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Objective: To explore rural general practitioners’ (GPs’) experiences of providing care in rural community hospitals (CHs) in northern Sweden.

Design: An interview study, using qualitative content analysis.

Setting: The study was conducted in Norrbotten and Västerbotten counties in Sweden and included eight rural CHs.

Participants: Semi-structured interviews were conducted in 2018 with 15 rural GPs.

Results: Two themes were identified: ‘Being the hub in the patient’s healthcare pathway’ and ‘Offering person-centred care far from hospital’. CHs are suitable for elderly, multimorbid and end-of-life patients, emphasising proximity, familiarity and discharge planning. They serve as primary care and intermediate hospital care hubs, collaborating with general hospitals and municipal caregivers. The rural GPs interviewed, as generalists, value holistic hospital patient care, and benefit from longitudinal patient knowledge. They highlighted these advantages and the cost-effectiveness of the CH model, arguing that it should be extended to urban regions. The rural GPs described their work situation as stimulating, but role conflicts in tight-knit communities, geographical distances and limited medical resources pose rural-specific ethical dilemmas.

Conclusions: Rural GPs value the holistic generalist perspective of CH care and emphasise the high-quality care that the CH setting enables them to provide. Despite rural-specific ethical dilemmas, they value the CH model and are concerned about its closures.

A school's culture has been shown to influence medical students in their choice of future discipline. Therefore, we aimed to explore the culture towards the general practice discipline, as reflected in comments to medical students from their teachers and clinical tutors. Students in their 6th and 11th terms at the Universities of Umeå and Uppsala participated in a questionnaire study. A qualitative analysis of free-text answers of comments was conducted with thematic analysis. The students reported receiving both appreciative and deprecatory comments about general practice and GPs, which altogether ended up in two head themes: work-related factors and opinions about GPs. Appreciative comments included "important", "varying", "responsible work", "broad skills", and "good working hours". Deprecatory comments included "stressful jobs", "unstimulating routine work", "incompetent doctors", and "low status". Considering the present shortfall of GPs, such deprecatory comments are worrying and could hamper the future recruitment of GPs.

Background: Rural community hospitals (CHs) are vital in delivering healthcare services in sparsely populated regions such as northern Sweden. In Sweden these facilities act as primary care units, staffed by general practitioners (GPs), nurses, and other healthcare professionals. They provide hospital beds, emergency care, and basic diagnostics. The CH model, with GPs responsible for hospital care has not been studied earlier in Sweden. 

Aims: This thesis aimed to examine the role and practices of the Swedish rural CH model within the healthcare system and the local community. Furthermore, to investigate the perspectives of rural doctors in Sweden and New Zealand (NZ) working within their respective hospital models. Specific aims: 

To characterise patients admitted to hospitals in Norrbotten and Västerbotten Regions and to compare hospitalisations at rural community hospitals and general hospitals (Study I)

To describe registered care measures carried out in rural community hospitals during episodes of hospital care for patients with heart failure, in comparison with a general hospital (Study II)

To explore rural hospital doctors’ experiences of providing care in rural hospitals in Southern New Zealand (Study III)

To explore rural general practitioners’ experiences of providing care in rural community hospitals in northern Sweden (Study IV) 

Methods and results: Four original papers form the basis of this thesis. In study I, hospital register data from Norr- and Västerbotten Regions were analysed, focusing on hospital admissions of patients enrolled at CHs 2010-2014. We compared CH admissions with general hospital admissions, examining factors such as age, sex, and diagnoses. CH patients were older than those in general hospitals (median age 80 vs. 68 years), and women had a higher likelihood of admission to CHs compared to men. Common diagnoses in the elderly, such as heart failure and pneumonia were more likely admitted to CHs than to general hospitals. Study II utilized hospital register data from Region Västerbotten to describe registered care measures carried out in rural CHs during episodes of hospital care for patients with heart failure 2015-2019, in comparison with a general hospital. CHs showed documentations by fewer individual doctors, more frequent nursing documentation, and fewer blood tests compared to general hospitals. Radiology, including echocardiography, was performed in general hospitals only but in a minority of cases. Documentation by physiotherapists, occupational therapists, and dietitians was limited in both hospital models.

Studies III and IV involved interviews with rural hospital (RH) doctors in New Zealand (NZ), and rural GPs in northern Sweden, respectively, to explore the role of their RH/CH. In both countries, doctors emphasised advantages with proximity and holistic, patient-centred care for elderly, multimorbid, and end-of-life patients. Their RHs/CHs were described to play a central role in rural patients' healthcare journeys, utilizing small, multidisciplinary teams and collaborating with general hospitals and municipal caregivers. Reported challenges for doctors in RHs and CHs included limited resources and inexperience in handling life-threatening, rare cases, and ethical dilemmas unique to rural practice. Despite this, RH doctors considered RH patient safety similar or better than that in general hospitals. CH doctors prompted the idea of expanding the CH model to urban areas. 

Conclusion: We conclude that CHs admit elderly and multimorbid patients elsewhere common in general hospitals. Care for patients with heart failure at CHs showed more nursing notes, greater doctor continuity, and less biomedical examinations. Our results suggest potential for further development in the multidisciplinary care in both hospital models. Rural generalist doctors in Sweden and NZ emphasise the central role of CHs/RHs, their proximity to patients, and their holistic, generalist approach, and they suggest advantages in the RH/CH care for the elderly compared to general hospitals. In Sweden, the importance of relational continuity was stressed, as rural GPs are familiar with their CH patients from primary care. 

Objective: To explore rural hospital doctors’ experiences of providing care in New Zealand rural hospitals.

Design: The study had a qualitative design, using qualitative content analysis.

Setting: The study was conducted in South Island, New Zealand, and included nine different rural hospitals.

Respondents: Semistructured interviews were conducted with 16 rural hospital doctors.

Results: Three themes were identified: ‘Applying a holistic perspective in the care’, ‘striving to maintain patient safety in sparsely populated areas’ and ‘cooperating in different teams around the patient’. Rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family, the generalist perspective of care and personal continuity. The presentation of acute life-threatening low-frequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience.

Overall, however, patient safety in rural hospitals was considered equal or better than in general hospitals. Doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients, and the advantages and disadvantages with small non-hierarchical multidisciplinary teams caring for patients. Collaboration with hospital specialists was generally perceived as good, although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context.

Conclusions: This study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care, and of how they perceive the quality and safety of that care. The long distances to general hospital care for acute cases were considered concerning.

OBJECTIVE: Patients in Sweden's rural community hospitals have not been clinically characterised. We compared characteristics of patients in general practitioner-led community hospitals in northern Sweden with those admitted to general hospitals.

DESIGN: Retrospective register study.

SETTING: Community and general hospitals in Västerbotten and Norrbotten counties, Sweden.

PATIENTS: Patients enrolled at community hospitals and hospitalised in community and general hospitals between 1 January 2010 and 31 December 2014.

OUTCOME MEASURES: Age, sex, number of admissions, main, secondary and total number of diagnoses.

RESULTS: We recorded 16,133 admissions to community hospitals and 60,704 admissions to general hospitals. Mean age was 76.8 and 61.2 years for community and general hospital patients (p < .001). Women were more likely than men to be admitted to a community hospital after age adjustment (odds ratio (OR): 1.11; 95% confidence interval (CI): 1.09-1.17). The most common diagnoses in community hospital were heart failure (6%) and pneumonia (5%). Patients with these diagnoses were more likely to be admitted to a community than a general hospital (OR: 2.36; 95% CI: 2.15-2.59; vs. OR: 3.32: 95% CI: 2.77-3.98, respectively, adjusted for age and sex). In both community and general hospitals, doctors assigned more diagnoses to men than to women (both p<.001).

CONCLUSIONS: Patients at community hospitals were predominantly older and women, while men were assigned more diagnoses. The most common diagnoses were heart failure and pneumonia. Our observed differences should be further explored to define the optimal care for patients in community and general hospitals.

Background: Umeå University Faculty of Medicine (UUFM), Sweden, has a regionalized medical program in which students spend the final 2½ years of their undergraduate degree in district hospitals. In late 2018, UUFM started a "rural stream" pilot exposing students to smaller rural locations.

Methods: The objectives are to deliver the benefits for medical education and rural workforce development that have been observed in longitudinal integrated clerkships (LICs) while maintaining consistency between learning experiences in the main campus, regional campuses, and rural locations. This article compares the UUFM rural stream with those typical of the LICs described in the medical education literature. Comparisons are made in terms of the four key criteria for LIC success, and additional characteristics including peer and interprofessional learning, "'continuity," and curriculum development.

Results: The rural stream has elements of length, immersion, position in the degree program, and community engagement that are both similar to, and different from, LICs. Key challenges are to ensure that participating students create close relationships with host medical facilities and communities. The rural stream also has some potential advantages, particularly in relation to team learning.

Discussion: Alternatives to the LIC rural stream model as typically described in the literature may be required to allow for immersive medical education to occur in smaller rural communities and to be suitable for medical schools with more traditional approaches to education.