to an hour away when called. This will only worsen this ‘inequity’ though

However, for medical events this hour cut-off is a bit more arbitrary. There are few medical events that require treatment within an hour in a major centre that cannot be initiated in rural practice. STEMI can be and are lysed. Airways can be secured. Vasopressors and antibiotics initiated. There are also CT scanners available in a few rural hospitals with Telestroke and stroke fibrinolysis also being available – although stroke care is a mobile beast with the advancement of clot retrieval. Further, many undifferentiated cases may never require transfer to a major centre once proper assessment and investigations are completed in a capable rural centre (either Hospital/GP). If all these patients were transferred immediately, would this be a good use of NZ’s limited resource?

Involving the established rural sector in this care is going to be important to ensure the best use of these resources.

It would be good to use this methodology to look at more patient centred outcomes in the (hopefully near) future.

Abstract

Objective Rapid access to advanced emergency medical and trauma care has been shown to significantly reduce mortality and disability. This study aims to systematically examine geographical access to prehospital care provided by emergency medical services (EMS) and advanced-level hospital care, for the smallest geographical units used in New Zealand and explores national disparities in geographical access to these services.

Design Observational study involving geospatial analysis estimating population access to EMS and advanced-level hospital care. Setting Population access to advanced-level hospital care via road and air EMS across New Zealand. Participants New Zealand population usually resident within geographical census meshblocks. Primary and secondary outcome measures The proportion of the resident population with calculated EMS access to advanced-level hospital care within 60 min was examined by age, sex, ethnicity, level of deprivation and population density to identify disparities in geographical access.

Results An estimated 16% of the New Zealand population does not have timely EMS access to advanced-level hospital care via road or air. The 700 000 New Zealanders without timely access lived mostly in areas of low-moderate population density. Indigenous Māori, New Zealand European and older New Zealanders were less likely to have timely access.

Conclusions These findings suggest that in New Zealand, geographically marginalised groups which tend to be rural and remote communities with disproportionately more indigenous Māori and older adults have poorer EMS access to advanced-level hospitals. Addressing these inequities in rapid access to medical care may lead to improvements in survival that have been documented for people who experience medical or surgical emergencies.

 

Edit; fixed link. Thanks to Linda Reynolds for pointing out!

Rural Generalist Workforce

Wednesday, September 25th, 2019 | Rory | No Comments

Rural Generalist Allied Health Workforce – turning lesser into more(er?)

George JE, Larmer PJ, Kayes N. Learning from those who have gone before: strengthening the rural allied health workforce in Aotearoa New Zealand. Rural and Remote Health 2019; 19: 4878. Open access https://doi.org/10.22605/RRH4878

 

“This study sheds light on the current state of NZ’s rural allied health workforce. It highlights opportunities that have been missed for both the advancement of the current and future workforces. Rural practice for Allied Health Professionals (AHP)’s is commonly seen as being lesser; less to offer, less quality, and less access. For those AHP’s who do venture into rural areas, they find that healthcare looks different to urban environments. It has its own unique challenges, having to work across multiple specialist areas with fewer opportunities to put their knowledge into practice. Despite this, specialism and extension of scope is still seen as the pathway for career progression for most AH professions. This can be unattainable in the rural environment due to constrained resources, recruitment challenges, and small numbers requiring speciality input. A potential solution for this issue is the development of a rural generalist role and recognition of this as an advanced scope in its own right.”

Comments with thanks by Sarah Walker – Physiotherapist at Central Otago Health / Dunstan hospital. She is doing a PhD on supporting allied health professionals in rural areas’ where she plans to define the scope of practice, the challenges they face and the attributes and skills needed to reach the full potential of their roles in the rural context.

Abstract:

Context and issues:

The pipeline for the allied health, scientific and technical workforce of Aotearoa New Zealand is under growing pressure, with many health providers finding recruitment and retention increasingly difficult. For health providers in rural settings, the challenges are even greater, with fewer applicants and shorter tenures. As the health needs of rural communities increase, along with expectations of uptake of technologies and the Ministry of Health’s strategy to ensure care is provided closer to home, being able to retain and upskill the diminishing workforce requires new ways of thinking.

Lessons learned:

Understanding the activity that has been undertaken by medical and nursing workforces in New Zealand and abroad, as well as the work of the Australian allied health workforce provides context and opportunities for New Zealand. The challenge is for educators, professional bodies, the Ministry of Health and health providers to develop new ways of thinking about developing a rural workforce for the allied health scientific and technical professions.

 

Sarah

POCUS for volume assessment

Tuesday, September 24th, 2019 | Rory | No Comments

POCUS influences clinical management – part 394.

Nixon G, Blattner K, Finnie W, Lawrenson R, Kerse N. Use of point‐of‐care ultrasound for the assessment of intravascular volume in five rural New Zealand hospitals. Can J Rural Med 2019;24:109‐14.

Another of Garry’s papers on POCUS, again showing it alters clinical decisions, this time for assessing intravascular volume.

Abstract

Introduction: Measuring the diameter of the inferior vena cava (IVC) or the height of the jugular venous pressure (JVP) with point‐of‐care ultrasound (POCUS) is a practical alternative method for estimating a patient’s intravascular volume in the rural setting. This study aims to determine whether or not POCUS of the IVC or JVP generates additional useful clinical information over and above routine physical examination in this context.

Methods: Twenty generalist physicians, working in five New Zealand rural hospitals, recorded their estimation of a patient’s intravascular volume based on physical examination and then again after performing POCUS of the IVC or JVP, using a visual scale from 1 to 11.

Results: Data were available for 150 assessments. There was an only moderate agreement between the pre‐ and post‐test findings (Spearman’s correlation coefficient = 0.46). In 28% (42/150) of cases, the difference was four or more points on the scale, and therefore, had the potential to be clinically significant.

Conclusion: In the rural context, POCUS provides new information that frequently alters the clinician’s estimation of a patient’s intravascular volume.

Fast and the Fastidious

Tuesday, August 20th, 2019 | Rory | No Comments

Nixon G, Blattner K, Muirhead J, Kiuru S, Kerse N. Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care. Rural and Remote Health 2019; 19: 5027.

Open access: https://doi.org/10.22605/RRH5027

Subgroup analysis of a larger study into Point-of-care ultrasound in rural NZ hospitals. This study looked at AAA and FAST scans performed by rural clinicians. Scans were correctly interpreted 91% in AAA scans and 97% in the case of FAST. Management was changed on the basis of this scan in 25% of cases for AAA scans and 20% for FAST. This is consistent with international emergency department literature.

This series of papers from this rural POCUS dataset continues to show the utility and benefits of bedside imaging. What was life like BU1?

Abstract

Introduction: Point-of-care ultrasound (POCUS) has the potential to improve access to diagnostic imaging for rural communities. This article evaluates the sensitivity and specificity, impact on patient care, quality and safety of two common POCUS examinations – focused assessment with sonography in trauma (FAST) and aortic aneurysm (AAA) – in the rural context.

Methods: This study is a subgroup analysis of a larger study into POCUS in rural New Zealand. Twenty-eight physicians in six New Zealand rural hospitals, with limited access to formal diagnostic imaging, completed a questionnaire before and after POCUS scans to assess the extent to which it altered diagnostic certainty and patient disposition (discharge v admission to rural hospital v transfer to urban hospital). The investigators and a specialist panel reviewed images for technical quality and accuracy of interpretation, and patient clinical records, to determine accuracy of the POCUS findings and their impact on patient care.

Results: For FAST and AAA scans respectively, sensitivities were 75% and 100%, and specificities 100% and 93%; rural doctors correctly interpreted their POCUS images for 97% and 91% of scans. The proportions of scans that had either a ‘significant’ or ‘major’ impact on patient care were 17% and 31%. POCUS resulted in the disposition being de-escalated for 15% and 10% of patients and escalated for 5% and 3% of patients.

Conclusions: In the rural context, POCUS AAA is a reliable ‘rule out’ test for ruptured abdominal aortic aneurysm and FAST scan has a role as a ‘rule in’ test for solid organ injury. These findings are consistent with larger studies in the emergency medicine literature.


  1. Before ultrasound ↩︎

 

Rural youth in distress

Monday, July 29th, 2019 | Rory | No Comments

Ferguson Isobel, Moor Stephanie, Frampton Chris, Withington Steve (2019) Rural youth in distress? Youth self-harm presentations to a rural hospital over 10 years. Journal of Primary Health Care 11, 109–116.

Open Access
https://doi.org/10.1071/HC19033

A very interesting, but concerning, paper from Ashburton showing significant and rising rates of self-harm in young Ashburtonians/Ashburtonites especially in Māori. We all know that mental health services need bolstering in NZ, especially rurally. Open access paper that is worth a read in full!

Abstract

Introduction: Despite growing awareness of increasing rates of youth suicide and self-harm in New Zealand, there is still little known about self-harm among rural youth.

Aim: This study compared: (1) rates of youth self-harm presentations between a rural emergency department (ED) and nationally available rates; and (2) local and national youth suicide rates over the decade from January 2008 to December 2017.

Methods: Data were requested on all presentations to Ashburton Hospital ED coded for ‘self-harm’ for patients aged 15–24 years. Comparative data were obtained from the coroner, Ministry of Health and the 2013 census. Analyses were conducted of the effects of age, time, repetition, method, ethnicity and contact with mental health services on corresponding suicide rates.

Results: Self-harm rates in Ashburton rose in the post-earthquake period (2013–17). During the peri-earthquake period (2008–12), non-Māori rates of self-harm were higher than for Māori (527 vs 116 per 100 000 youth respectively), reflecting the national trend. In the post-earthquake period, although non-Māori rates of self-harm stayed stable (595 per 100 000), there was a significant increase in Māori rates of self-harm to 1106 per 100 000 (Chi-squared = 14.0, P < 0.001). Youth living within the Ashburton township showed higher rates than youth living more rurally.

Discussion: Youth self-harm behaviours, especially self-poisoning, have increased since the Canterbury earthquakes in the Ashburton rural community. Of most concern was the almost ninefold increase in Māori self-harm presentations in recent years, along with the increasing prevalence among teenagers and females. Possible explanations and further exploratory investigation strategies are discussed.

Tracking the students

Friday, May 24th, 2019 | Rory | No Comments

Poole P, Wilkinson TJ, Bagg W, Freegard J, Hyland F, Jo E, et al. Developing New Zealand’s medical workforce: realising the potential of longitudinal career tracking. New Zealand Medical Journal. 2019;132(1495):9.

“Some of the key findings to date are:

  • Most New Zealand graduates wish to work in New Zealand.
  • Rural background is very important in rural career intention, justifying the rural preferential entry pathways to New Zealand medical schools.
  • Over time, fewer New Zealand students have an urban career intention, while rural and remote medicine is emerging as a career path.
  • Student perception places the major influence on career intention as ‘atmosphere/work culture typical of the discipline’. The importance of a range of positive undergraduate and early postgraduate experiences cannot be overstated, especially since most students are undecided at graduation. Specialties finding it difficult to attract sufficient numbers of trainees need to address factors that affect student choices“.

Note that rural is defined as ‘rural-regional’ (from location <100 000 population)

Summary

For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected survey information from medical students and junior doctors in Australia and New Zealand to look at social, demographic and training effects on career intentions. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results, and future directions.

Abstract

For over a decade, the Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) has collected data from medical students in Australia and New Zealand. This project aims to explore how individual student background or attributes might interact with curriculum or early postgraduate training to affect eventual career choice and location. In New Zealand, over 4,000 students have voluntarily provided information at various time points, and the project is at a stage where some firm conclusions are starting to be drawn. This paper presents the background to the project along with some early results and future directions.