Ep49: Training in the Bush Part 2—Remote WA

A third of Australia's population is classified as regional or remote, but as it's such a big place it's hard to provide comprehensive heath care all over. In the previous episode, we heard about an important referral centre in country NSW, but this episode takes us to Broome, a small town that's two and a half thousand kilometres from tertiary facilities in Perth.

On average, remote settings like this only have 11 percent as many specialists per capita as major cities and this means that pathology is often more advanced by the time it's diagnosed. The medicine can be confronting but the training experience is great and rewarding. In this episode we hear from an advaced trainee, a consultant, and a rural generalist GP about the unique skills and models of care they bring to this environment. 

Guests
Dr Lydia Scott FRACP (Broome Hospital)
Dr Lee Fairhead (Broome Hospital)
Dr Casey Parker FRACGP (Broome Hospital, at the Rural Clinical School of the University of Western Australia) 

Production
Written and produced by Mic Cavazzini. Music licensed from FreeMusicArchive; 'Fervent', 'Cast in Wicker' by Blue Dot Sessions, 'Hypocritopotamus' by Doctor Turtle, 'Slow Burn' by Kevin McLeod. Image licenced from Getty Images.

For a transcript and further references please visit https://www.racp.edu.au/pomegranate/view/ep49-training-in-the-bush-part-2. Fellows of the RACP can claim CPD credits via MyCPD for listening to this episode and reading the resources below.

Please visit the RACP website for a transcript embedded with citations. Fellows of the College can claim CPD credits for listening and additional reading.  

Transcript

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SPEAKER_01 0:08

Welcome to Pomegranate Health, a podcast about the culture of medicine. I'm Mick Kabazzini 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 more so when you realize a couple of regional archaeological sites have been dated back 47,000 years. This means that the Kimberley was not only one of the first inhabited areas in the continent, but that it was populated even before Europe was. Aboriginal people now 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 jewels and the seafood restaurants. But the experience for a health worker is very different. They are 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 five times higher. On average, remote settings in Australia only have 11% 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 40 beds, and there are five smaller hospitals in places like Derby and Kananara on the eastern edge of the Kimberley. The day-to-day operation of these is thanks to district medical officers or DMOs. These are GPs with procedural skills including anesthesia 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 model of care works because of the strong relationships between many different healthcare 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.

SPEAKER_03 2:38

So my name's Lydia Scott. I'm a general medical consultant with the Kimberley Regional Physician Team. I was a registrar with the Kimberley Regional Physician Team whilst I was doing my advanced training in general medicine. And I also lived in the Kimberley for a few years as a teenager and grew to love the region and the lifestyle up here.

SPEAKER_02 3:01

So my name is Lee 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 Kimberley as a student.

SPEAKER_01 3:22

And finally, this episode wouldn't be possible without the help of the Broom Doc Studios. So, Casey, tell us about yourself and what need you're trying to address with your website and podcast.

SPEAKER_00 3:34

Thanks, Mick. 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 Kimberley. I've been in the Northwest for 15 years now and in Broom 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 Broom Docs podcast about uh 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. And I just wanted to sort of share a lot of the stories and um bring together a community so that people wouldn't feel so 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 anetherists and critical care doctors all over the country. And we've just completed a survey actually that showed there were 655 GP anetherists in Australia.

SPEAKER_01 4:31

Yeah. Okay, let's talk about some of the perceived or actual challenges that come up about rural medicine and training in particular. Uh of course, in a big country like Australia, there's going to be resource limitations in ro regional and remote places. What are the some of the clinical tools that you have to do without up in Broome that city doctors might take for granted?

SPEAKER_03 4:56

Well, in Broome, we're about 2,500 kilometres from Perth. And in Catanara, our patients are over 3,000 kilometres 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.

SPEAKER_01 5:48

Maybe Lee can reflect on the the idea that you do have to be a bit of a jack of all trades in a regional centre. You'd end up doing a bit of everything which you might not get the chance to do in the in a busier training hospital in the city. Has that been your experience, Lee?

SPEAKER_02 6:04

In terms of being a jack of all trades, I 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 of skill set across a broad range of specialties. And that model works extremely well in the Kimberley. 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, you know, shared among more registrars in a larger hospital.

SPEAKER_01 7:07

That point you made about the patient focus, someone mentioned that as well, that you you get a real continuity of care with a particular patient. You might see them come into emergency, then you review them on the wards the next day, and in a week you'll you'll see them at an outpatient like the there's not as much farming out of those different roles.

SPEAKER_02 7:24

Exactly. It also allows you to be more patient focused and to work with the patient 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 had 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 over-the-phone relationships, as sometimes you experience as a sort of third-in-line service registrar in a larger hospital.

SPEAKER_01 8:25

We talked in the last episode about the specialist training program, which provides Commonwealth funding for registrar positions in regional locations and also encompasses suburban settings with high needs. Broom has two STP posts in general medicine and one in pediatrics, 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, you might not get as good supervision as you would in a bigger teaching hospital. Or for basic trainees preparing for clinical case presentations, that there wouldn't be enough exposure to a diverse caseload. While Broom doesn't currently take basic trainees, Lee Fairhead says these are not obstacles she's experienced in her own training pathway.

SPEAKER_02 9:18

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 Geralton. 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 Broom, even in a smaller centre. I'm 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 and being able to spend more time with them as well has been very varied. And in fact, is one of the biggest take-homes for me already is being able to be exposed to different consultant style, including supervision teaching and clinical provision of services.

SPEAKER_03 10:11

Yeah, and for the registrars that come up to the Kimberley, we're very mindful of providing a diversity of supervision. And just like we use telemedicine for 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, uh we deliberately try to include someone from a tertiary centre as a co-supervisor on that project. The the um visiting sub-specialists that come up here from cardiology and nephrology and rheumatology have also always been very supportive in helping support uh our 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 uh on particular areas of medicine while they're here. And if they feel that they need um exposure to a particular subspecialty to help round them out, we can we can do that. And that's part of just uh being in a small enough machine that we can individualize and personalise the supervision and content of the rotation more than I think a lot of tertiary departments would have the capacity to do.

SPEAKER_01 11:35

Yeah, so you've already described that framework that I was going to lead up to that um the RACP has a minimum standards for adequate supervision. Each basic training must be allocated to a rotation supervisor and then an educational supervisor who oversees longitudinal progression. And you know, 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 level, the many parts to this safety net in case um any listeners were worried of being stranded.

SPEAKER_02 12:09

And I think that that should be reassuring, um, Mick, and I can only speak from six months of experience so far, but um the capacity for myself to be supervised and have tailored uh input thus 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 that I sort of um explained before.

SPEAKER_01 12:35

Um I'm gonna refer a few times to some findings from Dr. Linda Selvie. She's a public health physician at the University of Queensland who's been co-directing a program called Building a Rural Physician Workforce. Uh she presented her data at Congress and she described the possibility of smaller centers 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. Uh, 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 center while the other was more claustrophobic and there was a high staff turnover and a potentially toxic atmosphere. Um, I don't want you to point any fingers at Broom Hospital, but um can you see uh examples of this that you really are reliant on strong leadership and can I comment on that one?

SPEAKER_00 13:30

Yeah, go ahead. Uh 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 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 that 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 broom with these guys here.

SPEAKER_01 14:00

No, you've you've counted a lot of the yeah, those stereotypes that people have or the fears that people have. Um again from Linda Selby's lecture, the she says that one problem with attracting people out to regional sites is that there maybe there's a lack of a professional identity amongst regional physicians, and um that that that's in perhaps in contrast to um the GP culture where the rural generalist really is a brand, it is a uh heroic kind of identity. Wouldn't would you see that contrast between the the two uh medical communities?

SPEAKER_03 14:36

I think that's an interesting observation. I think general medical physicians just generally don't have a as well developed identity um on the national level. But the extent to which that is 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 within your career. Uh I have found that working within the Kimberley, I've found that through technology I can link with professional development activities interstate, nationally, overseas. Uh 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 uh sort of uh counter the a perception of a lack of uh professional community. Uh the main thing is that a big sense, a big part of my professional identity here is that I work as part of a team, uh, you know, that might be different types of doctors, but that we all work together and I you know, and because of that, I don't feel a sense of professional isolation at all.

SPEAKER_01 16:20

In the Kimberley region, there's also a team of pediatricians, two obstetricians, a rotating team of surgeons, and a public health physician. There isn't much private medicine in the region, but throughout the year there are visits from city-based specialists in nephrology, rheumatology, cardiology, and ophthalmology, among others. There are also dialysis centres in Broome, Derby and Cunanura, 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 practice in a scarce setting.

SPEAKER_00 16:54

In terms of our sick patients, we have a high dependency unit as well, which allows us to manage pretty much um everything up to ICU level care. We now basically keep all of our septic patients and our a lot of our other unwell respiratory type patients as well. Whereas uh 10 years ago they probably would have gone out on a plane, which was a really um bad way to manage people in the Kimberley and cost a lot of resources. So the models really evolved with the use of the physician input and we uh utilise a uh daily video conference with one of our um sister hospitals down in the city, so we can talk to intensivists uh over a live VC and with the patients in the room. So um that's been really good both for patient care but also for the education of the generalist workforce up here.

SPEAKER_01 17:43

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?

SPEAKER_03 17:51

Telemedicine is definitely a part of our daily practice. We use telemedicine within the region often, as well as uh teleconferencing with with the tertiary sites. Oh, so you might be the you might be the base that uh Kananara speaks to for the Yeah, so as well as visiting Kananara and Halls Creek, Wyndham, Fitzroy Crossing, uh, and Derby uh and and many other communities in the region, as well as the in-person visits, we can provide ongoing continuity into patients patients' care by teleconferencing into that site when required. There are times where we've teleconferenced with with people at home. For example, I'd video conference with a young patient whose um comorbidities mean he can't he can't mobilize anymore. Rather than him go into the hospital, I I can actually um 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 uh or still are best done in person. But uh telemedicine is certainly a very good supplemental tool to to do that, which can help uh to make sure that we're providing people the frequency of reviews they should have uh and uh providing optimal care.

SPEAKER_01 19:12

All right, let's get into some of the sort of unique competencies that you can develop in a in a smaller center. Um, for example, point-of-care ultrasound. So 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 although perhaps not POTUS.

SPEAKER_00 19:36

Yeah, absolutely. Mick, it's something I'm very passionate about and try and spread the word about quite a bit. Um, it can really be a very useful tool to be able to move treatment forward, particularly after hours on weekends. Unfortunately, once again, the formal training pathways are probably not there yet. And um it's hard to acquire those skills in a rural place. But uh certainly if trainees have an interest in that and come to the rural areas with those skills, um, it would be very valuable.

SPEAKER_01 20:04

Can you describe the flow of a of a consultation that uh you uses this technique? Are you are you interpreting on the fly or do you still sometimes re send pictures off?

SPEAKER_00 20:15

Uh yeah, so a good example would be our renal patients. Um, they come in, may have missed dialysis, for example. That's a very common scenario here in Broome, and you need to 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 um the more traditional sort of ways of doing that would take a lot longer in in our department, particularly after hours. And so that's one example where um certainly there's a good evidence base for using ultrasound and um can often uh head off patients at the past before they get really sick if you know exactly where they're up to. Um, and probably is a a good safety backstop for us in rural emergency practice.

SPEAKER_01 21:00

One of the editors of this podcast from New Zealand recently did a course with the Targo 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 edema and fast scans on trauma patients. Um, are these things that you're sort of familiar with and competent with?

SPEAKER_02 21:24

So I 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. Um during our uh ward consultations to the patients admitted to the hospital. We regularly use ultrasound. Uh, for example, just this uh week, there's a patient with an empiemor and uh another patient with a pneumonia that uh may be uh progressing. So um uh I don't know that it would necessarily fit the definition of POCUS, but uh you know, a respiratory trained um physician is. 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.

SPEAKER_01 22:24

Another focus of regional practice is Indigenous health. Around 45% of the population in the Kimberley area is indigenous compared to Sydney and Melbourne where the average is just over 1%. Would you is it appropriate to think of Indigenous health as a unique competency?

SPEAKER_03 22:41

On commencement with the Kimberley Regional Physician team, we do provide orientation that includes cultural awareness training and there's new programs that the Yahoo people of Broom are running to help people have a more meaningful understanding of of the the local traditional culture. But across the Kimberley 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 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 uh experiences that our trainees have regularly when they're here as physician registrars is going to different Aboriginal communities and providing care on country um often in the clinics, 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 that person's broader life.

SPEAKER_01 24:18

Mm-hmm and 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 major cities according to the 2017 atlas from the Australian Institute of Health and Welfare. There are higher rates of risky drinking and and all of these figures are even higher in the Aboriginal population. Is uh should trainees have some good grasp of mental health before coming to a place like Broome?

SPEAKER_03 24:51

Certainly an important part of practising as a general physician is treating the whole patient. That's part of the 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 that someone interacts with their disease. From what we've found with the registrars that have come up to the Kimberley we have found that if they as long as they've completed basic physician training that provides them with a good starting point through which they can throughout their time here develop a deeper understanding of how the psychological factors and even historical factors might be interacting on any one person's medical presentation.

SPEAKER_02 25:39

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 obstetric 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 for our patients 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 before we finish just a few thoughts about quality of life.

SPEAKER_01 26:39

In the study we've been talking about 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.

SPEAKER_03 26:56

But rural medicine is compatible with many different lifestyles and at the risk of misappropriating a 90s tourism campaign you'll never never know if you never never go 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 you know our registrars learn a lot because they work hard. But I think everyone's very aware of the importance of recruiting and retaining staff and it doesn't get taken for granted that people have been willing to commit to coming up here to work. We respect the fact that in order for them to come and give us our best efforts in in clinic we also then need to give them time to um enjoy the region and have uh time to maintain their own mental health, their own their own lifestyle and relationships and and I would hope that we're able to to strike that balance and I I suspect that's probably why most of the consultant roster is is staffed by by three of us consultants that used to be registrars that chose to move back to Broom long term.

SPEAKER_01 28:14

I did laugh when I when I was looking you up Lydia I found an a 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 Asial waters of the Indian Ocean. That was me last weekend okay so it's not just the advertising material.

SPEAKER_02 28:31

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 crossed in the podcast. As a trainee to move two and a half thousand kilometres to change my hospital change my supervisors and to enter something unknown is definitely different. Moving to Broom 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 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 hardworking team that is genuinely interested in seeing you excel as a trainee is unique and should be strongly promoted many thanks to Lee Fairhead and Livia Scott for contributing to this episode of Pomegranate Health.

SPEAKER_01 30:36

And special thanks to Casey Parker for sorting out the recording. Make sure you check out his Broomdox 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 resources at RACP to browse the e-learning modules and video lectures for the basic training curriculum. There's also information about the specialist training program and other funding options for rural fellows to extend their skills. For example, Support for Rural Specialist Australia has four funding rounds a year that can go to all sorts of workshops Point of care ultrasound or echocardiography, vascular access, cardiac CT, 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 and New Zealand. Please put your colleagues onto Pomegranate Health and remember you can always send any feedback to podcast at reacp.edu.au I'm Mickey Kalazzini and I hope to hear from you