New Zealand's vocational Rural Hospital Medicine Training Programme: the first ten years
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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
ABSTRACT
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
experiences.
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
funding.
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.
T
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
Analysis
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
future.
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)
n(%)
Gender
Female 58 (59%) 15 (52%) 12 (60%) 31 (63%)
Male 40 (41%) 14 (48%) 8 (40%) 18 (37%)
Ethnicity*
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%)
Citizenship
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.”
R17
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
Flexibility
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
difficulties.
programme.
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
notable.
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
communities.
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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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
katharina.blattner@otago.ac.nz
URL:
www.nzma.org.nz/journal-articles/new-zealands-vocational-rural-hospital-medicine-train-
ing-programme-the-first-ten-years
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