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!

Recruiting and retaining

Thursday, August 27th, 2020 | Rory | No Comments

Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects                                                                     

Ogden J, Preston S, Partanen RL, Ostini R, Coxeter P. Recruiting and retaining general practitioners in rural practice: systematic review and meta-analysis of rural pipeline effects. Med J Aust. 2020;1–9.

Why is this paper important? 

It brings together the evidence in a formal systematic review and meta-analysis. It only includes papers that look at place of work after completion of postgraduate training. It does not include softer outcomes like intention to practice rurally, undertaking an intern or early PGY/registrar job in a rural area. 

Does is provide any new information? 

Not really. It just reinforces what we know about the 3 proven strategies.

That is:

1) taking students from a rural background,

2) prolonged (and ideally repeated) undergraduate attachments in rural areas and

3) targeted postgraduate training in rural communities.

All these increase the uptake of rural careers – and combining the strategies works even better.

Are there any surprises? 

Not really. There were not a lot of eligible studies, and none from NZ (someone needs to do one).

Many thanks to Associate Professor Garry Nixon and Katelyn Costello for their comments.

Abstract

Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas.

Study design: Systematic review and meta-analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas.

Data sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature.

Data synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta-analysis. Study quality, assessed with the Newcastle–Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta-analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12–3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48–2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80–7.46; eight studies).

Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government-led initiatives to support an adequate rural GP workforce.
Protocol registration: PROSPERO, CRD42017074943 (updated 1 February 2018).

Technology-facilitated care coordination in rural areas: What is needed?

Monday, July 6th, 2020 | Rory | No Comments

Gill E, Dykes PC, Rudin RS, Storm M, McGrath K, Bates DW. Technology-facilitated care coordination in rural areas: What is needed? International Journal of Medical Informatics. 2020 May;137:104102.

 

Comments by the lead author – Dr. Emily Gill from Opōtiki

Take-away

People who live in rural areas have poorer health than their urban counterparts, and for those with multiple, complex medical needs, this is impacted by health IT systems.  This research suggests US rural settings may contend with more unaffiliated electronic health records (EHRs a.k.a. PMSs), than urban settings.  The equivalent in NZ is that rural areas that border between DHBs are more likely to see patients from outside their own DHB, and this poses challenges of accessing and exchanging electronic information (e.g., electronic referrals) with unaffiliated DHBs.  Policy regulations should require that health information be exchanged between all health services, from pharmacy to private hospital to allied health providers, in a way that is ‘useable’ (e.g., user-friendly; without the need to login to multiple other platforms).  An important way to evaluate whether health IT systems are improving health is to focus on care coordination activities: for patients who see multiple health providers due to their complex, chronic needs, how easily can the patient and all the health providers involved access and know pertinent health information, especially when changes are occurring frequently? 

More details:

To provide coordinated care, health information needs to be frequently transferred across settings such as primary care clinics, acute care hospitals, and community health services. The U.S. government made a major financial investment in health information technology with the aim of improving improve care coordination and provided incentives for healthcare organizations to electronically exchange information in a more efficient and accurate process.  Given the increased health needs of the rural population, this research project sought to understand the experiences of healthcare providers in exchanging information during or in response to a transfer of care.

 

The interviews and surveys conducted through this research described numerous gaps between the necessary care coordination activities for patients with complex needs and the capacity for technology to facilitate the process. Healthcare professionals described low confidence in the integrity of the information they receive, and the effort required to gather needed information, including challenges with arranging real-time communication with other providers caring for the same patient.  Providers described care plans, a potentially useful tool in care coordination, as being regulated to such an extent that they are not used in routine decision making. In exchanging information between organizations using different Electronic Health Records (EHRs), most systems could not automatically incorporate the new information into the existing patient record. This lack of interoperability explains the large quantities of information the providers described faxing and scanning in.  Finally, rural healthcare professionals described the compounding impact of poverty on coordinating care for their patients. Not having transportation to specialist appointments; being geographically located between multiple larger health systems, which amplifies the number of external EHR systems in use; and the lack of access to specialty services all accentuate the challenges of information exchange during care transitions.

Both the U.S. and New Zealand should continue to focus on policy that drives the development of technology standards for how health information is exchanged.  In addition to promoting EHR systems that can receive and incorporate information automatically, standards should guide the usability of digital health data, and how it is aggregated across settings to create useful longitudinal care plans. Policy in both countries should encourage further research to define meaningful measures of how coordination technology tools impact population health.

Dealing with chest pain – a pathway protocol.

Friday, July 3rd, 2020 | Rory | No Comments

Miller R, Young J, Nixon G, Pickering JW, Stokes T, Turner R, et al. Study protocol for an observational study to evaluate an accelerated chest pain pathway using point-of-care troponin in New Zealand rural and primary care populations. Journal of Primary Health Care. 2020;12(2):129.
open access link

The study protocol for an observational study examining the safety a novel chest pain pathway that uses point-of-care troponin.

Chest pain pathway’s are used throughout the country but largely rely on laboratory based troponin assays, which are not available for a considerable proportion of the rural population.[1] This will be the first large study that examines a rural and/or primary care population.

Enrolment has been more difficult (and slower) than anticipated, but in more than 300 low risk patients (and preliminary analysis), there have been no missed Major Adverse Cardiac Events in the first 30 days after presentation. This is in line with other chest pain pathways that use the new high-sensitivity assays.

very preliminary analysis of the primary end-point 

If you have access to point-of-care troponin and aren’t involved as a study site then please get in touch with me, and if you are already contributing – thank you!! and think of entering patients with chest pain into the data collection tool!

 


  1. Miller R, Stokes T, Nixon G. Point-of-care troponin use in New Zealand rural hospitals: a national survey. New Zealand Medical Journal. 2019;132(1493):13.  ↩

Good care closer to home!

Monday, February 10th, 2020 | Rory | 2 Comments

Blattner K, Stokes T, Rogers-Koroheke M, Nixon G, and Dovey S. Good care close to home: local health professional perspectives on how a rural hospital can contribute to the healthcare of its community. New Zealand Medical Journal. Vol 133 No 1509: 7 Feb 2020 Link – NZMJ articles are open-access 6 months after publication

This paper from Kati illustrates the unique and special place that Hauora Hokianga has within NZ medical system. The four main themes: “Out context”, “Continuity of care”, “Navigation”, and “Home” encapsulate how many of us would like to view our health services.

Tino pai Kati

“Yes—observation. The medical intervention is quite a small part of medical treatment, isn’t it, often? It’s about being able to observe, have a place of safety, and have a place of recovery as well.”

Abstract

Aim

Hokianga Health in New Zealand’s far north is an established health service with a small rural hospital, serving a largely Māori community. The aim of this study was to gain insights into the wider roles of one rural hospital from the perspective of its staff.

Method

Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health, eight with past and current medical practitioners, three with senior non-medical staff. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the Framework Method.

Results

Four main themes were identified: ‘Our Context’, emphasising geographical isolation; ‘Continuity of Care’, illustrating the role of the hospital across the primary-secondary interface; ‘Navigation’ of health services within and beyond Hokianga; and the concept of hospital as ‘Home’.

Conclusion

Findings highlight the importance of geographically appropriate, as well as culturally appropriate, health services. A hospital as part of a rural health service can enhance comprehensive and continuous care for a rural community. Study findings suggest rural hospitals should be viewed and valued as their own distinct entity rather than small-scale versions of larger urban hospitals.


Kati also pointed me toward this article from this article by Glen Colquhoun. In it he describes a country of many Hauora Hokianga’s.

“The role of a health system is not to bounce patients away from it. It is to help, to open its arms and surround with care. It is to be the embodiment of nurturing – our mother’s wide open arms.”

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.”

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)


Vision:

 

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.

 

Objectives:

 

  • 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

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: http://www.cjrm.ca/text.asp?2020/25/1/41/273534

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.

Introduction

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.

Aim

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.  garry.nixon@otago.ac.nz

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