A novel methodological approach to participant engagement and policy relevance for community-based primary medical care research during the COVID-19 pandemic in Australia and New Zealand.

Community-based primary care, such as general practice (GP) or urgent care, serves as the primary point of access to healthcare for most Australians and New Zealanders. Coronavirus disease 2019 (COVID-19) has created significant and ongoing disruptions to primary care. Traditional research methods have contributed to gaps in understanding the experiences of primary care workers during the pandemic. This paper describes a novel research design and method that intended to capture the evolving impact of the COVID-19 pandemic on primary care workers in Australia and New Zealand. Recurrent, rapid cycle surveys were fielded from May 2020 through December 2021 in Australia, and May 2020 through February 2021 in New Zealand. Rapid survey development, fielding, triangulated analysis and dissemination of results allowed close to real-time communication of relevant issues among general practice workers, researchers and policy-makers. A conceptual model is presented to support longitudinal analysis of primary care worker experiences during the COVID-19 pandemic in Australia and New Zealand, and key learnings from applying this novel method are discussed. This paper will assist future research teams in development and execution of policy-relevant research in times of change and may inform further areas of interest for COVID-19 research in primary care.

Development of a rural strategy for an urban-based medical program: a pragmatic reality.

INTRODUCTION: Health disparities between rural and urban areas in Aotearoa New Zealand are exacerbated by rural workforce issues. Traditionally, undergraduate medical programs are urban-based, and reconfiguring the curriculum to meet the needs of rural communities is challenging. The aim of this project is explore how urban-located universities might develop and implement a rural strategy. Evaluation of a rural strategy may lead to the strategy's ongoing improvements designed to increase the rural workforce. METHODS: This is a qualitative study involving semi-structured interviews with purposively selected key stakeholders. Enquiry included the systematic identification of processes required to develop a rural strategy, including possible facilitators and challenges to be addressed. Qualitative analysis of de-identified data was conducted using a thematic approach. RESULTS: Fourteen stakeholders were interviewed: four rural GPs, two rural hospital doctors, four administrators involved in placing students, and four senior medical academics with involvement in the regional and rural programs. Five overarching themes were identified: (1) developing rural pathways into medical school, (2) improving and expanding rural exposures, (3) developing rural GP pathways, (4) implementing interprofessional education and (5) having a social mission. CONCLUSION: These findings align with the literature relating to developing rural strategies for universities. However, this study also suggested that rural health interprofessional programs may have a role. A key finding was that the social mission of a university may not be visible to rural stakeholders. Reorientating an urban-located university to having a rural strategy requires moving past having policy around social accountability to operationalising it.

Engaging with Brown Buttabean Motivation for Sustained Weight Loss.

Context Brown Buttabean Motivation (BBM) is a grassroot Pacific-led organisation aiming to reduce obesity amongst Pasifika (Pacific people in Aotearoa New Zealand) and Indigenous Maori, helping them choose a healthy and active life-style for themselves, their children and their wider family. BBM offers a holistic approach to weight loss, recognising that mental health, family and cultural factors all play essential and critical roles in nutrition and physical activity patterns. Objective To understand how participants experience and engage with BBM. Study Design &; Analysis Qualitative study conducted by our co-design research team within a broader BBM research project. Initial inductive thematic approach followed by theoretical deductive analysis of coded data guided by Pacific Fonofale and Maori Te Whare Tapa Wha health models. In this meeting-house metaphor, the floor is family, roof is culture, house-posts are physical, mental, spiritual and socio-demographic health and well-being, surrounded by environment, time and context. Setting South Auckland, New Zealand 2021 Population Studied BBM participants Instrument Semi-structured interviews Outcome Measures Narrative data Results 22 interviewees (50% female) aged 24-60 years of mixed Pacific and Maori ethnicities. Majority self-reported weight loss (between three and 135kg) since starting BBM. Two researchers independently coded data with adjudication (kappa=0.61) Participants identified the interactive holistic nature of health and wellbeing from BBM. As well as physical, mental and spiritual benefits, BBM helped many re-connect with both their family and their culture. BBM is seen as a new way of life. Participants "immediately belong to BBM family" regardless of culture or size, "with no judgements" and adopt the BBM motto "no excuses". Conclusions Many weight loss studies provide programmes to improve physical exercise and nutrition, but seldom address sustainability and other core factors such as mental health and motivation. BBM is a community-embedded Maori and Pasifika-led intervention, with no reliance on researchers nor external authorities for its ongoing implementation. It addresses factors impacting participants' lives and social determinants of health, including vaccination drives, food parcels and adapting to the COVID-19 pandemic and lockdowns. Our three-year longitudinal cohort study assessing sustained weight loss is ongoing.

Teaching medical students in general practice when conducting remote consults: a qualitative study.

BACKGROUND: Telehealth involves real-time communication (telephone or video-call) between patients and health providers. The COVID-19 pandemic propelled general practitioners to conduct most consultations remotely, seeing patients face-to-face only when required. Placement opportunities and experience for medical students were reduced. Initially online learning programmes replaced clinical attachments. Subsequently, clinical teachers supervised students to engage in remote consultations, either in clinics or from their homes. This study aimed to explore the experience of New Zealand general practitioners undertaking clinical teaching with medical students when telehealth consulting. METHODS: Semi-structured interviews with general practitioners who had taught medical students whilst consulting remotely. General inductive thematic analysis of transcribed interviews. RESULTS: Six female and four male participants aged 40 to over 65 years. Participants often focused on general practicalities of telehealth consultations and effects on the patient-doctor relationship, and needed direction to consider remote consultations with students, which added to the interactions. Four themes were identified: changes needed in teaching delivery format; direct comparison with face-to-face; challenges and advantages to remote teaching, each with subthemes. DISCUSSION: Clinicians needed to determine practical logistics and develop skills for both remote consulting and teaching. New format and structures of consultations needed planning. Differences from face-to-face teaching included scene-setting for the consultation and supervision factors. Telehealth teaching conferred new opportunities for learning but also challenges (e.g. consent, cues, uncertainty). Remote consultations are likely to remain a significant mode for doctor-patient interactions. Preliminary guidelines for teaching and learning using telehealth need to be developed and embedded into medical programmes and then evaluated.

Co-designing an intervention to prevent rheumatic fever in Pacific People in South Auckland: a study protocol.

BACKGROUND: Rheumatic fever is an autoimmune condition that occurs in response to an untreated Group A Streptococcus throat or skin infection. Recurrent episodes of rheumatic fever can cause permanent damage to heart valves, heart failure and even death. Maori and Pacific people in Aotearoa New Zealand experience some of the highest rates globally, with Pacific children 80 times more likely to be hospitalised for rheumatic fever and Maori children 36 times more likely than non-Maori, non-Pacific children. Community members from the Pacific People's Health Advisory Group, research officers from the Pacific Practice-Based Research Network and University of Auckland researchers identified key health priorities within the South Auckland community that needed to be addressed, one of which was rheumatic fever. The study outlined in this protocol aims to co-design, implement, and evaluate a novel intervention to reduce rheumatic fever rates for Pacific communities in South Auckland. METHODS: This participatory mixed-methods study utilises the Fa'afaletui method and follows a three-phase approach. Phase 1 comprises a quantitative analysis of the rheumatic fever burden within Auckland and across New Zealand over the last five years, including sub-analyses by ethnicity. Phase 2 will include co-design workshops with Pacific community members, families affected by rheumatic fever, health professionals, and other stakeholders in order to develop a novel intervention to reduce rheumatic fever in South Auckland. Phase 3 comprises the implementation and evaluation of the intervention. DISCUSSION: This study aims to reduce the inequitable rheumatic fever burden faced by Pacific communities in South Auckland via a community-based participatory research approach. The final intervention may guide approaches in other settings or regions that also experience high rates of rheumatic fever. Additionally, Maori have the second-highest incidence rates of rheumatic fever of all ethnic groups, thus community-led approaches 'by Maori for Maori' are also necessary. TRIAL REGISTRATION: The Australian New Zealand Clinical Trial Registry has approved the proposed study: ACTRN12622000565741 and ACTRN12622000572763 .

Study protocol for evaluating Brown Buttabean Motivation (BBM): a community-based, Pacific-driven approach to health.

BACKGROUND: Buttabean Motivation (BBM) is a Pacific-led organisation which aims to reduce obesity amongst Pacific and Maori people in New Zealand enabling them to choose a healthy and active life-style for the duration of their lives, their children, their wider family and the community. BBM offers a holistic approach to weight loss, recognising that mental health, family and cultural factors all play essential and critical role in nutrition and physical activity patterns. This study aims to evaluate the effectiveness of BBM for sustained health and wellbeing outcomes among its predominantly Pacific and Maori participants for both general BBM members and those with morbid obesity attending the 'From the Couch' programme. METHODS: Quasi-experimental pre-post quantitative cohort study design with measured or self-reported weight at various time intervals for both cohorts. Weight will be analysed with general linear mixed model for repeated measures, and compared with a prediction model generated from the literature using a mixed method meta-analysis. The secondary outcome is change in pre- and post scores of Maori scale of health and well-being, Hua Oranga. DISCUSSION: Multiple studies have shown that many diet and physical activity programmes can create short-term weight loss. The fundamental question is whether BBM members maintain weight loss over time. In New Zealand, Pacific and Maori engagement in health enhancing programmes remains an important strategy for achieving better health and wellbeing outcomes, and quality of life. Internationally, the collectivist cultures of indigenous and migrant and minority populations, living within dominant individualist western ideologies, have much greater burdens of obesity. If BBM members demonstrate sustained weight loss, this culturally informed community-based approach could benefit to other indigenous and migrant populations. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12621000931875 (BBM general members) First submitted 10 May 2021, registration completed 15 July 2021. ACTRN12621001676808 7 (From the Couch) First submitted 28 October 2021, registration completed 7 December 2021.

A qualitative study of patient perspectives of diabetes and diabetic retinopathy services in Vanuatu.

ISSUE ADDRESSED: Diabetes mellitus is an increasing global health problem, particularly in Vanuatu, where it poses a major health burden. There is paucity of information on how patients in Vanuatu perceive diabetes, diabetic retinopathy, access to services and management, health promotion and intervention services to alleviate the issues. This study aimed to explore the perceptions of diabetic patients in Vanuatu on these issues, to help inform the design of health promotion materials and community activities to empower people to self-manage and shape diabetic services that are integrated and people-centred. METHODS: Qualitative Talanga and Kakala Pacific research methodologies were applied. Participants were diabetic patients from both urban locations and rural villages in Vanuatu. Data were collected from four (two male, two female) focus group interviews and thematically analysed. RESULTS: There were 26 participants. System failures became apparent, including the inability of the health care services to meet the complex needs of patients with diabetes. The protective factors to reduce the risk and increasing incidence of diabetes and diabetic retinopathy included comprehensive village-based health promotion and community development programmes at the primary prevention level. CONCLUSION: This study described patients' experiences of their diabetic care and identified key barriers and facilitators of service delivery pathways. SO WHAT?: Vanuatu needs to expand nationwide health promotion and education programmes on nutrition and exercise, food insecurity and access through trade agreements and provide well-trained nursing and medical specialists for early diagnosis and adequate management of diabetes that all people can access and afford.

COVID-19 impact on New Zealand general practice: rural-urban differences.

INTRODUCTION: In countries such as New Zealand, where there has been little community spread of COVID-19, psychological distress has been experienced by the population and by health workers. COVID-19 has caused changes in the model of care that is delivered in New Zealand general practice. It is unknown, however, whether the changes wrought by COVID-19 have resulted in different levels of strain between rural and urban general practices. This study aims to explore these differences from the impact of COVID-19. METHODS: This study is part of a four-country collaboration (Australia, New Zealand, Canada and the USA) involving repeated cross-sectional surveys of primary care practices in each respective country. Surveys were undertaken at regular intervals throughout 2020 of urban and rural general practices throughout New Zealand. Five core questions were asked at each survey, relating to experiences of strain, capacity for testing, stressors experienced, types of consultations being carried out and numbers of patients seen. Simple descriptive statistics were used to analyse the data. RESULTS: A total of 1516 responses were received with 20% from rural practices. A moderate degree of strain was experienced by general practices, although rural practices appeared to experience less strain compared to urban ones. Rural practices had fewer staff absent from work, were less likely to use alternative forms of consultations such as video consultations and telephone consultations, and had possibly lower reductions in patient volumes. These variations might be related to personal characteristics of rural as compared to urban practices or different models of care. CONCLUSION: New Zealand rural general practice appeared to have a different response to the COVID-19 pandemic compared to urban general practice, illustrating the significant strengths and resilience of rural practices. While different experiences from COVID-19 might reflect differences in the demographics of the rural and urban general practice workforce, another proposition is that this difference indicates a rural model of care that is more adaptive compared to the urban one. This is consistent with the literature that rural general practice has the capacity to manage conditions in a different way to urban. While other comparable countries have demonstrated a unique rural model of care, less is known about this in New Zealand, adding weight to an argument to further define New Zealand rural general practice.

Design and implementation of a Pacific intervention to increase uptake of urate-lowering therapy for gout: a study protocol.

BACKGROUND: Gout is a painful chronic disease which disrupts work and family life and can lead to chronic joint damage. Pacific people in Aotearoa/New Zealand experience significant inequities, with over three times the gout prevalence of the non-Pacific non-Maori populations. Pacific people receive less regular urate-lowering drugs to prevent gout flare-ups, and have nine times the hospitalisation from gout compared with non-Pacific non-Maori people. Rates for Indigenous Maori lie between Pacific and non-Pacific non-Maori. A long-established Collective comprising community members from the Pacific People's Health Advisory Group, clinical staff from the Pacific Practice-Based Research Network, and University of Auckland researchers have identified that improving Pacific urate-lowering therapy use as the research question of prime importance for improved health outcomes of Pacific people in South Auckland. Building on the existing knowledge, this study aims to develop, implement and evaluate a novel innovative intervention to improve the uptake of urate-lowering therapy by Pacific patients with gout. METHODS: Three-phase mixed methods co-design study using the Fa'afaletui research framework following the STROBE statement. Phase1 is observational times series of prevalence of patients with gout, proportion with urate blood-level monitoring and use of urate-lowering medication over past 5 years. In Phase 2 the Collective will workshop new interventions to address previous uptake barriers, using culturally-appropriate Talanga communications with results synthesised in line with Kakala principles. The designed intervention will be implemented and process and outcome evaluations conducted. Finally, an implementation framework will be produced to facilitate further roll-out. DISCUSSION: The study aims to enhance health and reduce inequities for Pacific people, contribute to creation of Pacific health knowledge and translation of research findings into Pacific health gains. Potential longer-term impact is a gout-management pathway for use throughout Aotearoa/New Zealand. Maori have similar issues with high gout prevalence and low urate-lowering therapy use hence the intervention is likely to translate to Maori healthcare. The project will contribute to Pacific research capacity and capability-building as well as general upskilling of community and practice members involved in the co-design processes. TRIAL REGISTRATION: The Australian New Zealand Clinical Trial Registry is in process, request number 38206, 1-09-2021.

New Zealand health system: universalism struggles with persisting inequities.

New Zealand was one of the first countries to establish a universal, tax-funded national health service. Unique features include innovative Maori services, the no-fault accident compensation scheme, and the Pharmaceutical Management Agency, which negotiates with pharmaceutical companies to get the best value for medicines purchased by public money. The so-called universal orientation of the health system, along with a strong commitment to social service provision, have contributed to New Zealand's favourable health statistics. However, despite a long-standing commitment to reducing health inequities, problems with access to care persist and the system is not delivering the promise of equitable health outcomes for all population groups. Primary health services and hospital-based services have developed largely independently, and major restructuring during the 1990s did not produce the expected efficiency gains. A focus on individual-level secondary services and performance targets has been prioritised over tackling issues such as suicide, obesity, and poverty-related diseases through community-based health promotion, preventive activities, and primary care. Future changes need to focus on strengthening the culture and capacity of the system to improve equity of outcomes, including expanding Maori health service provision, integrating existing services and structures with new ones, aligning resources with need to achieve pro-equity outcomes, and strengthening population-based approaches to tackling contemporary drivers of health status.

Equivalency of the diagnostic accuracy of the PHQ-8 and PHQ-9: a systematic review and individual participant data meta-analysis.

BACKGROUND: Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9. METHODS: We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy. RESULTS: 16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (-0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01). CONCLUSIONS: PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.

The Accuracy of the Patient Health Questionnaire-9 Algorithm for Screening to Detect Major Depression: An Individual Participant Data Meta-Analysis.

BACKGROUND: Screening for major depression with the Patient Health Questionnaire-9 (PHQ-9) can be done using a cutoff or the PHQ-9 diagnostic algorithm. Many primary studies publish results for only one approach, and previous meta-analyses of the algorithm approach included only a subset of primary studies that collected data and could have published results. OBJECTIVE: To use an individual participant data meta-analysis to evaluate the accuracy of two PHQ-9 diagnostic algorithms for detecting major depression and compare accuracy between the algorithms and the standard PHQ-9 cutoff score of ≥10. METHODS: Medline, Medline In-Process and Other Non-Indexed Citations, PsycINFO, Web of Science (January 1, 2000, to February 7, 2015). Eligible studies that classified current major depression status using a validated diagnostic interview. RESULTS: Data were included for 54 of 72 identified eligible studies (n participants = 16,688, n cases = 2,091). Among studies that used a semi-structured interview, pooled sensitivity and specificity (95% confidence interval) were 0.57 (0.49, 0.64) and 0.95 (0.94, 0.97) for the original algorithm and 0.61 (0.54, 0.68) and 0.95 (0.93, 0.96) for a modified algorithm. Algorithm sensitivity was 0.22-0.24 lower compared to fully structured interviews and 0.06-0.07 lower compared to the Mini International Neuropsychiatric Interview. Specificity was similar across reference standards. For PHQ-9 cutoff of ≥10 compared to semi-structured interviews, sensitivity and specificity (95% confidence interval) were 0.88 (0.82-0.92) and 0.86 (0.82-0.88). CONCLUSIONS: The cutoff score approach appears to be a better option than a PHQ-9 algorithm for detecting major depression.

View From the Canoe: Co-Designing Research Pacific Style.

In 2016, Rose Lamont and Tana Fishman were the first patient-clinician dyad from outside North America to attend the North American Primary Care Research Group (NAPCRG) Patient and Clinician Engagement Program workshop. They returned to New Zealand inspired and formed the Pacific People's Health Advisory Group and a Pacific practice-based research network (PBRN). They are guided by the principles of co-design, and the Samoan research framework fa'afaletui, which emphasizes a collective approach and importance of reciprocity and relationships. Their collective inquiry aims to reduce health inequalities experienced by Pacific people in South Auckland. Their community group members and PBRN are generating research questions being answered by university-based graduate students. When they embarked, they knew not the direction in which they headed. With guidance, their community members and clinicians have led the way. By giving everyone a say in where they are going and how they get there, they are modeling what they wish to achieve-an egalitarian approach which decreases disparities for Pacific people.

Youth version, Case-finding and Help Assessment Tool (YouthCHAT): An electronic, psychosocial screener for young people with long-term physical conditions.

AIM: This study investigated the acceptability, clinical utility and preliminary effectiveness of Youth version, Case-finding and Help Assessment Tool (YouthCHAT), a novel electronic, tablet-based screener designed to identify issues similar to Home, Education/Employment, Activity, Drugs, Sexuality, Suicide/Depression, Safety assessment. METHODS: YouthCHAT was administered to a group of 30 young people aged 13-17 years with different long-term physical conditions attending outpatient clinics between September and December 2017. Outcome measures were: (i) acceptability and feasibility of YouthCHAT as assessed via feedback from young people and clinicians and the time taken to complete YouthCHAT screening; and (ii) detection rates for each domain of YouthCHAT measured by mental health or life-style issues 'present' or 'absent', and where relevant, validated symptom scores. RESULTS: YouthCHAT was quick to administer and positively received by both young people and clinicians. Rates of anxiety (37%) and depression (13%) detected using YouthCHAT were similar to those in previous studies of young people with long-term physical conditions. Rates of other problems were similar to a previously screened high school sample. CONCLUSIONS: YouthCHAT is a viable and acceptable psychosocial screener with the potential to improve the holistic care of young people with long-term physical conditions attending outpatient clinics. TRIAL REGISTRATION: This study has been registered with the Australian New Zealand Clinical Trials Network Registry ACTRN12616001243404p.

Digital Health Tools and Patients With Drug Use Disorders: Qualitative Patient Experience Study of the Electronic Case-Finding and Help Assessment Tool (eCHAT).

BACKGROUND: One of the promises of digital health is to better engage patients and improve care for vulnerable populations. Patients with drug use disorders are a vulnerable population who often do not receive the care they need, both for their drug use disorders as well as their other health care needs. Appropriate primary care for patients with drug use disorders needs to be patient-centered, holistic, highly accessible, and engaging. The electronic Case-finding and Help Assessment Tool (eCHAT) was designed as a patient-centered tool for the identification and measurement of problematic health behaviors and mood states. OBJECTIVE: The aim of this study was to explore the patient experience of eCHAT at an Australian family medicine clinic for patients with drug use disorders. METHODS: A total of 12 semistructured interviews were conducted with patients, two interviews were conducted with doctors, and one focus group was conducted with patient advocates who were former patients of the clinic where the study took place. The transcripts were analyzed using inductive thematic analysis. RESULTS: The key themes identified from the interviews and the focus group were as follows: (1) eCHAT helped reduce stigma related to drug use in the doctor-patient consultation, (2) restricted answer options impacted the ability of patients to tell their stories, (3) patient-related response factors, (4) increased efficiency in the consultation process, and (5) divergence in level of concern around security and privacy. CONCLUSIONS: eCHAT has the potential to help vulnerable patients in primary care to engage more with their doctors and reduce experiences of stigma. eCHAT may be a useful digital health intervention in a family medicine clinic for patients with drug use disorders. It has the potential to improve patient engagement and access to health care, which are crucial areas of need in this vulnerable population. However, it is important to clearly communicate the privacy risk of digital health tools and to implement eCHAT such that it will add value to, rather than displace, in-person consultations with the family doctor.

Correction: Comparison of YouthCHAT, an Electronic Composite Psychosocial Screener, With a Clinician Interview Assessment for Young People: Randomized Trial.

[This corrects the article DOI: 10.2196/13911.].

Is Reflective Learning Visible in Online Discussion Forums for Medical Students on General Practice Placements? A Qualitative Study.

Problem: Reflection is important for lifelong learning and professional development, and discussion forums have been highlighted as a potential platform for enhancing reflection further through peer interaction and teacher feedback. Forums provide students on general practice (GP) placement the opportunity to engage in collaborative reflective learning despite their geographical isolation and disparate schedules. This case report seeks to explore whether online discussion forums demonstrate community presence and reflective learning among medical students on GP placement. Intervention: Online discussion forums were introduced into the curriculum for University of Auckland Year 5 and 6 medical students on their respective 4- and 6-week GP placement. Via asynchronous posts and comments, groups of eight students on average presented cases and experiences for discussion with peers and an overseeing GP faculty member. Context: Students were dispersed across a large geographical area and were unlikely to have peer contact in their assigned practices. Online discussion forums were implemented for a number of reasons, including facilitating reflective learning. An adapted community of inquiry framework was used to investigate the cognitive, social, and teacher presence elements visible in the discussion forum transcripts of unanimously consenting groups. Content analysis of the transcripts was performed to evaluate the presence and quality of reflective learning. Impact: The forums were predominately student-led with relatively scarce comments by GP faculty facilitators. The majority of cases and experiences presented related to clinical management of patients and dissonance triggered by the on-site supervisor's actions. Ideas, knowledge, and understanding of presented encounters were shared and built on by positive and supportive interaction, broadening students' perspectives and, at times, leading to the formation of solutions. However, students' reflection was mostly superficial. Deep reflection was rarely present, and affective dimensions of reflection were disclosed relatively less than clinical cognitive aspects of reflection. Direct instruction, based on prior experience and pedagogical expertise, was the main form of comment made by faculty facilitators, who prompted with questions to a far lesser extent. Lessons Learned: Online discussion forums appeared to enable medical students on GP placement to interact positively with peers and faculty facilitators. However, deep reflection was not reached. Modifying the discussion forums to facilitate more peer interaction and addressing the barriers that limit faculty facilitation may encourage deeper and more affective reflections.

Provision of e-learning programmes to replace undergraduate medical students' clinical general practice attachments during COVID-19 stand-down.

Senior medical students at the University of Auckland, New Zealand spend most of their learning time in clinical attachments. Experiential apprentice-style training is traditionally recognised as an important aspect of obtaining competency. In March 2020 they were stood down from their general practice placements in the context of a national response to the COVID-19 pandemic. Acute conversion of their general practice education from experiential clinical exposure to online and offsite learning was required. This paper describes the steps taken and the underlying theoretical foundations for our expediently developed online course. Our online learning programme has three online components, reflecting the domains of educational environment theory: asynchronous discussion forums; a symposium facilitating social interactions and teacher presence, and a portfolio facilitating personal goal aspects. The latter is underpinned by a multi-theories model of adult learning, built upon the scaffolding framework that supports our entire medical curriculum. Within this theory, we propose a five-stage model of learning. Learning from this experience contributes to the body of knowledge around online education, particularly in meeting the needs of a clinical attachment traditionally grounded in experiential learning. It is hoped that the mechanisms described here might be useful to other educators facing similar challenges.

Determining rural learning outcomes for medical student placements using a consensus process with rural clinical teachers.

Short, longer and programmatic rural attachments have developed in a number of medical programmes around the world. However, there is limited literature on the development of the underpinning learning outcomes to guide these attachments. Rural populations are commonly under-served and the specific needs and challenges of rural health care need to be emphasised, as well as encouraging future practice in these areas. Our aim was to produce common rural-specific learning outcomes, aligned with a rationalisation of existing guiding principles and objectives, for our medical student regional-rural programmes. This was achieved through a Delphi technique involving the relevant clinical teachers and supervisors. Forty-nine consenting participants collectively provided 72 learning outcomes which were synthesised down to 16. A consensus process was used to anonymously rate and then rank to reach consensus for the top four learning outcomes. The learning outcomes were placed within the theoretical framework of a 'pedagogy of place' based on rurality and triangulated with rural learning outcomes from an Australian study. The four final outcomes were resolved around two areas of 'place': geographical and developmental. The co-design approach enabled those involved in providing the rural exposure education to generate appropriate learning outcomes.

New Zealand general practice registrars' views on their academic learning needs during vocational training: online survey.

Most doctors working in New Zealand general practice undertake vocational training through the Royal New Zealand College of General Practitioners. We aimed to explore general practice registrar views on their academic learning needs during and following vocational training. An online survey of all current NZ GP trainees in 2019 was completed by 314 registrars (54% response rate). The majority (88%, 275/314) were completing RNZCGP Fellowship only, and of these half (55%, 152/275) were planning a further postgraduate qualification. A minority (12%, 33/275) indicated a desire to undertake a masters or PhD degree. Almost all (99%, 310/314) intended to work in general practice; 9% (8/314) intending to also work as rural hospital doctors. The five most common areas of interest for further training were clinical skills (68%), practice-based teaching (66%), specific clinical conditions (63%), age or life-stage specific (47%) and non-clinical areas (41%). There is a considerable gap between completing RNZCGP Fellowship, intending to undertake further (formal postgraduate) education and actually enrolling. This is concerning given the need for lifelong learning and critical evaluation of practice and health service delivery. The future New Zealand general practice workforce needs GPs to be diverse and highly skilled members or leaders of expert teams.