Country practice

Getting more doctors and health specialists to take up practice in the bush has become a leading issue in small communities – which is why the ANU Medical School’s rural program is attracting so much attention in regional centres around Canberra.

Despite the reams of reports and news space dedicated to chronicling disappearing doctors in country areas, there is some good news for health care in rural and regional Australia.

In 2006, the first class of rural stream medical students from the ANU Medical School have been placed for the whole year in a regional town centre – and their feedback on the experience so far is encouraging, according to Associate Professor Amanda Barnard, the head of the Medical School’s Rural Clinical School.

“The rural health care environment is exciting – there’s no other word for it. These students are experiencing this excitement and we hope it will stay with them so that when they finish their training they will return.”

It’s known that doctors and nurses are more likely to practise in rural areas if they already have a rural background, they have a partner from a rural background or working in a rural area, and they have had prolonged positive training experiences in the bush.

“We’re really working on this last factor,” Barnard says. “Giving these students a sense of what it’s like to work in the country while they’re training seems to be crucial to them then putting down roots in regional areas after they’ve graduated.”

The ANU Medical School offers a four-year medical program to graduate students, with a strong emphasis on rural and regional health care. It currently has 254 students, with the first graduates due to complete their Bachelor of Medicine/Bachelor of Surgery at the end of 2007.

This year there are 11 students in the rural stream undertaking their Year 3 clinical year ‘out bush’ in the regions surrounding Canberra – Goulburn, Bega, Young, Cooma and Queanbeyan – while the rest of their peers are based at the new Clinical School at Canberra Hospital.

Barnard says that the year-long rural placement for the 11 students is particularly challenging, with its emphasis on self-directed learning and the demand that the students work more independently.

“It would be fair to say that initially, both staff and students have found this first full clinical year for rural stream students in the bush a bit of a challenge. It’s very different to the students still in Canberra, as there isn’t the same infrastructure behind you as there is on campus.

“But all the students have said the benefit of what they’re doing and the way they’re learning far outweighs the negative aspects of that challenge. In fact, many have commented on how they enjoy the independence of working more individually and how it allows them to follow their interests.

“One student I know who is keen on surgery is in surgery watching whenever possible, helping to the point where the surgeon has to tell him to just go home.”

Home for the students are flats or houses in the towns dedicated for the rurally placed students. In Young, this accommodation was partially furnished through community appeals – a clear indication of the appreciation and anticipation that the people in these towns have for the students.

“It has just been fantastic,” Barnard says. “The commitment by our administration and medical staff in these towns has been huge, as has the support in the community – to the point where students are provided with home-cooked meals and invited to local events.”

But it’s not just students who are benefiting from the arrangement. The Rural Clinical School also aims to build expertise and infrastructure in the regions too, which Barnard says helps attract and retain medical practitioners. ANU employs a number of doctors in the region who are the core staff providing the formal teaching and coordination of the students’ program.

“We’re working closely with Greater Southern Area Health Service to create joint appointments with the University, and looking to build up opportunities in the hospitals and local practices for postgraduate internships, which mean that once the students have established the links in the town they can continue them,” Barnard says.

“I spoke to one of the doctors recently who said the student who was with him at the time knew more about a patient who’d presented to emergency than he did, because the student had met the patient at general practice,” Barnard says.

“There’s a neat phrase about the ‘360-degree learning’ you do when you’re with a patient. When they’re with a patient, the students are part of the health community. They’re learning what the doctors do, what the nurses do, what the physios do, what the radiographers do – basically how health care hangs together in the health system.

“The extra bonus for these rural clinical students is that the environment is exciting. You’re in there with everything – emergency, obstetrics, procedural surgery.

“Over the long term there is also a lot more about the intricacies of rural health care revealed to the students. For example, they begin to see the subtleties of chronic disease management over time. This is the type of medicine that might not seem so interesting initially, but becomes more interesting as the cases unfold.”

The clinical year is very hands-on for all medical students, particularly for the rural stream students. But skills workshops and teaching delivered by local staff are still important throughout the year. One day a week all students attend tutorials, seminars and skills sessions. The Rural Clinical School employs a number of GPs, physicians and surgeons in the region.

“During orientation week in Merimbula we held a skills session on putting in catheters for drips. The next week, when the students had returned to their placement town, there was an emergency in Goulburn. I think the patient may have arrested, and one of the students put in the drip,” Barnard says.

“For the student it was exciting being able to do that successfully in that high pressure situation, and the amount of confidence that gives is so important.”

While the 11 Year 3 rural stream students are spending the year in a regional town, their peers are not left to live it up in the city – they also spend six weeks of their Integrated Child Health and Community term in rural towns and communities.

Meanwhile, Year 1 and Year 2 students are also involved early, travelling to a regional area for one week each semester for Rural Week.

A typical program for Rural Week might involve accompanying doctors on hospital rounds, speaking to cancer survivors, blood pressure testing in a public area, attending a community reception, visiting a local business and conducting interviews for a rural health care group assignment.

The communities are keen to make even the early year students feel welcome. In the past, baskets of local produce have been left in their cabins and local newspapers have run profiles on their front page.

“Rural Week provides students with the opportunity to observe firsthand all the problems we hear about in the bush, either through the media or at uni,” Medical School Rural Club head Claire Seiffert says.

The Rural Club leads rural high school visits promoting health careers to students, organises clinical skills day trips to rural areas, arranges guest speakers working in rural health and runs health-check stations in regional communities.

Just before the first Rural Week in March 2006, the Rural Club set up a stand at the Cooma show. They tested the blood pressure of hundreds of people, including that of the Governor-General, Major General Michael Jeffery, who officially opened the show.

The ANU Medical School’s rural program is aiming to grow to be able to enrol 25 per cent of all students in the rural stream. It has already been boosted with $5 million in funding from the Commonwealth Department of Health and Ageing this year. It works in partnership with the Greater Southern Area Health Service and doctors in the region in providing this educational experience.

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A day in the life

8.00am
The hospital corridors are quiet, and only one patient sits in the main waiting room. “It’s not like ER,” Year 3 medical student Justine O’Shea says as she meets ANU Reporter at the hospital reception, referring to the TV drama based in a Chicago emergency department where the medical crises never seem to stop.
Piper and Miller arrive a few minutes later and meet O’Shea in a room near the medical ward, where the three will have a weekly discussion with Dr Gabriel Kolos. This morning the students will present a ‘long-case’ of a patient to Dr Kolos. This is a full assessment of health, lifestyle and social life of the patient. Each student has seen a patient in a different environment, depending on where they are currently based in the health system in Goulburn. O’Shea has a patient from the surgery ward of the hospital, while Piper’s patient was assessed in the emergency department and Miller’s in general practice.
Each presents their case individually and Dr Kolos asks questions about symptoms, treatments, likely diagnoses and prevalence rates of certain diseases. It’s like a mini medical pop-quiz as they go through their notes.

9.10am
The students head to their teaching room, noted on the door in an older wing of the hospital as a ‘Teaching Facility of The Australian National University’. Next door is the part-time administration assistant, Gayle Stanton, who supports the students. Miller has picked up a toasted sandwich from the hospital kiosk on the way to the room; O’Shea makes a cup of tea once there. As well as using it as a common room, the students access their email, timetables and course information from an online computer here. It’s also set up so they can sit in on lectures from Canberra - for the first time last week the students saw a lecture by two-way video conferencing. “We didn’t realise how big the broadcast of us to Canberra Hospital was until friends in the lecture theatre in Canberra began sending us text messages about seeing us on the big screen, bigger than the lecture slideshow,” O’Shea says. The students are waiting to be paged by Dr Tony Whelan, who will test their patient assessment skills again in a round of short-case assessments.

9.50am
The students meet Dr Whelan in the medical ward. After some general reluctance to go first, Miller nominates to be the first to do his ‘short’ assessment. Dr Whelan asks a patient with respiratory illness if he is willing to be assessed by a training doctor - as he does before each patient a student meets - and the four go into the room. Miller finishes with the patient within about 10 minutes. Back in the corridor, the four discuss the case and debrief, again with Dr Whelan probing the students to examine symptoms, causes and possibilities of the patient’s illness.

10.15am
Piper examines a patient with a cardiac condition within the 10-minute timeframe. The discussion afterwards concentrates on technical aspects of irregular heartbeat sounds – slaps, clicks and murmurs. It is a practical test of the theory they learn in class.

10.40am
Dr Whelan asks O’Shea to examine a patient with a lung condition. Her short examination is thorough and gets a “solid pass”, though Miller thought she might have spent “too long on the hands”. They move into a staff room to discuss X-rays and CT scans of the patient’s lungs, identifying potential areas of concern, pushed along by Dr Whelan to relate symptoms and causes. The students are constantly comparing what they see in patients to the theory they’ve studied. Sometimes they don’t get it quite right or their memory fails them. “Some Thursdays can be bad for your self-confidence, but these sessions are great to test our clinical knowledge and direct us to the areas which need more attention” O’Shea says.

11.10am
The final task with Dr Whelan is for one of the students to deliver another long-care assessment. Piper summarises the findings from a neurological case. For 40 minutes the student doctors are again tested on the symptoms, side effects and treatments. Before finishing for the day, the students chat casually with Dr Whelan about how they feel the morning round helps their preparation for end-of-year exams. They also discuss a neurological test he’s prepared and general issues. Miller says he feels that he has finally got his “eye in” when examining patients’ eyes during assessment. “I’ve begun finding patient’s retinas more quickly when looking into their eyes. It was taking me a while but this morning it just clicked. I saw it straight away.”

12.00pm
The students are relieved of their clinical study morning and take a break for lunch, checking emails and making phone calls.

1.00pm
Thursday is ‘Grand Round’ day – a weekly seminar presented by a different member of the local health community on a particular topic. The Grand Round attracts local retired GPs and physicians, hospital staff, interns and nurses. The students attend every week and invariably are targeted for questions and answers. This week’s presentation is by intern Kam Cheong Wong on evidence-based research, where Piper is asked about the relative risk and odds ratio in a case study.

2.00pm
By this time of the day the hospital is bustling with patients heading in for X-rays, ultrasounds and endoscopies.
The students split up for the afternoon. Miller is off to Canberra where he works one day a week as a radiographer. Piper goes to the emergency department to “see what’s happening”, and O’Shea goes to the surgical ward to begin rounds with patients. Both the intern and registrar are in surgery, so O’Shea heads upstairs to see if the medical ward needs assistance. The intern there asks her to go to the intensive care unit (ICU) to insert a cannula into a patients arm. She gowns up for the procedure, at which she is getting better, much to her relief. “Initially my hit rate [for getting the cannula in the vein] wasn’t so good, but I’m improving. That one went in first time”.

3.00pm
While in the ICU, the duty nurse mentions that at 3pm there will be a talk on cardiac markers by a pathologist. O’Shea attends.

4.00 - 5.30pm
O’Shea checks the surgical and medicine charts of patients around the wards – surgical, medical, day procedure, maternity and the children’s ward. This is her second-last day based in the hospital wards before starting a six-week stint in general practice. “This year has been a great experience, lots of fun. I don’t really want to go back [to Canberra for Year 4]. It’s shown me what working in the country would be like, and it would be good.” Has it influenced her career choices? “It’s difficult to know what you like so early on, but it’s definitely helped me to know what I don’t want to do,” she says.

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ANU Reporter Spring 2006