AMSA FRONTIER Issue 3 2018 by The Australian Medical Students' Association

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Contents Letter from the Editor

Marisse Sonido

Meet the Team Report from the Chair

Frontier! Team

Gaby Bolton

RHS: An Insider Look

Marisse Sonido

Farm to Table

Baozhing Teng

Call for Opportunities

AMSA RH & ISN

My Time in Horsham

Time to Think Radical To Fix Rural NRHSN Report

Jessica Wong

Ross Lomazov

David Trench

Contents

22 24 25 27 31 32 34 37 43 Thoughts on Mental Health

Ruby Marslen

An International Studentâ&#x20AC;&#x2122;s First Experience in Rural Medicine

Linheng Zhao

What a Privilege

Amy Thwaites

Why Arenâ&#x20AC;&#x2122;t We Here Yet?

Rural Health Student Support Report Card Mental Health

The Growing Obesity Crisis in Rural Australia

Remote Medicine Done Remotely

Contributors

Muirin Healy

Jacoba van Wees

Natalie S

Carrie Lee

Alastair Weng

From the Editor MARISSE SONIDO UNSW (IV)

As you read this, you are holding the 2018 edition of Frontier!, AMSA’s official rural health magazine. Our theme ‘This is Rural’ hopes to represent rural life and medicine, featuring both its unique strengths and the challenges that rural communities face. In this edition, we were fortunate to have contributors tell their stories about rural Australia in a variety of ways. Placement reports like Jessica Wong’s ‘My Time in Horsham’ give us a glimpse of the invaluable experiences going rural has to offer. Creative pieces such as Amy Thwaites’s ‘What a Privilege’ and Natalie Seiler’s artwork about mental health deliver powerful messages that aren’t just intellectually stimulating but also emotionally striking. Opinion articles like Muirin Healy’s ‘Why Aren’t We Here Yet?’ and Ross Lomazov’s ‘Time to Think Radical to Fix Rural’ challenge us to keep pushing for change regarding the issues faced in rural Australia, such as the shortage of interns, inequalities in the health and education of Aboriginal and Torres Strait Islanders, and the growing rates of obesity in rural Australia.

A big thank you to all our contributors for the time, passion, and dedication that went into their respective works. Putting together Frontier! 2018 was both a rewarding and educational experience. As someone who has lived near cities all of her life, hearing so many experiences and points-of-view about what ‘rural’ means has given me a contrast to my own experiences that is necessary to becoming a more well-rounded practitioner and a better-informed individual. Working on Frontier! was also made fulfilling by the support I received from both my team and the AMSA Rural Health Committee. Their ideas, enthusiasm, and tireless promotion of Frontier! was what made the production of this issue both possible and enjoyable. We all hope you enjoy the fruit of our combined efforts! If you have any questions, please do not hesitate to contact me at my email, marisse.sonido@amsa.org.au.

FRONTIER! B A O Z H I N G T E N G . I joined the Frontier! team because it seemed like a really fun way for a lifetime city-dweller to get some different perspectives about rural health and distract from final year prep to do calming design things. I really hope you will enjoy this diverse and colourful issue and pass it onto a friend (and their friends). Itâ&#x20AC;&#x2122;s been a blast, and shoutout to the amazing, crazy-talented team for helping to make this all happen!

G A B R I E L L E B R A I L S F O R D . I am a final year medical student at the University of Tasmania. Moving to Tasmania from Queensland to study medicine opened my eyes to the world of rural health and its importance in our small rural Australian towns. Outside of medicine I love spending time with friends, drinking Hobart out of coffee and exploring the world!

TA M A R A H A L L . I am a final year student at Monash University. I have lived all over the place but my family is originally from North East Victoria, where I did most of high school. I used to run from the bush but am now fiercely protective and proud of the challenges and rewards of living and working in rural Australia!

MEET THE TEAM 5

REPORT

Report from the Chair Gaby Bolton, Chair of AMSA Rural Health Monash University (V)

fortunate enough to attend budget night where there were big announcements for rural medicine, including reforms to the bonding schemes that will see greater flexibility to return of service obligations from 2021 and the creation of a National Rural Generalist Pathway. Several members of the committee have also had the very exciting opportunity to work with both the National Rural Health Commissioner, Prof. Paul Worley, and the AMA Council of Rural Doctor on working groups aimed at implementing this new national training pathway.

2018 has been an exciting and challenging year as I embarked on my role as chair of AMSA Rural Health. Stepping up to such a leadership role definitely was daunting, however, my previous committee experience as well as my genuine passion for rural medicine has seen me through a very rewarding term, and I will be sad to say goodbye. As I write this, preparations are being made to elect the new faces of AMSA Rural Health for 2019. Regardless of whether you’ve got a CV a mile long or have never been on a committee, we’d love to have you involved. If you’ve got any questions please don’t hesitate to send an email to rural@amsa.org.au.

With the support of Health Workforce Queensland, AMSA Rural Health is very pleased to be continuing the rural elective bursary in 2018, giving financial support to students undertaking placements in regional and rural areas across the country. It’s always great to hear about the incredible experiences of students and we are proud to be

AMSA Rural Health’s advocacy has been front and centre in 2018, with the announcement of the Federal Budget. Our Vice-Chair, Candice, was

FRONTIER! able to help facilitate those who may otherwise have missed out on the opportunity to experience how fantastic rural medicine can be. Driven by our Members Without Portfolio, AMSA Rural Health is in the midst of a new initiative aiming to detail, both from a university and student point of view, resources and services available within communities and clinical schools for students undertaking rural placements. The ‘Rural Student Support Card’ will survey students from Victoria, NSW, ACT, and Queensland with the aim to expand in future to all states and territories. Another addition to the AMSA Rural Health resources for 2018 is the Rural Events Calendar. Our Events External Officer, Tessa, and Promotions Officer, David, have done an incredible job putting together a calendar of all things rural around Australia so keep an eye out on the AMSA website so you never miss a thing. A huge congratulations to the Rural Health Summit convenors Jordi and Dayna. Set to take place in Albury this September 28-30th, AMSA’s newest student conference has grown exponentially since its inauguration three short years ago, this year selling half of the available registrations in under an hour. The RHS subcommittee has put together an event beyond anything I could have imagined and delegates are set to have a weekend to remember with an inspiring and thought provoking academic program, incredible social events, and a ‘rural rescue challenge’ like nothing ever seen. A big thank you to Marisse and the publications sub-committee, without whom this fabulous magazine would not be possible. To wrap up, I want to extend a huge congratulations to all of my committee members. Working alongside such a passionate group, who share my love of rural medicine, has been an honour and a privilege. Thank you all so much for a fabulous year! Gaby Bolton

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RHS18

FRONTIER!

An Insider Look Two months before going beyond the border, we got a behindthe-scenes look from co-convener, Dayna Duncan, of all the planning, collaboration, and hard work that went into RHS18, as well as her experiences in helping lead the team that put together this one-of-a kind, whole-town event.

in a rural location such as this allows us to really showcase the area and all the opportunities rural life has to oﬀer: academic opportunities, work opportunities, or lifestyle opportunities. In Albury, there are so many areas to explore and things to do. What makes Albury a deﬁning location for an event like this?

What motivated you to volunteer as a co-convener for RHS18?

I think one thing about the location is that it’s halfway between Melbourne and Sydney and can capture audiences from both these cities. However, there’s a lot of interest from all over Australia and being in a central spot really helps us.

I was on the RHS17 Committee as an Academics Oﬃcer. I was a bit of a last-minute applicant for the position, and I wasn’t sure if I had the skills for the job. However, I was part of a really inspiring team during RHS17 and making an event of such a large-scale together made me really want to apply. During RHS17, I also got talking with my current co-convener, Jordan. We both realised we were applying for the position next year and we got together a few days after and discussed our ideas for next year’s RHS and what could be done better. Then, we decided to apply together.

Albury also has a really diverse lifestyle. It’s a few hours from the ski slopes, plenty of wineries, and a lot of other activities. There are plenty of learning opportunities that even I’m still learning about. There’s a brand-new border oncology centre which is doing great research. We have the only paediatric transgender clinic that is not in a major city. We also have a medical termination clinic supported by local doctors and nurses and a few refugee health centres.

What are some of these things that makes this year’s RHS different? A strength of this year’s RHS is that it’ll be held in Albury, which is more rural than the event’s previous locations. Last year’s event was held in Wollongong which, being a bit more city, was good with regards to travel and the availability of facilities. However, it doesn’t really make a lot of sense not to hold a rural event in a rural area. We found that the Albury community was super supportive of us as we planned the event. Holding RHS

There are also a lot of local doctors here that oﬀered their support for us. There are almost too many. As a result, the academics program is almost like a choose your own adventure. Delegates can choose to attend 26 break-out sessions, four plenaries, one panel discussion, and the rural rescue challenge.

FEATURE I’ve heard that all delegates get to participate in the rural rescue challenge. It sounds like a really big endeavour. It deﬁnitely is an ambitious event. We’ve been very fortunate to have Dr Moyle help us support such a big venture. He has a background in emergency medicine and he runs simulations for 6th year medical students based on a mass casualty scenario every year as their ﬁnal exam. This event will take that to a much bigger scale. We’ve gotten a lot of support on this from local services such as St John’s Ambulance and the SES. We’re hoping to make it a bit of a community event where members of the public can watch and see what medical students of Albury and all over Australia have been learning. How would you describe your team and how has it been working with them so far? They’ve been absolutely amazing. It was a bit of a process selecting the team. We looked at all the strengths of the applicants and how they could best work together. A few of our team members are in portfolios now that they didn’t initially apply for because we saw a lot of potential for learning there and, so far, everyone has done an incredible job. We were lucky enough to have a team retreat in Albury last April, with people from as far as Northern Queensland and South Australia coming. Everyone has their own unique passions, but the common goal of putting together this event has allowed everyone to really rally together.

Were there any unexpected changes from your initial plan and how will this aﬀect the event? I think maybe the team members would have more to say about that because they’re the ones on the ground. My role as convener has generally been a breeze where I check up on each portfolio every fortnight. The team is very good at handling any issues that come up and working through them. Our work as coconveners early on to foster a positive work culture was really important in giving our team the tools to do their best work.

How does the event, in its current form, compare with your initial vision of RHS18? It’s even bigger than we thought it would be. RHS17 had around 120 delegates and we aim to push this to 150–200. This was made possible by the local community in Albury, with local businesses giving in kind support and discounts on things like venue hire and catering. Local businesses also oﬀered sponsorships. This is a reﬂection of the Albury community and how it works together.

FRONTIER! What are the challenges of organising an event of this scale and how has your team handled these thus far? The main challenge was getting the word out about the event and showcasing what made it and our location special. Our publications and promotions portfolio has done an amazing job on this. Our logo has gotten some amazing feedback and our video was a lot of fun to make and was received very well in Council. We’ve also had a lot of help from the AMSA Rural Health Committee in spreading the word on this event. If you could choose one thing, what would you like delegates to take away from this event? I would like them to come away with a very different perspective of rural health. I know that, for example, in my medical school there is this notion that local students who are sent rural are being ripped off and that it’s inferior to staying in the city. But going rural comes with so much hands-on-learning, and there is so much diversity in what falls under rural health. You can tailor your practice and learning to your needs, like a choose your own adventure. We hope delegates get a sense of this at RHS18. Personally, what aspects of RHS18 are you most excited for and why? It’s hard to pick just one! Because I manage the academics portfolio, I think I’m most excited to go to the workshops. There are about 10 running at a time and delegates can choose between streams depending on their level of clinical experiences. For example, for the practical workshops, there are basic level ones, such as suturing, and advanced ones, such as ENT surgery. If there were no limits in the arrangements you could make for RHS18 (e.g., no budget constraints, any speaker you want), what would your ideal addition be to RHS18? I have more academic perspective on it. With regards to dream speakers, we already have my dream speaker. Dr Orr specialises in Indigenous, refugee, and women’s health. She’s the perfect example of how any doctor who takes initiative can have a big impact in a rural area and adapt their practice to suit their interest and the community’s needs. I would also love for every delegate to do as many hands-on practical workshops as they can. I’d also extend the event a couple of days so there is more time to showcase the area. We’d have an afternoon off just for delegates to explore the region and do activities like kayaking on the Murray and going to wineries.

FEATURE

The CHAPEL

good eddy

brunie, tasmania

orange, new south wales

press

social grounds

dubbo, new south wales

qudo

port macquarie, new south wales

teale cafe

bellingen, new south wales

Maitland, new south wales

seasalt

rustico

coff's harbour new south wales

orange, new south wales

FRONTIER!

CALL FOR OPPORTUNITIES FOR ALL MEDICAL STUDENTS

by Gaby Bolton Chair (AMSA Rural Health) with Zainul Abidin Azhar

(Co-Vice Chair, AMSA International Students’ Network)

All medical students should be given the oppor tunity to experience rural medicine. With the ongoing issue of doctor shor tages in rural Australia, the development of additional medical schools is not the solution. Instead, it will only tighten the bottleneck between medical school and the specialty training needed to become fully-qualified doctors. Arguably, a better solution is to focus on rural clinical placements and rural generalist training, with the aim of producing the well rounded doctors our rural communities need. Australian doctors don’t simply work within a single hospital or general practice—they work within a health system. An understanding of this system by doctors is crucial if we are to deliver the highest quality of healthcare to patients. Allowing all medical students, both domestic and international, the oppor tunity to spend time in the country provides future rural doctors rural doctors with this understanding. It also provides the oppor tunity to understand referral

Positive experiences in rural clinical settings also influence graduates’ decisions to practice rurally, irrespective of their background.

processes and build cross-specialty networks that will impact their future patients, regardless of whether they choose a rural path in the future. It is inevitable that, at some point, many patients from rural and regional areas will require referral to metropolitan ter tiary centres, due to the unfor tunate fact that access to many specialities remains limited outside of urban areas. Rural clinicians with an understanding of these pathways and metropolitan doctors with an awareness of the par ticular challenges faced by rural patients are vital to improve access and the health of rural residents. The greatest driver in achieving a sustainable rural medical workforce is to make rural practice attractive and allay any ‘fears of the unknown’. Graduates originally from rural areas are known to be more likely to want to return to such areas to work, but positive experiences in rural clinical settings also influence graduates’ decisions to practice rurally, irrespective of their background—country, city, or international. To provide these experiences, expanding access to the current system of Rural Clinical Schools, is essential. International students graduating from Australian universities have become a large proportion

OPINION of the junior doctors working in regional and rural Australia. Demand for rural placements among international students is especially high, yet a large majority of universities still exclude them from undertaking rural placements during medical school. With the current approach, how can these young doctors be prepared and appropriately equipped to give the highest quality of care to a population to which they have never been exposed? In order to produce the doctors that rural communities deserve and need, all medical students should be introduced to rural practice. In combination with enhanced access to rural training pathways after graduation, we will enablce them to become our future rural workforce.

My Time in Horsham

FRONTIER!

BY JESSICA WIN SEE WONG University of Melbourne (IV)

my self-confidence also grew immensely. Most importantly, I felt a sense of belonging with the medical team.

As I approached my final year of medical studies, I decided to complete a rural elective to expand my clinical knowledge and skills in a rural setting. Last summer, I had the opportunity to complete a three-week elective at the Wimmera Base Hospital in Horsham, Victoria. Located on the banks of the Wimmera River, Horsham is a fourhour drive from Melbourne. Surrounding Horsham are vast wheat fields, pastoral land and colourful fields of wildflowers. I thrived in the tight-knit Horsham community and thoroughly enjoyed the fantastic teaching culture in emergency medicine, paediatrics, and obstetrics and gynaecology. I had the opportunity to scrub-in as a first assistant in various gynaecological procedures and gained extensive hands-on experience. One of the highlights was assisting in a caesarean section while receiving one-to-one teaching time with consultants. My clinical knowledge and my skills in theatre, such as scrubbing and suturing, have vastly improved. With the encouragement and support I received from interns and nurses in performing ward tasks,

In the emergency department, I was involved in the management of critical cases such as a truck driver who suffered a spinal injury after colliding with another vehicle on the highway and a teenager who suffered a crush fracture after jumping off a 15 metre cliff. Furthermore, the lack of easy access to healthcare means that the rural patient often has signs or symptoms that are rare in a well-managed urban setting. I examined an elderly man who was reluctant to come to the hospital due to the long travelling distance and was found to have query rectal prolapse or thrombosed haemorrhoids. Furthermore, only one registrar and one intern are working per shift and I learned that they practice a very autonomous form of emergency medicine. With no trauma team, no residents to help with patient volume, and a lack of support specialties, the registrar and intern have to provide excellent care under additional pressure. These experiences

PLACEMENT Lastly, I enjoyed the lifestyle that rural Victoria has to offer and the elective has provided me with the opportunity to build close relationships with registrars and consultants. Together, we visited the Grampians and MacKenzie Falls and enjoyed the mountainous and rugged scenery. In particular, the water cascading over huge cliffs into a deep pool is a spectacular sight to behold. Overall, I believe that a rural placement is not only beneficial, but also essential to becoming a well-rounded physician. A rural placement shapes and cultivates a junior doctor. It not only allowed me to gain an insight into the complexities of the public healthcare system, but also enhanced my communication skills within a team. Without a rural placement, a city doctor cannot understand the sacrifices made by a patient to make his or her specialist

Without a rural placement, a city doctor cannot understand the sacrifices made by a patient to make his or her specialist appointment. appointment. Hence, I highly encourage everyone to seize this rewarding opportunity and undertake a rural elective this summer!

enabled me to fully appreciate the enormous need in rural communities and I believe there are great rewards in making a rural area safer and healthier. Although the resource allocation may be constrained, I have realised that working rurally as a junior doctor involves being a part of symbiotic relationship between medical and nursing staff. The support and camaraderie of the rural multidisciplinary healthcare team is substantial and I see a tremendous satisfaction in a career in rural medicine.

FRONTIER!

TIME TO THINK RADICAL TO FIX RURAL ROSS LOMAZOV

UNIVERSITY OF MELBOURNE (I) I have a secret. Medicine isn’t my sole passion. I have a guilty pleasure—the humanities. More specifically, politics. Yes, whilst others are dutifully jotting down lecture notes in their quest to be an excellent doctor, I am busy reading the latest political hot takes. I crave it all, ranging from international happenings to local councils—hell, there was a time when I was one of those annoying people trying to get you to vote in the student elections during Week 9. Yes, we all have a shameful past.

agricultural output at the same time? The solution was simple; starting in the 1950s youth from urban areas were organized to move to the rural countryside, especially to remote towns to establish farms. In the late 1960’s, the People’s Republic of China was undergoing the Cultural Revolution, with the material and social conditions of the nation in freefall. During this time period, the “Up to the Mountains and Down to the Countryside” Movement was instituted, resulting in roughly 17 million youth sent to rural areas. The reasons for this were numerous, ranging from ideological to economic. However, they may be summarised in three main goals: to aid agriculture, to know and understand peasant life, and not to forget the struggle of the peasant classes in the nation.

Politics goes hand in hand with history. One influences the other, like a hormonal feedback loop. It is not something that we should be afraid of–nearly every single problem we currently have has been previously encountered and solved, in some form or another. I am certain that I do not need to dwell long on the two largest problems facing Australian doctors and rising medical students: the paradox of an oversupply of medical practitioners in urban environments and their drastic undersupply in the rural areas of our nation. A solution to this population disparity lies in the pages of history, and whilst many may consider it radical, I’d like to believe that complex problems require revolutionary solutions. After the establishment of the People’s Republic of China, the nation found itself in a puzzle—what could it do to resolve unemployment in the cities, whilst boosting

OPINION If a compulsory year of rural placement is mandated during the first five or so years post-graduation, health outcomes for regional Australia will change for the better. That’s not even beginning to mention the economic impact that will be seen by rural towns. Coupled with potential expanded specialist training courses, healthcare provision in the most underserved regions of our country could rapidly shift for the better.

My solution, whilst radical, is simple and quite similar—have each recent medical graduate do a mandatory period of rural medical service within a set time frame post-graduation, most likely while they are interns, residents, or working as junior doctors. New doctors will understand the struggles of rural health first hand, experience extraordinary medical cases that they would not encounter in urban areas, and be able to form a lasting connection with underserviced areas of our nation. That doesn’t even cover the firsthand opportunities they will have to have an active role in treating patients that workplace ratios just do not allow in urban hospitals. Conversely, the rural areas also benefit— with a constant influx of new students, gaps in access to health workers would shrink, leading to increased positive patient outcomes and satisfaction.

Critics may say this may be a too radical solution — that is, however, the intended point. The healthcare labour system must be significantly disrupted if the bush doctor shortage is to ever be fixed. A similar initiative was introduced in Thailand. Discussing the Thai initiative, Wiwanitkit (2011) writes ‘all early-career health workers from public professional schools serve in rural areas as a governmental worker to maintain the rural health workforce. The system has ameliorated the shortage of physicians in rural areas’.

Previous, milquetoast attempts at fixing the problem have not worked. A staggering number of programmes have been introduced over the years, at a federal and state level. The current list of failed schemes is available on the Department of Health website. Bonded placement too has failed —student doctors merely began paying their way out of contractual debts. Now, a bonded placement lasts only a year. The carrot by itself has not worked. Perhaps the addition of a stick will motivate the mule of the medical workforce? Or, in this case, the rod of Asclepius.

In our medical schools, we constantly talk about the importance of regional health, about helping our community, and the necessity of having access to reliable, high-quality health care regardless of geographic location. It is time to walk the walk and try a radical approach to fixing the problems of rural health.

The data is on my side. Studies show that doctors who undergo training or placement in a regional setting are more likely to practise there than their urban counterparts. There are currently over 3000 students graduating medical school each year.

Medicine/Rural Clincal School/Albury-Wodonga Campus

Border Medical Training Hub

WELCOME TO ALBURY-WODONGA The Border Medical Training Hub (BMTH) would like to welcome all AMSA members to the Albury-Wodonga region. We are very pleased to be able to sponsor such a fantastic event. The program and activities have been very well thought out and we are certain that you will take away a lot of knowledge. We hope that you take the opportunity to explore our beautiful region while you are here.

Your Medical Career Pathway on the Border For those considering a career in a rural location this is the place for you! Albury-Wodonga offers world-class health care across two major public and private hospitals. From aged-care and maternity to oncology and mental health services, you have access to more than 200 GPs and medical specialists. Albury-Wodonga Health supports an outer catchment population of 250,000 and covers the North-East of Victoria and Southern New South Wales and is the first cross border public health service to exist in Australia providing the largest regional health care services between Sydney and Melbourne.

Albury-Wodonga Health has a large group of Senior Medical staff supporting our inpatient services, providing both elective and emergency care. Our Consultants are accessible to and supportive of our Junior Medical Staff and this, coupled with our broad range of clinical services, excellent opportunities for hands on experience and active education program, make Albury-Wodonga Health the perfect choice to kick start your career in medicine. The Border Medical Training hub is working closely with Albury-Wodonga Health, Murray City Country Coast GP Training, and Murray to the Mountains (M2M) intern training, Private hospitals and neighbouring hubs to create training pathways for you here on the Border.

What is the Hub? The Border Medical Training Hub is part of the UNSW Rural Clinical School. UNSW have been funded through the Integrated Rural Training Pipeline (IRTP) for Medicine to establish three Regional Training Hubs. The purpose of the Hubs is to improve the continuity of training for medical students and trainees and provide career pathways for doctors to train in rural and remote medicine. The Hubs aim to build upon the success of the Rural Clinical School program and provide the next phase of regional medical education.

Get in touch!

If you would like to discuss career pathways here on the Border we will be at the AMSA Rural Health Summit in Albury on the 29th September 2018 or contact us directly: E: Border_mth@unsw.edu.au or T: +61 (2) 6542 1346

REPORT

THE NRHSN AND THE RURAL HEALTH CLUBS

DAVID TRENCH, MEDICAL OFFICER NATIONAL RURAL HEALTH STUDENT NETWORK Rural health clubs around Australia have had an amazing first half of 2018. With the support of the NRHSN, the clubs have put on everything from speaker nights and gala dinners, to skills sessions and whole conferences. We are always blown away by the passion and enthusiasm shown for rural health by our clubs, so we thought we’d highlight just a few here. ARMS Close the Gap Conference 2018 (14th – 15th April) The 2018 Close the Gap Conference was an action packed weekend full of speakers, workshops, dancing, and cultural walks. The conference bought students from across ACT and NSW to ANU to discuss Indigenous health. The conference consisted of speakers including Dr Danielle Dries, Close the Gap Conference Founder, and Don Palmer, Malpa CEO, as well as cultural workshops and the bush dance.

FRONTIER! TROHPIQ and Hope4Health Skills Day (10th March)

ROUSTAH Rural High School Visit This day was a great way for students to learn more about health careers and what university life is like. They had a Gutsy Guts station, a Medical Imaging station, and a Nursing station in the schools in Whyalla and Coober Pedy. All the students showed enthusiasm and engaged in the activities. ROUSTAH would also like to say a special thank you to the Coober Pedy Hospital and the Ambulance service for providing them with opportunities to gain skills and knowledge about rural practice.

A group of over 90 TROHPIQ and Hope4Health members had the opportunity to join together for the first TROHPIQ Skills Day of the year. In two action-packed half day sessions, attendees were given a chance to get some hands on experience and try out new and valuable skills that are used every day in rural health care.

This is just a small taste of what our Rural Health Clubs around the country have been achieving in the realm of rural and Indigenous Australian health. With upcoming events such as ROUNDS’ and MIRAGE’s combined Indigenous Health Night, WARRIAHS’ Annual Ball, and SPINRPHEX’s GP Obstetrics Workshop. We would like to wish all our clubs the best of luck with the remainder of the year.

PLACEMENT

Thoughts on Mental Health In Rural Practice: A Car Ride Conversation RUBY MARSLEN, MONASH UNIVERSITY (III) We are driving on the dirt section of the road after three days of clinic out in the peninsula. Lucky it’s dry season; in the wet season, it fills up like a river—adding an extra layer of logistics when transferring patients out of community. Today the mental health team visited the clinic, particularly appropriate after three very recent deaths that had left a mountain of raw emotion and sadness among the local Indigenous community. Ironically, rural GPs are exceptional at looking after the health of others; managing complex chronic diseases of the young and old, reasoning through complicated 2am calls, and being world-class listeners of the biggest and smallest problems a patient may have. Yet, over and over again, there is a failure of doctors to reflect this quality of care towards themselves, especially their mental health and well-being. The doctor I was travelling with was very open and comfortable chatting about the reality and challenges surrounding the mental health and well-being of doctors and medical students in rural Australia. The sheer isolation, not only geographically but personally and professionally, was described as an enormous challenge for both students and doctors alike. However, the doctor expressed their gratefulness for the strong sense of community and belonging in their rural town, a place where your friends are your colleagues and your colleagues your friends. Whilst this may sound daunting to some, the strong friendships formed between like-minded individuals provides what was described as an unspoken code where everyone looked out for one another, especially each others’ mental health and well-being. This train of thought seamlessly progressed to one of the hardest challenges when managing mental health in rural and remote communities—everyone knows everyone. And whilst living in a small close knit community is also one of the positives about working in rural Australia, it also means that soon enough the whole town may hear about your recent battle with breast cancer or depression… or your colleague (who is most likely a personal friend as well) may be the one treating you. The Resources for doctors and combination of isolation and the lack of confidentiality can be frightening medical students: and overwhelming to some, creating a downward spiral that can make facing Doctor's Health Advisory Service (DHAS) mental health seem insurmountable. However this road is not as desolate as it may initially appear. One of the positive resources spoken highly of was the option and availability of support services such as Doctor’s Health Advisory, an organisation that provides a telephone helpline for

RACP Support Program consultant: 1300 687 327 (Aust) Bush Support Services 24/7 in Australia: 1800 805 391 Rural Family Medical Network in NSW, QLD, VIC or WA Beyondblue Doctors' Mental Health Program: 1300224636

FRONTIER! doctors and students seeking confidential support over the phone, no matter where they are located in Australia. As our conversion continued to unfold, the doctor shared with me their own personal story dealing with depression in a remote community. They expressed that one of the hardest things, no matter your profession, is acknowledging how you feel and seeking the help you need. Of course, there are a number of significant barriers that restrict some medical students and doctors when they seek help, and it is definitely easier said than done. They shared their concerns regarding confidentiality within the community and the challenges surrounding access to support due to geographical isolation or lack of time amidst a jam-packed roster that often overflows into late night paperwork. Other obstacles to seeking help include feelings of embarrassment, concerns regarding the impacts on career development, implications of mandatory notification, as well as the underlying stigma associated with mental health, which is particularly pervasive in the medical profession. After a long day in the clinic, we drove the 4WD across massive sand dunes to catch the sunset paint unbelievable shades of pink, purple, and orange through the sky—one of the very special things about being a medical student or doctor in rural community. It is little moments like this which play a central role in encouraging personal well-being and self-care as a fundamental part of maintaining a healthy body and mind to deliver quality patient care. The doctor explained the importance of their time outside medicine, which included many beach walks, bike rides, and coffees with friends. The other students were also involved in the local football team, enjoyed beach runs after a busy day in the hospital, and many weekend camping trips. Living over 2000 km from home, the students spoke about the close-knit friendships they had formed in the community and the importance of this support network for them throughout the year. Starting conversations about mental health amongst rural doctors and students is one of the first steps in planting seeds for positive change. The conversations need to challenge the culture and underlying stigma surrounding mental health and well-being, as well as the idealised perception that medical students and doctors are competent, resilient, and selfless individuals even in the most stressful of circumstances. Not only must we challenge these unrealistic expectations but, as medical students and junior doctors, we are responsible for gradually shifting the toxic cultural undertones within this profession. At the end of the day we are all human, and it is important to look after one’s own mental health. It is healthy doctors who are in the best position to provide patients with the care they need. Just like managing a mental illness, the road back to town can be unpredictable. Some parts are particularly bumpy, and you can occasionally go the whole way without passing anything other than a wild donkey—yet with every 4WD we pass, we exchange a friendly wave. A small gesture that gives so much to not only those who wave, but those who receive it—even on the bluest of days.

PLACEMENT

I have plans to return to Dubbo further on in my training, perhaps as an intern. My view of rural practice took a 180o turn after this experience in Dubbo. I liked how quiet and peaceful it was, and how shopping was so convenient. I was pleasantly surprised to see all the essential stores in town— Chemist Warehouse, Coles, and Woolies (and they were bigger!). I think rural life better suits my personality and I could imagine myself living in Dubbo as an intern. We also visited Dubbo Base Hospital, which had wards and equipment newer than those seen in some hospitals in Sydney and Singapore. I was so excited after the tour that I wished I was already working there.

NEVER HAVE I EVER: GONE RURAL AN INTERNATIONAL STUDENT’S FIRST EXPERIENCE WITH RURAL MEDICINE By Linheng Zhao, UNSW (IV)

I am not going to ramble on, but I hope to have sparked your interest in rural medicine. There is a major need for more doctors in these communities and it is saddening to know that people are not receiving the care they need as a result of a lack of resources. Regardless of what stage you are in your medical degree, I strongly encourage you to seek out experiences in rural medicine. You will learn heaps!

“WHAT? Bathurst is three hours away? That’s really far!” My friend had invited me to Bathurst for the weekend. I was expecting the drive to take not more than half an hour, which is a reasonable duration by my standards. Coming from Singapore, colloquially known as the “little red dot” because of its size (11,000 times smaller than Australia), my usual travelling time by public transport never exceeded half an hour. Each train station is only a two- to threeminute ride apart so you can imagine the culture shock when I moved here four years ago and had to travel two hours to get to university.

I wish that I had the opportunity for rural placements as an international student, but this is not the case at my university. My next step will be to apply for an elective in a rural area to learn more about its culture and lifestyle.

Last month, I participated in the Dubbo Ear Bus Project by Medical Outreachers Australia and fell in love with rural medicine. The trip was so impactful that it compelled me to write this article. I hope that my experience will address some myths and misconceptions about rural medicine and inspire more students to undertake rural placements, even if just for a brief period.

So, will you join me in advocating for rural health?

The trip was mainly spent teaching children about the importance of ear and nose health. Otitis media is a public health problem in Dubbo, where many children have hearing problems that go undiagnosed and untreated due to a lack of resources like GPs, screening programs, and funding. Needless to say, persistent otitis media can impact a child’s learning and social development. We partnered with the local organisation Hear Our Hearts and performed puppet shows about ear health to school children, observed audiologists at work in the ear bus clinic, and gained handson experience with tools to detect hearing loss in children.

Author (R) with Rachel Mills (L) , key Hear Our Heart advocate

FRONTIER!

what a privilege

AMY THWAITES UNIVERSITY OF SYDNEY (II)

I arrive for my first day. Struck with sandstone magnificence and stark grandeur, I’m reminded of my gratitude. My good luck. Hidden in a flock of hundreds it doesn’t take long to determine some here are in their own habitat and some have come from a very different place, privileged to be here. Some people know each other but many of us are outsiders who smile at each other cautiously. These people are going to mean so much to me. We are going to know each other. We are going to achieve a huge thing together. What a privilege.

I got into medicine. What a privilege. Whirlwind: tell my friends, family, quit my job, end my lease. One last holiday then say goodbye, fill my car, and drive north. For the first few hours I see familiar landscape. Rolling hills, treeless horizons, brown infinity of late summer, dusty sheep, and the graceful punctuation of wind turbines on ridges. I look up from my tired focus on the road ahead and suddenly everything has changed. Steep gorges, richly frosted with deep-green foliage contrasting yellow-orange wounds where the road cuts into the hillside. Dusk falls and, with no fanfare, I am in the suburbs. No views, no green, no space on the roads, reticular streets with aneurysmal roundabouts too small for my country car. I arrive at my new home. A building sandwiched between a train track and a carclotted highway. Construction in every view. I step over the remains of someone’s life—a dirty mattress, old television, a broken chair —sitting out on the kerb waiting to be taken away. This is my new home, on the third floor of a building hidden by the shadow of the one next door.

I move house. I move again. I’m envious of those who can stay in their family homes but they’re envious of me because I’m free. Where I grew up, the decision to go to university meant that I left home as soon as I finished school. There wasn’t a choice. Before medicine I was closer to home and family. I could visit. I had people to turn to. Medicine—you go wherever you get in. And some have had to travel much further than I. What a privilege. I get a job. I don’t want to. I’m so tired already. But this city is expensive. We talk as if opportunities are equal in education here. I have to move hundreds of kilometres and pay unaffordable

Welcome to Sydney. What a privilege.

CREATIVE more stresses to come. It’s only going to get harder. Perhaps if I’m finding this too difficult I shouldn’t be here at all. But I am. What a privilege. Ripe moments of aching beauty lie between bushy branches of laborious monotony and thorns of setbacks that prick me unexpectedly. I seek out these berries and pick them. Into my mouth and I savour the sweetness of deep friendship, tantalising acidity of exciting knowledge, and the heady, emotional experience of meeting patients with pain and heartbreak and grief who want to share themselves with me. I am excited about my future. I am excited about the person I will be at the end of this degree. I am excited to take the person that I make out of this dusty and sweaty city. I’m excited to take sagacity and skill back to a place where, for most people, moving to the city and spending four or eight years accruing education and gaining debt is an impossible dream. What a privilege.

rent and bills and food and clothes (to look professional), and even sometimes spend money on something fun or good. Then, there are some who live in a home where everything is paid for and everything is done. I wonder how I can hope to compete academically with these people. Maybe I will become a doctor but, at the end of our degree, they will have publications and networks and skills that I don’t have time to cultivate. But I’m here. What a privilege. I lay in bed early on a Monday morning and want to cry with tiredness. I’ve worked all weekend and barely had time to wash my clothes, let alone study. I have to get up—my alarm shouts at me—I have eight lectures today which I have no hope of ever catching up on if I miss them. But I just need to stay in bed because I haven’t had a day off this month. They say it’s not elite. They say that prospects are equal. But even I am lucky to be able to do this. Lucky that I can afford to not work (much) for another four years. That my family can help me a little. That I had some savings. For some people, coming to this far off and unaffordable place only to be suffocated with expectations and unsupported in adversary is an impossible dream. What a privilege.

Whenever I get the chance, I go home. Home has become anywhere I can see an uninterrupted horizon. I get in my car and, after two hours of navigating, Sydney traffic opens out into hills or ocean or farmland or a national park, and I’m home. The breath I didn’t know I was holding, sometimes for months, is suddenly released. I feel tension come out of my lungs, my muscles, my eyes. The big skies are my company and I don’t mind the drive, no matter how long. I cherish the quiet. I cherish the road. I cherish the speed. I cherish my family. I never want to come back to the city, but I always do. I may be in the wrong place, but I know I am on the right path.

Day in day out I try so hard. I try to be healthy, happy, frugal, dedicated, relaxed, organised, and, mostly, to just pass. Challenges remain the same, but expectations only grow. I thought, by now, it would be easier. We have a cursory conversation about mental health and support in the school, in the profession. I see a bureaucratic check box being ticked in the eyes of administrators but, looking around the room, I see fear and fatigue and frustration in the eyes of my peers. My friends. The people on my journey. We talk about how we’re struggling but no one has answers. Cries for help fall on helpless ears. We mollify our anxiety with thoughts of

I got into medicine. What a privilege.

Why Aren’t We Here Yet?

FRONTIER!

Muirin Healy, Monash University (V)

Halve the gap in child mortality by 2018

In 2008 the Australian government and ATSI community agreed ‘to work together to achieve equality in health status and life expectancy between Aboriginal and Torres Strait Islander peoples and non-Indigenous Australians by the year 2030′. As such, when I arrived at my remote health placement I expected to see these goals completed or in progress. Instead, I encountered a community which had made little progress. I was also shocked to see the ethical and practical dilemmas encountered each day by remote health practitioners. In such a resource poor setting, each decision made has dramatic

A two-year-old girl of ATSI background is brought to the emergency department by her mother. While playing with her dolls on the ground she was mauled by her aunt’s dog, which is trained to be violent to protect the house at night. There are no doctors in the hospital, so she receives first aid, and the family awaits the safety of daylight before making the two-hour journey to the nearest regional hospital. We try to counsel the family to remove the dog from the home, but they refuse. There is no pound and no vet in this remote town, the police only work at night, there are not enough staff to man the station during the day. With no way to forcibly remove the dog from the home all that can be done is to encourage them not to let her play on the floor.

effects on patients and their community, from who should get a seat on the bus to town, to who should get the last dose of antibiotics. But over

the course of my placement a bigger question emerged: if doctors are so important in ‘closing the gap’ should their decisions aim to help the community as a whole, or do they work for the patient in front of them?

Her mother tells me her daughter has a prosthetic eye due to retinoblastoma, worried that the socket may be infected. Looking

OPINION

through her records I see that her eye problems were first noted at six months but were not investigated until 14 months. Four fly-in doctors noted her squint and vision difficulties, each leaving a note for the next doctor to please bring an ophthalmoscope to check her red reflex. Eventually her parents drove her eight hours to a city doctor. Her eye was removed that week. The doctor who saw her six months later, when she was finally able to come home, writes ‘parents very angry’. I can’t help but think that they should be.

and says, ‘You know you don’t have to go back, you should be safe at work’. We can see that she’s contemplating leaving, but then she says, ‘If I don’t go back who will they send to replace me? Someone else will get hurt’. This was one of three teachers I saw that week. The school only had eight. Each described a school where students with no interest in learning tormented younger students and staff. They talked about being undermined and bullied by the Aboriginal teaching assistants. They were frustrated that ‘good’ students were too scared to come to school due to the toxic environment. Two had been physically assaulted, the other assaulted verbally. None of them felt they were doing any teaching.

In the flurry of heart attacks, injuries, and hand, foot, and mouth epidemics a note to check a baby’s eye seems so minor, what difference will two days, a week really make? But intermittent visits that week can quickly become months. In hindsight it’s clear that this equipment issue should have been addressed, but how do we practically stop an equipment issue arising again?

To close the gap, children need to go to school, but schools need teachers, and teachers need to be safe. In a broken system like this, is it better to exclude children from school and decreasing teacher turnover and increase school enjoyment for other students? Or should you sacrifice the teachers, burning them out facing abuse, and sending them home at the end of the year broken, a fresh group taking their place, in the name of providing education to all?

Close the gap in school attendance by 2018. Halve the gap in reading, writing, and numeracy by 2018. Halve the gap in year 12 attainment by 2020. Ensure 95% of ATSI four-year-olds are enrolled in early childhood education by 2025.

When we reviewed this teacher two days later, she tells me that the child who assaulted her has found her house; with their friends they have been throwing rocks at her window at night and stealing her belongings off the veranda. She leaves with a prescription for anxiolytics, ‘only nine months to go,’ she says as she leaves.

A 35-year-old woman presents to the fly-in GP. She moved to this remote town six weeks ago, one of the new teachers. She had hoped to make a difference, foster a love of learning in her students. She’s having panic attacks following being assaulted by a student. After an hour of therapeutic talking, examining the flight schedule to identify appropriate days for follow-up appointments and completing work cover paperwork the GP turns to her

FRONTIER!

How can we get there?

Close the gap in life expectancy by 2031. Halve the gap in employment by 2018.

Closing the gap is likely to be an ongoing issue during our careers, with particular difficulty for those of us working in remote communities. While more funding is definitely needed to adequately address the physical and mental health needs of the ATSI community, we also need to recognise that our role goes beyond the patient sitting in front of us. There is a need for us to approach the community as a whole, improve our cultural brokerage skills, and improve health literacy. Most importantly, we also need to work alongside and support our partners—the community elders, teachers, police officers, social workers, and employers—who will be key to closing the gap for everyone living in remote Australia.

A 28-year-old ATSI man sits across from me in the GP consulting room. I know him well. The first three weeks of my placement I played trivia with him in the local pub. The week before this review I resuscitated him following his attempted suicide. He’s one of the few people in town with a job. The last census estimated that 5/6 of the town is unemployed. He’s smarter and richer than 90% of the town but with that comes a huge responsibility: taking care of everyone else. Ultimately, the pressure proved to be too much. Each year, $1.2 billion is allocated to providing for the physical health needs of the ATSI population. Nephrologists, cardiologists, and endocrinologists all fly in bringing with them teams of allied health practitioners, tackling key areas: renal disease, cardiovascular health, and diabetes. In comparison, mental health is only allocated $30 million. In this small town, this means the psychologist flies in just once per month. With a waiting list in the double digits, he has no chance of seeing everyone who needs him. There are no psychiatrists. Locals tell me that young men have successfully committed suicide in the last year, the epidemic of poor mental health worsened by violence, alcohol abuse, and unemployment. Some of my patients are on community treatment orders. They want help, but there is no service to follow them up. It turns out that you an escape a mental health order, if you’re willing to travel far enough…

JACOBA VAN WEES MONASH UNIVERSITY (II)

a new initiative by AMSA Rural Health This year, AMSA Rural Health has been working on developing a new project called the ‘Rural Student Support Report Card’. The report card project aims to collect information on what resources and services are available to students in rural clinical schools around Australia in a number of different areas. As a rural student myself, I was drawn to this project as I think it is important to highlight the great support and services available to medical students undertaking a rural placement, while finding ways that we can continue to make rural placements an enriching and positive experience by improving access to these support services. Working on the ‘Rural Student Support Report Card’ has been a great experience and involved the creation of an online survey that was used to gather information from medical students within Victoria, New South Wales, and Queensland who had previously completed or who are currently undertaking a rural placement. More specifically, the questionnaire is looking at areas such as information about the clinical sites, academic and clinical teaching, financial support and accommodation, access to extracurricular activities, and health support services available in the region and options for student healthcare. We aim to include all rural clinical schools across Australia in the coming years and hope to regularly produce updated versions of the report as access to support and services continues to improve through advocacy, government, and university-led initiatives. For those of you who may have responded to this years online survey, we appreciate your time and valuable insight—projects like this cannot happen without the support and participation of students like you! For those of you who may have missed out or are from other states and territories, don’t fret—you should be seeing the Rural Student Support Report Card surveys each year, so make sure you follow the AMSA Rural Health Facebook, Instagram or Twitter page to have a chance to partake in future years.

If you're interested in seeing what type of support services are available across various clinical sites, keep an eye out on the AMSA Rural Health Facebook and website for the report results, coming soon!

ART

Mental Health Natalie S University of Melbourne (III) Being placed in an outer suburb hospital has inadvertently offered exposure to a range of patients who reside rurally. We receive many transfers from rural hospitals which are overburdened and underfunded. Our rural patients are confronted with many obstacles—constant travel for dialysis, lack of specialist care in their towns, and financial issues. As a medical student interested in psychiatry, I’m particularly struck by the prevalence of mental health issues in regional Victoria. A patient recently described how tough the past few years have been on farmers—his friends—due to weather conditions and the economy. Farmers especially have access to means when it comes down to risk assessment. The availability and accessibility of mental health services in remote and regional areas are of the utmost importance.

FRONTIER!

OPINION The obesity epidemic in rural and regional Australia is too big to ignore. Two in three people living in outer regional and remote areas are overweight or obese and almost 3 in 4 do not get enough exercise (AIHW, 2017a). Children in outer regional and remote areas are also more likely to be overweight and obese compared to those in major cities.

of a healthy basket of food for a four-person household was 26% higher in very remote stores compared to major cities (The State of Queensland, 2014). These cost barriers make it substantially more difficult for people in rural areas to access healthy food and implement healthy lifestyle practices. It is concerning, but understandable, that people struggling to get by would opt for cheaper, more calorie-dense foods.

And, indeed, we should be worried. More than half (57%) of Australians aged 15 and older are overweight or obese (AIHW, 2017b). We are performing poorly on the global scales, weighing in fifth, after America, Mexico, New Zealand, and Hungary (AIHW, 2017b). Obesity, rising amongst younger age groups, causes a multitude of medical and psychosocial problems throughout life: cardiovascular disease, diabetes, poorer mental health, and wellbeing. The rising prevalence of obesity and related comorbidities is already exerting greater economic burden on a public health system tasked with the challenge of managing complications, hospital admissions, and surgeries. In 2011–2012, the cost of obesity in Australia was estimated to be $8.6 billion (AIHW, 2017b).

Interestingly, however, a household survey in regional Victoria found that the availability of takeaway and fast foods was not associated with increased BMI (Simmons et al., 2005). Finding that older people who consumed fewer takeaway foods still had high rates of obesity, they cautioned against attributing too much of the obesity crisis to fast food. Instead, they noted an ‘alarmingly high prevalence’ of limited physical activity and emphasised the need to address the ‘obesogenic’ sedentary lifestyle (Simmons et al., 2005).

the growing obesity crisis in rural Australia

During my second John Flynn placement, I attended a day trip with the Nhulundu Indigenous Health Service, based in Gladstone, to the town of Woorabinda. An Aboriginal community located 170 km southwest of Rockhampton, Woorabinda is accessible by road —four hours each way from Gladstone—or by a small aircraft in the case of emergencies. With only a general store in town that sold packaged and deepfried food and the nearest supermarket a half-day’s bus ride away, the program officer said that it was difficult for the Woorabinda community to access healthy food. This situation parallels that of many other rural and remote communities.

carrie lee

The burden of obesity is not distributed equally across our society. Rates of obesity are higher amongst people living in rural areas and from socioeconomically disadvantaged backgrounds. Aboriginal and Torres Strait Islander Australians are also more likely to be overweight or obese (AIHW, 2017b).

UNSW (V)

These are hardly coincidences. They are a product of a failed system where social factors are driving inequalities in health outcomes. At the most fundamental level, costs of healthy food are prohibitively expensive for the average household, despite the irony that Australia depends upon our rural farmers for fresh produce. According to the 2014 Healthy Food Access Basket Survey in Queensland, the average cost

The Nhulundu Health Service also ran a successful healthy lifestyle program for Aboriginal elders living in Gladstone. Every Monday, Wednesday, and Friday, elders made the ‘Deadly Choice’ to come together for exercise sessions at the gym classes facilitated by one of the trainers, followed by a healthy lunch and discussion about nutrition. These were

FRONTIER! References Australian Institute of Health and Welfare (AIHW) (2017a). Rural and remote health. Retrieval from https://www.aihw. gov.au/reports/rural-health/rural-remote-health/contents/ health-risk-factors-and-remoteness.

positive sessions both in health promotion and in fostering relationships amongst friends and community, and it was encouraging to see how well it was received by the participants. In medical school, we learn a highly medicalised perspective about metabolic conditions like diabetes and obesity, and the realm of ‘non-pharmacological management’ often remains shrouded in mystery or put down to counselling about lifestyle modifications. What does that look like in practice? Do we need to reconsider what is most effective: a simple yet innovative community-based program or half an hour of the doctor imparting well-intended knowledge to a patient in the consulting room?

Australian Institute of Health and Welfare (2017b). A picture of overweight and obesity in Australia 2017 [PDF file]. Retrieved from https://www.aihw.gov.au/getmedia/172fba28-785e4a08-ab37-2da3bbae40b8/aihw-phe-216.pdf. National Rural Health Alliance (2018). Rural health alliance backs sugar tax & tougher ad rules. Retrieved from http://ruralhealth. org.au/sites/default/files/media-files/26072018-mediarelease-obesity-submission-final.pdf. The State of Queensland (Queensland Treasury and Trade) (2014). Healthy food access basket. Retrieved from https:// www.health.qld.gov.au/research-reports/reports/publichealth/food-nutrition/access/cost.

If we are to tackle the obesity epidemic in rural areas, much more needs to be achieved beyond encouraging individuals to adopt healthier lifestyles. Access to healthy food must be seen as an important, future cost-averting public health priority by the government. This year’s introduction of a tax on sugar-sweetened beverages is a first step and is supported by the National Rural Health Alliance (NRHA, 2018). However, more needs to be done to subsidise healthy foods and ensure their transport and availability, especially in rural areas.

Simmons, D., McKenzie, A., Eaton, S., Cox, N., Khan, M. A., Shaw, J., & Zimmet, P. (2005). Choice and availability of takeaway and restaurant food is not related to the prevalence of adult obesity in rural communities in Australia. International journal of obesity, 29(6), 703.

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REMOTE MEDICINE, DONE REMOTELY: A REFLECTION ON TELEHEALTH ALASTAIR WENG, UNIVERSITY OF MELBOURNE (I) Australia, with its boundless plains and dense shrubbery, is a country of stunning natural scenery and ample natural resources. Over 95% of our country lies outside the hustle and bustle of the cities and, for the 6.1 million people who live here, how blissful it is to see the horizon stretch into the distance unimpeded by human construction, to smell the local bakery selling its signature meat pies, and to hear the silence only broken by occasional chirp of crickets. Serene.

lack of transportation infrastructure, fewer career opportunities, and the long journey to the big cities to receive specialist care, especially for chronic conditions. So, what can be done about this? The ideal solution would, of course, be to increase the number of doctors, nurses, paramedics, and allied health professionals in rural Australia. There are several policies and incentives from the government which have strived to improve the situation, including the General Practice Rural Incentives Program (GPRIP) and the bonded status of some medical students. However, despite some improvement, there are still problems with lack of access to “the bush”, and there is one simple, unfortunate reality: doctors who grew up in the city, studied in the city, made friends in the city, do not want to leave the city. I had the pleasure of hearing Professor Paul Worley speak at the Tasmanian Rural Health Conference earlier this year, and he suggested that Australian universities should recruit students from rural backgrounds to serve the rural community. This is certainly a viable solution, but in the interim 20 years between starting medical school and becoming a consultant with regional roots, something else must be done.

So serene that no one can hear you scream as you feel a heart attack coming on. Of course, that is for the extreme hermit living in the middle of nowhere but, in Australia, we have so many middle-ofnowheres that it makes healthcare access a systemic problem. As a boy growing up in the big city, I never quite understood the fuss about lack of access. Sure, there are fewer doctors and healthcare professionals in these areas, but surely if there was a big enough problem they could just get flown to a bigger hospital. Then, bang, our first tutorial case as a medical student: ‘discuss the challenges faced by Kelly as a doctor in this rural situation.’ Gosh, did I learn a lot that week; low doctor-to-patient ratios, lack of diagnostic and imaging facilities, the primitive IT software…and that’s just the medical side. Those who have embraced the rural lifestyle are constantly under threat from the social determinants of health—

A few months ago, I heard the incredible story of a man who was in the exact situation I outlined at the start of this article. Ryan Franks—from the town of Coral Bay, WA,

OPINION

areas with tertiary hospitals whilst, in terms of specialties, 22% offer mental health support, with oncology, dermatology, and general practice also featuring prominently (Bradford, Cafferty and Smith, 2016). Most of Australia now has the infrastructure to set up a secure and stable internet connection conducive to consulting; business leaders often utilise conference calling for their trans-national meetings, why not doctors?

with a population of 190—suffered a myocardial infarction with no able healthcare professionals nearby. No doctors, no nurses, no paramedics. In fact, the one thing that saved him was that he was the healthcare professional, the only nurse for more than 150 km; such is the remoteness in some parts of Australia. Listening to his interview with the age-old Dr Normal Swan, Ryan recounts his pleasant morning activities turned sour by a central, crushing chest pain (Werner, 2018). With the help of his medical knowledge, two nearby St John’s Ambulance volunteers, and a cardiologist online in Perth, Ryan was able to make a full recovery.

Online health consultations are evidently beneficial as they improve access to specialist knowledge in these regional areas, which may only boast a handful of medical professionals locally. This provides much more accurate diagnoses and better ongoing management for patients. As a direct effect, we see rural Australia already becoming much more connected with the urban metropolis, with the opportunity to consult different specialists as if in the city. However, the benefits stretch far beyond that. No longer would patients need to travel an inordinate amount of time or distance to receive information for their condition, as all of this can be done within the comfort of one’s own bedroom. Without having to plan their day around their healthcare, patients have increased satisfaction towards the healthcare system. Indeed, a study in the US revealed that patients look positively towards video visits, citing comfort, short wait times, and ease of access for the disabled as some of the main reasons for satisfaction (Powell et al., 2017).

What can be done to ensure we have constant success stories like that of Ryan’s, especially in our country’s most remote settings? It was fortunate that Ryan had a background in nursing, but the same cannot be expected from all residents in the outback. Likewise, whilst volunteers are the backbone of many communities, dealing with life-or-death situations is not just a large ask but extremely confronting, especially for individuals without adequate training. Telehealth, however, seems to pose a viable solution. Telehealth is the use of telecommunications for providing healthcare and medical education, able to traverse geographic, and sometimes social and cultural, barriers (‘Telehealth’, 2015). It most commonly involves a video conference between the patient and doctor, presenting the case as if it were consultation in the doctor’s office despite being hundreds of kilometres apart. 68% of services in Australia connect regional

Telehealth not only benefits the patients, but also rural GPs. On average, rural GPs work 45.6 hours/week, compared to the 38.6 hours/week for their urban counterparts

FRONTIER! (McGrail et al., 2012). Furthermore, GPs in rural settings are more often on call afterhours given the lack of personnel, blurring that work-life balance that we medical students all hope to have when working as a practitioner. Because of this, rural GPs are also expected to maintain a broader skill set, including obstetrics, general surgery, and psychiatry. This is made much more difficult due to their distance from ongoing training services. Speaking to several general practitioners who have practiced in the most remote parts of Australia for decades, the overwhelming concern seems to be an inability to serve the community with their time or ability, even though their efforts would be more than commendable within an urban setting. By harnessing Telehealth and connecting with external services, there will be support for rural GPs for primary care, relieving them of the need to be constantly on the job.

consultations over 75 times a week. Apart from the opportunities it presents for a remote region without trained psychologists or psychiatrists, LYSN allows this meeting to take place in a comfortable environment, without the perceived stigma of visiting a counsellor, which is one of the main problems that Dr Geoffrey Toogood, founder of Crazy Socks 4 Docs, had identified. However, despite resulting in more accessible healthcare and thus superior management and outcomes, there are several shortcomings of Telehealth which need to be addressed before it becomes a mainstream tool in all of rural practice. One of the key concerns that Dr King voices surrounds the collection and use of data. Especially in the sensitive context of mental health, privacy is paramount to ensuring sustained, continual care. Medical devices also fall prey to this, conveniently uploading heart rate or glucose levels to the Cloud for easy access and tracking by our practitioners, but also risking sensitive information being leaked to a third party (Hall and McGraw, 2014). Currently, there is no specific privacy law for Telehealth, one that is transparent on how patient data is stored safely to inform best practice in a manner that would that ensure users trust the service.

Since 2012,Telehealth has been trialled in many disciplines, including primary care, chronic disease management, and mental health. It has even been ratified in the form of standard RACGP and RANZCP Clinical Guidelines for Telehealth (‘Clinical Guidelines’, 2014; ‘Professional Practice Standards’, 2013). There are governmentfunded Telehealth initiatives and infrastructure in most states and territories, including the Western Australian Country Health Service (WACHS) who connected Coral Bay and Perth for Ryan’s heart attack. I recently had the privilege of meeting Dr Jonathan King, founder of LYSN, a private service utilising telehealth to connect its users to psychologists for mental health

Although Telehealth has saved remote patients huge costs for travel and lost work, the system is not in place to the extent that it is overall financially sustainable. Much more infrastructure in the form of video/ audio devices and service providers is

OPINION required, and there is little financial incentive for innovation in medical technology used for this purpose (Jang-Jaccard, Nepal, Alem and Li, 2014). Currently, Telehealth simply cannot scale. Furthermore, without standardised remuneration policies for specialists playing the role of ‘distant doctor’, there is confusion between healthcare professionals and patients as to the financial burden, at times dissuading both doctors and patients from embracing this technology (Jang-Jaccard et al., 2014).

coaster. Reading some of the feedback, many of the public believed that the technology was very useful in the rural setting, but few were brave enough to sign up as a doctor’s remote assistant. It seems that Telehealth goes a long way to informing good practice, but some trained staff are still essential to carry out procedures and inform a diagnosis. Overall, there is no doubt that rural Australia has an access problem, and it is also evident that Telehealth does much to close the divide in healthcare outcomes. Its primary beneficiaries now have access to a wider range of specialists with whom to consult, whilst the pressure is also relieved from the already-stretched rural healthcare workers. However, Telehealth’s infrastructure is not yet rock-solid, nor are there foolproof privacy laws surrounding data storage. Despite this, Telehealth is evolving at a rapid pace, integrating health indicator tracking and clinical investigations into the suite available for a doctor to manage their patient remotely. I, for one, am excited to see where the technology takes us; if it’s saved someone having a heart attack, it’s already a success story.

For the run-of-the-mill medical professional, perhaps the biggest shortcoming of Telehealth is the inability to perform clinical examinations and investigations.Separated by a screen and several hundred kilometres, no longer can we hear the S4 heart sound, palpate an enlarged liver span, or illicit upgoing Babinski reflexes. That is not to say that Telehealth cannot assist with procedural work, as shown in Telestroke or Teleretrieval projects (Nagao et al., 2012; Sharpe et al., 2012). However, this requires trained professionals to be present and providing treatment with an expert on-line to advise best practice. Earlier this year, as part of Melbourne Knowledge Week, I took part in a simulation of this in a general practice. I, as a regular member of the community without any prior medical knowledge, relayed messages between the doctor and patient via an earpiece. Removing my hat as a medical student, I proceeded to talk to the patient about her problems, perform a suspiciously simple genetic test, and deliver the sad news that she had been diagnosed with diabetes. What an emotional roller-

References Sharpe, K., Elcock, M., Aitken, P., & Furyk, J. (2012). The use of telehealth to assist remote hospital resuscitation and aeromedical retrieval tasking: a 12-month case review.

Bradford, N. K., Caffery, L. J., & Smith, A. C. (2016). Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural and remote health, 16(3808).

Telehealth. (2015). In Department of Health. Retrieved July 17, 2018, from http://www. health.gov.au/internet/main/publishing.nsf/ content/e-health-telehealth

Clinical Guidelines. (2014). In The Royal Australian College of General Practitioners. Retrieved July 19, 2018, from https://www. racgp.org.au/your-practice/guidelines/ interprofessional/

Werner, Joel. (Producer). (2018, March 12). Health Report [Audio Podcast]. Retrieved from h t t p : / / w w w. a b c . n e t . a u / r a d i o n a t i o n a l / programs/healthreport/the-remote-nursewho-treated-his-own-heart-attack/9538610

Hall, J. L., & McGraw, D. (2014). For telehealth to succeed, privacy and security risks must be identified and addressed. Health Affairs, 33(2), 216-221. Jang-Jaccard, J., Nepal, S., Alem, L., & Li, J. (2014). Barriers for delivering telehealth in rural Australia: a review based on Australian trials and studies. Telemedicine and e-Health, 20(5), 496-504. McGrail, M. R., Humphreys, J. S., Joyce, C. M., Scott, A., & Kalb, G. (2012). How do rural GPsâ&#x20AC;&#x2122; workloads and work activities differ with community size compared with metropolitan practice?. Australian Journal of Primary Health, 18(3), 228-233. Nagao, K. J., Koschel, A., Haines, H. M., Bolitho, L. E., & Yan, B. (2012). Rural Victorian telestroke project. Internal medicine journal, 42(10), 10881095. Powell, R. E., Henstenburg, J. M., Cooper, G., Hollander, J. E., & Rising, K. L. (2017). Patient perceptions of telehealth primary care video visits. The Annals of Family Medicine, 15(3), 225-229. Professional Practice Standards and Guides for Telepsychiatry. (2013). In The Royal Australian and New Zealand College of Psychiatrists. Retrieved 19 July, 2018, from https://www. ranzcp.org/Files/Resources/RANZCPProfessional-Practice-Standards-and-Guides. aspx

CONTRIBUTORS Editor-in-Chief

Authors

Marisse Trongco Sonido

Zainul Abidin Azhar Gaby Bolton Muirin Healy Carrie Lee Ross Lomazov Ruby Marslen Natalie S Amy Thwaites David Trench Jacoba van Wees Alastair Weng Jessica Wong Linheng Zhao

Editors Gabrielle Brailsford Tamara Hall Designer Baozhing Teng

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