AMSA FRONTIER Issue 2 2017 by The Australian Medical Students' Association

AMSA Rural Health Magazine Issue II | 2017

CONTENTS FRONTIER II 2017 | AMSA RURAL HEALTH

Letter from the Editor

Report from the Co-Chairs

JFPP: Polar Medicine

JFPP: A Trip to the Torres Strait

Artwork

A GP's Rural Health Perspective

Q&A: An Intern's Rural Health Perspective

My Rural GP Placement

Bush Town Adopts Medical Student

The Outback: Kalkadoon Country

The Riverland

East Arnhem Dreaming

MyMedSchool

Let's Talk About Racism in Rural Hospitals

Rural Placement for International Medical Students

Domestic Violence in Rural Australia

Leaving Home to Find Myself â&#x20AC;&#x201C; A Perspective on Growing up Gay in Rural Australia

AMSA Rural Health Bursary Winner 2016 Report 1

AMSA Rural Health Bursary Winner 2016 Report 2

Red Dirt, Red Blood

Contributors

LETTER FROM THE EDITOR Jessica Win See Wong (University of Melbourne, III)

G’day! How are you finding this year’s FRONTIER? This year’s magazine features many well-written reflections on students’ rural placements. We have pieces on the John Flynn Placement Program, Royal Flying Doctor Service and also opinion pieces on topics such as domestic violence, racism and many more! This year, we have photos of students partaking in rural health research and also pieces of rural-inspired artwork. I am excited to say that there are wonderful reflection pieces by rural healthcare professionals too - a big thankyou to Dr.Aneesa Iqbal and Dr.Christopher Lai who took the time to contribute to FRONTIER! AMSA’s 2016 Rural Elective Bursary winners are also featured with an account of their experiences in rural Australia. It is awesome to see so many memorable and rewarding things that students take away from their placements. I would like to thank you my Publications Subcommittee, especially Greta Beale and Kim Lipsyzc, for their efforts in sourcing and editing the articles. I would like to thank Nicolas Soputro for designing the magazine. Also a big thank you to all the writers and artists who have contributed to the magazine! It has been an exciting year for AMSA Rural Health and we hope you enjoy our work If you have any queries or comments, please e-mail me at jessica.wong@amsa.org.au.

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REPORT FROM THE CO-CHAIRS Jenna Mewburn (University of Notre Dame, IV) & Brad Wittmer (Monash University, IV) 2017 has been exciting year for both of us as we have embarked on the role of cochairing AMSA Rural Health. Whilst both of us had committee experience it was the first time either of us had led a committee. We have both picked up a lot of skills, and we are proud to say that we have helped upskill each of our committee members. Our structure has remained largely the same as throughout 2016 with the exception of a few additions including a Policy Officer and Global Health Officer. We have also expanded the Events Officer (External) role to act as Co-Chair of our now annual conference, the Rural Health Summit (RHS) with the Events Officer (Internal). Applications for our 2018 committee will close in October. Weâ&#x20AC;&#x2122;d encourage anyone who is interested to consider applying. If you have any questions, you can get in touch via our Facebook page https://www.facebook.com/yourAMSArural/ or at rural@amsa.org.au A key role of AMSA Rural Health is to advocate for both rural students and rural Australians, this is largely done through our work on the AMSA National Advocacy team. We have participated in several MP meetings in Canberra and continue to get opinion editorials and responses posted in major media outlets throughout Australia. Our most noteworthy publication was by our Secretary, Sarah Clark, getting her piece published in The Australian (Rural communities canâ&#x20AC;&#x2122;t wait, we need rural doctors now, says AMSA; 23/06/2017). Our work advocating on rural health could only happen thanks to the great help of Doug Roche (AMSA Vice President External) and Isabella Gosper (AMSA Public Relations Officer).

We have also continued to remain involved with rural health policy. Our Policy Officer, Candice championed a review of the Bonded Medical Schemes Policy, which was passed at AMSA Council 2. At AMSA Council 3, her policy team will present a policy on rural health curriculum. Thank you to both Candice and Phoebe Macintosh-Evans (AMSA Central’s Policy Officer) for all your hard work in ensuring rural health policy remains a central focus of AMSA. From humble beginnings in 2016, this year the AMSA Rural Health Summit will host 120 delegates in Wollongong on September 16-17th. The event is shaping up to be an exciting one, with inspiring speakers, thought-provoking breakouts, trauma workshops, and great company. Congratulations to our convenors, Ryan and Nilasi and their sub-committee for all their hard work of putting the event together. With tickets selling out in just over an hour, we have no doubts that this event will continue to thrive in the future. A massive shout-out to Jess and her Publication Sub-Committee. They have worked hard all year to compile AMSA Rural Health’s monthly newsletter, which provides regular updates on the actions of our committee as well as rural conferences, scholarships and topical issues. We would encourage you all to sign up via our Facebook page. The Publications Team has also been responsible for compiling this fabulous magazine. Thank you to all who contributed to FRONTIER. We hope that your contributions will help foster discussion on rural issues, and inspire students to seek rural experiences. To finish up, thank you to our committee for 2017, who have worked tirelessly to ensure we uphold the values of AMSA Rural Health; to connect, inform and represent rurally interested students. Lastly, a massive thank you to AMSA Central and all AMSA members for your support throughout 2017. AMSA Rural Health continues to grow in both followers and impact, and without all of your support this would not have been possible. We’re both incredibly sad to be moving on from AMSA Rural Health. But, we can’t wait to see the wonderful achievements of the committee into the future, and read all about them in FRONTIER in 2018.

Jenna Mewburn & Brad Wittmer

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POLAR MEDICINE by Cassandra Brown (University of Notre Dame Sydney, IV) It was early October when the email, I had

ly find out, assistance and evacuation to the

been crossing my fingers to receive, arrived.

mainland might be days to months away. With

It was confirmed, I had a berth on the

this in mind, tough decisions are made daily

Australian icebreaker, the Aurora Australis.

that may even stop an expeditioner travelling

For the first time in my life I was going to

south on the day of departure. There is no

spend Christmas away from home in a very

backup if that stomachache turns into

cold, isolated and special place, Antarctica.

something sinister and it may mean that the

This once in a lifetime experience was all

entire ship and all its expeditioners must return

because of my John Flynn Placement at the

to Hobart immediately.

Australian Antarctic Division.

Heading South

Pre Departure

Finally the day arrived. It was an overcast and

Getting ready to head south starts months

dreary day in Hobart when the Aurora Australis

before you leave. The first lengthy step is to

left port and made its way south down the

pass your extensive medical. If you are lucky

Derwent River, past the headlands and out to

enough to be the station doctor departing

the sea. The voyage got off to a rocky start with

south for the winter, you additionally require

the Southern Ocean testing the quality of our

a prophylactic appendectomy. Many may

prophylactic seasickness measures. I became

know the infamous story of a wintering

an expert at walking uphill then downhill, or

Russian doctor who removed his own

on a constant 45-degree slant, and I learnt

appendix using only local anaesthetic. A

quickly that running on a treadmill is not a safe

story no wintering doctor wishes to repeat

way to keep fit when the ship is rolling

again.

constantly. In this first week, I volunteered for

Some may consider these measures extreme

as much as I could and became a pro at

but as some ill-fated expeditioners eventual5

peeling vegetables, fishing for krill and packing

important field kit into survival bags. As the first week rolled on, I got acquainted with the onboard medical facilities. The ship is equipped with enough equipment and supplies to perform emergency surgery on board and keep a patient stable until additional help can be sought. The ship's doctor, Dr. Roberts, and myself went through much of the emergency response kit and ensured that we both knew what we had and where it was located. We then got to test our knowledge during two muster drills. Time was also spent seeing patients for immunisations, common colds, general aches and pains, and dressing minor wounds.

In Antarctica, you learn quickly that you may be required at any minute to expand your skill set. If you are fortunate enough to winter over at one of the stations, many of these additional skills are taught well before you depart. The perfect example of this is the lay surgical

Before we knew it we had passed 60 degrees

assistants (LSA). Every year, a select bunch of

south and were truly in the territory of

wintering individuals, such as the cook,

icebergs and twenty-four hours of sunlight.

electrician and carpenter, are trained as theatre

Much time was spent, with most of those on

assistant prior to departure. Their very

board, on the bridge awaiting the first

important role is to assist the sole wintering

iceberg to appear. Once it did, their

doctor in any medical emergency.

presence was a constant reminder that we were now far from home and before we knew it we had reached the edge of the sea ice. We spent two days breaking through the ice to reach the continent on the other side. Along the way, our first sightings of penguins, seals and whales was to occur.

On two occasions I was lucky enough to be ferried ashore and spend the days on station. I spent much of this time in the medical facilities, which exceeded my expectations. The full size theatre was so similar to those in hospitals back home that I found myself looking around waiting for the next patient to

Casey Resupply

be wheeled in. In addition to the surgical

We arrived at Casey Station right on

theatre, there was a dental room (for all-

schedule and got straight into resupplying

important extractions and fillings), an

the station with much needed provisions for

examination room, drug and equipment stores,

the winter and year ahead. The roles of

and two long-stay beds. Whilst exploring the

everyone onboard, including that of the

medical facilities, I found the two resident

doctor, expanded during this week, as

Casey summer doctors, Dr. Fletcher and Dr.

volunteers were needed around the clock to

Vernon, both of whom I had met before. It was

assist.

great to see some familiar faces and catch up on what they had been up to. FRONTIER II | Page 6

At the end of the week we bade farewell to Casey and to Dr. Roberts, with a traditional send off of by the ship's horn and flares from the station. We made our way back towards the pack ice and onto the next stage of our expedition as I made a vow to return one day. Christmas, New Years, and Marine Science The first objective of the voyage was complete and whilst we spent three days making our way back through the pack ice, we finally celebrated Christmas, although several days late. From here we headed to the Totten, the Mertz and finally the Ninnis Glaciers. Itâ&#x20AC;&#x2122;s truly hard to describe in words and do justice to the imposing wall of ice that confronted us when we arrived at the Mertz Glacier. It was a special time in the trip and many budding photographers tried their best to catch the essence of the ice on film. Throughout these four weeks, the ships expeditioners and crew kept themselves very healthy. However, this resident medical student eagerly volunteered for as many jobs as possible from Dr. Vernon. Amongst all this, I used the opportunity to tap into Dr Vernonâ&#x20AC;&#x2122;s anaesthetics skills. He held several tutorials on how to use the onboard anaesthetic machine and the types of drugs to use that were available on board. Furthermore, I took the time to study up on the many medical conditions a doctor could encounter in cold climates and high altitude. Homeward bound After several weeks of completing science, it was time for the ship to finally make a turn for home. This time travelling back allowed us to catch up on sleep, farewell the last iceberg and be ceremoniously welcomed by

King Neptune to the Southern Ocean. There was little sea sickness onboard and thankfully no major illness or trauma. Before we knew it, the Aurora Australis was making its way back up the Derwent and towards the smell of fresh dirt and trees that hit us as we neared land. It was a day of mixed emotions for everyone when we finally stepped off what was our floating home for the past six weeks. It truly is hard to put into words the amazing experience I had. Countless expeditioners who travel south for a return voyage or for an entire year find this a difficult task. Many of the great people I met along the way will become life long friends as we lived alongside one another every hour of the day for six weeks. With this lies many difficulties for all expedition doctors when adjusting back into normal every day life once home. The fear of opening social media and addressing the thousands of unanswered emails was a daunting task. On my return I flew straight to Sydney and into three days of lectures as my final medical year commenced. It was a hard adjustment and I made sure to take some time to myself to reflect on the experience. The importance of reflection and debriefing after a trip south is critical. All expeditioners, including the doctor, leave their loved ones and families behind. Significant events may be missed and some relationships may never be quite the same on return. A trip to the end of the Earth is not a trip for everyone, but for any budding expedition doctor who is willing to step out of his or her comfort zone, it is a trip only few have the privilege.

A TRIP TO THE TORRES STRAIT by Jude Bottos (Flinders University, II) I was utterly thrilled to be placed on Thursday Island (TI) for my John Flynn Placement Program (JFPP), of which I experienced my first stint in December last year. I had expressed my desire to work in Aboriginal* health and as such, was fortunate to have obtained a placement in the Torres Strait. TI is in a unique position whereby it has a small hospital, but health services are provided to a large area, including all the islands in the Torres Strait, the Northern Peninsula and some of Papua New Guinea (PNG). Health services are provided both directly in the hospital, through adjacent Primary Health Care Centres, and by visiting clinicians and health practitioners whom provide an outreach service to patients on remote islands. I spent two weeks in the TI hospital, during which I was adopted not only by my mentor, but by what felt like the whole hospital team! It was a close-knit environment comprising of Australian and foreign doctors and nurses, all of whom were keen to involve you if you demonstrated being proactive - hands down, my specialty! The hospital comprised a general medical ward, a small emergency suite, an operating

theatre and a maternity ward. I shared my placement time with a few medical students from different Australian universities and between us we were encouraged to scrub in to surgery, attend ward rounds, participate in simulated exercises, for example paediatric resuscitations, request and analyse investigations and be involved in patient care. Most excitingly, we were able to attend outreach days where we would travel by boat or plane to neighbouring islands or to Cape York where the doctors would provide specialist services and maternal health checks to patients who otherwise had limited access to such healthcare. Adjacent to the TI hospital was the Primary Health Care Centre that provides medical, dental and a range of allied health services. Spending time in this clinic was important in order to better understand the scope of each of the different health disciplines, how they were integrated and this gave me some insight into the patients referred to these services. For example, spending time with the podiatrists meant I was able to see some of the patients who presented with chronic and/or infectious diseases that required cleaning, debridement and/or treatment. What also enriched my experience was sharFRONTIER II | Page 8

ing it with fellow students. As is often the case when people share close living quarters and experiences, we became quite close in a short period of time. Appended on the backdrop of sharing accommodation and experiences in the hospital, we learnt about each other, our challenges and achievements in our respective medical schools, as well as the endless options for our future in this fantastic, versatile and ultimately fulfilling career path. What I found to be of incredible value was learning about how a remote island hospital functions, what resources they utilise and limitations they encounter, what local and remote health services can be provided and what cases needed to be evacuated to the mainland. I saw the high prevalence of conditions such as tuberculosis and rheumatic heart disease, both of which are not frequently encountered in an urban setting and are disproportionately represented in the Aboriginal population. This said, what struck me was the positivity of the place – both the health facility and the island overall. The rapport between the medical staff and patients was respectful and encouraged mutual communication and understanding. Seeing how the patients benefited from this interaction serves as an impetus to uphold the same integrity in my 9

future practice. As I approach the end of my second year of medical school, I am excited to return to TI. This time I aim to extend the placement to 3-4 weeks and with a year of extra study under my belt, I look forward to being able to apply that knowledge into clinical practice.

An end-of-week cycling trip around Thursday Island. *The word ‘Aboriginal’ is used instead of ‘Indigenous’ and is inclusive of both Aboriginal and Torres Strait Islander peoples. It is the preferred term as per the National Aboriginal Community Controlled Health Organisation (NACCHO).

ARTWORK by Natalie Seiler (University of Melbourne, II) My placements are at Northern Hospital in Victoria. Due to our outer metropolitan location and large catchment area, many of our patients are rural residents. We also receive transfers from overburdened rural hospitals. Affordable dental services are scarce in these rural regions. The impact on our patients is clear, from the burden of unremitting dental pain, to tooth abscesses and septicaemia. Many of our rural patients no longer have their natural teeth, and this would have been preventable with subsidized dental care that is accessible.

Home Is Where The Heart Is Dentistry Accessibility

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A GP'S RURAL HEALTH PERSPECTIVE

by Dr. Aneesa Iqbal (GP, Neal Street Medical

Early 2002

I have been working here for nearly 9

‘Come on Aneesa, let’s do some visits’.

months now. The challenges of a rural

It was early 2007. My trainer, Jo, was showing me how a day in general practice usually was, the first week of my registrar year in semi-rural North Wales, UK.

general practice become easier as each day goes by. The awareness of knowing the distance patients travel to access care, the knowledge that a scan cannot be arranged the same day. The fear of trying to juggle

We made a nursing home visit to an elderly

care of the frail and elderly, not wanting to

patient who was suffering from Parkinson’s

be in hospital and at the same time not

disease and dementia. My trainer later told

compromising their safety, or care.

me he was an accomplished pianist and had presented initially as he was unable to play certain notes. Jo mentioned it made him sad to see this change, but also happy that he has continued to care for him.

The biggest challenge I see is the problem of retaining a rural workforce. This is impacted by factors including young doctors with families, a lack of social interaction and distances to access further

It was at that moment, that I realised that

education. Furthermore, a sense of isolation

being a GP meant more than medical care.

and long hours of work deter many from

It was a journey that meant standing

rural workplaces. However, with the

alongside patients through highs and lows,

advancement of technology, some of these

health and illness, births and deaths.

issues have been made easier, with the

I finished my training and moved to a larger

capacity to have video/teleconferences

city and then to Australia. It was 2015 when I again saw a job advertised in Gisborne. I visited the area, a little village, quaint and beautiful, the countryside quite breathtaking. It reminded me of my very first general practice experience. 11

Clinic)

means that sending and receiving images and investigations for further advice and specialist opinion is much easier. Looking at such perceived difficulties from a distance can seem very daunting, but if it is part of training, then it would be more acceptable. The quality of practices provid-

ing training in rural areas, the support network and mentoring would all improve student experiences. The general conception and association that somehow training and working in rural areas is less prestigious needs to be addressed at a student level. There are many advantages, such as being in a small team, the feeling of belonging and recognition, sense of community, as well as the hands-on experiences that are certainly not possible in urban practices. These benefits really need to be addressed and highlighted at a student level. Again, going back to my training, I remember going to a local pharmacy to collect a script for myself. The pharmacist looked at my name and said, ‘So you’re the new GP with the handwriting we can read – nice to meet you!’ The future of rural health lies in the way we educate our younger generation, not just doctors – but everyone. This can be done by portraying the benefits and removing the stigma associated with a village or rural career as well as incorporating rural placements as a regular part of the training program. Ensuring that student feedback along with supervisor experiences are relayed and shared amongst peers and juniors will encourage students to challenge themselves in a rural context. Last but not least, adequate financial remuneration is important – for after all, a holiday would not go amiss!

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Q&A: An Intern's Rural Health Perspective Dr. Christopher Lai (Intern, Goulburn Valley Health) Why were you interested in rural health? Hello there! My name is Christopher Lai and I am a University of Melbourne graduate. I am currently working as an intern in one of the University of Melbourne affiliated regional hospitals â&#x20AC;&#x201C; Goulburn Valley Health, Shepparton VIC. I was interested in rural health because rural health provides a spectrum of practice when dealing with pathologies. I was also able to form a deep relationship with the team I work with and I love it here! Based on your observations and experiences, what are the distinctive features of working in rural health, especially when compared to metropolitan areas (both the good and bad)? There are many advantages and disadvantages working in a rural healthcare setting. During my medical studies, my clinical placement was at the Royal Melbourne Hospital so I was able to compare my metro and rural health experiences. The pros working in a rural health area include more hands-on experience and having the opportunity to form a deeper relationship with the specialist consultants. As your registrars are often not in immediate vicinity, you are also being relied on as the first responder and assessor. The cons, however, include lack of access to metropolitan services and the potential difficulty in getting into specialist training programs. What factors do you think draw people to rural health as a future career? Some factors I think draw people to rural health as a future career are the geographical location, the spectrum of practice and the socio-demographic shift â&#x20AC;&#x201C; there are an increasing number of young professionals moving regionally for work and opportunities at the moment! Where do you see the future of rural health going? In the future, I see an increasing demand for specialist services in rural areas. I foresee an increasing number specialised hardware (i.e. MRI, PET scans) available in rural healthcare settings. I also hope to see more clinical rotations for medical students in regional places. It is a great learning experience and I hope every student gets a chance to get a taste of it!

MY RURAL GP PLACEMENT by Casey Barbis (University of Melbourne, III) “Meet me at the hospital instead of the clinic. We have a patient there this morning". That was all the message I was given at 7.30am during my fourth week of my rural General Practice rotation. I quickly made my way to the small "Urgent Care Unit" at the community hospital, oblivious of the patient behind the curtain and what was in store for the next few hours. There I was confronted by an elderly male who had experienced a fall in the middle of the night whilst walking down the stairs. An all too familiar story. He had returned to bed, but his wife was concerned with the cut and bruise on his head when they woke the next morning, and hence brought him in. As per protocol, the on-call doctor (my GP supervisor) was called by the nursing staff upon his arrival. Within just 30 minutes of our initial assessment, our patient's GCS began to rapidly decline. His wife then revealed he was on blood thinners. A subdural bleed was seemingly more and more likely. I was excited to make the diagnosis, then immediately, a wave of panic and fear came over me; what was going to happen to our patient? Within an hour, we had called Adult Retrieval Victoria (ARV) who quickly organised helicopter transport, with a team of retrieval emergency doctors and a Mobile Intensive Care Ambulance (MICA) paramedic. With them on their way, we moved our patient into the one and only resus room in the hospital, and began the agonising “watch and wait” process. 2 hours later, ARV arrived. There was a sigh

of relief from the doctor, nurse and myself, and the tension in the room dissipated. Help had arrived, and we were no longer in this alone. With a team, we felt able to tackle the issues, and quickly prepared the patient for sedation and intubation, ready for transport back to Melbourne. By 12.30pm, the helicopter was loaded, and taking off. My supervisor and I went for a wellearned coffee, and by 1pm, we were back in at the GP clinic, catching up on the long list of patients, postponed from the morning appointments. It was bizarre, to be taking a history from a mother and toddler about a runny nose and cough, knowing our first patient of the day was likely heading to neurosurgery and an ICU. Focusing during the day was a challenge, clouded with uncertainty on the outcome of the patient I had spent 5 hours caring for earlier. That day really emphasised the unpredictable nature of rural general practice, and that you truly never know what will walk through the door next! Above all, my rural GP placement gave me 6 weeks to fully immerse myself within the rural healthcare system, and gain first hand experience of Victoria's (and Australia's) rural workforce issues. Being the only doctor within a coastal town of several thousand people comes with great pride. Every member of the town was quick to sing their praises of my supervisor, and thank him for his dedication. Whether that was during a GP consultation, at the hospital or just strolling down the street. When we think of the rural workforce shortage, difficulties dealing with long distances, and city focused resources, we so often focus on patient FRONTIER II | Page 14

outcomes, and patient needs. And yes, as doctors, in both our everyday decisions and on a wider healthcare system scale, we want to (and are expected to) put our patients first. However, with the emergence of multiple pleas for a greater focus on doctors' own self care, mental health and the elusive "worklife" balance, my rural placement reminded me of how equally important it is to directly consider the doctors themselves. Burnout is not just for the overworked surgical registrars, or inner city junior doctors. It was certainly rife in a small town relying on one person to carry the medical needs of the town. Speaking to my supervising GP, and several locum doctors who came to the town to cover weekend shifts, it is clear that this remains a challenge of working rurally. Immense pressure is placed on a single person, or very small team; whether that be on a day-to-day basis in the GP clinic, or in emergency situations that arise, such as the one I witnessed. As a student, I've relied heavily on being around other students. To discuss cases, review management plans, and most importantly, to debrief with after a long day. Over my 6 weeks, I began to struggle with being removed from that support system. Yes, I was connected by phone, Facebook,

and weekend road trips back home, yet during the week, the days begin to run into each other. Despite being an amazing learning opportunity, as well as a beautiful place to live, I felt lonely, and that took away much of the energy and excitement from the things I was doing each day. If I felt that way after only a few weeks, I couldn't imagine how some general practitioners feel. Even later in our careers, most specialists will be expected to work within a team; junior doctors, registrars and consultants sharing the load. The importance of clinical discussions and team meetings is highlighted again and again. In a small town, with only one GP per day, there is often no way to get a quick second opinion, or helping hand, or debrief after a particularly difficult case. Yes, we can refer, or call, but in the small everyday moment, I've learnt that having fellow colleagues close by is a priceless resource. Yes, my rural placement gave me an insight into the way the rural healthcare system is organised and delivered, which was often very frustrating. However, it definitely hasn't deterred me from considering training to become a rural GP. In fact, seeing an area with the potential to be fully dedicated to a community, as well as advocate for structural change within the system, only drew me in more.

BUSH TOWN ADOPTS MEDICAL STUDENT by Liam Mason (University of Notre Dame, II)

The Bush Bursary is a two-week scholarship program offered by the NSW Rural Doctors Network. The scholarship aims to expose more medical students to the joys that working in a rural setting have to offer. The Lachlan Shire Council, located in central NSW, chose to sponsor me for this program to experience the services offered by the council. On my placement, I rotated around various hospitals and clinics located within Condobolin, Tottenham and Lake Cargelligo. I had the opportunity to shadow and be taken under the wing of some of the country’s finest rural doctors and allied health staff. Whilst on my placement, I also experienced a myriad of different services outside of medicine offered by the council, such as the preschool, community services, agriculture, pharmacy and paramedicine. One of the most exciting aspects of my placement was getting to spend the day with the Royal Flying Doctors’ Service. It

was absolutely exhilarating being rushed onto a tiny plane in the early hours of the morning to help retrieve a man crushed by a several hundred-kilogram fence overnight on the other side of the state. The community went to an incredible effort to make me feel at home on my placement. By the end of my two weeks, they had definitely achieved that – I felt like I practically knew the whole town! It’s experiences like these that make it such an easy choice when it comes to considering if one should practice in a rural setting in the future. The sense of community, the variation and the autonomy that your healthcare service can have and the lifestyle that you can live are all very enticing for me to come back to central NSW again in the future. I truly believe that if more students are exposed to the same type of experience that I have just come back home from, more students will want to practice in the country in the future.

FRONTIER II | Page 16

THE OUTBACK: KALKADOON COUNTRY

by Alice O'Sullivan (University of Notre Dame, II) In June 2017 I began my adventures in Outback Australia. Mount Isa is a famous mining town located almost 2000km northwest of Brisbane. Out there it is “Kalkadoon Country”, so called after the local Indigenous population. My placement began at Mt Isa Hospital where I spent my first day with the Surgery team. The day started early (as it does for surgeons) with the morning’s rounds. I tried to absorb everything I saw around me from the notices on the walls, to the location of hand sanitisers, the names and roles on the various staff identity badges and the social interactions between staff members as their day began. What stood out for me was that everyone was so friendly and welcoming. The consultant surgeon, his registrar, resident, intern and the medical students (including me) gathered together for the morning round. Observations, medications and discharge plans were all discussed as a team and before I knew it we were all heading up to theatres. I gowned up and played the part. Catching a glimpse of myself in the mirror I looked like the ‘real deal’. For the first time ever, it made me think that, yes, in a few years time, I will graduate and I will be in a hospital just like this one. For the first time I could now actually imagine my future and my part in it. I felt a part of something far larger than just me as an individual medic17

al student. It was a profession, a profession with a proud history and a future full of promise. This was “Medicine”. It was my chosen profession and this was my future. So many amazing experiences now lay ahead of me, beginning with today. Surgical theatres were almost magical to me. Everything had its rightful place. Everything was on-the-ready. It may not always be the case, but to me the room had a feeling of control and calm. The morning surgeries were quite straight forward, some BCC removals, two vasectomies and a cancellation. Then, all of a sudden, there was a rush of noise and movement. The next available surgical room was overrun with people from everywhere who seemed to come from nowhere. The words “Emergency C-Section” spread quickly on the lips of all those involved, and, before I knew it, I was looking at a new life. This was the first baby I have seen brought into this world and I will never forget the wonder of that moment.

I then spent some time in the Medical Ward reviewing so many chronic illnesses including complications of diabetes amongst the Indigenous patients. I followed a very knowledgeable registrar who was an excellent teacher. I heard my first aortic stenotic murmur and tried not to look too excited in front of the patient. I was astonished to learn that rheumatic heart disease is still common in Indigenous communities. A further stint in the Emergency Department focused on various acute presentations such as motor vehicle accidents, cardiovascular disease and also a notable suicide attempt by a 14 year old Indigenous girl. I saw the involvement of the Mental Health Team in an Emergency setting and the complexity of teamwork and communications required to assess and manage these cases. Towards the end of the week I followed a Mental Health Team to a remote Indigenous community one hour's flight north of Mt Isa. We were off to Doomadgee! As the plane was landing I could see the small river tributaries running across the land. Surrounding these rivers was greenery and life, but outside these areas was parched desert. It reminded me of fine capillaries running through the body, feeding the land and allowing life to survive and to thrive. It occurred to me that

health services and other services were similar in that way. They all feed life and health into these very remote areas. Like many remote communities, Doomadgee faces major challenges including poor school attendances, high unemployment, alcohol and drug problems, domestic violence, and, all this with the tyranny of distance and limited resources that are stretched too thinly and too widely. Doomadgee was not a place where normal outpatient clinics could be held for mental health and drug and alcohol patients. Patients would simply not turn up. Instead, the visiting Psychiatrist and the local Mental Health clinician jumped into the 4WD and located all of the patients wherever they were - at home, at a cousinâ&#x20AC;&#x2122;s home, or just walking along the streets. This seemed to work very well and there appeared to be good and trusting relationships that had developed between the mental health workers and the local Indigenous community. Another positive note was that these comFRONTIER II | Page 18

munities are now showing signs of selforganisation and improved community cohesion. I was also impressed with the ‘My Pathway’ community development programme which seeks to build stronger communities by work training, apprenticeships, developing education and support networks and by attempting to secure long term employment for local Indigenous people in the local workforce. Something that really struck me in Doomadgee was the number of horses, cattle and dogs which roamed the streets! Everyone seemed to own multiple dogs, and a horse! Although none were chained up or locked in a paddock, everyone seemed to know the owner and considered them as part of their larger family. After returning to Sydney and reflecting upon my time in the Outback (and in Kalkadoon Country), I realised how lucky I was to have had this experience. I gained first-hand knowledge and some insight into the difficulties and the triumphs of rural and remote medicine. I saw at first hand some of the more serious health issues faced by Indigenous Australians. We have a lot more work to do here in finally “closing the gap”.

THE RIVERLAND by Alexandra Durman (Flinders University, III) Having grown up and worked in country Queensland I thought I had a fair idea as to what I was getting myself into when moving to the small town of Waikerie in the Riverland Region. Now, six months in to my rural general practice placement, I reflect back on my greener self and chuckle. I could not have anticipated the excitement and challenges that comes with being a rural GP. I chose Waikerie for its reputation of providing an extensive hands-on teaching experience. The doctors here have a diverse range of skills with an impressive level of procedural skills. My week generally consists of parallel consults with GPs, hovering around the hospital hoping to catch a birth and travelling “up river” to the larger towns where I participate in consults and assist in theatres. In between all of that I try to find time to catch some shut-eye in preparation for on-call. In a town that is a popular holiday destination, as well as having residents on both ends of the socio-economic spectrum, the types of presentations are diverse. On my first weekend on call, I was involved in a resuscitation for a patient with severe septic shock. Feeling far out of my depth I found the nicest corner in the room and did my best to keep out of everyone’s way, as per

what I had learnt from my previous placements in a tertiary hospital. Pretty soon I was told to don a pair gloves and get into the thick of it. I learned quickly that even as a student I could be a useful member of team, and was expected to participate as much as any of the other staff. I relished this opportunity and the friendly environment has helped to develop my confidence in not only my procedural skills but also in my interactions with patients. Whether it be scrubbing for surgery, helping to deliver a baby, or practicing my suturing skills in Skin Clinic, I find immense professional satisfaction in the work that I am doing. But it’s not all work and no play, I have learnt to appreciate the need for work-life balance. I regard enjoying a cold cider while swapping stories with my fellow students, just as important as spending that extra time to memorise various clinical care guidelines. On my weekends I find myself exploring the nooks and crannies of the Murray River by kayak, indulging in delectable local fruits purchased from road side stalls and working my way through the endless distilleries and wineries in the region. To anyone who is umming and ahhing about whether to go rural for an elective placement, I say do it. It is an experience that you will not regret!

FRONTIER II | Page 20

EAST ARNHEM

DREAMING by Kim Lipszyc (Flinders University, III) It’s the middle of July and as I sit writing this article, there’s a soft 26-degree breeze and cockatoos screeching overhead. No, I’m not on a tropical holiday; this is just another day in the paradise of Nhulunbuy in East Arnhem Land. Nhulunbuy is the “hub” of East Arnhem, with a population of around 2,000. It’s a quick 1-hour flight from Darwin, or, if you’re game enough, over 1000km of 4WD track, which is inaccessible in the wet season. Nhulunbuy is a mining town where a strange relationship exists whereby Rio Tinto has a lease on the town. Rio Tinto built most of the housing, infrastructure, several sports clubs and shops, but no McDonald’s (yay!). In 2013, Rio laid off around 1000 workers. Not surprisingly, this had a medical outfall, including increased presentations of mental illness and resulted in the private GP clinic no longer being sustainable due to much of the employed population leaving town. This has resulted in a large increase in the number of presentations to ED for relatively simple ailments, like coughs and colds. Currently a confusing system exists whereby the private GP clinic can only operate if there are doctors available as rostering at the hospital takes priority. This can range anywhere from 1-3 days per week, leaving some of the locals waiting months to see a GP, with their only other option being to 21

present to ED so that they can be seen in a timely manner. There are two Aboriginal controlled health organisations, called Miwatj Health and Laynhapuy Homelands. Both of these coordinate care and transport of Aboriginal patients both “in town” and from the many traditional Homelands in East Arnhem. Laynhapuy even owns a fleet of small aircrafts for low-acuity patient transfers. This is one of the main differences in East Arnhem; the logistics of patient travel. If a patient does not “qualify” for a flight, they come in by “bush taxi”, aka. an indestructible Toyota troop carrier with no seatbelts and poor suspension. A patient’s journey may take anywhere from 2 to 12 hours, depending on the state of the 4WD track. After having my first experience in a troopie last weekend, I can say I now truly empathise with ill patients who need to travel this way. Sometimes, despite the best logistical planning, the wildlife here decides to stuff it up for you. Recently, we had a lady who had been bitten by a snake on a remote outstation. Care flight was summoned, but unable to land on the airstrip as there was a wild buffalo running along it. Eventually the station owners shot the buffalo, but by then the plane had had to refuel at a neighbouring airstrip and then come back to collect the patient, who luckily

hadn’t been envenomated! Some of the local wildlife is also part of the Yolngu people’s traditional diet, so one must always consider if patients have been eating dugong or turtle eggs when working them up for abdominal pain! Gove District Hospital is just adorable. At only 32 beds, it comprises two wards and an ED. We are very fortunate in that we rotate through the “whole hospital”, being maternity ward, the “general” ward (which literally has any and every presentation!) and ED. We also have a five-week outreach placement with Miwatj health to an island community called Millingimbi. There are both permanent and visiting allied health and specialist doctors, and through networking, one is able to join them on their outreach services to tiny Homelands of only 100 or so people. Some would argue that the pace here is too slow and boring, but I think it actually allows you to work up a patient properly and read up on guidelines and management. I find the medicine here fascinating, from the local disease epidemiology, and social determinants of health, to the more cultural presentations, which add a layer of complexity to your differential diagnosis. For example, we had a woman who presented with iron deficiency anaemia and we eventually worked out that it was from eating clay for cultural reasons.

fear that many Aboriginal Australians feel about losing their land, culture and traditions, and about losing many of their young ones to suicide, and drug and alcohol misuse. I have loved learning little bits of who passed away, which is one of the most powerful things I have learnt in medicine. I have been absolutely privileged to visit one of the Aboriginal homelands, where the family still lives a traditional lifestyle of hunting and gathering. I feel even more privileged to have experienced a Sorry Business Ceremony of an elderly Yolngu man who passed away, which is one of the most powerful things I have witnessed since beginning medicine. I urge every medical student to experience Aboriginal health, whether it be for a week or for a year. Creating meaningful relationships with the Yolngu people has been one of the most rewarding experiences of medical school and I most definitely see myself returning to the NT to complete my internship and future training.

No amount of reading or “culturally appropriate” class time could have prepared me for coming up here. It really is a case of learning on the job, matching your interactions to a patient’s and being as respectful as possible. As I learn more about Yolngu culture, I understand a lot more about familial relationships, the traditional way of living and sadly, the sense of loss and FRONTIER II | Page 22

#MYMEDSCHOOL Goes Rural - Featured posts from Facebook Rural isn’t a necessity, it is an opportunity. Spending 10 weeks in Charters Towers has been a brilliant experience from a personal development, academic and social point of view. The team at the hospital becomes your family, the sands of the desert your backyard and the pubs … well let’s not talk about the pubs. Tarren Zimsen (James Cook University, VI) Rural Placement in Charters Towers, QLD

It was with a heavy heart that I said goodbye to Heyfield this afternoon. Aged care proved to be far more enjoyable and rewarding than I had ever hoped. Spending the 6 weeks in a great rural town was just an added bonus. The responsibility and independence I was offered goes unmatched by any of my other placements. To my med friends, if you get the chance to do a rotation (GP or aged care) at Heyfield, do it! Brad Wittmer (Monash University, IV) Rural Placement in Heyfield, VIC

For me, going rural was never just about the medicine. It was about the wonderful people you meet and the communities that you form a part of. My move to Wagga has offered all this and so much more. The Riverina is a great region, with so much to offer. Living here means that I have had the luxury of not only an outstanding clinical experience, but being surrounded by great people and beautiful sights. Jenna Mewburn (University of Notre Dame, IV) Rural Placement in Wagga Wagga, NSW

I am now 4 months into my time at Bendigo and it's been a blast. My first rotation on surgery was an exciting introduction to the hospital and clinical life in general. Everyone was very welcoming and made you feel a part of the team and there was plenty of opportunity for hands-on experiences. Bendigo is also unique in that we have a blended curriculum between two medical schools and it's been great to really get to know students from a different University - plus we seem to get double the social (and learning) events with two rural health clubs looking after us! General highlights so far include pub trivia, the allyou-can-eat Pizza Hut (more for the novelty than the quality of food), the significant amount of natural light in the hospital, spontaneous board game nights, the pies from The Good Loaf and the fact that everyone's base level of friendliness has been quite consistently above average. It's been a great opportunity to get to know more about Central Victoria and I highly recommend spending time in Bendigo if you get the chance! Isabelle Urbano (University of Melbourne, II) Rural placement in Bendigo, VIC I had so many wonderful experiences in the Mallee (Mildura and Swan Hill), both clinical and nonclinical, but what sticks in my mind the most is the small things. It's the running through sand dunes, swimming in the river, smashing open local melons, walking your supervising GP's dog and the surprise parties your throw for your housemates - these are the smallest, but best parts of a rural placement. I think that when you go rural, you keep a bit of that place with you, so even when you're back in the city in a busy bar at your friend's 21st, there's still a small part of you out on the red cliffs, watching the Mallee soil wind through your fingertips. That's the part of you that will never want to leave, once you realize how great it is! Now, over a year and a bit since I commenced placement in the Mallee, I've made this video to show students the reality of a placement here: a lifechanging experience where you make best friends and learn from the most experienced clinicians. Whether you do 6 weeks in final year or a whole clinical year there, a rural placement is a must, and a good fit for everyone! Madeleine Leung (Monash University, IV) Rural Placement at Mildura & Swan Hill, VIC FRONTIER II | Page 24

Nestled in the heart of the Northern Rivers, in a little town called Kyogle, you’ll find the friendliest, kindest, truly salt-of-the-earth people. My JFPP in Kyogle was filled endless laughter, spectacular sunsets, and friendships I’ll always cherish. For three weeks, I was fortunate enough to be considered ‘part of the family’ by the Kyogle community. I helped weigh the newborn babies of mothers who had traveled over 100km from their remote farms, did home visits to houses that lived completely off the grid, and witnessed how trauma admissions ran in small town hospitals that had fewer resources than my local GP. From freak hailstorms to brown snakes to helping herd cattle, I saw it all and I can’t wait to go back. I’ll always remember my favorite patient telling me: 'Darlin’, you listen to me. Go on back to the big city, finish your training and come on back here to be our town doctor.' Nilasi Seneviratne (UWS, II) JFPP in Kyogle, NSW

I want to say a heartfelt thank you to the people of Wilcannia, who allowed me to be an integral part of the local health service and talked to me about the sociopolitical issues in their lives and in the community. I would also like to thank the health care practitioners who showed me how to provide healthcare through a framework of cultural security. I had a wonderful time and I would recommend this elective to those of you interested in remote health. This photo was taken when I was invited to co-host a session at the local radio station - never in my wildest dreams did I think I'd get to go on air during my elective! Shirley Jayasekara (UNSW, VI) Rural Placement in Wilcannia, NSW

LET'S TALK ABOUT RACISM IN RURAL HOSPITALS by Julia Lee (University of Melbourne, IV) Without a doubt, my time in a regional hospital was my favourite year of medical school. I specifically chose to go to the Rural Clinical School and I got exactly what I expected. It was the year I moved out with my friends, learnt how to be independent, and do doctor-y things! There was an incredibly rich teaching culture, a lot of ‘hands-on’ learning, and opportunities to meet dedicated and caring staff members. However, being an Australian-born Korean, at times I felt uncomfortable due to what was said by patients and staff members inside the hospital and by locals outside the hospital. Of course, these situations can also happen in metropolitan cities and hospitals as well. Unfortunately, growing up with racism in Melbourne was normal for me. I had stones thrown at me as a toddler while I was playing at the local park, and having expletives yelled at me regarding my race generally happens at least once a year. Considering that many students want to experience rural medicine, I think racism during rural clinical rotations is an important topic to discuss. Because in the end, rural experiences are unique and allow us to be well-rounded future doctors. The most common remarks that I came across from patients, staff and locals were often related to my English language skills or my appearance; casual racism. “’Julia? That’s not a very Chinese name!” “You speak English very well for an Asian student.” “You don’t have an accent. You know, it really hard to understand those Asians sometimes” “You’re very friendly for an Asian person.”

“You look so exotic. Are you Japanese?” “Ni hao!” Comments such as these are quite commonly recounted amongst students from nonCaucasian backgrounds – however, I can only speak from the perspective of someone of Asian descent. Despite a lack of malicious intent, comments like these can leave people frustrated, offended and uncomfortable. Initially, I felt this way as well. I wondered why it was necessary for them to point out my ethnicity. However, after spending time and understanding the community, I have thought: 1. Many locals may have spent most of their lives without meeting someone like me; an Australian-born person of ethnic background. Because of this, there is genuine curiosity. 2. Some patients feel vulnerable and scared about being in hospital and want to distract themselves by learning more about me and taking an interest in who I am and how I came to be a medical student in this town. 3. Patients or staff members may feel the need to small-talk to fill in the silence and think that a way to break the ice was to talk about something they have noticed. FRONTIER II | Page 26

I think understanding this changed my perspective and the way I respond to such comments. I stopped being frustrated and described my background clearly in a friendly manner. I would then start asking questions about the patient to show interest in them, or leave if situation continued to be inappropriate. Things that I have found which can help rapport with patients, staff and locals include: - Integrate into the community! Show that you want to be there and that you want to learn about their community. Go to the art museums, local restaurants, farmers markets and events so you can talk about them. - Understand the current, significant issues of the community e.g. unemployment rates, drug use, environmental issues such as draught or bushfires. - If you feel uncomfortable, acknowledge how you feel and either leave or get someone else to join you seeing this patient. - If you hear someone say something inappropriate, please speak up! Sometimes people don’t know that their words are making someone feel uncomfortable or that they are inappropriate. I have seen fellow colleagues step in and explain to the patients or staff members that their comments were inappropriate. Of course these are general hints and tips and don’t apply to every situation, hospital or medical student; be tactful but assertive at the right times. I wish I could say all encounters were relatively benign like those mentioned. Unfortunately, I recall an overtly racist encounter that made me feel unsafe and scared. As another student and I were walking to the hospital for surgical ward rounds (7am!), a car full of grown men drove 27

past us while yelling “Hey Asian sluts, go back to where you came from” before swearing at us and hurling bottles towards us. We tried to walk away, but they continued to follow us, making both racist and sexist comments. The only recommendation that I can make here is try to be safe and street smart. In these situations, get yourself to an area with more people and/or call the police. So where do we draw the line? When does racism stop being casual and where does it begin? When can we say this person is being racist rather than being ignorant? The ideal answer is that racism should not exist at any spectrum. However, even though a lot of people don’t mean offence by it, I think it is important that everyone should be more culturally sensitive and aware that their words could be negatively stereotyping or offending someone. Despite these encounters, the many positive experiences of being a medical student in rural hospital completely and utterly outweighed the negative experiences. If I could do it all over again, I would do it without a second thought. Additionally, as a soon-to-be-graduating medical student, the current war against all types of discrimination in hospital environments is something I feel incredibly proud about. Let’s keep up the great work! Let’s strive for safe and comfortable workplaces so we can focus on providing the best care for our patients and the community.

SHOULD INTERNATIONAL STUDENTS GO RURAL? by Nicolas Soputro (University of Melbourne, III) In 1988, the New South Wales (NSW) government announced the â&#x20AC;&#x153;NSW Rural Resident Medical Officer Cadetship Programâ&#x20AC;?, providing bonded scholarships for students in their final two years of medical degree in exchange for completing two of their first three postgraduate years in rural hospitals. This program, which is only available for NSW residents, has been proven to be successful in addressing the shortage of medical workforce in rural communities by increasing the likelihood of medical graduates to go rural based on their positive exposures(1). Studies have shown that medical students with multiple rural exposures and those with longer rural placements are more likely to work as a rural general practitioner(2). However, despite the success of the program and the availability of rural placements in medical school for domestic students, the issue of doctor shortage in Australian rural setting still remains as an ongoing challenge. It is not uncommon to read the struggles of different patients in the media as a consequence of this shortage, such as one reported in ABC News a few months ago regarding a patient that waited years to be diagnosed with Churg-Strauss syndrome and now needing to travel more than 200km for Specialist follow-ups in Canberra(3). Numerous solutions have been proposed and executed in the past few years to tackle the issue, spanning from planning new med-

ical schools in rural areas to increasing the proportions of International Medical Graduates (IMG) on the basis of the ten-year moratorium. Within the medical education system, medical schools are in agreement with the Federal Department of Health to provide Australian medical students with structured rural placement opportunities. Hence, students are also eligible for reimbursements relating to their travel and accommodations throughout their placements. The aforementioned solutions can be deemed suboptimal to address this developing crisis. Firstly, the current agreement between the Federal Government and the medical schools are limited to domestic students, meaning that international medical students, which constitutes up to 20% of the 17,000 Australian medical students(4), will have to spend their own money to accommodate their selfarranged rural medical placements or missing out on the opportunity completely. This additional cost can unfortunately be a huge barrier for most international students, having paid the astronomical tuition fees of around $65,000 per annum(5). This fact also contradicts the proposed ideas for new rural medical schools to fill the shortage as there is considerably huge pool of untapped resources, namely international medical students, in the looming presence of the infamous medical training bottleneck. The utilisation of IMGs, which currently FRONTIER II | Page 28

constitutes up to 40% of doctors in rural and remote areas can also be deemed suboptimal. According to the Australian Medical Association (AMA), the recruitments of IMGs to rural areas can possess safety risk to themselves and patients due to limited exposures and experiences in rural medicine. AMA also stated that this is a transient, rather than sustainable solution to bridge the gap in medical workforce availabilities between metropolitan and rural areas(6), some preferring to return to metropolitan areas following the end of their rural contractual obligations. One can only imagine the risk faced by the local communities when they are left with no doctors, simply due to the transient solution reaching its expiration date. In summary, with the growing challenges of inadequate medical workforce in rural and remote communities, the government can adopt a grass root approach by supporting the provision of equal rural placement opportunities for both domestic and international students, as those are the ones who are trained locally and with more familiarity to Australian medical system and culture. In addition, with studies showing positive correlations between early exposures and career selection into rural medicine, having people appropriately educated and encouraged to consider careers in rural and remote medicine is a far better and sustainable solution, for it is better to have people go rural because they want to and not because they have to.

References: 1. Dunbabin JS, McEwin K, Cameron I. Postgraduate medical placements in rural areas: their impact on the rural medical workforce. Rural and Remote Health. 2006; 6: 481. 2. Woloschuk W, Tarrant M. Does a rural educational experience influence students' likelihood of rural practice? Impact of student background and gender. Medical Education. 2002; 36: 241-247. 3. Coote G. (2017, Jan 7). Doctor shortages spark questions over viability of small rural communities. Retrieved from: http:// www.abc.net.au/news/2017-01-07/viability-ofsmall-rural-communities-in-doubt-amid-drshortage/8165560 (Accessed 9 July 2017) 4. Australian Medical Studentsâ&#x20AC;&#x2122; Association (2017). About AMSA. Retrieved from: https:// www.amsa.org.au/about-amsa (Accessed 9 July 2017) 5. Australian Medical Association (2015). International Medical Students and Graduates. Retrieved from: https://ama.com.au/careers/ international-medical-students-and-graduates (Accessed 9 July 2017) 6. Australian Medical Association (2015, Dec 9). International Medical Graduates 2015. Retrieved from: https://ama.com.au/positionstatement/international-medical-graduates-2015 (Accessed 9 July 2017)

FUN FACT: Do you know that 1 in 5 Australian medical students are international students? 29

E C N E L O I V C I T S E DOM IN

RURAL AUSTRALIA

by Melanie Engel (University of Melbourne, IV)

Domestic Violence (DV) in Australia is at epidemic proportions, and its impact on the health and well-being of affected individuals cannot be understated. The interplay of socio-economic factors, gender, culture and able-bodied status make this issue extremely complex and victims may experience vulnerabilities in multiple areas, including whether they live rurally. Whilst metropolitan areas offer a variety of GP clinics, shelters and other DV services, a victimâ&#x20AC;&#x2122;s options may be severely limited if they live in a rural or remote location. There may be no local or easily accessible shelters, leaving victims fleeing their homes with the only immediate option of homelessness. There may be no resource centres, making it harder to seek useful information and advice. And there may only be one GP clinic in the area. DV is multifaceted, encompassing many types of abuse. It is not restricted to physical and sexual threats or violence, but rather includes subtler forms such as emotional and financial abuse. These types of abuse in conjunction with controlling and isolating behaviors can leave victims without resources of their own and alienated from family and friends. Additionally, seeking help and leaving an abusive partner is a time of particular danger, and it is imperative that a victim has adequate supports to ensure their safety. In rural and remote areas, a victimâ&#x20AC;&#x2122;s best (and only) option for support may be their local GP clinic. However, health professionals and medical students need to be willing to listen and take an active role in helping their patients who are experiencing DV. It takes tremendous courage to seek

help after experiencing abuse, and there are many barriers that prevent victims from being able to do so in the first place. A victim asking for help directly, or indirectly through recurrent presentations, deserves support to navigate these awful experiences and situations. Dismissing their concerns, giving the impression of disinterest, or simply not wanting to deal with this type of issue, can leave victims of DV stranded and alone. In metropolitan areas, these patients experiencing DV may still be able to find the determination to seek help from someone else, whether that be another local GP, a shelter or resource center. In rural areas, patients may not have the luxury of finding an alternative source of support if their local GP is not willing to be one. Speaking up about abuse takes tremendous courage, and with so many barriers to seeking help, these opportunities cannot be missed. As a medical student, it is your job to protect and advocate for the health and well-being of your patients. If a patient tells you or another health professional at the clinic that they are a victim of DV and is attempting to seek help, followup on the issue and ensure it is addressed. If a patient comes in with unusual or recurrent physical ailments, listen to them, take a thorough history and examination, and never dismiss them outright. Although any person of any gender, culture, socio-economic or ablebodied status may be a victim, certain demographics in Australia are more likely to be victims. At present, one woman a week is being killed by a current or former male partner. Allowing your patients the time, safety and assurance to speak up and seek help may just save a life. FRONTIER II | Page 30

LEAVING HOME TO FIND MYSELF: A PERSPECTIVE ON GROWING UP GAY IN RURAL AUSTRALIA by Ryan Horn (UNSW, III) My Story – The Abridged Version Being raised in a rural community is like growing up under a microscope; each miniscule difference dramatically accentuated. I always knew that I was a little bit different, but before I had come to realise exactly how, I was already being taunted with terms like ‘faggot’, ‘gay’, ‘queer’ and ‘poofta’. Increasingly, these words gained power, instilling me with fear, anxiety and eventually denial about my identity. Over time I became so incapacitated by these words that I couldn’t even acknowledge my feelings towards those of the same sex. At times there was more darkness than light, but I dared not show weakness in a culture of stoicism. The internet became both my best friend and my worst torment. It was a place in which I could find solitude with others sharing my experience, but also a place that harboured those who thought I would be better off dead. It’s hard to freely explore your identity in a community where sex education only acknowledges heterosexual relationships. It’s hard to stand up against bullying and harassment based on sexual orientation when that would mean admitting not only to yourself, but also those around you that you are gay. It’s hard to believe that you will be accepted by your community when your own federal member for parliament votes against marriage equality, not once, but three times all whilst you are struggling with your sexual identity. 31

I felt as though I didn’t have anyone to look up to, and no one to ask for advice. There were no openly gay community figures that I could take example from or from whom I could seek advice. I couldn’t even talk to my doctor about it as they also cared for the rest of my family, and would usually invite my mother into consultations with me. For me rural Australia was hardly a conducive environment for exploring my sexual identity, and with all of these barriers concealing who I really was, I knew that I needed to leave. I was drowning in oppression, be it actual or perceived. I needed to get out. I focused on my studies and soon moved to Sydney for university. Being now in a city where more than half a million people come together each year to celebrate and share pride with the LGBTI community, I finally felt safe to be who I truly was. I wouldn’t say that I found a new home, but I certainly found myself. Coming out for me was surprisingly uneventful, so I’ll get to the crux of the matter. Given my more recent experiences and involvement in the LGBTI community, I have come to learn that my story is the exception, and not the rule. At the time, I thought I was alone in my struggle, but the truth is that many LGBTI youth growing up in rural and remote Australia go through far worse than what I endured. I was lucky that the abuse I faced was limited to verbal and emotional abuse and never became

physical. I was lucky that when I did come out, my family and friends were extremely supportive. I was lucky that I didn’t have to battle with mental illness, that I didn’t reach the point of harming myself, that I didn’t feel that my only option was to take my own life, and that I didn’t develop an addiction to drugs or alcohol. It shocks me that this is still happening, and that things do not seem to be improving. The Problem Unfortunately, many young LGBTI Australians growing up in rural Australia are still struggling with mental illness, self-harm and suicide. Some facts outlining the problem include: - LGBTI youth are 6 times more likely to attempt to take their own lives than their heterosexual counterparts(1). - 41.1% of same-sex attracted individuals aged 16 and over experienced mental illness in the past 12 months. - 20% of LGBTI youth are living in rural and remote Australia(2). - The rate of suicide in rural and remote areas is 40-50% higher than in metropolitan areas despite the similar prevalence of mental health disorders(3). - Rural and Remote LGBTI youth are at a ‘particularly high risk’ of mental illness, selfharm and taking their own lives. So What Can WE Do About It? As the future of the medical profession in rural and remote Australia we stand in a unique position to make change. But how do we go about it? Aiming to create a more inclusive environment that is sensitive to the LGBTI Australians living in rural and remote areas is key, and as a rural medical professional the following steps can be taken: 1. Demonstrate that your practice is LGBTI inclusive – through a message of welcome at

the practice entry (e.g. a rainbow sticker), communicating LGBTI and confidentiality information in service orientation, signage, pamphlets and advertisement in LGBTI media. 2. Promote diversity competence among rural and remote medical professionals and practice staff – e.g. not assuming heterosexuality and using gender neutral pronouns when discussing relationships. 3. Focus on mental illness prevention, rather than crisis intervention – sponsoring, publicising and advocating for LGBTI programs and partnering with LGBTI organisations. 4. Promote awareness and diversity competence within schools – as community leaders, rural GPs are in a unique position to promote LGBTI awareness and diversity competence in schools(4). 5. Advocate for legislative and policy changes that ensure LGBTI inclusion and equality – inclusive policy, particularly when it comes to marriage equality, may reduce the risk of mental illness in the LGBTI community(5). If this story raises concerns for you, please call Lifeline on 13 11 14; or beyondblue on 1300 224 636. References: 1. Rosenstreich, G. (2013). LGBTI People: Mental Health & Suicide. National LGBTI Alliance. Sydney. 2. Hillier, L., Jones, T., Monagle, M., Overton, N., Gahan, L., Blackman, J., & Mitchell, A. (2010). Writing themselves in 3: the third national study on the sexual health and wellbeing of same sex attracted and gender questioning young people. Melbourne: Australian Research Centre in Sex Health and Society, La Trobe University. 3. National Rural Health Alliance. (2009). Suicide in rural Australia. Fact Sheet 14 4. The Rainbow Centre. Suicide Prevention: For Lesbian, Gay, Bisexual and Transgender Youth. (2002). Atlanta, US. 5. Arnold, M., & Rosentreich, G. (2011). The mental health of sexuality, sex and gender diverse Australians. Paper presented at the 11th National Rural Health Conference.

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AMSA Rural Health Bursary Winner Reports 2016:

MY ELECTIVE AT EMERALD by Mariana Boscariol (University of Queensland) My rural elective with TROHPIQ (Towards Rural and Outback Health Professionals In Queensland) was in Emerald, located in the Central Highlands area of Queensland. I completed two weeks at the Emerald Hospital and two weeks at Priority Health General Practice. The doctors, nurses and other allied health workers that I had the privilege to work with taught me so much. The first two weeks in Emerald I was in the hospital. I worked in the hospital ward, the ED, the OR, the wound care clinic, the antenatal clinic, and the delivery suites. Though Emerald is not a large city, the hospital serves many patients in the Central Highlands who have to travel in for care. Being in a regional hospital, I was able to see a wide variety of patients and cases. At the beginning of my time there, with help from the doctors and nurses in ED, I was able to practice my cannulation and venepuncture skills. I eventually built up my skills and by the end of my two-week placement I was given the responsibility of helping to stabilise Category 2 patients.

Since Emerald is the only birthing hospital in the region I was able to observe two caesarean sections and assist during one vaginal birth, which was my favourite experience at the hospital. The last two weeks was spent at Priority Health Group Family Practice. It was a great experience doing general practice in a rural area. I saw a wide variety of patients and health concerns from simple to more complex cases that involved multiple specialists and allied health workers. Being located in Central Queensland along the Tropic of Capricorn, there were also frequent cases of skin cancer. From the beginning of my time at the clinic I was able to take skin biopsies for testing. The next week I was then able to suture up after skin cancer removals and even excise a skin cancer lesion with the help of the GP. My favourite experience at the GP clinic was listening to Johnny Cash and chatting with the patient while I sutured the wound closed after excising a skin cancer lesion from him. Doing this rural elective, I had many experiences and opportunities to develop my

professional and personal skills. As Emerald Hospital is a regional hospital, the doctors see patients with a wide range of medical needs. Shadowing these doctors allowed me to see a wide range of patients with symptoms ranging from urological to neurological conditions. This demonstrated the importance of doctors having a broad set of skills necessary to diagnose and/or treat these patients. Equally important is knowing their limits and when to consult with and/or refer onto a specialist. This was a very important lesson that I learned during my rural placement. Working in a rural GP clinic I came to understand how GPs are in charge of a patientâ&#x20AC;&#x2122;s overall care. In rural settings, it can be difficult for patients to access specialist care, but with the advancement of telehealth medicine it is making it slightly easier for them to obtain the help they need. While at the GP clinic I was fortunate enough to be able to sit in on a telehealth consult with a psychiatrist in Brisbane. This saved the patient from having to drive three hours to Rockhampton and they were able to receive the care they needed in a more timely manner.

While in Emerald I tried to see as much of the town and the surrounding area as possible. The Emerald botanical gardens were beautiful and had a large population of Black Flying Foxes roosting in the trees overhead. I was also able to rent a car on the weekends and see the Central Highlands area. The Gem Fields, which the Emerald Hospital has a clinic at, is known for its abundance of sapphires. While there I tried my hand at what the locals do and mined for sapphires. Just south of Emerald is Fairbairn Dam on Lake Maraboon. It is a great place to cool down in the central Queensland heat.

This was my first placement in a clinical setting and the first time that I really interacted with patients. It was a great experience to develop my personal skills, talking with the patients to take their history and developing rapport with them. Because I saw a wide variety of patients I learned to employ different techniques while taking different patient histories.

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AMSA Rural Health Bursary Winner Reports 2016:

COMPASSION IN THE HEART OF CENTRAL AUSTRALIA by Belinda Chai (University of Notre Dame) Background Alice Springs Hospital is the only major secondary referral hospital in Central Australia with a catchment that covers approximately 1.6 million square kilometres. It has approximately 199 acute care beds. Hospital services include emergency department, intensive care unit, general medicine, general surgery, orthopaedic: in & outpatient units, renal dialysis unit, obstetric, paediatric, psychiatric & rehabilitation services. I chose to do my elective placement in emergency medicine at Alice Springs Hospital because I wanted to gain clinical exposure in managing acute common presenting pathologies relevant to Indigenous communities in rural Australia. Clinical Experience During my four weeks at Alice Springs Hospital, I have witnessed and involved myself in the front-of-house care of patients with pathologies that one could only learn in either the developing countries or the developed nations. I have had the privilege to immerse myself in the management of patients from across this vast spectrum of social & geographical diversity. There are a high number of trauma cases from minor facial lacerations to major stab wound injuries from the catchment area around Alice Springs. As most people live in 35

remote regions and need to travel long distances to access healthcare services, many presentations of illness occurred late, with serious and poor outcomes. I was involved and assisted in the management of missed dialysis, stab wound injuries causing haemopneumothorax, pneumonia, malaria, meningitis, polypharmacy overdose, miscarriages, paediatric non-accidental injuries, domestic violence and neonatal sepsis. In addition, I am also involved in the care of patients with NSTEMI, STEMI, heart failure, acute renal failure and respiratory failure due to exacerbation of chronic obstructive pulmonary disease. Furthermore, I witnessed how the medical team dealt with drug and alcohol-induced pulmonary disease. I also witnessed how the medical team dealt with drug and alcohol induced violence professionally. The compassionate care, sensitive cross cultural communication skills, professionalism and clinical expertise demonstrated by the team of nurses and doctors in the emergency department also highlighted that team effort yields better outcomes for the patients. As it is a fairly large ED with an extensive pool of ED specialists from diverse background, I had the opportunity to work with the most interesting personalities who are passionate about both medicine and clinical teaching. I was given the opportunity to take

histories, perform physical examinations, present clinical cases to the consultants and supervising registrars with my differentials and management plan. The nurses and doctors also supervised me performing bedside clinical skills. I had the opportunities to enhance my skills in IV cannulation, venepuncture, female & male catheterisations, suturing and wound management. Furthermore, I have also assisted in the insertion of chest drains and lumbar puncture; and observed multiple resuscitations involving rapid sequence induction and endotracheal intubation. In spite of their busy clinical load, most specialist consultations took time to talk through the clinical reasoning process in most of the patients I encountered. On one occasion, I was given the opportunity to perform an infraorbital nerve block under direct supervision after going through a short video tutorial. It was an amazing opportunity to gain the trust and rapport with the consultants, to be able to participate in multiple facets of care for the patients and have multiple opportunities for hands-on clinical skills.

ionally and personally. I have witnessed clinicians administering words of comfort at the coal-face of medicine, and very often that is what patients yearn for in an emergency presentation. I have the privilege to work alongside professionals with interesting backgrounds, each of them having their own unique story to tell about what brought them to Alice Springs. But the consistent message is that they are passionate about practicing medicine and improving the health of the local Indigenous community. This elective opportunity has allowed me to appreciate the challenges of medical services unique to Central Australia and has enhanced my cultural understanding of the Indigenous community. I have gained a lot and been inspired to consider broader training experiences in the future to develop appropriate skills to be able to contribute back to a community in need. I am exceedingly grateful to AMSA Rural Health for the offer of financial assistance for my elective experience. I would not hesitate to return to Alice Springs at some stage as I journey through my medical career.

Aside from medicine, I was also able to explore the Alice Springs Township and the Western MacDonnell (the locals refer to it as â&#x20AC;&#x2DC;West Macâ&#x20AC;&#x2122;) ranges. I am particularly fond of the Orminston Pond Loop walk that takes approximately 3 hours to complete the circuit. The diversity of flora and fauna on the West Mac is spectacular, and the waterhole at the end of the walk is refreshing and invigorating in the midst of the desert heat! Reflection Completing my final elective placement at Alice Springs Hospital has been an invaluable experience for me both professFRONTIER II | Page 36

RED DIRT, RED BLOOD by Joshua Briotti (University of Notre Dame Fremantle, I) & Darielle Brown (University of Notre Dame Fremantle, IV) The Medical Student Association of Notre Dame’s (MSAND) Rural team hosted their first event of the year this June, which featured an assortment of rural practitioners and bush tucker. The aptly named event, ‘Red Dirt, Red Blood,’ sought to explore all things rural inspired to encourage current medical students in their pursuit of a potential career in rural medicine. The opening speaker of the night was Melissa Barret, a nurse practitioner currently working in Fremantle. She spoke of her experiences having worked throughout the Kimberley, Pilbara and many islands off the Western Australian Coast. She was followed by Duncan Wright, a documentary photographer and community development officer who works in Warburton, WA. This town is home to 400 Indigenous Australians and can only be entered by invitation only. He offered a valuable perspective regarding the disparities in health care and social support for those in rural and remote communities. Stephanie Jones spoke on behalf of Western Australian General Practice Education and Training (WAGPET) about her experiences as a GP registrar in Kattaning. She spoke about the recent and important advances in Telehealth, a program that offers support to those practicing in rural communities where doctors often work alone. Associate Professor Angus Turner continued the discussion and provided his experiences from using Telehealth as an ophthalmologist with the Lions Outback Vision (LOV). He spoke of the many kilometers he and his team would travel to provide ophthalmological care to many patients who otherwise would not be able to access. He was accompanied by his wife Ceire, an actress-come-chef-come-teacher who provided exciting nutritious meals for the team and kindly catered the event with 37

wattle-seed damper. Ceire currently heads the LOV foods program, which aims to educate children in remote communities about the importance of healthy eating. Lastly, Sally Edmonds shared her insights into life as a doctor for the Royal Flying Doctors Service (RFDS) and her encounter with Stephanie Jones for the first time, who was the familiar voice on the end of the phone for a number of patients she retrieved from Kattaning! The RFDS began in 1928, as the vision of John Flynn who sought to provide healthcare to the most remote corners of Australia. Today, the RFDS own a fleet of 66 fully instrumented aircraft that operate from 23 bases across Australia with their pilots annually flying the equivalent of 34 round trips to the moon! The event was a resounding success and undoubtedly provided encouragement for many students to consider a potential career in rural or remote Australia. MSAND Rural hopes to inspire medical students to become active participants in bridging the gap in rural and Indigenous health inequalities. The Team at MSAND Rural would like to thank those who took their time to come and speak for ‘Red Dirt, Red Blood’ and WAGPET for providing valuable insight into GP training. We would also like to specifically thank the local businesses in the Fremantle area who sponsored prizes for the night: Acai Bro’s, Ancient Earth Crystals and Gems, Chalky’s, Japingka Aboriginal Art Gallery, New Editions Bookstore Ohana, and Tamara Yoga.

CONTRIBUTORS Editor Jessica Win See Wong Sub-Editors Greta Beale Kim Lipsyzc Nicolas Soputro Contributors Alexandra Durman Alice O'Sullivan Aneesa Iqbal Belinda Chai Casey Barbis Cassandra Brown Christopher Lai Darielle Brown Joshua Briotti Jude Bottos Julia Lee Kim Lipszyc Liam Mason Marianna Boscariol Melanie Engel Natalie Seiler Nicolas Soputro Ryan Horn Zhong Yang Li Special Thanks Spotpress Printing 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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