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

HINTS exam – Head Impulse, Nystagmus, Test of Skew

Tuesday, November 2nd, 2021 | claly44p | No Comments

The HINTS exam: Who to perform the HINTS exam on, how to perform it, and how to interpret the result.

https://www.youtube.com/watch?v=1q-VTKPweuk

Check out this paper:

Quimby, A.E., Kwok, E.S.H., Lelli, D. et al. Usage of the HINTS exam and neuroimaging in the assessment of peripheral vertigo in the emergency department. J of Otolaryngol – Head & Neck Surg 47, 54 (2018). https://doi.org/10.1186/s40463-018-0305-8

Abstract

Background

Dizziness is a common presenting symptom in the emergency department (ED). The HINTS exam, a battery of bedside clinical tests, has been shown to have greater sensitivity than neuroimaging in ruling out stroke in patients presenting with acute vertigo. The present study sought to assess practice patterns in the assessment of patients in the ED with peripherally-originating vertigo with respect to utilization of HINTS and neuroimaging.

Methods

A retrospective cohort study was performed using data pertaining to 500 randomly selected ED visits at a tertiary care centre with a final diagnostic code related to peripherally-originating vertigo between January 1, 2010 – December 31, 2014.

Results

A total of 380 patients met inclusion criteria. Of patients presenting to the ED with dizziness and vertigo and a final diagnosis of non-central vertigo, 139 (36.6%) received neuroimaging in the form of CT, CT angiography, or MRI. Of patients who did not undergo neuroimaging, 17 (7.1%) had a bedside HINTS exam performed. Almost half (44%) of documented HINTS interpretations consisted of the ambiguous usage of “HINTS negative” as opposed to the terminology suggested in the literature (“HINTS central” or “HINTS peripheral”).

Conclusions

In this single-centre retrospective review, we have demonstrated that the HINTS exam is under-utilized in the ED as compared to neuroimaging in the assessment of patients with peripheral vertigo. This finding suggests that there is room for improvement in ED physicians’ application and interpretation of the HINTS exam.

“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.

 

The impact of interpersonal relationships on rural doctors’ clinical courage

Thursday, October 21st, 2021 | claly44p | No Comments

Walters L, Couper I, Stewart RA, Campbell DG, Konkin J. The impact of interpersonal relationships on rural doctors’ clinical courage. Rural and Remote Health 2021; 21: 6668. https://doi.org/10.22605/RRH6668

https://www.rrh.org.au/journal/article/6668

Commentary Sarah Walker (PhD Candidate): Following on from previous work on the role of clinical courage in rural generalism, Professor Walters and her colleagues explore how the relationships rural doctors develop impact on their clinical courage. The concept of clinical courage can sit uncomfortably with some of us, however the six features of clinical courage described in previous work (Konkin et al. 2020) alleviate those concerns. Although clinical courage Is formed amongst uncertainty (2) in often under resourced (4) settings, clinicians are cautious not to conflate confidence with competence (3) when clearing the cognitive hurdle and deciding on a point of action (5) that is often intrinsically tied to a deep commitment of providing care to their community (1). Critical to this is their “collegial support to stand up again” (6) where rural doctors can share discourse and use their peer reflections to support their own self reflections – it is this feature that Walters seeks to explore further in this study.

The community of practice that rural doctors build with their communities, patients, peers, and local and national healthcare teams and leaders does affect their clinical courage. The social and geographical bond these rural doctors have sets them apart from other medical communities of practice and suggest that clinical courage is seen as a meaningful and encouraged characteristic in rural generalist practice. The relationships formed within their community of practice are not taken lightly, requiring time and effort to develop and maintain. For the healthcare team, only once these relationships are appropriately developed can trust be placed on each other’s skillset, becoming an issue in areas where workforce turnover is unsettling.

Despite not being a rural doctor, Walter’s work piques my interest as a rural health professional. Working as a physiotherapist in a small team, across a large geographical area, and in many clinical areas, the concept of clinical courage resonates well with me as I am sure It does for my other allied health and nursing colleagues. I am certain that furthering our understanding of these other disciplines in rural areas will help in understanding the complex and dependent relationships and skills required for rural generalist practice.

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 Open 2020;10:e037705.  doi:10.1136/ bmjopen-2020-037705

 

Abstract:

Introduction:  Clinical courage occurs when rural doctors push themselves to the limits of their scope of practice to provide the medical care needed by patients in their community. This mental strength to venture, persevere and act out of concern for one’s patient, despite a lack of formally recognised expertise, becomes necessary for doctors who work in relative professional isolation. Previous research by the authors suggested that the clinical courage of rural doctors relies on the relationships around them. This article explores in more depth how relationships with others can impact on clinical courage. Methods:  At an international rural medicine conference in 2017, doctors who practised rural/remote medicine were invited to participate in the study. Twenty-seven semistructured interviews were conducted exploring experiences of clinical courage. Initial analysis of the material, using a hermeneutic phenomenological frame, sought to understand the meaning of clinical courage. In the original analysis, an emic question arose: ‘How do interpersonal relationships impact on clinical courage’. The material was re-analysed to explore this question, using Wenger’s community of practice as a theoretical framework. Results:  This study found that clinical courage was affected by the relationships rural doctors had with their communities and patients, with each other, with the local members of their healthcare team and with other colleagues and health leaders outside their immediate community of practice. Conclusion:  As a collective, rural doctors can learn, use and strengthen clinical courage and support its development in new members of the discipline. Relationships with rural communities, rural patients and urban colleagues can support the clinical courage of rural doctors. When detractors challenge the value of clinical courage, it requires individual rural doctors and their community of practice to champion rural doctors’ way of working.

Rural-urban and within-rural differences in COVID-19 vaccination rates

Friday, October 8th, 2021 | claly44p | No Comments

Sun, Y., & Monnat, S. M. (2021). Rural-urban and within-rural differences in COVID-19 vaccination rates. The Journal of Rural Health: Official Journal of the American Rural Health Association and the National Rural Health Care Association.

https://onlinelibrary-wiley-com.ezproxy.otago.ac.nz/doi/full/10.1111/jrh.12625

Abstract:

PURPOSE: COVID-19 mortality rates are higher in rural versus urban areas in the United States, threatening to exacerbate the existing rural mortality penalty. To save lives and facilitate economic recovery, we must achieve widespread vaccination coverage. This study compared adult COVID-19 vaccination rates across the US rural-urban continuum and across different types of rural counties. METHODS: We retrieved vaccination rates as of August 11, 2021, for adults aged 18+ for the 2,869 counties for which data were available from the CDC. We merged these with county-level data on demographic and socioeconomic composition, health care infrastructure, 2020 Trump vote share, and USDA labor market type. We then used regression models to examine predictors of COVID-19 vaccination rates across the USDA’s 9-category rural-urban continuum codes and separately within rural counties by labor market type. FINDINGS: As of August 11, 45.8% of adults in rural counties had been fully vaccinated, compared to 59.8% in urban counties. In unadjusted regression models, average rates declined monotonically with increasing rurality. Lower rural rates are explained by a combination of lower educational attainment and higher Trump vote share. Within rural counties, rates are lowest in farming and mining-dependent counties and highest in recreation-dependent counties, with differences explained by a combination of educational attainment, health care infrastructure, and Trump vote share. CONCLUSION: Lower vaccination rates in rural areas is concerning given higher rural COVID-19 mortality rates and recent surges in cases. At this point, mandates may be the most effective strategy for increasing vaccination rates.

Commentary:

The higher overall COVID mortality rates areas (and higher case fatality rates) observed in rural areas in the US, particularly in the later part of the pandemic, is not news.1 We also know rural health services have struggled to cope in the US.2  The considerably lower vaccination rates in rural vs communities (46% vs 60%) noted in this paper is therefore an obvious concern.

But at least they know there is a problem. In NZ rurality is still not a variable in the vaccination data that’s being reported. Hopefully this is not too far away. In the meantime Jesse Whitehead and Ross Lawrenson have published a paper demonstrating poorer access to vaccination in rural NZ (already posted on LOFP).3

  1.  Pro G, Hubach R, Wheeler D, et al. Differences in US COVID-19 case rates and case fatality rates across the urban-rural continuum. Rural Remote Health2020;20(3):6074. doi: 10.22605/RRH6074
  2.  Underwood A. COVID-19: A Rural US Emergency Department Perspective. Prehosp Disaster Med 2021;36(1):4-5. doi: 10.1017/S1049023X20001417
  3. Spatial inequity in distribution of COVID-19 vaccination services in Aotearoa   Whitehead J, Atatoa P, Scott N, Lawrenson R. Spatial inequity in distribution of COVID-19 vaccination services in Aotearoa. Preprint on medRxiv.            https://doi.org/10.1101/2021.08.26.21262647

 

Reflection: one journey, two deaths, multiple perspectives

Thursday, September 30th, 2021 | claly44p | No Comments

Reflection: one journey, two deaths, multiple perspectives

Katelyn Costello

Journal of Primary Health Care – https://doi.org/10.1071/HC21022
Published online: 13 August 2021

http://www.publish.csiro.au/HC/HC21022

A thought-provoking & powerful essay adapted from one of Katelyn’s assignments for GEN 725 Communication in Rural Hospital Medicine, a great course that includes a residential on a marae in the Hokianga! Katelyn is also a PhD candidate.

Abstract

This is a reflective piece from the author around death and dying. It shares her personal story from her own and close family perspectives. It then summaries these experiences into a few key themes and what she hopes are some lessons for doctors involved in the care of a dying person and their whānau.

 

A retrospective observational study of critically unwell patients retrieved from Thames Hospital between April 2018 and December 2020

Monday, September 27th, 2021 | claly44p | No Comments

Miller Rory, Bell Samuel, TenEyck Lisa, Topping Meg (2021) A retrospective observational study of critically unwell patients retrieved from Thames Hospital between April 2018 and December 2020. Journal of Primary Health Care. Published online: 25 August 2021

https://doi.org/10.1071/HC21058

Abstract

INTRODUCTION: In New Zealand, critically ill patients who present to rural hospitals are typically treated, stabilised and transferred to facilities where more appropriate resources are available.

AIM: The aim of this study was to describe patients who presented critically unwell and required retrieval from Thames Hospital in the Waikato region.

METHODS: Notes were reviewed retrospectively for patients who were retrieved from Thames Hospital between 1 April 2018 and 31 December 2020. Patients were excluded if they were retrieved from the offsite birthing centre or their notes were not available to the authors.

RESULTS: During the study period, 56 patients were retrieved by intensive care teams based at Waikato, Starship or Auckland Hospitals. Patients had a median age of 57 years and most were female (60.7%). Māori patients were over-represented in the retrieval cohort compared with the population presenting to the emergency department (30.4% vs. 20.1%, P < 0.001). We found that 41% of patients presented after-hours when there was only one senior medical officer available on site and 70 procedures were performed, including rapid sequence induction, which was required by 19.6% of patients.

DISCUSSION: This study describes a population of critically unwell patients who were retrieved from a rural hospital. The key finding is that nearly half of these patients presented after-hours when there was only one senior medical officer available on site. This doctor also has sole responsibility for all other patients in the hospital. We recommend that referral centres streamline the retrieval processes for rural hospitals.

Comment from Garry Nixon

This study documents the characteristics of a series of patients who were retrieved by air from Thames Hospital. What we can tell is that the patients were critically ill and the transfer process was complicated and time consuming, often occurring when there was only one SMO on duty at the rural hospital end. There is a lot we don’t know because little information on transfers is routinely collected.

Carol Atmore’s recent work demonstrated that rural patients who are transferred between hospitals have a higher risk of harm. (1) Trevor Lloyd listed the elements an ideal emergency transfer from rural to base hospital in 2011.(2) But there is little other published research on the topic, no national standards or policy, and a huge variation in procedures around the country. It’s perhaps not surprising interhospital transfer is the unresolved pandemic planning issue rural hospital doctors remain most concerned about. (3)

Maybe the new Health NZ (inclusive of the dedicated rural health unit) will set national standards for interhospital transfer (and other aspects of rural healthcare delivery).

Thanks Rory, Samuel, Lisa and Meg.

  1. Atmore C et al. Do people living in rural and urban locations experience differences in harm when admitted to hospital? A cross-sectional New Zealand general practice records review study. BMJ Open. 2021;11(5):e046207.
  2. Lloyd T et al. Transfers from rural hospitals in New Zealand. N Z Med J. 2011;124(1328):82-8.
  3. Exploring the response to the Covid-19 pandemic at the rural hospital – base hospital interface:  experiences of New Zealand rural hospital doctors. NZMJ In print.

 

 

 

 

Mandatory ultrasound training for rural general practitioners?

Friday, September 17th, 2021 | Rory | No Comments

A case for mandatory ultrasound training for rural general practitioners: a commentary

Arnold AC, Fleet R, Lim D.  A case for mandatory ultrasound training for rural general practitioners: a commentary . Rural and Remote Health 2021; 21:6328. Full text is open access:: https://doi.org/10.22605/RRH6328

Don’t disagree. Increasing access to cheaper devices (e.g. Butterfly) and multiple training opportunities including Postgraduate Certificate in Clinician-Performed Ultrasound (PGCertCPU)  will hopefully open up this diagnostic modality to more clinicians and patients. Multiple GPs and rural hospital docs have now done PGCertCPU.

Adequate peer-review and credentialing for clinicians, especially those in isolated practices/facilities, remains an issue.

ABSTRACT:

Context:  Point-of-care ultrasound is a rapidly evolving technology that enables rapid diagnostic imaging to be performed at a patient’s bedside, reducing time to diagnosis and minimising the need for patient transfers. This has significant applications for rural emergency and general practice, and could potentially prevent unnecessary transfers of patients from rural communities to more urban centres for the purpose of diagnostic imaging, reducing costs and preventing disruption to patients’ lives. Meta-analyses on point-of-care ultrasound have reported extremely high sensitivity and specificity when detecting lung pathology, and the potential applications of the technology are substantial. A significant application of the technology is in the care of rural paediatric patients, where acute lower respiratory pathology is the most common cause of preventable deaths, hospitalisations, and emergency medical retrievals from remote communities for children under five.

Issues:  Although widely available, point-of-care ultrasound technology is not widely utilised in Australian emergency departments and general practices. Issues with comprehensive training, maintenance of skills, upskilling and quality assurance programs prevent physicians from feeling confident when utilising the technology. In Canada, point-of-care ultrasound training is part of the core competency training in the Royal College of Physicians of Canada emergency medicine fellowship program. Point-of-care ultrasound is widely used in rural practice, although lack of training, funding, maintenance of skills and quality assurance were still listed as barriers to use.

Lessons learned:  Point-of-care ultrasound is a highly sensitive and specific technology with wide potential applications. Issues with quality control and maintenance of skills are preventing widespread use. Coupling point-of-care ultrasound with telemedicine could help increase the usability and accessibility of the technology by reducing the issues associated with maintenance of skills and quality assurance.

Keywords:

Australia, diagnostic imaging, paediatric diagnostic imaging, patient transfers, point-of-care ultrasound, rural medicine, telemedicine, training protocol.

 

Thanks to Fiona Doolan-Noble for forwarding this paper.

Reality of introducing a new point-of-care test!

Thursday, May 13th, 2021 | Rory | No Comments

Beazley Catherine, Blattner Katharina, Herd Geoffrey (2021) Point-of-Care Haematology Analyser Quality Assurance Programme: a rural nursing perspective. Journal of Primary Health Care 13, 84-90.

https://www.publish.csiro.au/HC/HC20080

An open access paper that is full of wisdom from the Hokianga. While we can reduce inequalities with near to patient technology, it is important not to neglect safety – QA! – and consider how that looks for your place: what is the resource? 

 

Abstract

BACKGROUND AND CONTEXT: Rural health services without an onsite laboratory lack timely access to haematology results. Set in New Zealand’s far north, this paper provides a rural nursing perspective on how a health service remote from a laboratory introduced a haematology analyser suitable for point-of-care use and established the associated quality assurance programme.

ASSESSMENT OF PROBLEM: Five broad areas were identified that could impact on successful implementation of the haematology analyser: quality control, staff training, physical resources, costs, and human resource requirements.

RESULTS: Quality control testing, staff training and operating the haematology analyser was more time intensive than anticipated. Finding adequate physical space for placement and operation of the analyser was challenging and costs per patient tests were higher than predicted due to low volumes of testing.

STRATEGIES FOR IMPROVEMENT: Through a collaborative team approach, a modified quality assurance programme was agreed on with the supplier and regional point-of-care testing co-ordinator, resulting in a reduced cost per test. The supplier provided dedicated hours of staff training. Allocated time was assigned to run point-of-care testing quality assurance.

LESSONS: Having access to laboratory tests can reduce inequalities for rural patients, but natural enthusiasm to introduce new point-of-care technologies and devices needs to be tempered by a thorough consideration of the realities on the ground. Quality assurance programmes need to fit the locality while being overseen and supported by laboratory staff knowledgeable in point-of-care testing requirements. Associated costs need to be sustainable in both human and physical resources.

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.