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Exploration of rural physician’s lived experience

Friday, September 4th, 2020 | Rory | 1 Comment

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 Open2020;10:e037705. doi:10.1136/bmjopen-2020-037705

Open access

A hermeneutic phenomenological study (look it up or read the methods) undertaken by a group of prominent rural health leaders, most of them well known to a us in Aotearoa. This qualitative study uses interviews with rural doctors to explore a fundamental part of rural medicine, practicing outside your comfort zone aka ‘clinical courage’. The investigators identified a number of features of clinical courage:

the commitment to deliver the care your community needs;

accepting uncertainty;

understanding and making the most of the resources at hand (limited as they are);

consciously testing and understanding your limits;

once you have decided that ‘its needs done’ and ‘you are the best person available to do it’, having the confidence to get on and act;

the importance of supportive rural colleagues in maintaining clinical courage.

The themes will resonate strongly with those working rurally and form a useful insight for those involved in educating the rural workforce.

Comment kindly from Associate Professor Garry Nixon

ABSTRACT

Objectives: Rural doctors describe consistent pressure to provide extended care beyond the limits of their formal training in order to meet the needs of the patients and communities they serve. This study explored the lived experience of rural doctors when they practise outside their usual scope of practice to provide medical care for people who would otherwise not have access to essential clinical services.

Design: A hermeneutic phenomenological study.

Setting: An international rural medicine conference.

Participants: All doctors attending the conference who practised medicine in rural/remote areas in a predominantly English-speaking community were eligible to participate; 27 doctors were recruited.

Interventions: Semi-structured interviews were conducted. The transcripts were initially read and analysed by individual researchers before they were read aloud to the group to explore meanings more fully. Two researchers then reviewed the transcripts to develop the results section which was then rechecked by the broader group.

Primary outcome measure: An understanding of the lived experiences of clinical courage.

Results: Participants provided in-depth descriptions of experiences we have termed clinical courage. This phenomenon included the following features: Standing up to serve anybody and everybody in the community; Accepting uncertainty and persistently seeking to prepare; Deliberately understanding and marshalling resources in the context; Humbly seeking to know one’s own limits; Clearing the cognitive hurdle when something needs to be done for your patient; Collegial support to stand up again.

Conclusion: This study elucidated six features of the phenomenon of clinical courage through the narratives of the lived experience of rural generalist doctors.

Rural post-graduate society:

We are still seeking feedback on developing a voluntary post-graduate rural society that will help fund exisiting CME activities that are free to access and allow development of future activities.

Please click here to let us know what you think!

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: http://www.cjrm.ca/text.asp?2020/25/1/3/273540

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.”

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

Rural and Remote – making it work: Learning from our Euro colleagues

Tuesday, October 29th, 2019 | Rory | No Comments

Making it work
open access
Longer and summary documents available

Taking the long view is essential

Some good stuff in this document. NZ has some of this in place, but tying it together without extra investment hard.

Plan/Recruit/Retain

  • Intersectoral investment in training and career promotion
  • Create desirable workplace
  • Create and incentivise a pool of transient workers to make a longer term commitment to your region

Plan/Recruit/Retain

Thanks to Fiona Doolan-Noble for the link

 

Fast and the Fastidious

Tuesday, August 20th, 2019 | Rory | No Comments

Nixon G, Blattner K, Muirhead J, Kiuru S, Kerse N. Point-of-care ultrasound for FAST and AAA in rural New Zealand: quality and impact on patient care. Rural and Remote Health 2019; 19: 5027.

Open access: https://doi.org/10.22605/RRH5027

Subgroup analysis of a larger study into Point-of-care ultrasound in rural NZ hospitals. This study looked at AAA and FAST scans performed by rural clinicians. Scans were correctly interpreted 91% in AAA scans and 97% in the case of FAST. Management was changed on the basis of this scan in 25% of cases for AAA scans and 20% for FAST. This is consistent with international emergency department literature.

This series of papers from this rural POCUS dataset continues to show the utility and benefits of bedside imaging. What was life like BU1?

Abstract

Introduction: Point-of-care ultrasound (POCUS) has the potential to improve access to diagnostic imaging for rural communities. This article evaluates the sensitivity and specificity, impact on patient care, quality and safety of two common POCUS examinations – focused assessment with sonography in trauma (FAST) and aortic aneurysm (AAA) – in the rural context.

Methods: This study is a subgroup analysis of a larger study into POCUS in rural New Zealand. Twenty-eight physicians in six New Zealand rural hospitals, with limited access to formal diagnostic imaging, completed a questionnaire before and after POCUS scans to assess the extent to which it altered diagnostic certainty and patient disposition (discharge v admission to rural hospital v transfer to urban hospital). The investigators and a specialist panel reviewed images for technical quality and accuracy of interpretation, and patient clinical records, to determine accuracy of the POCUS findings and their impact on patient care.

Results: For FAST and AAA scans respectively, sensitivities were 75% and 100%, and specificities 100% and 93%; rural doctors correctly interpreted their POCUS images for 97% and 91% of scans. The proportions of scans that had either a ‘significant’ or ‘major’ impact on patient care were 17% and 31%. POCUS resulted in the disposition being de-escalated for 15% and 10% of patients and escalated for 5% and 3% of patients.

Conclusions: In the rural context, POCUS AAA is a reliable ‘rule out’ test for ruptured abdominal aortic aneurysm and FAST scan has a role as a ‘rule in’ test for solid organ injury. These findings are consistent with larger studies in the emergency medicine literature.

  1. Before ultrasound ↩︎

 

More sense from Australia?

Tuesday, March 5th, 2019 | Rory | No Comments

Benefits of a rural clinical school: An Australian experience

McGirr J, Seal A, Barnard A, Cheek C, Garne D, Greenhill J, Kondalsamy-Chennakesavan S, Luscombe GM, May J, Mc Leod J, O’Sullivan B, Playford D, Wright J. The Australian Rural Clinical School (RCS) program supports rural medical workforce: evidence from a cross-sectional study of 12 RCSs. Rural and Remote Health 2019; 19: 4971. https://doi.org/10.22605/RRH4971

Open access link

An important paper on rural clinical school outcomes in Australia. What we need to aim for in NZ.

The MMM (modified monash model) is a better indicator of what we would consider ‘rural’ in NZ and that analysis is more relevant.

The take home message – rural origin programmes, yearlong placements in rural communities for undergraduates (the RMIP model) work. There is less evidence for short term rural placements. Rurally focused postgrad training may be at least, if not more important.

Overall 29% of Australian med students in this study undertook a year long RMIP type programme. RMIP is only 6% of the Uni Otago class. We need a more realistic target.

Garry

Abstract

Introduction: Many strategies have been implemented to address the shortage of medical practitioners in rural areas. One such strategy, the Rural Clinical School Program supporting 18 rural clinical schools (RCSs), represents a substantial financial investment by the Australian Government. This is the first collaborative RCS study summarising the rural work outcomes of multiple RCSs. The aim of this study was to combine data from all RCSs’ 2011 graduating classes to determine the association between rural location of practice in 2017 and (i) extended rural clinical placement during medical school (at least 12 months training in a rural area) and (ii) having a rural background.

Methods: All medical schools funded under the RCS Program were contacted by email about participation in this study. De-identified data were supplied for domestic students about their gender, origin (rural background defined as having lived in an Australian Standard Geographic Classification-Remoteness Area (ASGC-RA) 2–5 area for at least 5 years since beginning primary school) and participation in extended rural clinical placement (attended an RCS for at least 1 year of their clinical training). The postcode of their practice location according to the publicly available Australian Health Practitioner Regulation Agency (AHPRA) register was collected (February to August 2017) and classified into rural and metropolitan areas using the ASGC 2006 and the more recent Modified Monash Model (MMM). The main outcome measure was whether graduates were working in a ‘rural’ area (ASGC categories RA2–5 or MMM categories 3–7) or ‘metropolitan’ area. Pearson’s χ2 test was used to detect differences in gender, rural background and extended placement at an RCS between rural and metropolitan practice locations. Binary logistic regression was used to determine odds of rural practice and 95% confidence intervals (CIs) were calculated.

Results: Although data were received from 14 universities, two universities had not started collecting origin data at this point so were excluded from the analysis. The proportion of students with a rural background had a range of 12.3–76.6% and the proportion who had participated in extended RCS placement had a range of 13.7–74.6%. Almost 17% (16.6%) had a principal practice postcode in a rural area (according to ASGC), range 5.8–55.6%, and 8.3% had a principal practice postcode in rural areas (according to MMM 3–7), range 4.5–29.9%. After controlling for rural background, it was found that students who attended an RCS were 1.5 times more likely to be in rural practice (95%CI 1.2–2.1, p=0.004) using ASGC criteria. Using the MMM 3–7 criteria, students who participated in extended RCS placement were 2.6 times as likely to be practising in a rural location (95%CI 1.8–3.8, p<0.001) after controlling for rural background. Regardless of geographic classification system (ASGC, MMM) used for location of practice and of student background (metropolitan or rural), those students with an extended RCS had an increased chance of working rurally.

Conclusion: Based on the combined data from three-quarters (12/16) of the Australian medical schools who had a graduating class in 2011, this suggests that the RCS initiative as a whole is having a significant positive effect on the regional medical workforce at 5 years post-graduation.