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)


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.


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.

Masters theses conferred to rural docs

Tuesday, May 21st, 2019 | Rory | No Comments

Congratulations to two rural docs who were conferred their Masters degrees very recently from the University of Otago. Both theses are available free and open access from the University of Otago

Histories of Chest Pain from a Master of GP (credit) – Trevor Lloyd

Lloyd, T. (2018). Histories of Chest Pain: history of the presenting complaint as recorded by different health care providers of patients presenting to a rural hospital with suspected acute myocardial infarction (Thesis, Master of General Practice). University of Otago. Retrieved from Permanent link to OUR Archive version:

“Although there are many parallels between literature and clinical records, they are not the same thing. Clinical records are produced in a different way – typically by a team. They have different intended audiences. They have different associated ethical issues. Most importantly, they have different purposes.Clinical records are not designed to entertain, or to tell a story merely to find out “what happens next”. It is important to understand, for its purpose of facilitating clinical care, that the record is not merely a description of events. Each piece of information recorded by each health care provider is part of a carefully constructed document, that can be used for multiple purposes.The most important of these is to co-operate in describing, interpreting, and determining the best course of action, in the unique way that clinicians refer to as history and examination, diagnosis, and treatment.“


This thesis investigates how different health professionals record the history of the presenting complaint of patients with suspected acute myocardial infarction admitted to a rural hospital. Different health professionals, each with their own ways of working and communicating, co-operate in diverse teams that ideally have more to offer the patient than individual professionals working alone. This includes the taking and recording of the patient’s history. This account should not be regarded as merely a way of copying a component of a clinical encounter, but as part of a sophisticated tool to guide and organise patient care. This is a case study conducted by a participant observer. A range of qualitative research analysis methods for document analysis are used to analyse what is written in patients’ clinical records by general practitioners, ambulance officers, hospital nurses, and rural hospital doctors, about their presenting complaint. Of 347 patients admitted to the hospital in 2011 who had a Troponin I blood test ordered, the clinical characteristics recorded of 50 are compared, and 10 of these are selected for more in-depth analysis. The 10 records are analysed in terms of style, vocabulary, abbreviations, what gets recorded, what gets repeated, what gets added, what gets deleted, and what gets modified. Three of the 10 records are analysed to explore how the individual records are constructed. The clinical record emerges an incremental, multi-authored, multi-layered, intertextual account, being co-produced by a range of health providers, using information from a variety of sources. The different health providers, at different stages, and using their different voices, interact to record the history of the presenting complaint. In addition, the clinical record can be seen as a way of telling the patient’s story, like a novel where the central narrative is explored from the perspectives of different characters or commentators. The record is a carefully constructed document, whose chief purpose is to develop a shared understanding of the patient’s progress and the care that needs to be provided. Good documentation is equated with good care. It is important for practising clinicians to understand how the clinical record is constructed, as an organised interdisciplinary process, and how it is used in care. Furthermore, with a move to electronic health records, it is essential that those responsible for their introduction have a similar understanding of the nature of clinical records.

Impact of RHM vocational scope in the Hokianga from A Master of Health Sciences (distinction) – Kati Blattner

Blattner, K. (2019). The impact of the rural hospital medicine vocational scope on the Hokianga Health service (Thesis, Master of Health Sciences). University of Otago. Retrieved from

The study found that RHM with its associated targeted rural training and professional development programs has enabled the strengthening of both clinical practice and wider quality systems and standards at Hokianga hospital, thus meeting the intentions of the new scope at this site. Challenges arising from the new RHM scope were also identified at both the individual practitioner and the health service level. It is acknowledged that, ten years from the introduction of the RHM scope, it is still too early for the full impact of the RHM scope to be assessed. Though focused on one rural health service with a unique, long-established model of care, findings from the study are applicable to other rural health services in NZ and internationally.


Rural Hospital Medicine was recognised in New Zealand as a vocational scope of medical practice in 2008. The intention was to provide recognised standards of training and professional development for doctors working in rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health is an integrated community owned health service including a hospital in the far north of New Zealand, serving a rural Māori community. The aim of this thesis was to explore the impact of the Rural Hospital Medicine scope at Hokianga Health.

Methods A case study design using qualitative methods comprising a document analysis and interviews was chosen. A thematic analysis of key documents tracking change and development at Hokianga Health was undertaken. Twenty-six documents (ten internal and sixteen external to Hokianga Health) were included. Eleven individual semi-structured interviews were undertaken with past and present employees of Hokianga: eight were medical practitioners, three were senior non-medical staff. The interview explored the participant’s view of the Rural Hospital Medicine scope of practice. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken. The two data sources were analysed separately followed by a process of convergence and corroboration of findings.

Results Before 2008 there was a mismatch between the scope of medicine practiced at Hokianga and available medical training and professional development programmes: the hospital aspect of practice fell outside the General Practice scope. This created a vulnerability for individual practitioners and the hospital service. The Rural Hospital Medicine scope brought a specific focus to hospital practice and thus validation of this aspect of the medical practitioners’ work. The Rural Hospital Medicine and General Practice scopes together provided the right fit for medical practice at Hokianga. The strengthening of clinical practice and improved scope of services resulting from the alignment with Rural Hospital Medicine and the associated rural hospital regulatory policy, systems and processes, strengthened clinical safety and thus the viability of the hospital service. The Rural Hospital Medicine movement also strengthened Hokianga Health’s external strategic alliances helping to create a sense of belonging, and facilitating alignment with the changing external regulatory environment including nomenclature. Challenges resulting from the Rural Hospital Medicine scope at the individual practitioner level mirrored those at the health service level: rural practitioners and the rural hospital service attempting to deliver to regulatory systems and processes that had not been set up with their scope of practice and model of care in mind.

Conclusions The new vocational scope of Rural Hospital Medicine enabled the strengthening of both clinical practice and wider quality systems and standards at Hokianga Hospital, thus meeting the intentions of the new scope. In highlighting wider challenges to rural health the study supports the notion that New Zealand implements a process of rural health impact assessment. Though focused on one rural health service, findings are applicable to other rural health services in New Zealand and internationally.

POC testing changes practice in rural hospitals

Tuesday, April 30th, 2019 | Rory | No Comments

Blattner K, Beazley CJ, Nixon G, Herd G, Wigglesworth J, Rogers-Koroheke MG. The impact of the introduction of a point-of-care haematology analyser in a New Zealand rural hospital with no onsite laboratory. Rural and Remote Health 2019; 19: 4934. Open Access link

Mixed methods study from the team at Rawene in the Far North showing the, sometimes significant, impact of having a point-of-care FBC analyser in their small rural hospital. Knowledge is power and cost saving… Interesting that the largest cost saving is for the base hospital – something that seems like is missed in funding discussions.

Kati is a senior member of the rural section and convenes GENA 724 – The context of rural hospital medicine.



Hokianga Hospital is a small rural hospital in the far north of New Zealand serving a predominantly Maori population of 6500. The hospital, an integral part of a comprehensive primary healthcare service, provides continuous acute in-hospital and emergency care. Point-of-care (POC) biochemistry has been available at the hospital since 2010 but there is no onsite laboratory. This study looked at the impact of introducing a POC haematology benchtop analyser at Hokianga Hospital.


This was a mixed methods study conducted at Hokianga Hospital over 4 months in 2016. Quantitative and qualitative components and a cost–benefit analysis were combined using an integrative process. Part I: Doctors working at Hokianga Hospital completed a form before and after POC haematology testing, recording test indication, differential diagnosis, planned patient disposition and impact on patient treatment. Part II: Focus group interviews were conducted with Hokianga Hospital doctors, nurses and a cultural advisor. Part III: An analysis of cost versus tangible benefits was conducted.


Part I: A total of 97 POC haematology tests were included in the study. Of these, 97% were undertaken in the setting of the acute clinical presentation and 72% were performed out of hours. The average number of differential diagnoses reduced from 2.43 pre-test to 1.7 post-test, (χ2 tests p<0.05). There was a significant reduction in the number of patients transferred and an increase in the number of patients discharged home (χ2 tests p<0.05). Part II: Three main themes were identified: impact on patient management, challenges and the commitment to ‘make it work’. POC haematology had a positive impact on patient management and clinician confidence mainly by increasing diagnostic certainty. The main challenges related to the hidden costs of implementing the analyser and its associated quality assurance program in a remote-from-laboratory setting. Part III: Tangible cost–benefit analysis showed a clear cost saving to the health system as a whole.


This is the first published study evaluating the impact of haematology POC testing on acute clinical care in a rural hospital with no onsite laboratory. Timely access to a full blood count POC improves clinical care and addresses inequity. There was an overall reduction in healthcare costs. The study highlighted the hidden costs of implementing POC systems and their associated quality assurance programs in a remote-from-laboratory context.

The Trans-Tasman Issue

Saturday, October 13th, 2018 | Rory | No Comments

Australian Journal of Rural Health. Trans‐Tasman Issue. Volume 26, Issue 5. Pages: 303–378 October 2018


A landmark issue – one of the most important publications of the year! Open access until at least December.


Editorial Special issue: Trans-Tasman Issue
Garry Nixon and Oliver K. Burmeister

Alliances and evidence: Building the capacity and effectiveness of rural health
advocacy in Australia
Lesley Barclay and Gordon Gregory

Alliances and evidence: Building capacity and effectiveness of rural health advocacy in Australia: New Zealand commentary
Martin Thomas London

Two decades of building capacity in rural health education, training and research in Australia: University Departments of Rural Health and Rural Clinical Schools
David Lyle and Jennene Greenhill

Grasping the Ongaonga: When will New Zealand really integrate rural clinical education?
Martin T. London and John G. Burton

Learning from history: How research evidence can inform policies to improve rural and remote medical workforce distribution
John Humphreys and John Wakerman

Not counting
David Fearnley

Framework for examining the spatial equity and sustainability of general practitioner services
Jesse Whitehead, Amber L. Pearson, Ross Lawrenson and Polly Atatoa-Carr

Point-of-care ultrasound in rural New Zealand: Safety, quality and impact on patient management
Garry Nixon, Katharina Blattner, Marara Koroheke-Rogers, Jillian Muirhead,
Wendy L. Finnie, Ross Lawrenson and Ngaire Kerse

Kete pikau : A basket of knowledge – ‘guidelines from back home’
Marara Koroheke-Rogers and Katharina Blattner

Kete pikau : A basket of knowledge – ‘guidelines from back home’
Kate Senior

Improving the physical health of people living with mental illness in Australia and
New Zealand
Russell Roberts, Helen Lockett, Candace Bagnall, Chris Maylea and Malcolm Hopwood

Paramedicine in Australia and New Zealand: A comparative overview
Peter O’Meara and Sharon Duthie

Osteoporosis and low bone mineral density (osteopenia) in rural and remote Queensland
Campbell Bruce Macgregor, Jarrod D. Meerkin, Stephanie Jade Alley,
Corneel Vandelanotte and Peter John Reaburn

Perceptions towards research and academia by Māori and Pacific preclinical medical students
Yassar Alamri

Letters to the Editor
Research, education, advocacy: Keys to rural health success
Dalton Kelly

Rural health: An investment in regional development
Mark Diamond

Antimicrobial stewardship in rural hospitals

Thursday, September 20th, 2018 | Rory | No Comments

Green JK, Gardiner SJ, Clarke SL, Thompson L, Metcalf SC, Chambers ST. Antimicrobial stewardship practice in New Zealand’s rural hospitals. New Zealand Medical Journal. 2018;131(1481):11.

A mixed methods look at antimicrobial prescribing by a senior registrar in DRHMNZ and Infectious Diseases (RACP). An important strategy that needs development and implementing


AIMS: We aimed to describe how antimicrobial stewardship (AMS) is practised in New Zealand’s diverse rural hospital network.

METHODS: Rural hospital medical practitioners were surveyed to estimate the utilisation of prescribing resources and specialist support for AMS, and attitudes towards AMS. Questions reflected recommended strategies for AMS programmes.

RESULTS: The response rate was 80.8% (122/151) from 29 rural hospitals (3–114 beds). While 78.7% reported access to local antimicrobial prescribing guidelines, discordant answers from practitioners at the same institution were common. The practice of approval for access to broad-spectrum antimicrobial agents was uncommon. Most respondents had cared for a patient with a multi-drug resistant organism in the preceding 12 months. Only 34.8% of respondents reported receiving formal education on AMS principles, with at least 90% believing it was relevant irrespective of the clinical context considered. Respondents were more likely to believe that antimicrobial overuse and resistance were more relevant at sites distant from the context of rural hospital practice.

CONCLUSION: While AMS is perceived as relevant for rural hospital medicine, many of the building blocks of AMS systems are absent in this environment. This presents an opportunity for development as AMS strategies evolve in New Zealand.