Rural Doctors Research Articles

The accuracy of the Alvarado score in predicting acute appendicitis in the black South African population needs to be validated.

The Alvarado score is the most widely used clinical prediction tool to facilitate decision-making in patients with acute appendicitis, but it has not been validated in the black South African population, which has much wider differential diagnosis than developed world populations. We investigated the applicability of this score to our local population and sought to introduce a checklist for rural doctors to facilitate early referral. We analyzed patients with proven appendicitis for the period January 2008 to December 2012. Alvarado scores were retrospectively assigned based on patients' admission charts. We generated a clinical probability score (1-4 = low, 5-6 = intermediate, 7-10 = high). We studied 1000 patients (54% male, median age 21 yr). Forty percent had inflamed, nonperforated appendices and 60% had perforated appendices. Alvarado scores were 1-4 in 20.9%, 5-6 in 35.7% and 7-10 in 43.4%, indicating low, intermediate and high clincial probability, respectively. In our subgroup analysis of 510 patients without generalized peritonitis, Alvarado scores were 1-4 in 5.5%, 5-6 in 18.1% and 7-10 in 76.4%, indicating low, intermediate and high clinical probability, respectively. The widespread use of the Alvarado score has its merits, but its applicability in the black South African population is unclear, with a significant proportion of patients with the disease being potentially missed. Further prospective validation of the Alvarado score and possible modification is needed to increase its relevance in our setting.

Childhood disintegrative disorder misdiagnosed as childhood-onset schizophrenia

Childhood disintegrative disorder (CDD) is a rare pervasive developmental disorder, which is often misdiagnosed as schizophrenia, probably due to the resultant severe social impairment and withdrawn behaviour with stereotypys that could be mistaken for psychosis. We report a case of CDD that was misdiagnosed by a psychiatrist as childhood-onset schizophrenia and treated with high doses of antipsychotics. The patient did not show any improvement. This highlights ethical issues that arise from treatment modalities, with polypharmacy being the biggest culprit, and also points to the need to continue medical education at the level of primary health services and among practising rural doctors where tertiary centres with child guidance facilities and a multidisciplinary team are not available.

Are recent graduates enough prepared to perform obstetric skills in their rural and compulsory year? A study from Ecuador

ObjectivesThe aim of this study was to assess the possible mismatch of obstetrical skills between the training offered in Ecuadorian medical schools and the tasks required for compulsory rural service.SettingPrimary...

Prevalence of Willis–Ekbom disease in rural coastal Ecuador. A two-phase, door-to-door, population-based survey

ObjectiveTo estimate the prevalence of Willis–Ekbom disease (WED) in a racially homogeneous population of adults Amerindians living in rural coastal Ecuador, and to assess the reliability of the International Restless Legs Syndrome Study Group (IRLSSG) questionnaire when used in population-based studies. MethodsTwo-phase, door-to-door, population-based survey. During Phase I, rural doctors screened all Atahualpa residents aged ≥40years with the IRLSSG questionnaire. In Phase II, neurologists evaluated suspected WED cases and a matched sample of negative individuals. ResultsThe census identified 665 persons aged ≥40years. An affirmative response to the questionnaire was obtained in 94 persons. Medical history and neurological examination confirmed the diagnosis of WED in 40 of them. The evaluation of 188 non-suspected individuals revealed no further cases. The questionnaire had a sensitivity of 100% (95% CI, 89% to 100%), a specificity of 78% (95% CI, 72% to 83%), a positive predictive value of 0.43 (95% CI, 0.33 to 0.53), and a negative predictive value of 1 (95% CI, 0.98 to 1). The prevalence of WED in Atahualpa residents aged ≥40years was 6%. ConclusionThe prevalence of WED in this adult Ecuadorian population is higher than that reported from most studies conducted in tropical countries, but similar to that found in Brazil. Specificity and positive predictive value of the IRLSSG questionnaire are poor, which reinforces the need for a second phase that should include an expert interview.

Analysis of influencing factors of rural doctors' enthusiasm with the essential medicine system in place

Objective To study the working enthusiasm of rural doctors with the essential medicine system in place and identify the influencing factors.Methods 18 counties were picked from five cities and districts in the province for the study.621 rural doctors from 134 village clinics were randomly sampled for questionnaire survey and interview.Results The rural doctors were found with a low morale,as only 50.7％of them were found willing to receive patients.Major influencing factors for their working enthusiasm include facilities and equipments of the clinic,practitioner qualifications,professionalism,quality of the essential medicines,satisfaction of income,and increase of workload.A defective incentive mechanism was found for them in general.Conclusion Such measures as better hardware facilities at the village clinic,better professional training,improved essential medicine system,better subsidies policies can better mobilize their working enthusiasm. Key words: Essential medicine system; Rural doctor; Working enthusiasm; Influencing factors; Incentive mechanism

Evaluation of an Intervention to Improve Skills in Diagnostic Radiology of Rural Physicians over One Year in Four Rural Hospitals

BackgroundPrimary health care and patient triage are two basic functions of rural hospitals. As a routine test, the diagnostic radiology is still unavailable in some rural hospitals in China. Therefore, high-level hospitals are often the first choice of rural residents when they feel unwell. It brings serious social problems. This study was designed to propose an on-the-job drilling schema with integration of practical medical recordings and experienced radiological doctors as tutors to improve skills in diagnostic radiology of rural physicians.MethodsThe information technology was used to help the contact between rural doctors and tutors. In a longitudinal pre/post-test control study design, a cohort of 20 young physicians, each of whom was working in a rural hospital and had a work experience less than two years, were established as the trial group over one year. Another 20 similar counterparts were established as the control group. Participants' performances were evaluated in four categories at five-time point (TP).ResultsThe trial group significantly outscored the control group on the style of writing at the second TP (d = 2.28); on the accuracy of the image description at final TP (d = 1.11); on the accuracy of the diagnosis at the fourth TP (d = 3.62); and on the correct treatment selection at the third TP (d = 6.45). The aspects with the most improvement were the accuracies of the diagnosis and the treatment selection.ConclusionThis study provided the detailed evidences that applying the on-the-job drilling schema has a significant effect on the skills improvement in diagnostic radiology of rural physicians. It was also concluded that the educational intervention based on practical cases was better than that only based on didactic slides presentation.

Prevocational exposure to public health in the Kimberley: a pathway to rural, remote and public health practice.

To evaluate the Kimberley Population Health Unit (KPHU) prevocational public health placement in terms of its contribution to resident medical officers' (RMOs') knowledge, skills, career path and aspirations. All RMOs who had completed a public health placement at the KPHU (n=27) during 2001-2012 were invited to complete an online survey in September 2012. The KPHU, based in Broome, provides population health services to the Kimberley region, far north Western Australia. The extent to which RMOs perceived the development of public health skills and knowledge during the placement, and the degree to which RMOs believe this placement influenced future career pathways and their current practice. Twenty-three RMOs (85%) completed the survey. Sixty per cent are currently working in general practice or public health medicine; of these, 43% have returned to the Kimberley. Over 70% reported that the placement developed their knowledge of public health and Aboriginal health to a 'great' or 'very great' extent. Sixty-one per cent felt that their placement influenced their future desire to work in public health 'a lot' or 'a great extent'. This placement provides a unique opportunity for RMOs to undertake public health and Aboriginal health work in a remote setting. Given the increasing demand for prevocational placements, the value of imparting sound public health knowledge to the next generation of doctors and the urgent need to recruit and retain rural doctors, this placement provides a potential model that could be expanded to other locations.

Are rural placements positively associated with rural intentions in medical graduates?

Medical school curricula remain one of the key levers in increasing the future supply of rural doctors. Data from Australia and overseas have suggested exposure to rural practice via rural placements during basic medical training is positively associated with graduates becoming rural doctors. However, previous studies have suffered from serious methodological limitations. This study sought to determine whether rural clinical placements are associated with a higher proportion of graduating students planning rural careers and to explore associations with timing, duration and location of placements. Data were obtained from the Medical Schools Outcomes Database and Longitudinal Tracking Project, which is a longitudinal study with a high response rate that prospectively collects data, including practice location intention, from all Australian medical schools. Using logistic regression analysis, the association between placements and rural career intention was assessed, controlling for a number of demographic and contextual variables. The association between rural/remote placements later in the programme and rural practice intention was strongly positive whether viewed as simple occurrence or as duration, in contrast to later urban placements, which were strongly negative. A longer duration of placement enhanced the associations reported. Non-metropolitan medical schools were also associated with higher odds of intention to take up rural practice. However, the association with rural placements was overshadowed by the strong positive associations with rural background of students and their stated intention to become a rural doctor at the start of their studies. Exposure to rural practice during basic medical training, and the location and curriculum focus of a medical school are confirmed as factors that are positively associated with students' intention to become rural doctors after graduation. However, rural origin and the early intentions at the start of their medical training are better predictors of expressed intention to take up rural practice than rural clinical placements.

Effect of acetylcholinesterase (AChE) point-of-care testing in OP poisoning on knowledge, attitudes and practices of treating physicians in Sri Lanka

BackgroundToxicology and Emergency medicine textbooks recommend measurement of acetylcholinesterase (AChE) in all symptomatic cases of organophosphorus (OP) poisoning but laboratory facilities are limited in rural Asia. The accuracy of point-of-care (POC) acetylcholinesterase testing has been demonstrated but it remains to be shown whether results would be valued by clinicians. This study aims to assess the effect of seeing AChE POC test results on the knowledge, attitudes and practices of doctors who frequently manage OP poisoning.MethodsWe surveyed 23 clinicians, who had different levels of exposure to seeing AChE levels in OP poisoned patients, on a) knowledge of OP poisoning and biomarker interpretation, b) attitudes towards AChE in guiding poison management, oxime therapy and discharge decisions, and c) practices of ordering AChE in poisoning scenarios.ResultsAn overall high proportion of doctors valued the test (68-89%). However, we paradoxically found that doctors who were more experienced in seeing AChE results valued the test less. Lower proportions valued the test in guidance of acute poisoning management (50%, p = 0.015) and guidance of oxime therapy (25%, p = 0.008), and it was apparent it would not generally be used to facilitate early discharge. The highest proportion of respondents valued it on admission (p < 0.001). A lack of correlation of test results with the clinical picture, and a perception that the test was a waste of money when compared to clinical observation alone were also comments raised by some of the respondents.Greater experience with seeing AChE test results was associated with increased knowledge (p = 0.034). However, a disproportionate lack of knowledge on interpretation of biomarkers and the pharmacology of oxime therapy (12-50%) was noted, when compared with knowledge on the mechanism of OP poisoning and management (78-90%).ConclusionsOur findings suggest an AChE POC test may not be valued by rural doctors. The practical use of AChE in OP poisoning management is complex, and a poor understanding of how to interpret test results may have affected its perceived utility. Future research should evaluate the impact of providing both AChE and training in interpretation on clinicians’ attitudes and practice.

Managing the HIV-infected neonate: A rural doctor’s perspective

No Abstract Available

Recruitment of young rural doctors: are we adopting the qualitative and ethical approach?

Recruitment of young rural doctors: are we adopting the qualitative and ethical approach?

Telemedicine and Teleradiology in Saudi Arabia

Telemedicine offers the potential to alleviate the severe shortage of medical specialists in developing countries and promises to alleviate some of the difficulties rural doctors and hospitals have in accessing specialist advice in Saudi Arabia. Telemedicine programs between remote rural hospitals and central hospitals have been successfully implemented in Canada, USA, Australia and in Saudi Arabia. In all these countries telemedicine has allowed the specialist to come to the patient rather than the patient's having to travel vast distances to visit the specialist. There is an acute shortage of radiologists in rural regions of the country, particularly in southern region of Saudi Arabia, therefore applications include Teleradiology, Telepathology and teleconferencing between rural hospitals and central hospitals which is ideally suited to the development of a national telemedicine network. Nearly half a century ago, telemedicine was disregarded for being an unwieldy, unreliable and unaffordable technology. Rapidly evolving telecommunications and information technologies have provided a solid foundation for telemedicine as a feasible, dependable and useful technology. enhanced access to healthcare via telemedicine will be achieved only with the ubiquitous distribution of telemedicine systems networks. In fact, the need for increased access to healthcare, lower cost for healthcare and increased quality of such care is generally inversely related to populations or regions economic status. To achieve enhanced access in our educational fields, these systems must become more affordable and both the public and private sectors must assume their respective shares in this investment and also use full point in medical educational filed. This paper describes and clarify the role of Telemedicine and Teleradiology in education .Through identifying the relevant literature and provide suggestion that might be implemented and consider in the near future. Researchers expect that this study will enhance the level of understanding and meaning of telemedicine among stakeholders, new entrants researchers and students and eventually enabling a

A qualitative study on working experience of rural doctors in malappuram district of kerala, India.

Background:Improving the working conditions of rural doctors is an important issue to increase the quality of health services to target groups.Objectives:To assess the working experience of rural doctors at primary health care level.Materials and Methods:This qualitative study was conducted among 30 medical officers from 21 primary health centers in Malappuram district of Kerala, India. In-depth interview was conducted, and content analysis was performed with the identification of themes based on the responses obtained.Results:There were 19 males and 11 females belonged to 25 to 55 years age group. About 70% (21) of them were graduates with MBBS qualification, and the rest were postgraduates. About 2/3rd of them (20) had experience of less than 5 years. They expressed difficulty in managing the work in stipulated time period. However, this had never affected their OP management in anyway. They told that higher authorities were supportive, but they faced some opposition from the public in implementation of national program. Few opined that the training received was grossly insufficient in running the administrative affairs of the health center. Most of them satisfied with physical infrastructure, but manpower including medical officers and supporting staff were not sufficient. Some opined that the age of retirement is too early and should be increased. They participated in Continuing Medical Education, but expressed that it's content should suit to primary health care level.Conclusion:This study highlighted their concern to patient care and time, field work, administrative work, infrastructure, professional development, and future prospects. Further large scale evaluation studies will explore the situational analysis of it.

Further strategies to improve the working experience of rural doctors.

A number of concerns were identified– these included concerns with regard to time, administrative and management work, professional development, and future prospects. All these issues are clearly important; however, it would also have been interesting to hear of the rural GPs’ views on other topics such as the role of teams in rural and remote healthcare, the relationship between primary care and secondary care in rural and remote healthcare, and the professional status of rural GPs. These are just some of the plethora of factors that affect working experience in rural and remote healthcare.Thinking in this way is also helpful because it makes us realize that it will be impossible to address all these factors individually – there are too many of them and they are all interdependent. Only a programmatic approach will enable us to tackle the multiple areas that need to be improved in rural and remote primary care. Such a programmatic approach will involve the development of a package of resources to help GPs, their teams and their practices. One component of such as package that might have multiple effects would be to think about medical education in rural and remote healthcare as a continuum. Medical students should have attachments in rural primary care and postgraduate trainees in general practice similarly should have work placements in rural areas. This might give more medical learners a taste of rural primary care and might encourage some of them to take this option seriously as a career choice. It would also enable some rural GPs to develop their roles as teachers and to develop links with medical schools in the undergraduate arena and with medical training authorities in the postgraduate arena. This, in turn, might assist in the development of better partnership working. Education might also be interprofessional – thus enabling better relationships between medical and nursing schools, and in the long term enabling better interprofessional teamwork in the delivery of care.Strategies to improve the working lives of GPs in rural and remote areas should be joined up and if they are joined up then they are likely to have a range of positive effects on the practice, education and professional development opportunities for this group of doctors.Yours Sincerely,

Rural Clinician Scarcity and Job Preferences of Doctors and Nurses in India: A Discrete Choice Experiment

The scarcity of rural doctors has undermined the ability of health systems in low and middle-income countries like India to provide quality services to rural populations. This study examines job preferences of doctors and nurses to inform what works in terms of rural recruitment strategies. Job acceptance of different strategies was compared to identify policy options for increasing the availability of clinical providers in rural areas. In 2010 a Discrete Choice Experiment was conducted in India. The study sample included final year medical and nursing students, and in-service doctors and nurses serving at Primary Health Centers. Eight job attributes were identified and a D-efficient fractional factorial design was used to construct pairs of job choices. Respondent acceptance of job choices was analyzed using multi-level logistic regression. Location mattered; jobs in areas offering urban amenities had a high likelihood of being accepted. Higher salary had small effect on doctor, but large effect on nurse, acceptance of rural jobs. At five times current salary levels, 13% (31%) of medical students (doctors) were willing to accept rural jobs. At half this level, 61% (52%) of nursing students (nurses) accepted a rural job. The strategy of reserving seats for specialist training in exchange for rural service had a large effect on job acceptance among doctors, nurses and nursing students. For doctors and nurses, properly staffed and equipped health facilities, and housing had small effects on job acceptance. Rural upbringing was not associated with rural job acceptance. Incentivizing doctors for rural service is expensive. A broader strategy of substantial salary increases with improved living, working environment, and education incentives is necessary. For both doctors and nurses, the usual strategies of moderate salary increases, good facility infrastructure, and housing will not be effective. Non-physician clinicians like nurse-practitioners offer an affordable alternative for delivering rural health care.

Medical graduates becoming rural doctors: rural background versus extended rural placement

To determine whether recruitment of rural students and uptake of extended rural placements are associated with students' expressed intentions to undertake rural internships and students' acceptance of rural internships after finishing medical school, and to compare any associations. Longitudinal study of three successive cohorts (commencing 2005, 2006, 2007) of medical students in the Sydney Medical Program (SMP), University of Sydney, New South Wales, using responses to self-administered questionnaires upon entry to and exit from the Sydney Medical School and data recorded in rolls. Students' expressed intentions to undertake rural internships, and their acceptance of rural internships after finishing medical school. Data from 448 students were included. The proportion of students preferring a rural career dropped from 20.7% (79/382) to 12.5% (54/433) between entry into and exit from the SMP. A total of 98 students took extended rural placements. Ultimately, 8.1% (35/434) accepted a rural internship, although 14.5% (60/415) had indicated a first preference for a rural post. Students who had undertaken an extended rural placement were more than three times as likely as those with rural backgrounds to express a first preference for a rural internship (23.9% v 7.7%; χ(2) = 7.04; P = 0.008) and more than twice as likely to accept a rural internship (21.3% v 9.9%; χ(2) = 3.85; P = 0.05). For the three cohorts studied, rural clinical training through extended placements in rural clinical schools had a stronger association than rural background with a preference for, and acceptance of, rural internship.

Model Telediagnosis Serangan Jantung untuk Para Praktisi Kesehatan Menggunakan Mobile Phone

The lack of medical experts such as doctors at rural areas resulted in some problems such as the high cost of medical care and low service of doctors and medical resource provider. The conditions results in an idea to implement a communication system between rural medical practitioners and doctors in urban areas to perform remote diagnosis on patients (telediagnosis). The research involves several parties such as doctors, health centers, health practitioners (paramedics), patients, and hospitals and health institutions. The telediagnosis system development consists of the construction of a software application prototype as media input for patient data which will be sent to doctors at town, database systems design, integration of basic multimedia devices, medical diagnostic device integration, and application testing of telediagnosis performance using an android-based mobile application. Data integration patterns include patient data delivery patterns, checking a patient's diagnosis, saving and continuing to the physician or health care practitioner with real-timesystem. This study is conducted according to standard research stages: problem collection, problem analysis, research materials collection, research design, and research implementation. Telediagnosis system is used to facilitate remote diagnosis of patients at rural areas which is able to serve patients more quickly, and helps find out nearest location for patients to get medicines as well as recommendation of nearest hospital. This system helps decrease the workload of hospitals.

The value of survival analyses for evidence-based rural medical workforce planning

BackgroundGlobally, abundant opportunities exist for policymakers to improve the accessibility of rural and remote populations to primary health care through improving workforce retention. This paper aims to identify and quantify the most important factors associated with rural and remote Australian family physician turnover, and to demonstrate how evidence generated by survival analysis of health workforce data can inform rural workforce policy making.MethodsA secondary analysis of longitudinal data collected by the New South Wales (NSW) Rural Doctors Network for all family physicians working in rural or remote NSW between January 1st 2003 and December 31st 2012 was performed. The Prentice, Williams and Peterson statistical model for survival analysis was used to identify and quantify risk factors for rural NSW family physician turnover.ResultsMultivariate modelling revealed a higher (2.65-fold) risk of family physician turnover in small, remote locations compared to that in small closely settled locations. Family physicians who graduated from countries other than Australia, United Kingdom, United States of America, New Zealand, Ireland, and Canada also had a higher (1.45-fold) risk of turnover compared to Australian trained family physicians. This was after adjusting for the effects of conditional registration. Procedural skills and public hospital admitting rights were associated with a lower risk of turnover. These risks translate to a predicted median survival of 11 years for Australian-trained family physician non-proceduralists with hospital admitting rights working in small coastal closely settled locations compared to 3 years for family physicians in remote locations.ConclusionsThis study provides rigorous empirical evidence of the strong association between population size and geographical location and the retention of family physicians in rural and remote NSW. This has important policy ramifications since retention grants for rural and remote family physicians in Australia are currently based on a geographical ‘remoteness’ classification rather than population size. In addition, this study demonstrates how survival analysis assists health workforce planning, such as through generating evidence to assist in benchmarking ‘reasonable’ lengths of practice in different geographic settings that might guide service obligation requirements.

A multifaceted strategy using mobile technology to assist rural primary healthcare doctors and frontline health workers in cardiovascular disease risk management: protocol for the SMARTHealth India cluster randomised controlled trial

BackgroundBlood Pressure related disease affected 118 million people in India in the year 2000; this figure will double by 2025. Around one in four adults in rural India have hypertension, and of those, only a minority are accessing appropriate care. Health systems in India face substantial challenges to meet these gaps in care, and innovative solutions are needed.MethodsWe hypothesise that a multifaceted intervention involving capacity strengthening of primary healthcare doctors and non-physician healthcare workers through use of a mobile device-based clinical decision support system will result in improved blood pressure control for individuals at high risk of a cardiovascular disease event when compared with usual healthcare. This intervention will be implemented as a stepped wedge, cluster randomised controlled trial in 18 primary health centres and 54 villages in rural Andhra Pradesh involving adults aged ≥40 years at high cardiovascular disease event risk (approximately 15,000 people). Cardiovascular disease event risk will be calculated based on World Health Organisation/International Society of Hypertension’s region-specific risk charts. Cluster randomisation will occur at the level of the primary health centres. Outcome analyses will be conducted blinded to intervention allocation.Expected outcomesThe primary study outcome is the difference in the proportion of people meeting guideline-recommended blood pressure targets in the intervention period vs. the control period. Secondary outcomes include mean reduction in blood pressure levels; change in other cardiovascular disease risk factors, including body mass index, current smoking, reported healthy eating habits, and reported physical activity levels; self-reported use of blood pressure and other cardiovascular medicines; quality of life (using the EQ-5D); and cardiovascular disease events (using hospitalisation data). Trial outcomes will be accompanied by detailed process and economic evaluations.SignificanceThe findings are likely to inform policy on a scalable strategy to overcome entrenched inequities in access to effective healthcare for under-served populations in low and middle income country settings.Trial registrationClinical Trial Registry India CTRI/2013/06/003753.

Motivational interviewing improves exclusive breastfeeding in an Australian randomised controlled trial

To increase maintenance of breastfeeding through improved primary care support. A cluster randomised controlled trial recruited 15 rural family doctor's offices and 330 women who were currently breastfeeding took part. Eight practices formed the intervention group (154 women) and seven formed the control group (176 women). The practice nurses who provided the intervention used a specially designed motivational flowchart to speak to the mothers when they brought their child for immunisation at 2, 4 and 6months. The nurses also attended preparatory workshops on breastfeeding management, counselling skills, motivational interviewing and reflective practice and were given resources and support. Breastfeeding rates were measured at 4 and 6months. Randomisation equally distributed all measured variables except prenatal intentions to rejoin employment within 12months (70% intervention, 56% control, p<0.05). After adjustment, the 4-month figures showed significantly higher rates of exclusive breastfeeding (OR 1.88; 95%CI 1.01-3.50; p=0.047) and full breastfeeding (water/juice allowed) (OR 1.95; 95%CI 1.03-3.69; p=0.04) in the intervention group. There were no differences at 6months. A motivational interviewing intervention by primary care health professionals who have undertaken a replicable training programme is feasible and effective in increasing exclusive breastfeeding and full/predominant breastfeeding at 4months.