Delay to surgery: #NOF

Monday, October 5th, 2020 | Rory | No Comments

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

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

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

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

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



Webinar – Heart Failure

Friday, October 2nd, 2020 | Rory | No Comments

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

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

To register for this webinar click here.


Thursday, October 1st, 2020 | Rory | No Comments

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

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

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

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



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


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


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


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

Recruiting and retaining

Thursday, August 27th, 2020 | Rory | No Comments

Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects                                                                     

Ogden J, Preston S, Partanen RL, Ostini R, Coxeter P. Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects. Med J Aust. 2020;1–9.

Why is this paper important? 

It brings together the evidence in a formal systematic review and meta-analysis. It only includes papers that look at place of work after completion of postgraduate training. It does not include softer outcomes like intention to practice rurally, undertaking an intern or early PGY/registrar job in a rural area. 

Does is provide any new information? 

Not really. It just reinforces what we know about the 3 proven strategies.

That is:

1) taking students from a rural background,

2) prolonged (and ideally repeated) undergraduate attachments in rural areas and

3) targeted postgraduate training in rural communities.

All these increase the uptake of rural careers – and combining the strategies works even better.

Are there any surprises? 

Not really. There were not a lot of eligible studies, and none from NZ (someone needs to do one).

Many thanks to Associate Professor Garry Nixon and Katelyn Costello for their comments.


Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas.

Study design: Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas.

Data sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature.

Data synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle–Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12–3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48–2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80–7.46; eight studies).

Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce.
Protocol registration: PROSPERO, CRD42017074943 (updated 1 February 2018).

COVID in rural US

Saturday, August 22nd, 2020 | Rory | No Comments

Pro G, Hubach R, Wheeler D, Camplain R, Haberstroh S, Giano Z, Camplain C, Baldwin JA.  Differences in US COVID-19 case rates and case fatality rates across the urban–rural continuum. Rural and Remote Health 2020; 20: 6074.

This short letter published in Rural and Remote Health (Open access) shows that using a ranking score in the US up to April 2020; while there were fewer cases, the mortality was increased compared to metropolitan areas of the US.

The authors acknowledge issues with testing capabilities skewing the data, and we can only assume that things are getting worse given the US’ COVID trajectory.

Fortunately in NZ we don’t have nearly enough data to draw any conclusions (even if we could) but the important message from the paper is equally valid in a NZ context:

“The US and international responses to the COVID-19 pandemic must include plans for strengthening rural health systems, most notably in the form of improving access to treatment for severe cases.”


Worth noting that Doctors Without Borders was deployed in the US to help in rural areas with high proportion of indigenous peoples – the first time the aid organisation has had to be deployed. Gives some further perspective, if any more was needed, on the state of healthcare in the states.



Webinar # 4: Diabetes management

Thursday, August 20th, 2020 | Rory | No Comments

Diabetes management with Dr. Alex McCleod and Sharon Sandilansd, hosted by Dr. Matilda Hamilton. The link is below and is available on YouTube. The audio is also available via podcast on the Leaning on Fenceposts podcast via iTunes or wherever you listen to your podcasts (may take a few hours to become available).

Show notes:

Type I Diabetes & HHS

  • Type I diabetes
    • More common onset in the young
    • However, can occur any stage in life & second peak later in life
    • Will often present with higher sugars than a Type II diabetic
    • High glucose directly toxic to pancreas
      • Explains ‘honey-moon’ phase when Type I treatment starts, pancreatic function temporarily improves
    • Glucose spikes around meals, as opposed to Type II with higher basal BSL (although can develop post-prandial highs too)
  • HHS = Hyperglycaemic Hyperosmolar State (previously called HONK)
    • Profound metabolic derangement
    • Profound dehydration
    • Require large volumes & treatment underlying illness
    • Higher glucose levels than DKA/not acidotic/not ketosis
  • Continuous glucose monitoring
    • Available in NZ, not funded

Insulin in acute illness

  • Use novorapid for correction (NOT actrapid, it is actSLOW and lasts around 8 hours)
  • Novorapid – quick acting, 3 hours action
  • No insulin is as good as our native insulin – rapid onset/offset
  • Consider stopping metformin during acute illness and starting insulin
  • Don’t forget to restart metformin before discharge!
  • BSL monitoring during admission: pre-meal, pre-bed, 0200 (monitor for hypos) +/- post-meal (?post-prandial highs)
  • Suggested regime for basal/bolus regime during admission
    • Australian Subcutaneous Insulin Chart
    • Total daily insulin requirement = 0.5 units/kg
      • Split this 50:50 basal & bolus
    • Basal Wt(kg/4) = basal insulin requirement
    • Pre-meal blous = remaining daily insulin requirement/3
    • Example: 100kg woman
      • Estimated total daily dose = 0.5*100 = 50 units
      • Basal requirement = 100/4 = 25 units (note this is half daily dose)
      • Bolus doses = 25/3 = 8 units (8 units pre meal)
      • 25 units (basal) + 8 units + 8 units + 8 units = 50 units (daily dose)
    • Correction factors
      • These are doses of insulin given pre-meal (based on the BSL) that are added onto the usual pre-prandial (bolus) dose
      • Correction factor calculated 100/total daily dose (eg. Case above 100/50 = 2). The correction factor is the expected reduction in BSL for every unit of inulin. (For cases expect BSL to drop by 2 for every unit of insulin).
      • For example this patient may have BSL target of ~ 10.Pre meal BSL 20.  Want to drop BSL by 10, therefore add correction factor of 5 units onto usual pre-meal insulin.
    • Reviewing insulin dosing during acute admission
      • Add up previous 24 hours insulin requirement, then split this 50:50, adjusting the basal and bolus doses accordingly.

Insulin for long-term treatment:

  • When to start?
    • Not reaching target HbA1c despite ma oral therapy
    • Targets
      • Younger patients HbA1c ~50
      • Slightly older ~ 64
      • Elderly more lenient – must avoid hypos!
    • Continue metformin once on insulin
      • Improves insulin sensitivity
    • Options: long-acting vs mixed vs basal bolus
      • Need BSL profile to guide prescribing eg. Post-prandial highs may be indication for mixed insulin
      • Patient factors – eg. May opt for most simple option = safest
    • Mixed insulin – a note
      • Mixture or short-acting & intermediate acting
      • Last ~ 8 hours, therefore often BD dosing

Diabetic Medications – the old & the new

  • Metformin
    • Reduce oral absorption of glucose
    • Increase glucose uptake by cells, by increasing insulin sensitivity
    • Reduce liver production of glucose
    • Main side effect – GI upset
  • Sulfonylureas
    • Being phased out
    • Augment insulin secretion
    • Risk hypoglycaemia
  • GLP-1 receptor agonists (glucagon-like- peptide)/incretin mimetics
    • Increase insulin production when BSL elevated
    • Slow gastric emptying (can cause nausea)
    • Increase weight loss
    • Injection only
    • Not really available in Aotearoa
  • DPP – 4i, enzyme blocker
    • Reduce glucagon & increase insulin
    • Reduce weight
    • Vildaglitpin = Galvus (available in NZ)
    • Galvumet = vildagliptin + metformin
  • SGLT2 – inhibitors (Flozins)
    • NZ dapagliflozin (Forxiga) (not funded)
    • CKD/CVD benefits
    • Probably add on therapy for heart failure
    • Enhances renal excretion of glucose
    • Increase risk of UTIs and thrush
    • Risk DKA with relatively normal BSL

Non-pharmaceutical management = the important stuff

  • Remember the importance of advice around:
    • Diet to reduce glucose intake
    • Exercise to improve insulin sensitivity
  • Engage patients with appropriate services (eg. Free annual diabetic review, Kaupapa Māori services)
  • Walk beside your patients and be gentle on them – diabetes is a long, hard road.


Available on iTunes or any other podcast apps


Jenny and the Eddies – Caption Competition

Tuesday, August 18th, 2020 | Rory | No Comments

Competition time!!!

Hey everyone! It’s been a tough week in New Zealand but our team of 5 million has risen to the challenge and WE WILL defeat this terrible disease again! But we need to keep our spirits up!

Come up with a caption and write it in the comments section of @jennyandtheeddies or @New Zealand Doctor – there will be a prize each for the “funniest” and “most inspirational” comment, as well as three spot prizes. Prize winners will receive a print version of the picture. The overall best comment will be published, with the image, inside the next issue of New Zealand Doctor|Rata Aotearoa.

Don’t worry if you’re not feeling that creative. Just leave a comment to let everyone know what a great job they are doing and/or share

It goes without saying that swear words/inappropriate language will not be tolerated and will be deleted. The competition will close in two weeks, 31 August at 5pm.

Stay strong and stay safe! Cheers Rich


Jenny and the Eddies

Dr Richard Clinghan is a rural GP based in Oxford.  Over the last year and a half, he has written and drawn a comic book!  @Jennyandtheeddies. Richard was inspired to write it after the measles epidemic last year.  The book takes a new approach to viruses and vaccines by representing what they might look like and how they might behave if you could actually see them.  For instance, the main character Eddie (the MMR vaccine) is a dog-like creature and therefore he is brave, vigilant and loyal and he will not turn on us even if we turn on him.  The story centres around the origins of mistrust with MMR vaccine and he the book will help educate people and change the views of vaccine-hestitant patients and give vaccine-supportive patients information to defend vaccines.  He has also written and drawn a short comic about Covid-19 during lockdown.

If you are interested,  check out Richard’s facebook page @Jennyandtheeddies.  If you are really keen, you can buy a copy at or at GP CME South Friday 14th/ Saturday 15th August 2020.


COVID-19 pandemic response

Thursday, July 23rd, 2020 | Rory | No Comments

‘Exploring the response to the Covid-19 pandemic at the rural hospital – base hospital interface:  experiences of rural hospital doctors’ 

We are seeking rural hospital senior medical officers to undertake a short interview about their experiences working clinically during COVID-19 pandemic/lockdown. Ideally we are seeking doctors who were working clinically in NZ rural hospitals. If you are interested please click on the following link to read the information sheet and consent form.





There have been variations in the way in which different DHBs have managed the pandemic preparations for rural hospitals. There may be important lessons to be learnt from this. 

  We are undertaking a small qualitative study to explore, from the perspective of senior rural hospital doctors, clinical advice and arrangements for patient management put in place during the pandemic period. We are interested in identifying strategies that have and have not worked.  

To do this we are seeking one representative from each rural hospital to participate in a Zoom interviewThe participants should be senior rural doctors who take ultimate clinical responsibility for patients and organising inter-hospital transfers.  

 The total time commitment will be 30 minutes.    

We would really like to hear from a member of your frontline rural hospital medical team.  

We would be grateful if you could ask around your medical staff, and if someone is willing and able to participate, they should enrol by going to 

If anyone has  questions prior to enrolling they should feel free to contact one of us.  


Garry Nixon  

Kati Blattner 

Rory Miller   

Steve Withington 



Untangling statistical tests

Tuesday, June 16th, 2020 | Rory | No Comments

Turner R, Samaranayaka A, Cameron C. Parametric vs nonparametric statistical methods: which is better, and why?. New Zealand Medical Student Journal. 2020 Apr 12(30):61-2.

“Statistical decisions and interpretation are not clear cut and do not follow a series of “easy to apply in all situations” rules. There is a great deal of nuance when analysing and interpreting data and applying statistical tests.”

No kidding…

A really easy to understand article describing the difference between parametric and non-parametric tests and their assumptions.

Some highlights:

“For example, the t-test has been developed using normal distribution theory, so it has an underlying assumption that the distribution of the sample mean (which is a parameter) is normal. This does not mean that the population data or the sample data need to be normally distributed.”


“…this normality assumption will hold for large samples (usually 30 observations or more) regardless of the distributions of the data or underlying popu-lation. This is stated by the Central Limit Theorem. Therefore, when the sample size is large we can use this parametric procedure without worrying about the normality assumption.”


” In practice, if we are concerned about the assumptions, we may run the parametric test first and then run the nonparametric equivalent to see broadly if we get a similar answer. If we do get a similar answer we have some reassurance that the parametric test results are reasonable to report. If we get very different answers and we were concerned about the assumptions, then we would use the nonparametric results as we cannot trust the parametric results.”

Intentions of a rural applicant.

Friday, May 15th, 2020 | Rory | 2 Comments

This is a letter published in the Canadian Journal of Rural Health by a medical student. The full letter is feely available online and I have included some excepts below.

This relates to an editorial previously published in the same journal on the Northern Ontario School of Medicine. Both of NZ’s medical school have their own rural origin scheme but is it targeting the right people and how can we tell? The MSOD (Medical Schools Outcomes Database) captures those who enter medical school but what about those from rural and remote areas that are not even applying?

Smith S. The plight of being a rural applicant for medical school. Can J Rural Med [serial online] 2020 [cited 2020 May 13];25:87-8. Available from:

“…with Canada having up to 4000 applicants for some schools that may only have 100 seats available, the competition is extreme. Often, rural applicants are at a severe disadvantage, and out of desperation, try to find the route of least resistance.”

“…I applied to schools, including Northern Ontario School of Medicine (NOSM), as a rural applicant who had honestly grown up and lived in a rural community for my entire life but never had the genuine interest in returning in the future.”

“…students caught between their realities of where they statistically stand the best chance of acceptance and their integrity of where they genuinely hope to practise.”

“…There are real rural students – the true diehards of the North – who have the potential to return; however, these are the students who do not make it to the application phase. Due to the financial and psychological burdens required to round out one’s application coupled with the myriad of inaccuracies printed online, these students often feel like lone wolves in the application process and many change career paths before they even apply.”

For those that do apply and don’t end up in rural places – they shouldn’t feel bad!

Thanks to Fiona Doolan-Noble for sending on the letter.