Monday, 6 March 2017

PNG placement motivates medical student

His two-week placement in Papua New Guinea over the summer break, was the most confronting thing medical student, Tim O’Hare, has ever done. But while it was emotionally exhausting, it was also motivating. “Having the opportunity to do a medical degree in a place like Australia, you want to make the most of that because it’s such a privilege and you just get such valuable skills from it.”

Confronting: Tim O'Hare spent two emotionally-exhausting weeks in PNG over his summer break based at Garoka hospital, and spent New Year with a local family.

Now in the third year of his studies with the University of Melbourne, raised in Gisborne Tim spent last year with Monash Rural Health Bendigo as part of a unique partnership between the two universities. Students from both institutions complete their first year of clinical training together at Bendigo Health.

During that year, Tim decided he wanted to expand on the cultural safety training that was part of his studies and organised a cultural awareness seminar for students. “We did cultural safety online modules, but nothing that involved actual people.” So he contacted the Bendigo District Aboriginal Corporation (BDAC) who were delighted to have someone ask for their help.

Tim had tried to gauge students’ prior knowledge of Aboriginal health. Some of the responses questioned the need for an Aboriginal co-op: why can’t they just go to a normal GP? A social worker and family counsellor from BDAC came for an afternoon and talked about local issues. “It’s really close to home, but a lot of people in Australia don’t fully understand yet. It doesn’t get taught in high school that well,” he said.

Music for Cambodia

For many years Tim and his family have organised the annual Macedon Ranges Music Festival in March to raise money for the Cambodian Kids Foundation.

All the performers donate their time (including the band that Tim plays in) and all ticket sales go to the Foundation.

Growing up, Tim never had plans to study medicine. Then about four years ago, he accompanied a local Gisborne doctor to Cambodia as a volunteer and saw what you can do with a medical degree. “I kind of thought you worked as a GP or you worked in a hospital, but then saw the breadth of it and that got me interested,” he remembered.

He’s since been to a few countries in Asia and back to Cambodia volunteering. It was to Cambodia he wanted to return over his summer break. “But the timing wasn’t right.” So through a contact of his mother’s he learned about PNG. “I look into it and learned more about the highlands and the history of PNG. It sounded really interesting. I’d read about PNG back when I was doing my science degree. It’s really interesting in terms of anthropology; there’s over 600 languages still spoken there.”

The Highlands Foundation put him in touch with Garoka hospital. “They were rapt to have me visit and help out and learn, and teach if there was anything I could teach,” said Tim. “You had complete freedom to work wherever you want. You could introduce yourself to the doctor or the surgeon or the nurses or the midwives. So I just tried to do a bit of everything. I met the Public Health Director of the hospital and that’s who I went out to the rural clinics with.”

In the emergency department he saw extreme presentations that you wouldn’t see in Australia. “Ill kids were the hardest to see, especially when most are cases that would be easily treatable if the resources were there.”

He saw that the problem was not lack of skill on the part of doctors or staff, but lack of money. “It might have only been a couple of dollars for a certain drug but the hospital ran out and they just couldn’t get it. You’d see kids with something like typhoid or meningitis – they’d only get partially treated one day and the next day they wouldn’t have any drugs, so they’re just suffering and not getting better. That was pretty hard.

“Seeing such extreme suffering and poverty as the cause, not necessarily any other cultural thing. All these complicating things play a role, but at the end of the day it was just an equity thing.”

He found it hard coming back. “You can get there in a day. You learn the history a bit. PNG was a part of Australia and then got independence in the 70s. And then just seeing how poor access is for so many people to just really basic healthcare. That was pretty challenging.

“Doing something in global health or education or development have always interested me. But it [PNG] has definitely made me sure that’s something worth doing.”

As he gets further into his studies, his PNG experience keeps things in perspective. “There’s a lot of stress in medical school which is a shame because it makes people feel busier than they need to be. But it’s actually been really relaxing to get back to medical school. Every day I think: wow, what a great opportunity I’ve got!”

Many disciplines make productive research

Only medical students get summer research scholarships in the medicine faculty goes the thinking, but Biomedical Science/Law student, Katherine Allman, thought she’d have a go applying anyway.

The project she was offered, looking at advanced care plans for patients in a regional primary care setting, appealed to an interest awoken during a public health unit offered by Dr Helen Ackland. Far from being a disadvantage, the project’s supervisors, Dr Bernadette Ward and Pam Harvey, welcomed the legal perspective Katherine could bring to the project. She was in.

Through an audit of patients who had had an over-75 health check at the Bendigo Primary Care Clinic, the project team was looking for a correlation between chronic diseases and where advanced care plans were in place.

Multi-disciplinary team L-R: Pam Harvey, Katherine Allman, Nidhushie Tilak Ramesh, Dr Bernadette Ward, Dr Dennis O'Connor

Complementary skills

Interdisciplinary skills led to a natural split in the research tasks as Katherine worked closely with a final year medical student. “It was great fun. Nidhushie [Tilak Ramesh] was fantastic.” During the audit, Nidhushie was able to group patients into one of the eight chronic disease categories identified by the Australian Institute of Health and Welfare. “Having her able to do that and me not having to Google everything was brilliant.”

Katherine brought a completely different perspective. “We were reading through the literature, not just looking at the patients medically, but also legally: Who were the patients? Were they more vulnerable people?”

On the clinic’s side she was asking: “What are the obligations of a GP under the new legislation that will be introduced in March next year? What are the implications for best practice? Really trying to understand the tension between the demands of working in a GP clinic, but also trying to do the best thing for your patient,” she said.

Her ability to interpret legislation was valuable as was her training in statistics. “I basically become the stats monkey because I’d done quite a bit of stats training through my biomed degree. I did a lot of work with SPSS doing the data analysis, so I got very familiar with that. That was good to refresh those skills.”

Her law skills came into play most in the final analysis looking at how it all fitted into the framework. How do they make this meaningful?

Advanced Care Planning close to home

Katherine has firsthand knowledge of advanced care planning. “My mum has just been through making an advanced care plan. She’s had a few unexpected turns with her health in the last 12 months. So we’d gone through the medical power of attorney, all the ‘person responsible’ things as well as looking at getting an advanced care plan put into place for her. So it was something that was quite close to home, but because of that it had really inspired me to learn more about it because there’s not a lot of public awareness there.”

The research project also tapped into what she’d learned during a student project on euthanasia and the law. In Australia, she points out, death is a big taboo, so there is not much research around death. “The heavy lifters are really the US and Netherlands. When you come to Australia, everything is in the ICU and a little bit in emergency, which is where you’d expect it to be because they’re more the end of life stages. Nothing’s been done in a GP setting.”

Staying focussed

It’s a new field in Australia and as someone whose interests are so broad, Katherine found it easy to stray into related areas that intrigued her. “It’s very important to have a clear idea of what you want to achieve,” she laughed. “The time you’ve got, the funding you’ve got; you’ve got to come back to that one original idea.”

That focus enabled the team to come to some conclusions based on the data they'd collected. “Despite a government push for ACPs, medical powers of attorney are still predominant,” she said. They were also able to make recommendations about the need to review advanced care plans all along a patient’s health journey. Katherine’s final task was to draft an article for possible publication. “We’ve written the method we used in a way that we hope can be replicated in other clinics,” Katherine said.

While she’s leaning towards a career in health policy, Katherine has always been interested in medicine. Now she’s considering extending her studies to tackle graduate entry medicine. Whether she does end up in medicine, Katherine has at least proved that the “closed shop” reputation of research scholarships in the Faculty of Medicine, Nursing and Health Sciences is undeserved. Other disciplines have a lot to contribute to health care research.

Tuesday, 28 February 2017

First cohort of medical students starts in new Bendigo hospital

Thirty medical students have embarked on a full year of  clinical training  in the new Bendigo hospital.

Director of Monash Rural Health, Associate Professor Chris Holmes, said the students are part of a total cohort of over 150 second to fifth year students who will undertake placements in Bendigo this year, which also includes students from the University of Melbourne.

Thirty students from Monash Univesity and the University of Melbourne have started a full year's clinical training at the new Bendigo hospital.

“We have a unique program in Bendigo where students from Monash University and the University of Melbourne spend their first year of clinical training together at the Bendigo clinical school and in the Bendigo hospital,” said Associate Professor Holmes.

“University of Melbourne students also undertake shorter placements in Bendigo later in their training, once again learning alongside Monash students.”

The program introduces students in their second year to rural and regional medicine, and runs clinical training placements for students right through to the end of their studies.

“We know that a positive experience training in regional and rural areas does influence where students choose to practise when they qualify,” said Associate Professor Holmes.

“We hear so often that students love their regional placements; they get lots of hands-on experience and are treated as part of the team by clinicians who know their names and are willing to spend time with them.

“They enjoy it so much we see many of them come back as interns once they graduate.”

Of the 39 interns who began at Bendigo Health this year, 15 are Monash students and six, University of Melbourne students who studied at Monash Rural Health Bendigo.

As well as Bendigo Health, Monash Rural Health partners with hospitals, GP clinics and community health providers from Mildura all the way to Orbost.

The current program delivered by Monash Rural Health Bendigo and Bendigo Health is now in its fourteenth year.

Monday, 27 February 2017

A summer interest contributes to safe drug repository

Yi Sien Koo thought he might be bored during the summer holidays so he applied for a summer research scholarship at Monash Rural Health Churchill. The final year medicine student might joke about his reasons for wanting to undertake a short research project, but this wasn’t the first time he’d applied and he was pleased to be awarded the scholarship.

Over the course of his studies, Yi Sien developed an interest in women’s and children’s health. So the project – Milking the evidence: improving medicine information for lactating women about infant risk – supervised by Associate Professor Shane Bullock and Dr Adelle McArdle felt like a natural fit.

Creating an evidence repository

The project involved reviewing the evidence available for women and clinicians about the safety profiles of medications while breastfeeding. Working with another student, Jacoba van Wees, Yi Sien looked at the kind of evidence available, and what level of recommendations, if any, the literature offers. In addition, they wanted to know where people were looking for information and the factors driving their behaviour.

Reviewing one drug group can take up to several days, and in some cases there may be no end to the availability of literature to scour through. Nonetheless, they tried to compare the types of evidence offered across the drug groups. “For example, there was more literature on antibiotics use for mastitis during breastfeeding as compared to say drugs for asthma, and this is possibly because of the relationship breastfeeding has on the incidence of mastitis in the post-natal period,” he explained. The students found there  were differences in the type of information available to guide clinical judgement across the drug groups, and hence had to arrive at a consensus and agree on certain parameters to assess their safety profiles. This would allow a more targeted literature search and a focused agenda.

Communication and collaboration

It quickly became clear to Yi Sien that collaboration and communication skills in research are important at all levels. “Communicating with Adelle and Shane was really important. They did guide us a lot, but they gave us a lot of freedom as well,” he said. “It’s something that Jacoba and myself benefited a lot from because it allowed us to explore different drugs, or even different areas of parameters that we might not have focussed on. I learned to think, not solely of the project but of certain things we can do in the future too.”

“Shane and Adelle have been brilliant supervisors, not just in this project, but they’ve offered help beyond the project as well,” he said.

Learnings beyond the literature

Reading so much literature in a concentrated time gave Yi Sien more than an overview of medication evidence. “We also got the flavour of population health such as barriers to information that patients may encounter. I also read about cultural practices that have been ongoing which could influencehow women feel about lactation and drugs. On top of the medical information you get to understand how and why people behave in particular ways and the  aspects influencing people’s access to health information.”

He also developed skills in reviewing literature itself. “Going through tons of information over time allowed me to gradually learn to pick things up that were more relevant.”

Developing a mobile app

Collating the important information into an easily accessible source was the desired aim of the project. Associate Professor Bullock thought a mobile application that would be user friendly and convenient for both mothers and clinicians might achieve that. He drew on the expertise of another Monash Rural Health researcher in Mildura, Dr Naj Soomro, who has expertise in mobile apps for research and was very willing to help.

An app is a major project in itself, but by the end of the scholarship project, Yi Sien and Jacoba had at least drawn designs for a prototype application with Naj’s help: the home page, a drug page, the important parameters, and how a user might interact with the app.

While designs for a prototype were underway, Associate Professor Bullock approached an academic colleague from Monash Rural Health - Anne Leversha, an experienced senior pharmacist - to seek guidance from a contact of hers - another pharmacist at the Monash Medical Centre, who is one of the learning experts in lactation drugs, to review the parameters the students had developed.

Continuing the work beyond summer

Five weeks’ work established a good base for the evidence repository, but there’s a lot more to be done. Unsurprisingly, Yi Sien feels he’s invested a lot in the project and would like to continue working on it when his studies allow. And he’d certainly recommend the experience to other students. “As health professionals we always have to go into some sort of research these days,” he said. “But for students, it’s important to find something that interests you because it may not go as you expected.”

It’s a busy year for Yi Sien. His first rotation is in Frankston, he heads overseas for an elective and travels to Bendigo later in the year for another rotation. Coming from metropolitan Melbourne he really enjoyed his stay in the Monash Rural Health accommodation in Moe which is a short drive from Churchill where he was based for the project over the summer. “I really enjoyed staying in the rural setting coming from a metro life the past few years. So that’s something I was looking forward to when I applied for the project. I actually like the countryside, living there was great.”

And he certainly wasn’t bored over his summer break.

Friday, 24 February 2017

Final year student gets back in the swing of things in Leongatha

Susan Lee is doing a surgical rotation at Leongatha hospital
My name is Susan, and I’m a fifth year student doing my surgical rotation at Leongatha Hospital.

I was really nervous about starting this rotation – I’d taken two years off from medicine after fourth year, so I knew I’d be quite rusty. Fortunately, Leongatha has been such a wonderful place for me to get back into the swing of things. Everyone has been so welcoming and encouraging - staff are willing to teach, and patients are happy to give me a chance to learn.

The amount of hands-on experience I’ve had in the three weeks I’ve been here has been phenomenal, from assisting in surgeries, or cannulating and suturing, to seeing patients in the GP clinic.

To top it all off, there’s the gorgeous Gippsland beaches and scenery to soak in at the end of the day. The only downside of this rotation has been my cooking - but I’m working on it!

Tuesday, 21 February 2017

Jessica goes back to her roots for GP placement

Jessica Paynter returned to Swan Hill to learn from the GP who delivered her 21 years ago.
Not many medical students can choose to go and study with the obstetrician who was present at their birth, but Jessica Paynter figures she can learn a lot from the Swan Hill GP who delivered her, Dr Ernan Hession.

Jessica is one of eight Monash medical students doing an 18-week placement under the guidance of Dr Hession at the Swan Hill Primary Health Medical Centre.

Growing up in Nyah and Swan Hill, Jessica understands both the down- and upsides of living in a close-knit community. “That’s what rural medicine is all about: seeing your patients in the supermarket,” she said. “I’m sure it’s a challenge that doctors may feel that they never leave their profession.

“It’s a nice community though; I know a lot of people and I’ll probably see a lot more people than I expect while I’m here.”

The 21-year-old is the first in her family to study medicine; it was childhood experiences of the local medical workforce that got her thinking about medicine as a career. There weren’t many female GPs in Swan Hill when she was growing up, she remembers. “There’s a lot more now, but I has the impression when I was young that there weren’t many female doctors at all.”

Seeing an opening, enjoying physical activity and with an interest in science, Jessica thought medicine was a good fit, and she likes the Monash model. “I picked the ERC [Extended Rural Cohort stream] because I wanted to study rurally. I knew I had the option to come home and do a placement.”

She’s well aware of the importance of maintaining connections in sustaining a community. “If you don’t keep connections with a community, it just dies,” she said. Many of her friends also studied health sciences and some are returning to Swan Hill now. “One of my friends got a graduate nursing position in Swan Hill this year and another has got a new job as a speech pathologist.”

Will she be back too? She’s not sure yet where her career interests lie, although this placement is a “little trial” return to Swan Hill. “I’ll probably do a few junior years in a bigger centre and come back when I’ve specialised.

"I came in [to the medicine course] thinking I wanted to do general practice. I like the look of the GP lifestyle, especially rurally. It’s a lot more hands-on and keeping your skills up-to-date is important. A lot of GPs in Swan Hill do a lot of work in ED and have paediatric and other specialist diplomas.”

This semester studying with Dr Hession will certainly give her hands-on experience of working as a rural GP before she returns to Bendigo for the rest of the year.

While it’s a big year for a medical student returning home for a placement, it won’t be all hard work. The netball club she used to play for is trying to recruit her to come and play again while she’s in Swan Hill. It might be hard to resist those old connections.

(See story about the Swan Hill clinic where Jessica is studying...)

Swan Hill clinic works on solution to rural doctor shortage

Eight Monash University medical students have just begun an 18-week placement with the Swan Hill Primary Health Medical Centre as part of an ongoing program to alleviate the shortage of doctors in rural Australia. This year’s cohort of eight students is the most Swan Hill has hosted in its many years of educating students in a rural setting.

Local GP Dr Ernan Hession and Monash Hub Director, who has been involved in teaching Monash students in Swan Hill since 2010, said the whole community has a role to play in encouraging students to consider a career in rural practice.

Bridge over the Murray River at Swan Hill
Eight medical students will spend 18 weeks in Swan Hill learning from GPs and staff at the Swan hill Primary Health Medical Centre. Photo: Marcus Wong (wikimedia)

“The Swan Hill Primary Health Medical Centre was established with a culture of teaching, but students learn a lot from patients too. Many of our students are from country areas and it’s great that we can train them in the same environments they are used to – and hopefully also will return to.

“Being willing to see a student when you visit the clinic provides them invaluable opportunities to learn,” he said. “A welcoming community makes a huge difference to the experience students have on a clinical placement and our town has been very supportive of the programme over the last six years.

“The program is expanding in our area and this is a result of all of us – educators, community placements hosts, hospital and most of all our patients – have supported it.”

Director of Monash Rural Health Bendigo, Associate Professor Chris Holmes, agreed that the time students spend in centres like Swan Hill is a vital part of their clinical education and pivotal in career choices.

“We know that a positive rural experience during their training can have a big influence on students’ decision to pursue a career in rural practice.

Jessica Paynter grew up new Swan Hill and came back to learn from the GP who delivered her 21 years ago.
Read her story...
“Swan Hill has become a priority choice for students because of the wide variety of clinical opportunities available – and the high quality teaching support provided by educators like Dr Hession, Dr Julia Coshan and all the other wonderful teachers who give freely of their time.” said Associate Professor Holmes.

The eight students are in their second year of clinical training and will spend a significant portion of their time working in the medical clinic under the supervision of a GP. Here they have an opportunity for a wide range of clinical experiences both in the clinic and the hospital, especially in obstetrics, procedural general practice, Aboriginal health and emergency medicine.  They also attend formal tutorials and teaching sessions run locally and via videoconference facilities at the clinic.

The students come from regional Victoria and New South Wales, and include two from Melbourne.