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AMSA RURAL HEALTH RURAL IS THE FUTURE

Issue IV

2019


Contents Letter from the Editor ELLI IZRAILOV

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Introducing the Team FRONTIER! TEAM

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Chair’s Address JACOBA VAN WEES

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FUTURE EDUCATION AND TECHNOLOGY The Effect of Rural Medical Schools in improving Rural Health ELLI IZRAILOV

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AMSA 2020: Advanced Rural Health SARAH CLARK

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Research Connects Rural and Regional Victoria with Gold Standard Stroke Treatment HEATHER PAGRAM

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FUTURE RURAL PLACEMENTS The Road to Rural Placement in South Australia ANDREW BAKER

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A Rural Future for All of Us? JAMIE NICHOLLS

17 Sarah Clark

FUTURE ART

New England New South Wales

Ode to Hume ROSS LOMAZOV

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Tree of Hope: Stronger Rural Health through Collective Collaboration MERRYL RODRIGUES AND VAISHALI NAIR

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Contents FUTURE INDIGENOUS HEALTH Jacinta Power ELANOR GREGORY

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Broadening the Lens: Recognising and Embracing the Aboriginal and Torres Strait Islander Understanding of Health JACQUELINE BREDHAUR

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A True Calling ELANOR GREGORY

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FUTURE WOMEN’S HEALTH Management of Obstetric Complications in Regional Hospitals: A Case Report on Antepartum Haemorrhage BRIGID KING

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Time to Deliver on Rural Maternity Services ILLIE HEWITT

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Tales from the Top End KATIE BLUNT

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Sarah Clark

New England New South Wales


Letter from the Editor Elli Izrailov Monash University (III) chance to impact and shape the world we live in. And in terms of rural health within Australia, the theme became quite simple – ‘Rural is the Future’. How will Rural Health change in the next ten to twenty years? What changes will we see in the landscape? How will Rural Health be different to what it was at the turn of the millennium? Well in the 2019 edition of Frontier! we will be exploring that question, with an emphasis on Indigenous Health, Education, and Women’s Health. So, before I let you off and scamper away there’s a few people who need to be thanked. I would like to thank and congratulate all of our contributors for their high-quality submissions. Thank you to all of our photographers who’ve submitted their pictures showcasing Rural Australia which will appear throughout the entirety of this edition.

Welcome one and all to the 2019 Edition of Frontier! I am unbelievably excited to share this magazine with you, which is the fourth ever edition of Frontier! and what I hope will be a worthy successor in a line of quality publications.

I’d like to thank our publishers at SpotPress. I extend my appreciation and thanks to Jia He, the photographer of our Mt. Kosciusko cover, which perfectly captures our theme ‘Rural is the Future’.

When the AMSA Rural Health Publications Subcommittee sat down to discuss a theme for this year’s edition, a number of subjects ran through my mind.

Finally, thank you to the Publications Subcommittee, Bree Gardoll, Heather Pagram, Ross Lomazov, and Tu-An Ma who worked so hard on this edition of Frontier! to produce what I think is an incredible piece of work.

The 2018 edition by my predecessor, Marisse Sonido, was themed ‘This is Rural’. Having that theme in mind and coming to grips that we are now in the year 2019, which obviously means that 2020 is soon approaching, I began to think that the world is entering the ‘Next Twenties’. Rather than the America-centric ‘Roaring Twenties’, we are at the cusp of a new era.

Please enjoy, please share with your friends, and please think about how you can have an impact on shaping the ‘Next Twenties’. #ruralisthefuture

In another twenty years time, when people will be referring to ‘The Twenties’ will people reply “Which Twenties? The Roaring Twenties or?...” And this thought spiralled into how we – we as medical students, we as Generation Z and Millennials – have a

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Introducing the team Ross Lomazov I’m a 2nd year medical student from the University of Melbourne, and currently make up 50% of the Wangaratta Jewish community. When not saving lives in the ED with my 60% cannulation success rate, I’m involved in various committees and organisations, usually to the detriment of my future Z-score. My main interest for rural and remote health stems from my deep love for the RM Williams and Akubra brands. After all, what’s the point of being a rural medical student if people can’t see it?

Heather Pagram It was too easy to become passionate about regional and rural health, even though I grew up in suburban Perth! This aspect of Australian healthcare is so unique, and one has a sense that you are contributing to and becoming a part of a small community. Being able to explore the surrounding country and wilderness in one’s down time is an added bonus!

Bree Gardoll I’m a 4th year medical student at UNSW. Originally hailing from Southern Queensland, I endured endless heckling around recent State of Origin’s after the Sunshine State’s fall from #8inarow grace. Staying true to my townie rural roots, I’m member of the Country Women’s Association and much prefer learning how to advocate for rural communities over learning anatomy. I also loves racking up the kilometres on Doris, my beloved Pajero, and taking roadtrip pictures.

Tu-An Ma Been an urban ‘gal’ for 18 years straight, but something about rural medicine, I really can relate… To. Perhaps, wait... perhaps it’s being able to bring your skills to a place of need – Or – Exploring the hills, Rurality is beautiful indeed! (and contrary to popular belief it’s not just trees and leaves) So hear me out, come in come in, Just don’t listen to the haterz. Even though I’m a fresh baby-faced pre-clin Rural Australia: I’ll see ya laterz!

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Report from the chair Jacoba Van wees Monash University (IV)

For myself, 2019 has been the most challenging yet rewarding year so far. My time as Chair of AMSA Rural Health has been a steep learning curve in leadership, public speaking and political landscapes, but it’s also been humbling and inspiring.

None of these achievements would have been possible without the hard work and passion of the people within the AMSA Rural Health Committee. I am extremely honoured to have been able to work alongside the most passionate, dedicated and hard working group of students throughout this year, and I congratulate them all for the success of AMSA Rural Health in 2019.

In the wake of a federal election, some of the big issues in rural health have included the ongoing closures of rural maternity services and service centralisation, lack of access to specialist services among rural communities, the ongoing issue of rural workforce maldistribution; and how to incentivise students and junior doctors to #gorural.

Congratulations to Dan Mahon, Keegan Coomer, and the whole Rural Health Summit team for creating a unique, creative and inspiring conference to highlight the challenges, diversity and excitement that is rural health. An enormous thank you to Elli Izrailov and the publications subcommittee for their hard work in putting together this year’s incredible edition of Frontier, which is a wonderful showcase of all rural health has to offer!

AMSA Rural Health has certainly had a busy year - there’s been trips to Canberra to meet with the Department of Health regarding the changes to the Bonded Medical Places scheme, advocating for greater supports for bonded medical students. We’ve discussed rural workforce shortage issues with a number of national bodies, including the AMA Council of Rural Doctors.

In summary, the title of this year’s Frontier could not be more accurate - the future is rural, and I cannot wait to see how AMSA Rural Health expands and grows in the future. As I near the end of two years with the AMSA Rural Health family, I encourage every single one of you to apply for a role within AMSA Rural Health for the chance to learn more about rural health, connect with other like minded students, fuel your passion for rural medicine and inspire others to #gorural.

We’ve supported the push for increased research into rural health, and have committed to undertaking primary research into rural clinical placements and student perceptions of speciality training, with the aim of contributing to evidence based solutions for some of the big issues in rural health. AMSA Rural Health has been represented at state and national conferences, and attracted positive media attention through opinion pieces and media releases. We’ve debated mandatory rural placements within medical schools, and challenged views on rural internships. There’s been a strong rural health theme incorporated into all of AMSA’s major events, helping to increase broader student awareness of rural health issues.

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Elli Izrailov

Noojee Victoria

Future Education and Technology


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The Effect of Rural Medical Schools in Improving Rural Health Elli Izrailov Monash University (III) I recently had the pleasure of speaking to Associate Professor Shane Bullock, Deputy Head of the School of Rural Health at Monash University and Director of the Graduate Entry Pre-Clinical Year. What about? In essence, the effect that Rural Medical Schools (RMS) have in improving Rural Health.

undergraduate and first year postgraduate students. As the Deputy Head of the School of Rural Health his roles are broader, but he primarily supports the Head of School in terms of administration. Unfortunately, this interview has been abridged for spacing purposes. However, in terms of providing context to the entry point of this interview I feel as if a quick summary is needed. Shane and I discussed whether SRHs had a greater impact on rural or metro students – Shane stated that for some rural students these schools may strengthen their connection to their hometowns or to rural health in general, and for metro students these schools may open up their eyes to a new lifestyle they may come to find attractive. However, we need to acknowledge that isn’t the case for all students, as some rural students may want to move and some metro students will also want to return to the city.

But why Shane? Well, I was a student at the Monash School of Rural Health (SRH) Churchill campus in 2018, where Shane is currently the Director. I was impressed by his knowledge of Rural Health issues, as well as his experience teaching at Rural Medical Schools. So when it came to the theme ‘Rural is the Future’ I thought I’d reach out to him to discuss the impacts RMS are having, and what changes can be foreseen in the future.

Shane has found that couples who have come together in a rural setting, and who have both developed a rural perspective, are more likely to stay rural. However, life is not that simple. For some, life decisions pull them towards the city. For example providing their children with the perceived best possible education opportunities or conducting their specialty training in a metro setting.

Before we get into things, let me tell you a bit about Associate Professor Shane Bullock. Shane was born (I didn’t ask when) in Melbourne, and grew up “…in Clayton in the shadow of Monash University.” Shane ended up studying at Monash, completing his Bachelor of Science, his Honours, and then a PhD in “the development of brain asymmetry for the control of sexual and aggressive behaviour in the young domestic chicken.”

I suppose the solution of match-making in early years at Monash, for example, would potentially be an answer to the death of the ‘super-doctor’ in rural communities, who’ve sacrificed their entire lives to just treat the community.

Following the completion of his PhD, Shane thought that education was an area that he had some skills in and that he should pursue. He scored himself a position in what is now the Australian Catholic University (previously the Institute of Catholic Education), where he started teaching Science to Nursing and Science students. He left that position after some time and moved to James Cook University, “…primarily, to teach medical students pharmacology.” From that position at James Cook he transitioned to the Gippsland Medical School, which is now Monash SRH (Churchill), in their first year of teaching Monash Graduate Entry students back in 2008 “I came onboard and have been here ever since.”

I don’t think rural practice is like that these days. I think people have a different perspective as to what they want from their lives and may not accept that ‘I am the sole doctor within this town and I am going to practice here for my entire career.’

Shane is still teaching pharmacology to first year Monash Graduate Entry students, but he’s also the Director of the Monash SRH (Churchill). His primary role is to supervise and coordinate with his Direct Entry counterpart to ensure an alignment in education between first and second year

Australian medical schools still face challenges in creating a completely sustainable workforce within rural and regional Australia. My sense is that generally, society has changed; it’s not just about a medical career or practicing rurally.

Over the past how-many-ever-years, it seems as if the culture among medical students and doctors has changed from investing your entire life into medicine, to having medicine, as well as having your own personal life and trying to strike a balance there. In terms of cultures over the past few years, has the prospect of practicing rurally become more popular over time?

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Interview

Society’s changed about how people devote themselves to their work versus what they want out of their personal lives. What’s been happening in medicine just mirrors that general thing that people want the right balance between their lives and their workplace. It’s not just about medicine. It’s a societal change. It’s a cultural change. And young people are less inclined to make those sacrifices for their workplace, they want to make sure the balance is right there for their total lives. At least for helping improve a completely sustainable rural workforce, would that require having changes in the infrastructure of rural towns? Being able to foster a more ‘bubbly’ lifestyle, which encourages more people to stay? Well I think that’s true. There are some towns within Gippsland [Victoria] where you wouldn’t have trouble attracting a young couple. Let’s say one of the partners wants to work as a doctor, there are some towns that are livelier and more energetic, and there’s culture and there are some good schools not far away – it’s easy to attract people to those kind of areas. It’s more of a challenge when you go further out and more remote. To towns such as Mafra or Orbost, which are further away from the regional centres of Warragul, Traralgon, and Sale [Gippsland, Victoria]? They can be fantastic places to have medical training experience for a period of time, and students have talked about how great they were, but to attract students to practice there post-graduation is still a challenge. This is not the fault of these communities or the clinical practices there, who continue to offer interesting clinical work and great support to young doctors. It’s about perceived remoteness. What other barriers have you seen in your time to getting doctors to practice in rural areas? A major impediment has been the opportunities to specialise and do your specialty training within a rural or regional area. Most of the colleges insist that for the majority of the time during your specialty training, you be based in a metro hospital or a metro setting. And I believe there also is a big demand to increase the number of obstetric physicians. Especially because of the waiting times that some couples have to face to get to a hospital in order to have a safe delivery. The government, the universities, the hospitals, and the specialty Colleges are getting better at making partnerships. And the government’s done good work in terms of the initiative of the training hubs. I think [the training hubs] have a role in facilitating and bringing the colleges and hospitals together to have that conversation about what we need to do to flick the switch for someone who’s committed to rural. Is it possible to do less time in metro when taking part in a four year training program? Can we provide more training places? That would be very attractive in terms of keeping people in a rural setting.

A lot of it does sound like there needs to be changes to physical structures of rural communities as well as the infrastructure of medical courses further down the line. That starts before we get students into medical schools. In a rural environment there are certain disadvantages (access to teachers and other resources) to kids at school. I think we see the pipeline beginning there and not at medical school; creating the right environment, persuading students in secondary schools in particular that you can apply, even if you don’t get a top ATAR, and have a good chance of getting into Medicine. Do you believe that universities are doing enough for those students from a rural background to support them once they’re inside the medical courses? We have to support all students coming into medicine, it’s a very demanding course. The Monash course is quite good at supporting medical students, particularly school leavers. There are lots of good resourcing at the major campuses. You’ve been through a number of medical schools through your career, have you found that different medical schools around the country can learn from one another’s adversities? Especially tackling the problem of increasing a sustainable rural workforce? In fact, the SRHs that are associated with the Australian Medical Schools have a collaborative group called FRAME (Federation of Rural Australian Medical Educators). We get together regularly and talk about our problems and also get some information from the government about where their priorities are and if they align with our priorities and so on. And that’s a group that can be very beneficial in increasing sustainable workforce in rural areas, and how we facilitate Indigenous students enrolments and better engage with Indigenous communities. There’s a whole range of things that are kind of primarily rural issues that we are trying to think that as a large group outside of Monash or Melbourne or Victoria. If we were to look holistically, what impacts are SRHs having in improving Rural Health? The obvious thing is in education. We are trying to train a health workforce that stays in rural and regional Australia and is sustainable. Have you found that there’s been a lot of success in that? There have been some changes in the initiatives that have been provided by the Federal Government. Now the SRHs that have been primarily focused on medical education have to find ways to support Nursing and Allied Health in rural areas and to give them opportunities. And the focus of that has been providing accommodation for Nursing and Allied Health students in our regions because we have accommodation already established for medical students.

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That will enable them to have longer placement experience and support within rural environments, hoping again to come out with the same outcomes that they’ll want to practice rurally because they’ve had positive experiences there as students. And what do universities actively try to do to facilitate a positive experience? I think that we can’t do that alone. We can create a supportive and nurturing environment for students within our own School but we need the partnerships with the hospitals and community health services to make sure that when students are on placement, they are having positive interactions with staff, with the patients, and they are having the opportunities to get high quality and bountiful interactions with patients. Because that’s the key thing. We’ve talked about this before and students say this repeatedly, that getting better access to patients means also getting better access to the clinicians. That they get to know students better, that they seek out students to show them interesting cases, that they know students by name which is a much more humanising experience than ‘hey you come over here and take a look at this.’ If we can get medical practitioners into the workforce in rural and regional Australia, then other health professionals have better opportunities in terms of their career structures. There’ll be specialisations within regional hospitals that give opportunities to nursing and other allied health professionals to have a career structure in rural which has been a challenge. If you don’t have the right health infrastructure, then you can’t get career opportunities and you go back to metro because you can become stuck at one level. There’s also health professionals who are going to do Masters and other postgraduate training with us to upskill, particularly in research or education, in order to makes them more confident teachers or gives them the capacity to seek to answer the research questions they have about their practice. That upskilling, it’s not just about training doctors and giving opportunities for Allied Health students, it’s about once they become health professionals, how do we help them upskill and continue their professional education in a rural setting. Because there are in comparison to metro very limited research opportunities in terms of resources?

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Most funding tends to go to metro, even if there are good projects being proposed from rural. The largest pots of gold go to metro. So that’s a challenge. But people are doing good work in rural, and as an example our School has been doing work in cancer care, not just for general population but also for Indigenous communities. And having a look at the quality of cancer care and supporting cancer care health professionals in delivering those services. It’s an evidenced based approach. It’s not just about the training but also about improving the service quality as well. And Government isn’t going to change policy without any evidence in play which is where policy writers come in. That was exactly going to be my next point. That once you have the evidence you can present, that’s how you inform policy and procedure and get changes there. And that concludes the interview I had with Associate Professor Shane Bullock. While the main theme for the interview was how Rural Medical Schools impact Rural Health, our conversation flew off into many entertaining and educational tangents about his PhD, general advice he has for medical students, the relationship between medical students and secondary school students, all which unfortunately couldn’t be included here. If you’d like to read the full transcript of the interview, feel free to email me at elli.izrailov@amsa.org.au But to briefly summarise, I think that what can be learned from this interview/conversation is that Rural Medical Schools have a powerful place in improving Rural Health. Like a piece in a jigsaw puzzle, RMS are part of the solution, and have a key position in affecting other factors to improve Rural Health. This can include helping improve research opportunities, or; collaborating with Colleges and Hospitals to modify specialist courses, allowing up and coming professionals to train in a rural setting, or; helping increase the amount of rural students entering Medicine, or; encouraging a positive placement experience which encourages metro students to practice rurally. Frustratingly but clearly, there are many factors which come into play. But Rural Medical Schools, and their associated universities, are in a key position to help facilitate and improve a multitude of different factors which will benefit Rural Health.

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Jacoba Van Wees Gippsland Victoria


opinion

AMSA2020: Advanced Rural Health Sarah Clark University of New South Wales (V) “Be the change you wish to see in the world” - a Mahatma Gandhi mantra that we have all heard, and a mantra we all try to embody in some way or another. But what about when it comes to our education?

Rural Theory Up until recently I had not given much thought to the rural health teaching we receive at university throughout my medical training. Looking back, when I first began my medical degree at a metropolitan university, I’m not even sure I expected formal rural health teaching. I’m lucky that, compared to many of my peers, I have had first-hand knowledge of rural health - I am from a rural area, I’m set to complete half of my degree at a rural clinical school, I’ve been engaged with AMSA Rural Health for a number of years now, and it is without a doubt my largest medical passion. It may not necessarily matter to me that my formal rural health teaching from university professors in a lecture theatre is not particularly up to scratch. But I know that I am the exception to that kind of rural health curriculum, and not the rule. Many medical students enter medical school never having been to rural Australia. We often exist in their minds as stereotypical slang-speaking farmers walking around on dirt roads with our Akubras. The rural health lectures I received in my preclinical years sadly misrepresented what I have come to know as the “fair dinkum” rural health lived out by rural Australians. I remember the few lectures that we did have implying that rural health and Indigenous health were synonymous. This teaching contrasts ABS data from 2016 (1) which showed that 80% of Indigenous Australians live in metropolitan areas and face unique healthcare barriers that differ from Indigenous and non-Indigenous Australians living in rural areas. We relied very much on the stories of our peers to learn about medicine in any setting other than the one we grew up in – and if you didn’t have a rural peer, you didn’t learn about rural health, and its unique set of challenges. I don’t recall learning about how rural Australians have worse outcomes in literally every major disease (2). We didn’t learn about the increased prevalence of risk factors like smoking, being overweight/obese, sedentary lifestyles,

alcohol consumption, and hypertension that are present in rural Australians. Alarmingly, suicide rates are much higher too (3). Students are being biased against rural health purely because it’s not made to be at the forefront of their minds during preclinical years. We can’t change the health of rural Australia if we don’t know what needs to be changed.

Rural Placements If we don’t infuse students with a knowledge of rural health theory, they won’t know what to expect in rural health practically. Whilst I think rural health theory is important, another equally passionate part of me wonders how much theoretical rural health teaching a student can have, before you just have to throw your hands up and say, “You know what? You just have to experience it for yourself, see what it’s like – live in a rural doctor’s RMs for a day.” I commend the Federal Government for mandating some rural placement experience for medical students; universities are required to have at least half of Commonwealth-supported places (CSPs) participate in rural placements of at least four weeks, and at least 25% of CSPs to experience it for at least one year (4). While this is great, it does still leave half of all medical students in the dark when it comes to practical rural health experience. Rather than just meeting the Government mandate, we must urge our universities to go above and beyond for their students and grant them access to handson rural health experience. This experience can benefit students to no end. In the city, students are often found at the bottom of the food chain in a thrombus of consultants, doctors-in-training, and students from other health disciplines, which limits their hands-on exposure to patients and clinical medicine. In turn, this limits a student’s ability to develop their clinical skills. However, quite often in rural hospitals the students are valued members of a clinical team, with increased exposure to patients and thus enhanced clinical skills. This is reflected in the fact that students in rural settings, on average, perform better than students in urban settings (5). However, a rural placement is seen as a threat to some medical students. In some places, there is a preconception

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Andrew Baker

Lighthouse Beach New South Wales


that getting a long-term rural placement is a demonstration of your intellectual inferiority within your medical cohort. In other areas, a less insulting preconception exists – that you were the unlucky student who got “shafted” to a rural area. These preconceptions scare some students into concocting elaborate fictional stories convincing enough to extract a special consideration from their universities, so they don’t have to go. The stigma associated with rural placements is demoralising for students who choose to go rural. It also devastates rural communities in the long run, as people carry this “rural equals inferior” mindset into their future practice. And the complaints are freely flowing – it’s expensive, it’s far away from home, you miss out on your “real” life for however long you’re there. Whilst some of these complaints are admittedly valid, they should not be barriers to going rural. Universities need to adequately support students on placements; offer relocation scholarships, travel bursaries, appropriate accommodation options, and create a list of GPs and mental health support options for students in their placement location. Doing so will reduce the barriers to going rurally and even help students to enjoy it! However, the opportunity to gain rural experience is not afforded to all medical students. Many universities do not allow their international students to go on rural placements, and there is not a large incentive for universities to do so. In fact, universities lose money sending their international students rurally as they do not get additional funding to do this as they do for their domestic students.

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gage with rural health in a positive way has the ability to significantly improve the healthcare of regional, rural, and remote areas.

I don’t have the unreasonable expectation that every single medical graduate from here on out will want to work rurally. I know that some people want to be super subspecialised, which isn’t feasible in a rural area. I know that some people want to be close to family, and that means that rural medicine isn’t an option they would consider. I understand that too. But at the end of the day, even if you’re not working in a rural area, one day you will have a patient who presents to you after travelling hours – maybe even days – from their hometown to seek your specialist opinion about their health. Or maybe you will have a patient who is visiting the city and becomes unwell and presents to your GP practice. When this happens, patients deserve doctors who have a basic understanding of the adversities they have faced, especially when it comes to simply seeking care in the first place. Don’t these patients deserve a doctor who has had at the very minimum, some exposure to rural medicine as a student in order to provide appropriate care for their rural patient?

Despite this disadvantage for universities, I would argue that these placements are of upmost importance given that most international students end up completing rural internships because of undersubscription of rural hospitals among domestic students. These students are the ones that need to understand and enjoy rural life, so that their internship year can be as enjoyable and beneficial to them as possible.

As future members of the health profession and advocates for our patients, we have this amazing opportunity to shape the future – because it is both OUR future and THEIR future. How we perceive rural health now, shapes how others see rural health in the future. By taking a strong stance on the need for rural health to be an essential part of medical teaching for all students, we portray rural health as a branch of medicine to be taken seriously. Enthusiasm is infectious – if we show our enthusiasm and passion for rural health to these scared, sceptical medical students, we have the opportunity to make them enthusiastic too. “Be the change you wish to see in the world” - it’s time for us to step up and be the change.

All rural doctors were once medical students

References

“Why do you care so much about what we learn in medical school about rural health?”

1. ABS. Aboriginal and Torres Strait Islander Population, 2016 [Internet]. Abs.gov.au. 2019. Available from: https://www.abs.gov.au/ausstats/ abs@.nsf/Lookup/by%20Subject/2071.0~2016~Main%20F eatures~Aboriginal%20and%20Torres%20Strait%20islander%20Population%20Article~12 2. AIHW. Australia’s Health 2018 (Cat. no. AUS 221) [Internet]. AIHW. (2018) Australia’s Health 2018 (Cat. no. AUS 221). Retrieved from https:// www.aihw.gov.au/reports/australiashealth/australias-health-2018/. 2018. Available from: https://www.aihw.gov.au/reports/australiashealth/australias-health-2018/ 3. AIHW. Rural & remote health, Rural health - Australian Institute of Health and Welfare [Internet]. Australian Institute of Health and Welfare. 2019. Available from: https://www.aihw.gov.au/reports/rural-health/rural-remote-health/contents/rural-health 4. Department of Health. Rural Health Multidisciplinary Training (RHMT) 2016-2018 – Program Framework [Internet]. Www1.health.gov.au. 2017. Available from: https://www1.health.gov.au/internet/main/publishing. nsf/Content/rural-health-multidisciplinary -training-program-framework 5. Denz-Penhey H, Murdoch JC. Is small beautiful? Student performance and perceptions of their experience at larger and smaller sites in rural and remote longitudinal integrated clerkships in the Rural Clinical School of Western Australia. Rural Remote Health. 2010 Sep 21;10(3):1470 6. Playford, D. E., Evans, S. F., Atkinson, D. N., Auret, K. A., & Riley, G. J. (2014). Impact of the Rural Clinical School of Western Australia on work location of medical graduates. Medical Journal of Australia, 200(2), 104107.

Ultimately, my passion for rural health stems from the fact that rural Australians need a better standard of healthcare than what they currently have. These people are having their postcode determine their chance to be healthy, which is appalling. In order to improve their healthcare, we need to tackle the biggest problem – access to healthcare. Rural Australia needs more health facilities and resources, a major contributing factor being a lack of qualified doctors. But it’s not a numbers issue when it comes to a lack of doctors, it’s a distributive issue. Australia has enough doctors, it’s just that they don’t want to work rurally. So how do we encourage them to want to work rurally? By fostering positive rural experiences in medical school, we can shape doctors who want to work rurally in the future (6). Giving students the opportunity to learn about and en-

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NEWS

Research Connects Rural and Regional Victoria with Gold Standard Stroke Treatment Heather Pagram University of Melbourne (IV)

Frontier! spoke to Dr. Andrew Bivard, a research Fellow and the imaging co-ordinator for the VST. “Thanks to recent [international clinical] trials such as DAWN (1) and DEFUSE (2) we know that it can be beneficial to perform thrombectomy (clot retrieval) up to 24 hours post stroke”, he explained. “So that directly benefits regional and rural patients, because it allows enough time to transfer them to their nearest thrombectomy centre.” Further, in 2019, a meta-analysis of several trials showed that with adequate imaging guidance, thrombolysis is also beneficial to use up to 9 hours post-stroke in a select patient population (3).

In my first year of clinical training, one of our tutors explained to us how dangerous the “clot- busting” thrombolytic drugs used to treat ischaemic stroke could be. In fact, he hated using them and asserted that everyone in the Emergency Department did too. I was surprised. His perspective stuck with me, because I’d come into medicine from stroke research, conducted in a fully resourced tertiary centre with advanced medical imaging available, and multiple neurologists on call. There, thrombolytic drugs such as Tenecteplase and Alteplase were viewed differently – to be used with the respect demanded by a substance with potentially fatal side effects, yes, but not so openly avoided.

However, the key to success is not only time to treatment, but evidence-based patient selection for treatment. As with any intervention, not everyone stands to benefit. Over and under treatment cause harm at an individual and a population level. This is where the VST and advanced medical imaging comes in. Participating sites are kitted out with the scanning capability and software programs, and training required to operate them if necessary. Patients arriving in ED trigger a stroke protocol, and 24 hours a day, 7 days a week a neurologist is on call to assist local staff with their treatment decisions. Thrombolytic therapy may be given locally, or the patient may be transferred for thrombectomy, based on the imaging results and clinical consultation. Ambulance Victoria has also come on board, with additional stroke protocols and training allowing transfers to happen smoothly. “We’re also focusing on not transferring patients unnecessarily, for their sake”, Dr Bivard said. “No-one wants to be away from home when they are seriously unwell.”

However, it isn’t difficult to understand why in a regional or remote setting, one would take this stance. Ischaemic stroke can be acutely difficult to distinguish clinically from stroke mimics, such as Transient Ischaemic Attacks (TIAs), migraines or functional disorders. Further, without advanced imaging, such as perfusion CT and even MRI, one cannot accurately and acutely visualise the ischemia or infarcted area of brain to positively identify an ischemic stroke and guide treatment. Often, transfer is not an option – it will take too long which is catastrophic since the thrombolysis license is only for treatment within 4.5 hours of symptom onset; delayed treatment results in hypoxic brain tissue will death, resulting in worse patient functional and quality of life outcomes. Imagine having to make the recommendation to a patient’s family to administer life-altering medication without adequate information on which to base your decision. Your patient could get much better – or much, much worse. They may not have even had a stroke (and naturally recover). The side effects of Tenecteplase are unsurprisingly, bleeding – including cerebral haemorrhage. No one would want to be forced to make that call based on clinical signs alone, without the help of medical imaging, whilst adhering to the principle of “do no harm”. In Victoria, at least, such a scenario is no longer tenable. The Victorian Stroke Telemedicine service (VST), set in place a number of years ago, led by Prof Christopher Bladen, allowed rural patients to speak face-to-face with a neurologist, albeit via a computer screen. More recently, and in response to global stroke research, this service has been upgraded to include advanced imaging, most notably perfusion CT. Up to 16 sites are participating, including Bendigo, Ballarat, Wodonga, Taralgon and Swan Hill. Excitingly, this service allows regional patients access to more timely, personalised and efficacious stroke treatment. It also allows rural patients to participate in cutting-edge international research, should they wish.

The VST have setup the world’s first comprehensive stroke network which links neurologists with easy to access and standardised brain imaging which is crucial for treating stroke patients. Rural generalists and budding neurologists – this is a space to watch!

References 1. Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et al. Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. New England Journal of Medicine. 2017;378(1):11-21. 2. Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et al. Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging. New England Journal of Medicine. 2018;378(8):708-18. 3. Campbell BCV, Ma H, Ringleb PA, Parsons MW, Churilov L, Bendszus M, et al. Extending thrombolysis to 4·5–9 h and wake-up stroke using perfusion imaging: a systematic review and meta-analysis of individual patient data. The Lancet. 2019;394(10193):13947.

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Katie Blunt

Maryborough, Victoria


Future Rural Placement

Imogen Hines Kangaroo Island South Australia


Interview

The Road to Rural Practice in South Australia Andrew Baker University of Adelaide (V) The Rural Doctors’ Workforce Agency started the Road to Rural internship in order to give South Australian interns exposure to rural General Practice. In 2019, 20 interns will undertake 10-week placements in Crystal Brook, Jamestown, Kadina or Port Lincoln.

deliver the town’s next generation and, if you’ve still got energy after that, do a few anesthetics lists a week. How good?!

AMSA Rural Health had a chat to Peter Litwin who has just recently returned from his Road to Rural placement in Port Lincoln.

The Boston Bay Family Health Practice in Port Lincoln had a real focus on paediatric and obstetric care thanks to the efforts of its principal GP, Dr Kris Bascomb. For most medical graduates, these are invariably going to be your weakest areas, because we simply just don’t do enough. This rotation gave me the opportunity to brush up on these skills in a primary care setting.

Hi Peter, would you like to introduce yourself to our readers? Hi, my name’s Peter and I’m born and bred in Adelaide, having lived and studied here my whole life, apart from brief medical school placements at the Alice Springs hospital and in Jamestown and Peterborough in mid-north SA. This year I’m a CALHN (Central Adelaide Local Health Network) intern, and have just been in Port Lincoln for my 10-week rural GP placement as part of the Road to Rural program. Why did you want to take part in the Road to Rural Program? This was a chance to explore an exciting and fundamental part of health care in Australia. Rural GPs have the challenge and privilege of serving a small community where their work is almost always extremely valued. And they certainly enjoy the best variety of any area of medicine: where else can you run a GP practice, see emergencies, admit and manage hospital patients,

Could you tell us a bit about the GP practice you went to in Port Lincoln?

What did the placement involve? This rotation was primarily GP clinic based, with various optional extras including antenatal care, ED shifts, medical and surgical inpatients and deliveries. Getting any Primary Care, Paediatric or Obstetrics and Gynaecology exposure as an intern is virtually almost impossible, and I managed to get all 3!

What would you say to anyone who is considering a rural placement as part of their internship? Australia is geographically unique which impacts on access to medical supplies, facilities and the need for patient transfer. Even doctors who have no desire to work in a rural area need to understand this, so when they get a call from a rural GP, they understand the limitations and implications this has on patient care. Firsthand experience is always the best experience, so a rural placement is simply the way to go! Thanks Peter, sounds like you had a fabulous time in Port Lincoln, and good luck for your future career as a rural GP! If you would like to learn more about the Road to Rural program, check out the RDWA’s website: https://www.ruraldoc.com.au/ road-to-rural-r2r-intern-program

What impact has the Road to Rural program had on the specialty you’re interested in? Rural GP was high on my list of career options post my 6th year placement in Jamestown and Peterborough. Needless to say, it’s moved higher on my list!

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Peter Litwin at the Port Lincoln GP Clinic, 2019.


Frontier!

A Rural Future for All of Us? Jamie Nicholls University of Melbourne (IV) Being a final year student in Victoria, I was thrown into the daunting task of selecting, applying, interviewing and preferencing internships at various hospitals. Unfortunately, the prevailing ethos is that that your entire future depends on your choice of hospital and which one you end up at… *Lies*…

(some very much stronger than others). However, this conversation had sparked an interesting point. I wanted to know how queer final year students felt about potentially moving to the country for their internships and if participating in rural placements during medical school had changed their outlook, delving deeper into two additional variables that need to be taken into account.

In amongst this chaotic flurry of scrapped cover letters, horrendous rumour mongering and downright confusion, you find a way to try to assess and order a list of fairly ubiquitous health services which will determine your skill and prowess as a budding doctor… *Cough cough*…

Issue 1. Discrimination. I feel very privileged to say that the rural district I trained in voted ‘yes’ with a significant majority [in the 2017 same-sex marriage plebiscite]. I can’t however say the same for all my LGBTQIA+ peers in other states/areas. Even with the fantastic outcome of the postal vote, I myself have been subject to harmful comments from medical seniors and bigotry from people outside of the health service in an area voting overwhelmingly ‘yes’! Owing to the limited number of medical practitioners in rural towns, inappropriate behaviour and off-handed bigotry can be shrugged off simply because “that’s the best this town’s got”. Rural students and community members fear holding these professionals accountable to their behaviour because access to healthcare and teaching could be withdrawn. If anything, this just goes to show that it’s one thing to attain the right to marry and another entirely to foster tolerance, acceptance and accountability. It may not seem like a lot to others but being able to choose a workplace where I’ll be respected as a member of the community, both in and out of the health service, is really important to me. As we move into the future with the increase in rural training pathways and rural medical school positions, people of minority groups are likely to interact and train in these services more and more frequently. Damaging views, comments and actions towards the queer and other communities only os-

Perhaps a little arbitrarily, through this process I learnt how much I cared about whether free pens were available in doctors’ rooms, or if there was a McDonald’s within walking distance (because that seemed to be the goal of the ED night shift). I’ve been fortunate enough to be placed rurally for a significant amount of time and the primary considerations here were the distance from my support networks, quality of hospital and size of town. Having thought I had considered all possible avenues of assessing potential suitability of my future employers, I was a bit taken aback when I was in the waiting room for an internship interview with a close friend who discussed his personal top rationale behind his selection: ‘simply, their inclusivity policy’. I was floored by this statement. As an engaged member of the queer community myself who is also on the AMSA Queer Projects Team, I was shocked I didn’t even think of this as a point to differentiate on, particularly owing to its potential major difference between metropolitan centres (queer utopia) and smaller rural hubs (perhaps not so much). I was relieved to realise that retrospectively most of the hospitals I had preferenced had some form of LGBTIQA+ or related inclusivity policy

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OPINION

Frontier!

tracise people who have the potential to be valuable members of already under resourced rural centres.

against discrimination, and in order to prevent potentially harmful acts against the queer community, we need to facilitate open access to queer initiatives groups that are easy to find. For instance, simply wearing a rainbow lanyard, sporting a rainbow badge or having statements of inclusion around the hospital or general practice, can make a huge difference, not only for patients but health professionals as well! The LGBTIQA+ community does actually exist in these regional and remote areas (you just need to take a close look sometimes) and we as medical professionals can aid in how they are both included into the health services and the stigma associated with our community.

Issue 2. Visibility. When I discuss with my metropolitan queer peers about their apprehension to training in the country, it wasn’t just the lack of training programs but the perceived lack of a bustling queer community which seemed most inhibitory. Having grown up in rural New South Wales and completing most of my medical school rurally, I’m well aware that the rural queer community is alive and kicking! This community is one of the most welcoming and tight knit collectives I’ve ever come across. But even having all that rural experience, it still took a long time for me to scope out this community and the LGBTIQA+ services afforded to these areas. I can only imagine that for those who are unaware of this community, like moths to a rainbow flame, the elusive pull of the metropolitan ‘queer utopia’ is all too strong. With all this in mind I feel that the lack of visibility of these initiatives in rural areas significantly hinder queer health professionals from seeking the crisp countryside air.

Jamie Nicholls AMSA Queer Team Member

The solutions… This brings me to what can be done to increase the opportunities for queer medical students and health professional in rural settings. The first thing to note is that these two issues are not mutually exclusive. In order to improve visibility, we need to take a stand

“For instance, simply wearing a rainbow lanyard, sporting a rainbow badge or having statements of inclusion around the hospital or general practice, can make a huge difference, not only for patients but health professionals as well!”

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Imogen Hines

Weethalle New South Wales

Future Art


ART

Ode to Hume

Ross Lomazov University of Melbourne (II) And on and on and on The grey asphalt snake extends Across the rivers, over the hills The mighty road that bends Beyond the trees, beyond my vision Avoiding a kangaroo collision The hours all merge into one A streak of cars all driving by The background all the while the same A searing mark upon my eye Just green, then grey, then black Colour returning at dawn’s crack No end in sight, no lights at night Against the sleepiness I fight Like Ozymandias I stand, The lone and level sands stretch far away Except it’s asphalt, and not sand That causes my poor mind’s decay The truckers roar past one another The signs whizz past me much the same Two lanes uniting, just like lovers To reach my placement is the aim A familiar friend, an ageless foe How much I seem to despise thee And yet again, much to my woe When I close my eyes you’re all I see And on and on and on The grey asphalt snake extends Across the rivers, over the hills The mighty road that bends

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Frontier!

Rural Health is like a plant that will grow into deep rooted trees through collective collaboration across Australia (red and blue colours of people joining hands). The world map illustrates that rural health is a global challenge, yet learning of various innovative global strategies surrounding rural health may spark some innovation in ours. The light bulbs signifies various small ideas that collectively spark changes and brightens up a dark bleak (current challenges) sky. These bright ideas may start off as a small plant, only to evolve later into a tree with stronger, and deeply rooted networks of care.

Tree of Hope

Merry Rodrigues (Monash University, III) and Vaishali Nair

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Additional skills for stronger communities

Become a rural GP Learn about the specific health needs of rural and remote communities, and develop skills to meet those needs with the RACGP’s Fellowship in Advanced Rural General Practice (FARGP). The FARGP is awarded in addition to the vocational Fellowship of the RACGP (FRACGP)* and has pathways for junior doctors and registrars. Combine FRACGP and FARGP over a four year program and achieve dual RACGP Fellowship. The RACGP is recognised as a leader in the provision of general practice education and training, supporting more than 23,000 GPs to achieve Fellowship since 1958. We represent more than 40,000 members working in or towards a career in general practice. Make a real difference • Develop additional skills • Build strong community connections • Broaden options for safe, accessible and comprehensive healthcare • Gain greater depth and breadth of experience • Access clinical opportunities in hospital and community-based work. Learn more about the FARGP today.

*The FARGP cannot be undertaken as a stand-alone qualification.


FUTURE INDIGENOUS HEALTH

Frontier!

Sarah Clark

New England New South Wales


Interview

A Powerful Force in Indigenous Health Eleanor Gregory JCU External Communications Coordinator For Townsville GP Jacinta Power, seeing women through their pregnancies, the birth of their babies and then watching their children grow never grows old. “I really love women’s health. I think that’s what keeps me going. I get to see the pregnant women, the new babies and then the children. It’s definitely my area”, she explains.

chance meeting with an Aboriginal Elder who helped set up Australia’s first Aboriginal Medical Service in Sydney’s Redfern. “She came into TAIHS and she just broke down crying to see how far we had come. From the early days when she was trying to set up the first Aboriginal Medical Service to being at TAIHS, which is an Aboriginal and Islander service, and then to be seen by an Indigenous doctor was for her, amazing. To her, that was the goal. To get to the stage where we could be looking after our own mob. That was a really special moment.”

The former JCU medical student was Fellowed as a General Practitioner through JCU General Practice Training in Townsville last year. Excitingly, this makes her the second Indigenous doctor to complete the program so far.

Growing up on a farm in rural north Queensland Dr. Power always wanted to work in the health field. Her desire to make a difference is driven by the loss of her brother to cancer as a child,

Dr. Power completed the final years of her specialty training with the Townsville Aboriginal and Islander Health Service (TAIHS) and has remained with the service as a GP and cultural mentor. As an Indigenous doctor, she always wanted to use her skills to better the health of Aboriginal and Torres Strait Islander people.

“The main reason why I wanted to be involved in health was because of my brother. With everything we went through, being around doctors and the hospital, I always wanted to do something to help people. You need those motivating factors to get through medicine.”

“I wanted to do Indigenous health; whether it was a mainstream clinic with a focus on Indigenous health, or in an Indigenous organisation. There’s a spiritual connection there, another level of connection. Whatever specialty I chose, it was always going to be something that I would use to help my people”, Dr Power said. Working in the Aboriginal medical service has allowed her to do just that. This decision was validated by a

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Nonetheless, it hasn’t always been a straightforward path. As a shy teenager, she lacked the confidence to aim for medicine, which was further exacerbated by a school guidance counsellor who told her she wasn’t smart enough to study physics in her final years of schooling. It wasn’t until she read the story of the inspi-


Frontier! rational African American neurosurgeon, Ben Carson, that she felt she too could try for medicine, “He came from such a disadvantaged low socioeconomic background and showed he could get to the top. He overcame so many hardships and went on to have such a big impact. It was inspiring.” Yet, she still doubted her own ability. “I honestly thought I couldn’t do it. I graduated from a high school in a small rural town. I think I was the first to go into medicine. It seemed like something out of reach. I was just so shy and introverted.” Despite her misgivings, Dr. Power secured a place in the JCU medicine degree in Townsville. She was attracted to the program for its focus on rural, remote and Aboriginal and Torres Strait Islander health. And for its proximity to home. “I loved the fact that right from second year you went out into rural towns and learnt from doctors in those areas. They’re very inspiring people. Their level of enthusiasm and knowledge is amazing. It takes a lot to be a doctor in a rural town, so it was really inspiring for students coming through to learn in those settings.” Dr. Power believes the rural training JCU students get during their degree gives them an edge going into their intern year. The solid foundation is also highly regarded by the hospitals they go in to, “JCU has made a name for itself because its students learn a lot of skills in their rural placements. Whereas you might not learn them if you go through some of the other medical schools. You certainly go into the intern year knowing you have a good set of skills.” Dr. Power also found the support offered through the Indigenous Health Unit at the university to be valuable during her degree. Despite this, she believes Indigenous students still face barriers others might never be aware of, particularly concerning family. Many of

her friends came from large families rife with poor health and high suicide rates. She saw them struggle to complete their courses while struggling with family tragedy. She also saw the impact of crippling self-doubt many Indigenous students suffer from. Now having completed medical school, her intern years and now specialist training, Dr. Power would love to inspire other Indigenous students, “I would say to them to give it a go and just believe in yourself because it is very daunting. I had such low confidence, thinking I wasn’t as good as everyone else. But you are. You’re as good as anybody else. And medicine is attainable, it is doable. It’s so rewarding in the end. It was hard work but for me and it seemed like something I wouldn’t achieve but I did. So just give it a go, what do you have to lose?” After two years in the hospital system, Dr. Power started her specialisation through JCU General Practice Training, with placements in Townsville and Ingham. She has nothing but praise for the support of the Medical Educators and Supervisors through the program and is now giving back as a Cultural Mentor for current registrars. “Having a cultural mentor gives registrars a support person. If you come from a completely different cultural background you might not know certain practices and you might not understand why a patient acts in a particular way. If they have a person they can ask and debrief with, it provides a more positive experience than they might otherwise experience with the cultural barriers. Each community is very different as well, and having a cultural mentor in each of those places is definitely necessary. It creates more support for registrars.” While Dr. Power is enjoying her general practice work with the Aboriginal medical service, long term she would like to focus on preventative health, particularly nutrition. This is an area she sees as key to tackling chronic disease among

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Aboriginal and Torres Strait Islander people, “I sometimes feel like sitting at the desk and seeing people is a bit of a band-aid. I chose general practice because you are working in the community. You are seeing people and following up. I’d like to take it that step further and get involved outside the clinic as well. Work on the root causes of the problems and so much of that is good nutrition”, she explains. Ultimately, Dr. Power would like that to include a return to her farming roots and involve community food production. She’d like to follow a model used in the Northern Territory where communities grow their own food, providing both employment and the foundations of good health. For now, though, she delights in her general practice- in the mums she helps, the children she treats and the new lives she gets to meet.


Opinion Broadening the Lens: Recognising and Embracing the Aboriginal and Torres Strait Islander Understanding of Health

Imogen Hines

Jacqueline Bredhauer Monash University (BMedSci)

Cradle Mountain Tasmania

I had heard about the issues and I had read the numbers, but it was not until my year-long placement in Mildura, a regional town in north-west Victoria, that I fully understood the health disparity between Indigenous people and other Australians. Local Aboriginal people were over-represented in the emergency department, the general medical ward, the drug treatment clinic and, sadly, in suicide statistics. Patients of Aboriginal origin tended to be sicker – there were patients who were coming in for amputations or dialysis as a result of their diabetes, who were repeatedly presenting with end stage heart failure or COPD, or who were struggling most severely with substance abuse or depression.

The Aboriginal and Torres Strait Islander understanding of health encompasses, “mental health and physical, cultural and spiritual health” (2). This holistic concept of health involves the whole community throughout the entire life course and incorporates traditional knowledge, traditional healing and connection to country (2). In my opinion, Australia’s predominately biomedical, disease-focused health system would benefit from taking Aboriginal and Torres Strait Islander perceptions of health and wellbeing onboard. This is especially so, in light of our current epidemic of largely lifestyle-related, non-communicable disease. I would like to ask - what if we didn’t solely employ Indigenous liason officers to deliver culturally appropriate health care? What if we treated Indigenous knowledge around health with more respect, and incorporated it as an integral part of Australia’s healthcare system?

I became acutely aware of and saddened by the determinants of health that were leading to these dire outcomes for Indigenous people – poverty, lack of control and chronic stress, disconnection from traditional ownership of land, intergenerational trauma and colonisation (1). I saw some fantastic initiatives within the Indigenous health space – multi-disciplinary teams, dedicated Indigenous health officers in the hospital, and an Indigenous clinic that incorporated social services, community events and even a gym. Yet, it was clear that we still have so far to go - that Indigenous health outcomes will only improve if Australia truly respects and embraces the rich culture and knowledge of our Aboriginal and Torres Strait Islander people. Aboriginal and Torres Strait Islander people have a unique and fascinating understanding of health that I believe could beneficially inform Australia’s health-care system.

Now, I acknowledge the fine line between respect through mutual understanding and shared knowledge, and cultural appropriation. What I imagine here is not only the potential benefits of a more holistic approach to healthcare, but a system that is designed by and for a people that has been spoken about and for by others, for too long. A system that stands to benefit everyone. Imagine if Indigenous elders were consulted in the design of health facilities. Further, what if we collaborated to design holistic rehabilitation programs that considered a patient’s spirituality and unique understanding of the world as being integral to their healing? Or if we incorporated, “so-

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Frontier!

cial prescribing” protocols into our mental health system, to connect socially isolated, anxious and depressed people with community activities and groups? I posit that if we designed such concepts in accordance with Indigenous leaders, we would have a healthcare system that would be set up to be accessible to Aboriginal and Torres Strait Islander people at baseline. Not only this, but we would likely stand to improve outcomes for the general population as a whole.

and beliefs front and centre, rather than tacked on to the side of our predominantly Western health care system. I also strongly believe that in doing so, we would see positive spill on health effects for all Australian citizens. So, next time you see an Indigenous patient, work with an Indigenous health worker or chat to an Indigenous medical student, let’s not stop at learning how to deliver culturally appropriate care. Let’s actively seek to understand the Aboriginal and Torres Strait Islander concept of health and wellbeing, and even have a think about how we could apply it to our practice.

Beyond health system design, we could look further to concepts of traditional Indigenous bush medicine with an open mind. Aboriginal and Torres Strait Islander people have a rich history of bush medicine that was designed in accordance with a holistic understanding of health to restore or balance a person’s mind, body and spirit (4). Bush medicine practices differ greatly between tribes, incorporating unique rituals and the use of local plants (4). Whilst substantial knowledge was lost after colonisation, fortunately there remain traditional Indigenous healers who practice today (4). I think Australia would benefit from including Indigenous practitioners as formal members of multi-disciplinary health-teams within services that cater to Aboriginal and Torres-strait Islander clientele. In doing so we would see improved health outcomes for Indigenous patients and progress in reconciliation with Indigenous people.

References 1. Social determinants and the health of Indigenous peoples in Australia – a human rights based approach. [cited 2019 Jul 15]. https://www. humanrights.gov.au/about/news/speeches/social-determinants-and-health-indigenous-peoples-australia-human-rights-based: Australian Human Rights Commission. 2. Swensen G, Serafino S, Thomson N. (1995). Suicide in Western Australia 1983-1992. Epidemiology Branch, State Health Purchasing Authority, Health Dept. of Western Australia. 3. Neumayer H. (2013). Changing the Conversation: Strengthening a rights-based holistic approach to Aboriginal and Torres Strait Islander health and wellbeing. Indigenous Allied Health Australia. 4. Ralph-Flint J. (2001). Cultural borrowing and sharing: aboriginal bush medicine in practice. Aust J Holist Nurs. 8, 43–6.

Just as the scope of the indigenous concept of health is broad, so are its practical applications to health care. For Indigenous people, land is central to wellbeing (2). An Aboriginal and Torres Strait Islander approach to health in the 21st century would consider global warming and the degradation of the natural world a severe and imminent threat to human health and well-being. Through this lens, health workers and public health organisations would take climate change very seriously, and, “prescriptions” for conservation and sustainability would be in the scope of healthcare. Ancient, natural landscapes that hold spiritual significance to human beings would be prioritised over roads or expendable resources. Importantly, Aboriginal and Torres Strait islander knowledge and input would be central to this public health effort to conserve our land. Indigenous people would be further empowered to improve the health of their own communities and of the wider society through collaboration in health system design, health-care provision and priority-setting for politics and public health. I would view an embracing of Indigenous health culture as a returning of sovereignty and control to Indigenous people, by putting Indigenous needs

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Interview

A True Calling Eleanor Gregory JCU External Communications Coordinator As a young boy growing up in Alice Springs, Aaron Scolyer always knew he wanted to be a doctor.

my mob that I want to help. That’s been my driving force,” he explained. But for Aaron, the path to medicine wasn’t easy. At high school, the proud Aboriginal student was discouraged by a guidance counsellor and began doubting his ability.

“From when I was a little kid I always wanted to do medicine,” the sixth year James Cook University medical student said. “My parents would always say that that was the only thing that I ever wanted to do.”

Eventually, he gave up his dream and studied to become a paramedic. Despite working in the field for several years he couldn’t let go of his desire to make a difference in the lives of those who needed it most.

The more he saw of the disadvantage around him, and the impact the lack of health care had on communities, the more he felt drawn to the field of Aboriginal and Torres Strait Islander health.

“I saw the need for health care in rural and remote places and that’s exactly why I wanted to study medicine. In cities, there is a doctor on every corner, but in rural areas, there might be one doctor in the town. There’s also a huge lack of specialist services.”

“We have huge problems in this country with the lack of health care serving Indigenous Australians. It is so sad and it is so wrong. You see things in rural and remote communities that you just shouldn’t see in this day and age. From lack of access and lack of healthcare, to a lack of engagement with the health care system. “If you are white and wealthy the world is your oyster – but for the majority of us, it’s not that way. If I can make some people’s lives a little bit easier, that’s all that I need. It’s my people,

“Knowing exactly what I wanted to do and knowing the change that I wanted to make was why I decided to go back. I wanted to make more of an impact.”

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Aaron said he chose to study Medicine at James Cook University because of its focus on rural and remote medicine. He hasn’t looked back.


Frontier!

“You do a lot of rural placements as part of the JCU curriculum, which is great. As a med student in a big hospital you are at the back of the line and don’t get to do a whole lot. But in rural medicine you can be really useful.”

this box and sometimes it isn’t easy to figure out your path, or way forward. I would love to be that person to motivate and encourage these students.” Aaron Scolyer said he’s received great support and mentoring at JCU is urges other Indigenous students to surround themselves with strong role models.

“I just finished my sixth-year rural placement which was ten weeks in Ingham. It was fantastic. You get to be part of the team as a senior medical student and your responsibility and trust go right up.”

“We all want to do something with our lives that’s going to matter and medicine is a pathway that can do that. Stay focused, keep your eye on the prize, and surround yourself with positive people”

Aaron has also continued to work as a paramedic throughout his degree, gaining further experience in rural and remote Queensland. “During holiday times I’ve always taken rural relief for my ambulance job and I’ll always go to the hospital and introduce myself. You become part of that little community which is exactly what I want to do.”

He believes joining the Indigenous Doctors’ Association of Australia was also a turning point in his life. “I went to one of their conferences and I was surrounded by hundreds of accomplished really successful doctors doing things that you could never think possible. They all came from the same background as me and all had similar stories.”

As part of the JCU medicine degree, the sixth and final year is spent working full time in hospitals. Aaron believes this has given him the skills and experience to make the leap from student to doctor with ease.

“I already had motivations, but that was life-changing. I was surrounded by all these really incredible people and I realised I wanted to be one of them.”

“I definitely feel ready. It’s scary and it’s daunting but it’s very exciting as well. I can soon move on to the next step which is advanced training and then start working in rural medicine and making the change that I want to,” Aaron said. With his passion for rural and remote medicine, Aaron has joined the Rural Generalist pathway and plans to undertake advanced skills training in obstetrics and Women’s Health, with a focus on Aboriginal and Torres Strait Islander health. Down the track he hopes to further specialise to bring more desperately needed services to underserved communities. He also hopes to inspire the next generation of indigenous students. “I want to be a mentor; I want to be a teacher for other medical students and other health professionals who identify as Indigenous. “As an Indigenous student you can get put in

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More choice, more locations Bonded Medical Program

Better support, streamlined conditions and more locations for doctors to work in rural and remote areas across Australia.

Bonded Return of Service System (BRoSS)

3 YEAR Return of Service Obligation (RoSO)

Guidance to fulfil RoSO

ACCESS to flexible arrangements

RoSO in more LOCATIONS

STREAMLINED conditions

From 1 January 2020 New students – enter the program under the new bonded arrangements

Existing students and doctors – may have the choice to move across to the new system.

For more information visit: www.health.gov.au or email Bross@health.gov.au


Future Women’s Health

Jacoba Van Wees Derwent River Tasmania


Case Report Management of Obstetric Complications in Regional Hospitals: A Case Report on Antepartum Haemorrhage Brigid King University of Queensland (IV)

Synopsis

Case Report

Antepartum haemorrhage (APH) is an important complication of pregnancy that always warrants investigation. Potentially serious underlying causes include placenta praevia and placental abruption. As APH is a risk factor for preterm labour, in a regional hospital it is also important to consider if steroid loading and transfer to a tertiary facility is required, depending on the gestational age of the fetus. This case highlights some of the challenges surrounding decision-making in obstetric care, particularly in a rural context. As Queensland continues to experience issues with closure of rural maternity services, it is important to consider the consequences that a lack of timely obstetric care could have upon our rural communities.

A 37-year-old G3P2 woman currently at 24+6 weeks gestation of pregnancy was referred to Bundaberg Hospital by her GP, following an episode of postcoital vaginal bleeding. The patient lived in a rural community approximately 2 hours from Bundaberg, which was the closest available obstetric department.

Case presentation

During her current pregnancy, antenatal scans were notable for an adequate cervical length (41 mm) with an anterior placenta positioned at the fundus and clear of the os. Her blood group was O positive, routine serology screening was negative and had a positive rubella titre. Her past medical history included hypothyroidism for which she was taking thyroxine. Other regular medications included iron supplements and a pregnancy multivitamin. Her latest haemoglobin level was 113 g/L. She had also developed gestational diabetes mellitus, which was adequately controlled with diet.

The blood was bright red with some clots, and enough in volume to soak through 3 pads. There was no associated abdominal pain, no dyspareunia, no other abnormal vaginal discharge (specifically no fluid loss) and no previous episodes of bleeding reported in this pregnancy. There was no history of trauma to the abdomen and no symptoms of infection. Fetal movements were normal.

This report presents the case of a 37 year-old G3P2 woman, pregnant with her third child at 24 + 6 weeks gestation. She presented to Bundaberg Base Hospital (BBH) for an antenatal assessment following referral from a GP in her rural community. Her presenting complaint was an episode of bright red PV bleeding which occurred immediately post coitus.

Conclusion

The patient is a stay-at-home mum with two other young children, who both born via spontaneous vaginal delivery. Her obstetric history was notable with both her previous children being born premature, at 34/40 and 35/40 weeks respectively. Her second pregnancy was associated with a shortened cervical length and the delivery was followed by a postpartum haemorrhage (PPH) of 500 mL.

This case highlights the following: 1) There is a need to have clinicians in rural communities that are practiced at recognising and dealing with obstetric emergencies 2) Antepartum haemorrhage should always be investigated to exclude serious causes such as placenta praevia and placenta abruption 3) Patient setting and rural context is important to take into consideration when developing a management plan 4) It is important with obstetric cases to plan ahead and consider early transfer to a tertiary facility if necessitated by the clinical picture, given most regional centres do not have the capacity to care for babies born at a gestational age (GA) < 32 weeks 5) Through appropriate escalation of care and timely recognition of potential obstetric emergencies, safe and comprehensive care can be provided to mothers in regional centres

On examination, her observations were within normal range. The patient appeared anxious but clinically well. Her abdomen was soft and not tender, with a fundal height of ~ 25cm. A speculum examination showed that the cervix was long and closed, with a small amount of dark red blood and mucous discharge that appeared to be coming from inside of the os. A high vaginal swab was taken at the time which came back negative for any vaginal infections. Her initial work up included a cardiotocograph (CTG) to assess fetal wellbeing, the results of which were reassuring.

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Upon discussion with a senior obstetrician and, given that the patient had a history of preterm labour and lived approximately 2 hoursâ&#x20AC;&#x2122; drive from BBH, she was admitted overnight for observation and pad checks. Her management included daily CTGs to assess fetal wellbeing, TEDS for VTE prophylaxis and monitoring for recurrence of bleeding. If the patient had another episode of PV bleeding or began having contractions, she was for consideration of transfer to Brisbane with nifedipine, steroid and MgSO4 administration as per the protocol for preterm labour.

vaginal infection, cervical carcinoma and cervical insufficiency.

Often, the initial evaluation of an APH will fail to find an underlying cause, in which case it is classified as an unexplained APH. Pregnancies in which there is an unexplained APH are still associated with an increased risk of preterm delivery and therefore require close follow-up. This pregnancy is classified as high risk so that antenatal appointments are made with a senior obstetrician, as well as the addition of serial ultrasound growth scans to the antenatal care schedule.

On review the next morning, the patient appeared well and had not experienced any further episodes of PV bleeding overnight. Fetal movements were normal and the patient was happy to return home. A follow-up appointment was arranged in antenatal clinic. She was discharged and asked to return if she experienced another episode of bleeding, decreased fetal movements, fluid loss or had any other concerns. The episode was classified as an unexplained APH, and as such the pregnancy will be classified as high risk and serial ultrasounds for fetal growth will be performed in addition to ongoing routine antenatal care.

Reflection This patient will now have to attend more regular antenatal appointments in Bundaberg, even though she lives more than 2 hours away. She was already concerned about the time she was spending away from her two other children, and understandably quite distressed at the thought of being transferred to Brisbane. In this case, her rural setting also impacted the management plan. If the patient had lived nearby, she may have been able to go home to her family and return in the morning for review.

Discussion

As a student, this case demonstrated to me the importance of making timely medical decisions for patients experiencing obstetric complications. Identifying when an obstetric complication is an emergency or not is essential to decide if transfer of the patient to a tertiary facility is required. The management of these cases not only impacts the remainder of the pregnancy but could impact the baby for the rest of its life, given the increased morbidity and mortality associated with preterm delivery.

Antepartum haemorrhage (APH) is defined as vaginal bleeding occurring anytime from 20 weeks until birth, without the presence of labour or delivery. Life-threatening causes of APH include placenta praevia and placental abruption. Placenta praevia has been associated with an increased risk of NICU admission, neonatal death and perinatal death due to its association with preterm labour. Early identification of placenta praevia is important as monitoring and aggressive management has been shown to significantly reduce perinatal mortality, with the aim of delivering at GA > 37 weeks.

This case also demonstrates the importance of having rural GPs that are practiced at handling and recognising potential obstetric emergencies, allowing them to perform timely escalation of care when required. Closure of rural maternity centres has been a significant issue in areas of rural Queensland, placing significant strain on regional obstetric departments. As time goes by, closure of these services may create more strain on regional centres and result in less than adequate care for our rural communities. All women and families are deserving of access to timely, appropriate and safe obstetric care.

Placental abruption characteristically presents with vaginal bleeding (80%), uterine tenderness (70%) and uterine contractions (35%). The pain is caused by extravasation of blood into the myometrium, as maternal vessels rupture into the decidua basalis. Placental abruption can present as an emergency with haemodynamic instability of the mother and evidence of fetal compromise. It is also possible to have a low pressure venous haemorrhage at the periphery of the placenta, which is typically self-limited and results in a small area of separation. As the pregnancy progresses, with these smaller haemorrhages comes the risk of oligohydramnios and fetal growth restriction developing over time. Many cases of APH will be benign and self-limiting. There are a number of local causes of APH, including cervicitis, cervical ectropion, trauma to the vulva/vagina/cervix,

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Opinion

Time to Deliver on Rural Maternity Services Illie Hewitt - University of Sydney (II)

The town of Parkes is outraged and rightly so. They have lost their maternity service in their brand new hospital due to skilled doctor shortages. It is an intricate issue taken at surface value for the majority of the local community. Can we possibly expect them to understand the complexity of rural doctor shortages? Closure and centralisation of maternity services has been happening in rural Australia for some time now, with mass closures reported leading up to the millennium. Whilst recent data from QLD suggests that there have been less closures in recent years, we still see cases such as Chinchilla (QLD) in 2018 and now Parkes (NSW). (1) It is important to recognise that these are thriving rural towns. They are successful and progressive communities where access to quality maternity services shouldn’t even be a question. Parkes is a town of 10,000 people. There are five schools, a mine that provides almost $100 million to the region in a year, and development underway for a National freight logistics centre including an international freight airport. You can tell this is a town of great progress, and one which will not go down without a fight for their maternity services. Most importantly for me, this is my hometown. I have pondered this issue for quite a while now. I have searched the literature and the media, I have consulted with retired GP obstetricians who kept this department afloat for over 40 years. I have tried to construct a list of differentials that might possibly lead me to a diagnosis for rural maternity departments. Who is to blame? Is it the doctors? The government at a local, state or national level? Is it the hospital? The medical schools? The education and training departments? Is it simply a change in era and the age of the workhorse GP ending while this generation of doctors prioritise their work/life balance? My conclusion – It is a systematic failure. A failure that is simply a news story or a statistic to many. However, when it is your family, it matters to you. Maternity departments are a vital community service to rural towns like Parkes and no statistic can describe this as well as the people who are bearing the brunt of this reality. After closure of the department in Parkes in June, a rally was held by community members where hundreds gathered with onesies dedicated to their babies born in Parkes maternity department. The issues that arise with the closure of a rural maternity department are much more complex than what initially meets the eye. Firstly, the most important consideration is ensuring safe and timely services for the mother and her baby. Interestingly, the reason provided by the government when a maternity department is closed has often been that of safety. They suggest that it is unsafe for the department to remain open due to increased risk with lack of availability of skilled professionals. However, the closure only shifts this risk onto those of the vulnerable pregnant women and their families who put their trust in our health system. In fact, a recent investigation by the QLD taskforce investigation into rural and remote maternity services found more than a doubling of babies born before arrival at hospital since 2000. Risking delivering at home or on the side of the road is not an acceptable position for any rural woman to have to face. Aside from the medical risks involved with closing down the services, there are the social and economic implications for giving birth away from your family and support networks. In addition, it’s important to consider the implications for the local health services and the community as a whole. Loss of a department leads to downskilling and possible loss of other services in the hospital, such as the theatre department. It also takes away an opportunity for trainees in the community to learn and develop their skills in obstetrics and makes it a less desirable training location for desperately needed locum health professionals. Ambulance services are expected to pick up the slack and wear the burden of moving mothers in labour to services in surrounding areas, taking away from their ability to serve the local community. As for the town as a whole, consider the decline in appeal for young families to relocate to these areas and set up in the community. For a moment, consider what it’s like to be a young professional couple working in mining management or engineering roles. They have a lot to bring to the wealth and prosperity of a community like Parkes, however lack of access to maternity services may be a consideration that draws them elsewhere. Where do we go from here? The media is aware of the issues and the towns are angry, this is a good start.

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Closure of rural maternity departments is the pinnacle of a much greater issue that is the chronic shortage of the rural medical workforce. The national rural generalist pathway initiative is also a step in the right direction and we are at a critical point where this needs to be effectively and sustainably implemented. However, there is still a long way to go. There needs to be long term sustainability planning that factors in the requirements for rural communities, including consideration of the changing landscape for rural GPs, education, and training opportunities. The future of rural medicine is in our hands, we need to build a sustainable workforce now in order to ensure adequate maternity services for the women and babies in our rural communities. References 1) Queensland Health. (2019). Rural Maternity Taskforce Report - June 2019 - Executive Summary, Recommendations and Fast Facts [PDF file]. Retrieved from https://clinicalexcellence.qld.go v.au/priority-areas/patient-experience/rural-maternity-taskforce/rural-maternity-taskforce-report. 2) Rural Doctors Association of Australia. (2018). Rural Maternity Policies Position [PDF File]. Retrieved from https://www.rdaa.com.au/documents/item/591

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Bree Gardoll

Girrahwheen New South Wales


Placement REport

Tales From the Top End Katie Blunt Monash University (V) The Larrakia people are the traditional owners of the Darwin region. It is a beautiful part of the world, blessed with a gorgeous coastline and surrounded by stunning national parks. Over the course of my 6-week elective placement in Obstetrics and Gynaecology at the Royal Darwin Hospital (RDH), I’ve enjoyed over 30 breathtaking sunsets and marvelled at the consistently perfect dry season weather. Despite being the third largest Australian jurisdiction, the Northern Territory is home to only 1% of the national population and 10% of the total Australian Aboriginal population. Additionally, 31% of the total Northern Territory population are Aboriginal, with the majority (80%) residing in remote areas. These unique characteristics underpin health service provision in Central Australia and the Top End.  The Royal Darwin Hospital is the principal tertiary referral centre in the Top End. It is a 360-bed public hospital with a large range of specialty services. While watching the sun rise over the city from the labour ward on the sixth floor, it is easy to forget the chaos elsewhere in the hospital. Overcrowding at RDH is a persistent crisis and the hospital teetered on the brink of a code yellow (internal emergency) in July whilst functioning at 140% capacity. This resulted in the suspension of all elective surgeries (including many gynaecological patients awaiting major procedures) and other non-essential services. As a result of this, in recent years, completion rates for category 3 surgeries (recommended within 365 days) have persistently been around 80%. This is well below the national average of approximately 90%.   The medical workforce at RDH seems to experience high rates of clinician turnover. Darwin is an attractive destination for health professionals due to the incredible lifestyle on offer as well as the challenging but rewarding clinical environment. The majority (but not all) of medical staff in the O&G department seem to be from “down South” - from large East Coast metropolitan hospitals, with plans to return home eventually. It can be difficult to provide continuity of care, especially to remote communities that are serviced by RDH.  Despite the high turnover of staff, the O&G staff specialists at RDH are committed to patient well-being and working towards ‘closing the gap’ (which is very real). Morning handover involves productive discussion about socioeconomic factors impacting patient management. The cases seem to feel more complex than my previous experiences in O&G. Medical conditions such as rheumatic heart disease and frozen pelvis from pelvic inflammatory disease frequently complicate management and require multidisciplinary input.   It is also inspiring to see doctors like Dr Kiarna Brown, a RDH staff specialist and one of only five Aboriginal FRANZCOGs, working tirelessly to improve health outcomes for Aboriginal patients, their babies and their communities.  I have also been impressed by the Midwifery Group Practice (MGP) continuity model of care, which has been successfully implemented to support pregnant Aboriginal women from remote communities. Every pregnant woman living in a remote area of the NT is encouraged to travel to an urban centre where birthing facilities can support a safe birth for the mother and baby. Many women, however, experience difficulties in leaving their families and communities and struggle in the hospital setting. The MGP was established in an attempt to overcome some of these barriers to care; each woman is assigned a midwife after their first visit to a remote

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community health centre, who is then accessible to them via mobile phone throughout the pregnancy. Patients are transferred to Darwin at 38-weeks, and supported by their midwife during their delivery and through to their return home. Another element of service provision in the Top End are specialist outreach services (SONT). I had the incredible opportunity to join a 2-day gynaecology outreach trip to Nhulunbuy in East Arnhem Land. We flew on a Royal Flying Doctor Service charter flight with other outreach doctors and a couple of patients returning home. 40 patients were booked to attend the clinic over two days. There were no appointment times; instead, a staff member from the clinic drove around the community picking up patients as available. The highlight of the clinic was spending an hour yarning with a local community elder about how the outreach team can provide better education to the local community about “women’s business” and about how traditional practices could be integrated into the clinic.  I also had the opportunity to work with the visiting gynaecological oncologist from Brisbane, who spends three days of the month consulting, operating and reviewing patients at RDH.  I would highly recommend the Royal Darwin Hospital as an elective destination. I organised the elective through Flinders University and was able to access their teaching program, cultural awareness training and student accommodation. I was well supported by a midwife educator and was able to get hands-on experience in birth suite, scrub-in often in theatre and be actively involved in clinics.  It was a privilege to work with and learn from the patients and staff at RDH. Whilst the clinical medicine was interesting, I benefited most from the insight I gained into the complexity of cross-cultural clinical practice. I believe we have a responsibility as future medical professionals to understand the health inequities that exist within our country. The ‘gap’ can be invisible from a distance, but at RDH and in the Top End it is glaring.

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Contributors Editor in Chief Elli Izrailov

Frontier! Subcommittee Bree Gardoll Heather Pagram Ross Lomazov Tu-An Ma

Aurthors and Photographers Andrew Baker Brigid King Eleanor Gregory Illie Hewitt Imogen Hines Jacoba Van Wees Jacqueline Bredhauer Jamie Nicholls Katie Blunt Merryl Rodrigues Sarah Clark Vaishali Nair

Special Thanks To Our Publishers at Spotpress Jia He for providing our beautiful Front Cover

The content of this magazine is from individual members and does not necessarily reflect the views of the entire AMSA organisation

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NORTHERN QUEENSLAND REGIONAL TRAINING HUBS

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Discover your medical training opportunities in northern Queensland Visit: nqrth.edu.au 15


ON BEHALF OF EVERYONE AT AMSA RURAL HEALTH THANK YOU FOR READING

Rural is the future

Profile for The Australian Medical Students' Association

AMSA FRONTIER Issue 4 2019  

AMSA Rural Health's Fourth Yearly Publication: Frontier! - Rural is the Future This issue of Frontier! takes a look at the potential of Rur...

AMSA FRONTIER Issue 4 2019  

AMSA Rural Health's Fourth Yearly Publication: Frontier! - Rural is the Future This issue of Frontier! takes a look at the potential of Rur...

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