AMSA FRONTIER Issue 1 2016 by The Australian Medical Students' Association

AMSA Rural Health Magazine Issue 1, 2016

Contents 2.

Letter from the Editor

Report from the Co-Chairs

AMSA National Convention

Keeping doctors in the bush

Out in the open

27. Groote Eylandt - The Pinnacle of Remote Locations 29. JFPP:West Wyalong 30. Inequality and mangoes in the Wild West: an elective perspective

1 0. It's time to pay more attention to international medical students

33. Nine valuable lessons in nine hours

1 3. Acknowledging the ‘elephant in the room’: Why we need to work with, not against, complementary and alternative medicine

38. Rural conferences to watch out for

1 5. Fracture healing in a new climate 1 8. The importance of access and equity in the treatment of eating disorders

36. A Rural adventure in Canada

40. Rebuilding Des Bowen’s Healing Place – a ROUNDS Initiative 44. The eyes have it 45. The Alliance welcomes the new Frontier!

20. AMSARural Elective Bursary winners, 201 5 24. Honey Ant Dreaming 25. From the city to the desert; Remote Health Placement in Central Australia

Letter from the Editor Bhagya Mudunna It is with great pleasure that the AMSA Rural Health team introduce our first rural health magazine FRONTIER! FRONTIER! aims to bring together medical students throughout regional Australia as well as students who are interested in rural health. As you may be aware, there have been many heavily debated issues highlighted in the press this year such as the new proposed rural medical school, lack of rural specialty training opportunities and funding for rural hospitals. AMSA Rural Health and many of our members have been actively advocating for rural students so that their experiences and learning can be improved. This magazine provides all our budding writers a platform to voice their opinions on these issues and other topics that concern healthcare in rural Australia. FRONTIER! also hopes to bring the large community of Australian rural medical students together and allow them to share memorable rural placement experiences such as the John Flynn Placement Program and rural electives. It is remarkable to see how much we learn from short placements like these in remote locations with very few resources. AMSA's 2015 Rural Elective Bursary winners are also featured with an account of their experiences in rural Australia. I would like to thank the Publications Subcommittee for all their tireless efforts in sourcing and editing articles, the AMSA Rural Health General Committee and the Excecutive Committee for their continued support. A special thanks should also go to Grace Ng for designing the logo for Frontier! and the front cover. And a very big thank you must go to all our writers and contributors for the excellent quality of the submissions, and for bearing with us while we edited their articles and put this magazine together. You have made the first edition of FRONTIER! very exciting. On behalf of AMSA Rural Health, we hope you enjoy our magazine. If you have any queries or comments, please email me at: bhagya.mudunna@amsa.org.au Here is to many more issues of FRONTIER! Bhagya Mudunna

Report from the CoÂChairs Skye Kinder and Sophie Alpen AMSA Rural Health came from humble beginnings in 2015, with little more than the passion and ambition of a few. Experiencing exponential growth in the two years since its creation, AMSA Rural Health has continued to connect, inform, and represent rural-background students, rural clinical school students, and students interested in rural health. Our structure in 2016 consists of a 12-person Committee and two Subcommittee teams, one of which is the Publications team responsible for the creation of this first edition of FRONTIER! At the time of writing we have also begun the exciting process of electing new faces to our 2017 Committee, and we canâ&#x20AC;&#x2122;t wait to welcome them on board. Due to popular demand from you, our members, this year we have launched an AMSA Rural Health newsletter that provides updates on our all our activities each and every month. Our newsletter will serve as your one-stop rural health shop between FRONTIER! editions, and we would encourage you to subscribe and send in your events, activities and advocacy. We are pleased to see so many of our activities reflected in these pages, including reports from our 2015 Rural Elective Bursary winners. Our Rural Elective Bursary has grown to be a huge success, with a 350% increase in applications from previous years. In 2015 the Bursary awarded $1000 worth of funding to support AMSA members to undertake a rural elective, and in 2016 we doubled this to $2000. This is one of the only forms of elective financial support that is open to both domestic and international students, and we are proud to provide rural opportunities to our international student members, we hear you. Many of our members have also contributed opinion editorials and other advocacy pieces, which we feel embody the true spirit of AMSA Rural Health. Our Committee works tirelessly to advocate on a variety of rural health issues, and we hope to empower our members to contribute to these discussions. Much of our advocacy this year has focussed on regional and rural vocational training with our Committee developing the Doctors For Rural Communities proposal to this end.

We championed this proposal in visits to Parliament and received significant media coverage, coordinating a social media campaign as well (can anyone say #RuralDocsNow?). AMSA Rural Health continues to raise other items under rural advocacy such as a reduction in the BMP return of service, flexibility in the MRBS contract, and scholarship support for rural-background students. Finally, this year we are preparing to hold our first national event known as the Rural Health Colloquium. This event will consist of plenaries, panel debates and workshops that allow delegates to upskill and become engaged in AMSA activities in rural health. It will also be the first time in two years that those who are engaged with AMSA Rural Health will physically be in the same room. While RHC16 wonâ&#x20AC;&#x2122;t feature in this edition of FRONTIER!, we canâ&#x20AC;&#x2122;t wait to see it in the next one. A big thank you to Bhagya and her Publications Team who put in solid hours to deliver such a phenomenal magazine which we hope will inspire students to seek rural experiences and be treasured at rural campuses. Our address would also not be complete if we failed to acknowledge the contributions of our AMSA members to this edition. From opinion pieces, to reflections, to reports, every contributor played an important role in bringing this edition of FRONTIER! to life. As outgoing Co-Chairs we would like to take a moment to thank all of the AMSA members who have supported us in 2016, and we know that there are only bigger and better things to come for our next FRONTIER! in 2017 and beyond.

Skye Kinder

Sophie Alpen

AMSA National Convention, Townsville 2016 Satyen Hargovan, Sajid Chowdhury, Sophie Manoy, Annabelle Chalk and Isabel Guthridge on behalf of the Townsville 2016 Convention Team Between the 2nd-9th of July, 2016 our team was thrilled to host the 57th Annual AMSA National Convention in Townsville, Queensland. This was the first time in AMSA’s history that its premier event had been held in a rural/regional location – a fact that our Convention team is proud of, and actively embraced. As one of this nation’s fastest growing regions, Townsville is a bustling cultural centre where cutting edge metropolitan living meets an idyllic tropical lifestyle. Its ample nightlife, restaurants, bars and world-class entertainment precincts provide the perfect contrast to the regions pristine beaches, warm waters and lush rainforest. Home to James Cook University, delegates got to experience a taste of socially accountable medicine with a particularly strong focus on rural/remote medicine and lifestyle. Isabel Guthridge and Annabelle Chalk, our fantastic Academic Convenors found that “Convention was one of the most special weeks of our lives! We always knew that we wanted our academic program to have a rural and remote health focus, with a tropical twist. We dedicated an entire academic day to ‘Bring Back the Bush’. With plenaries from Prof Richard Murray on social accountability and the maldistribution of doctors, to Dr Damien Brown on the similarities and differences between his work in Tennant Creek and his work with MSF in South Sudan. We were especially lucky to have Jenna and Mitch contact us from AMSA Rural Health with a proposal to run a panel session on ‘Bush-ing the Limits’. The session was a total hit and included rural doctors from around Australia discussing everything from rural medical schools and bonded medical places, to sending overseas-trained doctors to rural areas, to raising a family in remote Australia. But it wasn’t all about lectures! We tried to pack the day with as many skills as possiblefrom airway management, to skin flaps and suturing, to hands on with hearts, toads and venoms. It wasn’t just one day of rural medicine though, we really tried to keep a regional focus running throughout the week- with a majority of our speakers coming from

Townsville, Cairns or up on the Cape. As the week wrapped up, we felt like we’d achieved our goal; to shake up the Southerners and show them that rural health is fun and fulfilling, and to inspire the development of 1000 new rural generalists (one can live in hope)”. Our Deputy Co-convenor Sophie Manoy, born and raised in Far North Queensland was “thrilled that Convention was held in a regional location this year! It gave us the opportunity to highlight what is great about holding an event outside of a big city and we were able to feature local speakers who are experts in rural health such as Professor Richard Murray and Professor Tarun Sen Gupta. It was heartening to see students engaged and interested in rural health as they asked questions and challenged our speakers. Additionally, Elise Buisson, our lovely AMSA President, was able to speak on the merits of rural health to open our Convention”. Our other Deputy Co-convenor Sajid Chowdhury was glad to see that “Townsville shines!!! It provides this intersection that we do not really see elsewhere in the country. Geographically, politically, culturally and economically there is juxtaposition between the old and the new, the well off and the under-served, rural and urban life. Convention we hope was the spark that ignites the passion for all our delegates. As doctors we are very fortunate to have a myriad of ways of helping people in life. Many of us decide to make a change in the big centres as specialists and some of us even try to make larger change and will get into politics, but we are losing the value of the rural country doc who can do everything and anything. The doctor who is at the GP clinic in the morning resuscitating a patient in ED in the afternoon and delivering a baby at night. Delegates definitely found their moment in Townsville 2016, we can only hope that moment is the start of 1000 new rural generalists who want to explore and change the world, one country town at a time”. Myself, as someone who was born and raised a city-slicker in Sydney city, I had never even heard of Townsville before I made the move to JCU. Now, Townsville holds a special place in my heart. Whilst somewhat different to the big cities, it is just as good in its own unique way if one is open-minded and ready to embrace it. The fantastic lifestyle, warm community vibe, genuine people and stunning scenery you find in rural/remote areas sells itself. It was fantastic to see the QLD medical student fraternity rally around our local event and help out. There have already been many new friendships made, great memories created, vital skills learned and leaders that have emerged. This will bode well for the future of healthcare in rural Australia. It was a privilege to be able to welcome guests to my adopted home and showcase our slice of paradise. I hope delegates enjoyed it - they are welcome back at any time.

Keeping doctors in the bush Morgan Jones Many doctors who want to live and work rurally cannot due to the structure of the training system we have here in Australia. The majority of medical training (apart from general practice) is metro-centric which forces the hand of young doctors with rural aspiration to relocate to the city when it comes time in their training. In the face of poorer health outcomes for rural communities compared to their metropolitan counterparts, this is baffling. Latrobe and Charles Sturt Universities are desperately pushing for their $43 million ‘Murray Darling Medical School’, despite a plethora of evidence to suggest it will not solve any of Australia’s medical workforce maldistribution. We have seen a drastic increase in the number of medical students - an increase of 150% since 2004 - however there has not been a commensurate increase in vocational training places to produce fully qualified doctors. In order to become a specialist, such as an emergency physician, surgeon or general practitioner, you need to complete 5-10 years of additional training once you graduate from university, but there are now proportionally fewer opportunities and places within training programmes than ever before. In real terms, this means fewer doctors can complete training to become fully-qualified specialists. There is an emerging mismatch between the number of domestic medical graduates and vocational training opportunities, which will extend to a shortfall of over 5000 places by

2030. This will only be exacerbated by the addition of the Liberal government’s new Curtin University Medical School, as well as the many other medical school proposals currently on the table for funding. A lack of training places is a concern for everyone, but will most significantly affect the many Australians who live outside of major metropolitan centres. Approximately 31% of the Australian population live in regional, rural or remote areas but only 14.6% of practicing surgeons live in these areas and this percentage is even lower for most other medical specialists. The success of Government programs that deliver positive experiences to students who rotate through rural areas has been well noted. As students become doctors in training it is important such experience and opportunities are continued so the end goal of boosting the rural health workforce is achieved. It is my hope that the investments in the rural training pathway through “Building a Health Workforce for Rural Australia” will ensure that doctors in training who wish to undertake their longerterm vocational training in rural areas are able to. It is paramount that doctors in training can be based rurally to continue connections to rural communities. Doctors may currently have an opportunity to visit a regional or rural area for around six months during their training, but they will always be based at a metropolitan centre.

This means that training specialists can never be based rurally or regionally for all of their 5-10 years of training outlined above. By the time doctors become fully-qualified specialists most will be into their thirties and beyond, with partners and families who cannot simply uproot their lives to move. The recruitment and retention challenges in rural and regional areas mean that it is crucial that we foster and develop pathways to fill workforce gaps. This is a complex issue that at its core is being exacerbated by a lack of supportive training infrastructure. It is important to consider past initiatives that have failed when assessing whether new policy will be successful, or whether it is simply political point scoring - something we see all too often in the health sector. A number of rural incentives and programs for trainees in the past have not worked, therefore it is imperative that the government and colleges adopt an evidence-based approach. The Royal Australasian College of Surgeons themselves agree that there is a shortage of appropriate post fellowship training opportunities in generalist practice as would be appropriate for rural and regional surgeons, however it remains to be seen the direct action the college is taking to counter this.

At this stage, it seems unlikely that the government will engage in any legitimate discussion around directing colleges to expand rural training programs. This issue will also require leadership from the colleges, who themselves can do more to correct this ever increasing imbalance. For the colleges, along with the government, the primary focus should be in meeting population needs for this part of our country that is too often neglected. It is crucial that the government works towards a targeted program to facilitate the medical workforce to train in regional and rural areas. There needs to be a concerted focus on the expansion and development of vocational training places for doctors in rural and regional areas, because the desire to train and work rurally as a doctor is already present. A new medical school will clearly not address this, and will only create more medical students, not more rural doctors. No personâ&#x20AC;&#x2122;s health outcomes should be determined by their postcode, so with all this considered, why are we sending our country doctors to the city? Morgan is a third year medical student at the University of Notre Dame Australia, and a Committee member of AMSA Rural Health.

Knowing that the colleges themselves have failed at recruiting rural doctors, it is concerning that the government is not engaging specialty colleges to change base training regionally.

Out in the open Asiel Adan Lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) individuals are every nook and cranny in Australia, no matter how isolated, small or remote the community may seem. So, whether you have done a rural placement or are considering rural practice, chances are you'll come across LGBTI individuals no matter where youâ&#x20AC;&#x2122;ll be practicing medicine. Rural healthcare settings need to be safe spaces for people to come out. Many LGBTIQ people report either experiencing outright discrimination or having to educate their doctor about their healthcare needs. While in metropolitan centres, LGBTIQ people can go to other healthcare services if they have a negative experience, in regional, rural and remote settings, they might not have that luxury. This is a real barrier to primary healthcare and worsens clinical outcomes for LGBTIQ people. For LGBTIQ young people in rural places, a supportive environment is vital. Isolation, lack of community engagement and poor social access often lead to decreased mental health outcomes for LGBTIQ young people compared to people in metropolitan regions. All it takes is five supportive individuals to change the outlook for LGBTIQ young people. With less than five supportive individuals in their lives, LGBTIQ young people are more likely to internalise homophobia and have a destructive notion of self, leading to depression, anxiety and selfharm. On the other hand, with five or more supportive individuals in their lives, LGBTIQ young people are more likely to be accepting of themselves, build resilience and avoid internalising homophobic abuse. A friendly GP clinic could make the biggest difference in supporting young LGBTIQ people, connecting them with wider LGBTIQ community groups and resources. Creating safe and inclusive spaces can sometimes be tricky- we have to be able to give people the opportunity to come out without dragging them out of the closet. Practically, this translates to small things in day to day clinical practice. This could range from ensuring admission forms acknowledge transgender and gender diverse individuals, which is best done by simply leaving a blank line when asking for gender. Similarly, there could be a small rainbow flag somewhere or a poster from Gay and Lesbian Health Victoria around the clinic that tells people they will be accepted and respected for their identity. Our day to day language also makes a huge difference. Not assuming people's sexual identity and using gender-neutral pronouns when referring to their partners could also be subtle hints that is a safe space. Similarly, asking patients for their pronouns as part of your regular practice will minimise alienating trans and gender diverse patient. Integrating all those basic elements into rural practice could make a big difference for the health of LGBTIQ individuals in the community.

There's some extra considerations we have to take into account when it comes to LGBTIQ patients in rural and remote Australia. For one, patient confidentiality becomes a much bigger priority than in metropolitan centres. In big city hospitals we might be able to casually mention your last patient was thinking of transitioning or that the lady with abdominal pain in ED told you she was a lesbian when you asked about pregnancy risk. We are unlikely to run into the same patient again and confidentiality is not much of an issue and this information is unlikely to reach their family, their friends or their employers. However, in rural, remote and regional services, casually mentioning the last patient you saw was gay to the nurse or receptionist could have big implications. A patient might suffer severe psychological distress, harm to his family relations and could potentially be the target of homophobia and transphobia. It is much easier to inadvertently out a patient to the entire community in a rural setting with quite significant consequences for the patient. As a medical student, the best you can do is educate yourself! Learn about inclusive practice, read up about gender neutral pronouns, know the referral pathways for people seeking gender affirmation. You donâ&#x20AC;&#x2122;t have to do this alone, thereâ&#x20AC;&#x2122;s plenty of LGBTIQ organisations who would be happy to engage with you and guide you to the best resources out there. Get familiar with the LGBTIQ organisations in your area and the support available for LGBTIQ people. Your referral could save a life.

It's time to pay more attention to international medical students Zheng Jie Lim

Introduction International medical students make up a significant proportion of medical students in Australia, with an estimated 1 in 5 medical students who train in Australia having a citizenship elsewhere [1]. While Australia faces a lack of doctors in rural and regional areas [2], we are in a perplexing situation where both international and Australian students face a lack of internship in Australia upon graduation which is necessary to register as a medical practitioner. Research into the extent of contribution international medical students have on alleviating the medical workforce shortage have been limited. Hawthorne and Hamilton showed a strong desire of these students to undertake internships in Australia, with most of them wishing to migrate to Australia [3].

Do international medical students desire working in Australia? Unlike domestic medical students, international medical students often face the question of whether to return to their home country for postgraduate training. While Australia represents an attractive place to work, attaining an internship is difficult, given the lack of available internships. In 2016, the Australian Medical Students’ Association (AMSA) Rural Health team conducted an online survey of international medical students to understand their interest in rural placements and internships during their time in medical school and post-graduation. The survey was distributed via social media such as Facebook, with emails sent to international medical students. It is important to note that this survey was distributed with web-based links. As such, the reliability and validity of the survey results remain questionable due to non-universal reach of all International students in Australia. Results of the survey A total of 287 responses were recorded from 14 universities across Australia, with all participants identifying as international undergraduate or postgraduate medical students. 231 (80.49%) expressed their interest in practising in Australia, of whom 178 (77.06%) expected to stay in Australia beyond their specialty training. 275 (95.82%) of international students would consider a rural placement if it increased their likelihood of an internship. 239 (83.28%) students expressed interest in working in regional and rural Australia, with 153 saying they were ‘very interested’ and 86 ‘somewhat interested’. However, 94 (32.75%) of international students expressed that their university did not provide rural placements for international students, while opportunities to experience rural health via the John Flynn Placement Program (JFPP) excludes international students. When asked, 213 (74.22%) of students were ‘very interested’ and 41 (14.29%) were ‘somewhat interested’ in participating in the JFPP. Discussion The survey shows that a significant number of international medical students are interested in working in Australia after graduation. For many final year international medical students, internship is the first step to permanent residence in Australia. International medical students do all their medical training (4-6 years) in the Australian healthcare system, are well acculturated to Australia, have a good command of English, and graduate with domestically relevant professional training [4]. With a lack of internship positions available in some states, international medical students find it difficult to commence employment as a medical practitioner here in Australia. As a result, many return back to their home country for postgraduate training.

It is unfortunate that many international medical students are not eligible for extended rural placements in their universities despite an overwhelming desire. International students are private, full-fee paying students, where they can be expected to pay over $350,000 in tuition fees alone [5, 6, 7]. Rural placements have been shown to provide valuable experience to medical students, where they were not only given an opportunity to understand rural health care, but to appreciate a rural community as well [8]. Providing rural placements will encourage these students to work and reside in Australia. International medical students are an untapped workforce that can aid in alleviating medical workforce shortages in rural and regional Australia. Australia currently employs International Medical Graduates, many of whom work in a regional and rural area, constituting more than a quarter of the medical workforce [9]. These graduates often face significant communication, language, professional and cultural barriers [10]. Having spent up to 6 years in Australia, international medical students are more equipped with the skills and knowledge suited to an Australian healthcare system. Conclusion Given Australia’s ever increasing demand for doctors, it is prudent not to ignore international medical student numbers in medical workforce planning. They are a potential resource with minimal employment barriers and should be considered during internship allocations. Postgraduate training is a requisite to becoming an independent medical practitioner, with a medical degree the initial step in becoming a fully-fledged doctor. Further evaluation and research should be conducted to facilitate a pathway for international medical students to be part of the Australian medical workforce. 1.

Australian Medical Students’ Association: International Students’ Network [cited 19 July 2016] Available from: https://www.amsa.org.au/initiatives/isn/

National Rural Health Alliance: How many doctors are there in rural Australia? December 2013 [cited 19 July 2016] Available from: http://ruralhealth.org.au/sites/default/files/publications/nrha-factsheet-doctor-numbers.pdf

Hawthorne L, Hamilton J. International medical students and migration: the missing dimension in Australian workforce planning? The Medical journal of Australia. 2010;193(5):262-5.

Hawthorne L. “Picking Winners”: The Recent Transformation of Australia's Skilled Migration Policy. International Migration Review. 2005;39(3):663-96.

The University of Sydney (2016). Bachelor of Medical Science and Doctor of Medicine. [cited 30 April 2016]. Available from: http://sydney.edu.au/courses/bachelor-ofmedical-science-and-doctor-of-medicine

Monash University (2016). Medicine and Surgery. [cited 30 April 2016]. Available from: http://www.study.monash/courses/find-a-course/2016/medicine-and-surgery4531?international=true#entry-requirements-2

The University of Adelaide (2016). Bachelor and Medicine and Bachelor of Surgery. [cited 30 April 2016]. Available from: http://www.adelaide.edu.au/degree-f inder/2017/bmbbs_bmbbs.html

Sen Gupta TK, Muray RB, McDonell A, Murphy B, Underhill AD. Rural internships for final year students: clinical experience, education and workforce. Rural and remote health. 2008;8(1):827.

Medical Training Review Panel, Australian Government Department of Health and Ageing. Overseas Trained Doctor Subcommittee Report. Canberra, ACT; Medical Training Review Panel, 2004.

10.

Wright A, Regan M, Haigh C, Sunderji I, Vijayakumar P, Smith C, et al. Supporting international medical graduates in rural Australia: a mixed methods evaluation. Rural and remote health. 2012;12:1897

Acknowledging the ‘elephant in the room’: Why we need to work with, not against, complementary and alternative medicine Shyamini Naidu Complementary and alternative medicine (CAM) use has exploded in popularity in the rural and regional South West of Western Australia where you’ll find no shortage of holistic practitioners. A large proportion of patients in the South West access a number of practitioners ranging from naturopaths to osteopaths and engage with natural and organic ways of living. I’ve had the privilege of living in the South West for my rural clinical year and in my short time here, I have seen a widespread use of CAM, with patients often describing a strong therapeutic alliance and an overall beneficial effect on their sense of health and wellbeing. Needless to say, the controversy lies in the efficacy of these holistic practices. Do they really work and why do patients so readily invest in these therapeutic channels? The most popular modalities in Australia are natural therapies such as natropathy, acupuncture and chiropractics, some of which are founded in cultural or ritualistic practices and others on anatomical and physiological principles. In a given year in Australia, there is an estimated total of 70 billion visits to a CAM practitioner, approximately the same estimation for medical practitioners, and a $4 billion total

expenditure, set to increase with the further integration into conventional medicine. Often GPs are relied upon to provide evidence based guidance to patients towards individualised and suitable CAM therapy.[1 ]

However, the main criticism of CAM is the lack of robust evidence to support its efficacy.[2] The endorsers of Evidence Based Medicine (EBM) aim to establish ‘their particular epistemology as the primary arbiter of all medical knowledge’. Some would argue that CAM cannot become evidence based because, by nature, they don’t fit specific clinical frameworks. Some CAM modalities have different underlying theories of illness as well as difficult to measure outcomes such as perceptions of illness and wellbeing.[3] This becomes problematic, mainly for medical practitioners whose practice is based on EBM. But can we ignore the growing popularity and demand for CAM and its integration into conventional medicine? I spoke to GP Obstetrician Dr Sarah Moore, based in Busselton, WA, who founded the South West Holistic Practitioner Network about her views on the issue.

Why did you start the South West Holistic Practitioner Network? To learn about what other CAM practitioners actually do, and understand how I can work together with them to support my patients to optimise their health and wellbeing. What do you think motivates patients in the South West of WA to use CAM? Many patients have had negative experiences with Western medical practitioners, or feel they have not got the help they need from them, so seek CAM practitioners to access different approaches to optimising their health. The population here is very committed to using natural approaches and products in all areas of their lives, including to maintain and support health. We have an incredible range of experienced CAM practitioners here in the South West, many of whom work together to provide patient-centred care. In your capacity as a GPO, what challenges do you face when combining clinical medicine with CAM? CAM is often expensive and doesn't attract Medicare rebates, so this can be a major factor for patients wishing to access CAM. Although there is growing evidence to support some CAM modalities, there is still a lot of uncertainty amongst Western medical practitioners. All of my knowledge about CAM has been developed through my own self-directed learning, and many doctors just don't make the time to find out what CAM practitioners do, which means they just avoid it all together. Research suggests that people in rural areas utilize CAM more than their urban counterparts.1 Why do you think this is the case? Certainly in the South West I think this is true. I think living in rural areas, surrounded by beautiful natural landscapes, is a motivation for people to seek natural remedies for their symptoms. Finally, where do you see CAM in the future in terms of integration into the medical fraternity? I am optimistic that with more research, medical leadership and community demand, CAM will become more integrated into health care.

Whilst we need to remain critical of CAM as we are with any new therapies without a solid evidence base, discussion with Dr Moore and her patients shows that an integrated approach can help develop patient rapport and trust, and significantly improve patient satisfaction and have meaningful therapeutic value. This is what we need to focus on. CAM isn’t going away and is only growing in popularity and demand. That’s not to suggest we completely support or condone its use, but we need to acknowledge that it’s a very real part of a lot of patients’ lives and to learn more about it through open conversation with both patients and CAM practitioners. This is important for holistic, patient-centred care. 1.

Ys Lee A, Foong YC, C Le H. Complementary and alternative medicine and medical students in Australia:Where do we stand? The Australasian Medical Journal. 2012 02/29;5(2):144-149. Available from: PMC

Staud R. Effectiveness of CAM therapy: understanding the evidence. Rheum Dis Clin North Am. 2011 Feb;37(1):9-17.

Tonelli MR, Callahan TC. Why alternative medicine cannot be evidence-based. Acad Med. 2001 Dec;76(12):1213-20.

Fracture healing in a new climate Grace Fitzgerald She had been limping on her left ankle for a month now. She’d slipped and twisted it while out feeding the kelpies at the end of a long day. It was uncharacteristic for her not to have been paying attention to her footfall, but the last twelve months had been an endless stream of distracting stressors. The bruising had subsided, but there was evident residual swelling. Dorsiflexion was painful, as was any effort to weight bear. She winced as I everted her foot. A stoic farmer, she had given up on using simple analgesia, and wanted to know if there was anything else she could be doing to help the injury heal. At the top of my differential diagnoses was a small fracture somewhere around her lateral malleolus. Short of expensive and dramatic surgical intervention, my advice would have been a period of non-weight bearing with continued analgesia as needed and physiotherapy to help strengthen the surrounding area.

there were families struggling locally. No, she wouldn’t bother with an x-ray if all it could tell her was to stay off her feet. If they were to avoid selling their stock off, she’d need to keep feeding them.

There was a shriek of laughter as I attempted to gauge her likelihood of staying off the foot. I should have known it to be a stupid question. The lack of rain in the last year had scorched any potential for rest. With an older husband crippled by arthritis, she held the sole responsibility for feeding the sheep. Her husband, who was born on the hand-hewn timber floor of their kitchen, couldn’t remember the last time both dams had run dry. They’d been reduced to tears of gratitude some months earlier when a friend of their son’s had dropped off a truck load of sorghum. The grain was donated as drought relief for properties in western Queensland, but the young bloke couldn’t see the sense in driving it that far when

Unlike events such as earthquake or flood that have immediate and identifiable consequences, prolonged dryness in Australia is insidious and most acutely harmful to those in rural and regional areas who are already vulnerable to poorer health outcomes. Agricultural drought poses immense financial challenges to farmers and farming communities [1]. The decision making processes required to deliberate culling of stock and withholding from cropping are a source of great anxiety for those whose agricultural practices have been honed over generations [1]. Drought-induced stress is aggravated as the closure of health services and small businesses erode the sense of community, and a loss of employment

It didn’t take a born-and-bred local to recognise the dry, undulating hills of parched grass shimmering in the sunset, and golden carpets alongside the highway. The cloudless blue skies were hostile in their absence of signs of rain. As we chatted, my patient mused at the uncertainty of her future. She wasn’t even particularly concerned about bushfire risk over the weekend just passed. There wasn’t much to burn, she said. Life on the land had always been tough, and generations of her family knew deep to their core. Yet the climate was changing – had been changing since the Millennium Drought – and she was starting to worry that this might be a new hellish normal.

contributes to a population drift away from agricultural centres [2]. The exacerbation of socio-economic hardship in rural and regional communities increases exposure to psychosocial risk factors such as reduced personal autonomy, negative self perception, stress, insecurity, and social isolation [3]. For my patient, the above factors manifested as a teary request for help with a painful ankle. No doubt there were countless others in the community who lacked the permission to seek help granted by a physical injury. Community wellbeing is a difficult construct to measure, however the observations of counsellors who provided support to rural communities in the period from 2002/2003 provides some insight into the effects of drought [4]. Many seeking help felt dependent about the erosion of family and community support as their rural community faced decline. For others, efforts to alleviate financial hardship entailed a repositioning of role outside of the traditional family structure common in rural areas and were a source of conflict. In communities that pride themselves on stoicism and traditional values, those experiencing relationship breakdowns or victim to domestic violence felt isolated in their suffering. Callers to the hotline articulated that the scarcity of support resources available was accentuated by feelings of shame or fear and a lack of privacy in tightly-knit communities. It is acknowledged that while drought may have induced a crisis in rural communities, much of the distress experienced is associated with pre-existing vulnerabilities resultant to chronic rural disadvantage [4].

Water shortage is inextricable from the process of drought, and it is expected that water shortages will place increasing strain on urban water supplies [6]. Both the increase in drought and the decline in water security will have significant implications for human health, agriculture, and the environment. We do not have frameworks in place to protect Australians from the harms associated with drought [7, 8]. The National Drought Policy, borne out of the Millennium Drought, recommended that farming practices in Australia be adapted so as to be appropriate to both the variability of the climate and its dryness [9]. The policy framework thus focused on risk management practices, based on a sensitive and thus controversial assumption that farmers who cannot sustain their farm business throughout climatic variations may not be viable into the future [9]. The panel highlighted the importance of adopting â&#x20AC;&#x153;longterm sustainable approaches based on the delivery of existing human support services, focused on planning for the wellbeing of farm families, rural businesses and rural communities prior to periods of drynessâ&#x20AC;? [2]. In short the panel recognised our vulnerability to the climate, and advised that we do our best to protect ourselves from its growing wrath. In the absence of any clear policy direction that might guide an Australian response to drought and dryness in the future, the importance of

My patientâ&#x20AC;&#x2122;s fears about a new normal are echoed in scientific predictions for our future. As anthropogenic climate change alters weather patterns, it is expected that Australian rainfall will decline by as much as 10% by 2030, and by up to 30% by 2070, and that drought frequency and severity will increase [5].

strengthening healthcare systems crystallises. We know that the capacity of health systems to respond effectively to the short and longer term impacts of climate change is likely to be limited, particularly in rural areas where existing services are insufficiently resourced to meet current demand [3]. Indeed as climate change exacerbates the volatility of this land of drought and flooding planes we must steel our healthcare system to deal greater rates of injuries, disease and deaths associated with more intense heatwaves, fires and other extreme weather events [10, 11]. In June of 2016, the Climate and Health Alliance - a coalition of concerned health groups, researchers, academics and professional associations - is calling for Australia to develop a national strategy for climate, health and wellbeing. The national strategy would enable Australia to adequately respond to the risks to health from climate change, and promote education and awareness about climate change and health among the health professions and the wider community, so both can be better prepared. It would strengthen climate and health research to identify population groups and communities particularly vulnerable to health risks from climate change and develop strategies to 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

reduce those risks, while investing in research to quantify the health benefits of different emissions-reduction scenarios to guide climate policy choices. It doesn’t take a crystal ball to see the effects of climate change on our communities. Patients are already making choices that are influenced by an increasingly hostile climate. We know that our health and wellbeing is inextricably tied to that of the land on which we live. As we edge closer to the terrifying precipice of catastrophic global warming, the health community has a huge responsibility to attend to the code blue for medical emergency. Fortunately, we have the technical and economic tools available to us to tackle the climate crisis [12]. What we lack at present is the political will to harness the opportunities presented by a healthier, fairer, more sustainable society. A national strategy on climate, health and wellbeing would provide a prescription for a healthier future for all Australians. To download a copy of the Discussion Paper: Towards a National Strategy for Climate, Health and Wellbeing for Australia, visit http://caha.org.au/campaigns/national-strategyclimate-health-wellbeing/

Hanigan, I.C., et al., Suicide and drought in New South Wales, Australia, 1970-2007. Proceedings of the National Academy of Sciences of the United States of America, 2011. 109(35): p. 13950–13955. Drought Policy Review Expert Social Panel, It’s about people: Changing Perspective. A Report to Government by an Expert Social Panel on Dryness, in Report to the Minister for Agriculture, Fisheries and Forestry, Canberra,. 2009. Fritze, J.G., et al., Hope, Despair, and Transformation: Climate Change and the Promotion of Mental Health and Wellbeing. International Journal of Mental Health Systems, 2008. 2(1): p. 13. Hall, G. and M. Scheltens, Beyond the drought: Towards a broader understanding of rural disadvantage. Rural Society, 2005. 15(3): p. 348-358. Intergovernmental Panel on Climate Change, Working Group II contribution to the fifth IPCC assessment report Climate Change 2014: Impacts, Adaptation and Vulnerability. Chapter 25: Australasia. 2014. Steffen, W., Thirsty Country: Climate change and drought in Australia. 2015, Climate Council of Australia. Van Dijk, A. Australia is not ready for the next big dry. 2013. Alston, M. and J. Kent, Social Impacts of Drought: A report to NSW Agriculture. 2004, Centre for Rural Social Research, Charles Sturt University: Wagga Wagga. Botterill, L.C., Lessons for Australia and Beyond, in From Disaster Response to Risk Management, L. Botterill and D. Wilhite, Editors. 2005, Springer Netherlands. p. 177-183. McMichael, A.J. and E. Lindgren, Climate change: present and future risks to health, and necessary responses. J Intern Med, 2011. 270(5): p. 401-13. Climate and Health Alliance, C.I., Our Uncashed Dividend: The health benefits of climate action. 2012: Available at: http://caha.org.au/wpcontent/uploads/2010/11/OurUncashedDividend_CAHAandTCI_August2012.pdf. Watts, N., et al., Health and climate change: policy responses to protect public health. The Lancet, 2015.

The importance of access and equity in the treatment of eating disorders Cara Templeton Over 9% of Australians are currently living with an eating disorder , whilst an estimated 2,000 people lose their battle annually. Despite these alarming numbers, sufferers are still unable to access safe and equitable treatment. Eating disorders are highly complex with serious physical, social and psychological consequences. Without early intervention they can be long-term, disabling disorders with high levels of morbidity and mortality, that carry considerable costs to the community and public health system. With the total socio-economic cost an estimated $69.7 billion and Anorexia Nervosa and Bulimia Nervosa in the top 10 leading causes of burden of disease , the cost of untreated or inappropriately treated eating disorders is much greater than the cost of adequate provision of care. It is time that the government prioritises early and equitable access to specialist treatment and services. The National Eating Disorders Framework stated in the first national schema for eating disorders in 2012, that patients should have equal access and entry to treatment facilities. And yet, in 2016, there are only 37 adult hospital beds in Australia that cater specifically for eating disorders and they

are all located in the state capitals. Whilst it is commendable that the Victorian Government is leading the way in diversifying eating disorder treatments and investment in services , these facilities and programs exist solely in metropolitan Melbourne and there is no provision of care outlined for those living in rural or regional areas. The biggest barrier to treating eating disorders is having access to somewhere that is specifically set up to treat them. With funding for the Butterfly Foundationâ&#x20AC;&#x2122;s national support service in jeopardy, our health care system is continuing to fail those living in rural/regional areas by not providing the support, resources or funding that they deserve. Eating disorders do not discriminate based on geographic location and patients deserve safe treatment irrespective of where they live. The most dangerous experiences of patients with eating disorders in public health services have occurred because there was nowhere else for them to go. The best option for hospital treatment is admission to a general medical ward with staff that are trained in eating disorders; a general psychiatric ward is not a suitable place for treatment. Furthermore, current treatment practices focus almost exclusively on weight restoration rather than addressing the full spectrum of the disorder.

Whilst medical stabilisation is often necessary, simply discharging a patient without a referral or transfer to an eating disorders specialist program will only result in reduced recovery outcomes and repeated re-admissions to hospital. Health professionals and hospitals in rural/regional areas are currently ill equipped to treat, support and provide appropriate care for patients. Safe treatment must be founded on evidence-based, multidisciplinary approaches and address all aspects of the illness; physical, behavioural and psychological. Early identification followed by prompt and skilled responses is vital, as targeted prevention and intervention strategies will reduce the incidence and duration of the disorder. Consequently, the Victorian Government must deliver increased regional and remote access to treatment, either through specialised training of rural professionals or improved access to city based services; with the provision of accommodation and support for rural individuals and their families.

If you or anyone you know needs help with disordered eating, please contact the Eating Disorders Helpline on 1300 550 236. Registered GPs can sign up for a credited online learning module on ‘Recognising Eating Disorders in General Practice’ via the RACGP website http://gplearning.racgp.org.au/ 1 The National Eating Disorders Collaboration, 2012 2 “Investing in Need” - Changing Australia’s commitment to investment in eating disorders,

Christine Morgan, CEO

Butterfly Foundation https://mhaustralia.org/general/investing-needchanging-australias-commitment-investmenteating-disorders 3 Deloitte Access Economics, 2012 4 Submission to Mental Health Commission, The Butterfly Foundation, <http://nswmentalhealthcommission.com.au/sits /default/files/TheButterflyFoundation_SubmissionMentalH ealthCommissionNSW.pdf> 5 An Integrated Response to Complexity National Eating Disorders Framework, 2012 <http://www.nedc.com.au/files/pdfs/National%20 Framework%20An%20integrated%20Response%20to%20C omplexity%202012%20-%20Final.pdf>

If the Victorian Government aims to fulfil the principles of the National Eating Disorders Collaboration (NEDC) and provide every Australian at risk of, or suffering from, an eating disorder access to an effective continuum of prevention, treatment, care and recovery support, they must invest in state wide supports and services. Without significant intervention and investment in accessible and equitable services, the impact of eating disorders will continue to increase and represent a significant burden to the community.

Cara Templeton, B.A. (Comms), Grad. Dip (Applied Learning) is a teacher who lives in Gippsland and is in recovery from Anorexia Nervosa.

6 Victorian Eating Disorders Strategy, 2014 7 Submission to Mental Health Commission, The Butterfly Foundation 8 Submission to Mental Health Commission, The Butterfly Foundation 9 http://www.nedc.com.au/files/pdfs/NEDC_National%20Fra mework_Final.pdf

AMSA Rural Elective Bursary winners, 2015 Melanie Geoghegan (Kahl) Darwin, NT

During August/October of 2015 I undertook my medical school elective in the ICU in Darwin Northern Territory. The team was very welcoming and in true Territory style somewhat relaxed compared to my experiences in Geelong Hospital. Darwin is a small hospital and as such you quickly become an integral part of the team, even if itâ&#x20AC;&#x2122;s as a coffee mule to begin with. The days start at 8am with handover. Day one at ICU 8am handover consisted of 4 patients who have been in a motor vehicle accident 4 hours before my day started. They had previously been in a high-speed chase with police that ended with 2 of these people being admitted to the ICU. I was quickly gowned up and put to work performing a secondary survey. Within my first 4 hours I learned how to perform Brain death testing on one of these patients. This was a traumatic first day in the Darwin ICU.

Things didnâ&#x20AC;&#x2122;t improve over my first 2-weeks, we had a period one after the other of severe motor vehicle accident and patients with traumatic brain injuries. My two favorite patients were 2 youngsters who had a quad bike accident at the age of 15 and 17. Their prognosis was difficult to determine and for the first three weeks we saw little to no improvement and were concerned that neither boy would ever have quality of life outside of nursing home. During this time I learned that prognosticating for TBI is difficult in any age group and even more so in younger patients, thankfully towards the end of my 6 week these two boys recovered enough to move to a rehab ward and even began communicating and walking again in the last week of my placement. In the ICU in Darwin there are a high proportion of patients that are indigenous and many are flown into the ICU from rural communities around the NT. I witnessed first hand the life expectancy gap in the Indigenous population during my placement. One of my patients a 35-yearold woman died due to Ischemic heart disease during my visit, she had a short history of contact with health services and quickly deteriorated during her stay. Another indigenous man had a cardiac arrest in a small rural community in Arnhem Land and was resuscitated by the local clinic, he was flown to Darwin were he later died in our ICU due to Respiratory failure.

He was 52. It was confronting to witness the deaths of such young patients dying of essentially preventable conditions within our rural communities in a first world country. Despite the traumatic introduction to Darwin ICU I loved working with the team, the culture of Darwin hospital. I enjoyed practicing new procedures such as placing arterial lines and central venous catheters and learning that in the tropics its important to include in your differential diagnosis conditions that are essentially not seen in other parts of Australia. Example of this included rheumatic heart disease and melioidosis. Two young girls in their early teens spent time in our ICU with Rheumatic heart disease before being transferred to Adelaide for valve replacement. They both returned following surgery to the ICU in Darwin for early stages of recovery and it was gratifying to see them transferred feeling much more themselves to the wards.

I doubt I will ever receive such personalised teaching again in my career and feel incredibly lucky to have had this opportunity. My time in Darwin wasnâ&#x20AC;&#x2122;t all work; part of the culture of the Northern Territory is to enjoy time outside, relaxing when you can. The easy going culture in Darwin doesnâ&#x20AC;&#x2122;t take long to rub off on you, when you have beautiful beach views 5 minutes walk from the hospital, a stunning waterfront swimming spot and beach markets like Mindil beach on Thursdays and Sunday nights. Weekends were spent visiting my Family Mango farm in Katherine where I grew up or hanging out at stunning Litchfield park and Edith Falls water holes for a swim. This is one of the best experiences I have had throughout my medical school career and it has truly driven home my wish to return to the NT to practice in ICU or Anaesthetics in the future, for the interesting Medicine, the fabulous weather and the culture engrained in life in the NT

I received some excellent formal and informal teaching during my placement. Consultants, most of whom loved to teach, surrounded me and for 4 weeks of my placement I was the only medical student on the ward. Hence I had a virtual smorgasbord of Consultants and Registrars willing to teach me on a one to one basis. They took the time to run through ECG interpretation as well as arterial blood gases. I also took part in formal teaching about ventilators and understanding them, using haemo-filtration devices and how to put in chest drains. The chest drain tutorial was perhaps my favourite were the consultant brought in a rack of pork ribs for us to use to practice putting in chest drains. I think he cooked them afterwards for dinner.

Sean McGrath Alice Springs

As I stepped out of the plane at Alice Springs airport I was struck by the contrast from the cold, wet Melbourne I had just departed from to the hot, dry, red-sand covered landscape around me. A smile crept across my face, as the warm realisation hit that it was good to be back in the country again, after spending the first half of the year in metropolitan hospital placements For my final year elective placement I was torn between choosing an overseas placement in a developing nation or experiencing another side of the Australian healthcare system within a remote community. Both had their pros and cons but ultimately it was my curiosity to find out what remote medicine was like that led to me choosing a placement in emergency medicine at Alice Springs Hospital. I had long held a vision of my future self, working in remote communities around Australia as a rural general practitioner. I wanted to find out a bit more about whether the reality matched my expectations, and also to garner some insightful practical experience before my internship.

So what was it like? The department ran in much the same way as the Melbourne hospital ED where I had been placed earlier in the year. Consultants allocated me a mixed caseload ranging from fast track patients with simple musculoskeletal injuries to category 2 patients in septic shock. Indigenous patients made up a large percentage of total presentations and would often have advanced disease, due to delays and difficulties in accessing treatment. There was a large burden of disease related to renal failure with 350 patients on dialysis in the region. Most of these were Indigenous Australians with renal failure secondary to diabetes or recurrent childhood glomerulonephritis. Missed dialysis was common with patients presenting in various degrees of fluid overload with resultant respiratory distress and other complications. Unfortunately, domestic violence and alcohol-related presentations were also very regular. Paediatric patients were treated with a much lower threshold than I was used to in Melbourne. Opportunistic screening of growth and development was always conducted as these children were often not regularly seen by healthcare workers. The department staff were generally very supportive and there was an extensive range of teaching available, from lunchtime grand rounds presented by visiting specialists to weekly departmental tutorials for junior doctors. The placement was organised through the Flinders University medical school as Alice Springs is one of their clinical sites. They also offer subsidised accommodation within walking distance to the hospital, sharing with other students.

Whilst on placement I was given the opportunity to participate in a Royal Flying Doctors Service retrieval flight. The Alice Springs RFDS base covers a vast land area of 1.25 million square kilometres, stretching into Queensland, South Australia and Western Australia. After an early morning departure from the RFDS hangar at Alice Springs airport we flew north to a small town to bring back a young woman who required acute medical management which couldnâ&#x20AC;&#x2122;t be provided in their healthcare centre. The experience highlighted to me the sheer remoteness of these communities and the difficulties that are posed in trying to provide equitable healthcare to their residents.

Alice Springs is surrounded by spectacular desert landscapes and mountain ranges. Mountain biking, fun runs, bushwalking and other outdoor activities are very popular, especially over the cooler winter months. Most students on placement also fit in a weekend camping trip to visit Uluru, Kata Tjuta and Kings Canyon. So if youâ&#x20AC;&#x2122;re looking for an elective that encompasses remote and Indigenous health in a highly supportive environment as well as the opportunity to experience an amazing part of our beautiful country then consider Alice Springs Hospital.

I was also able to join the ophthalmology team for one of their regular remote community visits. This was a multidisciplinary clinic involving an ophthalmology registrar, optometrist, optometry nurse and an Aboriginal liaison officer. The community we went to was a 17 hour drive by road from Alice Springs but thankfully only a 1 hour flight by small chartered jet. It was great to get an insight into the lives of those who live in these remote communities and meet some of the healthcare workers who treat them, in often highly challenging situations with limited support and with RFDS retrieval doctors potentially many hours away. Aside from the medicine related aspects of the placement, I was also able to explore the quirky town of Alice Springs and some of the beautiful red centre of Australia. There was so much to see and do and the flexible nature of our timetable allowed plenty of time to so.

Honey Ant Dreaming Mitchell Simpson Located 300km northwest of Alice Springs on the edge of the Tanami desert is the Warlpiri community of Yuendumu. Home to a transient population of anywhere between 600 and 800 people at any one time, plus the touring Kardiya (nonIndigenous folk), this is the location of my John Flynn Placement Program. Unless you’re lucky enough to own your own troopie, then the bush bus is your best bet of getting there. With bag packed to the brim with non-perishables, and cooler bags stashed with frozen meat and veg, you wait at the bus stop in Alice ready to go at 7am. Out here, things run on ‘bush-time’ however, so don’t be surprised if the bus doesn’t actually arrive until after 9am. Fear not, it’ll come, and you’ll get there seven hours later.

in particular brings everyone together, and ensures the young men remain in the community instead of heading back into the troubles of town. One of my ultimate highlights was being asked to play for North Camp in the round robin competition. To my surprise, each of the locals had a fresh pair of brightly coloured Nike boots; a clear contrast to their often well-worn clothes. With not an inch of grass in sight, I ran around trying my best to keep up with the speed and pace of the local game. The skills and agility exemplified their love for the sport, and natural athleticism. With my head held high, both arms and legs bloody and grazed from the red dirt, I left the field with a smile and marched myself straight to the clinic for a tetanus shot.

For somewhere so isolated, Yuendumu is a vibrant and busy community. It boasts a range of highly talented artists, it’s own media centre, and a Old People’s Program (YOPP). While most of my time was spent at the clinic, working alongside the amazing Remote Area Nurses (RAN’s), I spent the rest of my time immersing myself in the community in every way possible. It’s here that I gained a true appreciation for the Warlpiri people and culture, and where I grew the most from my placement experience.

Like many remote communities, Yuendumu is challenged by larger social inequalities. Health, education, alcohol abuse, petrol sniffing, and violence are at the core of the issues facing the residents. In 1993, local Warlpiri pair Peggy Brown and Johnny Miller started the Mt Theo Project. Prompted at the time by the increase in petrol sniffing, the project went on to tackle drug and alcohol abuse, youth education, and leadership development. In 2008 the organization officially changed its name to Warlpiri Youth Development Aboriginal Corporation or WYDAC for short, which is based out of Yuendumu but provides services for all surrounding Warlpiri communities. It’s program has been admired and modelled by communities around Australia and is the first of it’s kind, employing many local and travelling staff, and funding services such as the pool

On my first journey down the Tanami, I came in the summer months during the wet season. Averaging well over 30 degrees everyday, the tropical storms provided only temporary relief. Sport is a large part of rural life, and the Aboriginal community of Yuendumu is no different. Australian Rules

which has resulted in a reduction in children’s skin infections due to treated water. The highlight of my second trip was enhanced by the renewed friendships from my placement only six months prior. One of the local yapa (Indigenous) men working at the clinic invited me on a journey to the community’s local water hole. He told me of the dreamtime stories, and showed me a sunset that one can never justifiably describe. The following evening, my friend knocked on my door; his young boy in one

hand, an ice-cream container in the other. Inside the container were these large golden balls of sweetness. Bush tucker at it’s finest; these were the local honey ants I’d heard so much about. This type of gesture is not common in the local culture, and it was a sign of respect and honour. I felt truly humbled. From the moment I arrived in Yuendumu, until the moment I left, I felt welcome. The friendships forged, the experiences had, and the memories made I will look back on fondly for the rest of my life. It’s truly been a remarkable John Flynn Placement.

Groote Eylandt The Pinnacle of Remote Locations Georgia Foley

In the Gulf of Carpentaria and approximately one and a half hours flight from Darwin, Groote Eylandt is a beautiful oasis off the coast of the Northern Territory with little over 1,500 people in this warm and friendly local population. The John Flynn Placement Program enabled me the wonderful opportunity to undertake placement on Groote Eylandt, giving me the skills and desire to hopefully one-day return to remote work as a doctor. In June 2016 I was fortunate in completing my second John Flynn Placement on Groote Eylandt. This was my first time being placed on Groote, and found it to be a unique, exciting and rewarding placement. During my time on Groote, I was placed in both Alyangula Clinic and Angurugu Clinic, a clinic based within the Indigenous township of Angurugu. Having the experience of working with both the Indigenous and Non Indigenous populations of Groote Eylandt was incredibly interesting and allowed me to gain a much greater understanding of life in a remote community.

In 2014 I completed my first John Flynn Placement in Ampilatwatja, an Indigenous community approximately four hours north east of Alice Springs in the Northern Territory. In Ampilatwatja, I had my eyes opened to the role of doctors and nurses in remote Indigenous communities, and had my interest in returning to these communities as a doctor firmly cemented. In Angurugu Clinic, I was able to build on my experiences in Ampilatwatja, working with the local people to achieve the right balance between Bush Medicine and Western Medicine, encouraging me to improve upon my understanding of the Aboriginal culture and way of life. In Angurugu I saw a multitude of illnesses, many of which are rare in the rest of Australia. Angurugu has the highest rates of Rheumatic Fever and Rheumatic Heart Disease in Australia, allowing me to gain a solid practical understanding of working with patients with Rheumatic Fever, in recognising the need for intensive patient and practitioner co operation over a significant period of time and in understanding the limitations of Rheumatic Fever treatment in remote communities. Melioidosis, a common occurrence on Groote Eylandt, came up regularly, whereby I saw a number of patients with prostate abscesses, a common presentation in Melioidosis. In addition to these conditions, I was interested to learn that the very rare Machado – Joseph Disease (MJD), previously known as Groote Eylandt Syndrome, has a huge impact on families within Groote, with the Island having the highest incidence of MJD internationally. Machado – Joseph Disease, an autosomal dominant spinocerebellar degenerative disorder, causes progressive, severe ataxia. In Angurugu, as in Ampilatwatja, STI’s, skin sores, such as scabies, and mental illness are all highly prevalent, and cause a substantial burden to the health of the local population. As a result, much of the health prevention and early detection in the clinic is aimed toward STI’s, along with that for prevention of Rheumatic Fever. Whilst in Angurugu, I found the community incredibly welcoming, and thoroughly enjoyed my time in this clinic. In addition to my time in Angurugu clinic, I travelled to Numbulwar on the main land and Umbakumba, on the other side of Groote Eylandt. Both of these communities were small Aboriginal communities, and were very similar to Ampilatwatja and Angurugu. Again these communities experienced very similar health problems to those in Angurugu. In my free time, I went walking to the amazing beaches and around the community of Alyangula where I stayed. The community of Alyangula is predominately a mining community, and was very well resourced for a remote community, having a store, golf club, pool, tennis court, gym, hardware store and clothes shops. Overall I had a fantastic placement on Groote Eylandt and found the communities and clinic staff to be beyond welcoming. My second John Flynn Placement has reaffirmed my desire to work as a doctor in remote Aboriginal communities in the future, and I greatly look forward to returning to Groote for my next placement.

From the city to the desert; Remote Health Placement in Central Australia Greta Beale Before heading out to Docker River, the realities of remote health were largely the stuff of lecture slides and anecdotes. Throughout my undergraduate degree, I had developed an interest in the inequities of access to education and other services through various endeavors, and after starting my medical degree, had the opportunity to go and experience the challenges of remote health first hand through the John Flynn Program. Docker River (Kaltukatjara) is a predominantly indigenous town in Central Australia with a population of around 300 people. My desire to do a remote placement had been well and truly fulfilled when I learned that the journey to my post would be a 12 hour bus ride from Alice Springs, on the “Bush Bus”; a notoriously hot and arduous trip through the desert. The trip lived up to expectations and I arrived in Docker River sweating and exhausted. My complaints quickly subsided when I learned that a fellow traveller had been returning home after a miscarriage at 20 weeks, and that various other passengers were returning to town after specialist appointments or hospital stays in Alice Springs. It was my first glimpse of the challenges of remote health, before I had even set foot in the clinic .

The Docker River Medical Centre served as a general practice, pharmacy, emergency department, dentist and as place where locals would come and have a “yarn” with the nurses. The town was heavily populated with dogs, which would seek out the shade and line the perimeter of the medical centre. As I set out for an evening walk each night, a line of dogs would follow me, and I would see the occasional donkey, camel or wild brumby – I was definitely not in the city any more! I was lucky enough through my remote placement to see a new part of Australia, and was taken aback by the vibrancy of the colours of the desert. Opening my bag on the first night, a fine red dust had infiltrated my clothes, which proved to be quite hard to get out, so from the outset I was told I looked like a local! With no resident doctor, two remote health nurses ran the clinic. They were tough and pragmatic and between them they had a wealth of knowledge and experience, using a telehealth referral service when medications needed to be prescribed or difficult diagnoses made. Their dedication was unrelenting, and it seemed as though the medical centre was a central hub of the town, where locals would come when they needed not only medical

assistance, but counseling, help with administrative tasks or even something to eat. The issue of access was further emphasized when, after a storm, Telstra lines were down and the whole town was cut off from phone access. The already treacherous dirt road into Docker River was flooded, so the situation remained unresolved for three days. The phone line also supplied the clinic’s computer system, so during this time we couldn’t access patient notes, medication lists or call out for help. With the added challenge of many patients speaking English as their third or fourth language, discerning the presenting problem became increasingly difficult. The nurses took the situation in their stride and told me with a laugh “that’s remote health for you!” During my placement I took part in a Royal Flying Doctors evacuation, helped manage a suspected acute MI and a septic child via tele-health and learned about the resourcefulness of medicine practiced in a remote setting. I also witnessed the pitfalls of remote health – the lack of funding, the lack of staff support and the difficulties in dealing with chronic disease and mental health issues in the setting of lack of education and resources to manage such patients. The extent of disease in a low socioeconomic, remote community was astounding and highlighted the disparity between indigenous and nonindigenous health outcomes, which were further exacerbated by a lack of access to services. Many of the patients needed dialysis, however were not willing to leave their town, and it was not feasible for a dialysis facility to be set up in Docker River, nor for patients to travel 12 hours to Alice Springs multiple times each week. The experience was very humbling and reinforced the enormous respect I have for those who dedicate their lives to remote health. The nursing staff reported a very high turnover rate, as people were burnt out by the demanding work, and the lifestyle. Although I wish I could say that I sailed through my remote placement, I was naive to think that I would not struggle with the isolation. I learnt quite quickly the importance of reaching out to colleagues and ensuring that I had a support network for debriefing. It was an eye opening experience and very confronting at times, but one that I am very glad that I undertook .

JFPP : West Wyalong Kate Thimbleby In the past mid-year break, I was lucky enough to return to West Wyalong, NSW, for my second John Flynn placement. My rural placement is undoubtedly the best experience I could have possibly asked for. It provided me an opportunity to develop longterm relationships; there were entire families who I remembered from my first placement! The people in the community are some of the kindest I have come across and are more than happy to let you, a complete stranger, into the most intimate parts of their lives. They put themselves in your hands, usually with the throw-away comment, ‘well, you’ve gotta learn somehow’. The diversity of patients and conditions I saw each day were unmatched and their easy going attitude towards life meant that I enjoyed the experience so much that I would often go without breaks the entire day, keen not to miss a thing. My mentorship was second to none; everyone was so willing to teach me and enormously generous in giving up their time to do so. I felt involved and valued and this helped me build my confidence in communicating with patients. Dr. Matrook would share wisdom and insights from her career as a doctor and I learnt a huge amount from her about not just medicine, but about people. I left each day exhausted but inspired.

‘Over the past couple of days, I have seen the complete spectrum of the human life. I have seen a fetus little more than 2mm wide, I have observed a miscarriage counselling, I have learnt how to do an antenatal check (including feeling a baby’s head through it’s mother’s swollen belly which was pretty incredible). I have examined people from the age of 7 months to 70 years both in sickness and in health. I have observed as people with terminal conditions planned for their future, listened to people’s reflections as they were palliated and I have seen the effect a death has on such a tight community. It’s impossible not to become personally invested in a community like this when they so readily open their arms to you. I have laughed and cried with them and been deeply moved. Lectures will never measure up to real life.’

I think a caption I wrote for the inevitable Instagram update sums up the experience pretty well:

Inequality and mangoes in the Wild West: an elective perspective Anna Elliston Kununurra, at the top end of Western Australia, is a stark place. Red dust, mangoes, boab nuts and the sibilance of deafening cicadas. Brilliant sunsets and fearsome lightning storms. Air so thick in the wet season it feels as though you could slice through it with the ragged, broken edge of a turfed XXXX beer can. Baubles hang on boab trees at Christmas. The occasional croc attack might be the nonchalant topic of yarns weaved between yawns of people sitting in the shade, listless in their efforts to escape the unrelenting heat. I was lucky enough to spend three weeks there at the end of 2014 (the third year of my MBBS) on an elective placement. Coming from my beloved, yet sheltered Tasmania, I was ignorant enough not to have any correct preconceptions about Kununurra and its people. Tassie also has a unique history with regard to its Indigenous population so our present situation is different to the mainland. I had listened to lectures on the cultural and geographical determinants of health in the early years of med school. But it was only when I was witnessing the real discrepancies in health outcomes between rural and urban, as well as Indigenous and nonIndigenous Australians, I started to understand how rife inequality still is. Perhaps I should be ashamed of my naivety as it was, but I’d rather use it as a basis to discuss these inequalities and my experiences. Australia still has huge gaps in health outcomes and without personally experiencing this, it’s easy to become blinkered and immune. Australia is not necessarily a lucky country. It is sprawling and diverse, with ingrained inequality that should be confessed and addressed.

Kununurra has a population of about 7000 and was originally set up as a town for workers in the Ord River Irrigation Scheme. The name means “Big Waters” in the local Miriwoong language, and it’s pretty much the big smoke of the East Kimberley. Kununurra is home to many members of the Malngin, Miriwoong, Wadainybung, Dulbung, Gidja and Kuluwaring groups. [1] There are three pubs and three bottle shops, one small hospital with a 5-bed emergency department, and a service that picks up drunk people off the street at night and takes them to a place where they can dry out. There’s a Subway and the singularly enticing Rosie’s Chicken at the servo, but happily not yet a McDonald’s or KFC. I point this out because large fast-food chains serve up super-sized helpings of poor health outcomes in the communities they penetrate. [2, 3] This, combined with the fact that the skill of cooking has often been lost to generations of previously institutionalised Aboriginal people, creates the ultimate combo of cardiovascular risk, diabetes and obesity. A basket of healthy food at the supermarket is around 20% more expensive than in the city, leaving many people with even less choice. [4] My experience in Kununurra was often confronting and sad, leaving me with a deep impression of past and present trauma. For example, I met a twelve-year-old Indigenous girl who tried to hang herself – she was one of many. A doctor told me the tiny hospital had seen nine suicides in three months. Sadly, because of the small population, there is no mental health facility in Kununurra. This means that sometimes psychiatric patients are flown

to Perth, Broome or Darwin and this can require sedation, for safety. Face-to-face mental health services are generally rare in remote Australia, which is nonsensical since rates of suicide increase with geographical isolation. Rates of suicide are 66% higher in remote places than in the city and 2.7 times higher for Aboriginal and Torres Strait Islander people, and highest in Indigenous youth. [5] Rates of drinking are also higher in rural areas than in Australian cities, for many reasons. However, it is very important to mention that Indigenous Australians are 1.4 times more likely than non-Indigenous people to abstain from alcohol altogether. Even so, it is a dangerous cocktail of easy accessibility, unfortunate role modelling, boredom and cultural decimation, as well as so many other complex risk factors, that mean that those who do drink are 1.5 times more likely to drink at risky levels. [6] I saw so many medical, psychological and relationship problems related to alcohol in Kununurra. I saw a lot of alcohol-related injuries in the emergency department - injuries from fights, car and motorbike accidents, as well as simply tripping over and kicking stuff. I heard stories of family violence. I also saw many kids with visible and behavioural signs of Foetal Alcohol Spectrum Disorder (or “Fazz-Dee” as it is referred to with dismayed familiarity), which has implications for mental health, education, drug and alcohol abuse and crime. [7] I saw a 14-year-old girl have her Implanon changed. She had recently come out of jail. She liked it there because it gave her relative safety, three meals a day and her own room with a TV. Incidentally, Implanon (also known as “Slutstick” in the local slang) is the first and only type of contraception you can see or feel on the person’s body. One of the doctors I worked with said this may, horribly, increase the risk of rape. I spent a day with a community nurse who was going around the town, changing people’s ulcer dressings

Much of the housing in Kununurra is new, and much of it is already wrecked. I don’t understand why, but the nurse suggested it was related to alcohol use. At one house we stopped at, there was an immaculately dressed, yet frustrated woman holding a takeaway coffee in her hand. She was a social worker, and her job that morning was to get the little boy in the household to school. It was difficult: his mum was sleeping off a heavy night of drinking and he couldn’t find his shoes. The scene spoke loudly of rifts and differing agendas. Speaking of rifts, Australia still struggles with huge differences in lifespan. We may have among the longest average lifespan, but we still have a gap of up to four years’ difference between rural and metropolitan areas. [9] The lifespan gap between Indigenous and nonIndigenous people is worse: 11.5 years for males and 9.7 years for females. [10] The life expectancy for Indigenous Australians is 67.2 for males and 72.9 for females, which is about on par with many developing countries worldwide. [10,11] Lifespan is just one way of demonstrating the differences in health outcomes across Australia and should serve as a serious reminder that we still have a lot of work to do in making Australia as equal and developed as we would like to imagine it is. “Take any pathology from a textbook,” one doctor said to me, “and look at the age of onset. Here - you need to take ten or twenty years off that. So there’s people with chronic kidney disease in their forties, sometimes their twenties. People have heart attacks in their thirties.” I didn’t quite believe him until I saw that Kununurra has as big a dialysis clinic as Hobart does. In fact, rates of end-stage kidney disease can be up to four times higher in remote parts of Australia compared to metropolitan areas, which has serious consequences on quality and quantity of life for individuals in those communities. [8]

I met an Indigenous lady in the Kununurra emergency department who looked incredibly weathered and whom I innocently imagined to be about 90 years old. She had congestive heart failure secondary to chronic hypertension and rheumatic heart disease, atrial fibrillation and she was on warfarin. But what dose of warfarin? There were discrepancies between her Webster pack, her doctor’s progress notes and her medical records. No one, let alone the patient herself, had any idea what was going on. Her INR was eight, when it should be between two and three. In her case, her alcohol use and the fact that she travelled from a nearby community with different doctors were the main problems causing the confusion. I was shocked to learn that she was only 60. There were countless others like her. All this also reminded me that we are, as doctors in training, taught on a basis of ideals. The ideal HbA1c or blood glucose level. The ideal blood pressure. An acceptable number of years lived. These ideals are targets, but there were rarely any bullseyes in Kununurra. It seemed too easy to say, well, this is a different population, so the numbers are different. But I also thought, why lower the standard because of the social and political history of the region? The professionals I shadowed took all this into account and just got on with things. I was very impressed by the health workers I met in Kununurra - midwives, doctors, nurses, podiatrists, physios and others. There’s a saying that the only people who get jobs in the Wild West are missionaries, mercenaries and misfits. Those that don’t fit in the city. Or worse, that “Kartiya [which means ‘non-Indigenous people’ in some north-western Indigenous languages] are like Toyotas: when they break down, we get a new one”. [11] My experience was the opposite: on the whole the professionals I met are incredible, culturally sensitive, passionate and welcoming people.

Most of them live in Kununurra long-term, despite short-term locum stereotypes. They are generalists who make the most of the few resources they have. They made their jobs look rewarding and even sexy. Yes, they are mostly non-Indigenous: currently, only 1% of the health workforce is Indigenous. [12] Hopefully this is changing with slow-yet-celebrated increases in numbers of Aboriginal and Torres Strait Islander medical students and doctors. [13] While in Kununurra I came to realise that the meaning of ‘health’ for Indigenous people in the region differed from my own. A sense of belonging and of being on country is important, and that this has effects on mental and physical health. [15] Even direct questioning can be confronting for Indigenous people - yet it is an everyday technique of history taking. The Western paradigm of health and healthcare can fail to take into account these fundamental differences, which can leave its service lacking. Australia needs more Indigenous doctors and impassioned advocates to guide us on these matters. I went to Kununurra as a blank slate, simply from having experienced nothing like it before. I left humbled, indebted and passionate, having pieced together a bit of an understanding of the challenges faced by the community, as well as an aptitude for plucking high-up mangoes out of trees. The Wild West can be beautiful, but its social circumstances are not pretty. We live in a country that still struggles with many problems and I hope that this snapshot of my experiences serves as an honest memo. As students, it is difficult to see that our contribution is meaningful, but it is still important to go on placements even if just to listen, observe, absorb stories and try to understand. But as future health professionals, we’re well-placed and arguably obliged to act.

Nine valuable lessons in nine hours Ariah Steel In January I completed the New South Wales Rural Doctors Network bush bursary scholarship in Leeton, NSW and I had the absolute privilege of spending one day of my two week placement with a legendary and truly wonderful Australian rural doctor – Dr. Bob Byrne. With a long-lived and successful career Dr. Bob is a local hero. He grew up a country boy in Cootamundra, NSW and went on to university on a commonwealth scholarship to study Medicine at The University of Sydney. This was back in the day when a large cohort of first year students would compete to graduate on to second year where there were only half the number of the spots available. I have been told this was cut throat, intense and quite literally ball breaking. Only the crème de la crème would be able to realise their dreams of becoming doctors. As Dr. Bob described to me, he was studying for an exam, reading a textbook. The next day he sat the exam and was able to remember every single thing he had read the day before – he discovered he had a photographic memory. Just his luck! I think it started him off on a trajectory that never slowed. At the completion of university studies Dr. Bob went on to work in Hobart, where he worked as a resident doctor and said he felt like he was running the hospital and described himself there as a ‘jack of all trades’. He said it was there he learnt the broad and varied skill set necessary to face the challenges and commotion that come with working as a doctor in the country. He started working in the Riverina, the agricultural region of South Western New South Wales (stretching from the foothills of Snowy Mountains to inland and coursing along the Murrumbidgee River) in 1967 and not long after moved to the new town of Colleambally, a small town in the Riverina (now with a population of 700 people) with his family where he became the 24/7 hospital. He never looked back.

Lesson one.

‘Listen to your patient. He is telling you the diagnosis.’ - Sir William Osler Dr. Bob is genial, charming, charismatic and kind. He is a devoted and highly cherished GP and he really cares about his patients, who are not just patients but friends. Lesson number one started immediately. For every patient that would come through the door he would start with some general conversation – about the football on the weekend, his race horse, about how the family was going, or how Rick was going with the new business and how Shelley was coping with moving to a new school (you catch my drift). He is a natural conversationalist. The intricate nuances he could remember about each person’s life was highly impressive and well-received. This seemingly nonspecific conversation that looked to me like two old friends catching up was actually very purposeful. Lesson one: Dr. Bob told me history and examination are the single most important things you can do.

Lesson two

You will never get a good history from a patient who doesn’t feel comfortable. The non-specific conversations at the beginning of the consultation relaxed the patient so the most accurate history could be obtained and therefore the best care could be given with an accurate diagnosis. Lesson two: in order to heal one must master the art of conversation.

Lesson three

Not only is he a natural conversationalist, Dr. Bob has clinical expertise. He has an acute attention to detail, making sense of each aspect of each patient’s history. Nothing felt rushed and not once did I notice a patient feel like they weren’t being understood or listened to. Despite sticking to his time schedule he made it feel as though he had all the time in the world for his patients and you could tell they really appreciated that. People opened up to him because he listened to them, engaged with them on a personal level and showed that he cared about their well-being. This dose of compassion was enough to make his patients leave the surgery already feeling significantly better than when they arrived. Lesson three: connection heals.

Lesson four

Dr. Bob has a laid back, relaxed demeanour but don’t let that fool you. He is incredibly thorough and meticulous in his clinical reasoning. Checking the results of every MRI or X-ray himself (not relying on the radiologist report alone) that came in to determine his clinical diagnosis. He argued that the radiologist report cannot be a definitive diagnosis because they have not seen the patient. He used his photographic memory and high functioning cerebral cortices to fit each piece of the puzzle to accurately diagnose the patient right in front of him. Lesson four: never accept a report blindly - everything must fit into the clinical picture i.e. the patient you see in front of your eyes. As an aside, he actually brought medical imaging to rural towns – revolutionising healthcare in the country. This is just one of his many life achievements.

Lesson five

With an extensive list of achievements and a long, successful career, ageing comes inevitably. At the ripe old age of seventy-seven, Dr. Bob is aware of his limitations –he is technically retired! However, he still works casually when there is a staff shortage (he owns the Murrumbidgee medical practice in Leeton and sleeps upstairs when he works there as he usually lives an hour’s drive away in the large rural centre of Wagga Wagga) but he won't be foolish. He knows he cannot do certain procedures anymore as his eyes are slowly deteriorating on him. His typing is slow – being limited to his two index fingers (by choice) and often humorously incorrect – he often wrote antibody as “anti-boy” which he also called a ‘lemon dropper’. He wants to be remembered for his highlights, not some blunders he made in his older years due to the waning of his once sharp senses. Lesson five: know your limits. Lesson six Lesson six included expanding my vernacular. While I was with Dr. Bob I learnt a vast array of new words previously foreign to me including (as mentioned above) ‘lemon dropper’ – a girl who is ‘anti-boy’, she got ‘knees up mother brown’ (someone who is pregnant) and your ‘constitution’ - the abdominal fat that surrounds us all in varying shapes and forms. He is certainly not one to be without humour – I have not met a doctor so jovial, cheeky and good-natured with his patients and I could see it really put them at ease.

Regarding his achievements, Dr. Bob also has been recognised with a Medal of the Order of Australia for his services to the medical and broader community. He is such a humble man that I only discovered most of his accomplishments after I had left Leeton. For example, he holds a role as Associate Professor of Clinical Medicine at The University of Wollongong. During that day in his practice, being the inquisitive and unashamedly nosey person I am I kept pestering him as to what he had done to be recognised with an OAM. He finally gave in and described to me how he was the chair of the area health service in Griffith in a time where many school children were dying from drownings in the local area. He implemented a swim school program for the kids in the Riverina. A fantastic solution that was in full fight when tragedy struck. One afternoon when the school bus was driving back from Darlington Point from the swimming lessons with over eighty children on board, a semitrailer collided with the bus in a horrific accident, causing severe life threatening injuries to many of the children on board including multiple fatalities. Dr. Bob and his wife, Fahy, a nurse, were first on the scene. He described to me in a solemn but calm voice how one child had died instantly and they had to step over the child in the ambulance while they acted fast and treated the other children who had serious, life threatening injuries but could still be saved. Another child died not long after the accident en route to hospital and another child who happened to be close to his family is only still alive today because of the quick thinking, expertise and hard work by Dr. Bob and his wife. What made my hair stand on end though was what he told me next. The child that had already died, who they had to step over to treat the others in order save their lives, was their own eight-year-old daughter, Catherine. There are no words to describe the immense sadness that came over me hearing these words in between patient consultations. I had to wipe my red puffy eyes dry before the next patient came in and struggle relentlessly to hold back my tears. I was shocked. This doctor who I had seen so happy, so caring and loving towards his patients who deserved the world had suffered such an agonising, traumatic life altering ordeal. How is that fair? My heart aches for him and his family. What bewilders me is when I asked him how he could do what he did that day given the circumstance he simply told me if he had let his emotions overcome him during that trip to hospital as he saw his young daughter lay dead on the floor of the ambulance there would have been many more fatalities that day. I cannot even begin to imagine the courage, strength and heartbreak he would have been experiencing and internalising during that critical time of need. Lesson six: If you think you can’t do something, you’re wrong.

Lesson seven

I was perplexed by how Dr. Bob was able to go on – to not become jaded, angry and bitter about the hand he was dealt. His response to this is something I will remember clear as day in my mind forever. He turned around, stared at me straight in the eyes and said “shit happens – life goes on”. Lesson seven – life goes on. He said he had the choice to be sad forever and come to a stand still in his life brooding and moping around or he could acknowledge and accept his pain and sorrow but go on with his life and achieve countless extraordinary things. He chose the latter. I could not appreciate the value of this statement until I heard it from him. How could this kind, gentle man have been through so much, had his world turned upside down, suffered an indescribable loss and still stand here today smiling and cracking jokes? His resilience and devotion to his family and career is truly inspiring.

In the nine hours I spent with Dr. Bob I learnt more than I have learnt in my entire medical school degree about how to connect and communicate with patients – and people for that matter something that can only be gained through experience. Sir William Osler once famously quoted ‘the good physician treats the disease. The great physician treats the patient who has the disease.’ Dr. Bob seems to live by this mantra. With his sharp diagnostic skills, his caring and empathetic nature, passion for his work and devotion to his patients and community he heals through connection.

Lesson eight

I want to share this story because I think that every student could gain a deeper understanding of what it means to be a health professional from spending an afternoon with Dr. Bob. When I think about what kind of doctor I aspire to be – it’s one like him. Thank you to Dr. Bob, you have touched the hearts of many far and wide and I feel lucky to have stumbled across your practice and acquired a few precious pearls of wisdom. This brings me to lesson eight: you never know who or what might lie behind the consultation room door and you never know what you might learn – any knowledge gained is no time wasted.

Lesson nine

The ninth and final lesson I learnt only after I spent time reflecting on my placement in Leeton, and refers to ‘Law 17’ from the novel the House of God by Samuel Shem: “Learn your trade, in the world. Your patient is never only the patient, but the family, friends, community, history, the climate, where the water comes from and where the garbage goes. Your patient is the world. [1]” For Dr. Bob, this echoes true and the world is a better place for it. 1.

Samuel, S., 1978. House of God.

A Rural adventure in Canada Judy Keith The 2016 ICEMEN or International conference on Community Engaged Medical Education in the North held in Sault Ste Marie in Northern Ontaria is the biennial medical education conference held together in partner with Flinders University and the Northern Ontario School of Medicine. The conference focused on social accountability for all individuals, with a heavy aspect on community engagement. Along with a number of other Flinders University medical students, I had the privilege of attending the conference as one of their guest presenters.

As a prelude to the conference, a ‘’Conference on the Move” was convened with a two-day bus trip from Toronto to Sault Ste Marie. The bus toured through rural areas of Northern Ontario and there were many opportunities to appreciate the natural landscapes as well as gain a deeper appreciation of the particular issues related to population health in Northern Ontario. Although difficult to compare, the Aboriginal population of Canada has

suffered a somewhat similar history to that of the Aboriginal and Torres Strait Islander population from Australia. Both suffer from large health disparities that have been largely attributed to intergenerational trauma that has persisted from a history of colonization and systematic policies that once aimed for total assimilation. However, just like the Aboriginal population of Australia, the Canadian Aboriginal population share a rich and proud cultural identity that we had the great honour of being shared with us as we visited a number of First Nation sites on the Manatoulin Island; the largest island in a fresh-water lake in the world. We were invited to participate in an early morning ceremony on the Summer Solstice in Little Current and learned about the importance of Spirit, Body, Mind and Emotions. We also experienced Smudging ceremonies with the four sacred medicines of the Ojibwah people; sage, tobacco, sweet grass, and cedar. Following a wilderness emergency medicine simulation exercise in the Bidwell Township we were treated to a shared meal of corn soup and scone bread. Luckily a hike on the Cup and Saucer Trail followed which burned off some of the excess deliciousness that we picked up on the way!

reference to the unimaginable suffering of the Stolen Generation of Australia. A former resident told us of her experiences where she was forbidden to speak her language, and study only in English. Canada has a Truth and Reconciliation Commission which in addition to investigating past wrongdoings towards Aboriginal people has made a raft of recommendations which are in the process of being implemented, including apologies and reparations. My podium presentation at the ICEMEN 2016 conference was entitled â&#x20AC;&#x153;Learning to be a Culturally Safe Clinician; A Students Perspectiveâ&#x20AC;?. It was the perfect conference to be able to share my personal insights into the challenges and rewards of developing culturally safe practices. Attending the conference, particularly the Conference on the Move, also expanded my knowledge and appreciation of different cultures which I know wholeheartedly will reflect upon me in my career as a medical officer.

Highlighting the history of the One Nation people on Manitoulin Island was a performance by a group of highly entertaining and thought provoking artists on the shore of Lake Huron, who channeled their story through singing and acting. Warm, inviting Cedar tea was followed. A visit to the ruin of one of Canadaâ&#x20AC;&#x2122;s Residential Schools in Spanish where Canadian Aboriginal children were sent from the age of five years of age; often with no contact with their family; was emotionally stirring, and made me draw

Rural Conferences to watch out for... State-Based Events Conference: ‘Rotto Ramble’- A med race for Junior Doctors Date: 9-11 Sep 2016 Location: Rottnest Island, WA What to expect: A medical wilderness adventure race around Rottnest island. This race will test both your wilderness survival medical skills and fitness through simulated emergency scenarios and physical challenges. Only suitable for 5th and 6th year medical students. Conference: NSW Rural Health and Research Congress Date: 9-11 Nov 2016 Location: Tweed Heads, NSW What to expect: During this conference, you will have the opportunity to hear from inspiring keynote speakers, innovative researchers and attend interactive forums and workshops around the 2016 theme of “The Rural Health Vision – translate, integrate and innovate!” Conference: NSW RDN/RDA 2016 Rural GPs Conference Date: 25-27 Nov 2016 Location: Coogee Beach, NSW What to expect: Update your clinical knowledge and skills amongst rural GPs for this two and a half day event. The event hosts not only the NSW RDN/RDA Annual General Meetings but also presentation for this year’s Rural Medical Service Awards .

National/International Events Conference: CRANAplus 34th Annual Conference Date: 12-14 Oct 2016 Location: Hobart What to expect: With the theme of “GOING TO EXTREMES: How Isolation, geography & climate, build resourcefulness & innovation in healthcare,” this year’s conference will act as a fantastic networking opportunity with other regional and remote healthcare individuals. With an impressive lineup of keynote speakers including Dr Bob Brown and The Hon. Michael Kirby AC CMG, this is an event not to be missed!

Conference: Rural Medicine Australia Date: 20-22 Oct 2016 Location: Canberra What to expect: Run by the ACRRM and RDAA, this is the peak national event for rural doctors and medical students passionate about rural health. This conference attracts over 700 doctors, students, educators and academics, catering for a wide range of interests all centered around rural and remote health. Conference: 14th National Rural Health Conference Date: 26-29 April 2017 Location: Cairns What to expect: The 14th Conference is part of 'A World of Rural Health' that also includes the 14th World Rural Health Conference, which will be held directly after it. There will be presentations, networking opportunities, various art displays, and healthcare presentations as well as an exhibition of organisational services aimed at the betterment and advancement of rural and remote wellbeing. Conference: 14th WONCA World Rural Health Conference Date: 29 April - 2 May 2017 Location: Cairns What to expect: While the 14th National Rural Health Conference focuses on the health of 6.7 million Australians living in the rural and remote regions of Australia, this is an International event that will see delegates from all over the world exchange and discuss information on the newest developments and challenges in rural and remote health globally. A discount rate will be available to delegates who register for both events.

Rebuilding Des Bowen’s Healing Place – a ROUNDS Initiative Emily Neville

Ariah Steel

Cape York Elders, Des and Estelle Bowen started the Healing Place in Hope Vale to help reduce the rates of youth suicide in their local community through connecting at risk youth to their land and culture. This was a sacred place where local elders could teach Indigenous youth about culture and connect them to their country to promote a sense of identity. Connection to country and culture has been shown to improve the mental health and wellbeing of Indigenous youth (Australian Indigenous HealthInfoNet, 2015). “The Healing Place gives an opportunity to youth to deviate from the path that they are on, so they don’t end up in a place where we visit them in the end” – Hope Vale Elder Estelle Bowen, 2015. Australia’s Indigenous population has the highest rates of youth suicide in the world (Australian Bureau of Statistics, 2015). Rates of intentional self-harm in the 15-24 year old bracket are 5.2 times higher in Indigenous Australians compared to nonIndigenous Australians (Culture Is Life, 2013). Unresolved historical and intergenerational trauma (frontier massacres, dispossession from traditional lands, assimilation policy, stolen generations, racism, abuse), unemployment and lack of opportunities, poverty and overcrowding, disempowerment, loss of community control and traditional authority and ongoing racism and institutional prejudice have also been identified as risk factors for

Morgan Jones

youth suicide (Culture Is Life, 2013). For many non-Indigenous Australians, the above are foreign concepts and they have never personally experienced these factors. While the atrocities committed against Aboriginal people occurred in a generation previous to ours, we were uneasy with our current contribution to repairing those relationships and restoring Aboriginal culture. In 2014 Des Bowens Healing Place was destroyed by Cyclone Ita. Morgan Jones, project leader and former ROUNDS CoChair, watched a video from Culture is Life outlining the extent of damage and devastating effect this was having on the program Des and Estelle had worked so hard to establish. ROUNDS (Rural Health Organisation of University of Notre Dame Sydney) rallied behind Morgan and decided that we would help rebuild the Healing Place so that Des and Estelle could continue their work. We had initially planned on completing the rebuild in July 2015, however, Uncle Des took a mustering job in Cape York for five months and the project was pushed back. While disappointed at the time, this was actually a blessing in disguise as it gave ROUNDS more time to fundraise and look for corporate support. With the addition of Suncorp to our team, the project escalated quickly and it was clear we would need more ideas, money and resources. Suncorp generously supported us with thirty

tradespeople through their subsidiaries in Cairns and Cooktown and coordinated the drafting of building plans, costings and budgets for material and tools. ROUNDS also secured support from Jetstar and fundraised locally which helped the project to go ahead. In October 2015, six ROUNDS members arrived in Hope Vale to embark on a week of building. It was a physically and emotionally exhausting week. We woke early every day and were covered in grime by sundown. The builders were quite impressed by our aptitude and commitment to the build and reported that for a group of medical students we did a lot better than they thought we would! Each day we were challenged and surprised by how little we knew and understood about Aboriginal culture. We faced culture barriers and challenges and we questioned whether we were doing the right thing on many occasions. We did not want to impose our ideas, values or morals on this community, we wanted the build to be driven by the local Elders and their needs. Throughout the build it was particularly obvious that what we value and perceive to be important is not the same for the local Aboriginal people. We had dedicated a year of preparation to this project and we thought the local community would be super excited and enthusiastic about the rebuild. Over the week it became clear that it was not a lack of enthusiasm, simply that higher importance is placed on family and community than a building. Nala McKenna, a youth worker from a Tasmanian Aboriginal centre sums it up nicely – “In white society, a person’s home is a structure made of bricks or timber, but to our people our home was the land that we hunted and gathered on and held ceremony and gatherings”.

What was important to the community of Hope Vale was not the re-build of the house itself, but the relationships to the land and getting out on country to heal. In December 2015, the first camp was held at Des Bowens Healing Place after its destruction. Twenty-one Indigenous men from the local community, including sixteen Elder males (early 20’s – 69 years) and five younger males (12 – 16 years), participated in the five-day camp. The initiative conducted by Hope Vale Elders and the Royal Flying Doctors Service (Queensland Division) took young Guugu Yimithirr men onto their country for cultural healing and to reinforce their cultural identity. (Riley, 2016). We received a final report from RFDS officer in Hope Vale John Riley detailing the success of the camp and the impact it had on the young men who attended. The most moving statement was from Uncle Des himself “I think we have crossed a barrier, and I say that because we have doubled the adult men attending and increased the young men from 1 to 5 attending” (Riley, 2016). The success of the men’s camp in Hope Vale highlights the need to direct indigenous youth suicide programs to the Elders and give them the power as they know how to heal their community (Culture is Life 2013). It is through this that the youth can gain experience and wisdom of the Elders to understand their responsibility and place in the world as members of family, community, society and the natural world (Riley, 2016).” ROUNDS, along with support from Jetstar and Suncorp, has facilitated the continuation of a community led program created by Indigenous people for

Indigenous people and this will help to return harmony to their communities and reduce the rates of indigenous youth suicide among other social issues. We feel privileged to be able to have been part of this.

Keep an eye out for the ROUNDS Culture is Life Fundraiser in early September 2016 https://www.facebook.com/events/210975 229272999/ Australian Bureau of Statistics (2015). Aboriginal and Torres Strait Islander Suicide Deaths.

We did not appreciate the scale or gravity of this project until its completion. It was not about receiving praise for our preparation, hard work and rebuilding the healing place or to make us feel better about the atrocities committed by our ancestors. This project was focused on Des and Estelle, the local community and at risk youth. It was about working towards achieving equity, justice and assisting the Elders in what they think is needed in their community. While we cannot correct the past, we can contribute to the future and build trust between Indigenous and non-Indigenous Australians. Being a part of this project has provided us with invaluable insight, and we feel very privileged to be able to share our experiences with others. A community driven approach is needed to finally ‘Close the Gap’.

Retrieved 23/07/2015 from http://www.abs.gov.au/ausstats/abs@.nsf/Products/3309 .0%7E2010%7EChapter%7EAboriginal+and+Torres+Strait+I slander+suicide+deaths?OpenDocument Australian Indigenous HealthInfoNet (2015). Summary of Australian Indigenous Health, 2014. Retrieved 23/07/2015 from http://www.healthinfonet.ecu.edu.au/healthfacts/summary Australian Institute of Family Studies. (2015). What works in effective Indigenous community-managed programs and organisations. Child Family Community Australia. 32. Retrieved from https://aifs.gov.au/cfca/sites/defauly/files/publicationdocuments/cfca-paper32-indigenous-programs.pdf Culture is Life (2013). The Elders’ Report into Preventing Indigenous Self-harm and Youth Suicide. People Culture Environment, Melbourne.

We are currently working with Culture is Life to develop a similar project in Arnhem land. Given the solid foundation and momentum this project has provided we are confident we will have a positive impact on this community as well. Watch this space. More information about the project can be found at our website http://yungee.weebly.com If you would like to contribute to our next project, please contact the ROUNDS team at roundsnd@gmail.com or alternatively https://www.facebook.com/dotheROUNDS/

Retrieved 23/07/2015 from https://bepartofthehealing.org/EldersReport.pdf Riley, J. (2016). On Country Healing Camp Report – Hope Vale Queensland. Royal Flying Doctors Service.

Des Bowens Healing Place pre rebuild

ROUNDS members and builders

Des Bowen place post rebuild

Aboriginal land in Hope Vale

Visiting Aboriginal Land with Aunty Phylamena Morgan Jones, Emily Neville, Ariah Steel, Phylamena (Hope Vale Elder), Sarah Flynn & Jenny Stokes

The eyes have it The National Rural Health Student Network (NRHSN) is celebrating its 21st birthday in 2016. As part of the celebrations, it is highlighting former Rural Health Club members who have gone on to make an impact with their careers. Outback ophthalmologist Dr Angus Turner is one of them…

Picture courtesy Alan McDonald, Fred Hollows Foundation

WHEN Angus Turner enrolled in medicine at the University of Western Australia in 1995, he joined the SPINRPHEX Rural Health Club. It was, as he says, “what got me started on my rural health journey”. His travels have since taken him to some of WA’s most remote corners, where he has restored sight to hundreds of people. Dr Turner, the McCusker Director of Lions Outback Vision, is determined to make eye health care accessible for remote people, particularly those living in Indigenous communities. The need is overwhelming. Aboriginal and Torres Strait Islanders are six times more likely than other Australians to go blind. “We know that 94% of vision loss in Indigenous Australians is preventable or treatable,” Dr Turner says. “However, 35% of Indigenous adults have never had an eye exam.” After completing his medical degree in 2000 - including stints on the SPINRPHEX executive and John Flynn placements on Christmas Island – Dr Turner specialised in ophthalmology. His heroes were people like Fred Hollows and WA ophthalmologist Phil House, who had been visiting the Pilbara for more than 20 years to deliver care. In 2012, Dr Turner founded Lions Outback Vision, part of the Lions Eye Institute at the University of Western Australia. Dr Turner continues to run clinics in the bush as part of an outreach program that includes a team of optometrists, orthoptists, nurses and liaison workers. “Patients who may have been blind in both eyes have a short procedure that doesn’t cause pain and then the next day they can see their children and grandchildren,” he says. “It’s just great to be part of that.”

The team also treats conditions such as diabetic retinopathy, which causes blindness if not identified in time. Lions Outback Vision has also been using telehealth so remote patients can have consultations with eye specialists in Perth. Dr Turner was present for the launch in March this year of the new Lions Outback Vision Van. This mobile eye health facility has three consulting rooms, filled with specialist equipment. It provides comprehensive care for cataracts, refractive error, trachoma, glaucoma and diabetic retinopathy. The van is expected to travel more than 24,000 kilometres a year providing services in Albany, Esperance, Kalgoorlie, Leonora, Wiluna, Newman, Roebourne, Karratha, Port Hedland, Broome, Derby, Fitzroy Crossing, Halls Creek, Kununurra and Katanning. When he’s not flying in to a remote clinic, Dr Turner maintains a busy schedule from his Perth base. An Associate Professor at UWA, he is involved in a number of research projects at the Lions Eye Institute, focusing on service delivery for remote and Indigenous people. He also co-chairs the WA Eye Health Advisory Group, is a consultant at Fremantle Hospital and an ophthalmology teacher for the Rural Clinical School of Western Australia – encouraging the next generation of rural health leaders. Interested in following in Dr Turner’s footsteps? Get connected to a Rural Health Club at www.nrhsn.org.au

The Alliance welcomes the new Frontier! The National Rural Health Alliance congratulates the Australian Medical Students’ Association (AMSA) on the first edition of its new Rural Health Magazine, Frontier. The Alliance appreciates this opportunity to provide some information about the National Rural Health Alliance and hopes some of it will be of interest to AMSA members. The National Rural Health Alliance (NRHA) is a collective of 38 national organisations which represents the consumers and providers of health services in rural and remote Australia. A full list of NRHA Member Bodies can be found at: www.ruralhealth.org.au/about/memberbodies. The Vision of the National Rural Health Alliance, as the peak non-government rural and remote health organisation, is good health and wellbeing in rural and remote Australia. The Alliance is an advocacy body and seeks input from its 38 Member Bodies and others to formulate policy on a wide range of rural and remote health issues.

There are a number of ways students can get involved with the Alliance and be part of the rural health sector in Australia. Visit our website Take the time to visit www.ruralhealth.org.au. Here you will find everything the Alliance has ever published from media releases, submissions, factsheets, conference proceedings and webinars. The making of Australia's rural and remote health sector – and its challenges for the future In April 2016 the Alliance’s Foundation CEO, Gordon Gregory, retired and the Alliance hosted a webinar to celebrate his achievements and to provide an opportunity for people involved with rural and remote health in Australia to reflect on the years since the 1st National Rural Health Conference was held in Toowoomba in February 1991. Presentations were made by a range of rural health colleagues, including medical student, Danielle Dries. The webinar is a good history of rural health and can still be viewed here: http://ruralhealth.org.au/events/webinar/-the-making-of-Australias-rural-and-remotehealth-sector-and-its-challenges-for-the-future Join Friends of the Alliance Friends of the Alliance is a network of people and organisations that come together to support the work of the National Rural Health Alliance and provide additional grassroots connections for its work. Student membership of Friends for the 2016/17 financial year is $46.00 (gst inc) – and you can find out more about Friends or join online via http://www.ruralhealth.org.au/friends Attend or present at the 14th National Rural Health Conference, Cairns, 26-29 April 2017 In April 2017 the 14th National Rural Health Conference is a part of A World of Rural Health and students are encouraged to submit an abstract for a potential place on the Conference Program. Students help invigorate the Conference with their youthful energy and there is a discounted registration fee available for them. The call for abstracts is open until 30 September 2016 so start thinking about a presentation now – perhaps you’d like to consider a joint presentation with one of your colleagues? Visit the Conference website for more information about the Conference: www.ruralhealth.org.au/conference Follow us on Twitter (@NRHAlliance) and ‘like’ us on Facebook (www.facebook.com/NRHAlliance) Please stay in touch The Alliance is based in Deakin in Canberra and visitors are always welcome. Our Policy, Conference and Scholarship staff are always happy hear from you on all things rural and remote. Phone us on 02 6285 4660, email us at nrha@ruralhealth.org.au or drop in with a packet of chocolate biscuits! #loverural

Contributors Editor: Bhagya Mudunna Sub-Editors: Emily Mogridge Jasper Lin Kate Thimbleby Logo and Front Cover Design: Grace Ng Co-Chairs: Skye Kinder Sophie Alpen Sponsorship Officer: Ryan Horn Writers: Satyen Hargovan Sajid Chowdhury Sophie Manoy Annabelle Chalk Isabel Guthridge

Morgan Jones Asiel Adan Zheng Jie Lim Shyamini Naidu Grace Fitzgerald Cara Templeton Melanie Geoghegan Sean Macgrath Mitchell Simpson Georgia Foley Greta Beale Kate Thimbleby Anna Elliston Ariah Steel Judy Keith Emily Neville Lucinda Roberts Matt Lennon Emily Powell Jiwanjot Kaur Special Thanks: On-Demand Printing

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