RESEARCH is needed to determine whether significant numbers of Australian students are trying to improve their academic performance by taking diverted prescription stimulants, according to academics from three Australian universities and a Canadian research institute.
Dr Jayne Lucke, principal research fellow at the University of Queensland’s Centre for Clinical Research, said there were anecdotal reports of students taking methylphenidate and dexamphetamine, to improve concentration and memory.
These reports suggested students were obtaining the drugs from family or friends who had been prescribed them for attention deficit hyperactivity disorder (ADHD).
In a letter to the Medical Journal of Australia, Dr Lucke and Professor Wayne Hall, also from the Centre for Clinical Research, said there were good reasons to be concerned about non-medical use of prescription stimulants, yet there was “surprisingly little empirical data on the extent of non-medical use of prescription stimulants in Australia”. (1)
They have teamed with the National Drug and Alcohol Research Centre at the University of NSW, Deakin University in Victoria and the Clinical Research Institute of Montreal to apply for grant research funding from the Australian Research Council to explore the issue.
Dr Lucke told MJA InSight it was important to determine whether non-medical use of stimulants might partly explain the 87% increase in stimulant dispensing in Australia from 2002 to 2009.
Dr Sharlene Kaye, research fellow at the National Drug and Alcohol Research Centre at the University of NSW, said the increase might reflect increased recognition of ADHD, but her recent research suggested diversion was an issue.
She found that 31% of 269 illicit drug users had used diverted prescription stimulants, while only 7% had been prescribed them.
“The implication is that these drugs are getting out to a lot more people than they’re being prescribed for”, she said. “It’s not only happening among university students, but among the illicit drug population as well.”
Dr Kaye said United States studies showed that 23%–84% of college students who had been prescribed stimulants had experienced people asking for them or offering to buy them.
Dr Lucke said there was a great deal of hype in the US about using medication to boost brain power, with research suggesting 7% of US college students had taken methylphenidate and dexamphetamine as study aids.
“Often you find it’s male students not getting great grades, who have higher levels of alcohol and other recreational drug use”, she said.
Dr Lucke said increased financial and academic pressure may be influencing students’ non-medical use of prescription stimulants, but recreational use also had to be considered.
Ms Jade Tyrrell, president of the Students Association of the University of Technology in Sydney, said she had heard of a couple of students taking the drugs but she wasn’t aware that it was a widespread issue.
“I’m sure it goes on with the higher pressure subjects. Some students pull out all stops to try and balance the financial and academic pressures they face”, she said.
“No-Doz [caffeine] is pretty standard in exam time for cram sessions towards the end of semester and energy drinks are standard for sure”, she said.
Ms Tyrrell said the high cost of living in Sydney placed a lot of pressure on students, particularly when they had to combine work and study.
Dr Lucke said despite the toxic side effects of stimulant misuse and dependence, clinicians seemed more concerned about non-medical use of opioids prescribed for chronic pain.
“Is that because we haven’t got the proper studies to show the extent of non-medical use of stimulants by students in Australia?” she said.
Heather Wiseman won National Press Club of Australia’s 2012 Health Journalist of the Year award with this feature.
Published: Australian Rural Doctor, April 2012
One rural GP was so disturbed by the high suicide rate in his small town that he decided to tackle suicide head on. Twenty-six years later, and against all odds, rigorous statistical analysis has shown that he achieved dramatic results. Read more
Published: Diabetic Living, September 2014
For author and former The Age editor Michael Smith, 63, a type 2 diagnosis was just the wake-up call he needed. Read more.
Published: Australian Doctor, 30 August 2013
Identifying human remains fished from a river is just another challenge for the Olding sisters as they volunteer in a PNG hospital. Read more
Published: MJA InSight, 6 August 2012
RESEARCH is needed to determine whether significant numbers of Australian students are trying to improve their academic performance by taking diverted prescription stimulants, according to academics from three Australian universities and a Canadian research institute. Read more
Published: Diabetic Living, November 2014
Devoted mum Kelly Belcher reveals her secrets for achieving the ultimate balancing act between managing 13-year-old son Will’s type 1, and letting him still be a kid. Read more
Published: Australian Rural Doctor, March 2012
When the NSW town of Albury experienced a desperate doctor shortage five years ago, one inspired specialist called a community meeting and a recruitment taskforce was formed. The simple concept was so successful, other regional cities are following suit. Read more
Published: Australian Rural Doctor, September 2011
A GP who was one of the first on the scene of the Grafton bus crash 22 years ago reveals why he has joined a group of doctors lobbying to upgrade the deadly Pacific Highway on the NSW north coast. Read more
Published: Australian Doctor, February 2008
After leaving general practice for a high-profile media career spanning more than two decades, this year Dr John D’Arcy plans to become a GP again. Read more
Published: Diabetic Living, November 2014
Keen traveller Margaret Fordon-Bellgrove, 82, hasn’t let a type 2 diagnosis keep her from exploring the far corners of the world. ‘I knew if I looked after myself I’d be alright,’ says Margaret, who has been to 31 countries since her diagnosis. Read more.
Published: Australian Doctor, February 2008
A series of tragic cases of child abuse is prompting experts to call for a new national approach to protecting children at risk – and that could mean a bigger role for GPs. Read more
Published: Australian Doctor, February 2008
GPs are required to report any suspicions of child abuse – but that doesn’t mean authorities have to act. Read more
Published: Australian Doctor, February 2007
Many doctors see plaintiff lawyers as the human equivalent of a pit bull terrier, but this one belongs to a less ferocious breed. Read more
Published: Australian Doctor, August 2007
A recent family tragedy has focused attention on the Church of Scientology’s controversial stance against psychiatric care. Read more
Published: Australian Doctor, November 2006
Confronted by the violence of the Cronulla riots, Dr Jamal Rifi came up with an unexpected way to build bridges between Sydney’s warring communities. Muslim teenagers from the city’s west would be trained as surf lifesavers. Read more
Published: Australian Doctor, November 2006
As controversy rages over late-term abortion, women may increasingly struggle to find a doctor prepared to perform the procedure. Read more
Published: Australian Doctor, November 2006
Calls to bring clarity to Australia’s confusing and inconsistent abortion laws may sound convincing, but some experts believe national reform could make doctors more vulnerable. Read more
Published: Australian Doctor, September 2006
Dr Geoff Hittmann has never shied away from conflict, but now the anti-VR campaigner is fighting a new battle – against a terminal brain tumour and the medical treatment that comes with it. Read more
For author and former The Age editor Michael Smith, 63, a type 2 diagnosis was just the wake-up call he needed.
Old-school journalists have a reputation for working and playing hard. Were you guilty of that?
I was a journalist for 25 years and my lifestyle was disgusting. I didn’t eat regularly, and what I did eat was bad. I drank too much alcohol, smoked, didn’t exercise and put on too much weight.
I spent several years as a medical reporter and knew about diabetes, but I didn’t follow the advice I was giving my readers. I was young and thought I was bulletproof. It sounds crazy, but that’s what happened.
You were initially diagnosed with type 2 in 1995. What did you do to get your health under control?
For a year or so I exercised every day. I went to the gym and the pool, walked and cycled. I ate plenty of fresh fruit and vegetables, protein in moderation, and minimal fat and sugar. I lost about 10 kilos, but then my diabetes became so stable that I was lulled into a false sense of security and slackened off. Subconsciously, I thought I’d beaten it. Over the next few years, I slowed down on the exercise, until I was going for several weeks at a time without exercising. I gained weight. I was working very hard and I was stressed.
My blood glucose levels started to go up and I couldn’t control them. I needed more medication and, eventually, had to go on insulin. And then I had a heart attack, which really woke me up. That was seven years ago.
So, in a strange kind of way, a heart attack saved you?
I remember staring up into the lights in the cardiac catheter lab at my wife, kids and grandkids, not knowing whether I would pull though. That’s when I decided to change my ways. I could have died. I had a 90 per cent blockage – it wasn’t trivial – but they put in a couple of stents and I immediately felt good. In fact, I felt better than I had in 10 years. I was extremely lucky. I didn’t deserve that second chance, so I was determined to repay whoever gave it to me by not abusing the gift.
Was that when you decided to write a book about diabetes?
After having the stents put in, I was told I would have to stay in hospital. I needed something to keep me busy. The reporter in me took over and I started to learn about heart disease and what I had to do so it wouldn’t happen again. I wrote my book, Downsize Me: How to Fight Diabetes and a Heart Attack. The book has a chapter on diabetes, because it is one of the biggest heart-attack risk factors and the origin of my problems.
Did you decide you needed a complete lifestyle makeover after having your heart attack?
You don’t have to be a cloistered nun to live a good, healthy lifestyle with diabetes. You just have to make sensible, permanent changes. Quitting smoking was one of them for me. I used to say it was easy to give up smoking – I’d done it 100 times! But after my heart attack, I gave it up immediately and never wanted a cigarette again. That’s how powerful that epiphany was. I cut stress out of my life, too. I run my own PR business, so I jacked up the fees. I ended up earning more money, doing less work with less stress, and losing 20 kilos in 18 months.
What changes did you make to your eating and exercise regimes?
If there are 21 meals in a week, I aim to get 19 of them near perfect. I eat mainly carbohydrates, protein in moderation, plenty of fibre and fresh fruit and veg, and avoid fat and high-sugar foods. Following this plan for 19 out of 21 meals gives me two wildcards a week, so I can go to a restaurant and loosen the reins a bit. I get great satisfaction out of taking a brisk walk for an hour every morning. I love it when the weather is bad – when it is wet and cold – because I’m doing it despite the elements and nothing is going to stop me. I give myself five exercise wildcards a year, for when I’m sick or travelling. If I use one of my wildcards, I generally make it up – I do two sets of exercise in one day, to get it back.
Were there any challenges you didn’t anticipate?
Decoding food labels, because the food industry is so clever in making us buy things we shouldn’t. It’s almost as though the food labelling system in Australia was designed to confuse you. But if you stick with it, and learn the basic rules and what to look for, you can decipher the code.
Have you done it all on your own, or did you need support?
My wife, Kay, has been trying to save me from myself for 45 years, with some success recently. My heart attack didn’t surprise her. But she didn’t abandon me. She gave me 100 per cent love and support to make sure it didn’t happen again.
Associate Professor John Kelly reflects on his career in dermatology.
Melbourne dermatologist Associate Professor John Kelly is Director of the Victorian Melanoma Service at the Alfred Hospital, a leading force in multidisciplinary cancer care. He also runs a specialist practice in Armadale.
To read more, click on the page below, or here.
Professor Louise Newman reflects on her career in psychiatry.
Melbourne infant psychiatrist Professor Louise Newman specialises in disorders that make parenting difficult. At Monash University, she is Professor of Developmental Psychiatry and Director of the Centre for Developmental Psychology and Psychiatry. Professor Newman is Chair of the Detention Expert Health Advisory Group for the Department of Immigration and Citizenship. She is also Chair of the Borderline Personality Disorder Expert Reference Group for the Department of Health and Ageing. In January, she was appointed a Member of the Order of Australia in recognition of her services to medicine in perinatal, child and adolescent mental health, to education and as an advocate for refugee and asylum seekers.
To read more, click on the page below, or here.
Professor Michael Barton reflects on his career in radiation oncology.
Michael Barton, OAM, is professor of radiation oncology at the University of New South Wales. He is also research director of the Collaboration for Cancer Outcomes Research and Evaluation and research director of the Ingham Institute of Applied Medical Research at Liverpool Hospital.
To read more, click on the page below, or here.
Devoted mum Kelly Belcher reveals her secrets for achieving the ultimate balancing act between managing 13-year-old son Will’s type 1, and letting him still be a kid.
Did you have any sense that Will was seriously unwell before his diagnosis?
Not at all. He’d just had bad tummy aches. But the weirdest thing happened on the way to see the doctor. Quite out of the blue, Will said, ‘I wonder if I’ve got diabetes.’ To this day I don’t understand where that question came from. I said, ‘No way. You’re just really constipated. I’ll fall off my chair if you’ve got diabetes.’ Will is the first person in our family to be diagnosed with type 1, so we didn’t know the first thing about it. It wasn’t on our radar.
Did you flip out when you got the news?
No, funnily enough, I was totally relaxed because I didn’t really understand the severity of it and Will looked fine. The doctor told us to go to the hospital and I said, ‘I’ll just pop home first and put some clothes on the line.’ The doctor replied, ‘No, you really need to go to the hospital right now.’
What has Will’s little sister made of it all?
Cailyn may only be three, but she loves keeping her big brother on track. She says, ‘Test your levels, Will’, and tells him where to put in the cannula in his tummy. Will always smiles and says thank you.
So Will has an insulin pump?
Yes. For the first 18 months he was injecting himself with insulin every day, but now he has a pump. He has to change the line and rotate the cannula site every three days or so.
Has the pump made life easier?
It has, but things can still go wrong. We got a scare recently when we tested him at midnight and it read 20, when he should have been between four and eight. It turned out he hadn’t fully clicked his cannula in after his shower, so he wasn’t getting any insulin for a few hours. We learned yet another lesson from that alarming experience. He also got down to 1.4 recently, which was his lowest reading ever. That was a bit frightening. We had climbed a hill to watch planes take off and land at the airport, and he didn’t eat enough food quickly enough. It’s such a tricky balancing act.
Does he have lots of medical paraphernalia?
He started off with a small cooler box and moved up to a larger plastic container. Then he needed a couple of storage boxes for all of his ketone strips, reservoirs, fusion sets, sharps containers and alcohol wipes, and the rest. Now he has started taking over my pantry, which is something I wouldn’t normally let anyone do. He has a whole shelf!
Do you do stocktakes on his supplies?
My husband and I decided early on that it was important for Will to manage his own supplies, and to make sure he never runs out of anything. One day he is going to move out and will do it on his own, so the training starts now.
What has helped you rest easier?
I think the more you understand something, the less you fear the unknown, so I decided to study a Certificate II course in Diabetes Management. Understanding more has been really good, but it’s also heartbreaking to realise the damage that occurs when you don’t have good control. When Will’s blood sugars aren’t in range, I think, ‘What is going on with your heart, veins and arteries, right now?’ I know we’re doing the best we can and we’re managing it well. But I still lie in bed at night sometimes wondering if I am doing the right thing or if there’s anything I could be doing to manage it better.
What has been the hardest thing to explain to Will about his condition?
Will has always been obsessed by planes – his room is full of them – and his dream is to be a pilot in the air force. It was horrible breaking the news to him that he would never be able to fly a commercial plane or fly with the defence force. My husband and I were worried it would kill his passion, but it hasn’t. He’s now looking at becoming an engineer, so he gets to work on planes. And he also plans to get a private pilot’s licence and buy his own plane so he can fly for fun.
Is it hard letting go when Will isn’t by your side?
We live in Cairns and, recently, he went to an airforce cadet camp in Toowoomba, 1700 kilometres away. I found that hard because it was the first time Will was entirely responsible for managing his diabetes. But he was fine. Right from birth Will has been an old soul, but the diagnosis has forced him to grow up quickly and be responsible. He loved the camp. He got to fly a Cessna aircraft, and came back so excited that he started looking into getting his private pilot’s licence. He’s now counting down until he is 14 years and nine months so he can get a job and start saving for it.
Keen traveller Margaret Fordon-Bellgrove, 82, hasn’t let a type 2 diagnosis keep her from exploring the far corners of the world ‘I knew if I looked after myself I’d be alright,’ says Margaret, who has been to 31 countries since her diagnosis.
We hear you’re a bit of a globetrotter…
I’ve travelled to 31 countries since I was diagnosed with type 2 diabetes 13 years ago. I usually travel on my own, but sometimes I go with a friend. On my last trip, I went from Amsterdam to Budapest on a cruise ship, and then I met some lovely people in Canada and Alaska. I was away for two-and-a-half months.
How do you manage your diabetes on long trips?
I’m on a few different medications, including insulin, so I work out exactly how much I will need for the whole time I am away and then take a little bit extra. I take all of my prescriptions with me, and a letter from my doctor saying I have diabetes. I carry it all in my handbag, so it is safe, even if one of my bags goes missing.
Have you ever been unwell when overseas?
I had a hypo on the plane coming back from the Netherlands a few years ago. With all the different time zones, I was very tired and I missed one of my insulin injections. It was horrible. I felt very ill, and was trembling and perspiring. The hostesses asked three people to move so I could lie down and gave me some fruit juice. From that, I’ve learned not to get overtired and, instead of going cattle class, I now go business class. It is expensive but I can rest when I need to.
Do you carry your medical history with you?
I wear an SOS medical alert, which is gold and looks like a locket. Inside, it has a strip of paper about 40cm long. That’s where I’ve written everything medical people would need to know, along with my doctor’s name and phone number.
Is it hard to keep your diet on track when you’re travelling?
On my last trip, I was on a ship for 46 days. For breakfast and lunch you could help yourself to a buffet and eat as much as you like, but I was very careful. Every morning I had two pieces of fruit and two cups of green tea. For lunch, I had salads with not much dressing. For dinner, we chose from a menu and I usually had a prawn cocktail. I really like those! There was always fish or meat, and wholemeal rolls, but they hardly have any vegetables on cruise ships. I’d ask for vegies and they would bring me a tiny bowl. Thank goodness for the salads!
Do you have to fight a sweet tooth?
I went through the war [WW2] as a child in Holland and there were food shortages. When it was over, and we were getting some food again, I couldn’t stand the smell of sugar. I still don’t like it so that’s a blessing. I have fruit and yoghurt rather than sweets and I don’t drink alcohol or soft drinks. I have coffee, tea and water. I also test myself each day. If my blood sugars are a bit too high, I am more careful the following day.
Are you always disciplined?
I’m not always good! At my retirement village, we have monthly get-togethers and they have forbidden food. Recently, I had quiche. My dietitian said it’s okay to bend the rules once in a while. You’ve got to live a little.
How do fellow travellers respond to your eating habits?
On one trip, a lady kept encouraging me to have sweets. After I’d politely declined, several times, she told me I was too disciplined and strict. Because I look well and you can’t see my diabetes, it can be hard for people to understand. Another person on the cruise said to me, ‘It’s a very boring diet.’ I told them, ‘No, it’s a very healthy diet.’ My doctor once said people dig their own grave with a knife and a fork. I won’t be doing that.
Did your diabetes diagnosis come as a surprise?
No, I knew I was going to get it sooner or later, because it runs in my family. My parents were both diagnosed with type 2 in their early 60s. Each of them had one parent with diabetes, too. My doctor tested me every year, faithfully, and then one day he said to me, ‘You have it, I’m sorry.’ That was 13 years ago when I was 69 years old. I was then put on metformin as well as daily insulin injections. The diagnosis didn’t worry me because I felt well and I knew if I looked after myself I would be alright. I never worry about things. What will be, will be.
How much did your diagnosis change your lifestyle?
I saw a dietitian who told me to eat lots of carbs, vegetables and fruit, which wasn’t a big adjustment. Exercise wasn’t a problem, either. I was already very fit. I walked every day for at least an hour and went to the gym twice a week. In summer, I swam for an hour every day and did water aerobics twice a week.
Do you still enjoy exercise now?
I love walking. I go for a walk every day for about half an hour. If it is shockingly hot in the summer, I go early in the morning or late in the afternoon. When I need to go to the bank or down town, I leave my car at home and walk. Sometimes, I forget that I’m walking and go shopping and have to carry my groceries home!
I’m 82, but my mind says, ‘No you’re not.’ I feel young and so I do things. That’s why I have a sore knee now. I’ve been enjoying repotting some plants and mulching my garden. My doctor said, ‘No more gardening!’ That’s okay, because it’s all finished now.
Belinda Olding, left, and sister Dr Melanie Olding.
IT’S Sunday morning and Dr Melanie Olding, relaxing on the front step at home, is about to hear a story, PNG style.
It’s a story about something unexpected, gory and very smelly, but she has no sense of that yet, as Pius, the emergency nurse, strolls past the high mesh security fence and down the boggy driveway towards her.
Having spent five months in Namatanai, the second largest settlement on the remote island province of New Ireland, Melanie knows she’s probably in for a long-winded account of something that may, or may not, be urgent. The volunteer with Australian Doctors International, a not-for-profit medical aid organisation that focuses entirely on PNG, drops any Australian-based expectations of how things should be, and nods, encourages and listens respectfully to the end.
Pius tells her about someone with a bedsore he’s seen that morning and spends 10 minutes detailing his treatment. In a seemingly random offering, he adds that people have been fishing off Number Two Bridge. He does a bit of scene setting,
explaining who was there and why, and says a fisherman hooked something and dragged it in. With no increase in animation, his story suddenly gets interesting. The catch is human remains. Melanie is required at Namatanai Hospital,
where a crowd thinks someone has been killed, and at least partly consumed, by a crocodile. They are waiting for her to identify the deceased.
“I’ll identify it as bits of stuff,” Melanie confides as we walk to the hospital, just minutes up the road. The 32-year-old emergency registrar from Darwin has passed her primary emergency exams and hopes to start studying for the ACCRM fellowship next year.
She’s no expert in forensic pathology. But that’s no bother to the 30-odd people standing expectantly near a rice bag of entrails, tied with string. The fisherman asks for DNA testing. Others ask whether it was a man or a woman. Can she tell them who it was?
Melanie is hosing down expectations — “I’m happy to look but I won’t be able to tell you much today” — and trying to call the coroner when her sister, Belinda Olding, comes tearing around the corner.
Belinda is wearing a pair of latex gloves and has come from the delivery suite, but she is no doctor.
The 30-year-old from Newcastle has a construction background and is saving lives in other ways.
Her main aim at the moment is to install four water tanks to get running water to hospital wards, which should significantly reduce infection and prevent deaths.
The 56-bed hospital in Namatanai, which sees about 77,000 patients a year, has four small rainwater tanks — each with a tap.
It’s not enough to provide drinking water for patients during the dry season, let alone wash, clean, or flush toilets. Earlier this
year, a patient walked down the hill behind the hospital to a creek so she could wash after giving birth. She slipped on the way back up, haemorrhaged and died.
Installing extra tanks would be a no-brainer for Belinda in any Australian context, but here it is a slow and tedious process that will take far longer than the Olding sisters’ six-month stay, which ends in August.
Between battles with dysfunctional bureaucracy and noble attempts to vanquish corruption, Belinda is putting her project management skills to use across a range of other projects. She’s trying to introduce a triage system at the hospital (patients
are currently given a number according to when they arrive and are seen in that order, even if their child is dying) and a system for unpacking AusAID boxes (when the sisters arrived, the hospital had run out of supplies, but 500 boxes were
sitting — unpacked — in a storeroom).
Her fundraising efforts have paid for the construction of seven pit toilets (patients previously defecated on hospital lawns and in the backyards of staff homes) and solar lighting (many night-time emergencies and births occurred in the dark).
The situation in Namatanai is far from unusual in PNG. The country has fewer than 400 doctors, only 51 of whom practise outside the capital of Port Moresby. In New Ireland Province, there are just seven doctors serving a population of 160,000
— all of them based in the provincial capital, Kavieng, despite 91% of the population living in rural areas.
On this not-so-lazy Sunday, while Melanie has been dealing with the fisherman’s catch, Belinda has been touring
the maternity ward. She’s under no illusions about her (lack of) medical qualifications.
But she knows that feverish children are automatically treated for malaria, sometimes repeatedly; it has become instinctive for her to feel little heads for bulging fontanelles.
Belinda also knows many viable newborn babies die at the hospital, having been put aside, unattended, while medical staff focus entirely on the new mother. So she’s also a regular at the maternity ward where, today, she’s found an unattended newborn in trouble. That is why she has made haste to get her sister.
Melanie follows Belinda to the flat, cyanotic baby with excessive secretions and obstructed breathing.
Within 20 minutes, Melanie has stimulated, suctioned, bagged and masked the baby, and it has brightened and settled. Melanie has no obstetrics training or experience. This is her least favourite part of the hospital.
There’s no fetal monitoring and no chance of a caesarean or blood transfusion.
Humidicribs are made with glad wrap. There’s no ventilator, autoclave or phototherapy lamp, or regular electricity to run them. Even taking a woman’s blood pressure can swallow half an hour; it’s a struggle to find a sphygmomanometer that achieves pressure and isn’t spilling balls of mercury.
It’s a depressing place, where patients lie on putrid, torn mattresses that have absorbed decades of bodily fluids.
“The wards are filthy so we have enormous amounts of maternal and neonatal infection and mortality,” Melanie says. “In a lot of cases, women would be better off taking their chances in their village.”
Melanie is making her final assessments on the revived newborn when a woman bursts forcefully through the door, rips off her sarong and makes a beeline for a delivery bed.
Wisely, she avoids the bed with exposed foam poking through cracked vinyl and a mysterious big hole, placed, it seems, for newborn babies to fall through.
This woman has had contractions for days. They stopped after she was treated for malaria (which she’d caught while in hospital) and an STI, but it’s clear her baby is finally on its way.
Melanie and the nurse do their best, but don’t manage to save the woman’s perineum as the baby is born, dark blue, without a heartbeat, in a flood of meconium.
Without the luxury of a laryngoscope, Melanie resorts to deep, blind suctioning and wishes she had the support of someone who could put in an umbilical line.
Intramuscular adrenaline doesn’t achieve a heartbeat.
For the second time in her life she tries a single shot of intra-cardiac adrenaline.
Within 30 seconds the baby’s heart rate is perfect and there’s a short-lived burst of euphoria.
It’s ridiculously humid. Sweat runs down the Olding sisters’ arms for the 90 minutes they try to resuscitate the baby. But the baby’s lungs have stiffened. This baby will never draw her own breath.
Belinda walks the hospital in search of staff and brings five to stand around the baby to learn an essential new skill. The mother watches on as Melanie teaches each of them how to use the bag and mask, encouraging them to reposition the mask each time its seal breaks. Calmly and gently, she cycles each of them through the process twice, mindful that in Australia no mother would watch on so patiently, waiting to hear their first child’s fate.
“I feel horrible for that mother,” Melanie says later.
“But I think it’s a price worth paying because there are now potentially five staff members who could save a baby, when yesterday I can assure you they couldn’t.
“You have to find silver linings or it’s just too sad.”
She says the hospital has three rotating on-call midwives, but they rarely attend deliveries because there is a culture of not calling for help. Compounding that, hospital staff are paid when they don’t turn up for work, and are unwilling to engage
with a rostering system or find someone to fill their shifts.
“If you’re lucky, babies are delivered by a nurse with some obstetrics experience, more likely by a community health worker, which is similar to a nursing assistant. In many cases, because of the rostering system, they birth without anyone present.”
Melanie leaves the last staff member to continue with the bag and mask and walks over to the woman still lying on the delivery bed. Gently, Melanie explains that her baby is very unwell, was not breathing when it was born and had no heartbeat.
“We managed to get the heart working again, but the baby’s brain has gone to heaven and because of that, the baby can’t breathe anymore,” she says.
“So we will stop breathing for the baby now and we will bring the baby to you for cuddles. Would you like to cuddle your baby?”
The woman smiles, reaches out to hold Melanie’s hand and says thank you.
Melanie has been so composed and so sensitive it’s a surprise when her voice gains a terse edge. “She holds the baby for as long as she wants,” she instructs the nurse, before leaving the room.
Melanie does ward rounds before facing the morgue, where the rice bag and its followers await her.
She opens the bag, which challenges even her clinically hardened stomach, assesses the decaying contents and scratches out a note for the police.
“Intestinal remains bought to me. Indeterminate — possibly human, unable to tell if male or female. Possibly large animal. Recommend coroner’s involvement. Please call me for clarification. Dr Melanie.”
Melanie then wanders home, where she debriefs with Belinda about the death of a baby who likely would have lived had it been born in Australia. She provides an entertaining account of the vile smelling entrails — “Holy mother of God” — while downing a quick 3pm lunch of twominute noodles.
When Melanie first arrived at Namatanai, she wanted to tackle and change everything that was wrong, but she soon learned that was futile, a one-way ticket to burnout.
“I see so much that is wrong, every day,” she says.
“What I have to do is pick the problems that I can make meaningful change to, otherwise I’d go crazy.”
In a culture heavily focused on personal relationships, she spent the first three months listening, building the respect of hospital staff and trying to understand why strange things happen.
“It’s easy to walk in and say ‘That’s not right’, but you have to sit back and learn. Sitting back is the hardest thing you can do.”
The sisters say they wouldn’t have coped in this place, where nothing makes sense or goes to plan, without having one another for support.
“You can’t keep an emotion for an hour,” says Melanie.
“Just when you hit rock bottom, something wonderful happens and just when you have a win, everything comes crashing down.
“Any win is always shortlived and any loss is just surpassed by something else. You need a familiar face to bounce things off and say,‘Did that really just happen?’”
Working in the dark
DR Melanie Olding will never forget the night she sewed up a seven-year-old child with 13 puncture wounds from a crocodile bite, by the light of a head torch and a kerosene lantern.
Called to the hospital at 1.30am, Melanie tracked the chest wounds and found that some were the depth of her index finger.
One tooth had punctured the child’s skull.
Melanie supervised a hospital colleague as he flushed the wounds, administered antibiotics and stitched in makeshift drains made from urinary catheters, sterile gloves and tape.
Knowing that no surgeon was available at Kavieng, a bumpy five-hour drive away,
Melanie bent the rules and evacuated the patient by boat to another province, where there were three surgeons.
The child made a full recovery.
‘That was heartbreaking’
Soon after arriving at Namatanai Hospital, Dr Melanie Olding realised children were dying of cerebral malaria and meningitis, and so made this the focus of her regular staff teaching sessions.
She was thrilled when staff could parrot the sessions back to her. The quality of admissions was improving, the
correct drugs were being used more often and fewer children were dying.
“I was feeling really great that people were starting to take it in,” she says.
“And the next day I stumbled onto the ward to find this child who had presented and been turned away.”
The 18-month-old had been brought in twice by well-educated and concerned parents. But he had been given IM penicillin and sent home both times.
By the time the baby was admitted to hospital, where Melanie discovered him a day later, it was too late.
“I worked on the baby for ages. It was severely dehydrated, end-of-the-bed septic and nonresponsive,” she says.
She gave him the correct antibiotics and fluids, but the baby arrested two hours later.
“That was heartbreaking, because it was the one thing I had been trying to focus on with the staff and it was such a textbook example.
“You could see when you walked into the room he was septic. He had a bulging fontanelle.”
Melanie, who delivered 70 interactive teaching sessions during her stay, says she sobbed and had a moment of wondering, ‘What’s the point?’
“It was heartbreaking. You understand people don’t have the education, knowledge or skills.
People here genuinely want to do the right thing, but the frustration of everything going wrong despite everything you’ve tried to do — that’s the worst.”
Emotionally exhausted, Melanie headed back to the hospital later that afternoon. She found a healthy baby to model the case on, pulled out the whiteboard and ran the education session again.
When Dr Graham Fleming heard that a local 15-year-old boy had hanged himself, he worried about who might be next. The GP, from the small isolated community of Tumby Bay, 600km from Adelaide, was already concerned about his huge crisis counselling load. And as the parent of teenagers, he was deeply disturbed by the young man’s senseless and unnecessary death.
“That death created a great deal of despair in the town,” says Dr Fleming. “I looked upon it as if it had been my kid and thought it was the most shocking thing.
“I knew the child. I wasn’t caring for him, but I did a psychological post-mortem and there was evidence to me that he had depression. I went out and said we need to get rid of depression, and [if we do,] we’ll get rid of suicide.”
That single-minded decision marked the beginning of a project that consumed Dr Fleming over more than 20 years and led to a dramatic reduction of suicides at Tumby Bay. The district of just 3000 people lost 12 people to suicide in the 10 years to 1996. In the following 16 years, to now, it has lost four.
Dr Fleming involved the school, hospital and community groups, and the project grew well beyond depression. In 2000, it dawned on him that his work had made a difference.
“I said, my goodness me, something tremendous has happened here,” he says.
He contacted Emeritus Professor Robert Goldney, a professor of psychiatry at the University of Adelaide, who is recognised as one of the world’s foremost researchers on suicide and depression.
“I asked, am I barking up the wrong tree, or is this relevant information?” Dr Fleming says.
“He said you’ve got to write it up.”
Two years later, after 13 rewrites, on top of working 70-80 hours a week, Dr Fleming had done just that. His peer-reviewed thesis, which received high commendation, gave him a postgraduate Doctor of Medicine degree and confirmed through rigorous statistical analysis that suicide rates in Tumby Bay had dropped below the national average.
Having tried, without success, to get better mental health support for Tumby Bay, the aim of his thesis was simple: “to determine whether suicidal behaviour in the Tumby Bay district could be reduced by enhancing and utilising community resources.”
Professor Goldney supervised the writing of Dr Fleming’s thesis. As he told Australian Rural Doctor: “It was good work. It was terrific.”
Professor Goldney says while many countries have pulled teams of experts together to formulate national suicide programs, Dr Fleming’s effort embodied all the broad-brush suicide prevention strategies those committees typically came up with. And he’d done it alone, based on common sense.
“It was a massive undertaking. I can’t speak too highly about what he has done,” Dr Goldney says.
“There is no doubt that it has made a difference. What he introduced has worked.”
Dr Fleming is pleased to have reduced his crisis counselling load and the trauma the town has experienced.
“The disappointing thing is no one has said this should be run as a broader trial.
“Part of that is my fault, because I probably should have written it up in something like the MJA (Medical Journal of Australia). But writing up that thesis exhausted me, mentally and physically,” he says.
Dr Goldney sees no reason why Dr Fleming’s approach couldn’t be replicated elsewhere, except that it would require another person like Dr Fleming.
“In some ways, it’s almost too hard, because there is an enormous personal commitment that goes into it – a long-term commitment. You have to have that fire in the belly, and it’s hard to maintain that over a long time. And it really has to be developed from within the community.”
After the teenager’s suicide in 1986, Dr Fleming started out in a very simple way. Although the term “mental health literacy” had not yet been coined, he started teaching community groups about depression’s causes, symptoms and treatment, aiming to demystify it and reduce its stigma.
“I went into every organisation in the town I could think of – church groups, school groups, the Parents and Citizens, Lion’s, everybody. I’d talk and try to get them to understand depression.”
He also ran an education program for teachers in the local school. Five other schools in the region took up his offer to run the program too.
Some mental health experts in Adelaide suggested his approach might do more harm than good, which concerned Dr Fleming, but didn’t put him off. He became a vigilant note keeper, which later proved a godsend in tracking the long-term impact of his work.
It helped him, for instance, many years later to see the difference his training and talks had made. Once a statistician had overcome the problem of working with small figures, Dr Fleming could identify that this was when the suicide rate started to level off.
“Probably dealing with depression alone had more of an effect than we thought it did at the time,” he says.
He noticed small but significant changes.
“We had farmers coming in and saying, excuse me, doc, I’m feeling stressed and I think I need some help, whereas in the past they’d probably have gone to the pub.”
However, the problem was a long way from solved, with another seven local people committing suicide after the teenager, in the seven years to October 1992.
He sought help from government and academics to address the alarming suicide rate, “but the answer was always that there was no money or resources”, Dr Fleming writes in his thesis.
“Furthermore, it was suggested any interventions should begin in the major centres where resources could be used more effectively, and lessons learnt could then be applied to the rural sector.
“It was also suggested that the situation seemed too dangerous for novices to dabble in, and perhaps the alarming suicide rate may have occurred because interventions had somehow produced a morbid community fascination and focus on depression and suicide. Overall the process had become very disheartening.”
He found some mental health workers in Adelaide who said they would come and assess what the town’s problems were, if he could raise a couple of hundred thousand dollars.
“We said we know what the problems are: people are killing themselves,” Dr Fleming says.
“I didn’t know what I was doing, but I’ve got a reasonable degree of intelligence and have lived in rural communities all of my life.”
Then, in 1993, another tragedy rattled the town to its core, and eroded Dr Fleming’s confidence. A high-profile, widely adored school teacher killed himself. He was friends with Dr Fleming and another GP at the town’s three-doctor practice.
“He was probably my GP colleague’s best mate and his wife worked as a receptionist in the surgery,” Dr Fleming says.
“He had gassed himself in the car. I was called to try and resuscitate him. It took me an hour to decide to give up, which was probably 40 minutes more than it should have.”
Dr Fleming was devastated he hadn’t realised his friend was so distressed, that his friend hadn’t called on him for help, and that he hadn’t been able to resuscitate him.
“I was hurting after that and probably still do hurt after that,” Dr Fleming says.
“I said, I’m getting out of general practice. I was going to specialise in obstetrics.”
Dr Fleming met at the pub with two concerned local people who were also grieving – the local hospital’s director of nursing, Pauline Kearns, and then school principal Kent Spangenberg.
“I said general practice is not for me anymore. Those people said let’s talk about it. What are our problems? What are our assets?”
Mr Spangenberg says they grappled with the concept of the teacher being so private in his suffering; that his suicide had come as such a shock.
“The teacher had just had a second child after 13 years of trying, and he’d just implemented a maritime studies course in year 12, which he’d wanted to do for a long time,” Mr Spangenberg says.
“Two weeks before, he’d taken his class away sailing for four or five days. That was his ultimate achievement. It appeared he was achieving, from a family and professional perspective, things he’d been aiming for, for years.
“His death really devastated the whole community.”
The pub discussion strengthened Dr Fleming’s resolve. And his most basic coping mechanisms gave him the drive to work longer hours.
“Being a country GP, you’re supposed to solve everybody’s problems and not your own. You tend to work harder to take your mind off it.”
He realised he needed a broader focus, beyond depression to what constitutes good mental health.
“Good mental health is not the same as an absence of mental illness,” he says.
“At the end of the day, healthy, happy people don’t commit suicide. So if people have mental health issues and are not happy, they are at risk.”
His research showed that many of those who had committed suicide had not had regular contact with
GPs, and that ultimately, suicide prevention was a responsibility the entire community would have to own. He also figured it was more likely problems could be managed locally if they were identified early.
Dr Fleming established a reference group, which he sat on, along with a nursing representative, a mental health patient and their carer, a minister of religion, school and community counsellors and a medical administrator.
He also persuaded retired professionals, including school teachers, nurses and social workers, to study mental health and counselling. Four registered nurses, and a retired school teacher – Dr Fleming’s wife, Gladys completed a postgraduate course in counselling. Gladys also achieved a graduate certificate in community mental health. Other retired teachers worked with an educational psychologist to help students with learning difficulties and improve their reading.
It was at a time when there were no models of depression, so Dr Fleming developed and then widely presented one. It explained six common causes of poor mental health, based on the conditions he had treated locally and what he thought the community could recognise and understand.
“Overall the community was taught to recognise poor mental health in their family and neighbours and a plea was made for early referral to well-known entry points,” Dr Fleming writes in his thesis.
The model covered “worriers”, which included people with anxiety disorders ranging from nervousness to panic attacks; mood disorders including depression and bipolar; schizoid disorders; personality disorders; substance and alcohol dependence; and grief reactions.
“The causes, symptoms and treatments were discussed, with emphasis on consequential secondary behaviours, of which suicide was the most dramatic,” Dr Fleming writes.
He emphasised that most mental disorders were reversible and, if they were identified early, they could be managed locally. And he outlined where people could access care and crisis resources.
When talking to nurses, he placed emphasis on somatisation and depression occurring with physical illness.
“As nurses were often the first points of triage, they were trained to assess presenting symptoms, and assess urgency and safety issues with regard to potential suicidality,” he writes. “A planned protocol of questions to ask … was devised to assist the nurses and ensure appropriate follow-up.”
Dr Fleming says the training had a huge impact on the nurses’ confidence, particularly when dealing with patients experiencing a psychotic episode.
“Instead of the [nurses] being terrified, they would calmly say to the patient, what are the voices telling you?
More importantly, we developed a protocol, so if anyone came into the hospital with a mental health problem then they would go through a list of questions. Patients knew the nurse was on their wavelength.”
When presenting to teachers, he covered psychological principles, learning disorders, signs of possible dysfunction and personality development.
“They were taught the main foci of assessment such as behaviour, progress in learning, psychiatric symptoms and social milieu.”
A senior educational psychologist presented an hour-long presentation on learning difficulties.
Dr Fleming and Mr Spangenberg also discussed how to approach children who had bad conduct or were refusing to go to school, recognising that poor mental health often started in children. They decided to focus on children who were more than one academic year behind, and were behaving abnormally or in a way that was different to their peers.
Teachers were trained to observe the students and identify those considered appropriate for assessment. With their parents’ consent, children were then assessed to exclude physical illness, determine their behaviour at home and with peers, their academic progress, social interaction and signs of psychiatric illness.
Of the 350 students at the school, 51 were regarded as dysfunctional and considered suitable for formal assessment. Parents of 49 students agreed to them being assessed, which revealed co-morbidity in many students and a significant psychiatric illness in 20. Twenty-six had psychiatric problems, 35 had behaviour problems, 20 had learning problems (19 significant) and 20 had social problems, which reflected dysfunction or disadvantage in their social environment.
Dr Fleming achieved grants which paid travel costs for a senior child and adolescent psychiatrist, and an experienced senior educational psychologist from Adelaide. The psychiatrist, who agreed to bulkbill, formally assessed children with frank psychotic symptoms, and the psychologist assessed those with learning difficulties.
Therapists, teachers and parents then addressed each child’s needs. Evaluations six months and then 12 months later showed they, and the students, universally agreed the interventions were worthwhile.
Dr Fleming couldn’t believe just how skilled teachers became at picking up subtle early warning signs in children.
“It blew my mind. The teachers were so good. They were on to it straight away, because it made their class management so much easier.
Initially they only referred the really difficult kids, but then they picked up more subtle signs.”
Before setting up the program, Dr Fleming had a joint meeting with the state’s ministers for education and health, who approved his work. Then, a year later, Dr Fleming tried to extend the program to a double-blind trial across the Eyre Peninsular, but a change in government had significantly dampened enthusiasm.
“The education department said we’d never let a program like that run in our schools,” he says.
Mr Spangenberg, however, did what he could to see the benefits push farther than Tumby Bay when he moved to Loxton, eight hours away.
He invited Dr Fleming to present his model and a session on risk factors to an extended staff meeting and established a new relationship with a Loxton GP who could refer to a visiting psychiatrist. But Mr Spangenberg hasn’t had the resources to employ an educational psychologist and paediatric psychiatrist in order to run the program rigorously.
Having arrived at Tumby Bay shortly after the teenager’s suicide, been “massively” affected by the suicide of the teacher from his school, having seen first-hand the impact Dr Fleming’s work had on the wellbeing of teachers and students at his school, Mr Spangenberg is resolute that the program deserves far more attention than it has received.
“What Graham has done has been truly outstanding and it needs to be picked up and run with throughout rural and metropolitan communities, throughout Australia,” he says. “There’s no doubt about that, as far as I’m concerned.”
Findings from Dr Fleming’s thesis
Model is ‘majestic’ but hard to replicate, academic says
Involving the whole community is the only way Dr Fleming’s initiative could be replicated in other parts of the country, says Dr Angelo De Gioannis, senior lecturer at the Australian Institute for Suicide Research and Prevention at Griffith University in Queensland.
He says that, even with broad community involvement, it would require a strong individual who was prepared to take ownership, get things done, and follow up outcomes – labour-intensive work that would come with limited rewards.
“It was wonderful to be able to do it, but I’m pretty sure the main reason we haven’t heard of it elsewhere is it’s probably very difficult to replicate,” says Dr De Gioannis, who is also a consultant psychiatrist at the institute’s Life Promotion Clinic.
“The principle, I fully agree with. That particular application was majestic, which is why it was so effective and is hard to replicate.”
He says there are some key aspects of the work that rural GPs could adopt, particularly Dr Fleming’s “hard-line approach to addressing any sign of distress”.
“I thought that was really valuable and can be done in different settings, regardless of how much time you have available,” he says. “If you see somebody who is struggling, you don’t just ignore it.
“We expect people to be stressed, depressed or angry, and so we have a very high level of tolerance for those things.”
He says there is plenty of research that shows that GPs make a huge difference when they have a five-minute chat with patients about cigarettes or alcohol. “If GPs did it also for anxiety and depression, it would also make a difference,” Dr De Gioannis says.
It’s rare in life that someone takes you under their wing and solves your problems, free of charge. But that’s the essence of what Denise Klemm does for doctors who move to Albury and Wodonga, regional cities located either side of the Murray River on the NSW/Victorian border.
As the recruitment officer for the Border Medical Recruitment Taskforce, Denise has a novel job, one focussed entirely on attracting doctors and overcoming hurdles that might deter them from staying.
Denise’s efforts are responsible, in part, for the border cities securing 87 new GPs and specialists in just four years. So too is the carefully constructed taskforce of five executive members, who are all ideally placed to convince local high school students, visiting medical students, registrars and junior doctors that the border is a great place to call home.
The taskforce was born in 2007, in a community facing a crisis. In October 2006 Albury and Wodonga had just three general practices that were prepared to accept new patients.
But by May 2011, about 20 new GPs had moved in and 20 practices had open books. Anaesthetists, general surgeons, psychiatrists, and a paediatrician, gastroenterologist, oncologist and urologist, were among the extra 67 specialists who had also joined the ranks.
“Now, we have a growing regional medical population,” Denise says. “We were in decline before that. We were in real strife.”
There’s little wonder the concept has attracted interest from other doctor-starved regional centres.
Bendigo in Victoria looked to Albury for support and advice before establishing the Central Victorian Medical Recruitment Taskforce 18 months ago. So too did Tamworth before establishing the Tamworth Health Recruitment Taskforce in September last year (see box ‘A model worth replicating’, below).
Rather than focusing solely on its own turf, the border taskforce is keen to see the concept adopted elsewhere.
“If enough regional cities gang up on the city, we could form an alliance,” Denise says. She figures that, by working together, they might encourage doctors to stay in regional areas, making any investment in training more worthwhile.
“We’re happy to invest in training if people stay rural. We don’t want to train them up to move to cities.”
Knowing how to overcome the local workforce crisis was something that had troubled border medicos for some time. Dr Peter Vine remembers attending informal lunch meetings with local doctors and hospital administrators. The retired paediatrician, who heads the University of NSW Rural Clinical School campus in Albury, remembers concerned discussions about doctors retiring, there being no succession planning in place, and a lot of shrugging of shoulders and uncertainty about what to do.
The local newspaper was adding heat. It featured a new resident who had moved from Melbourne and waited eight months to get her first appointment with a border GP.
“Since her arrival in Albury she has had to return regularly to Melbourne to see her previous GP and access prescriptions,” the Border Mail reported.
“She said the situation was a deterrent to young families, including her daughter, son-in-law and two grandchildren, who were thinking of moving to the area.”
Then Dr Scott Giltrap, a local obstetrician and gynaecologist, called a public meeting. About 90 local movers and shakers came along. Businesses reported it was becoming hard to recruit staff from larger cities, because prospective new employees were concerned about access to health care.
It became clear it was an issue that was starting to hamper economic development and it was an issue the business community and local councils needed to solve as well.
“That meeting decided to set up a taskforce,” says Dr Vine, who was one of the five people appointed to the voluntary alliance. About $700,000 was secured in donations, council grants, and in-kind donations, to be given over the following three years. The taskforce, headed by Dr Giltrap, was then in a position to employ Denise (see box ‘Joining all the dots’, below).
“The crux of the taskforce is having a project officer who takes care of people, who arranges their visit and accommodation, and introduces them to people they should talk to, so they see the hospital and around the area,” Dr Vine says.
Another taskforce member, Nicki Melville, CEO of Bogong Regional GP Training, agrees. She says it’s what sets the border region apart from other towns that don’t have someone dedicated to the role.
“Denise is the right type of person because what she has to do is a lot of stuff you couldn’t even put in a position description.
“I think it’s been a very successful model because it’s quite informal and very much about relationships.
“Also, we’re not an authority or a body, so we’re not bogged down in red tape.”
There’s an advantage in Dr Vine and Ms Melville being on the taskforce together, as she relies on having access to the rural clinical school to promote general practice as a career. The clever connections don’t stop there.
Ms Melville also works with taskforce member Linda Moon, who is Medical Services Manager for Albury Wodonga Health – Australia’s first cross-border public health service, which merged Albury Base Hospital in NSW and Wodonga Regional Health Service in Victoria.
Ms Melville and Ms Moon combine forces to help medical students achieve jobs as hospital interns, and then appropriate specialist and general practice rotations as junior doctors.
“We can plan well together to plan those jobs for them,” Ms Melville says, adding that taskforce members all believe in the area growing its own workforce, as well as attracting new doctors.
“The taskforce has made it much easier to join the pathway up so they [students] can train for every bit of their general practice career locally.
“They can do all of their training in Albury, from undergraduate medical students right through their hospital work, to Bogong, as general practice registrars, until they come out as fellows.”
The results suggest it’s an approach that is working. Of the 61 doctors who had completed GP training in Albury Wodonga by the end of 2009, 42% are still in rural general practice in Victoria and southern NSW and another 32% are still GPs in the Albury Wodonga region.
Ensuring Denise is in regular contact with taskforce members helps her to meet new doctors’ needs too.
Having recently attracted a top-notch surgeon to the town, she learnt he was interested in lecturing at the university. She rang Dr Vine and the surgeon became a further asset to the community as a senior lecturer.
“It all feeds off itself,” Denise says.
These days the Albury Wodonga GP Network also plays an active role in supporting GPs who come to town. It too has representation on the taskforce, in the form of CEO Trevor Cowell. It also employs a staff member to support GPs who move here.
Mr Cowell says the taskforce’s achievements have had spin-off benefits that continue to make it easier to find GPs.
“Undoubtedly, it’s helpful if they know they have support in town to refer patients to,” he says.
“If they have support of specialists locally it makes living here more attractive.”
As the recruitment officer for the Border Medical Recruitment Taskforce, Denise Klemm is required to be a well-connected relationship builder, real estate scout, tour guide, social organiser and self-directed personal assistant.
She works days, evenings and weekends, according to when she’s needed, and cheerfully announces that although she is paid for three days, she often works five.
Denise has learnt that it’s the little things that matter, when it comes to having doctors come to Albury Wodonga and choosing to stay.
While work is important, having a fantastic house, great social connections and feeling part of the community are factors that carry equal, if not greater, weight.
Denise has built relationships with some local real estate agents to ensure they contact her if they have a quality home, before it is listed.
On hearing one new doctor’s partner was feeling isolated, having moved from Sydney with a baby, Denise sweet-talked a tight-knit mothers’ group into accepting just one more member. Another doctor needed executive-style housing out of town with a paddock for a pony. Denise found it.
If a new medical family needs to borrow a car for a few weeks, wants a run-down on local schools, or a non-medical job for the doctor’s partner, Denise knows whom to call. And if they fancy a tour of local wineries, a day trip to the snow, or someone to cycle or water ski with, Denise makes it happen.
She works closely with the taskforce to keep close tabs on how doctors are coping with their workloads and future workforce gaps likely to arise.
They are also keen to keep its mature and experienced doctors in a position where they have time to teach, particularly given the huge influx of medical students.
If there is one thing the past five years has taught her, it’s that work-life balance is the key to retention.
“People come for lifestyle and if it becomes unbearable because they’re working too hard, they’ll go,” she says.
The success of the recruitment taskforce in Albury Wodonga has inspired the communities of Bendigo in Victoria, and Tamworth, NSW.
But when a recruitment taskforce was first proposed for Bendigo, some local GPs were concerned. There wasn’t a GPs shortage and while several were facing retirement, it was likely there would be enough new graduates to meet demand.
Specialists, however, were a different matter and the region’s smaller towns were short of GPs.
That’s why the Bendigo-based taskforce, formed 18 months ago, was called the Central Victorian Medical Recruitment Taskforce, according to its executive officer, Peter Hyett (below).
Having recruited a few GPs and registrars and 10 new specialists for Bendigo, he says the taskforce is now aiming to support smaller doctor-starved communities in the region such as Echuca, Kerang and Swan Hill.
The not-for-profit taskforce has received state and local government funding, and donations from the public and private hospitals, local day surgery, radiology and anaesthetic services, Bendigo Bank and local specialists.
“However, we are self-funding and it is necessary to hold fundraising events, like a golf day, where local businesses support us financially or provide prizes,” he says.
Tamworth, in northern NSW, has also watched the Albury Wodonga experience with interest. The new Tamworth Health Recruitment Taskforce appointed a recruitment officer in September last year. Tamworth needs 10-12 GPs and there’s a shortage of specialists across the region, according to the interim CEO of the New England Medicare Local, Graeme Kershaw.
He says the taskforce, which includes representatives from Council and the business community, understands the broader financial imperatives of the region having an adequate medical workforce.
“We’re seeing it very much as an economic development issue, as well as a health issue,” he says.
Bunbury, WA, was also inspired by the Albury Wodonga experience, but hasn’t been able to secure funding for a full-time employee. The South West Medical Attraction Taskforce was formed in 2009, and local consultant Alison Comparti was commissioned to write a report on local medical workforce issues, and recommended employing a recruitment officer as the Taskforce’s first priority.
Funding for the position was attempted through the Royalty for Regions agreement in WA, but was not successful, so Alison now works voluntarily in the role, part time, without the support of a Taskforce.
“I’ve been doing it for love ever since and we’ve had limited success,” says Alison. “It’s frustrating we don’t have a dedicated organisation to oversee it.”
Despite that, Bunbury has managed to overcome its severe GP shortage, largely due to recruitment efforts by individual general practices.
In October last year the Bunbury Mail reported that 81 doctors now worked in the region, up 35% on the 60 GPs working in January 2010.
Albury Wodonga’s efforts to recruit and retain medical staff extend beyond the efforts of the Border Medical Recruitment Taskforce. A range of scholarships to study medicine are also offered in the hope that local students who graduate from medical school will decide to return and apply their skills on the border.
“If a child spends five years in the country, there is a 30% chance of [their] returning to the country if they become doctors, increasing to 50% if they spend 10 years in the country,” says Dr Pieter Mourik (below), a retired obstetrician and gynaecologist who raises funds for the Border Medical Association scholarships, which 82 students have received since 1991.
Dr Mourik, who is the association’s social secretary, says almost 80% of these scholarship recipients have entered a rural training program or are practising in the country. While few have yet settled on the border, he’s confident that once they finish their training, many will.
The golf day he runs each year raises up to $24,000 for scholarships, which is divided equally among the number of local high school students accepted to study medicine.
For the past five years, students have received a minimum of $1000, sometimes more, and one student is given $1000 for each of six years. The National Australia Bank provides an extra $500 for each student on a bank card.
Each scholarship recipient is also allocated a GP mentor, or sometimes a specialist. “We look after them like our own children,” he says.
“Having part of your medical training in the country, even a work attachment, increases your chances of returning after graduation.”
Albury Council also gives $5000 scholarships to two local high school graduates accepted to study medicine. Also, a past president of Albury Rotary left a bequest three years ago that funds seven $1000 scholarships for fifth-year medical students studying at the local University of NSW rural clinical school.
Dr Mourik believes the border is more conscientious about achieving an adequate medical workforce than anywhere else in Australia.
“All rural towns have the opportunity to attract future Australian-trained doctors, reducing our reliance on overseas-trained doctors,” he says.
“Sadly, very few have anything like the robust program we have. Every local town can follow our lead. Go to your local businesses, get your local council on board, get a leader with some drive and run with it.”
IT’S 9.30pm. Dr Nicholas O’Ryan is still at his desk, after a long and demanding day at the surgery. But his energy levels are high.
The solo GP, from the tiny NSW town of Canowindra, is fired up with enthusiasm, having entered the new world of video conferencing just a few weeks earlier.
Dr O’Ryan, 55, isn’t overly computer savvy, which partly explains his excitement. He sounds chuffed when he tells Australian Rural Doctor that he set up a video conferencing system in just five minutes. It cost him nothing. He hooked up to Skype and had a spare computer video camera to hand.
Having experienced the buzz of giving his isolated patients quick and easy access to a city psychiatrist, he’s reassured that they’re enthused too. Even a conservative elderly patient with depression and anxiety was impressed by the quality of her first online appointment.
“She told me she felt like the psychiatrist was in the room with her,” Dr O’Ryan says.
While video conferencing has left Dr O’Ryan flying high, it’s a subject that leaves other GPs feeling fatigued and frustrated. Despite the Federal Government launching MBS item numbers and a $6000 incentive in July, it’s clear that the rural GPs who’ve jumped on board are a small, not particularly conservative, minority.
Dr Ewen McPhee, a GP from the remote Queensland town of Emerald, has spent six months trying to get a system operating, with the help of his IT-trained son. He’s keen to get started, but internet speeds are proving a problem.
“Because there are so many fingers in the pie trying to deliver the service and so many providing it, it’s quite a maze to wade through to find the best connections and best speeds,” he says. “Speeds have been an issue for years. My branch practice is really suffering in terms of reliability of service.”
In July Dr Bill Boyd, an obstetrician at Mackay Hospital in Queensland, set up a computer and camera and downloaded Skype. He then contacted all the GPs in the region, including Dr McPhee, to encourage them on board.
“It has scarcely been taken up,” he says.
According to the Health Department, about 1200 rural doctors – including specialists – have claimed the $6000 telehealth incentive. From July to October last year, 899 of the 12 telehealth item numbers GPs can claim had been processed. That’s about 220 per month, nationally.
Those figures are very low, according to Dr Tori Wade. She is working on a PhD that explores the uptake and sustainability of telehealth services in Australia, having spent 15 years as a GP in Adelaide.
“I expected it to be low because every GP I know is booked solid with patients. Why would they spend time trying to work it out, when they’re flat out?”
She says item numbers were introduced too early and is concerned about the long-term implications of rural GPs not being ready to run with them. “There is a danger that two to three years down the track, the government will say ‘That didn’t work’ and cancel them,” Dr Wade says.
Dr Wade’s main concern is shared by every person interviewed for this feature. To put it simply, there is not one system that will communicate with all online specialists. In fact, GPs could potentially need a different system for each specialist they want to consult online.
Dr Wade says there are 50 different types of video conferencing software. While a few claim to be able to interoperate with other software, in reality, they don’t.
“As soon as someone does an update, it falls apart,” she says.
“Running real-time video is like having a canary in your coal mine. If there is any problem the video conference falls over.”
Dr Wade says the compatibility issue is so significant it could lead to telehealth’s undoing.
“I really want it to work and I’m really worried it won’t. I’d like it to take off in the broader scale, but I am not convinced it is going to happen,” she says.
She thinks it is unreasonable to expect busy rural GPs to overcome these hurdles.
“I don’t see why they should. You’ve got them to set up a resource and then you waste their time, asking them to become IT and telecommunications experts.
“I think the Commonwealth Government has got it wrong. If they wanted this to work they really should have supplied a network.”
She says a public switch video network would overcome the problem, just as a public switch telephone network enables Telstra and Optus to shunt calls between their systems.
“Why couldn’t we set something up like that for video calls?” she asks. “Interoperability should be public infrastructure.”
Former GP Dr David Allen agrees that system compatibility is a significant problem and he also doesn’t want it to undermine telehealth’s potential value in rural areas. Having worked in private practice providing occupational health consultations online for many years, he has established Telehealth Solutions Australia, which offers a free system for secure video conferencing.
He says he established the not-for-profit organisation because a lot of doctors were having bad experiences.
“A lot of people are paying far too much money and setting up systems that won’t talk. Ultimately, who loses out? The patient.
“I want doctors to get involved but if it’s too hard they won’t offer telehealth, which means patients will miss out.”
He says his system can manage 1000 simultaneous video consultations.
“We’ve opened it up and given doctors across Australia access to so that they don’t have to pay anything. It’s an easy system to use, providing high definition. It runs off windows and Mac.
“When I tell people this their jaw drops. It’s all paid for. Some of the vendors out there are trying to make a lot of money out of this.”
He says GPs involved in video consultations are “few and far between”. Those who are are largely using Skype and he understands why, although he says it doesn’t give adequate stability or definition. “It’s a nice starting point. It’s a consumer-grade system. GPs are using it and they find it’s easy and accessible.”
Skype isn’t adequate, according to Dr Wade, who became so frustrated with the technical support required by software options that she explored hardware. She became involved in a business specialising in video phones, which she says are more expensive than software, but also more reliable. At this stage, video phones are enabling nurses to call patients at home and supervise them as they take medication, rather than being used broadly in general practice. One GP who has tried them, Dr Tim Kelly from Crystal Brook, SA, wasn’t enthused.
Dr Kelly, who works at a three-partner general practice, found the extra equipment cumbersome compared with using Skype.
For the past four years he has used Skype to connect patients in his region to a rheumatologist in Adelaide. Two interns run the program, which ran initially as a grant-funded pilot.
“One [intern] sees the patient for 15 minutes, and then they sit in for the 15-minute consultation with the rheumatologist, while the other intern is doing the next consult in the next room.”
Dr Kelly says its good training for interns to be dealing with specialists directly, and he’s looking to expand the model to include the practice’s visiting endocrinologist.
Dr Kelly says while he’d like to upgrade to something more secure than Skype, he doesn’t consider Skype a large risk in the context of rheumatology.
Skype’s safety also doesn’t particularly concern Dr Trevor Lord, a GP who works for the Kimberley Aboriginal Medical Services Council in WA. Dr Lord is one of the country’s more technologically savvy GPs. He is one of the Clinical Leaders on the National E-Health Transition Authority, and recently established an electronic patient record system for 21,000 patients in the Kimberley.
He says Skype isn’t the best tool, but it works, it’s easy and security issues are largely overplayed. “It may be that the Russians have broken into Skype and are watching our consults and we don’t know, but it’s unlikely,” he says.
However, the Kimberley “must have the worst bandwidth in Australia”. “I deal in Broome in bits per second, not mega bits per second,” he says.
Dr Lord doesn’t have the upload speeds required for any kind of video conferencing. Instead, he takes a photo – say of a rash or infection – and sends it to a specialist using his mobile phone. They then call and discuss it, which he says works well. Other forms of this “store and forward” approach, sometimes using video footage or images which are sent over the internet, have been used to get input from ENT specialists and ophthalmologists.
He says being able to conduct six-week post-surgical checks using video conferencing would make an enormous difference to Aboriginal people who are reluctant to travel the significant distances to Perth for a five-minute consultation. He estimates they would save the health system $2000-$3000 for each visit.
But he says once you leave regional centres in WA, internet access is “all over”.
He says national broadband went into Geraldton and Mandurah – “they consider that to be rural”.
“We’re going to have to sit around until 4G gets going,” he says.
Having said that, he said WA does have its own unique challenges when it comes to establishing IT infrastructure. Dr Lord says last year a cable that carried a 3G system from Derby to Broome was cut.
“We lost communication for two or three days,” he says. “Allegedly, a crocodile chewed it.”
LIKE TAKING THE PATIENT TO THE SPECIALIST YOURSELF
Dr Nicholas O’Ryan had a serious incentive underpinning his foray into telehealth, and it was nothing to do with a $6000 Federal Government grant. The isolated rural GP was concerned about a family member with depression and wanted him seen by a good psychiatrist, fast.
“I looked locally and they couldn’t see him in Bathurst or Orange. I needed something immediate,” says Dr O’Ryan, who has practised in Canowindra, in central-west NSW, for 25 years.
He spoke with Sydney psychiatrist Dr Errol Jacobson, who works as a visiting medical officer for Dr O’Ryan’s local division, where he’d been involved in a tele-psychiatry trial.
Dr Jacobson encouraged Dr O’Ryan to set up a Skype account, so that the consultation could take place online between Canowindra and Sydney. “I thought it sounded logical. I thought, oh well, let’s try it,” Dr O’Ryan says.
He set up a computer in his nurse’s room, and dug out a few $70 video cameras he’d bought to improve practice security.
“I set up a dedicated Skype account. It took five minutes, if that, and it works amazingly well.”
When Dr O’Ryan spoke to Australian Rural Doctor, five of his patients had seen Dr Jacobson, via video, from the comfort of Dr O’Ryan’s surgery. And Dr O’Ryan had seen a range of advantages he hadn’t anticipated, largely because the process overcomes the delays and limitations of referral and follow-up letters.
Dr O’Ryan sits with his patient and introduces them to Dr Jacobson. Dr O’Ryan leaves the room while the consultation takes place, but returns once the patient has left. He then discusses Dr Jacobson’s management plan in depth.
“Where else could you get that?” says Dr O’Ryan.
“It’s like taking your patient to the specialist. You get better feedback and you can ask appropriate questions. It’s much better care and it is more satisfying. You can develop a relationship.”
Dr Jacobson says there is great benefit in being able to discuss a management plan so it can be put in place instantly.
“Rural medicine has to be a collaboration between GP and specialist,” he says. “A lot of management is carried out by the GP, so it cuts through the whole waiting game.
“Face-to-face is definitely better. But if face-to-face is 100%, then telemedicine is 98%. It’s made up with accessibility, cost and assists the GP.”
About one-fifth of Dr Jacobson’s consultations are now held via video conference, and that proportion is growing. He recently conducted 12 consultations from home, on his laptop, travelling the equivalent of 5000km without leaving his desk. At his practice, in Bronte, Sydney, he will see a patient face-to-face, then one in Tasmania, another in his rooms, and then another in Parkes.
Having conducted more than 100 video consultations, he’s never had a complaint or concern about quality. “I always have my iPad nearby and a landline phone as a backup as well. [But being online has] never impeded my ability to establish a diagnosis, establish a management plan or develop a report with someone.”
Dr Jacobson finds it odd that some GPs have found video conferencing a challenge to establish. “Perhaps they’re losing the simplicity of it. It’s frighteningly easy to set up. All GPs need is Skype, or an equivalent AV software program, a web cam and microphone through a computer in a room. That’s it.”
NO ONE-SIZE-FITS-ALL SOLUTION
About 200 doctors have contacted ACRRM’s Telehealth Advisory Service for help with setting up video conferencing. Vicki Sheedy, ACCRM’s Strategic Programs Manager, e-Health, says solutions depend on what bandwidth GPs have and everyone’s context is different.
ACCRM’s online system provides tailored solutions, based on individual circumstances and needs. “They describe their technical environment and the specialists they need to talk to. We give them a range of options for them to consider.”
ACRRM also has a free directory that lists telehealth-enabled clinicians by specialty. It indicates what technology they use and where they are located. The ACRRM address is http://www.ehealth.accrm.org.au/
VIDEO A NATURAL FIT FOR RURAL GPs
As Chief Medical Officer for the Australian Antarctic Division, Dr Jeff Ayton (above) has had the opportunity to trial telemedicine technology that has supported health care in other isolated environments.
He’s worked with NASA, through a research memorandum of understanding, but says there’s an emphasis on ‘store and forward’ technology – SMS and email – rather than real-time video.
He says the distances involved in space travel result in a delay of up to 20 minutes in messages getting through.
Video conferencing also hasn’t played a significant role in Antarctica, despite phone-based telemedicine having been practised in support of Australian expeditions since 1948.
While there is the capacity for video conferencing, there hasn’t been the clinical need to use it, and there are significant challenges in ensuring the patient and doctors are available at the same time.
Those issues aside, Dr Ayton applauds the Federal Government’s significant investment in video conferencing, which he says will expand the number of specialists becoming involved.
“It’s a fantastic initiative which cuts across the inequities of specialist access in remote and rural Australia,” says Dr Ayton, who is chair of ACRRM’s National Telehealth Advisory Committee. Dr Ayton says rural GPs should now be considering video conferencing for all referrals, when they think it clinically appropriate.
He says that one of the barriers to uptake is that one system cannot connect to every doctor. But GPs should start by working with specialists they already refer to, and look at having a number of different systems in place.
“Until the technology is ubiquitous and there is connectivity between the various video conferencing systems, there is going to be a challenge,” he says.
“There are ways to get a fit-for-purpose solution but it will take years to get a more ubiquitous solution.”
He says using Skype may not be suitable for sensitive health discussions where there may be significant concerns about privacy.
“It needs to be a judgement of the clinicians at both ends,” he says. “It would be very concerning if video feeds of a medical nature reached the public domain.”
However, one way of managing the risk was to use Skype for video and the telephone for voice, he said.