New Zealand postgraduate medical training by distance for Pacific Island country-based general practitioners: a qualitative study

Keywords: Cook Islands, distance education, general practice, medical education, Pacific, postgraduate medical training, remote learning, rural medicine, workforce.

Health Ministries and clinicians of Pacific Island countries play a key role in the development and extension of health workforce training programmes in the Pacific Region.¹ New Zealand health training institutions have an important role in supporting these health workforce programmes, ensuring health disparities are addressed and local capacity is developed. Pacific Island countries, especially the Pacific Realm countries (Cook Islands, Niue and Tokelau), have long-established connections with the New Zealand health system, including patient referral pathways.¹

Postgraduate distance study for health professionals is well established across New Zealand’s academic institutions. The University of Otago’s Rural Postgraduate programme is largely distance-taught (each paper has a 3–5 day in-person residential component) with papers leading to a postgraduate Certificate or Diploma in Rural and Provincial Hospital Practice (PGCertRPHP and PGDipRPHP).² The papers are targeted at New Zealand doctors practicing or training in rural and remote general practice and rural hospital medicine, and are designed to be taken while continuing to work full-time.³ Since 2009, the Rural Postgraduate programme has provided the academic component of the Royal New Zealand College of General Practitioners’ (RNZCGP) vocational Rural Hospital Medicine training programme.⁴ General practice in Pacific Island countries has synergies with rural practice in New Zealand in that the scope of clinical practice may be broader than urban general practice and can include emergency and in-hospital care.⁵

From 2010, the Cook Islands Ministry of Health looked to strengthen its medical workforce in the area of primary health care, but there was no non-specialist or general practice training pathway option through traditional institutions.⁵ This led to the establishment of the Cook Islands General Practice Training Programme in 2015, a Cook Islands Ministry of Health initiative created in partnership with the University of Otago and the RNZCGP.⁵ The academic component of the Cook Islands General Practice Training Programme is provided by the University of Otago through the Rural Postgraduate programme. The second component, New Zealand-based clinical attachments, is provided through the RNZCGP’s General Practice training programme.³ Although some Cook Islands-based doctors have undertaken the formal Cook Islands General Practice Training Programme, others (some of who may subsequently enter a different medical specialty pathway) are studying single papers. Some Cook Islands-based doctors who are engaged in the formal Cook Islands training programme have self-funded their study in various papers.

Individual doctors based in other Pacific Island countries specifically Niue and Samoa, have also completed the University of Otago’s Rural Postgraduate programme papers. Niue’s health directorate is currently establishing its own postgraduate medical pathway incorporating Rural Postgraduate Programme academic papers.

Pacific Island country-based students studying in the Rural Postgraduate programme fall into all three of the ‘Distance’, ‘Pacific’ and ‘International’ cohorts of University of Otago students. All 12 Pacific Island-based students who have enrolled in the Rural Postgraduate programme since 2014 have successfully completed papers. One student has been awarded the Diploma in Rural and Provincial Hospital Practice (PGDipRPHP). Five have been awarded the Certificate in Rural and Provincial Hospital Practice (PGCertRPHP) and are working towards the Diploma.

Although there is national and international literature regarding support for distance students across national borders and across cultures,^6–9 little is known regarding the experiences of postgraduate medical professional students based in the Pacific region and studying at a New Zealand institution by distance.

The qualitative analysis presented here is part of a wider study undertaken to explore ways to improve academic support for Pacific Island country-based students at the University of Otago.¹⁰ The aim of this paper was to explore the experience of these students.

The study employed qualitative methods comprising a document analysis and interviews. Documentary analysis was used to establish background and context regarding the development of University of Otago study for Pacific Island Country-based students, whereas interviews permitted in-depth exploration of student experiences.

The analysis involved key documents from both inside and outside the University of Otago (including Cook Islands and Niue documents) from 2013 to 2019. In total, 18 documents (most in electronic but some in paper form) were identified, including: emails from students and from health ministries, reports, newsletters, media releases and meeting minutes. A qualitative content analysis was conducted according to Bowen’s systemic document review method.¹¹ Document excerpts were collated using descriptive coding, and through an iterative analytical process, overarching themes were identified. N-Vivo (QSR International) was used to manage the analysis.

All 12 Pacific Island country-based students who had undertaken the Rural Postgraduate papers to December 2018 were invited by email to participate in this research. There were four non-respondents, all originally based in the Cook Islands. Of these four, three had completed single papers, were not undertaking the Cook Islands General Practice Training programme and had subsequently entered other medical specialties’ training pathways based at Fiji National University.

Semi-structured interviews were conducted from May to August 2019 by authors AF, MS, and KB. The interview schedule explored the students’ university experience and included questions about paper content and relevance, managing technologies, classroom dynamics and study support. Average interview duration was 45 min and interviews were digitally recorded and transcribed. Transcripts were sent to participants to check accuracy. Interviews were analysed thematically using the framework method by authors KB, AF, and RR.¹² N-Vivo software (version 10) was used to manage the analysis. The two data sets were analysed concurrently but separately and integrated during interpretation.

Ethical approval for the research was obtained from the University of Otago Human Ethics Committee (D19/059). The study received approval from the Cook Islands Ministry of Health.

Sixteen documents were included in the final analysis. Two documents with no relevant codes found were excluded.

Eight students participated, seven in interviews: three face-to-face and four virtually using videoconferencing. Three were individual interviews, whereas two involved pairs of students. One student was unable to attend an interview but sent written responses to the interview schedule questions. Participants were designated a number (1–8) and were referred to throughout the study by this coding. Characteristics of participants are shown in Table 1.

Table 1.  Key characteristics of participants (n = 8).

We identified four themes capturing the main issues. Illustrative participant quotes are presented.

Immediate clinical synergy and applicability of a generalist medical programme with a relevant curriculum, geographical isolation emphasis, delivered mainly by distance and tailored to working professionals, were identified as major strengths:

All the papers were very relevant to my everyday clinical practice here as a doctor. The only difference would be if the investigations or medications suggested were not available locally, for example unavailability of CT scan. (P8)

Clinically … I think the most important thing that I gained was practicing according to evidence base. (P6)

Benefits to individual students had flow-on effects to their wider clinical teams. Although most of the initial perceived benefit was in strengthening clinical knowledge and expertise, non-clinical aspects (communication skills, professionalism, scholarship) became more valued as students progressed.

Many students were better digitally connected than their New Zealand peers and they embraced the distance education modalities. Students found the course structure a good fit with its mix of asynchronous (web-based discussion forums accessible at any time) and synchronous (scheduled videoconferences) distance technology, as well as in-person components:

Zoom has been really good, because you can see the other person. It’s different when you put a face with the name, and then you can see all your classmates…it’s really encouraging. It’s good to see the faces before we actually meet in person, and because some people are there [who] we have already met in previous papers. (P1)

Although technologies did pose some problems, these were generally easily solved by faculty members with experience and expertise in delivery of innovative distance education, well linked to and supported by university information technology services.

Students became part of a wider collegial network with other Pacific-based students and also their New Zealand-based peers, linking to health professional organisations such as the RNZCGP. Gaining a sense of belonging to a community of doctors reduced professional isolation:

I loved the virtual classroom …it was a way where I felt some form of connection to the class, and did not feel so isolated being on the island. I could relate to the scenarios put up as well. (P8)

Yeah, studying …really improved my clinical skills, and also, I gained connections, friends in New Zealand. So, we have good relationships with our New Zealand colleagues, and they come to here and they can see what we have, and so they understand more about us. (P2)

The in-person residential workshops were particularly valued:

Residentials are really important, because it was like seeing people for the first time, rather than through the computer. You get to meet them one-on-one. It’s finally putting something into practice I guess both medical and clinical, but there are scenarios as well that you go through, and it’s helpful in person to discuss. There’s a lot of support amongst students. (P3)

The cohort of Pacific Island-based students were all experienced clinicians, often more than a decade out from undergraduate study and many struggled initially with their return to study.

Personal doubt. You need people beside you just to give you a push as well. So, I had the family push. I had the conveners’ push. The facilitators, and the [local leadership] so you don’t want to let them down…. I really felt that it was just more of an internal challenge, just to get my ‘A into G’ and just get that ball rolling. (P3)

Most students had gained their undergraduate medical degree outside New Zealand and were therefore unfamiliar with the New Zealand education system. However, familiarity and confidence grew for students with consecutive papers as relationships were established, especially when they saw their colleagues managing well. The biggest hurdle was the first paper, especially for the first cohort of students.

I think over time, as I got up to the second paper it became quite comfortable. I think partly to do with the facilitators directing and getting that involvement from us … it was quite nerve-wracking at the beginning, but I think over time the more experience you gain, the better and more comfortable you become. (P1)

Time zone differences (up to 2 h) could make it challenging for the evening synchronous (videoconference) sessions. Some country-specific hidden costs were identified, particularly high internet charges. The slow speed of internet in some countries affected download time for resources, which could be frustrating.

The initial focus of study for the students was on clinical aspects. Specific academic aspects of the papers, such as critical reading and writing, were less familiar and created more anxiety:

You sort of want to put your head in the sand and say, nothing’s wrong…so yeah just that uncertainty of not knowing how to write …requirements about referencing and all that. I was like, well what is that? (P3)

However, as the students felt more confident and supported, they rose to the challenge and saw their skills improving:

Initially I struggled [with formal writing] – that is extra stuff on top of the clinical stuff – [but] for the second paper, it was easier. It doesn’t mean that I wasn’t supported, but I think in the end, it is us, we have to do it, ourselves. (P4)

Challenges arising for the university were associated with providing and effectively delivering study support for the Pacific Island country-based students, who fell outside most established student support systems as they were off-campus and out-of-country. Many university resources were poorly visible and not easily accessible at the point-of-need for this cohort of students.

…most things [emails from Otago University] that I’ve briefly read have related to things happening in Otago [on campus], so I’m just not paying very much attention to them, and if there are things specifically for the Pacific, with support by distance, I’m not really aware of anything in particular. (P7)

Faculty of the distance education Rural Postgraduate programme were experienced in effectively combining academic and personal skills to provide support, and were accessible:

Yeah, not only did you have access during the videoconference, but you also had their emails as well. Also, papers I’ve done have been a lot more… like… supported in a sense – you feel supported, you feel like part of the team. (P3)

The early University of Otago establishment of a Pacific Nations Liaison role provided additional navigation (‘our go-to person’) for both the students and the Rural Postgraduate faculty, linking expertise from senior University of Otago Pacific leadership into the students’ support systems. In this way, programme support and its effective delivery was underpinned by knowledge of the students’ context:

It’s good to know that our [university] facilitators who are taking the papers are aware of our current situation in here and what is available and what isn’t, so that there’s sort of that understanding of the context. (P3)

With no previous option for a General Practice career pathway, access to the academic component of a recognised New Zealand vocational training programme with a relevant curriculum represented a milestone for some Pacific Island countries and for individual doctors:

There were things I could do by distance, but there weren’t post-grad things that I was able to access from here. I only found out at the beginning of last year that this was being done by distance, and that I could actually qualify to enrol in it. That was just a dream come true and definitely I felt, everything in it, helped me. It’s just like… I’m working in the middle of nowhere… (P7)

There was an expectation that the distance nature of the programme with its innovative use of technologies might mitigate, at least to some degree, the loss of medical professionals from some countries.

Cook Islands-based students (for many, their study was part of an in-country training pathway) recognised the support provided by their Ministry of Health and this helped drive their motivation, confidence and performance. For the students, their exposure to general practice as a medical specialty career pathway was a new opportunity and this created a sense of excitement and hope:

…people really didn’t think that General Practice was a specialty. I think it [general outpatient department] was like a place where people just finish from medical school and filled in the gaps. There was no career path for us, unless you wanted to specialise into surgery or medicine or paeds [paediatrics]. (P1)

Students valued consistency in the programme and a clear course of study, as this enabled forward planning. Students strived for qualification completion rather than a single-paper approach.

…as a student, if there is a [supported, structured] pathway, then there is more certainty around what you’re going to achieve at the end of it. (P3)

For students undertaking study as individuals, outside a formal in-country programme, everything (financial costs but also drive and motivation) were the responsibility of the individual.

The University of Otago’s distance-taught Rural Postgraduate programme is relevant, accessible, and achievable for Pacific Island country-based postgraduate students. The programme also provides Pacific countries with part of a solution for general practice vocational training.

Key facilitators for successful study by this cohort of students included the distance nature of education (allowing the doctors to stay in-country), linking to a recognised vocational training programme with clinical practice synergies, available collegial support networks, and the provision of effective and individualised support. Study findings concur with previous research that distance students who have a sense of belonging to a community of learners not only learn more effectively, but are more satisfied.^6,13

Study works best for Pacific Island country-based students when their course of study is aligned with an in-country training pathway, concurring with the literature that sustainable training pathways are likely to be those led by Pacific countries and incorporated into individual countries’ longer-term workforce capacity-building plans.¹

Findings also concur with previous research finding that support in the international, postgraduate distance education context is complex and multi-dimensional, more than simply the provision of a product or service.^6,7 The study extends previous findings that identified a safe learning environment as an important factor for a ‘pedagogy of success’ for New Zealand-based Pacific on-campus tertiary students.¹⁴ Creating a similar safe environment for Pacific Island country-based distance education students is more challenging, but can be achieved using a tailored approach with multiple layers of support, starting inside the programme (in this case the Rural Postgraduate programme), involving the institutions’ Pacific leadership and connecting to the relevant Pacific Island country’s leadership.

Findings highlight the importance, for sustained success for this cohort of students, of both innovative support solutions and ongoing internal and external stakeholder engagement and collaboration. Findings may be transferable to other health professional groups and other distance education programmes.

The small number of interviews was a limitation and, with the majority of documents analysed and interviewees being Cook Islands-based, the transferability of study findings to other Pacific Island countries may be limited.

Further research is needed to evaluate the contribution of this programme of academic study to improving local Pacific Island country workforce capacity.

The list and attributes of data used in the document analysis has not been included for publication, but will be shared upon reasonable request to the corresponding author.

The authors declare no conflicts of interest.

This study was funded through a University of Otago Teaching Development Grant, 2019.