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: http://hdl.handle.net/10523/8612

“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.“

Abstract:

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 http://hdl.handle.net/10523/9067

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.

Abstract

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.