Monday, 18 September 2017

Rural exchange in Balclutha, NZ

Each year, a Monash medical student based in East Gippsland for their second clinical year heads off to a New Zealand rural region and a student from Otago University takes their place here. James Davey reports on his experiences in New Zealand during the 2017 exchange.

Cold arrival

I was bursting with excitement as I left Melbourne destined for New Zealand to start my fortnight long exchange between Monash's School of Rural Health (East and South Gippsland) and Otago University's Rural Immersion Program (RMIP). Flying from Melbourne to Christchurch in the early hours of Saturday morning, I was treated to an amazing little look back on the Gippsland. As it was my first time visiting New Zealand my excitement only grew as I flew Christchurch to Dunedin. When I arrived it was dark, cold and rainy, but I was met at the airport by the warm smiles of my two new flatmates Dan and Grace. Their kind welcome instantly put any uncertainty I had aside as we headed out to for a dinner at the local pub over an exciting rugby game between the All Blacks and The Lions.

Sunday’s weather was again wet, cold, windy and rather miserable, but I dragged Dan and Grace out to brave the weather to explore some of the Catlins region. They were excellent tour guides and I was impressed with their depth of knowledge about the region, flora and fauna. We visited the Nugget Point Lighthouse to take in the rugged but beautiful coast, as we were hit with icy winds coming off the Southern Ocean. We ventured on to Cannibal Bay where I got to see sea lions play fighting on the beach. The water is a beautiful shade of blue though far too cold to swim, besides I forgot my "togs". That night we enjoyed a great dinner full of laughs with the Clutha Health First clinic’s administrator, my first introduction to Balclutha’s lovely small town hospitality.

Warm welcome - Clutha Health First

The following day I received an incredibly warm welcome to the Clutha Health First Clinic and a tour of the great facilities. Clutha Health First integrates a General Practice clinic, a fifteen bed inpatient ward, outpatient services for visiting specialists, a midwife run maternity unit, a medical assessment unity (a practice nurse run mix between ED and GP) and multiple allied health services like X-ray and a basic pathology service. Clutha Health First has an incredibly unique set up and an interesting backstory behind it. Balclutha originally had a hospital, but as Health Care Otago moved to retract funding from rural areas, it left the town with only general practice services. The dissatisfied community, rallied and marched in Dunedin demanding that their region have more. As a result, Clutha Health First opened in December 1998 funded and owned by the community of Clutha; an achievement that they are rightly very proud of.

My time spent at Clutha Health First during the first week was spent in a mix of general practice, outpatient psychiatry, the inpatient ward and the medical assessment unit. This gave me the opportunity to work with and learn from an incredibly multifaceted team in a hands on way.  Working with the team at Clutha Health First, I gained further insights into the challenges of rural practice in a smaller setting than I am used to, for example only having access to X-ray rather than a CT scanner. It was great to see the way that different areas of the clinic came together to handle some challenging medical problems. I really enjoyed my time in the Medical Assessment Unit with exposure to a great mix of GP and ED cases; I was really impressed that all of this was handled by incredibly capable nurse practitioners rather than doctors.


During the weeks I spent my moments of free time making the best of the weather by exploring the town and surrounds. On sunny days I’d take a walk at lunch or in the evening through the main street of town or to check out the Clutha River (New Zealand’s largest volume river) and the Clutha River Bridge. When the temperature dropped, I’d be up early to take a walk through the frost and break frozen puddles as the sun rose over Balclutha. Although I got excited for snow a couple of times with freezing temperatures, we received no more than a minimal dusting, but got plenty of ice and sleet instead. Despite this my excitement over the ice and frost remained high and my flatmates jokingly likened me to a child as I continued to smile until my teeth literally hurt from the cold.

I celebrated the end of an amazing first week in Balclutha with with a fun filled Friday night at the Kaka Point Pub’s ‘open mic night’. My very talented flatmate Grace joined a number of excellent performances and we all had an absolute ball. I spent Saturday morning working alongside another fantastic nurse practitioner in the Medical Assessment Unit. On Saturday afternoon Grace and I left for Queenstown to go stay with some of the other RMIP students who are based there.  Despite stopping for a number of photos and needing to slow down for some icy roads, we made it in time for the final rugby game between the All Blacks and the Lions over dinner with some of the other students. It was great to hear about some of their experiences and challenges they were facing treating a population dominated by tourists.

Riding through a winter wonderland

On Sunday Grace and I set out exploring on an ambitious bike ride along the Queenstown trail which ran around lake Hayes, out to Arrowtown and back along the Kawara River. The scenery set to a backdrop of mountains was breath-taking, and I was in absolute awe! We rode through the most incredible ‘winter wonderland’ like thick frost coming into Arrowtown. Despite running relatively short on remaining daylight, we were confident in our riding ability so decided that making it home before sundown was still possible even if we took the longer scenic route. This would have been perfect had we not taken a wrong turn and added an extra 8km to our trip with a detour. We were still riding when the sun set and the temperature began to drop, we pushed on to eventually make it back to the car exhausted as the moon rose overhead.

Multidiscplinary week two

 Like my first week at Clutha Health First, my second was split with time across multiple disciplines and teams. I was fortunate enough to even spend some time parallel consulting with Dr Branko Sijnja who heads the entire Otago University RMIP program and Dr Rebecca Canner who runs the teaching for the RMIP students in Balclutha; both coming from an incredible wealth of knowledge that I had the privilege of learning from. I also got to spend some time with the Balclutha midwifery team and gained some valuable insight through discussions about the differences between a midwifery run centre with no theatre like Clutha Health First, and Sale with its large obstetric team. Additionally, I spent an amazing day with a GP in Milton, one of the small towns near Balclutha, gaining some exposure to the aged care system and having the opportunity to do some suturing. Although the presenting complaints and core medicine are similar, it has been interesting to see how the Australian and New Zealand health care systems manage patients slightly differently; something I will continue to reflect on in future practice.

I’m incredibly grateful to have been given this unforgettable and invaluable experience. Without hesitation I’d recommend this opportunity to broaden your perspective, gain insight and overall grow as a future doctor to everyone!! Throughout my journey I was generously welcomed and supported by so many incredible people! They all played a part in making this the enriching experience it was, I could never thank them enough for what they have given me!

I’ll definitely have to return to New Zealand real soon! Maybe even to spend some more time at Clutha Health First in the future.


Friday, 8 September 2017

Stronger guidelines needed for alcohol at school events new study recommends

Schools should consider what message they're sending young people when providing alcohol at events where children are present. Image: Kimery Davis (CC BY 2.0)

An Australia-first study has found a strong correlation between explicit education department guidelines and reduced availability of alcohol at school events where children are present.

The study found the rate of temporary liquor licences issued in Queensland was more than twice that of Victoria, five times that of WA and sixty times that of NSW; while that average annual licences per hundred schools was highest among the independent and Catholic school sector.

Lead author, Dr Bernadette Ward of Monash University, said that licensing legislation alone in the various jurisdictions does not explain the disparity in the number of liquor licences issued for school events, rather that clear education department policies may be the reason

“In Queensland those relatively high rates of licences may reflect the lack of education department policy,” said Dr Ward. “Similarly, the relatively high rates in Victoria may reflect the devolution of decision making to school principals and councils, while the restrictive NSW policy is consistent with the relatively low rates of temporary liquor licences issued to schools in that state.  Across all jurisdictions, independent and Catholic schools are not subject to education department guidelines, if they exist, with school principals and councils making the decision to offer alcohol at school events where children are present.”

Early initiation to drinking and risky use of alcohol by children and adolescents is associated with significant harm and alcohol dependence in adult life.

“In Australia, alcohol at social occasions is normalised,” said Dr Ward. “Having alcohol-free events at schools shows children that they can have fun without alcohol. It also reduces the risk of alcohol-related violence that has been reported by some school principals.”

While parents play a critical role in teaching young people about alcohol, schools play a role generally embedding messages about responsible use in the curriculum. However, the study’s authors say, schools can also influence children’s alcohol perceptions and possible use when adults consume alcohol at school events in the presence of children.

“We’re definitely not saying that you shouldn’t have a drink at school events,” said Dr Ward. “We are saying you need to be aware what message this sends to children who are present, and explicit policy guidelines seem to be helpful for schools in deciding what is appropriate. It also seems that schools find it helpful where strong guidelines exist to guide decisions suggesting that there’s an important role for education department policy.”

The study examined temporary liquor licensing data in NSW, Queensland, Victoria and WA, as well as licensing legislation and education department guidelines in the four jurisdictions. The aim of the research was to identify the conditions under which Australian schools must apply for a liquor licence and the associated prevalence of liquor licences for these events where children were likely to be present.

The paper, ‘Liquor licences issued to Australian schools’ is available online at BMC Public Health.

Thursday, 7 September 2017

High turnover of remote health workforce puts patients' health at risk

Staff turnover in remote health centres is unsustainable new research finds.

Half the staff working in a remote NT healthcare clinic leave after four months on the job, two thirds leave remote work altogether every year and any one clinic can see a 128 per cent turnover of staff each year, putting patient health at risk, new research shows.

On the tenth anniversary of the UN Declaration on the Rights of Indigenous Peoples, the study raises concerns about how the rights to health of Aboriginal and Torres Strait Islander people living in remote communities are compromised by an unstable remote health workforce.

Lead author Dr Deborah Russell of Monash University said that there was considerable anecdotal evidence about the difficulties remote communities face attracting and retaining suitably skilled health staff and their increasing reliance on agency nurses.

“This is a landmark study that actually measures turnover from the perspective of a particular remote health service,” said Dr Russell. “It shows extreme fragility of the remote workforce, confirming that there is a heavy reliance on agency nurses to provide primary health care in NT remote communities. Lack of continuity of care has serious implications for both patient health and staff safety in remote communities across Australia. Constantly having to recruit and orient new staff is also a serious drain on resources and can make it very difficult for these health services to participate in quality improvement.”

The study was a collaboration between Flinders University, Monash University, Macquarie University, the University of Adelaide, the University of Sydney and the Northern Territory Department of Health. It is part of a larger program of research investigating the impact and cost of short-term health staffing in remote communities to determine whether ‘FIFO’ is the cure or the curse. The study looked at data provided by the NT government payroll and account system from 2013 to 2015 covering 53 remote clinics.

While the study looked specifically at NT health services, the authors say that extremely high turnover and heavy reliance on short-term agency nurses for supply has important implications for remote health services anywhere in Australia.

“There’s good evidence that primary health care is critically important for achieving equitable population health outcomes,” said Dr Russell. “A chronic lack of continuity of care sees people less likely to access primary health care in a timely way and to disengage from their health care altogether. And, ultimately, that results in poorer health outcomes.”

The study’s Chief Investigator Professor John Wakerman, Associate Dean Flinders NT, says there is no one simple solution to this issue.

“The work to date suggests a number of possible strategies. These include increased investment in recruiting and retaining local Aboriginal Health Practitioners and consideration of utilising remote nurse practitioners where there are no doctors to provide higher level care and stabilise the nursing workforce. We can also learn from successful strategies used for training and retaining doctors and apply them to nursing and allied health professionals,” said Professor Wakerman. “This would entail prioritising remote and rural origin and Aboriginal students in undergraduate courses; early exposure and training in remote areas and developing clear career pathways for these remote area health professionals.”

The paper “Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013-2015” is available online at Human Resources for Health.

See also an editorial on Croakey.

Wednesday, 6 September 2017

Cancer campaigns need rethinking new study finds

Traditional cancer awareness campaigns may need rethinking to target at risk groups a new study suggests.

Research conducted by Monash University in collaboration with Cancer Council New South Wales shows that young people and men have poor awareness of common cancer risk factors such as UV exposure and tobacco smoke.

While there's awareness of some cancer risk behaviours, more work is needed.

Lead author, Monash University’s Associate Professor Rebecca Kippen said there was a need for more carefully targeted social marketing campaigns to get the message through to these groups.

“In Australia around one third of cancer cases are due to modifiable lifestyle factors,” said Associate Professor Kippen.

“We know that awareness of these risks is an important influence on people’s attitudes and behaviour about cancer prevention.

“This research shows that, in particular, young people and men don’t seem to be aware of these common risk factors and so they’re not engaging in protective behaviour.”

The study analysed the responses of 3,301 adult residents across New South Wales to a survey conducted by Cancer Council New South Wales in 2013.

Respondents were asked to rate seven risk factors – UV exposure, smoking and passive exposure to smoke, alcohol consumption, not eating enough fruit and vegetable consumption, and high body weight – and report on their own protective behaviour.

The study shows that, overall, there is high community awareness of the cancer risks of UV exposure, smoking and passive smoking, but much lower awareness of the link between cancer and being overweight, alcohol intake and low fruit and vegetable consumption.

Women were more likely than men to practise all the “protective” behaviours, except for being “sunsafe”.

Respondents over 50 were more likely than those aged 18-39 to be sunsafe and non-smokers, drink less alcohol and eat two or more fruit serves daily, but they were also more likely to be overweight.

There were also correlations between higher educational levels and protective behaviours.

“Historically, the largest cancer prevention campaigns in Australia have focussed on UV exposure and smoking, and they’ve been successful in raising community awareness of these risk factors,” said Associate Professor Kippen.

“But community understanding of other risk factors remains poor and it’s clear that campaigns targeted at specific audience segments, such as young people and men, are needed.”

The study is one of the first of use multiple variables to analyse the association between awareness of risk factors and health behaviour. The paper is available online at BMC Cancer.

Friday, 26 May 2017

Locals learn the ropes in Gippsland hospitals

Nine students who grew up in Gippsland are among 94 first year students doing placements in hospitals across Gippsland during 2017. The students, all studying the graduate entry medicine course, spend their first year based in Churchill and their reasons for studying medicine are as varied as their postcodes.

Local learning: eight students who grew up in Gippsland are now studying medicine based in Churchill. L-R: Niharika Ojha, Melissa Bruerton, Olivia Ferretti, Holly Rennie, Tumi Yusuf, Stephanie Wall, Jacoba van Wees, Max McKenzie.

Tumi Yusuf’s father is a doctor working in Warragul where she grew up. “My dad was a doctor, so I thought that was pretty cool. But I got to the end of high school and started to rebel,” she said. “I thought, I don’t want to do what my dad does.” In the end she decided medicine did provide useful skills.

Others were influenced by personal experiences as they grew up.

Olivia Ferretti’s father was in a serious truck accident when she was ten years old, and spent four weeks in intensive care followed by another six or seven months rehabilitation in Melbourne. It was a long way from Bairnsdale where the family lived. “We were involved in his recovery and he’s still getting ongoing treatment now. I’ve been heavily involved with his treating team,” she remembered.

Melissa Bruerton was originally from Hazelwood North. Guidance from good teachers and how moved she was by the needs of people living in poverty when she travelled overseas led to her choice.

Some students started out on a career in medical research, but found they wanted a closer relationship with the people they were working to help. Max McKenzie of Sale wanted to give back to the community on a more personal basis. Jacoba van Wees, who’s lived all over Gippsland, came to the same conclusion. “I didn’t like how distant research felt from people. I wanted to have the opportunity to have direct impact even if it’s only in a small way.”

They are certainly discovering the personal side of medicine while on placement. Warragul locals, Holly Rennie and Tumi Yusuf, are both based at Warragul hospital. Running into people they know is common and, though they laugh about it, it’s a positive part of studying locally. “You just see everyone and I find it comforting,” said Tumi.

Stephanie Wall’s interest in medicine started when she found herself enjoying looking at the pictures in nursing textbooks as a kid. Like Holly and Tumi, she’s fond of her home town, Warragul, and the community there. “It’s really important to do what we can to keep that community together. I’d really like to be able to facilitate people staying in their community for help,” she said.

Holly also wants to stay rural. “There’s a need in rural areas that I could jump in and fill. That’s really attractive to me and giving back to the community as well. People wouldn’t have to travel all the way to Melbourne if I was a specialist there,” she mused.

Once they complete this year the students may stay in Gippsland, be placed in other parts of regional Victoria or go to Melbourne to finish their medical course. And while their path will take a couple more years to complete than if they’d stepped in straight from secondary school, they all agree that a first degree was excellent preparation for the medicine course and gives them something else to fall back on.

Niharika Ojha, who originally hailed from Traralgon, and Jacoba van Wees both said they felt more equipped to deal with the course then if they’d gone in straight from secondary school. Holly Rennie is quite sure her biomedical studies and a few years spent out of school will make her a better doctor. She started out studying education, then moved into biomedicine. “It was through that and working with the YMCA – which was really hands-on and helping people – that I decided I wanted to go into medicine. Coming into this after six years of working in the outside community, I know I have a whole different outlook on medicine.

Friday, 28 April 2017

Testing the waters in Year 2

Tom Trengrove: life as a medical student.
Tom Trengrove turned up at ICU at Sale hospital on Wednesday morning last week feeling a little tentative. He’s one of 16 Year 2 students on placement in Sale for a fortnight. That day he was the only one of the group scheduled on ward rounds, but it all turned out OK. The Year 3B students who were there explained what was going on until they had to leave. And then the registrars and consultants slowed down sometimes to explain.

It’s not his first experience in a hospital though. Tom’s part of the John Flynn Placement Program and spent some of his summer break in Gympie, a town of about 20,000 people 160 km north of Brisbane and one hour’s drive inland from Noosa. Tom was placed in the emergency department of the hospital. “I didn’t spend all my time with my mentor and got to see a lot of the eight doctors who work in the emergency department.” From them he learned a lot, especially when they gave him the non-urgent cases to assess before they came to talk to the patient.

Tom hails from Auckland and applied to Monash because there are no direct-entry medical courses in New Zealand. And he’s been making the most of Melbourne’s proximity to some great surfing. “I used to surf in Auckland,” he said, “but Australia has much better surf.” He and friends travel to Phillip Island on weekends.

Where is he thinking about going for Year 3B? “I’m thinking about Traralgon – it’s closer to Melbourne and will make it easier to stay in touch with my friends there.” But Sale might be on the agenda. “Is it far from Phillip Island?” he asked.

Monday, 24 April 2017

Paediatrician leaves large educational legacy in Latrobe Valley

Some of Associate Professor Joseph Tam’s career pathways may be the result of his inability to say no to a good cause, but many people have certainly benefited from his “weakness”!

Numerous children and their families in the Latrobe Valley have received his expert care over the last 19 years. And in parallel to his clinical role, the Traralgon-based paediatrician has spent many years educating younger generations of doctors.

Always a teacher

This teaching has included working as an instructor for the Acute Paediatrics Life Support program and examining for both the Royal Australian College of Physicians (RACP) and the Australian Medical Council. He is also a member of the RACP General Paediatrics Advanced Training Committee and the Overseas Trained Paediatrician Sub-committee.

Monash Rural Health will remember him for his long contribution to the rural medical education program, particularly in Gippsland.

Dr Tam has stepped down as the Clinical Lead in Paediatrics at the Latrobe Regional Hospital after 12 years on the job, and as director of Monash University’s Latrobe Valley & West Gippsland after three years at the helm. But his involvement with Monash goes back much further.

A long involvement with Monash

Professor Roger Strasser, who was instrumental in establishing Monash Rural Health in the early 1990s, approached Dr Tam to teach on an honorary basis soon after he arrived in Traralgon 19 years ago. In 2003, he was engaged as a Senior Lecturer at the then Gippsland Regional Clinical School. Subsequently, Dr Tam was appointed as an Honorary Senior Lecturer, Department of Paediatrics, Monash University. In 2005, Dr Tam became the Discipline Lead in Children Health, Monash Rural Health Latrobe Valley & West Gippsland - a position he held until 2015 when he was appointed as an Associate Professor in Rural Medicine (Hospital Education) and the Director of Monash Rural Health Latrobe Valley & West Gippsland.

Dr Tam has seen many changes over that time including the duration of placements. Students would come from Clayton Melbourne for nine weeks; now they can spend a year or more in the region. “A lot of progress has been made providing education, teaching and training in rural areas. I think we’re heading in the right direction,” he said.

Teaching with Monash was an extension of work Dr Tam was already doing at the hospital. When he arrived at Latrobe Regional Hospital in 1998, many international medical graduates (IMGs) were studying for the AMC exams. “I always enjoyed teaching and sharing my knowledge and experience with the younger doctors,” said Dr Tam. Before long he was running tutorials for IMGs to help with the paediatric component of their clinical exams. In 2009, Dr Tam became a clinical examiner in paediatrics for the Australian Medical Council (AMC); seven years ago he became a Regional Examiner and in 2014 a member of the National Examination Panel for the FRACP clinical examination of the Royal Australasian College of Physicians (RACP).

Choosing regional practice

Traralgon is a long way from the large teaching hospitals in Sydney where the Hong Kong born doctor had worked since his internship. After completing two years in paediatric nephrology training at the Children’s Hospital at Westmead, Dr Tam faced the choice between a self-funded trip to Canada to complete a PhD as part of his training or a clinical role in regional general paediatrics practice. The decision was made easy when he was approached about the position at Latrobe Regional Hospital. “I came down to have a look and said to myself: ‘this is too good to be true'. There was no paediatrician and all the work was waiting for one. So I came.”

Dr Tam became the only visiting consultant paediatrician at Latrobe Regional Hospital and oversaw the growth of the small paediatric service into a department of five paediatricians, two paediatric advanced trainees and five paediatric hospital medical officers, who provide 24-hour, seven-day on-site paediatric services at the hospital.

Regional recruitment - the social dilemma

During his tenure, Dr Tam has seen trainees and junior colleagues return to work in regional and rural areas. “It’s rewarding especially when they turn out to be good ones,” he said. While he was delighted to see young graduates return, Dr Tam acknowledged there are challenges in recruiting and retaining health professionals in rural areas. “Most of them like the work in the regional areas although some of them feel a little apprehensive in the beginning. But once they come, they all love the work. It’s just the social factors that stop some of them from coming or returning.”

Most families now have two working parents, he pointed out. Sometimes partners have jobs that are not available in regional areas which makes it difficult for a health professional who might otherwise be interested in working in a rural context. Paediatrics, particularly, is a difficult profession to attract. “The majority of paediatricians are female and quite a lot of them have families,” said Dr Tam. “They cannot come out to work in the regional areas where it involves after hours on-call work. It is not easy when they have young children and have no extended family to provide support.” The solution he suggested – only half in jest – is to ensure students meet and marry local people.

The future is regional

Dr Tam plans to continue working in paediatrics in a regional area, and to teach both within and outside hospital settings. “We just have to keep on pushing the boundary so that hopefully we can teach and train the workforce entirely in a rural area. That would certainly be the ultimate success,” he said. Given his track record, it’s unlikely Dr Tam will say no to any opportunities to be involved in educating and supporting future doctors.