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:

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.”

Rural Simulation Faculty Development Plan

Monday, January 20th, 2020 | Rory | No Comments

The simulation team that put on the rural inter professional simulation course have developed a Rural Simulation Faculty Development Plan.

This useful document provides a pathway that those that are interested can follow to up-skill in simulation and debriefing.

Look forward to more simulation resources being made available – and perhaps a repository of NZ rural cases and scenarios that we can contribute to and access.

Check out the Rural Health Academic Centre, Ashburton (RHACA)  (permanent link in the side bar) and I know Marc and Sampsa will welcome any correspondence. Drop them a line!

click here to access the document in full (PDF)



The Rural Simulation Faculty vision is of a pool of inter-professional faculty with expertise around simulation-based education (SBE) and debriefing who can all contribute to all rural simulation courses as needed. The group of rural courses should be strategically planned each year by the whole group to maximise value and demand. Each course will have designated course directors or leaders but can expect assistance from all faculty group members as available.




  • Establish a broad interprofessional rural group of SBE faculty across NZ.
  • Describe a common pathway for rural faculty to be credentialled as course providers through a shared understanding and experience of SBE
  • Maintenance and development of simulation expertise through feedback, mentoring and sharing of learning resources
  • Develop opportunities for learning, developing and collaborating using simulation-based education.
  • Design interprofessional educational courses for rural health care workers.
  • Research and evaluation of rural SBE



Rural simulation faculty development stream:


  1. Open for all doctors, GP’s, nurses, paramedics, allied health and midwives involved in rural health care at all levels of training.
  2. Faculty development stream comprises 7 components within three tiers, with stepwise progression through.
  3. Participation is purely voluntary and is expected to be self directed

Crowd sourcing rural undergraduate learning objectives

Friday, January 17th, 2020 | Rory | No Comments

Kyle Eggleton, Andy Wearn & Felicity Goodyear-Smith (2019): Determining rural learning outcomes for medical student placements using a consensus process with rural clinical teachers, Education for Primary Care, DOI/Link 10.1080/14739879.2019.1705921

A paper from the GP & Primary Health Care team at the University of Auckland that defines rural learning objectives for their regional-rural undergraduate programmes, which are expanding in 2020. These were derived from educators in the rural space

Great progress from Auckland!

The top four:

Recognise the breadth of presentations in comprehensive rural generalist care

Recognise the challenges presented by geography, distance and local resources in managing patients in rural NZ

Describe barriers to health care for rural Māori

Identify the roles of rural doctor which go beyond being the ‘medical expert,’ including advocate, communicator, collaborator, leader, professional and community member.


What do you think? Comment below.


Short, longer and programmatic rural attachments have developed in a number of medical programmes around the world. However, there is limited literature on the development of the underpinning learning outcomes to guide these attachments. Rural populations are commonly under-served and the specific needs and challenges of rural health care need to be emphasised, as well as encouraging future practice in these areas. Our aim was to produce common rural-specific learning outcomes, aligned with a rationalisation of existing guiding principles and objectives, for our medical student regional-rural programmes. This was achieved through a Delphi technique involving the relevant clinical teachers and supervisors. Forty-nine consenting participants collectively provided 72 learning outcomes which were synthesised down to 16. A consensus process was used to anonymously rate and then rank to reach consensus for the top four learning outcomes. The learning outcomes were placed within the theoretical framework of a ‘pedagogy of place’ based on rurality and triangulated with rural learning outcomes from an Australian study. The four final outcomes were resolved around two areas of ‘place’: geographical and developmental. The co-design approach enabled those involved in providing the rural exposure education to generate appropriate learning outcomes.

Take your paddle (bougie) up the creek!

Monday, December 23rd, 2019 | Rory | No Comments

Up the creek with a paddle!

Johnston TM, Davis PJ. The occasional bougie-assisted cricothyroidotomy. Can J Rural Med [serial online] 2020 [cited 2019 Dec 23];25:41-8. Available from:

Hopefully not a very frequently required procedure but a nice, easy to follow description – for when the time comes on the side of road or in hospital.

You can download the ‘blueprint’ and  print a 3D larynx to practice on. 

open access (html version – pay for PDF).


Interested in medical workforce/education research?

Thursday, December 19th, 2019 | Rory | No Comments

Interested in medical workforce/education research?


A team of supervisors from Auckland and Otago Universities is currently looking for Masters and/or PhD students to work with the MSOD project.


About half of doctors make career decisions in the early postgraduate years, rather than during medical school. But we are aware from the international literature and our own research on Otago and UoA MBChB graduates that there are multiple factors that influence decision making starting with who is selected to become a medical student. Currently there is a mismatch between what doctors might decide as a career and the health workforce needs of Aotearoa New Zealand.

The Medical Schools Outcomes Database (MSOD) is a national longitudinal project collecting information on intended career choices and locations.  Medical students are surveyed at entry to and exit from medical school and graduates are surveyed 1, 3, 5 and 8 years after graduation.  Included in the surveys, are 24 questions that ask about influences on career choices – respondents are asked to rate these in importance.


To better understand what factors influence the career decisions recently graduated doctors make. (using the database).

If you might be interested I can provide further information and contacts.

The pipeline disconnect: A worrisome tale

Tuesday, December 10th, 2019 | Rory | No Comments

Seleq S, Jo E, Poole P, Wilkinson T, Hyland F, Rudland J, et al. The employment gap: the relationship between medical student career choices and the future needs of the New Zealand medical workforce. N Z Med J. 2019;132(1506).

Commentary from Associate Professor Garry Nixon

In a nutshell. 20.7 percent of meds students are interested in GP at graduation. But 37.4% need to be in order to maintain the current workforce. It’s bad news.

No attempt is made to differentiate rural and urban GP. There is a category called ‘rural and remote medicine’ which I assume is ‘rural hospital medicine’. The interest amongst students is 2.2% with 1.1% needed to maintain the current workforce. Better news but …

A rural view: Its critical that an attempt is made to differentiate the rural and urban workforce and workforce intentions (and be clear about terminology for rural scopes of practice). The last paper published by this group suggested that the interest in working in communities of less than 10,000 people was very low (and fell considerably between entry and exit from medical school).1

The biggest limitation in this study is the assumption that we can base the future needs on the size of the current workforce, this ignores existing deficits, and risks perpetuating inequalities.
The whole thing needs a ‘rural lens’ applied to it. There needs to be at least someone, even just one person, with a rural background on the these sorts of studies. This is government funded work and such an approach would be consistent the promise to ‘rural proof’ government policy.

The authors know the solution; “students indicated that the atmosphere, work culture and the experience they have of a specialty during medical school are the most important factors influencing career decisions”. If their experience (and role models) is metropolitan hospital medicine then they will want to be metropolitan hospital doctors.


AIMS: To determine the career decision intentions of graduating doctors, and the relationship between these intentions and the predicted medical workforce needs in New Zealand in 10 years’ time.

METHODS: A workforce forecasting model developed by the Ministry of Health (MOH) has been used to predict the proportion of doctors required in each medical specialty in 2028 in New Zealand. The future work intentions of recently graduated doctors at the Universities of Auckland and Otago were collected from the Medical Student Outcomes Data (MSOD), and compared with these predicted needs.

RESULTS: Between 2013 and 2017, 2,292 doctors graduated in New Zealand, of whom 1,583 completed the MSOD preferences section (response rate 69%). Of these only 50.1% had decided on a future medical specialty. The most popular were surgical specialties (26.2%), general practice (20.7%), and internal medicine (11.0%). Compared to the MOH workforce forecast model there appears to be insufficient interest in general practice at the time of graduation.

CONCLUSIONS: To shape the medical workforce to meet forecast needs, multiple stakeholders will need to collaborate, with a special focus on the early postgraduate years, as many doctors have yet to decide on specialisation.

  1. Poole P, Wilkinson TJ, Bagg W, Freegard J, Hyland F, Jo CE, et al. Developing New Zealand’s medical workforce: realising the potential of longitudinal career tracking. N Z Med J. 2019;132(1495):65-73. (Covered here on LOFP) ↩︎


Rural Hosptial Medicine: Scope of practice “out there”

Thursday, December 5th, 2019 | Rory | 1 Comment

Blattner K, Stokes T, Nixon G. A scope of practice that works ‘out here’: exploring the effects of a changing medical regulatory environment on a rural New Zealand health service. Rural and Remote Health 2019; 19: 5442.

Open Access

A great piece of research and writing from work done for Kati’s Masters project, which was awarded with distinction.

“Rural disadvantage can lie in distance to secondary and tertiary care so that well educated rural hospital generalists have a critical role in minimising inequity of care and opportunity.”




In 2008, the Medical Council of New Zealand recognised rural hospital medicine as a vocational scope of practice. The aim was to provide training and professional development standards for medical practitioners working in New Zealand’s rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health in New Zealand’s far north is an established integrated health service that includes a rural hospital and serves a largely Māori community. The aim of this study was to explore how the new scope had affected health practitioners and the health service at Hokianga Health.


A case study design was used, employing qualitative methods. Documentary analysis was undertaken tracking change and development at Hokianga Health. Twenty-six documents (10 from within and 16 from outside Hokianga Health) were included in the analysis. Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health. The interviews explored participants’ views of the rural hospital medicine scope. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately.


Four themes capturing the main issues were identified: (1) ‘What I do’: articulating the scope of medical practice at Hokianga, (2) ‘What we do’: the role of the hospital at Hokianga, (3) ‘On the fringes’, and (4) Survival. With changing regulatory policy an established part of Hokianga Health practice, the hospital aspect was outside the scope of general practice. This mismatch created a vulnerability for individual doctors and threatened the hospital service. The new scope filled the gap, rural hospital medicine together with general practice now covering the whole practice scope at Hokianga Health. With the introduction of the rural hospital medicine scope and the accompanying national definition of a rural hospital came a sense of belonging and increased connectedness, Hokianga Health and its practitioners realigning with the new scope, its policies, processes and language. The new scope brought for the first time a specific focus on the inpatient and emergency care aspects of practice at Hokianga and with this validation of the hospital aspect of the medical practitioners work. The critical importance of a fit-for-purpose scope and rural-specific postgraduate training programs in minimising inequity of care and opportunity for rural communities was emphasised. The importance of benchmarking with its associated costs was also highlighted. The main challenges identified related to the real (as well as potential) increased regulatory requirements of two separate scopes of practice for practitioners and a small rural health service working across primary and secondary care.


In better equipping medical practitioners for rural hospital work and strengthening hospital systems and standards, the rural hospital medicine scope has met its intentions at Hokianga Health. The rural hospital medicine pathway is a necessary partial solution to rural medical practitioners maintaining a broad skill set. Continued flexibility is required in training programs in order to meet a range of different practitioner and rural health service needs.

Kati is a senior member of the rural post-graduate team and is involved in multiple papers throughout the year.

Guidelines kete: LOFP

Wednesday, December 4th, 2019 | Rory | 1 Comment

Kia ora kotou,

We now have a guidelines/protocols section of LOFP. You can find this on the menu to the left of the screen.

Over here

Many thanks to Jono Wills (Dunstan Hospital) who provided the first contribution.

People may find these useful to adapt to their own working environments in an effort to stop reinventing wheels from scratch. Initially these

are local guidelines but as we find time we will add links to relevant international and national guidelines that maybe useful for rural practice.

You can send your guidelines/protocols you want considered to go up to

Apologies for the previous post misadventures



Leaning on Fence Posts: 2019 Taranaki CME workshop a success. Join in Rarotonga 2020!

Tuesday, December 3rd, 2019 | Rory | No Comments

The 2019 Rural Generalist CME Workshop was held in New Plymouth in early November, with the support of Taranaki DHB, Te Rau Ora and Matua Raki.  Local and distant resource experts, including rural doctors, shared their knowledge and experience over the three day workshop.  It was an excellent opportunity for rural doctors (from general practice and rural hospitals) to spend valuable time together, and we were very pleased to have several rural hospital registrars join us this year.  The weather was beautiful, giving us a chance to enjoy the stunning Taranaki scenery.

Next year’s CME Workshop will be held in Rarotonga, September 9-11 2020.  Please contact Matilda Hamilton if you are interested in attending. More details to follow soon.

photo credit: Katherine Orme, RHM registrar


last try. the stoats have been humanly dealt with. Sorry for the spam

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


Any views or opinion represented in this site belong solely to the authors and do not necessarily represent those of the University of Otago. Any view or opinion represented in the comments are personal and are those of the respective commentator/contributor to this site.


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