New Zealand's vocational Rural Hospital Medicine Training Programme: the first ten years


       New Zealand’s vocational
       Rural Hospital Medicine
        Training Programme:
          the first ten years
      Katharina Blattner, Rory Michael Miller, Rachael Lawrence-Lodge,
                  Garry Nixon, Patrick McHugh, Joel Pirini

AIMS: The Rural Hospital Medicine Training Programme (RHMTP) was established in 2008 to develop New
Zealand’s rural hospital medical workforce. This study evaluates the RHMTP’s first 10-year outcomes.
METHODS: A mixed-methods descriptive study. Database interrogation of: the Royal New Zealand College
of General Practitioners records; University of Otago’s e-Vision; the Medical Council of New Zealand’s
register of doctors. A survey of trainees who had graduated or withdrew from the programme. Survey
questions included: current scope and place of employment; undergraduate rural experience; and trainee
RESULTS: From 2009–2018, 98 doctors entered the RHMTP: 29 graduated, 20 withdrew and 49 are active
registrars. Of the graduates, more than half (17/29) also completed GP training. Overall survey response
rate: 80% (39/49). Graduate response rate: 97% (28/29). 92% (24/26) of currently practising graduates are
working in rural New Zealand, mostly (22/24) in rural hospitals. Trainees value the RHMTP’s flexibility and
breadth of clinical exposure. The main challenges relate to a lack of alignment of training requirements and
CONCLUSIONS: In its first decade, the RHMTP has been successful in generating a rural hospital workforce
and the programme is steadily growing. Attention to existing barriers is needed to ensure the RHMTP can
reach its potential to benefit all of New Zealand’s rural communities.

      argeted rural postgraduate training              Medical Council of New Zealand (MCNZ) as a
      pathways are recognised internation-             vocational scope of practice.9 The intention
      ally as playing a critical role both in          was to provide recognised training stan-
recruitment and retention of a rural medical           dards for the medical workforce and to
workforce and in reducing inequity of care             encourage the development of systems, such
and opportunity for people living away from            as clinical governance, in rural hospitals.9
urban centres.1–4                                      The scope of RHM is defined by its context,
   In New Zealand, though data are limited,            the rural environment including geographic
indications are that people living rurally             isolation, and, in contrast to general practice
have poorer health outcomes than people                (GP), is orientated to secondary care.10
living in urban areas, and this is accentuated           Rural hospitals in New Zealand are small
for Māori.5,6 Around 19% of New Zealand’s              and geographically distant from a base
population rely on rural health services, and          hospital; they have acute bed capacity and
around 15% rely on rural hospitals for their           limited diagnostics; and they have a predom-
healthcare.5,7,8                                       inantly generalist medical workforce.8
  In 2008, in response to serious rural                However, New Zealand’s rural hospitals
hospital workforce shortages and the lack              are not homogenous (variations include
of any training pathway, rural hospital                governance, funding models and integration
medicine (RHM) was recognised by the                   with primary care), nor do they fit seam-

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lessly into either of the two tiers of the New    college-based route used for GP training.17
Zealand health system (community–primary          Some base and tertiary hospitals offer
care or hospital services).11                     specific clinical rotations for RHM trainees.
  The Rural Hospital Medicine Training            Some DHBs offer a scheme where all or
Programme’s (RHMTP’s) history and devel-          most clinical rotations are available in a
opment have been previously described.12          single region. Many rural hospitals and rural
Though there have been early improve-             general practices offer accredited rotations,
ments in the rural hospital workforce since       but not all have the same access to HWNZ
the RHM scope’s inception, serious staff          funding. Difficulty accessing funding for
shortages remain.13–15                            accredited training posts, especially for
                                                  rural hospital and rural general practice
  The RHMTP is New Zealand’s only
                                                  placements, has been reported at DRHMNZ
rural-targeted vocational training
                                                  council meetings.
programme. The professional body for RHM,
the Division of Rural Hospital Medicine             The main aim of this study was to evaluate
(DRHMNZ), sits as a chapter within the            the outcomes of the first decade of the
Royal New Zealand College of General              RHMTP. The study also aimed to determine
Practitioners (RNZCGP) and reports directly       the geographic spread of both graduates and
to the MCNZ as the branch advisory body           trainees; to gain insights into the influence
for the RHM scope. Factors considered in          of undergraduate rural training exposure
positioning the DRHMNZ in the RNZCGP              on subsequent rural career choice; and to
included close ties and overlap with rural        explore trainee experiences of the RHMTP.
general practice and the small size of the        The career choice of the first RHMTP
RHM workforce.12                                  graduate cohort is reported elsewhere.18

    The Rural Hospital                                         Methods
    Medicine Training                             Design
                                                    This was a mixed method descriptive
       Programme                                  study.
  The key programme principles include            Sampling and data collection
recognition of prior learning, compe-
tence-based assessment and a modular              Database interrogation
(rather than a linear) pathway.8,12 The             Data were extracted from: the MCNZ
academic component of the training                Register of Doctors; UoO student enrolment
programme is provided largely by the              records (eVision); and the RNZCGP’s
University of Otago’s (UoO’s) distance-taught     database. Data were sought on all indi-
Postgraduate Rural Programme (PGRP).16            viduals entering the RHMTP from December
The RHMTP’s flexibility is important, not         2008 to December 2017. Records were
only for integration with other training          reviewed through to 1 August 2019. The
programmes, but to facilitate logistics for       RNZCGP data was collected manually at the
trainees moving between rural and urban           RNZCGP’s Wellington offices. The MCNZ and
attachments and across regions and to             UoO databases were accessed electronically.
accommodate academic components.12 Dual           Survey
training with other specialties, particularly       All trainees who had graduated or with-
GP, is encouraged; however, there is no           drawn from the RHMTP (before 1 August
formal GP–RHM training pathway.12                 2019) were invited by email to participate
  The requirements of the RHMTP, which            in an electronic survey. The survey was
cross primary–secondary, hospital–                generated using Qualtrics (Prova, Utah, US).
community and urban–rural settings, are           All potential participants were then sepa-
outlined in Table 1 and detailed elsewhere.8      rately emailed a unique link that gave them
  The Rural Hospital Medicine Training            immediate access to the survey and the
Programme is subsidised by Health Work-           participant information and consent forms.
force New Zealand (HWNZ) through the              The survey was open for 10 weeks.
hospital specialties route via district health      The survey included questions about
boards (DHBs), not the alternative HWNZ           participants’ current employment and

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locality as well as questions (free text) about              Pukawakawa: Northland Regional-Rural
the best aspects and greatest challenges of                  program, University of Auckland (UoA);
the training programme, self-funding the                     Rural Health Interprofessional Education
training and, where relevant, reasons for                    Programme, UoA). No definitions of ‘urban’
withdrawal from the programme. Partic-                       or ‘rural’, nor of ‘rural undergraduate
ipants were also asked to indicate (Yes/                     training’, were provided.
No) any rural undergraduate experience
by year of training (during the 4th, 5th or 6th
                                                               Database and survey data were separately
undergraduate year) and whether this was a
                                                             collated and entered into respective Excel
‘rural rotational run’ (not further specified)
                                                             (Microsoft Corporation, Redmond, WA,
or one of the rural-specific undergraduate
                                                             US) spreadsheets. To maintain participant
programmes (eg, Rural Medical Immersion
                                                             anonymity, all respondents were desig-
Programme (RMIP), UoO; Tairāwhiti Inter-
                                                             nated a number (1–XX) and were referred to
professional Education programme, UoO;
                                                             throughout by this coding.

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

                                   GENA 724: Context of Rural Hospital Medicine†

                                   GENA 725: Communication in Rural Hospital Medicine

                                   GENA 726: Obstetrics and Paediatrics in Rural Hospitals

                                   GENA 727: Surgical Specialties in Rural Hospitals, or
                                   POPLPRAC 740: Urgent Primary Surgical Care; Auckland University
 Academic components
                                   GENA 728: Cardiorespiratory Medicine in Rural Hospitals

                                   GENA 729: Medical Specialties in Rural Hospitals

                                   GENA723: Trauma and Emergencies in Rural Settings, or
                                   The Emergency Medicine Certificate from the College of
                                   Emergency Medicine

                                   Rural hospital medicine: (Two different locations, total 12 months FTE; At
                                   least one of the rural hospital runs must be in a Level 3 rural hospital.)

                                   Rural General Practice: (6 months FTE)

                                   General Medicine: (6 months FTE)
 Clinical attachments
                                   Emergency Medicine: (6 months FTE)

                                   Paediatrics: (3 months FTE)

                                   Anaesthetics or Intensive Care: (3 months FTE)

                                   Elective: (12 months FTE)‡

                                   Advanced Cardiac Life Support (ACLS)

                                   Advanced Paediatric Life Support (APLS), or
 Compulsory courses
                                   Paediatric advanced life support (PALS)

                                   Emergency Management of Severe Trauma (EMST)

  * 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).

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  Simple descriptive statistics were used         uates spent in the programme was five years
to summarise gender, age, ethnicity, New          and seven months. Twenty trainees subse-
Zealand citizenship status, the institution       quently withdrew: five in 2015 and between
awarding the undergraduate degree, current        one and six trainees per year from 2016 to
practicing status and other postgraduate          2019. For these trainees, the median time
qualifications.                                   spent in the programme was two years and
  The location of compulsory training rota-       nine months.
tions and the primary place of graduates’         Undergraduate training
current employment were tabulated then              Overall, 69/98 (70%) trainees had gained
mapped using R.19 The 2018 New Zealand            their undergraduate medical degree in
Index of Deprivation decile for the Statistical   New Zealand, and half (49/98, 50%) were
Area (Level 2) where New Zealand rural            awarded their degrees by the University of
hospitals were located was determined and         Otago.
overlaid in the map.
  Free-text responses were reported as            Participation in other vocational
quotes, then coded and collated according         training programmes and additional
to the survey categories. For data collected      qualifications
in the categories of ‘Best aspects’, ‘Chal-         Participation in other training
lenges’ and ‘Other comments’, common              programmes is described in Table 2. Most
themes were identified using an inductive         graduates (17/29, 59%), active trainees
thematic approach. (KB RLL). Team                 (39/49, 80%) and withdrawn trainees (17/20,
members (RM, GN) reviewed the analysis to         85%) are participating in or have completed
ensure theme consensus. NVivo qualitative         another vocational training programme;
data analysis software (QSR International         nearly two-thirds of them participated in
Pty Ltd, Version 12, 2018) was used to            or completed general practice vocational
manage the analysis.                              training (62/98, 63.3%).
  Ethics approval for this study was                The majority of graduates had completed
obtained from the University of Otago             more than one postgraduate diploma or
Human Ethics Committee, Reference                 certificate (25/29, 86%). All 29 RHMTP
D19/194.                                          graduates had completed a Postgraduate
                                                  Diploma in Rural and Provincial Hospital
                Results                           Practice (PGDipRPHP), UoO, and more than
                                                  half (17/29, 59%) had completed a Post-
Database findings                                 graduate Certificate in Clinician-Performed
Demographics                                      Ultrasound (PGCertCPU), UoO.
  The records for 98 trainees who had
                                                  Geographical location of compulsory
entered the RHMTP were available for
analysis in the RNZCGP database. Those
                                                  hospital training rotations
graduating with a Fellowship in Rural
                                                  undertaken by RHMTP graduates
                                                    As trainees, programme graduates had
Hospital Medicine (FDRHMNZ) made up
                                                  undertaken a total of 123 compulsory
under a third (29/98, 29.5%), half (49/98,
                                                  hospital rotations (71 in urban and 52 in
50%) were active trainees and a fifth (20/98,
                                                  rural hospitals) in New Zealand. (NB: One
20.4%) had withdrawn.
                                                  rural hospital rotation had been undertaken
  Detailed demographic information is             at Rarotonga Hospital, Cook Islands.) The
summarised in Table 2.                            majority of urban (48/71, 66.7%) and rural
Entry, completion or withdrawal                   (38/52, 71.7%) rotations were undertaken
   Intake into the RHMTP was between 6            in the South Island. The distribution and
and 10 trainees per year over the first four      numbers of both rural and urban hospital
years, after which annual cohorts increased.      rotations are shown in Figure 1.
The highest intake during the study period        Survey results
was 26 admissions in the tenth year. The            The survey response rate was 80% (39/49).
first two trainees graduated in 2012. From        Nearly all graduates (28/29, 97%), and over
2013, between four and six fellowships were       half 55% (11/20) of withdrawn trainees,
awarded each year. The median time grad-          responded.

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Quantitative findings                                            four not currently practising in a rural
                                                                 location, half (2/4, 50%) indicated that
Rural undergraduate training
                                                                 they would work in rural practice in the
  Rural undergraduate experience is
described in Table 3. More than half (25/39,
64%) of survey respondents indicated that                          Most RHMTP graduates (22/28, 78.6%)
they undertook a rural placement during                          currently work in a rural New Zealand
their undergraduate training.                                    hospital. Nearly half, in addition to RHM,
                                                                 work in another area of practice (13/28,
Current employment of RHMTP graduates                            46.4%): either general practice or emer-
  The majority (26/28, 92.9%) of graduates                       gency medicine. Two-thirds (14/22, 63.6%)
are actively practising medicine, mostly                         of graduates currently practising in rural
(24/28, 85.7%) in rural locations. Of the                        hospital medicine work in the South Island,

Table 2: Summary of graduates, withdrawals and active trainees of the Rural Hospital Medicine Train-
ing Programme between 2008 and 2017.

                                Total                  Graduates            Withdrawn        Active

 Total number                   98                     29 (30%)             20 (20%)         49 (50%)

                                                                 Median (range), years

 Age at entry                   30 (25-48)             29 (25-39)           29 (26-42)       30 (25-47)



 Female                         58 (59%)               15 (52%)             12 (60%)         31 (63%)

 Male                           40 (41%)               14 (48%)             8 (40%)          18 (37%)


 NZ European/Pakehā             61 (62%)               18 (62%)             12 (60%)         31 (63%)

 NZ Māori                       6 (6%)                 2 (7%)               1 (5%)           3 (6%)

 Pacific                        2 (2%)                 1 (3%)               1 (5%)           0 (0%)

 British/Irish                  17 (17%)               7 (24%)              4 (20%)          6 (12%)

 Other                          24 (24%)               7 (24%)              3 (15%)          14 (29%)


 NZ citizen                     69 (70%)               18 (62%)             14 (70%)         37 (76%)

 NZ permanent resident          26 (27%)               10 (34%)             5 (25%)          11 (22%)

 Unknown †                      4 (4%)                 1 (3%)               1 (8%)           2 (4%)

 University of undergraduate degree

 Otago                          49 (50%)               16 (55%)             11 (55%)         22 (45%)

 Auckland                       20 (20%)               3 (10%)              3 (15%)          14 (28.5%)

 Other                          29 (30%)               10 (35%)             6 (30%)          13 (26.5%)

 Participation in or graduation from other vocational training programmes

 General practice               62 (63.3%)             17 (59%)             13 (65%)         32 (65%)

 Other                          16 (16.3%)             0 (0%)               4 (20%)          7 (14%)

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

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predominately within the Southern DHB               broad and varied clinical exposure and
(10/22, 45.5%). The distribution of graduates       a relevant and complementary academic
employed in rural hospitals is shown in             programme. The collegiality and networks
Figure 2.                                           built during the training programme, partic-
                                                    ularly the academic programme residentials,
Additional professional roles of graduates
                                                    were highly valued:
  A quarter (7/28, 25%) of graduates also
held leadership positions: three (10.7%)                “A comprehensive fit for purpose
were DRHMNZ Council representatives,                    generalist training programme
three (10.7%) were in clinical director roles           for Rural Hospital Medicine. The
and one (3.6%) held a senior academic                   breadth of training (both clinical
position. Five (17.9%) other graduate                   and academic) was excellent. Colle-
respondents held other academic positions,              giality in meeting, training with and
and four (14.3%) held both leadership and               working alongside others passionate
academic positions.                                     about (and keen to work) rurally.”
Qualitative findings                                    “The academic programme comple-
Trainee RHMTP experiences                               mented the clinical training
  The key qualitative findings are                      programme, especially bringing out
summarised in five main themes. Illustrative            the importance of the rural context
participant quotes are presented.                       through all of the papers. It was
                                                        important to have rural doctors who
A fit-for-purpose training programme
                                                        understand the complexities of the
  The RHMTP was perceived by most
                                                        rural environments facilitating the
respondents (both graduates and those who
                                                        papers.” R11
withdrew) to be rural-practice specific with

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

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Navigation                                                      placements, when [there were] lots
  While navigating the programme, most                          of costs involved.” R15
respondents experienced challenges,                             “Financial pressures regarding fees
which mainly revolved around securing                           that are not covered when you are
programme components and the accompa-                           outside the hospital-based runs, as
nying funding in a timely way. Respondents                      you need to find your own attach-
reported ‘falling through funding gaps’                         ments.” R36
when moving across the country and
between DHBs, or while completing
                                                              Respondents saw programme flexibility
programme-accredited clinical rotations in
                                                            as integral to a fit-for-rural-purpose training
health services to ‘where HWNZ funding
                                                            programme, as flexibility allowed exposure
does not flow’:
                                                            across the whole healthcare system and
      “It was a bit confusing under-
                                                            provided opportunities to experience
      standing and navigating the
                                                            diverse contexts:
      programme… understanding and
                                                                “Best aspects included the flexibility
      then… accessing funding for runs
                                                                of the training programme to allow
      and academic components. Espe-
                                                                opportunities to experience rural
      cially in the smaller rural hospitals
                                                                medicine in many areas of NZ. Devel-
      with limited funding. This was a
                                                                oping generalist skills and a broad
      real issue when choosing my final

Table 3: Findings from surveying graduates/withdrawals of the Rural Hospital Medicine Training Pro-
gramme, 2008 to 2017.

                                                 Total                    Graduates       Withdrawn

 Survey respondents                              39                       28 (71.8%)      11 (28.2%)

 Currently practising                                                           n(%)

 Yes                                             36 (92.3%)               26 (92.9%)      10 (90.9%)

 No                                              3 (7.7%)                 2 (7.1%)        1 (9.1%)

 Practising in a rural location                  28 (71.8%)               24 (85.7%)      6 (54.5%)

 Practising scope                                                                n*

 Rural hospital                                  24                       22              2

 General practice                                17                       13              4

 Emergency medicine                              7                        5               2

 Urgent care                                     2                        1               1

 Other                                           7                        5               2

 Undergraduate rural placement                                                 n† (%)

 Rural rotational run                            25 (64%)                 16 (57%)        9 (82%)

 Rural Medical Immersion Programme‡              11 (28%)                 6 (21.4%)       5 (45.4%)

 Pukawawa RRP§                                   0                        0               0

 Tairawhiti IPE¶                                 1 (2.6%)                 0               1 (9.1%)#

  * 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.

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    scope of practice - a jack-of-all-trades                    a valid training pathway. I felt like I
    doctor in a secondary care envi-                            spent considerable time and energy
    ronment - and developing a ‘thinking                        educating others (including GPs)
    outside the box’ attitude to chal-                          about the programme and advocating
    lenging situations.” R11                                    for myself to get the training expe-
  At the same time, flexibility was perceived                   rience at I required.” R26
by many to be a major contributor to navi-                   Respondents described a growing
gation difficulties:                                       awareness of the wide variations, as well
    “[The] RHM Training programme has                      as fragility, of rural hospital services and
    lots of potential. For those who want                  systems. For graduates, the transition to
    it, a more structured training pathway                 employment in senior rural hospitals posi-
    with placement certainty would be an                   tions could be daunting:
    incentive. As would funding following                       “...the local rural context and rural
    the trainee e.g. meeting [payment] for                      practices may not complement the
    exit exams or rural academic papers                         expectations of a RHM trainee.
    while doing GP placements etc.” R39                         Rural hospitals in NZ remain fragile
                                                                systems. Many new vocationally
A new specialty
                                                                trained rural hospital doctors are
  While there was a sense of excitement in
                                                                asked to take on not only new senior
forging a new vocational pathway, it came
                                                                doctor positions… but also senior
with challenges:
                                                                leadership positions.” R22
    “…many other doctors/ depart-
    ments did not understand what                          Family
    RHM was, or even recognised it as                         Many respondents struggled to find

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.)

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a balance between the programme’s                training pathway.
requirement and family needs. For some,            Findings concur with previous research
moving around with family for clinical rota-     that confirms overseas trained doctors
tions was the biggest challenge, while others    (OTDs) constitute a high proportion of
saw this as a programme highlight.               doctors working rurally.15,22
Self-funding                                       Both the withdrawal rate and the uneven
  Half of the respondents (20/39, 51.3%)         geographic spread of trainee rotations are
reported they had self-funded components         noteworthy.
of their RHMTP, including academic paper           It is reassuring that a high proportion
fees and costs associated with assessments       of trainees who withdrew began with the
(eg, final fellowship visit costs).              intention of doing GP and RHM training
                                                 and, after withdrawal from the RHMTP,
Reasons for withdrawal
                                                 are continuing with training in GP, and
  Reasons for withdrawal from the RHMTP
                                                 many are working in rural GP. Withdrawal
(11 respondents) fell into three categories:
                                                 numbers will need further exploration as
family/life related; programme related;
                                                 the programme grows, including the extent
and career related. Programme-related
                                                 to which GP–RHM trainees are eventually
comments almost all related to navigation
                                                 opting to continue with just one training

            Discussion                             In addition to personal and family factors
                                                 (known to be strong career drivers),25
   This mixed methods study presents the
                                                 findings point to programme-related factors
first decade outcomes of New Zealand’s Rural
                                                 (eg, access to funding, organisational
Hospital Medicine Training Programme.
                                                 placement aspects and institutional bureau-
Through the provision of a targeted rural
                                                 cratic complexities) that are influencing
career pathway, the RHMTP is growing a
                                                 trainees’ decisions and impacting progress
cohort of highly qualified doctors, of which
                                                 through the RHMTP for some trainees.
the majority (92% of graduates currently
                                                 The lack of a consistent mechanism within
practicing)18 are working in rural New
                                                 the current funding model to ensure that
Zealand. Most have two specialist fellowships
                                                 funding follows trainees into a critical
and multiple postgraduate university quali-
                                                 proportion of their training (that under-
fications, and many are taking up leadership
                                                 taken in rural settings) seems particularly
positions early in their careers. The findings
concur with the literature: dedicated rural
                                                   Although this study did not examine the
training pathways contribute to the rural
                                                 reasons for geographic variations for trainee
medical workforce.1,3,20,21
                                                 rotations, the specific local–rural context is
  This study provides the first evidence on
                                                 probably an important contributing factor.
actual postgraduate practice locality for
                                                 Findings suggest that there are localities
rural career choice in New Zealand. These
                                                 across New Zealand where RHMTP rota-
outcomes compare favourably with interna-
                                                 tions with associated funding and supports
tional postgraduate rural programmes.22,23
                                                 have been streamlined. Naturally, trainees
  The number of doctors identifying as           gravitate towards set-ups that work and are
Māori (6%) is similar to other comparable        high quality. The gains for a rural hospital
programmes,24 has remained small (7% in          of a steady stream of senior doctors-in-
graduate and 6% in active trainee cohorts)       training cannot be underestimated: not only
and needs attention.                             does this result in much needed service
  Many RHMTP graduates report no rural           provision, but it likely creates ripple effects
undergraduate experience. It is likely too       for wider local capacity building. This would
early to see the influence of rural–regional     in turn contribute to the wider goals of
undergraduate programmes on RHMTP                the RHMTP in strengthening rural hospital
entry. However, the number of Rural              services. It is important to note that many
Medical Immersion Programme (RMIP)               rural hospitals have not yet achieved the
students entering RHMTP training may be          stability in their workforce that is required
an early indication of the value of a rural      to enable the provision of a professional

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environment that both supports and attracts      tions of using a survey, which was conducted
RHMTP trainees.                                  with the expectation of complete databases, is
  Dual GP–RHM training is likely high value,     acknowledged. This survey method provided
given the need for a New Zealand rural           limited information on the influence of
medical workforce across the primary–            undergraduate rural programmes.
secondary care spectrum, and it is clearly       Policy implications and
popular among trainees. With both training       recommendations
programmes situated within the RNZCGP,              It is well documented that rural-targeted
opportunities for reducing bureaucratic          vocational pathways require innovation and
complexities associated with GP–RHM dual         flexibility in order to be responsive to the
training should be within reach, as previ-       clinical and structural requirements of rural
ously noted.26                                   practice.1–3,25 Study findings provide insights
  Country-specific solutions have been           regarding what is working well and highlight
found for postgraduate rural training.           issues requiring attention.
Recent Australian research has highlighted         Recommendations based on the findings
the importance of national rural faculties       include:
as a strategy to build and sustain a rural
                                                   •   The RHMTP funding mechanism is
medical workforce.22
                                                       reviewed to ensure alignment with
  The overarching aim of rural-targeted                the programme’s structure. A solution
training pathways, in providing a robust               is needed that reaches across the two
pathway to a rural-based employment, is                health system tiers, multiple organi-
the provision of health services to rural              sations and geographical boundaries
areas.1,20,25 The RNZCGP-DRHMNZ has a                  and balances regional versus national
responsibility not only to its trainees, but,          interests.
particularly in light of New Zealand’s wider
                                                   •   The DRHMNZ’s governance structure
policy context,11,27 to reduce chronic health-
                                                       within the RNZCGP is reviewed to
access inequities for all rural and remote
                                                       ensure it facilitates optimal support
communities. Although important gains
                                                       for trainees and training sites and
have been made with many rural hospital
                                                       provides strong advocacy for all rural
vacancies across New Zealand being filled by
RHMTP graduates, findings also indicate that
many rural hospitals, including some serving       •   General practice–rural hospital
communities with the greatest health-access            medicine training is recognised
inequities (particularly Māori communities),           formally as a dual pathway, opti-
are not yet benefiting from the RHMTP.                 mising operational efficiencies and
                                                       aligning funding mechanisms.
  Study findings highlight the knowledge
gap (previously identified)28 regarding rural      •   The RNZCGP and DRHMNZ continue
hospitals in New Zealand. International                to increase the diversity of grad-
studies have shown rural hospitals to be               uates entering the RHMTP and, in
important providers of healthcare that can             particular, consider ways to support
benefit the health of rural populations,29 but         more Māori graduates through the
similar research has not been undertaken in            programme.
New Zealand.                                       •   Diversity in rural health service
Study strengths and limitations                        exposure for RHM trainees is widened.
  The study’s perspective is that of the         Other opportunities
RHMTP provider and its trainees and does           The RHMTP provides just part of the
not include the views of rural hospitals         solution to building rural workforce capacity.
or communities. The study used mixed             The critical role of other health professionals,
methods, and the findings corroborated           particularly nurses, both in rural hospital
across datasets. The study was limited by        and other rural health services roles, must be
the quality of the RNZCGP database, which        acknowledged. All rural health professionals
was incomplete (in particular, locality of the   should be supported to develop their own
RHMTP general practice rotation). Although       rural-specific training and continuing-edu-
the survey response rate was high, the limita-   cation pathways.

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                                                                              ISSN 1175-8716            © NZMA

  The RHMTP is contributing to building              Future research
rural health academic capacity with dual               Further and ongoing studies investi-
clinical–academic roles based in rural loca-         gating future RHMTP outcomes, including
tions. A national rural-centric academic             recruitment and retention factors for
structure would provide mechanisms that              RHMTP graduates and the influence of
help early career academics thrive in active         a coordinated rural-origin, rural-under-
rural–clinical practice across all health-pro-       graduate and rural-postgraduate pathway
fessional disciplines.                               for rural career choice in the New Zealand
  In aiming to improve health-access                 context, are required.
inequalities for all New Zealanders, consid-           Wider research is needed into the
eration should be given to how the RHMTP             current status and role of New Zealand’s
could add value to the emerging general              rural hospitals and the extent to which all
practice training programmes of two of New           rural health services improve access to
Zealand’s realm countries, the Cook Islands          healthcare, improve health outcomes and
and Niue. These programmes already share             improve health equity for New Zealand’s
academic components.16                               rural communities.

                                       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
      RHMTP's academic component. Joel Pirini is a current trainee of the RHMTP.
                                        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.
                                       Corresponding author:
      Katharina Blattner, PO Box 82, Omapere, Hokianga, New Zealand, 0064 21 457736

1.   World Health Organiza-             from: http://www.who.        4.   Wearne SM, Wakerman J.
     tion (WHO). Increasing             int/hrh/news/2018/                Training our future rural
     access to health workers           delhi_declaration/en/.            medical workforce. The
     in remote and rural          3.    Sen Gupta T, McKenzie A.          Medical Journal of Austra-
     areas through improved             Postgraduate pathways             lia. 2004;180(3):101-2.
     retention: global policy           to rural medical practice.   5.   Fearnley D, Lawrenson R,
     recommendations.                   2014. In: Rural Medical           Nixon G. ‘Poorly defined’:
     Geneva: WHO; 2010.                 Education Guidebook               unknown unknowns
2.   World Organization                 [Internet]. Bangkok,              in New Zealand Rural
     of Family Doctors                  Thailand: WONCA Avail-            Health. N Z Med J.
     (WONCA). The Delhi                 able from: https://www.           2016;129(1439):77.
     Declaration: Alma Ata           6.   Ministry of Health NZ.
     revisited Delhi2018 [cited         ingParties/RuralPractice/         Mātātuhi Tuawhenua:
     2018 June 12 ]. Available          ruralguidebook.aspx.              Health of Rural Māori,

                                                                                  NZMJ 5 February 2021, Vol 134 No 1529
                                                                                  ISSN 1175-8716            © NZMA

     2012. Wellington, N.Z.:       16. Blattner K, Nixon G,               journal of Environmental
     Ministry of Health.; 2012.        Gutenstein M, Davey E. A           Research and Public
7.   Williamson M, Gormley             targeted rural postgraduate        Health. 2020;17(13):4652.
     A, Dovey S, Farry P. Rural        education programme–           23. MacQueen IT, Maggard-Gib-
     hospitals in New Zealand:         linking rural doctors across       bons M, Capra G et al.
     results from a survey. N          New Zealand and into the           Recruiting Rural Health-
     Z Med J 2010;123(1315).           Pacific. Educ Prim Care.           care Providers Today: a
                                       2017;Vol.28(6):346-50.             Systematic Review of Train-
8.   Royal New Zealand College
     of General Practitioners      17. Ministry of Health New             ing Program Success and
     (RNZCGP). Division of Rural       Zealand. Health workforce          Determinants of Geograph-
     Hospital Medicine Training        Investment and purchasing          ic Choices. Journal of
     Programme Handbook.               2020 [cited 2020 7 May ].          General Internal Medicine:
     Wellington: RNZCGP; 2020          Available from: https://           JGIM. 2017;33(2):191-9.
                                         24. Australasian College for
9.   Nixon G, Blattner K. Rural
                                       our-work/health-workforce/         Emergency Medicine. 2017
     hospital medicine in New
                                       investment-and-purchasing.         FACEM and Trainee Demo-
     Zealand: vocational regis-
     tration and the recognition   18. Blattner K, Lawrence-              graphic and Workforce
     of a new scope of practice.       Lodge R, Miller R, Nixon           Report. Melbourne, Austra-
     N Z Med J. 2007;120(1259).        G, McHugh P, Pirini J. New         lia Australasian College
                                       Zealand’s Rural Hospital           for Emergency Medicine
10. Medical Council New
                                       Medicine training program          Department of Policy,
    Zealand. Vocational scopes
                                       at 10 years: Locality              Research & Advocacy; 2018.
    of practice. Wellington
                                       and career choice of the       25. Eley DS, Synnott R, Baker
    MCNZ; 2015 [cited 2016
                                       first graduate cohort.             PG, Chater AB. A decade
    May 8]. Available from:
                                       Aust J Rural Health.               of Australian Rural
                                       2020;00:1–3. https://doi.          Clinical School graduates
                                       org/10.1111/ajr.12678              - where are they and
                                   19. R Core Team. R: A language         why? Rural and Remote
11. Health and Disability
                                       and environment for statis-        Health. 2012;12(1).
    System Review. Health
                                       tical computing Vienna,        26. Blattner K, Stokes T, Nixon
    and Disability System
                                       Austria: R Foundation              G. A scope of practice
    Review – Final Report –
                                       for Statistical Computing,         that works ‘out here’:
    Pūrongo Whakamutunga.
                                       ; 2020 [Available from:            Exploring the effects
    Wellington: HDSR.; 2020.
                                     of a changing medical
12. Nixon G, Blattner K,
                                   20. Strasser R, Neusy AJ.              regulatory environment
    Williamson M, et al.
                                       Context counts: training           on a rural New Zealand
    Training generalist
                                       health workers in and for          health service. Rural and
    doctors for rural practice
                                       rural and remote areas.            Remote Health. 2019;19(4).
    in New Zealand. Rural
                                       Bull World Health Organ.       27. Came H, O’Sullivan D,
    Remote Health. 2017;17.
                                       2010;88(10):777-82.                Kidd J, McCreanor T. The
13. Lawrenson R, Nixon G,
                                   21. Schmitz D, Doty B. Training        Waitangi Tribunal’s WAI
    Steed R. The rural hospital
                                       in family medicine for             2575 Report: Implications
    doctors workforce in New
                                       rural practice in the USA.         for Decolonizing Health
    Zealand. Rural Remote
                                       2014. 2014. In: WONCA              Systems. Health and Human
    Health. 2011;11(2):1588.
                                       Rural Medical Education            Rights. 2020;22(1):209.
14. Lawrenson R, Reid J,               Guidebook [Internet]           28. Health and Disability
    Nixon G, Laurenson                 [Internet]. Bangkok:               System Review. 2019.
    A. The New Zealand                 WONCA. Available from:             Health and Disability
    Rural Hospital Doctors             https://www.globalfam-             System Review - Interim
    Workforce Survey 2015.                 Report. Hauora Manaaki
    N Z Med J. 2016;129:7.             WorkingParties/RuralPrac-          ki Aotearoa Whānui –
15. Wong DL, Nixon G. The              tice/ruralguidebook.aspx.          Pūrongo mō Tēnei Wā.
    rural medical generalist       22. McGrail M, O’Sullivan              Wellington: HDSR.
    workforce: The Royal               B. Faculties to Support        29. Vaughan L, Edwards N.
    New Zealand College of             General Practitioners              The problems of smaller,
    General Practitioners’             Working Rurally at                 rural and remote hospitals:
    2014 workforce survey              Broader Scope: A National          Separating facts from
    results. J Prim Health Care.       Cross-Sectional Study of           fiction. Future Healthcare
    2016;Vol.8(3):196-203.             Their Value. International         Journal. 2020;7(1):38.

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                                                                                  ISSN 1175-8716            © NZMA
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