MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini, for the Royal Australasian College of Physicians.
In the last episode, we heard about specialty training in a typical country town. Today we’re going much further into the bush. If you fly into Broome from the east you’re struck by the emptiness and the colours. For hours you see nothing but red desert, then over the Kimberley you see river gorges carved through rocky scrub. Finally you hit the shocking turquoise of the Indian Ocean and a strip of impossibly white sand.
The remoteness is humbling- even moreso when you realise a couple of regional archeological sites have been dated back 47,000 years. This means that the Kimberley was not only of the first inhabited areas in the continent, but that it was populated by humans even before Europe was. Aboriginal people make up almost half the region’s population and many are living on traditional country.
For a tourist on a brief visit to Broome, these epic scales can be easily forgotten as they stroll down the main drag looking at pearl jewellers and the seafood restaurants. But the experience for a health care worker is very different. They’re there to serve a region twice the size of Victoria, with a scattered permanent population of 45,000 and an annual tourist traffic that is 5 times higher.
On average, remote settings only have 11 percent as many specialists per capita compared to major cities and this means that pathology is often much more advanced by the time it’s diagnosed. Broome itself only has about 19,000 residents, and according to the Modified Monash Model, you’re in the most remote classification the moment you pass the Malcolm Douglas Crocodile Park on the edge of town.
Broome hospital has forty beds and there are five smaller ones in places like Derby and Kununurra on the eastern edge of the Kimberley. The day-to-day operation of these is hospitals is thanks to district medical officers or DMOs—these are GPs with procedural skills including anaesthesia and obstetrics. The regional service team has two physician roles that are based in Broome, who run outreach clinics at 22 remote locations.
Although there are hours of dirt roads and resources might be scarce, this remarkable care model works because of the strong relationships between many different health care professionals. To get a sense of what it’s like to work and train in this environment, I called up three medics who’ve made Broome their home.
LYDIA SCOTT: So my name's Lydia Scott, I’m a general medical consultant with the Kimberly Regional Physician Team. I was a registrar with the Kimberly Regional Physician Team whilst I was doing my advanced training in general medicine and I also lived in the Kimberly for a few years as a teenager and grew to love the region and the lifestyle up here..
LEE FAIRHEAD: So my name is Leigh Fairhead and I am a first year General Medicine Advanced trainee so I have relocated to Broome to do 12 months of core General Medicine Advanced training and that’s having completed my basic physician training in Perth in western Australia. I myself also spent time in the Kimberly as a student.
MIC CAVAZZINI: And finally, this episode wouldn’t be possible without the help of the BroomeDocs studios, so Casey, tell us about yourself and what need you’re trying to address with your website and podcast?
CASEY PARKER: Oh, thanks, Mic, yeah. My name's Casey Parker, I am a rural generalist, so I’m a GP by trade but work as a hospitalist up here in the Kimberly, I’ve been in the Northwest for 15 years now and in Broome for 12. The general ward is generally run by GPs or generalists like myself, and we certainly work very closely with our physician colleagues because we have a lot of complex medicine.
So I started the Broome Docs podcast about eight years ago now; the main reason we started it was because I know there’s a lot of really smart GPs out there that do lots of amazing medicine, at this point I just wanted to share a lot of the stories and bring together a community so that people wouldn’t feel to isolated and could learn off one another, so that was the basic premise.
It's actually a little known fact that there’s actually a lot of procedural GP, anaesthetists and critical care doctors all over the country, and we’ve just completed a survey, actually, that showed there were 655 GP anaesthetists in Australia.
MIC CAVAZZINI: Yeah. Okay, let’s talk about some of the perceived or actual challenges that come up about rural medicine and training in particular. Of course, in a big country like Australia there’s going to be resource limitations in regional and remote places; what are some of the clinical tools that you have to do without up in Broome that city doctors might take for granted?
LYDIA SCOTT: We’re 2,500 kms from Perth and in Kununurra our patients are over 3,000 kms from the MRI machine for Western Australia. But there’s nothing that helps clarify your thought process as to whether an MRI is really needed as just trying to explain to the patient they’re going to have to take three days off work to travel to get an MRI. practising up here without all the resources of a tertiary centre also puts the focus back on clinical skills and the cognitive aspects of medicine. It certainly does help you clarify in your own mind what investigations are really necessary and whether they will actually change outcomes for the patient.
MIC CAVAZZINI: Maybe Lee can reflect on the idea that you do have to be a bit of a Jack-of-all-trades in a regional centre, you end up doing a bit of everything which you might not get the chance to do in a busier training hospital in the city. Has that been your experience, Lee?
LEE FAIRHEAD: In terms of being a Jack-of-all-trades, I think that that’s what any generalist is expected of and general medicine is a specialty itself which allows one to have a high level skill set across a broad range of specialties. And that model works extremely well in the Kimberly. I would argue that certainly what happens in the regions is that you get exposed to what actually general medicine is as a specialty rather than what it has perhaps been watered down to in a tertiary hospital. It does allow you to invest yourself more in patient care because you’re here for a longer time and you can follow patients through their inpatient journey, their outpatient journey in a way that is just usually, not necessarily, able to be facilitated in shorter rotations or more, shared among more registrars in a larger hospital.
MIC CAVAZZINI: That point you made about the patient focus, someone mentioned that as well, that you get a real continuity of care with a particular patient, you might see them come into emergency and then you review them on the wards the next day and in a week you’ll see them at an outpatient [clinic], there’s not as much farming out of those different roles.
LEE FAIRHEAD: Exactly. It also allows you to be more patient-focused and work with the patients because the consequences for their medical management if they are in a remote community, or if they require transfer to Perth, and the impact on their family and their wider community is really brought more to the fore. And learning those skills as a trainee is invaluable no matter where you are and really hone your outpatient and long term chronic disease management skills for patients. And I think as a team, in particular, we then work closely, as Casey has said, with the DMOs in hospital, and that’s a huge advantage with being in a smaller centre where you have personal relationships with your colleagues rather than third in line service registrar in the larger hospital.
MIC CAVAZZINI: We talked in the last episode about the Specialist Training Program, which provides Commonwealth funding for registrar positions in regional location, and also encompasses suburban settings with high needs. Broome has two STP posts in General Medicine and one in paediatrics, and regional outreach is written into these job descriptions. The hope for the Specialist Training Program is that trainees will remain in such settings to continue their career.
But there are many perceptions about the rural experience that put trainees off. One of these is that in a small supervision team, and you might not get as good supervision as you would a bigger teaching hospital. Or for basic trainees preparing for clinical case presentations, that there wouldn’t be enough exposure to a diverse case load. While Broome doesn’t currently take Basic Trainees, Lee Fairhead says that these has been obstacles experienced in her own her training pathway.
LEE FAIRHEAD: I think if you look at the entire training pathway, so I’ve not come across that issue. As an intern I was in the regional town of Geraldton. I’ve obviously done my basic physician training in Perth again, with a different model, a different model of care and different exposure to specialists. And then being in Broome, even in a smaller centre I am supervised obviously by Lydia as one of the consultants, but then I have supervision from a consultant who's actually based in Melbourne, a consultant who's based in one of the tertiary hospitals in Perth and actually heads general medicine training in WA, so my exposure has been very varied and in fact one of the biggest take-homes for me already is being able to be exposed to different consultants' styles including supervision teaching and clinical provision of services.
LYDIA SCOTT: Yeah, and for the registrars that come up to the Kimberly, we’re very mindful of providing a diversity of supervision, and just like we use telemedicine as a clinical tool, we also use technology as a tool to supplement our teaching, supervision and research capacity as well. So for most of the research projects that our trainees do up here we deliberately try to include someone from a tertiary centre as a co-supervisor on that project. The visiting sub-specialists that come up here from cardiology and nephrology and rheumatology have also always been very supportive in helping support our trainees and helping diversify the supervision.
And because we have such a wealth of pathology and workload to work with up here we can also help trainees focus on particular areas of medicine while they’re here, and if they feel that they need exposure to a particular subspecialty to help round them out we can do that. And that’s part of just being in a small enough machine that we can individualise and personalise the supervision and content of the rotation more than, I think, a lot of tertiary departments would have the capacity to do.
MIC CAVAZZINI: So you’ve already described that framework that I was going to lead up to. The RACP has a minimum standard for adequate supervision—each basic trainee must be allocated a rotations supervisor and an education supervisor who oversees longitudinal progression. And trainees listening should be encouraged by the fact that from next year the selection and appointment of supervisors and network directors will be competency based. There’s many parts to this safety net, in case any listeners were worried of being stranded.
LEE FAIRHEAD: And I think that that should be reassuring. I can only speak form six months experience so far. But the capacity for myself to be supervised and have tailored input this far has been some of the best supervision that I have had. It should also be seen as an advantage to have a smaller team for the reasons I explained before.
MIC CAVAZZINI: I’m going to refer a few times to the findings of Dr Linda Selvey. She’s a public health physician at the University of Queensland who’s been co-directing a program called Building a Rural Physician Workforce. She presented her data at Congress and she described the possibility of smaller centres to be what she called “fragile” workplaces in that there’s a small leadership team so the success of that place really depends on the personality of just a few individuals. And there were historic examples of similar-sized institutions with exactly the same sort of complement of staff and isolation. And one was thriving as a training centre while the other was more claustrophobic and there was a high staff turnover and a potentially toxic atmosphere. I don’t want you to point any fingers at Broome Hospital but can you see examples of this that you really are reliant on strong leadership?
CASEY PARKER: Can I comment on that one, Mic?
MIC CAVAZZINI: Yeah, go ahead.
CASEY PARKER: Like, I’ve been in small hospitals for 20 years now and one thing I really like about small hospitals is that those small cogs turn faster. And so when you want to change something, if you want to improve the quality of the your service, it’s actually a lot easier to do because I can sit in a room with every doctor that works in the hospital and we can talk about stuff, whereas trying to change something in a department of 50 or 60 doctors is really hard to do, but you’re right, it does require good leadership, and we’re lucky to have that in Broome with these guys here.
MIC CAVAZZINI: You’ve countered a lot of those stereotypes that people have or the fears that people have. Again, from Linda Selvey’s lecture that, she says that one problem with attracting people out to regional sites is that maybe there’s a lack of a professional identity amongst regional physicians, and that’s perhaps in contrast to the GP culture where the rural generalist really is a brand, it is a heroic kind of identity. Would you see that contrast between the two medical communities?
LYDIA SCOTT: I think that’s an interesting observation. I think general medical physicians just generally don’t have an as well-developed identity on the national level. But the extent to which that’s a problem is probably another question. A sense of professional identity is important in the sense of you want to feel supported by colleagues in your same profession and you want to be reassured that there’s a way to maintain professional development in your career. I have found, working in the Kimberley, I’ve found that through technology, I can link with professional development activities interstate, nationally and overseas.
Within Western Australia there’s a WA Regional Physicians Network, we have a weekend once a year where we request lectures and updates on the topics that we most need, and we stay in touch throughout the year, and I think that helps counter a perception of a lack of professional community. The main thing is that a big part of my professional identity here is that I work as part of a team—that might be different types of doctors—but that we all work together and because of that I don’t feel a sense of professional isolation at all.
MIC CAVAZZINI: In the Kimberley region there is also a team of paediatricians, two obstetricians, a rotating team of surgeons, and a public health physician. There isn’t much private medicine in region, but throughout the year there are visits from city-based nephrologists, rheumatologists, cardiologists ophthalmologists, dermatologists cardiologists, orthopaedic team and ENTs. There are also dialysis centres in Broome, Derby and Kununurra with a total capacity for 120 patients. Casey Parker describes some of the more recent developments at Broome Hospital, and also some of the competencies unique to practicing medicine in a remote setting.
CASEY PARKER: In terms of our sick patients we have a high dependency unit as well which allows us to manage pretty much anything up to ICU level care we now basically keep all of our septic patients and a lot of our other unwell respiratory-type patients as well, whereas ten years ago they probably would have gone out on a plane, which is a rally bad way to manage people in the Kimberley and costs a lot of resources. So the model’s really evolved with the use of the physicians input. And we utilise a daily video conference without one of our sister hospitals doing in the city so we can talk to intensivists over a live VC with the patients in the room. So it’s been really good both for patient care but also for the education of the generalist workforce up here.
MIC CAVAZZINI: Is that a daily, is that a bread and butter process that you might consult with a specialist back in Perth or is it special occasions type thing?
LYDIA SCOTT: Telephone medicine is definitely part of daily practice, we use telemedicine within the region often as well as teleconferencing with the tertiary sites.
MIC CAVAZZINI: Oh, so you might be the base that Kununurra speaks to for expertise.
LYDIA SCOTT: Yeah. So as well as visiting Kununurra and Halls Creek, Wyndam, Fitzroy Crossing and Derby and many other communities in the region, as well as the in-person visits we can provide ongoing continuity into patient care by teleconferencing into that site when required. There are times where we’ve teleconferenced with people at home. For example, I video conference with a young patient whose comorbidities mean he can’t mobilise anymore. Rather than him going to the hospital I can actually just video conference him for a lot of the appointments. It doesn’t replace in-person care, there are a lot of things that still need to be, or still are best done in person but telemedicine is certainly a very good supplemental tool to do that which can help to make sure that we’re providing people the frequency of reviews they should have and providing optimal care.
MIC CAVAZZINI: Alright let’s get into some of the unique competencies that you can develop in a smaller centre, for example, point of care, ultrasounds, many rural generalists don’t have a radiology department on hand, and point of care ultrasound has become a pretty standard skill in those settings; Casey, I know from your website that you’re a huge fan of POCUS, although perhaps not POTUS?
CASEY PARKER: Yeah, absolutely, Mic, it’s something I’m very passionate about and try and spread the word about quite a bit, it can really be a very useful tool to be able to move treatment forward, particularly after hours on weekends. Unfortunately, one again, the formal training pathways are probably not there yet and it’s hard to acquire those skills in a rural place, but certainly if trainees have an interest in that and come to the rural areas with those skills, that'd be very valuable.
MIC CAVAZZINI: Can you describe the flow of a consultation that uses this technique, are you interpreting on the fly or do you still sometimes send pictures off, how's does that work?
CASEY PARKER: Yes. A good example would be our renal patients, they come in, may have missed dialysis, for example, that’s a very common scenario here in Broome and just sort of work out where they’re at. And it’s certainly a lot faster for me to assess their volume status and how much lung water is going on with an ultrasound, which I can do in a few minutes at the end of the bed whereas the more traditional sort of ways of doing that would take a lot longer in our department, particularly after hours, and so that’s one example where certainly there’s a good evidence base for using ultrasound and can often head off patients at the pass before they get really sick if you know exactly where they’re up to, probably is a good safety backstop for us in rural emergency practice.
MIC CAVAZZINI: One of the editors of this podcast from New Zealand recently did a course with the Otago University and he learned a few applications of point of care ultrasound that are not that common for traditional sonographers such as chest ultrasound for pneumothorax and pulmonary oedema and FAST scans on trauma patients, are these things that you’re familiar with and competent with?
LYDIA SCOTT: So I can probably speak to this from the perspective of respiratory ultrasound. So one of our consultants here is dual-trained in respiratory and general medicine. During our ward consultations to their patients admitted to the hospital we regularly use ultrasound. For example, just this week there’s a patient with an empyema and another patient with a pneumonia that may be progressing, so I don’t know that it would necessarily fit the definition of POCUS but a respiratory-trained physician uses that technology on a regular basis here in Broome and on the ward, which also then means that we can make decisions and liaise with specialists in Perth or make interventions here, and that’s of a huge advantage particularly because we don’t have after-hours radiology.
MIC CAVAZZINI: Another focus of regional practice is indigenous health, around 45 percent of the population in the Kimberly area is indigenous compared to Sydney and Melbourne where the average is just over one percent; would you, is it appropriate to think of indigenous health as a unique competency?
LYDIA SCOTT: On commencement with Kimberly regional physician team, we do provide orientation that includes cultural awareness training, and there’s new programmes that the Yawuru people of Broome are running to help people have a more meaningful understanding of the local traditional culture. But across the Kimberly there are many different cultural groups.
I think practising well in indigenous health or practising well in a cross-cultural context, usually at its heart means that you’re considering the background of the patient in front of you, it means you’re considering their own priorities, and that’s good to do no matter where you work in medicine. Definitely when you’re working in indigenous health you won’t be able to practice medicine well unless you do that, and so I think working in indigenous health can make people better practitioners in that sense.
One of the experiences that our trainees have regularly when they’re here as physician registrars is going to different aboriginal communities and providing care on country, often in a clinic, sometimes on home visits. And so I like to think that helps the patients but I also think it helps our trainees understand how important it is to consider their plan for the patient's medical care in the context of that person's broader life.
MIC CAVAZZINI: Now let’s talk about the psychosocial features of the rural population generally. We know that the rate of suicide is 1.7 times higher than what it is in the major cities according to the Australian institute of Health and Welfare. There are higher rates of risky drinking and all of these figures are even higher in the aboriginal population. Should trainees have some good grasp of mental health before coming to a place like Broome?
LYDIA SCOTT: Certainly an important part of practising as general physician is treating the whole patients, that’s part of the basis of the specialty of general medicine. And that includes understanding the psychological cofactors that may be a result of their disease or contributing to their illness behaviour in the way someone interacts with their disease.
From what we’ve found with the registrars that come up to the Kimberley , what we’ve found is that as long as they’ve completed basic physician training that provide them with a good starting point from which they can develop deeper understanding of how the psychological factors and even historical factors might be impacting on any one person’s medical presentation.
LEE FAIRHEAD: And I can add from a Trainee perspective—each Tuesday we discuss all of the patients who are in hospital and that meeting is attended by the inpatient team, the local psychiatry team, the local obstetrics team, the local Kimberley renal services, the local Aboriginal medical services, the local palliative care team. Although you may be faced with maybe unique situations or complex comorbidities, the way that we’re able to offer continuity of care as well as work together closely with specialties means that even though you’ve got a complex patient the plans often seem to be easier to enact than sometimes when you come across that in a tertiary setting
MIC CAVAZZINI: Before we finish, just a few thoughts about quality of life. In the study we’ve been talking from the University of Queensland, it’s been shown that rural practitioners have equally high job satisfaction ratings to their metropolitan peers. And yet a lot of them still move on for personal reasons- We talked in the previous episode about the difficulty of finding work for a partner. But rural medicine is compatible with many different lifestyles and at the risk of misappropriating a nineties tourism campaign, “You’ll never never know, if you never never go.”
LYDIA SCOTT: Yeah, we expect that when our registrars are working for us we’re going to be deliberately stretching their brains in all sorts of different directions, asking them to apply knowledge that they’ve developed over the last few years in challenging contexts, and our registrars learn a lot because they work hard, but I think everyone’s very aware of the important. And it doesn’t get taken for granted that people have been willing to commit to coming yup here to work.
We respect the fact that in order for them to come and give us their best efforts in clinic we also then need to give them time to enjoy the region and have time to maintain their own mental health, their own lifestyle and relationships. And I would hope that we’re able to strike that balance. And I suspect that that’s probably why most of the consultant roster is staffed by three of us consultant that used to be registrars that chose to move back to Broome long-term.
MIC CAVAZZINI: I did laugh when I was looking you up, Lydia, I found a job ad for a registrar position that you'd posted, and it had pictures of the camels on Cable Beach and people kayaking on the azure waters of the Indian Ocean -
LEE FAIRHEAD: That was me last weekend.
MIC CAVAZZINI: Okay, so it’s not just the advertising material?
LEE FAIRHEAD: Nope, it’s not just the advertising, it’s a beautiful backyard. And genuinely, seriously, as a trainee, the opportunity to do remote clinics and to actually see patients on country and in community whilst seeing the beautiful Kimberly, is absolutely a huge attractant to the job.
Perhaps. Hopefully this is one of the most important things that gets across in the podcast. As a trainee to move 2,500 kms to change my hospital, change my supervisors and to enter something unknown, is definitely different. Moving to Broome and taking this opportunity, though, is one of the best things that I’ve ever done, and I would hope that those perceptions and trainees who have those perceptions just take the time to have a chat to people and to explore the options.
This job, in particular, has been the most flexible job that I’ve ever been in. And having come out of exams and feeling thoroughly burnt out, the opportunity to be slightly more in charge; to be allowed access to your leave, you know, obviously in consultation with the team; but you know not dealing with a faceless administration to get access to leave; truly being able to plan your year, including professional development to make sure that even if it’s just a perception that you’re missing something in the city you can upskill on things that maybe you’re not being exposed to;
There’s huge advantages. And it was certainly an unknown, me coming, my partner also moved here, but things do tend to work out in the long run, and a close-knit hard working team that is genuinely interesting in seeing you excel as a trainee, is unique and should be strongly promoted.
MIC CAVAZZINI: Many thanks to Lee Fairhead and Lydia Scott for contributing to this episode of Pomegranate Health. And special thanks to Casey Parker for sorting out the recording – make sure you make sure you check out his BroomeDocs podcast and blog for lots more great discussion about generalist medicine in the bush.
You’ll find this linked at our website racp.edu.au/podcast. There’s also a transcript of this episode, a comments forum and links to other great resources for trainees. Or just search for Online Learning Resources @ RACP and browse the e-Learning modules and video lectures for the Basic Training Curriculum.
There’s also information about the Specialist Training Program and funding options for rural Fellows to extend their skills. For example Support for Rural Specialists Australia has four funding rounds a year that can go towards all sorts of things like attending workshops in vascular access, point-of-care ultrasound or echo, Cardiac CT, and even to brush up in a subspecialist department in a tertiary hospital. Finally, you can also nominate a colleague for the RACP Medal for Clinical Service in Rural and Remote Areas, which recognises outstanding service in Australia or New Zealand.
Please put your colleagues onto Pomegranate Health, and remember that you can always send any feedback to firstname.lastname@example.org. I’m Mic Cavazzini. I hope to hear from you.