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Targeted rural postgraduate training pathways are recognised internationally as playing a critical role both in recruitment and retention of a rural medical workforce and in reducing inequity of care and opportunity for people living away from urban centres.1–4

In New Zealand, though data are limited, indications are that people living rurally have poorer health outcomes than people living in urban areas, and this is accentuated for Māori.5,6 Around 19% of New Zealand’s population rely on rural health services, and around 15% rely on rural hospitals for their healthcare.5,7,8

In 2008, in response to serious rural hospital workforce shortages and the lack of any training pathway, rural hospital medicine (RHM) was recognised by the Medical Council of New Zealand (MCNZ) as a vocational scope of practice.9 The intention was to provide recognised training standards for the medical workforce and to encourage the development of systems, such as clinical governance, in rural hospitals.9 The scope of RHM is defined by its context, the rural environment including geographic isolation, and, in contrast to general practice (GP), is orientated to secondary care.10

Rural hospitals in New Zealand are small and geographically distant from a base hospital; they have acute bed capacity and limited diagnostics; and they have a predominantly generalist medical workforce.8 However, New Zealand’s rural hospitals are not homogenous (variations include governance, funding models and integration with primary care), nor do they fit seamlessly into either of the two tiers of the New Zealand health system (community–primary care or hospital services).11

The Rural Hospital Medicine Training Programme’s (RHMTP’s) history and development have been previously described.12 Though there have been early improvements in the rural hospital workforce since the RHM scope’s inception, serious staff shortages remain.13–15

The RHMTP is New Zealand’s only rural-targeted vocational training programme. The professional body for RHM, the Division of Rural Hospital Medicine (DRHMNZ), sits as a chapter within the Royal New Zealand College of General Practitioners (RNZCGP) and reports directly to the MCNZ as the branch advisory body for the RHM scope. Factors considered in positioning the DRHMNZ in the RNZCGP included close ties and overlap with rural general practice and the small size of the RHM workforce.12

The Rural Hospital Medicine Training Programme

The key programme principles include recognition of prior learning, competence-based assessment and a modular (rather than a linear) pathway.8,12 The academic component of the training programme is provided largely by the University of Otago’s (UoO’s) distance-taught Postgraduate Rural Programme (PGRP).16 The RHMTP’s flexibility is important, not only for integration with other training programmes, but to facilitate logistics for trainees moving between rural and urban attachments and across regions and to accommodate academic components.12 Dual training with other specialties, particularly GP, is encouraged; however, there is no formal GP–RHM training pathway.12

The requirements of the RHMTP, which cross primary–secondary, hospital–community and urban–rural settings, are outlined in Table 1 and detailed elsewhere.8

Table 1: Outline of the Rural Hospital Medicine Training Programme.*

* Royal New Zealand College of General Practitioners (RNZCGP). Division of Rural Hospital Medicine Training Programme Handbook. Wellington: RNZCGP; 2020.
† GENA indicates papers administered through the University of Otago, rural post graduate programme.
‡ Can be used to gain advanced or extended experience and skills (eg, in Anaesthetics or Obstetrics OR for those dual training with GP used to complete GPEPI (intensive year of GP training).

The Rural Hospital Medicine Training Programme is subsidised by Health Workforce New Zealand (HWNZ) through the hospital specialties route via district health boards (DHBs), not the alternative HWNZ college-based route used for GP training.17 Some base and tertiary hospitals offer specific clinical rotations for RHM trainees. Some DHBs offer a scheme where all or most clinical rotations are available in a single region. Many rural hospitals and rural general practices offer accredited rotations, but not all have the same access to HWNZ funding. Difficulty accessing funding for accredited training posts, especially for rural hospital and rural general practice placements, has been reported at DRHMNZ council meetings.

The main aim of this study was to evaluate the outcomes of the first decade of the RHMTP. The study also aimed to determine the geographic spread of both graduates and trainees; to gain insights into the influence of undergraduate rural training exposure on subsequent rural career choice; and to explore trainee experiences of the RHMTP. The career choice of the first RHMTP graduate cohort is reported elsewhere.18

Methods

Design

This was a mixed method descriptive study.

Sampling and data collection

Database interrogation

Data were extracted from: the MCNZ Register of Doctors; UoO student enrolment records (eVision); and the RNZCGP’s database. Data were sought on all individuals entering the RHMTP from December 2008 to December 2017. Records were reviewed through to 1 August 2019. The RNZCGP data was collected manually at the RNZCGP’s Wellington offices. The MCNZ and UoO databases were accessed electronically.

Survey

All trainees who had graduated or withdrawn from the RHMTP (before 1 August 2019) were invited by email to participate in an electronic survey. The survey was generated using Qualtrics (Prova, Utah, US). All potential participants were then separately emailed a unique link that gave them immediate access to the survey and the participant information and consent forms. The survey was open for 10 weeks.

The survey included questions about participants’ current employment and locality as well as questions (free text) about the best aspects and greatest challenges of the training programme, self-funding the training and, where relevant, reasons for withdrawal from the programme. Participants were also asked to indicate (Yes/No) any rural undergraduate experience by year of training (during the 4th, 5th or 6th undergraduate year) and whether this was a ‘rural rotational run’ (not further specified) or one of the rural-specific undergraduate programmes (eg, Rural Medical Immersion Programme (RMIP), UoO; Tairāwhiti Interprofessional Education programme, UoO; Pukawakawa: Northland Regional-Rural program, University of Auckland (UoA); Rural Health Interprofessional Education Programme, UoA). No definitions of ‘urban’ or ‘rural’, nor of ‘rural undergraduate training’, were provided.

Analysis

Database and survey data were separately collated and entered into respective Excel (Microsoft Corporation, Redmond, WA, US) spreadsheets. To maintain participant anonymity, all respondents were designated a number (1–XX) and were referred to throughout by this coding.

Simple descriptive statistics were used to summarise gender, age, ethnicity, New Zealand citizenship status, the institution awarding the undergraduate degree, current practicing status and other postgraduate qualifications.

The location of compulsory training rotations and the primary place of graduates’ current employment were tabulated then mapped using R.19 The 2018 New Zealand Index of Deprivation decile for the Statistical Area (Level 2) where New Zealand rural hospitals were located was determined and overlaid in the map.

Free-text responses were reported as quotes, then coded and collated according to the survey categories. For data collected in the categories of ‘Best aspects’, ‘Challenges’ and ‘Other comments’, common themes were identified using an inductive thematic approach. (KB RLL). Team members (RM, GN) reviewed the analysis to ensure theme consensus. NVivo qualitative data analysis software (QSR International Pty Ltd, Version 12, 2018) was used to manage the analysis.

Ethics approval for this study was obtained from the University of Otago Human Ethics Committee, Reference D19/194.

Results

Database findings

Demographics

The records for 98 trainees who had entered the RHMTP were available for analysis in the RNZCGP database. Those graduating with a Fellowship in Rural Hospital Medicine (FDRHMNZ) made up under a third (29/98, 29.5%), half (49/98, 50%) were active trainees and a fifth (20/98, 20.4%) had withdrawn.

Detailed demographic information is summarised in Table 2.

Table 2: Summary of graduates, withdrawals and active trainees of the Rural Hospital Medicine Training Programme betw3eeen 2008 and 2017.

* Participants can self-identify as more than one ethnicity. † Data missing for these four participants.

Entry, completion or withdrawal

Intake into the RHMTP was between 6 and 10 trainees per year over the first four years, after which annual cohorts increased. The highest intake during the study period was 26 admissions in the tenth year. The first two trainees graduated in 2012. From 2013, between four and six fellowships were awarded each year. The median time graduates spent in the programme was five years and seven months. Twenty trainees subsequently withdrew: five in 2015 and between one and six trainees per year from 2016 to 2019. For these trainees, the median time spent in the programme was two years and nine months.

Undergraduate training

Overall, 69/98 (70%) trainees had gained their undergraduate medical degree in New Zealand, and half (49/98, 50%) were awarded their degrees by the University of Otago.

Participation in other vocational training programmes and additional qualifications.

Participation in other training programmes is described in Table 2. Most graduates (17/29, 59%), active trainees (39/49, 80%) and withdrawn trainees (17/20, 85%) are participating in or have completed another vocational training programme; nearly two-thirds of them participated in or completed general practice vocational training (62/98, 63.3%).

The majority of graduates had completed more than one postgraduate diploma or certificate (25/29, 86%). All 29 RHMTP graduates had completed a Postgraduate Diploma in Rural and Provincial Hospital Practice (PGDipRPHP), UoO, and more than half (17/29, 59%) had completed a Postgraduate Certificate in Clinician-Performed Ultrasound (PGCertCPU), UoO.

Geographical location of compulsory hospital training rotations undertaken by RHMTP graduates.

As trainees, programme graduates had undertaken a total of 123 compulsory hospital rotations (71 in urban and 52 in rural hospitals) in New Zealand. (NB: One rural hospital rotation had been undertaken at Rarotonga Hospital, Cook Islands.) The majority of urban (48/71, 66.7%) and rural (38/52, 71.7%) rotations were undertaken in the South Island. The distribution and numbers of both rural and urban hospital rotations are shown in Figure 1.

Figure 1: Location of compulsory New Zealand-based rural and base hospital training rotations undertaken by graduates of the Rural Hospital Medicine Training Programme.

Survey results

The survey response rate was 80% (39/49). Nearly all graduates (28/29, 97%), and over half 55% (11/20) of withdrawn trainees, responded.

Quantitative findings

Rural undergraduate training

Rural undergraduate experience is described in Table 3. More than half (25/39, 64%) of survey respondents indicated that they undertook a rural placement during their undergraduate training.

Table 3: Findings from surveying graduates and withdrawals of the Rural Hospital Training Programme, 2008–2017.

* Can practice in more than one scope at a time.
† Can undertake more than one undergraduate rural placement.
‡ Rural Medical Immersion Programme, University of Otago.
§ Pukawakawa Rural–Regional programme, Auckland University.
¶ Tairawhiti Interprofessional Education programme, Otago University.
# Also completed Rural Medical Immersion Programme, University of Otago.

Current employment of RHMTP graduates

The majority (26/28, 92.9%) of graduates are actively practising medicine, mostly (24/28, 85.7%) in rural locations. Of the four not currently practising in a rural location, half (2/4, 50%) indicated that they would work in rural practice in the future.

Most RHMTP graduates (22/28, 78.6%) currently work in a rural New Zealand hospital. Nearly half, in addition to RHM, work in another area of practice (13/28, 46.4%): either general practice or emergency medicine. Two-thirds (14/22, 63.6%) of graduates currently practising in rural hospital medicine work in the South Island, predominately within the Southern DHB (10/22, 45.5%). The distribution of graduates employed in rural hospitals is shown in Figure 2.

Figure 2: Location and number of graduates of the Rural Hospital Training Programme (2008–2017) who are working in New Zealand rural hospitals.

* 2018 New Zealand Index of Deprivation determined by the statistical area level 2 where that rural hospital is situated. (Atkinson J, Salmond C and Crampton P (2019). NZDep2018 Index of Perivation, User's Manual. Wellington: University of Otago.)

Additional professional roles of graduates

A quarter (7/28, 25%) of graduates also held leadership positions: three (10.7%) were DRHMNZ Council representatives, three (10.7%) were in clinical director roles and one (3.6%) held a senior academic position. Five (17.9%) other graduate respondents held other academic positions, and four (14.3%) held both leadership and academic positions.

Qualitative findings

Trainee RHMTP experiences

The key qualitative findings are summarised in five main themes. Illustrative participant quotes are presented.

A fit-for-purpose training programme

The RHMTP was perceived by most respondents (both graduates and those who withdrew) to be rural-practice specific with broad and varied clinical exposure and a relevant and complementary academic programme. The collegiality and networks built during the training programme, particularly the academic programme residentials, were highly valued:

“A comprehensive fit for purpose generalist training programme for Rural Hospital Medicine. The breadth of training (both clinical and academic) was excellent. Collegiality in meeting, training with and working alongside others passionate about (and keen to work) rurally.” R17

“The academic programme complemented the clinical training programme, especially bringing out the importance of the rural context through all of the papers. It was important to have rural doctors who understand the complexities of the rural environments facilitating the papers.” R11

Navigation

While navigating the programme, most respondents experienced challenges, which mainly revolved around securing programme components and the accompanying funding in a timely way. Respondents reported ‘falling through funding gaps’ when moving across the country and between DHBs, or while completing programme-accredited clinical rotations in health services to ‘where HWNZ funding does not flow’:

“It was a bit confusing understanding and navigating the programme… understanding and then… accessing funding for runs and academic components. Especially in the smaller rural hospitals with limited funding. This was a real issue when choosing my final placements, when [there were] lots of costs involved.” R15

“Financial pressures regarding fees that are not covered when you are outside the hospital-based runs, as you need to find your own attachments.” R36

Flexibility

Respondents saw programme flexibility as integral to a fit-for-rural-purpose training programme, as flexibility allowed exposure across the whole healthcare system and provided opportunities to experience diverse contexts:

“Best aspects included the flexibility of the training programme to allow opportunities to experience rural medicine in many areas of NZ. Developing generalist skills and a broad scope of practice - a jack-of-all-trades doctor in a secondary care environment - and developing a ‘thinking outside the box’ attitude to challenging situations.” R11

At the same time, flexibility was perceived by many to be a major contributor to navigation difficulties:

“[The] RHM Training programme has lots of potential. For those who want it, a more structured training pathway with placement certainty would be an incentive. As would funding following the trainee e.g. meeting [payment] for exit exams or rural academic papers while doing GP placements etc.” R39

A new specialty

While there was a sense of excitement in forging a new vocational pathway, it came with challenges:

“…many other doctors/ departments did not understand what RHM was, or even recognised it as a valid training pathway. I felt like I spent considerable time and energy educating others (including GPs) about the programme and advocating for myself to get the training experience at I required.” R26

Respondents described a growing awareness of the wide variations, as well as fragility, of rural hospital services and systems. For graduates, the transition to employment in senior rural hospitals positions could be daunting:

“...the local rural context and rural practices may not complement the expectations of a RHM trainee. Rural hospitals in NZ remain fragile systems. Many new vocationally trained rural hospital doctors are asked to take on not only new senior doctor positions… but also senior leadership positions.” R22

Family

Many respondents struggled to find a balance between the programme’s requirement and family needs. For some, moving around with family for clinical rotations was the biggest challenge, while others saw this as a programme highlight.

Self-funding

Half of the respondents (20/39, 51.3%) reported they had self-funded components of their RHMTP, including academic paper fees and costs associated with assessments (eg, final fellowship visit costs).

Reasons for withdrawal

Reasons for withdrawal from the RHMTP (11 respondents) fell into three categories: family/life related; programme related; and career related. Programme-related comments almost all related to navigation difficulties.

Discussion

This mixed methods study presents the first decade outcomes of New Zealand’s Rural Hospital Medicine Training Programme. Through the provision of a targeted rural career pathway, the RHMTP is growing a cohort of highly qualified doctors, of which the majority (92% of graduates currently practicing)18 are working in rural New Zealand. Most have two specialist fellowships and multiple postgraduate university qualifications, and many are taking up leadership positions early in their careers. The findings concur with the literature: dedicated rural training pathways contribute to the rural medical workforce.1,3,20,21

This study provides the first evidence on actual postgraduate practice locality for rural career choice in New Zealand. These outcomes compare favourably with international postgraduate rural programmes.22,23

The number of doctors identifying as Māori (6%) is similar to other comparable programmes,24 has remained small (7% in graduate and 6% in active trainee cohorts) and needs attention.

Many RHMTP graduates report no rural undergraduate experience. It is likely too early to see the influence of rural–regional undergraduate programmes on RHMTP entry. However, the number of Rural Medical Immersion Programme (RMIP)students entering RHMTP training may be an early indication of the value of a rural training pathway.

Findings concur with previous research that confirms overseas trained doctors (OTDs) constitute a high proportion of doctors working rurally.15,22

Both the withdrawal rate and the uneven geographic spread of trainee rotations are noteworthy.

It is reassuring that a high proportion of trainees who withdrew began with the intention of doing GP and RHM training and, after withdrawal from the RHMTP, are continuing with training in GP, and many are working in rural GP. Withdrawal numbers will need further exploration as the programme grows, including the extent to which GP–RHM trainees are eventually opting to continue with just one training programme.

In addition to personal and family factors (known to be strong career drivers),25 findings point to programme-related factors (eg, access to funding, organisational placement aspects and institutional bureaucratic complexities) that are influencing trainees’ decisions and impacting progress through the RHMTP for some trainees. The lack of a consistent mechanism within the current funding model to ensure that funding follows trainees into a critical proportion of their training (that undertaken in rural settings) seems particularly notable.

Although this study did not examine the reasons for geographic variations for trainee rotations, the specific local–rural context is probably an important contributing factor. Findings suggest that there are localities across New Zealand where RHMTP rotations with associated funding and supports have been streamlined. Naturally, trainees gravitate towards set-ups that work and are high quality. The gains for a rural hospital of a steady stream of senior doctors-in-training cannot be underestimated: not only does this result in much needed service provision, but it likely creates ripple effects for wider local capacity building. This would in turn contribute to the wider goals of the RHMTP in strengthening rural hospital services. It is important to note that many rural hospitals have not yet achieved the stability in their workforce that is required to enable the provision of a professional environment that both supports and attracts RHMTP trainees.

Dual GP–RHM training is likely high value, given the need for a New Zealand rural medical workforce across the primary–secondary care spectrum, and it is clearly popular among trainees. With both training programmes situated within the RNZCGP, opportunities for reducing bureaucratic complexities associated with GP–RHM dual training should be within reach, as previously noted.26

Country-specific solutions have been found for postgraduate rural training. Recent Australian research has highlighted the importance of national rural faculties as a strategy to build and sustain a rural medical workforce.22

The overarching aim of rural-targeted training pathways, in providing a robust pathway to a rural-based employment, is the provision of health services to rural areas.1,20,25 The RNZCGP-DRHMNZ has a responsibility not only to its trainees, but, particularly in light of New Zealand’s wider policy context,11,27 to reduce chronic health-access inequities for all rural and remote communities. Although important gains have been made with many rural hospital vacancies across New Zealand being filled by RHMTP graduates, findings also indicate that many rural hospitals, including some serving communities with the greatest health-access inequities (particularly Māori communities), are not yet benefiting from the RHMTP.

Study findings highlight the knowledge gap (previously identified)28 regarding rural hospitals in New Zealand. International studies have shown rural hospitals to be important providers of healthcare that can benefit the health of rural populations,29 but similar research has not been undertaken in New Zealand.

Study strengths and limitations

The study’s perspective is that of the RHMTP provider and its trainees and does not include the views of rural hospitals or communities. The study used mixed methods, and the findings corroborated across datasets. The study was limited by the quality of the RNZCGP database, which was incomplete (in particular, locality of the RHMTP general practice rotation). Although the survey response rate was high, the limitations of using a survey, which was conducted with the expectation of complete databases, is acknowledged. This survey method provided limited information on the influence of undergraduate rural programmes.

Policy implications and recommendations

It is well documented that rural-targeted vocational pathways require innovation and flexibility in order to be responsive to the clinical and structural requirements of rural practice.1–3,25 Study findings provide insights regarding what is working well and highlight issues requiring attention.

Recommendations based on the findings include:

  • The RHMTP funding mechanism is reviewed to ensure alignment with the programme’s structure. A solution is needed that reaches across the two health system tiers, multiple organisations and geographical boundaries and balances regional versus national interests.
  • The DRHMNZ’s governance structure within the RNZCGP is reviewed to ensure it facilitates optimal support for trainees and training sites and provides strong advocacy for all rural communities.
  • General practice–rural hospital medicine training is recognised formally as a dual pathway, optimising operational efficiencies and aligning funding mechanisms.
  • The RNZCGP and DRHMNZ continue to increase the diversity of graduates entering the RHMTP and, in particular, consider ways to support more Māori graduates through the programme.
  • Diversity in rural health service exposure for RHM trainees is widened.

Other opportunities

The RHMTP provides just part of the solution to building rural workforce capacity. The critical role of other health professionals, particularly nurses, both in rural hospital and other rural health services roles, must be acknowledged. All rural health professionals should be supported to develop their own rural-specific training and continuing-education pathways.

The RHMTP is contributing to building rural health academic capacity with dual clinical–academic roles based in rural locations. A national rural-centric academic structure would provide mechanisms that help early career academics thrive in active rural–clinical practice across all health-professional disciplines.

In aiming to improve health-access inequalities for all New Zealanders, consideration should be given to how the RHMTP could add value to the emerging general practice training programmes of two of New Zealand’s realm countries, the Cook Islands and Niue. These programmes already share academic components.16

Future research

Further and ongoing studies investigating future RHMTP outcomes, including recruitment and retention factors for RHMTP graduates and the influence of a coordinated rural-origin, rural-undergraduate and rural-postgraduate pathway for rural career choice in the New Zealand context, are required.

Wider research is needed into the current status and role of New Zealand’s rural hospitals and the extent to which all rural health services improve access to healthcare, improve health outcomes and improve health equity for New Zealand’s rural communities.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Katharina Blattner: Rural Doctor and Senior Lecturer, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Rory Miller: Rural Doctor and Senior Lecturer, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Rachael Lawrence-Lodge: Research Fellow, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Garry Nixon: Associate Professor Rural Health and Rural Doctor, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Patrick McHugh: Primary Care Practitioner, Turanga Health, Gisborne, New Zealand. Joel Pirini: Rural Doctor, Kaitaia Hospital, Northland District Health Board, New Zealand.

Acknowledgements

Correspondence

Katharina Blattner, PO Box 82, Omapere, Hokianga, New Zealand, 0064 21 457736

Correspondence Email

katharina.blattner@otago.ac.nz

Competing Interests

Katharina Blattner and Garry Nixon have teaching roles in the RHMTP’s academic component. Patrick McHugh has been involved in RHMTP governance. Rory Miller is a graduate of the RHMTP and is involved in teaching of the RHMTPs academic component. Joel Pirini is a current trainee of the RHMTP.

1. World Health Organization (WHO). Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: WHO; 2010.

2. World Organization of Family Doctors (WONCA). The Delhi Declaration: Alma Ata revisited Delhi2018 [cited 2018 June 12 ]. Available from: http://www.who.int/hrh/news/2018/delhi_declaration/en/.

3. Sen Gupta T, McKenzie A. Postgraduate pathways to rural medical practice. 2014. In: Rural Medical Education Guidebook [Internet]. Bangkok, Thailand: WONCA Available from: https://www.wonca.net/groups/WorkingParties/RuralPractice/ruralguidebook.aspx.

4. Wearne SM, Wakerman J. Training our future rural medical workforce. The Medical Journal of Australia. 2004;180(3):101-2.

5. Fearnley D, Lawrenson R, Nixon G. 'Poorly defined': unknown unknowns in New Zealand Rural Health. N Z Med J. 2016;129(1439):77.

6. Ministry of Health NZ. Mātātuhi Tuawhenua: Health of Rural Māori, 2012. Wellington, N.Z.: Ministry of Health.; 2012.

7. Williamson M, Gormley A, Dovey S, Farry P. Rural hospitals in New Zealand: results from a survey. N Z Med J 2010;123(1315).

8. Royal New Zealand College of General Practitioners (RNZCGP). Division of Rural Hospital Medicine Training Programme Handbook. Wellington: RNZCGP; 2020

9. Nixon G, Blattner K. Rural hospital medicine in New Zealand: vocational registration and the recognition of a new scope of practice. N Z Med J. 2007;120(1259).

10. Medical Council New Zealand. Vocational scopes of practice. Wellington MCNZ; 2015 [cited 2016 May 8]. Available from: https://www.mcnz.org.nz/get-registered/scopes-of-practice/.

11. Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR.; 2020.

12. Nixon G, Blattner K, Williamson M, et al. Training generalist doctors for rural practice in New Zealand. Rural Remote Health. 2017;17.

13. Lawrenson R, Nixon G, Steed R. The rural hospital doctors workforce in New Zealand. Rural Remote Health. 2011;11(2):1588.

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Targeted rural postgraduate training pathways are recognised internationally as playing a critical role both in recruitment and retention of a rural medical workforce and in reducing inequity of care and opportunity for people living away from urban centres.1–4

In New Zealand, though data are limited, indications are that people living rurally have poorer health outcomes than people living in urban areas, and this is accentuated for Māori.5,6 Around 19% of New Zealand’s population rely on rural health services, and around 15% rely on rural hospitals for their healthcare.5,7,8

In 2008, in response to serious rural hospital workforce shortages and the lack of any training pathway, rural hospital medicine (RHM) was recognised by the Medical Council of New Zealand (MCNZ) as a vocational scope of practice.9 The intention was to provide recognised training standards for the medical workforce and to encourage the development of systems, such as clinical governance, in rural hospitals.9 The scope of RHM is defined by its context, the rural environment including geographic isolation, and, in contrast to general practice (GP), is orientated to secondary care.10

Rural hospitals in New Zealand are small and geographically distant from a base hospital; they have acute bed capacity and limited diagnostics; and they have a predominantly generalist medical workforce.8 However, New Zealand’s rural hospitals are not homogenous (variations include governance, funding models and integration with primary care), nor do they fit seamlessly into either of the two tiers of the New Zealand health system (community–primary care or hospital services).11

The Rural Hospital Medicine Training Programme’s (RHMTP’s) history and development have been previously described.12 Though there have been early improvements in the rural hospital workforce since the RHM scope’s inception, serious staff shortages remain.13–15

The RHMTP is New Zealand’s only rural-targeted vocational training programme. The professional body for RHM, the Division of Rural Hospital Medicine (DRHMNZ), sits as a chapter within the Royal New Zealand College of General Practitioners (RNZCGP) and reports directly to the MCNZ as the branch advisory body for the RHM scope. Factors considered in positioning the DRHMNZ in the RNZCGP included close ties and overlap with rural general practice and the small size of the RHM workforce.12

The Rural Hospital Medicine Training Programme

The key programme principles include recognition of prior learning, competence-based assessment and a modular (rather than a linear) pathway.8,12 The academic component of the training programme is provided largely by the University of Otago’s (UoO’s) distance-taught Postgraduate Rural Programme (PGRP).16 The RHMTP’s flexibility is important, not only for integration with other training programmes, but to facilitate logistics for trainees moving between rural and urban attachments and across regions and to accommodate academic components.12 Dual training with other specialties, particularly GP, is encouraged; however, there is no formal GP–RHM training pathway.12

The requirements of the RHMTP, which cross primary–secondary, hospital–community and urban–rural settings, are outlined in Table 1 and detailed elsewhere.8

Table 1: Outline of the Rural Hospital Medicine Training Programme.*

* Royal New Zealand College of General Practitioners (RNZCGP). Division of Rural Hospital Medicine Training Programme Handbook. Wellington: RNZCGP; 2020.
† GENA indicates papers administered through the University of Otago, rural post graduate programme.
‡ Can be used to gain advanced or extended experience and skills (eg, in Anaesthetics or Obstetrics OR for those dual training with GP used to complete GPEPI (intensive year of GP training).

The Rural Hospital Medicine Training Programme is subsidised by Health Workforce New Zealand (HWNZ) through the hospital specialties route via district health boards (DHBs), not the alternative HWNZ college-based route used for GP training.17 Some base and tertiary hospitals offer specific clinical rotations for RHM trainees. Some DHBs offer a scheme where all or most clinical rotations are available in a single region. Many rural hospitals and rural general practices offer accredited rotations, but not all have the same access to HWNZ funding. Difficulty accessing funding for accredited training posts, especially for rural hospital and rural general practice placements, has been reported at DRHMNZ council meetings.

The main aim of this study was to evaluate the outcomes of the first decade of the RHMTP. The study also aimed to determine the geographic spread of both graduates and trainees; to gain insights into the influence of undergraduate rural training exposure on subsequent rural career choice; and to explore trainee experiences of the RHMTP. The career choice of the first RHMTP graduate cohort is reported elsewhere.18

Methods

Design

This was a mixed method descriptive study.

Sampling and data collection

Database interrogation

Data were extracted from: the MCNZ Register of Doctors; UoO student enrolment records (eVision); and the RNZCGP’s database. Data were sought on all individuals entering the RHMTP from December 2008 to December 2017. Records were reviewed through to 1 August 2019. The RNZCGP data was collected manually at the RNZCGP’s Wellington offices. The MCNZ and UoO databases were accessed electronically.

Survey

All trainees who had graduated or withdrawn from the RHMTP (before 1 August 2019) were invited by email to participate in an electronic survey. The survey was generated using Qualtrics (Prova, Utah, US). All potential participants were then separately emailed a unique link that gave them immediate access to the survey and the participant information and consent forms. The survey was open for 10 weeks.

The survey included questions about participants’ current employment and locality as well as questions (free text) about the best aspects and greatest challenges of the training programme, self-funding the training and, where relevant, reasons for withdrawal from the programme. Participants were also asked to indicate (Yes/No) any rural undergraduate experience by year of training (during the 4th, 5th or 6th undergraduate year) and whether this was a ‘rural rotational run’ (not further specified) or one of the rural-specific undergraduate programmes (eg, Rural Medical Immersion Programme (RMIP), UoO; Tairāwhiti Interprofessional Education programme, UoO; Pukawakawa: Northland Regional-Rural program, University of Auckland (UoA); Rural Health Interprofessional Education Programme, UoA). No definitions of ‘urban’ or ‘rural’, nor of ‘rural undergraduate training’, were provided.

Analysis

Database and survey data were separately collated and entered into respective Excel (Microsoft Corporation, Redmond, WA, US) spreadsheets. To maintain participant anonymity, all respondents were designated a number (1–XX) and were referred to throughout by this coding.

Simple descriptive statistics were used to summarise gender, age, ethnicity, New Zealand citizenship status, the institution awarding the undergraduate degree, current practicing status and other postgraduate qualifications.

The location of compulsory training rotations and the primary place of graduates’ current employment were tabulated then mapped using R.19 The 2018 New Zealand Index of Deprivation decile for the Statistical Area (Level 2) where New Zealand rural hospitals were located was determined and overlaid in the map.

Free-text responses were reported as quotes, then coded and collated according to the survey categories. For data collected in the categories of ‘Best aspects’, ‘Challenges’ and ‘Other comments’, common themes were identified using an inductive thematic approach. (KB RLL). Team members (RM, GN) reviewed the analysis to ensure theme consensus. NVivo qualitative data analysis software (QSR International Pty Ltd, Version 12, 2018) was used to manage the analysis.

Ethics approval for this study was obtained from the University of Otago Human Ethics Committee, Reference D19/194.

Results

Database findings

Demographics

The records for 98 trainees who had entered the RHMTP were available for analysis in the RNZCGP database. Those graduating with a Fellowship in Rural Hospital Medicine (FDRHMNZ) made up under a third (29/98, 29.5%), half (49/98, 50%) were active trainees and a fifth (20/98, 20.4%) had withdrawn.

Detailed demographic information is summarised in Table 2.

Table 2: Summary of graduates, withdrawals and active trainees of the Rural Hospital Medicine Training Programme betw3eeen 2008 and 2017.

* Participants can self-identify as more than one ethnicity. † Data missing for these four participants.

Entry, completion or withdrawal

Intake into the RHMTP was between 6 and 10 trainees per year over the first four years, after which annual cohorts increased. The highest intake during the study period was 26 admissions in the tenth year. The first two trainees graduated in 2012. From 2013, between four and six fellowships were awarded each year. The median time graduates spent in the programme was five years and seven months. Twenty trainees subsequently withdrew: five in 2015 and between one and six trainees per year from 2016 to 2019. For these trainees, the median time spent in the programme was two years and nine months.

Undergraduate training

Overall, 69/98 (70%) trainees had gained their undergraduate medical degree in New Zealand, and half (49/98, 50%) were awarded their degrees by the University of Otago.

Participation in other vocational training programmes and additional qualifications.

Participation in other training programmes is described in Table 2. Most graduates (17/29, 59%), active trainees (39/49, 80%) and withdrawn trainees (17/20, 85%) are participating in or have completed another vocational training programme; nearly two-thirds of them participated in or completed general practice vocational training (62/98, 63.3%).

The majority of graduates had completed more than one postgraduate diploma or certificate (25/29, 86%). All 29 RHMTP graduates had completed a Postgraduate Diploma in Rural and Provincial Hospital Practice (PGDipRPHP), UoO, and more than half (17/29, 59%) had completed a Postgraduate Certificate in Clinician-Performed Ultrasound (PGCertCPU), UoO.

Geographical location of compulsory hospital training rotations undertaken by RHMTP graduates.

As trainees, programme graduates had undertaken a total of 123 compulsory hospital rotations (71 in urban and 52 in rural hospitals) in New Zealand. (NB: One rural hospital rotation had been undertaken at Rarotonga Hospital, Cook Islands.) The majority of urban (48/71, 66.7%) and rural (38/52, 71.7%) rotations were undertaken in the South Island. The distribution and numbers of both rural and urban hospital rotations are shown in Figure 1.

Figure 1: Location of compulsory New Zealand-based rural and base hospital training rotations undertaken by graduates of the Rural Hospital Medicine Training Programme.

Survey results

The survey response rate was 80% (39/49). Nearly all graduates (28/29, 97%), and over half 55% (11/20) of withdrawn trainees, responded.

Quantitative findings

Rural undergraduate training

Rural undergraduate experience is described in Table 3. More than half (25/39, 64%) of survey respondents indicated that they undertook a rural placement during their undergraduate training.

Table 3: Findings from surveying graduates and withdrawals of the Rural Hospital Training Programme, 2008–2017.

* Can practice in more than one scope at a time.
† Can undertake more than one undergraduate rural placement.
‡ Rural Medical Immersion Programme, University of Otago.
§ Pukawakawa Rural–Regional programme, Auckland University.
¶ Tairawhiti Interprofessional Education programme, Otago University.
# Also completed Rural Medical Immersion Programme, University of Otago.

Current employment of RHMTP graduates

The majority (26/28, 92.9%) of graduates are actively practising medicine, mostly (24/28, 85.7%) in rural locations. Of the four not currently practising in a rural location, half (2/4, 50%) indicated that they would work in rural practice in the future.

Most RHMTP graduates (22/28, 78.6%) currently work in a rural New Zealand hospital. Nearly half, in addition to RHM, work in another area of practice (13/28, 46.4%): either general practice or emergency medicine. Two-thirds (14/22, 63.6%) of graduates currently practising in rural hospital medicine work in the South Island, predominately within the Southern DHB (10/22, 45.5%). The distribution of graduates employed in rural hospitals is shown in Figure 2.

Figure 2: Location and number of graduates of the Rural Hospital Training Programme (2008–2017) who are working in New Zealand rural hospitals.

* 2018 New Zealand Index of Deprivation determined by the statistical area level 2 where that rural hospital is situated. (Atkinson J, Salmond C and Crampton P (2019). NZDep2018 Index of Perivation, User's Manual. Wellington: University of Otago.)

Additional professional roles of graduates

A quarter (7/28, 25%) of graduates also held leadership positions: three (10.7%) were DRHMNZ Council representatives, three (10.7%) were in clinical director roles and one (3.6%) held a senior academic position. Five (17.9%) other graduate respondents held other academic positions, and four (14.3%) held both leadership and academic positions.

Qualitative findings

Trainee RHMTP experiences

The key qualitative findings are summarised in five main themes. Illustrative participant quotes are presented.

A fit-for-purpose training programme

The RHMTP was perceived by most respondents (both graduates and those who withdrew) to be rural-practice specific with broad and varied clinical exposure and a relevant and complementary academic programme. The collegiality and networks built during the training programme, particularly the academic programme residentials, were highly valued:

“A comprehensive fit for purpose generalist training programme for Rural Hospital Medicine. The breadth of training (both clinical and academic) was excellent. Collegiality in meeting, training with and working alongside others passionate about (and keen to work) rurally.” R17

“The academic programme complemented the clinical training programme, especially bringing out the importance of the rural context through all of the papers. It was important to have rural doctors who understand the complexities of the rural environments facilitating the papers.” R11

Navigation

While navigating the programme, most respondents experienced challenges, which mainly revolved around securing programme components and the accompanying funding in a timely way. Respondents reported ‘falling through funding gaps’ when moving across the country and between DHBs, or while completing programme-accredited clinical rotations in health services to ‘where HWNZ funding does not flow’:

“It was a bit confusing understanding and navigating the programme… understanding and then… accessing funding for runs and academic components. Especially in the smaller rural hospitals with limited funding. This was a real issue when choosing my final placements, when [there were] lots of costs involved.” R15

“Financial pressures regarding fees that are not covered when you are outside the hospital-based runs, as you need to find your own attachments.” R36

Flexibility

Respondents saw programme flexibility as integral to a fit-for-rural-purpose training programme, as flexibility allowed exposure across the whole healthcare system and provided opportunities to experience diverse contexts:

“Best aspects included the flexibility of the training programme to allow opportunities to experience rural medicine in many areas of NZ. Developing generalist skills and a broad scope of practice - a jack-of-all-trades doctor in a secondary care environment - and developing a ‘thinking outside the box’ attitude to challenging situations.” R11

At the same time, flexibility was perceived by many to be a major contributor to navigation difficulties:

“[The] RHM Training programme has lots of potential. For those who want it, a more structured training pathway with placement certainty would be an incentive. As would funding following the trainee e.g. meeting [payment] for exit exams or rural academic papers while doing GP placements etc.” R39

A new specialty

While there was a sense of excitement in forging a new vocational pathway, it came with challenges:

“…many other doctors/ departments did not understand what RHM was, or even recognised it as a valid training pathway. I felt like I spent considerable time and energy educating others (including GPs) about the programme and advocating for myself to get the training experience at I required.” R26

Respondents described a growing awareness of the wide variations, as well as fragility, of rural hospital services and systems. For graduates, the transition to employment in senior rural hospitals positions could be daunting:

“...the local rural context and rural practices may not complement the expectations of a RHM trainee. Rural hospitals in NZ remain fragile systems. Many new vocationally trained rural hospital doctors are asked to take on not only new senior doctor positions… but also senior leadership positions.” R22

Family

Many respondents struggled to find a balance between the programme’s requirement and family needs. For some, moving around with family for clinical rotations was the biggest challenge, while others saw this as a programme highlight.

Self-funding

Half of the respondents (20/39, 51.3%) reported they had self-funded components of their RHMTP, including academic paper fees and costs associated with assessments (eg, final fellowship visit costs).

Reasons for withdrawal

Reasons for withdrawal from the RHMTP (11 respondents) fell into three categories: family/life related; programme related; and career related. Programme-related comments almost all related to navigation difficulties.

Discussion

This mixed methods study presents the first decade outcomes of New Zealand’s Rural Hospital Medicine Training Programme. Through the provision of a targeted rural career pathway, the RHMTP is growing a cohort of highly qualified doctors, of which the majority (92% of graduates currently practicing)18 are working in rural New Zealand. Most have two specialist fellowships and multiple postgraduate university qualifications, and many are taking up leadership positions early in their careers. The findings concur with the literature: dedicated rural training pathways contribute to the rural medical workforce.1,3,20,21

This study provides the first evidence on actual postgraduate practice locality for rural career choice in New Zealand. These outcomes compare favourably with international postgraduate rural programmes.22,23

The number of doctors identifying as Māori (6%) is similar to other comparable programmes,24 has remained small (7% in graduate and 6% in active trainee cohorts) and needs attention.

Many RHMTP graduates report no rural undergraduate experience. It is likely too early to see the influence of rural–regional undergraduate programmes on RHMTP entry. However, the number of Rural Medical Immersion Programme (RMIP)students entering RHMTP training may be an early indication of the value of a rural training pathway.

Findings concur with previous research that confirms overseas trained doctors (OTDs) constitute a high proportion of doctors working rurally.15,22

Both the withdrawal rate and the uneven geographic spread of trainee rotations are noteworthy.

It is reassuring that a high proportion of trainees who withdrew began with the intention of doing GP and RHM training and, after withdrawal from the RHMTP, are continuing with training in GP, and many are working in rural GP. Withdrawal numbers will need further exploration as the programme grows, including the extent to which GP–RHM trainees are eventually opting to continue with just one training programme.

In addition to personal and family factors (known to be strong career drivers),25 findings point to programme-related factors (eg, access to funding, organisational placement aspects and institutional bureaucratic complexities) that are influencing trainees’ decisions and impacting progress through the RHMTP for some trainees. The lack of a consistent mechanism within the current funding model to ensure that funding follows trainees into a critical proportion of their training (that undertaken in rural settings) seems particularly notable.

Although this study did not examine the reasons for geographic variations for trainee rotations, the specific local–rural context is probably an important contributing factor. Findings suggest that there are localities across New Zealand where RHMTP rotations with associated funding and supports have been streamlined. Naturally, trainees gravitate towards set-ups that work and are high quality. The gains for a rural hospital of a steady stream of senior doctors-in-training cannot be underestimated: not only does this result in much needed service provision, but it likely creates ripple effects for wider local capacity building. This would in turn contribute to the wider goals of the RHMTP in strengthening rural hospital services. It is important to note that many rural hospitals have not yet achieved the stability in their workforce that is required to enable the provision of a professional environment that both supports and attracts RHMTP trainees.

Dual GP–RHM training is likely high value, given the need for a New Zealand rural medical workforce across the primary–secondary care spectrum, and it is clearly popular among trainees. With both training programmes situated within the RNZCGP, opportunities for reducing bureaucratic complexities associated with GP–RHM dual training should be within reach, as previously noted.26

Country-specific solutions have been found for postgraduate rural training. Recent Australian research has highlighted the importance of national rural faculties as a strategy to build and sustain a rural medical workforce.22

The overarching aim of rural-targeted training pathways, in providing a robust pathway to a rural-based employment, is the provision of health services to rural areas.1,20,25 The RNZCGP-DRHMNZ has a responsibility not only to its trainees, but, particularly in light of New Zealand’s wider policy context,11,27 to reduce chronic health-access inequities for all rural and remote communities. Although important gains have been made with many rural hospital vacancies across New Zealand being filled by RHMTP graduates, findings also indicate that many rural hospitals, including some serving communities with the greatest health-access inequities (particularly Māori communities), are not yet benefiting from the RHMTP.

Study findings highlight the knowledge gap (previously identified)28 regarding rural hospitals in New Zealand. International studies have shown rural hospitals to be important providers of healthcare that can benefit the health of rural populations,29 but similar research has not been undertaken in New Zealand.

Study strengths and limitations

The study’s perspective is that of the RHMTP provider and its trainees and does not include the views of rural hospitals or communities. The study used mixed methods, and the findings corroborated across datasets. The study was limited by the quality of the RNZCGP database, which was incomplete (in particular, locality of the RHMTP general practice rotation). Although the survey response rate was high, the limitations of using a survey, which was conducted with the expectation of complete databases, is acknowledged. This survey method provided limited information on the influence of undergraduate rural programmes.

Policy implications and recommendations

It is well documented that rural-targeted vocational pathways require innovation and flexibility in order to be responsive to the clinical and structural requirements of rural practice.1–3,25 Study findings provide insights regarding what is working well and highlight issues requiring attention.

Recommendations based on the findings include:

  • The RHMTP funding mechanism is reviewed to ensure alignment with the programme’s structure. A solution is needed that reaches across the two health system tiers, multiple organisations and geographical boundaries and balances regional versus national interests.
  • The DRHMNZ’s governance structure within the RNZCGP is reviewed to ensure it facilitates optimal support for trainees and training sites and provides strong advocacy for all rural communities.
  • General practice–rural hospital medicine training is recognised formally as a dual pathway, optimising operational efficiencies and aligning funding mechanisms.
  • The RNZCGP and DRHMNZ continue to increase the diversity of graduates entering the RHMTP and, in particular, consider ways to support more Māori graduates through the programme.
  • Diversity in rural health service exposure for RHM trainees is widened.

Other opportunities

The RHMTP provides just part of the solution to building rural workforce capacity. The critical role of other health professionals, particularly nurses, both in rural hospital and other rural health services roles, must be acknowledged. All rural health professionals should be supported to develop their own rural-specific training and continuing-education pathways.

The RHMTP is contributing to building rural health academic capacity with dual clinical–academic roles based in rural locations. A national rural-centric academic structure would provide mechanisms that help early career academics thrive in active rural–clinical practice across all health-professional disciplines.

In aiming to improve health-access inequalities for all New Zealanders, consideration should be given to how the RHMTP could add value to the emerging general practice training programmes of two of New Zealand’s realm countries, the Cook Islands and Niue. These programmes already share academic components.16

Future research

Further and ongoing studies investigating future RHMTP outcomes, including recruitment and retention factors for RHMTP graduates and the influence of a coordinated rural-origin, rural-undergraduate and rural-postgraduate pathway for rural career choice in the New Zealand context, are required.

Wider research is needed into the current status and role of New Zealand’s rural hospitals and the extent to which all rural health services improve access to healthcare, improve health outcomes and improve health equity for New Zealand’s rural communities.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Katharina Blattner: Rural Doctor and Senior Lecturer, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Rory Miller: Rural Doctor and Senior Lecturer, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Rachael Lawrence-Lodge: Research Fellow, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Garry Nixon: Associate Professor Rural Health and Rural Doctor, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Patrick McHugh: Primary Care Practitioner, Turanga Health, Gisborne, New Zealand. Joel Pirini: Rural Doctor, Kaitaia Hospital, Northland District Health Board, New Zealand.

Acknowledgements

Correspondence

Katharina Blattner, PO Box 82, Omapere, Hokianga, New Zealand, 0064 21 457736

Correspondence Email

katharina.blattner@otago.ac.nz

Competing Interests

Katharina Blattner and Garry Nixon have teaching roles in the RHMTP’s academic component. Patrick McHugh has been involved in RHMTP governance. Rory Miller is a graduate of the RHMTP and is involved in teaching of the RHMTPs academic component. Joel Pirini is a current trainee of the RHMTP.

1. World Health Organization (WHO). Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: WHO; 2010.

2. World Organization of Family Doctors (WONCA). The Delhi Declaration: Alma Ata revisited Delhi2018 [cited 2018 June 12 ]. Available from: http://www.who.int/hrh/news/2018/delhi_declaration/en/.

3. Sen Gupta T, McKenzie A. Postgraduate pathways to rural medical practice. 2014. In: Rural Medical Education Guidebook [Internet]. Bangkok, Thailand: WONCA Available from: https://www.wonca.net/groups/WorkingParties/RuralPractice/ruralguidebook.aspx.

4. Wearne SM, Wakerman J. Training our future rural medical workforce. The Medical Journal of Australia. 2004;180(3):101-2.

5. Fearnley D, Lawrenson R, Nixon G. 'Poorly defined': unknown unknowns in New Zealand Rural Health. N Z Med J. 2016;129(1439):77.

6. Ministry of Health NZ. Mātātuhi Tuawhenua: Health of Rural Māori, 2012. Wellington, N.Z.: Ministry of Health.; 2012.

7. Williamson M, Gormley A, Dovey S, Farry P. Rural hospitals in New Zealand: results from a survey. N Z Med J 2010;123(1315).

8. Royal New Zealand College of General Practitioners (RNZCGP). Division of Rural Hospital Medicine Training Programme Handbook. Wellington: RNZCGP; 2020

9. Nixon G, Blattner K. Rural hospital medicine in New Zealand: vocational registration and the recognition of a new scope of practice. N Z Med J. 2007;120(1259).

10. Medical Council New Zealand. Vocational scopes of practice. Wellington MCNZ; 2015 [cited 2016 May 8]. Available from: https://www.mcnz.org.nz/get-registered/scopes-of-practice/.

11. Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington: HDSR.; 2020.

12. Nixon G, Blattner K, Williamson M, et al. Training generalist doctors for rural practice in New Zealand. Rural Remote Health. 2017;17.

13. Lawrenson R, Nixon G, Steed R. The rural hospital doctors workforce in New Zealand. Rural Remote Health. 2011;11(2):1588.

14. Lawrenson R, Reid J, Nixon G, Laurenson A. The New Zealand Rural Hospital Doctors Workforce Survey 2015. N Z Med J. 2016;129:7.

15. Wong DL, Nixon G. The rural medical generalist workforce: The Royal New Zealand College of General Practitioners’ 2014 workforce survey results. J Prim Health Care. 2016;Vol.8(3):196-203.

16. Blattner K, Nixon G, Gutenstein M, Davey E. A targeted rural postgraduate education programme–linking rural doctors across New Zealand and into the Pacific. Educ Prim Care. 2017;Vol.28(6):346-50.

17. Ministry of Health New Zealand. Health workforce Investment and purchasing 2020 [cited 2020 7 May ]. Available from: https://www.health.govt.nz/our-work/health-workforce/investment-and-purchasing.

18. Blattner K, Lawrence-Lodge R, Miller R, Nixon G, McHugh P, Pirini J. New Zealand's Rural Hospital Medicine training program at 10 years: Locality and career choice of the first graduate cohort. Aust J Rural Health. 2020;00:1–3. https://doi.org/10.1111/ajr.12678

19. R Core Team. R: A language and environment for statistical computing Vienna, Austria: R Foundation for Statistical Computing, ; 2020 [Available from: https://www.R-project.org/.

20. Strasser R, Neusy AJ. Context counts: training health workers in and for rural and remote areas. Bull World Health Organ. 2010;88(10):777-82.

21. Schmitz D, Doty B. Training in family medicine for rural practice in the USA. 2014. 2014. In: WONCA Rural Medical Education Guidebook [Internet] [Internet]. Bangkok: WONCA. Available from: https://www.globalfamilydoctor.com/groups/WorkingParties/RuralPractice/ruralguidebook.aspx.

22. McGrail M, O'Sullivan B. Faculties to Support General Practitioners Working Rurally at Broader Scope: A National Cross-Sectional Study of Their Value. International journal of Environmental Research and Public Health. 2020;17(13):4652.

23. MacQueen IT, Maggard-Gibbons M, Capra G et al. Recruiting Rural Healthcare Providers Today: a Systematic Review of Training Program Success and Determinants of Geographic Choices. Journal of General Internal Medicine: JGIM. 2017;33(2):191-9.

24. Australasian College for Emergency Medicine. 2017 FACEM and Trainee Demographic and Workforce Report. Melbourne, Australia Australasian College for Emergency Medicine Department of Policy, Research & Advocacy; 2018.

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Targeted rural postgraduate training pathways are recognised internationally as playing a critical role both in recruitment and retention of a rural medical workforce and in reducing inequity of care and opportunity for people living away from urban centres.1–4

In New Zealand, though data are limited, indications are that people living rurally have poorer health outcomes than people living in urban areas, and this is accentuated for Māori.5,6 Around 19% of New Zealand’s population rely on rural health services, and around 15% rely on rural hospitals for their healthcare.5,7,8

In 2008, in response to serious rural hospital workforce shortages and the lack of any training pathway, rural hospital medicine (RHM) was recognised by the Medical Council of New Zealand (MCNZ) as a vocational scope of practice.9 The intention was to provide recognised training standards for the medical workforce and to encourage the development of systems, such as clinical governance, in rural hospitals.9 The scope of RHM is defined by its context, the rural environment including geographic isolation, and, in contrast to general practice (GP), is orientated to secondary care.10

Rural hospitals in New Zealand are small and geographically distant from a base hospital; they have acute bed capacity and limited diagnostics; and they have a predominantly generalist medical workforce.8 However, New Zealand’s rural hospitals are not homogenous (variations include governance, funding models and integration with primary care), nor do they fit seamlessly into either of the two tiers of the New Zealand health system (community–primary care or hospital services).11

The Rural Hospital Medicine Training Programme’s (RHMTP’s) history and development have been previously described.12 Though there have been early improvements in the rural hospital workforce since the RHM scope’s inception, serious staff shortages remain.13–15

The RHMTP is New Zealand’s only rural-targeted vocational training programme. The professional body for RHM, the Division of Rural Hospital Medicine (DRHMNZ), sits as a chapter within the Royal New Zealand College of General Practitioners (RNZCGP) and reports directly to the MCNZ as the branch advisory body for the RHM scope. Factors considered in positioning the DRHMNZ in the RNZCGP included close ties and overlap with rural general practice and the small size of the RHM workforce.12

The Rural Hospital Medicine Training Programme

The key programme principles include recognition of prior learning, competence-based assessment and a modular (rather than a linear) pathway.8,12 The academic component of the training programme is provided largely by the University of Otago’s (UoO’s) distance-taught Postgraduate Rural Programme (PGRP).16 The RHMTP’s flexibility is important, not only for integration with other training programmes, but to facilitate logistics for trainees moving between rural and urban attachments and across regions and to accommodate academic components.12 Dual training with other specialties, particularly GP, is encouraged; however, there is no formal GP–RHM training pathway.12

The requirements of the RHMTP, which cross primary–secondary, hospital–community and urban–rural settings, are outlined in Table 1 and detailed elsewhere.8

Table 1: Outline of the Rural Hospital Medicine Training Programme.*

* Royal New Zealand College of General Practitioners (RNZCGP). Division of Rural Hospital Medicine Training Programme Handbook. Wellington: RNZCGP; 2020.
† GENA indicates papers administered through the University of Otago, rural post graduate programme.
‡ Can be used to gain advanced or extended experience and skills (eg, in Anaesthetics or Obstetrics OR for those dual training with GP used to complete GPEPI (intensive year of GP training).

The Rural Hospital Medicine Training Programme is subsidised by Health Workforce New Zealand (HWNZ) through the hospital specialties route via district health boards (DHBs), not the alternative HWNZ college-based route used for GP training.17 Some base and tertiary hospitals offer specific clinical rotations for RHM trainees. Some DHBs offer a scheme where all or most clinical rotations are available in a single region. Many rural hospitals and rural general practices offer accredited rotations, but not all have the same access to HWNZ funding. Difficulty accessing funding for accredited training posts, especially for rural hospital and rural general practice placements, has been reported at DRHMNZ council meetings.

The main aim of this study was to evaluate the outcomes of the first decade of the RHMTP. The study also aimed to determine the geographic spread of both graduates and trainees; to gain insights into the influence of undergraduate rural training exposure on subsequent rural career choice; and to explore trainee experiences of the RHMTP. The career choice of the first RHMTP graduate cohort is reported elsewhere.18

Methods

Design

This was a mixed method descriptive study.

Sampling and data collection

Database interrogation

Data were extracted from: the MCNZ Register of Doctors; UoO student enrolment records (eVision); and the RNZCGP’s database. Data were sought on all individuals entering the RHMTP from December 2008 to December 2017. Records were reviewed through to 1 August 2019. The RNZCGP data was collected manually at the RNZCGP’s Wellington offices. The MCNZ and UoO databases were accessed electronically.

Survey

All trainees who had graduated or withdrawn from the RHMTP (before 1 August 2019) were invited by email to participate in an electronic survey. The survey was generated using Qualtrics (Prova, Utah, US). All potential participants were then separately emailed a unique link that gave them immediate access to the survey and the participant information and consent forms. The survey was open for 10 weeks.

The survey included questions about participants’ current employment and locality as well as questions (free text) about the best aspects and greatest challenges of the training programme, self-funding the training and, where relevant, reasons for withdrawal from the programme. Participants were also asked to indicate (Yes/No) any rural undergraduate experience by year of training (during the 4th, 5th or 6th undergraduate year) and whether this was a ‘rural rotational run’ (not further specified) or one of the rural-specific undergraduate programmes (eg, Rural Medical Immersion Programme (RMIP), UoO; Tairāwhiti Interprofessional Education programme, UoO; Pukawakawa: Northland Regional-Rural program, University of Auckland (UoA); Rural Health Interprofessional Education Programme, UoA). No definitions of ‘urban’ or ‘rural’, nor of ‘rural undergraduate training’, were provided.

Analysis

Database and survey data were separately collated and entered into respective Excel (Microsoft Corporation, Redmond, WA, US) spreadsheets. To maintain participant anonymity, all respondents were designated a number (1–XX) and were referred to throughout by this coding.

Simple descriptive statistics were used to summarise gender, age, ethnicity, New Zealand citizenship status, the institution awarding the undergraduate degree, current practicing status and other postgraduate qualifications.

The location of compulsory training rotations and the primary place of graduates’ current employment were tabulated then mapped using R.19 The 2018 New Zealand Index of Deprivation decile for the Statistical Area (Level 2) where New Zealand rural hospitals were located was determined and overlaid in the map.

Free-text responses were reported as quotes, then coded and collated according to the survey categories. For data collected in the categories of ‘Best aspects’, ‘Challenges’ and ‘Other comments’, common themes were identified using an inductive thematic approach. (KB RLL). Team members (RM, GN) reviewed the analysis to ensure theme consensus. NVivo qualitative data analysis software (QSR International Pty Ltd, Version 12, 2018) was used to manage the analysis.

Ethics approval for this study was obtained from the University of Otago Human Ethics Committee, Reference D19/194.

Results

Database findings

Demographics

The records for 98 trainees who had entered the RHMTP were available for analysis in the RNZCGP database. Those graduating with a Fellowship in Rural Hospital Medicine (FDRHMNZ) made up under a third (29/98, 29.5%), half (49/98, 50%) were active trainees and a fifth (20/98, 20.4%) had withdrawn.

Detailed demographic information is summarised in Table 2.

Table 2: Summary of graduates, withdrawals and active trainees of the Rural Hospital Medicine Training Programme betw3eeen 2008 and 2017.

* Participants can self-identify as more than one ethnicity. † Data missing for these four participants.

Entry, completion or withdrawal

Intake into the RHMTP was between 6 and 10 trainees per year over the first four years, after which annual cohorts increased. The highest intake during the study period was 26 admissions in the tenth year. The first two trainees graduated in 2012. From 2013, between four and six fellowships were awarded each year. The median time graduates spent in the programme was five years and seven months. Twenty trainees subsequently withdrew: five in 2015 and between one and six trainees per year from 2016 to 2019. For these trainees, the median time spent in the programme was two years and nine months.

Undergraduate training

Overall, 69/98 (70%) trainees had gained their undergraduate medical degree in New Zealand, and half (49/98, 50%) were awarded their degrees by the University of Otago.

Participation in other vocational training programmes and additional qualifications.

Participation in other training programmes is described in Table 2. Most graduates (17/29, 59%), active trainees (39/49, 80%) and withdrawn trainees (17/20, 85%) are participating in or have completed another vocational training programme; nearly two-thirds of them participated in or completed general practice vocational training (62/98, 63.3%).

The majority of graduates had completed more than one postgraduate diploma or certificate (25/29, 86%). All 29 RHMTP graduates had completed a Postgraduate Diploma in Rural and Provincial Hospital Practice (PGDipRPHP), UoO, and more than half (17/29, 59%) had completed a Postgraduate Certificate in Clinician-Performed Ultrasound (PGCertCPU), UoO.

Geographical location of compulsory hospital training rotations undertaken by RHMTP graduates.

As trainees, programme graduates had undertaken a total of 123 compulsory hospital rotations (71 in urban and 52 in rural hospitals) in New Zealand. (NB: One rural hospital rotation had been undertaken at Rarotonga Hospital, Cook Islands.) The majority of urban (48/71, 66.7%) and rural (38/52, 71.7%) rotations were undertaken in the South Island. The distribution and numbers of both rural and urban hospital rotations are shown in Figure 1.

Figure 1: Location of compulsory New Zealand-based rural and base hospital training rotations undertaken by graduates of the Rural Hospital Medicine Training Programme.

Survey results

The survey response rate was 80% (39/49). Nearly all graduates (28/29, 97%), and over half 55% (11/20) of withdrawn trainees, responded.

Quantitative findings

Rural undergraduate training

Rural undergraduate experience is described in Table 3. More than half (25/39, 64%) of survey respondents indicated that they undertook a rural placement during their undergraduate training.

Table 3: Findings from surveying graduates and withdrawals of the Rural Hospital Training Programme, 2008–2017.

* Can practice in more than one scope at a time.
† Can undertake more than one undergraduate rural placement.
‡ Rural Medical Immersion Programme, University of Otago.
§ Pukawakawa Rural–Regional programme, Auckland University.
¶ Tairawhiti Interprofessional Education programme, Otago University.
# Also completed Rural Medical Immersion Programme, University of Otago.

Current employment of RHMTP graduates

The majority (26/28, 92.9%) of graduates are actively practising medicine, mostly (24/28, 85.7%) in rural locations. Of the four not currently practising in a rural location, half (2/4, 50%) indicated that they would work in rural practice in the future.

Most RHMTP graduates (22/28, 78.6%) currently work in a rural New Zealand hospital. Nearly half, in addition to RHM, work in another area of practice (13/28, 46.4%): either general practice or emergency medicine. Two-thirds (14/22, 63.6%) of graduates currently practising in rural hospital medicine work in the South Island, predominately within the Southern DHB (10/22, 45.5%). The distribution of graduates employed in rural hospitals is shown in Figure 2.

Figure 2: Location and number of graduates of the Rural Hospital Training Programme (2008–2017) who are working in New Zealand rural hospitals.

* 2018 New Zealand Index of Deprivation determined by the statistical area level 2 where that rural hospital is situated. (Atkinson J, Salmond C and Crampton P (2019). NZDep2018 Index of Perivation, User's Manual. Wellington: University of Otago.)

Additional professional roles of graduates

A quarter (7/28, 25%) of graduates also held leadership positions: three (10.7%) were DRHMNZ Council representatives, three (10.7%) were in clinical director roles and one (3.6%) held a senior academic position. Five (17.9%) other graduate respondents held other academic positions, and four (14.3%) held both leadership and academic positions.

Qualitative findings

Trainee RHMTP experiences

The key qualitative findings are summarised in five main themes. Illustrative participant quotes are presented.

A fit-for-purpose training programme

The RHMTP was perceived by most respondents (both graduates and those who withdrew) to be rural-practice specific with broad and varied clinical exposure and a relevant and complementary academic programme. The collegiality and networks built during the training programme, particularly the academic programme residentials, were highly valued:

“A comprehensive fit for purpose generalist training programme for Rural Hospital Medicine. The breadth of training (both clinical and academic) was excellent. Collegiality in meeting, training with and working alongside others passionate about (and keen to work) rurally.” R17

“The academic programme complemented the clinical training programme, especially bringing out the importance of the rural context through all of the papers. It was important to have rural doctors who understand the complexities of the rural environments facilitating the papers.” R11

Navigation

While navigating the programme, most respondents experienced challenges, which mainly revolved around securing programme components and the accompanying funding in a timely way. Respondents reported ‘falling through funding gaps’ when moving across the country and between DHBs, or while completing programme-accredited clinical rotations in health services to ‘where HWNZ funding does not flow’:

“It was a bit confusing understanding and navigating the programme… understanding and then… accessing funding for runs and academic components. Especially in the smaller rural hospitals with limited funding. This was a real issue when choosing my final placements, when [there were] lots of costs involved.” R15

“Financial pressures regarding fees that are not covered when you are outside the hospital-based runs, as you need to find your own attachments.” R36

Flexibility

Respondents saw programme flexibility as integral to a fit-for-rural-purpose training programme, as flexibility allowed exposure across the whole healthcare system and provided opportunities to experience diverse contexts:

“Best aspects included the flexibility of the training programme to allow opportunities to experience rural medicine in many areas of NZ. Developing generalist skills and a broad scope of practice - a jack-of-all-trades doctor in a secondary care environment - and developing a ‘thinking outside the box’ attitude to challenging situations.” R11

At the same time, flexibility was perceived by many to be a major contributor to navigation difficulties:

“[The] RHM Training programme has lots of potential. For those who want it, a more structured training pathway with placement certainty would be an incentive. As would funding following the trainee e.g. meeting [payment] for exit exams or rural academic papers while doing GP placements etc.” R39

A new specialty

While there was a sense of excitement in forging a new vocational pathway, it came with challenges:

“…many other doctors/ departments did not understand what RHM was, or even recognised it as a valid training pathway. I felt like I spent considerable time and energy educating others (including GPs) about the programme and advocating for myself to get the training experience at I required.” R26

Respondents described a growing awareness of the wide variations, as well as fragility, of rural hospital services and systems. For graduates, the transition to employment in senior rural hospitals positions could be daunting:

“...the local rural context and rural practices may not complement the expectations of a RHM trainee. Rural hospitals in NZ remain fragile systems. Many new vocationally trained rural hospital doctors are asked to take on not only new senior doctor positions… but also senior leadership positions.” R22

Family

Many respondents struggled to find a balance between the programme’s requirement and family needs. For some, moving around with family for clinical rotations was the biggest challenge, while others saw this as a programme highlight.

Self-funding

Half of the respondents (20/39, 51.3%) reported they had self-funded components of their RHMTP, including academic paper fees and costs associated with assessments (eg, final fellowship visit costs).

Reasons for withdrawal

Reasons for withdrawal from the RHMTP (11 respondents) fell into three categories: family/life related; programme related; and career related. Programme-related comments almost all related to navigation difficulties.

Discussion

This mixed methods study presents the first decade outcomes of New Zealand’s Rural Hospital Medicine Training Programme. Through the provision of a targeted rural career pathway, the RHMTP is growing a cohort of highly qualified doctors, of which the majority (92% of graduates currently practicing)18 are working in rural New Zealand. Most have two specialist fellowships and multiple postgraduate university qualifications, and many are taking up leadership positions early in their careers. The findings concur with the literature: dedicated rural training pathways contribute to the rural medical workforce.1,3,20,21

This study provides the first evidence on actual postgraduate practice locality for rural career choice in New Zealand. These outcomes compare favourably with international postgraduate rural programmes.22,23

The number of doctors identifying as Māori (6%) is similar to other comparable programmes,24 has remained small (7% in graduate and 6% in active trainee cohorts) and needs attention.

Many RHMTP graduates report no rural undergraduate experience. It is likely too early to see the influence of rural–regional undergraduate programmes on RHMTP entry. However, the number of Rural Medical Immersion Programme (RMIP)students entering RHMTP training may be an early indication of the value of a rural training pathway.

Findings concur with previous research that confirms overseas trained doctors (OTDs) constitute a high proportion of doctors working rurally.15,22

Both the withdrawal rate and the uneven geographic spread of trainee rotations are noteworthy.

It is reassuring that a high proportion of trainees who withdrew began with the intention of doing GP and RHM training and, after withdrawal from the RHMTP, are continuing with training in GP, and many are working in rural GP. Withdrawal numbers will need further exploration as the programme grows, including the extent to which GP–RHM trainees are eventually opting to continue with just one training programme.

In addition to personal and family factors (known to be strong career drivers),25 findings point to programme-related factors (eg, access to funding, organisational placement aspects and institutional bureaucratic complexities) that are influencing trainees’ decisions and impacting progress through the RHMTP for some trainees. The lack of a consistent mechanism within the current funding model to ensure that funding follows trainees into a critical proportion of their training (that undertaken in rural settings) seems particularly notable.

Although this study did not examine the reasons for geographic variations for trainee rotations, the specific local–rural context is probably an important contributing factor. Findings suggest that there are localities across New Zealand where RHMTP rotations with associated funding and supports have been streamlined. Naturally, trainees gravitate towards set-ups that work and are high quality. The gains for a rural hospital of a steady stream of senior doctors-in-training cannot be underestimated: not only does this result in much needed service provision, but it likely creates ripple effects for wider local capacity building. This would in turn contribute to the wider goals of the RHMTP in strengthening rural hospital services. It is important to note that many rural hospitals have not yet achieved the stability in their workforce that is required to enable the provision of a professional environment that both supports and attracts RHMTP trainees.

Dual GP–RHM training is likely high value, given the need for a New Zealand rural medical workforce across the primary–secondary care spectrum, and it is clearly popular among trainees. With both training programmes situated within the RNZCGP, opportunities for reducing bureaucratic complexities associated with GP–RHM dual training should be within reach, as previously noted.26

Country-specific solutions have been found for postgraduate rural training. Recent Australian research has highlighted the importance of national rural faculties as a strategy to build and sustain a rural medical workforce.22

The overarching aim of rural-targeted training pathways, in providing a robust pathway to a rural-based employment, is the provision of health services to rural areas.1,20,25 The RNZCGP-DRHMNZ has a responsibility not only to its trainees, but, particularly in light of New Zealand’s wider policy context,11,27 to reduce chronic health-access inequities for all rural and remote communities. Although important gains have been made with many rural hospital vacancies across New Zealand being filled by RHMTP graduates, findings also indicate that many rural hospitals, including some serving communities with the greatest health-access inequities (particularly Māori communities), are not yet benefiting from the RHMTP.

Study findings highlight the knowledge gap (previously identified)28 regarding rural hospitals in New Zealand. International studies have shown rural hospitals to be important providers of healthcare that can benefit the health of rural populations,29 but similar research has not been undertaken in New Zealand.

Study strengths and limitations

The study’s perspective is that of the RHMTP provider and its trainees and does not include the views of rural hospitals or communities. The study used mixed methods, and the findings corroborated across datasets. The study was limited by the quality of the RNZCGP database, which was incomplete (in particular, locality of the RHMTP general practice rotation). Although the survey response rate was high, the limitations of using a survey, which was conducted with the expectation of complete databases, is acknowledged. This survey method provided limited information on the influence of undergraduate rural programmes.

Policy implications and recommendations

It is well documented that rural-targeted vocational pathways require innovation and flexibility in order to be responsive to the clinical and structural requirements of rural practice.1–3,25 Study findings provide insights regarding what is working well and highlight issues requiring attention.

Recommendations based on the findings include:

  • The RHMTP funding mechanism is reviewed to ensure alignment with the programme’s structure. A solution is needed that reaches across the two health system tiers, multiple organisations and geographical boundaries and balances regional versus national interests.
  • The DRHMNZ’s governance structure within the RNZCGP is reviewed to ensure it facilitates optimal support for trainees and training sites and provides strong advocacy for all rural communities.
  • General practice–rural hospital medicine training is recognised formally as a dual pathway, optimising operational efficiencies and aligning funding mechanisms.
  • The RNZCGP and DRHMNZ continue to increase the diversity of graduates entering the RHMTP and, in particular, consider ways to support more Māori graduates through the programme.
  • Diversity in rural health service exposure for RHM trainees is widened.

Other opportunities

The RHMTP provides just part of the solution to building rural workforce capacity. The critical role of other health professionals, particularly nurses, both in rural hospital and other rural health services roles, must be acknowledged. All rural health professionals should be supported to develop their own rural-specific training and continuing-education pathways.

The RHMTP is contributing to building rural health academic capacity with dual clinical–academic roles based in rural locations. A national rural-centric academic structure would provide mechanisms that help early career academics thrive in active rural–clinical practice across all health-professional disciplines.

In aiming to improve health-access inequalities for all New Zealanders, consideration should be given to how the RHMTP could add value to the emerging general practice training programmes of two of New Zealand’s realm countries, the Cook Islands and Niue. These programmes already share academic components.16

Future research

Further and ongoing studies investigating future RHMTP outcomes, including recruitment and retention factors for RHMTP graduates and the influence of a coordinated rural-origin, rural-undergraduate and rural-postgraduate pathway for rural career choice in the New Zealand context, are required.

Wider research is needed into the current status and role of New Zealand’s rural hospitals and the extent to which all rural health services improve access to healthcare, improve health outcomes and improve health equity for New Zealand’s rural communities.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Katharina Blattner: Rural Doctor and Senior Lecturer, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Rory Miller: Rural Doctor and Senior Lecturer, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Rachael Lawrence-Lodge: Research Fellow, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Garry Nixon: Associate Professor Rural Health and Rural Doctor, Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, New Zealand. Patrick McHugh: Primary Care Practitioner, Turanga Health, Gisborne, New Zealand. Joel Pirini: Rural Doctor, Kaitaia Hospital, Northland District Health Board, New Zealand.

Acknowledgements

Correspondence

Katharina Blattner, PO Box 82, Omapere, Hokianga, New Zealand, 0064 21 457736

Correspondence Email

katharina.blattner@otago.ac.nz

Competing Interests

Katharina Blattner and Garry Nixon have teaching roles in the RHMTP’s academic component. Patrick McHugh has been involved in RHMTP governance. Rory Miller is a graduate of the RHMTP and is involved in teaching of the RHMTPs academic component. Joel Pirini is a current trainee of the RHMTP.

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