rural

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare, rural , , , , ,

Clinical Snippets May 2026

https://open.spotify.com/episode/36kWoqOhzJqdOdVy1lvsp0?si=oFfT4qOmS_SJJoS1E_u1Cw

Clinical Snippets May 2026

1.  Youth issues

(i)  Choking: A recent NZ Doctor article noted that strangulation during sex (often euphemistically labelled “choking”) is on the rise, especially among young people. The widespread access to pornography and influence of social media depicting “vanilla” sex as somehow shameful or boring is influencing sexual practice. There are new “norms” and some people think strangulation during sex is to be expected.  There is reference to a recent study of Australians aged 18–35 found 57% had been strangled during sex (61% of women, 43% of men, 79% of trans or gender-diverse people). Participants most commonly reported becoming aware of “sexual choking” during ages 16–18. Pornography was the most common source by which those reported first hearing about it (35%). There was a general perception that strangulation during sex can be safe and expected behaviour, and the authors highlighted this is contrary to the numerous and potentially significant harms that can result from strangulation.  The issue of consent is discussed in some detail and it is noted the concept of “consent” is a moot point when being strangled – how can you have informed consent and continue to consent when the practice reduces oxygen to your brain and your cognitive capacity?  The study concluded that results indicate the need for developing strong sexual health education around consent, harms, and normative expectations around sexual strangulation.  When talking about safe sexual practices with youth the issue of sexual choking should probably be included together with pregnancy and STI prevention.  

(ii)  Sexual violence disparities: A recently published study on sexual violence and unwanted sexual experiences among adolescents in Aotearoa New Zealand using Youth 2000 data and reviewed in issue 120  Maori Health Review found significant disparities between various ethnic and minority groups.  Māori adolescents experience a greater burden of sexual violence than the general adolescent population. The overall prevalence of sexual violence among adolescents was 12.4% in 2019, an increase from 9.5% in 2012. Prevalence was higher in girls (19%), Māori (15.3%), and those in socioeconomically deprived schools (15.3%) and neighbourhoods (13.4%). However, even higher rates of sexual violence occurred in transgender adolescents (31.9%), those involved with statutory child protection (26.7%), those with long-term conditions (23.4%), and sexual minorities (22.1%). The reviewer comments include: This study showing the extent of sexual violence among rangatahi Māori is deeply concerning because (1) this type of violence destroys rangatahi flourishing and (2) it reflects the fact that we aren’t adequately protecting Māori young people. Addressing this requires prevention and support approaches that are Māori-led – grounded in kaupapa Māori values and tackling broader determinants.

(iii)  Looksmaxxing:  A Medscape article titled ‘The Extremely Risky Trend That Should Be on Family Doctors’ Radar’ discussed the looksmaxing social media trend aimed mainly at teen and young adult males with influencers promoting a narrow and idealized version of masculinity centred on the belief that real men must have specific physical traits like a square jawline, tall stature, muscular build, perfect hair, and clear skin.  The article notes a growing number of men are taking cosmetic procedures into their own hands, injecting themselves with neuromodulators, fillers, fat dissolving products, and peptides, and some even taking mallets to their faces to reshape their bone structure. Followers are encouraged to use techniques like mewing and bone-smashing (repeatedly hitting the face with a blunt object) to reshape their face. Mewing, where the tongue is repeatedly pressed to the roof of the mouth, was developed by US orthodontist John Mew and is a looksmaxxing practice aimed at achieving a more defined jawline. He encouraged up to 8 hours of mewing daily and lost his license in 2017 due to unproven claims. The American Association of Orthodontists (AAO) advised against the practice in 2024, warning it carries risks for loosened teeth, misaligned bite, and speech impediments, all of which may require “complicated treatment” to resolve. Looksmaxxing is felt likely to be a risk factor for the development of an eating disorder or muscle dysmorphia.  The article recommends physicians become familiar with Looksmaxxing, pay closer attention to self-esteem and self-image among young men and boys, and provide body positivity resources (Link to some NZ resources here) . Validating that people are treated differently based on their appearance — a form of bias known as “looksism” — can also be a starting point for discussions about looksmaxxing, and it is important to push back or provide counterfactuals against looksmaxxing’s “really limited notions of what it means to be a man” and “derogatory opinions” of both women and other men.

2. Insulin update

(i)  A reminder that there are ongoing changes to availability of some insulin preparations.   Eli Lilly is stopping supply of some insulin products in 2026. This only affects the 10 mL vial presentation of the following products (the penfill versions remain available) with supplies ending at end of June 2026 for most:

  • Humalog
  • Humulin NPH
  • Humulin 30/70
  • Humulin R

Novo Nordisk has added two products to the discontinuation list (supplies end at end of 2026):

  • Actrapid Penfill 3mL
  • Protaphane Penfill 3mL

Details on insulin discontinuation and supply dates is available on the Pharmac website.

(ii)  There is an excellent resource on use of Ryzodeg, including case studies, on the Goodfellow Unit site, with further information on use of pre-mixed and co-formulated insulins available on the NZSSD website (also a great algorithm for initiating and adjusting insulin in patients with type 2 diabetes).    

(iii)  Patient information on insulin is available on Healthify and Starship Hospital has a link to a Ryzodeg patient leaflet with a more formidable consumer information sheet available from Medsafe. 

3.  Assessment and management of Abnormal Uterine Bleeding

Health New Zealand | Te Whatu Ora have shared the new national Assessment and management of Abnormal Uterine Bleeding (AUB) guideline which has been endorsed by the RNZCGP. It provides clear evidence-based best practice on the management of AUB in non-pregnant women of reproductive age.  Regional Health Pathways are being aligned with the guidelines and will be kept updated so worth consulting these in the first instance although the guideline document contains more detail on various aspects of management.   Health Pathways has additional sections on post-coital bleeding and post-menopausal bleeding,    Health Pathways in conjunction with Te Whatu Ora have made available an accompanying hour long webinar titled Abnormal Uterine Bleeding (AUB): What general practice needs to know. 

4.  MHT and all-cause mortality

A Danish registry-based cohort study recently published in BMJ aimed to assess whether menopausal hormone therapy increases the risk of all-cause mortality.  Almost 900,000 women born between 1950 and 1977 were involved in the study with follow-up from age 45 years ending on 31 July 2023 (median follow-up time 14.3 years).   Exclusion criteria included history (at time of entry) of thrombophilia, liver disease, arterial thrombosis or venous thrombosis, breast cancer, endometrial cancer, ovarian cancer, previous use of menopausal hormone therapy, or previous bilateral oophorectomy. Just under 12% of women received a prescription for MHT during the study period.  The principal findings were summarised as:

  • There was no epidemiological evidence of excess mortality following menopausal hormone therapy use.
  • Women who had undergone bilateral oophorectomy between age 45 and 54 years, were associated with a significant survival benefit when using menopausal hormone therapy, corresponding to a 27-34% decrease in mortality hazard.
  • Stratified analyses found the lowest mortality among women predominantly using transdermal menopausal hormone therapy formulations, oestrogen monotherapy, cyclic progestogen regimens, and among women initiating menopausal hormone therapy aged 52 years or older, although these findings should be interpreted with caution and await scrutiny in future studies.
  • No unambiguous changes in cause-specific mortality were found between groups.

5.  That’s interesting

(i)  Dry eye and vitamin D:  In a study recently published in the American Journal of Ophthalmology researchers conducted a retrospective cohort study involving about 12 million adults to evaluate whether adults with a deficiency of vitamin D were at an increased risk of developing dry eye disease.  During a median follow-up period of around 3.5 years there was a new diagnosis of dry eye disease in 3.3% of adults with a deficiency of vitamin D compared with 2.7% of those without the deficiency corresponding to a 28.6% higher risk of developing dry eye disease in those with the vitamin deficiency.   The authors concluded that in patients with dry eye disease, “identifying and correcting low vitamin D levels may be a reasonable adjunct to standard…therapies, while recognizing that supplementation should be guided by general medical indications rather than used as a stand-alone treatment” for the condition. 

(ii)  Topical lignocaine for IUD placement:  A College of Family Physicians of Canada ‘Tools for Practice’ addressed the question: Does topical lidocaine decrease pain during tenaculum placement and intra-uterine device (IUD) insertion? The ‘botom line’ was that topical lidocaine-prilocaine 2.5% cream (EMLA – 2mL applied with cotton swab 5 minutes before procedure) reduces pain with tenaculum placement and copper/levonorgesterel IUD insertion by about 2-3 points more than placebo on a 10-point scale (minimum clinically important difference for pain is 1.3-2). Lidocaine 10% spray reduces the proportion of women experiencing moderate/severe pain to 6% versus 41% on placebo, but ~55% experience vaginal irritation.  Topical lidocaine 2% is likely ineffective. 

(iii)  Jess’s Rule:  Jess’s Rule is a NHS England initiative launched in September 2025 that mandates a “three strikes and rethink” approach for GPs. The rule is named after 27-year-old Jessica Brady, who died of cancer in 2020 after over 20 GP consultations over six months with no clear diagnosis.  The stated purpose of the initiative is to prevent avoidable deaths by ensuring persistent, unexplained symptoms are not dismissed, particularly in young or, minority ethnic patients who may face diagnostic delays. Patients are encouraged to mention “Jess’s Rule” if they have seen a doctor three times for the same issue without improvement. The core approach is the three Rs: Reflect, Review, Rethink.

  • Reflect: Think back on previous consultations, particularly if they were remote, and invite the patient for a face-to-face, physical exam.
  • Review: Discuss the case with peers and check for “red flags,” disregarding assumptions based on young age.
  • Rethink: If appropriate, refer onwards for further tests or for specialist input.

6.  Paediatric asthma

A recent Research Review educational series article on treating small airways dysfunction with extrafine inhaled corticosteroids in children with asthma included the following take home messages:

  • The small airways are a major source of airway limitation in many children with asthma, across all levels of disease severity
  • The use of extrafine ICS (inhaled corticosteroid – MMAD ≤2 μm) improves medicine deposition in the peripheral airways compared to larger-particle ICS, which may result in better lung function, reduced exacerbations and better asthma control in children with small airways involvement
  • Extrafine BDP (beclomethasone diropionate) (Qvar®) is the only fully funded extrafine ICS available as a single product inhaler in New Zealand and low dose therapy (100 mcg/day) is recommended by local and international guidelines for maintenance treatment in children with asthma from age 5 years
  • Extrafine BDP has a higher potency than budesonide and other formulations of BDP in New Zealand and is taken at half the dose, resulting in less systemic exposure and potentially fewer adverse effects (comparative tables available in the original article and Medsafe data sheet together with advice to take care to educate whānau when a change in inhaler translates to different practice.)
  • Stepping up to extrafine BDP from a larger-particle inhaler appears to be as effective as adding on a LABA
  • Extrafine BDP is most likely to benefit paediatric asthma patients with:
    • An increased exacerbation risk
    • Nocturnal symptoms
    • Increased bronchial hyperresponsiveness
    • Exercise-induced asthma
    • Reduced QoL.

7.  Post-vaccination observation time

  • BPAC Bulletin 142 notes the standard post-vaccination wait time now 15 minutes for all publicly funded vaccines in New Zealand.  This change applies to all age groups and all vaccines, whether administered alone or at the same time as other vaccines.
  • A shortened wait time of five minutes can also be considered in people who meet all of the following criteria:
  • No known history of severe allergic reactions
  • Has been assessed for immediate post-vaccination adverse reactions (after five minutes)
  • Knows when and how to seek post-vaccination advice
  • An adolescent or adult will be with them for the first 15 minutes post-vaccination
  • Agree not to drive, skate, scoot, ride a bike or operate heavy machinery until 15 minutes post-vaccination
  • Can contact emergency services if required
  • Vaccinators may consider advising post-vaccination observation wait times longer than 15 minutes, in some clinical situations, e.g. history of allergy, syncope. IMAC has produced a flow chart for vaccinators. 

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare, rural , , ,

Clinical Snippets April 2026

Clinical Snippets April 2026

1.  Diabetes

As part of the recently released National Diabetes Roadmap Te Whatu Ora has published a notice stating they will align New Zealand’s diagnostic threshold for diabetes and pre-diabetes with international standards to facilitate timely and appropriate diagnosis of diabetes and to minimize the risk of overdiagnosis of pre-diabetes.

Effective 1 July 2026 the national diagnostic thresholds for HbA1c are changing to:

  • Diabetes: HbA1c ≥ 48 mmol/mol (lowered from the current ≥ 50 mmol/mol).
  • Prediabetes: HbA1c 42 – 47 mmol/mol (previously 41 – 49 mmol/mol)
  • Normal: HbA1c < 42 mmol/mol.
  • No confirmatory test required if HbA1c > 53 mmol/mol.
  • Confirmatory test required as soon as practical if HbA1c 48 – 52 mmol/mol eg. repeat HbA1c, fasting glucose or random glucose (if symptomatic)

It is worth keeping in mind that diabetes exists on a spectrum. Microvascular risk begins to increase above an HbA1c of 39 mmol/mol, which is the threshold used for prediabetes in some countries. At the borderline range, diabetes is not usually symptomatic. 

2.  Whole body scanning

An excellent article by Dr Orna McGinn in a recent issue of NZ Doctor examined the risks of consumer driven health testing including whole body scanning which is being promoted on social media and by some imaging providers.  About the same time, the Canadian primary care evidence summary service Tools for Practice  released their summary #410 titled Whole-Body MRI for Cancer Screening: Many findings, little benefit with the clinical question   What are the potential benefits and harms of performing whole-body MRI for cancer screening in asymptomatic adults?  The bottom line was that systematic reviews of observational studies found that 94% of patients who undergo whole-body MRI will have a radiologic abnormality and up to 30% require additional investigations. Ultimately, 1.1-1.6% will have a pathologically confirmed cancer (most commonly prostate, renal, lung, thyroid). No data on mortality exists. Whole-body MRI for cancer screening in asymptomatic individuals should not be encouraged.  The summary notes that patients who undergo whole-body MRI have higher downstream health care costs, primarily from additional imaging and speciality consultations.  The time to perform whole-body MRI depends on machine, sequences captured and protocols, but typically 60-90 minutes which is about three times as long as a body-specific MRI (eg brain or knee). 

3.  Sepsis 

A recent NZ Doctor article on sepsis promoted the new pre-hospital and primary care sepsis screening and action tools we have discussed previously in Snippets and which are available from the NZ Sepsis website and the HQSC clinical guide.  The article emphasises the four principles of screen, stratify, act immediately and use critical language, and notes that clinical judgement remains central. The HQSC clinical guide accepts that while not every person with amber flags needs transfer to hospital, this is warranted where there is persistent whānau concern or acute functional decline, or when people lack the ability to return for assessment in the event of deterioration.  Three primary care cases are presented and there is a list of practical points:

  • Build a sepsis habit.  Note normal temperature does not exclude sepsis. 
  • Communicate clearly and transfer early [use terms such as red flag sepsis]
  • Antimicrobials (prompt administration of IV ceftriaxone or other available broad spectrum antibiotic – antibiotics are first priority and while blood cultures are very helpful they can remain positive for up to 30 minutes after antibiotics are given, so can follow a dose of antibiotics if IV access is initially difficult)
  • Safety netting vital if the patient is believed suitable for observation in the community
  • Embed the tools locally. Add the sepsis pathways PDFs to your practice intranet, put laminated copies in triage rooms, and run a short huddle to rehearse the flags.

4.  1 May Privacy Act updates

 From the April issue of GP Pulse is a reminder that the Privacy Amendment Act 2025 will introduce a new Information Privacy Principle (IPP 3A) which will come into effect on Friday 1 May. From this date, if your organisation collects personal information from third parties (i.e. not from the individual concerned) you must take reasonable steps to ensure the individual is aware.  The Privacy Commission has published updated guidance on application of the principle

Essentially, under the existing principle IPP3, agencies (businesses or organisations) must already inform people when they collect their personal information from them. Under IPP3A, if an agency collects a person’s personal information from someone other than the person themselves (i.e. indirectly), then that agency is required to tell the person, unless an exception applies.

If an agency has collected personal information indirectly, IPP3A requires them to take reasonable steps to make sure that the person concerned is told:

  • that the information has been collected
  • the purpose of the collection
  • the intended recipients of the information
  • the name and address of the agency that is collecting the information and the agency that holds the information
  • whether the collection is authorised or required by law and which particular law
  • their right to access and correct their information.

MPS has developed guidance for members on what these changes mean for clinicians and explains what your practice should think about and implement before 1 May.  It is expected the majority of practice obligations under IPP3A will be met by an update of the practice’s existing Privacy Statement. The Privacy Statement needs to describe the types of information collected and the purpose for which it is collected. This means that if a practice receives information from a source not explicitly mentioned in their Privacy Statement, they will not generally need to re-notify the patient, provided the information is of the same type and collected for the same purpose.  The guidance gives specific advice on what the Privacy Statement should contain and discusses exceptions to IPP3A requirements and the issue of receipt of unsolicited third-party information.  

5.  Smartphones and kids

A study recently published in Pediatrics and reviewed in Issue 269 of GP Research Review looked at health outcomes at age 12 associated with smartphone ownership.   Researchers analysed data from 10,588 participants in the Adolescent Brain Cognitive Development (ABCD) study.  Compared with non‑owners, 12‑year‑olds with smartphones had higher odds of depression, obesity, and insufficient sleep after adjustment for socioeconomic, developmental, and monitoring factors. Earlier acquisition was additionally associated with obesity and insufficient sleep. Among youth without a smartphone at 12, those who obtained one by age 13 showed increased clinical‑level psychopathology and insufficient sleep even after controlling for baseline status. Findings were robust across sensitivity analyses. Overall, smartphone ownership – particularly earlier ownership – was consistently associated with adverse mental and physical health indicators in early adolescence, with implications for caregivers and policy.

6.  MPS Resource

MPS has released the Safe Prescribing podcast series – a five‑episode, practical, medicolegal resource designed to help you reduce risk, streamline decision‑making, and feel more confident in everyday prescribing.

  • Episode 1: 12‑month prescriptions: What the law change means in practice, how to decide on prescription length, and strategies to minimise complaints.
  • Episode 2: Prescribing by telehealth and narrow‑scope clinics: The rise of telehealth brings new risks. We explore how to keep patients safe and protect yourself when consulting remotely.
  • Episode 3: Prescribing by proxy: when care is shared:  Shared care is now the norm. We unpack the medicolegal implications of prescribing for patients you haven’t personally assessed, and how to stay aligned with Medical Council expectations.
  • Episode 4: Standing orders:  A clear, practical look at your obligations when using standing orders, and how to ensure you’re meeting regulatory requirements.
  • Episode 5: Dangerous drugs: focus on Methotrexate – Using a real case example, we highlight why methotrexate remains a high‑risk medication and how to avoid the errors that lead to serious harm.

7.   Spotlight Series

The NZ Doctor Spotlight series looking at prescribing data analysed using the Conporto Health Event Detection & Mitigation service has reported on several prescribing issues:

(i)  Co-prescribing of PDE5 inhibitor and nitrates.  There were 10 events over a fortnight amongst 196k interactions.

  • avoid concurrent use of nitrates (this is a contraindication – concurrent use may cause potentially life-threatening hypotension and, in severe cases, can precipitate myocardial infarction).
  • if nitrates must be given, allow a minimum of 24 hours after sildenafil or 48 hours after tadalafil, and consider a longer interval in anyone with factors that could raise PDE5 inhibitor levels (eg, interacting medicines)
  • review patient medicine histories to identify any prescription of a nitrate (eg, glyceryl trinitrate, isosorbide mononitrate)
  • counsel patients to tell emergency or ambulance staff when they last used a PDE5 inhibitor, so nitrates are avoided in acute care
  • check for cardiovascular disease – ask about angina, chest pain, shortness of breath, palpitations or syncope, even if the patient is not on nitrate therapy

(ii) Prescribing of metformin in patients with severe renal impairment, defined as an eGFR below 15ml/min/1.73m2. At this level of kidney function, metformin is generally contraindicated because the risk of metformin-associated lactic acidosis increases significantly. Lactic acidosis carries a high fatality rate and can be difficult to recognise early because symptoms are often non-specific.  There were 5 episodes of such prescribing over a fortnight amongst 227k interactions.

  • stop metformin in patients with an eGFR <15ml/min/1.73m2
  • review the most recent renal function results before issuing a new or repeat prescription or adjusting the dose
  • check for episodes of acute illness (eg, dehydration, vomiting or infection) that may reduce kidney function, and consider temporarily withholding metformin
  • assess for risk factors that increase susceptibility to lactic acidosis, including poorly controlled diabetes, heart failure, liver disease or alcohol misuse
  • consider alternative glucose-lowering therapies more suitable for patients with severe renal impairment
  • discuss sick day management and the need to pause metformin during acute illness, and reinforce the importance of regular renal monitoring
  • advise patients to seek medical attention promptly if they develop symptoms such as unusual fatigue, muscle pain, abdominal discomfort, rapid breathing or nausea, as these may indicate lactic acidosis or acute kidney injury.

(iii) First prescriptions of allopurinol at doses >200mg per day in patients with severe renal impairment, defined as an eGFR below 30ml/min/1.73m2.  There were 9 episodes of such prescribing detected over a fortnight amongst 212k interactions. 

  • Allopurinol and its metabolites are renally excreted, and impaired kidney function leads to accumulation. This increases the risk of serious adverse reactions, including allopurinol hypersensitivity syndrome and drug reaction with eosinophilia and systemic symptoms (DRESS), which can be life-threatening. Renal impairment has an additive effect on genetic susceptibility to these reactions, making cautious initiation and slow titration essential.
  • The New Zealand Formulary advises caution in renal impairment and suggests the following dosing for gout prophylaxis:
    • eGFR 30–60: start at 50mg once daily and increase by 50mg every four weeks, if tolerated, until target serum urate level (<0.36mmol/L) is reached
    • eGFR <30: start at 50mg every second day and increase by 50mg every four weeks, if tolerated, until target serum urate level (<0.36mmol/L) is reached.
  • Before initiating allopurinol, check renal function and document baseline eGFR. Start at the lowest recommended dose and titrate slowly, monitoring serum urate and renal function. Advise patients about hypersensitivity reactions. Patients should be counselled to stop taking allopurinol at the first sign of a rash (even if mild) or if they develop other symptoms of an allergic reaction (eg, swelling of the lips or mouth, difficulty breathing, fever) and to seek urgent medical help. Consider alternative urate-lowering strategies and/or specialist input for patients with significant renal dysfunction.

8.  Post Script

One of our listeners, Dr Andre Bonny from Nelson, took up the challenge to produce a Medsafe-type information sheet for alcohol (see below).  Perhaps a bit light on the social harms including family and relationship damage, crime, accidents and injuries, and economic and workplace issues.  From an economic perspective, a 2024 report to the Ministry of Health/Manatu Hauora included the following statistics for the 2023 year:

  • $9.1b estimated total cost of alcohol harm based on disability-adjusted life years
  • $4.8b associated with disability-adjusted life years from Fetal Alcohol Spectrum Disorder (FASD)
  • $1.2 b associated with disability-adjusted life years from alcohol use disorder
  • $281m – intimate partner violence (for alcohol use disorder alone)
  • $74m – child maltreatment (for hazardous drinking alone),
  • $2.1b in societal cost of road crashes where alcohol was a factor
  • $4b in lost productivity associated with alcohol use, including FASD, crimes and workplace absenteeism
  • $810m, predominantly in health and ACC spending

Ethanol (Ethyl Alcohol) – One Page Safety Summary (Medsafe■Style)

Overview

Ethanol is a psychoactive central nervous system depressant commonly present in alcoholic beverages and some medicinal preparations. While widely consumed socially, ethanol has no routine therapeutic indication and is associated with significant health risks, particularly when used regularly or combined with other medicines. It affects brain neurotransmitters including GABA and glutamate, leading to sedation, reduced inhibition, impaired coordination, and altered judgement.

Key Health Risks

Short■term: impaired judgement, reduced coordination, slurred speech, nausea, vomiting, slowed reaction time, injury risk.

Serious acute effects: respiratory depression, hypoglycaemia, seizures, loss of consciousness, alcohol poisoning.

Long■term: liver disease (fatty liver, hepatitis, cirrhosis), cardiovascular disease, increased cancer risk, cognitive impairment, and alcohol dependence.

Adverse Effects

Common: headache, fatigue, dehydration, sleep disturbance, mood changes. Less common: gastric irritation, memory impairment, anxiety or depression. Serious: severe intoxication, cardiac arrhythmias, acute pancreatitis, liver failure.

High■Risk Groups

Young people and adolescents; pregnancy (risk of Fetal Alcohol Spectrum Disorder); people with liver disease; people with mental health disorders; individuals taking sedating medicines.

Interactions With Medicines

Medicine TypeInteraction Risk
BenzodiazepinesExcess sedation, respiratory depression
Opioid pain medicinesIncreased overdose risk
Sleeping medicinesSevere drowsiness and impaired breathing
AntidepressantsIncreased sedation and impaired cognition
AntipsychoticsEnhanced CNS depression
Warfarin / anticoagulantsIncreased bleeding risk

Dependence and Withdrawal

Regular heavy use may lead to tolerance and physical dependence. Withdrawal symptoms may include tremor, anxiety, sweating, agitation, and seizures in severe cases requiring medical supervision.

Key Safety Message

Ethanol significantly increases the risk of sedation, overdose, injury, and drug interactions, especially when combined with other central nervous system depressants.

The New Zealand General Practice Podcast

opotikigp family medicine, general practice, Healthcare, rural, Uncategorized , , , , , ,

https://open.spotify.com/episode/5zPf8bAGVqeeIKF9sGd7zT?si=xGcqfnVjRaGp8jhaCPrbeg

Clinical Snippets October 2025

Clinical Snippets October 2025

1. Suicide prevention

(i) A recent Goodfellow Gem drew attention to the NHS guidance Staying safe from suicide (2025) which includes references to NICE Guideline NG225: Self-harm: assessment, management and preventing recurrence.  Of note, the NICE guideline strongly advises against the use of risk assessment tools and scales, or global risk stratification into low, medium, or high risk, to predict future suicide or repetition of self-harm or to determine who should or should not be offered treatment or be discharged. 

(ii) The NHS guidance has 10 key principles:

  • relational safety: build and maintain trusting, collaborative therapeutic relationships. These are the strongest predictor of good clinical outcomes
  • biopsychosocial approach: address safety as part of a broad biopsychosocial approach aimed at improving overall well-being by considering biological, psychological and social aspects
  • safety assessment and formulation: reach a shared understanding with the individual about safety and changeable factors that may affect this
  • safety management and planning: consider the need for immediate action and work with the individual to navigate safety and the factors impacting this over time.
  • dynamic understanding: regularly assess and adapt formulations and safety plans based on the individual’s changing needs and circumstances
  • evidence-based practice: base work on the latest research and understand population-level risk trends
  • involving others: encourage the involvement of trusted others, where possible and as appropriate
  • inclusivity: Ensure practices are inclusive and adaptable, particularly for marginalised and high-risk groups
  • clear communication: use simple language tailored to the individual and don’t use jargon. Use interpreters or approaches like drawing, if needed
  • continuous improvement: regularly review and refine approaches based on outcomes and feedback

(iii) A written, prioritised list of coping strategies and/or sources of support that the person who has self-harmed can use to help alleviate a crisis. Components can include recognising warning signs, listing coping strategies, involving friends and family members, contacting mental health services, and limiting access to self-harm methods.  The NZ Mental Health Foundation provides an editable Personal Safety Plan which is also available as hard copy.  Other suicide related resources are also available.   

(iv) Community Health Pathways has sections on Suicide Prevention in Adults and Suicide Prevention in young People.  The Pathways do currently include risk stratification but also emphasise the most important priorities are to engage the patient, provide hope, and look at ways to keep them safe. Hopelessness has a high correlation with eventual suicide.  The Pathway also emphasises the importance of building a strong therapeutic alliance by:

  • Communicating empathy and understanding for patient’s extreme suffering.
  • Providing reassurance that recovery is possible.
  • Reinforcing the patient’s help-seeking behaviour in coming to see you for treatment.

2. Ondansetron in pediatric gastroenteritis

Issue 259 of GP Research Review looked at a double blind study published in NEJM in which just over 1000 children between the ages of 6 months to <18 years with acute gastroenteritis associated vomiting whose carers were provided with 6 doses of oral ondansetron or placebo at the time of ED discharge, with instructions to use in the case of ongoing vomiting. Outcomes were measured in symptom continuation and deterioration, duration, total number of vomiting episodes and the need for further medical intervention. In the 7 days after enrolment, those prescribed ondansetron had significantly less chance of deterioration and reduced episodes of vomiting. Adverse events were balanced between study arms. Take-home message: Ondansetron is effective in reducing vomiting from gastroenteritis in those aged between 6 months and 18 years. NZFC notes acute gastroenteritis-related vomiting associated with dehydration is an indication for a single dose of ondansetron in children. 

3.  HIPC Rule 11

A recent issue of NZ Doctor contained an article from the office of the Privacy Commissioner on Rule 11 of the HIPC which links to last month’s discussion around suicide prevention.   

The question is presented: When a patient insists that their parents not be told about what’s going on in their life, but you think their mental health is at risk and parental support could lessen that threat, what should you do?  If a patient refuses consent to share their health information, but a GP believes their safety is at risk, Rule 11 of the Health Information Privacy Code may allow the doctor to act.

Rule 11 of the HIPC permits the disclosure of health information if it is necessary to prevent or lessen a serious threat to the life or health of any person, or to public health or safety (the serious threat exception). In each case, specific requirements must be met for the serious threat exception to apply. If another piece of legislation requires or allows you to share the health information in question, you should rely on that legislation rather than Rule 11. For example, if sharing is permitted by the Oranga Tamariki Act 1989 you should rely on that as your authority. You don’t need to also make an assessment under Rule 11.

If no other piece of legislation applies, you need to assess the disclosure under Rule 11. There are four steps to work through.

(i) Has the person authorised you to share their health information?  If yes you can release information as agreed with the person.  

(ii) If you do not have authorisation, it reasonably practical to seek authorisation? For the serious threat exception to apply, you need to have reasonable grounds to believe that it is not desirable or practical to seek the individual’s authorisation. If you request authorisation to disclose the information but the individual does not grant it, you must consider why the authorisation was not granted and whether it is appropriate to proceed with the steps. If the threat is serious enough, you might find that it outweighs the need for authorisation. If it is not desirable or practicable to seek authorisation, go to step three.

(iii) Is there a serious threat to the life or health of a person?

The serious threat exception applies to serious threats to the life or health of the person whose information it is, that of any other person, or public health or safety. When considering whether there is a serious threat, you need to use your clinical judgement to assess the likelihood of the threat occurring, the seriousness of the threat and the harm that could eventuate and the imminence of the threat. If the threat does not meet the “serious threat” threshold, you cannot rely on this exception. If there is a serious threat, go to step four.

(iv) Is the disclosure to someone who can help lessen or prevent the threat?

You can only disclose health information under this exception if you are sharing the information with someone who can help lessen or prevent the threat, and only as much information as is needed to do so. For example, if you have gone through these four steps and concluded that involvement from a patient’s loved one in their care would lessen the threat, you should still only share as much information as is necessary to do that.

As always, it will be crucial to document your decision-making process. It may help to record the answer to the four steps sequentially in your notes as you are deciding on the best course of action, as well as your rationale for these answers.  The full guidance on this exception is available in the resources and learning section at privacy.org.nz.

4. Long-acting insulin

  • A recent Tools for Practice from the College of Family Physicians of Canada looked at the evidence comparing once-weekly insulin icodec (Awiqli) compared to daily long-acting insulins in type 2 diabetes?  The bottom line was that once-weekly insulin icodec is as effective as daily long-acting insulin (glargine or degludec) in lowering HbA1c. Safety and hypoglycemia risk appear similar, though data are limited for patients or situations at risk for hypoglycemia such as sick days or in frail patients. 
  • Insulin icodec is not yet approved for use in New Zealand but is approved in Australia for type 2 diabetes in adults and adult type 1 diabetes with some restrictions.   Insulin icodec (Awiqli™ 700 units/mL, 2100units/pen) is an ultra-long-acting insulin.  In insulin naive patients, initial recommended dosage is 70 units once per week, equivalent to 10 units daily. Maximum dose per injection 700 units. When switching from another long-acting insulin, use the equivalent total weekly dose but a one-time 50% higher loading dose may be considered.  However, it may be a while before it is approved in New Zealand – it is more expensive than other long-acting insulins.  Approximate costs per month for 40 units/day or 280/week: Glargine: $70; Degludec: $100; Icodec: $115  NZD equivalent. 

5. Insomnia medication

The Research Review Educational Series has published an update on recent advances in the management of insomnia.  Behaviour therapy is the recommended first line treatment for insomnia with hypnotics being used as adjunctive or alternative therapy. Health Pathways has a comprehensive summary of accepted insomnia management practices. 

The publication reviews the various available hypnotics including dual orexin receptor antagonists (DORAs) which are a newer class of hypnotic. In December 2024, the Minister of Health consented to the distribution of the DORA lemborexant (Dayvigo®) in New Zealand for treatment of insomnia in adults. The following ‘take home’ messages relate to lemborexant. 

  • RCTs, meta-analyses and network analyses have shown lemborexant has favourable efficacy and side effect profiles compared to placebo and benzodiazepine receptor agonists. Lemborexant significantly reduced time to sleep onset and increased overall sleep time compared to placebo and zolpidem at 1 month, and compared to placebo at 6 months with these effects maintained to 12 months.
  • Discontinuation of lemborexant therapy was not associated with rebound insomnia and lemborexant did not significantly impair next-day memory or driving, compared to placebo and benzodiazepine agonist receptors.
  • Lemborexant was well tolerated with a TEAE (treatment emergent adverse event) rate similar to placebo.  TEAEs most commonly associated with lemborexant are somnolence, headache, nightmares and/or abnormal dreams. A single retrospective study found Lemborexant was associated with a lower rate of falls in hospitalised patients compared to benzodiazepine receptor agonists.
  • Information on dosing and precautions is available in NZ Formulary and the Medsafe data sheet.  The drug is not currently subsidised and is an unapproved medicine (s29).   The Better Sleep Clinic website has a page dedicated to comparing the various medications used in insomnia management which might be a useful resource for patients.  The cost of a four week supply of Lemborexant in NZ (Pharmacy Direct) is $113 for the 5mg tab and $143 for the 10mg tab. 
  • There is a recent Goodfellow Gem briefly summarising relevant prescribing data 

6. Triple therapy for COPD

A recent NZ Doctor article on triple therapy for COPD  includes the following take home points:

  • For mild COPD, monotherapy with a bronchodilator is usually adequate; start a regular LAMA early; if symptoms increase, add a LABA.
  • An eosinophil count ≥0.3×109/L helps identify people with frequent exacerbations who are most likely to respond to an ICS.
  • If an ICS is indicated, it should be part of triple therapy (ICS + LAMA + LABA not ICS + LABA).
  • Strongly recommend vaccinations (encourage the unfunded vaccines, especially pneumococcal) and pulmonary rehabilitation (refresher course every two to three years).
  • The debate around the benefits and risks of therapy for COPD involves the place of inhaled corticosteroids. When we had limited inhaled therapy options for COPD, many people with COPD were initiated on an ICS + LABA combination. Subsequently, different phenotypes of COPD have been identified, and those with frequent exacerbations (two or more exacerbations in 12 months) have been shown to have fewer exacerbations when on an ICS. Those without frequent exacerbations derive no benefit but are at increased risk of adverse effects from ICS therapy, such as pneumonia.

7. Resource – iron studies and anaemia

A recent Research Review Educations Series titled What the ferritin? Is well worth an hour of CME.  It covers the basics of iron metabolism and then the various blood test used to asses iron status.  There is a very helpful table to aid distinguishing iron deficiency from anaemia of chronic disease and an acute phase reaction, and algorithms aiding differentiation of absolute versus functional iron deficiency.  The importance of investigating an underlying cause of absolute or functional iron deficiency is emphasised.  Take home messages include:

  • Low serum iron is not a reliable indicator of depleted iron stores (diurnal variation and inter-individual variation, sensitive to recent iron intake, acute and chronic illness.
  • Low transferrin saturation (TSAT) with low ferritin is consistent with iron deficiency (ID). High TSAT with high ferritin indicates iron overload. TSAT alone is not a reliable marker of iron status.
  • A normal or raised serum ferritin level does not necessarily exclude ID; it is important to distinguish between absolute and functional ID, especially in patients with inflammation or chronic disease.  However, serum ferritin is a sensitive and specific test for ID.  Low ferritin levels are highly specific for ID; high ferritin levels do not necessarily indicate iron overload.
  • The reticulocyte haemoglobin equivalent RET-He test is a rapid, inexpensive indicator of ID in chronic disease.
  • If patients are started on oral iron replacement therapy, they should be checked at 6 weeks to ensure the medication is being tolerated and that haemoglobin levels are increasing.  Patients who receive IV iron replacement therapy should have a full blood count at 2–3 months post-infusion to check for haemoglobin normalisation. 

8.  Follow-ups

(i)  Adult ADHD management:  MyHealthHub has hosted a webinar ADHD in Adults – the Primary Care Perspective by Auckland psychiatrist Dr Sidesh Phaldessai.  The hour-long webinar is eligible for PD points and explores explore the diagnosis, referral, management and long-term care of adult ADHD.  Dr Phaldessai is also hosting an online Adult ADHD GP Masterclass which is a series of six webinars 7.30pm-8.30pm every Wednesday from 22 October until 26 November 2025 covering all aspects of adult ADHD diagnosis and management.  It is RNZCGP endorsed (12 CME points) and if you are unable to attend on the given date and time – the webinar will be recorded and you can access it later. 

(ii)  Further to a discussion in the last Snippets regarding medications that can affect the QTc interval, Christchurch Medicines Information Service have recently published a succinct 2-page bulletin on the issue including predisposing risk factors, culprit drugs and drug interactions and how best to manage the risk.   There are links to the CredibleMeds website which enables you to search individual medications and categorises them as:

  • Known Risk of Torsade de Pointes (TdP) – These drugs prolong the QT interval AND are clearly associated with a known risk of TdP, even when taken as recommended.
  • Possible Risk of TdP – These drugs can cause QT prolongation BUT currently lack evidence for a risk of TdP when taken as recommended.
  • Conditional Risk of TdP – These drugs are associated with TdP BUT only under certain conditions of their use (e.g. excessive dose, in patients with conditions such as hypokalemia, or when taken with interacting drugs) OR by creating conditions that facilitate or induce TdP (e.g. by inhibiting metabolism of a QT-prolonging drug or by causing an electrolyte disturbance that induces TdP).
  • Drugs to Avoid in Congenital Long QT Syndrome (cLQTS) – These drugs pose a high risk of TdP for patients with cLQTS and include all those in the above three categories (KR, PR & CR) PLUS additional drugs that do not prolong the QT interval per se but which have a Special Risk (SR) because of their other actions.

Church Street Surgery 2016 Strategic Planning

opotikigp family medicine, general practice, Healthcare, rural

How do you make a strategic plan a living document?

Our last plan 2013-2016 helped us to set values that we have stuck to and remembered for 3 years.

CARE – Compassion, Attitude, Respect and Excellence were linked to the local DHB values – we felt this would align us more closely with the DHB services in our region.

Last time we agreed goals around workplace improvements, process improvements, improved patient outcomes and improved services.

We have achieved a number of these goals and embedded them into our system – we have morning meetings, names on our doors, agendas for every meeting, reduced bad debt, expanded funding streams, and produced quarterly newsletters.

We now have an ecg and defibrillator as we planned, we have reduced waiting times and our waiting list, we have trialled nurse practitioner services and expanded our teaching opportunities.

Several issues we aimed for have not been achieved – we don’t have an USS and in retrospect most of our identified goals were achieved in the first 6 months after the plan was set.  Those we did not achieve were large projects that needed a long term focus – such as reducing teenage pregnancies in the town and running a community awareness programme on gout.

This year our strategic planning process was an opportunity to revisit our team culture and to revitalise our values , to find out what our community think of us and set some short term achievable goals, the start of a cycle of 3 monthly improvement plans.

Executive Summary:

Our New Values

Integrity Compassion Excellence Teamwork

ICE –T

 

Our Next Goals

Weekly Clinical Meetings

Expand the uptake of MMH – 300 by May 2016

Expand use of technology to educate patients – students to produce a MMH promotion video

Reduce waiting times for patients – expand the doctor workforce

Increase patient numbers to 3600 by May 2016

 

 

Detailed Report

VALUES

On Wed March 2nd we closed the surgery for the afternoon and after a shared lunch reminded ourselves of our #my3words for 2016 – a personal values exercise we had undertaken the week before.

For me those values for 2016 are Centre, Connect, Create. I need to remind myself to “centre” and look after myself physically and emotionally, if I can “connect” with others I will be more effective, and I will enjoy life more if I “create” new things.

We then moved onto a values exercise –

The instructions were to silently organise ourselves into a hierarchy of values (we had words posted on our backs) – once we had silently agreed an order we had to then speak to the value we had been assigned and argue for why it should be in our top 4.

We chose

integrity – because without integrity we have nothing

compassion – because you cannot do this job without compassion

excellence – because this encompasses a passion for quality, effectiveness, and great patient outcomes and

teamwork – because we need each other, our patients, and our colleagues to achieve our goals.

 

COMMUNITY INPUT:

We then headed out into the community to find out the community and patient view of our service:

In pairs we went out into the street and shops and spoke to at least 3 people and asked what they thought the surgery does, what it should do more of and what it should do less of.

We posted the findings on facebook and will continue to reflect on comments we get from our facebook followers.

FINDINGS:

What’s the most important things to you about your health ? Eating properly, keeping fit, lifestyle issues , be healthy for my kids and myself, having support, being well informed, being able to make decisions about your health, mental health, being given the tools to make my own decisions, Knowing my doctor is approachable and knowledgeable Making sure I am trying to help myself, Keeping informed and knowing my options

What are the most important things about a good GP surgery? Showing interest, thorough examinations, approachable, seeing the same doctor, familiarity Having good staff getting an appointment when needed, flexible times, reasonable price, affordable, good communication and openness – never rushed Care about the bigger picture – holistic health Being understood, people who listen On time Appointment availability friendly service Confidentiality

What would you like to your GP to do more of in the next 3 years ? Less waiting times, longer consultation times, after hours, educational sessions – smears and breast screening etc More doctors , after hours clinics. Push the antismoking – clean up the street education Use the whanau ora services to support wider families, one day late night clinic a week, Home visits Develop a formal engagement with the police More follow ups with the hospital – it is very hard to see a specialist Our next exercise was to reflect on these comments – and to use a set of craft materials to develop a model structure that described our ideal surgery in the next 3 years – we broke into two groups and thought about  what we should do more of as a team, what we should do less of as a team, and built our ideal worlds :

The “Whare Waka” model was based on Mason Durie’s Te Whare Tapa Wha model and “The Blue Path” was based on the materials in the box !

The Blue Path

The Whare Waka

The ideal world exercise was fun and creative and it also made concrete our values and started us thinking about the bigger and longer term picture for the surgery.

The videos can be viewed on Vimeo.com

The Blue Path – https://vimeo.com/157862107

The Whare Waka – https://vimeo.com/157812550

Each group then further explored the things we should do more of, the things we should do less of and 3 achievable goals for the next 3 months.

BRAINSTORM :

 

More of:

  • time availability to interact between staff – we need to be able to see more of each other to discuss clinical cases
  • awareness of how long people have been waiting in the book – protect your time for other patients
  • involvement of reception if the appointment is going to blow out in time
  • planning for unexpected patients.
  • longer opening hours
  • education training for staff
  • doctors
  • MMH – expanding the uptake

Less of:

  • chasing up patients – we can go round in circles chasing up things for patients
  • short staff days
  • bullying from patients
  • phone calls
  • bad debt
  • outstanding debt
  • people not using MMH even though they are signed up

Goals

Increase patient numbers to 3600 by May

Increase MMH numbers to 300 by May

MED students to do a video to promote health

Waiting time improvement.

Clinical time set aside every week

Our New Values

Integrity Compassion Excellence Teamwork

ICE–T

Our Next Goals

Weekly Clinical Meetings

Expand the uptake of MMH – 300 by May 2016

Expand use of technology to educate patients – students to produce a MMH promotion video

Reduce waiting times for patients – expand the doctor workforce

Increase patient numbers to 3600 by May 2016

WE WILL REVISIT THIS IN MAY 2016

 

The Importance of Training in Rural Areas

opotikigp family medicine, general practice, Healthcare, rural ,

The recent Rural Health Conference in Gramado gave us time to reflect on a number of important issues facing rural communities across the world – along with the pressures of climate change, population growth and increasing burdens of chronic disease the “perfect storm” is compounded by the continued problem of access to the quality medical services.

New Zealand began life as a rural nation, and our national identity takes pride in our ‘can-do’ approach to life. It is a fundamental human right that people living in all regions have access to high quality health services, perhaps especially in regions at distance from main population centres, regions that are often the backbone of a country’s economic wealth, and centre of leisure activities (1).

Having a healthy, engaged and well educated health workforce is important to the wellbeing of all communities. Attracting health professionals to live and work in rural areas is an international problem familiar to all WONCA members (2).

It may be a little confusing why this is a problem for those of us that have made this lifestyle choice, but it may be more prevalent in areas where there is a high demand, especially on after hours care, low reward and professional isolation and where family and social issues put pressure on rural providers (3).

In New Zealand year after year GP workforce surveys have detailed the on-going problems of recruitment and retention into rural practice (4-6), and the shortage of providers in rural areas continues, with over 25% of practices currently seeking full time GPs and Nurses (Rural General Practice Network unpublished data 2014.)

The medical workforce is the best studied example of a need that is widely reported to affect rural nurses, pharmacists, midwives, dentists and physiotherapists (7).

New Zealand needs 50% of its medical graduates to choose General Practice as a career, currently only 29% have a “strong interest” in doing so at the end of the medical degree offered by Auckland University, (8) and it is unclear how many NZ graduates actually become GPs and even less is known about how many of them to choose rural practice.

We do know that currently only 9.2% of doctors working in rural areas are NZ trained, and only 16.4% of NZ trained GPs choose to work in rural areas (9). We do know that as a proportion of the workforce the number of GPs is falling compared to specialists (10).

Rural workforce statistics show that the average age of rural General Practitioners continues to age and these communities rely heavily on international medical graduates to provide services. This leads to a continuing need for recruitment as we are failing to “grow our own” health workforce (9).

If we are to “grow our own” workforce it is very clear from international studies that choosing students with rural interests and backgrounds, exposing undergraduates to positive training experiences in rural areas, and providing well supported career pathways in rural practice increases the intention of medical students to work in rural communities once they graduate (2, 11).

We know that the career decisions of students and young professionals in the future will be affected by the way health career choices are viewed by society, available financial incentives, appropriate professional development and career opportunities, the availability of locums, a good quality of life ability to achieve balance, and the lifestyle choices of their spouses and family needs (2).

Many of us involved in education will be aware of the idea of “constructive alignment” of intended learning outcomes – what we hope to achieve – and the assessment and learning activities that are planned. The same theory applies to issues that face us in our rural communities.

We want to see an improvement in the health outcomes for rural communities, “Health for All Rural People”, we need our governments, colleges and colleagues to be measuring these outcomes – because of it is not measured it won’t be changed – and then we need our recruitment and retention and service delivery model thinking to be focused on achieving these outcomes.

This may seem bigger than Ben Hur but from what we do know it is clear that in order to meet the needs of our current and future population, in order to achieve equity and fairness or health outcomes for rural communities, in order to support and further develop the economic health of our rural sector, government needs to further support and expand initiatives that that increase exposure of training health professionals to positive rural experiences.

Dr Jo Scott-Jones

REFERENCES:

1. Ministry for Primary Industries : Rural Communities 2014 [09/05/2014]. Available from:http://www.mpi.govt.nz/agriculture/rural-communities.
2. WHO. Increasing access to health workers in remote and rural areas through improved retention:global policy recommendations. Geneva: World Health Organisation, 2010.
3. Burton J. Rural Health Care In New Zealand. Wellington: Royal New Zealand College of General Practitioners, 1999.
4. London M. New Zealand Annual Rural Workforce Survey 2000. Christchurch: Centre For Rural Health; 2001.
5. Mel Pande M, Fretter J, Stenson A, Webber C, Turner J. Royal New Zealand College Of General Practitioners Workforce Survey 2005 part 3: General Practitioners In Urban and Rural New Zealand. 2006.
6. The New Zealand Medical Workforce 2007. New Zealand Medical Council; 2008.
7. Health Workforce Development: An Overview. In: Health Mo, editor. Wellington, New Zealand2006.
8. Poole P, Bourke D, Shulruf B. Increasing medical student interest in general practice in New Zealand: where to from here? The New Zealand medical journal. 2010;123(1315):12.
9. Garces-Ozanne A, Yow A, Audas R. Rural practice and retention in New Zealand: an examination of New Zealand-trained and foreign-trained doctors. The New Zealand Medical Journal (Online). 2011;124(1330):14-23.
10. Medical Council of New Zealand: The New Zealand Medical Workforce in 2012 Wellington, New Zealand2013.
11. Walker JH, DeWitt DE, Pallant JF, CE. C. Rural origin plus a rural clinical school placement is a significant predictor of medical students’ intentions to practice rurally: a multi-university study. Rural and Remote Health. 2012;12(1908):Online.
12. Farry P, Hill D, Isobel Martin I. What would attract general practice trainees into rural practice in New Zealand? NZMJ. 2002;115(1161).
13. Worley P, Strasser R, D. P. Can medical students learn specialist disciplines based in rural practice: lessons from students’ self reported experience and competence. Rural and Remote Health. 2004;4(338):Online.
14. Ministry of Health: Voluntary Bonding Scheme Wellington, New Zealand2014 [09/05/2014]. Available from: http://www.health.govt.nz/our-work/health-workforce/voluntary-bonding-scheme.
15. Rural Health Interprofessional Immersion Programme Wellington, New Zealand2014 [09/05/2014]. Available from: http://www.rhiip.ac.nz/.
16. University of Otago: Rural Medical Immersion Programme Otago University, New Zealand2014 [09/05/2014]. Available from: http://rmip.otago.ac.nz/.
17. P Poole, W Bagg, B O’Connor, A Dare, J McKimm, K Meredith, et al. The Northland Regional-Rural program (Pukawakawa): broadening medical undergraduate learning in New Zealand. Rural and Remote Health. 2010;10(1254):Online

 

(published in Wonca News June 2014)

Wonca World Rural Health Conference Gramado April 2014

opotikigp family medicine, general practice, Healthcare, rural , , , ,

The WONCA WORKING PARTY on RURAL PRACTICE is the rural working group of the world organisation of academic associations and national colleges.
Amongst other work it runs regular conferences and Gramado in Brazil was host to the 12 th WWPRP conference.

The picture above is of Carlos Grossman and his wife Doris, he was heralded during the conference as the father of family medicine in Brazil, I spoke to him about why as a cardiologist in the 1970s he had decided to set up a family medicine programme.

His response was both simple and profound : ” We need to be close to the people.”

Is there a better explanation ?

Rural people are disadvantaged from the outset because of distance, Carlos Grossman recognised it is essential to have health care that is provided close to the people, by a professional trained to engage closely with them in their work and family life, a professional who shares the closeness of the community. This shared experience, also identified by McWhinney as a essential part of family practice, brings with it opportunities for fantastic work in supporting people to live happier and healthier lives.

It is a phenomenal thing to come to a realisation that the culture you work in as a GP is substantially different from that of other GPs, and the question of what it means to be a “rural” GP is worth a later exploration, suffice to say being able to spend time with like minded but different people, with a richly diverse way of dealing with a common set of challenges was not only interesting but I suspect will prove useful in the New Zealand context.

My task now is to share some of the ideas that were shared with me during the event.

For those of you who “twitter” searching through my recent tweets using #nzrgpn you will be able to find slides and comments from the main speakers.

Consider following me @opotikigp and @ruralwonca for future links and conversations about rural health.

First Post -Truth develops over Time

opotikigp family medicine, general practice, Healthcare, rural , ,

Don’t shoot the messenger.

The purpose of taking this step into bloggersphere is to provide another outlet for my own opinions about the state of healthcare, in particular how rural communities, and in particular rural communities in New Zealand, fare.

I suspect that when Don Berwick and his colleagues delivered their Don Berwick’s report for the UK NHS they felt a bit like Phiddepides the apocryphal first marathon runner.

Phiddepides bore bad news of invasion, and of the failure of the government of the day to respond.

Berwick et al told the bad news to the UK government of the need for systematic and widespread change to address the failures of the health system, to develop a culture of learning and patient safety, and the letters he wrote, to management, staff and the public exhort a response. They not only challenge the system in England, but internationally. Have we responded?

Famously Phideppides died at the end of his courier run, conveniently I suspect, since the bearers of bad news often did not fare too well in ancient times.

Many bearers of bad news are still “shot down” at least metaphorically, and perhaps in an effort to avoid this people who challenge the status quo will couch their approaches as “solutions” spinning the bad news to assuage the anxieties of leading political parties.

The problem is it is almost impossible to keep everyone happy all the time whilst maintaining the feeling of freedom of expression.

I have been told that you need to play the game if you are to have influence, to treat the powerful like they are children in a sandpit, fighting for the bucket that makes the sandpies.

It seems to me that a regular personal viewpoint, expressed clearly and with the acknowledgement that it is often through expressing ideas and debate that opinions form, could help to get the message through to the children in the sandpit.

Here’s hoping they don’t shoot….