Author: Antonia Clarke
Editor: Abhi Pal
I received mixed reactions when telling friends and family I was off for three and half months on my rural placement this year, my first term as a medical registrar. Mum said “oh, isn’t there a zoo there?”. My sister soothed, “don’t worry, it’s not that far from Sydney”. A senior colleague mused that “we weren’t really supported out there, I heard things are better now”. A mixture of excitement and trepidation settled in as I drove west of Sydney and the skies became bigger and bluer, the land flat and golden. As Google maps told me to “continue straight for 70km, turn right and continue straight for another 90km”, the scope of my learning began to crystallise.
Previous onthewards blogs have provided the grounding for the benefits of studying and working in rural medicine. This piece will advocate that a rural placement is not only beneficial but essential for a junior doctor – intern, resident or registrar – hoping to practice anywhere in Australia. The rural placement drives a junior doctor to improve their clinical acumen, better understand health economics and resource allocation and enhance his or her communication skills within a team.
As I drove and drove, Mackellar’s “pitiless blue sky”  represented the immense distances between the city and regional and rural centres. The expansive distances that meant a nurse working at a health care outpost near the South Australian border had the crucial role of recognising a patient presenting with an acute myocardial infarction or gastrointestinal haemorrhage, and relaying that urgency to the nearest regional centre. The distances that meant the current six hour thrombectomy rule for stroke management was already shaved in half if someone lived outside of town. As a doctor working in a regional centre, you may be the person at the end of the nurse’s phone call, or the first medical staff member that stroke patient sees. As a brand-new registrar, you rely heavily on your team of Interns, senior colleagues and nursing staff. You learn to listen carefully to that voice over the phone and very quickly learn to ask clear, precise questions to get to the nub of the problem. When time is tight and the distances are far, efficient, coherent communication and early identification of the patient’s disposition are key to improved patient outcomes.
The distances to travel also entail hidden costs for the healthcare system and patients alike. For example, the Western NSW Local Health District covers 276,000km . For this area there are 7,000 medical, nursing and allied health staff who travel 13 million kilometres each year to look after their patients. Emergencies need air retrieval, transfers and nursing and medical staff to travel with the patient. How do you choose who to transport if simultaneous, urgent transfers are required? In this setting, you will work with medical administrators, who play a key role in resource allocation and triage that will save a life on a busy shift.
For less emergent situations, resource allocation and costs still colour patient care. Those boundless plains reminded me that for patients needing speciality care, their specialist might be a six-hour drive from home. Patients may find it difficult to attend their appointments because of the hidden costs of a doctor’s visit – petrol or flight costs, accommodation, food, parking – not to mention the doctor’s bill. One patient needing a valve replacement told me I had “Buckley’s chance”  of convincing him to head to Sydney for treatment. He’d left the big smoke years ago, and had no intention of returning. The lack of easy access to healthcare means that the rural patient often has signs or symptoms that are rare in a well-managed urban setting. As a medical registrar, each day, each patient and each presentation was completely unique. I palpated retrosternal thyroids and pitting oedema to the umbilicus. I saw necrotic toes and auscultated severe mitral stenosis. When there is no routine access to overnight imaging without calling a radiographer in to the hospital, I was reminded to believe in myself, to rely on my clinical judgment and devise differentials based on a thorough history and examination.
A rural doctor is a true general physician, a jack of all trades. And a junior doctors’ clinical judgment is necessarily influenced by the epidemiology of regional and rural medicine and the particular issues facing centres in these areas. Eleven per cent of the Western NSW LHD is Indigenous. Understanding the complexity of the relationships between Indigenous Australians and our health care system is a crucial part of being a doctor, regardless of your intended speciality. Closing the gap in part means working to forge a relationship between the patient, medical and nursing teams and Indigenous Support Officers to help to enable early screening, referral and management for Indigenous Australians at risk of chronic disease.
The opioid overuse crisis is a health care issue that disproportionately affects our regional and rural centres. [4, 5]. Recognising the effects of drug intoxication may save a young rural person’s life in the acute setting. Emphasising the importance of allied health involvement and communication with family members may facilitate early referral to rehabilitation centres. In a broader sense, awareness of issues facing Australians across the country makes us better and more informed health care advocates. Why is this epidemic affecting our young people and what can we do about this growing threat?
The reciprocal reliance on nursing and allied health colleagues and the abrogation of traditional medical hierarchies is an enjoyable part of the rural experience. Resource allocation may be constrained, but the support and camaraderie of the rural multidisciplinary health care team is considerable. Those days of unnerving, unsupported night shifts out bush are long gone, and consultants and registrars emphasise that help is only a phone call away. A physiotherapist can help you to determine whether an elderly woman is safe for discharge, when home is four hours further west. The pharmacist knows that a patient’s medications need to be ready for the only bus leaving for Brewarrina that day. Pleading for imaging is a non-event when you jog around the river on Saturday mornings with the radiographer. And knowing to put aside what you are doing when one of the nurses states, “we have to act quickly” is invaluable.
Now, when my friends and family ask if I am excited to be heading west on another rural placement next year, I can say a definitive and enthusiastic yes. A rural term shapes and cultivates a junior doctor. It gives you an insight in to the complexities of the public health care system. Without a rural term, a city doctor cannot understand the sacrifices made by a patient to make his or her specialist appointment or the significance of including family in health care discussions for an Indigenous patient. Working rurally as a junior doctor involves being a part of the symbiotic relationship between medical, nursing and administration staff, a relationship built on crisp communication and combined clinical gestalt that may save a life for a patient living out the back of Bourke. And yes, there is a zoo in Dubbo, and it is definitely worth a visit.
- Dorothea Mackellar, “My Country”, 1908
- Western NSW Local Health District. Our Health District in Numbers. [Internet]. Australia: NSW Ministry of Health; 2017 [updated 2017; cited 2017 Sep 3]. Available from: https://wnswlhd.health.nsw.gov.au/
- Michael Quinion. Buckley’s chance [Internet]. Australia: World Wide Words; 2017 [updated 2017; cited 2017 Sep 21]. Available from: http://www.worldwidewords.org/qa/qa-buc2.htm/
- Degenhardt L et al. The extent and correlates of community-based pharmaceutical opioid utilisation in Australia. Pharmacoepidemiol Drug Saf. 2016. Abstract available from PubMed: https://www.ncbi.nlm.nih.gov/pubmed/26781123
- Gisev N et al. A nation-wide study of the extent and factors associated with fentanyl use in Australia. Res Social Adm Pharm. 2017. Abstract available from PubMed: https://www.ncbi.nlm.nih.gov/pubmed/28455195
My year as a rural medical student by Sophie Collins, March 2017
Nothing ventured, nothing gained by Rob Zielinski, October 2016
Going Rural – living and working as a doctor in the country by Lauren Cone, September 2016