Australian Rural Doctor


Mission for Life
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Photo by: Tim Berry. Dr Fleming outside the pub where he met two concerned local people who helped strengthen his resolve.

FINAL low res Dr Flemming leaning against wall

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

  •  There is a significant increase in suicide rates of young men in towns with fewer than 4000 people, compared with those in more urban areas in NSW.
  •  In spite of the suicide rates being higher in rural areas, research has not proven significant differences in mental health status between rural and urban Australians.
  • The number of people who commit suicide exceeds those killed in motor vehicle accidents.
  • More people die from suicide than armed conflicts around the world. 

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.

Clever connections
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Photo by: Simon Dallinger. Denise Klemm and fellow taskforce member Nicki Melville

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.”

Joining all the dots

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.

A model worth replicating

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).

Peter Hyett

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.

A helping hand for students

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 Pieter Mourik

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.”

 

 

Bridging the distance
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Photo by: Robyn Wilkinson. Canowindra GP, Dr Nicholas O'Ryan.

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. 

Highway of broken promises
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Photo by: Trevor Veale. Drs Ray Jones with Drs Harriet Playle (left) and Edwina Guard...

At first he thought he’d tripped over a brick. But it was a foot – a human foot on the side of the road.

It was at that moment, in the near dark of early dawn, that Grafton GP Dr Ray Jones got a sense of what he was in for – a scene of devastation on the Pacific Highway that would affect the rest of his life.

A semi-trailer had sliced the side off a passenger bus, killing 20 people and an unborn child, and injuring 22 others.

Dr Jones remembers “body parts, spread all over the place” and a sickly sweet smell. Pineapple. The truck driver had been hauling a load of juice.

By the time Dr Jones arrived at the scene, ambulance officers had sorted through the mess.

“They had the living people in the middle of the road in a circle, covered in blankets, and in a paddock they had all the dead people, under blankets,” Dr Jones says.

The only other doctor at the scene was an intern, a junior resident from Scotland, sent by the local hospital.

“She was sitting in the middle of the highway, crying. She was totally overwhelmed. I sat with her and we went through the living, from one to the next.”

Dr Jones has rarely spoken of the infamous Grafton bus crash, which occurred 22 years ago, not even with other doctors who attended the scene.

But having worked through post-traumatic stress syndrome, a broken marriage and years of professional counselling, he’s now at the forefront of a lobby group of 70 medicos – Doctors for a Safe Pacific Highway – who are taking a stand against the highway’s death toll.

“We are sick of attending accidents,” Dr Jones says.

“People are still dying unnecessarily because of the state of the road.”

While the Grafton tragedy occurred two decades ago, it is horribly relevant to the lobby group’s cause.

The crash occurred on a narrow section of highway where there was little margin for error.

“There was barely enough room for two vehicles to pass,” Dr Jones says.

“The coroner recommended that in the next five years it be upgraded to two lanes. Twenty years later it’s still not fixed.”

That inaction has also angered Kevin Waller, the then NSW coroner. Mr Waller conducted the inquest into the Grafton crash, and another Pacific Highway crash that occurred just three months later: two full coaches crashed head on at Kempsey, 200km south of Grafton, killing 35 tourists and injuring 41.

On the 20th anniversary of the Grafton accident, Mr Waller described the slow progress on a dual carriageway as “appalling”.

In May, the Prime Minister and State Member promised a dual carriageway by 2016 but that does not placate Dr Jones.

“They’d need $10 billion and they’ve allocated $5 billion over seven years. There is nowhere near enough allocated to meet the deadline,” he says.

“If it happened in the city they would have fixed it 20 years ago. They would have spent $10 billion on a tunnel. In the country, it is out of sight out of mind.”

Dr Harriet Playle, who moved from Nambucca Heads to Coffs Harbour so her children wouldn’t have to travel a dangerous section of the highway on a school bus, is also sceptical about political promises.

She says the state and federal governments have built, on average, less than 10km of divided highway a year. “Of the 373km between Port Macquarie and Ballina, only 52km is completed, with 69km in progress. At the current rate, the total highway will not be completed by 2050,” she says.

Dr Playle, a founding member of the doctors’ lobby group, says important upgrades are starting to occur. The group made a submission to a Roads and Traffic Authority safety review about a stretch of road near Urunga. Afterwards, the speed limit was reduced and two dangerous overtaking lanes were removed. Dr Playle understands there have been no fatalities since on this notorious section of highway.

The group is now focused on the dangerous 42km between Warrell Creek and Urunga – a relatively small section of road where there were 229 accidents between 2003 and 2007.

This stretch alone highlights the extraordinary cost of upgrading a narrow two-lane highway. Dr Playle says the Federal and NSW governments have spent $47.9 million and the project still doesn’t have approval or a detailed design.

Dr Playle and Dr Jones were both on the board of the Mid North Coast Division of General Practice when the idea of a lobby group was floated in September 2010. At the time, board members had the opportunity to speak to a local candidate standing in the last federal election. They all felt passionately about the highway. “Around that time there was a big flurry of accidents on a stretch we all felt nervous driving on,” Dr Playle says.

“All of us had near misses. There is an area where you can’t turn right onto the highway without risking your life.

“Many of the doctors in our group, including myself, have been nearly run off the highway by large trucks, particularly at night at the end of overtaking lanes.”

Dr Playle says the doctors were shocked by the local candidate’s lack of interest in the issue.

“We decided to suss out what the interest was in a doctors’ advocacy group and we found we had massive interest.”

Sixty doctors joined within four weeks; almost half of the doctors in the area.

The group has achieved extensive media coverage, organised a petition and rally, distributed thousands of bumper stickers and erected signs at blackspots.

The group has copped flak for its efforts, with a few local residents concerned that their signs warning about black spots could distract drivers.

Dr Playle defends the group’s efforts: “The signs were essential prior to Christmas 2010 because there was no black spot signage from the RTA despite many major accidents in the previous 18 months,” she says. “We couldn’t let another holiday period with high tourist traffic and volume go past without warning motorists about what they were entering into.”

Dr Playle says the group’s medical qualifications won’t necessarily mean their advocacy will succeed, but politicians should heed health professionals’ advice.

Having studied a post graduate degree in public health, she believes GPs are ethically bound to speak up on issues that affect their community’s safety, whether it’s bike helmet use, pool fences or injury prevention.

“Advocating a safe major highway for the community to travel on to reach their school, shops, doctors and hospitals is definitely a role for a health professional,” she says.

She says local people question whether to apply for jobs, or attend doctors’ appointments if it means they have to travel on the highway. Doctors in outer-lying areas are missing local educational events because they don’t feel safe driving the highway at night.

Dr Playle does a return trip from Coffs Harbour to Nambucca Heads once a week to work at an Aboriginal Health Clinic. The trip is risky, given half of it is over one of the highway’s most notorious sections. But Dr Playle is committed to her patients, so she’ll keep driving to work and fighting for the highway to be upgraded.

She’s also been moved by Dr Jones’s story. It wasn’t for some months after the lobby group was formed that Dr Playle learnt he had attended the Grafton bus crash.

“It makes me less willing to give up,” she says. “I know he’s been through a lot.”

 

BUS CRASH LEFT ITS MARK ON MANY WHO TRIED TO HELP

Dr Ray Jones’s determination to see the Pacific Highway make headlines is borne not only of the trauma he experienced on the day of the crash.

He understands that a split-second error of judgement on a narrow two-lane highway can wreak havoc on peoples’ lives forever – both victims of the accident and those sent to help them.

“It affected a lot of people who attended the accident very badly,” he says.

“The chief police forensic officer who photographed all the bodies – it was the last job he ever did. The young policeman who had to work out what caused the accident killed himself a year later. The head of the SES had to leave work five years later due to post-traumatic stress disorder and the ambos were all significantly traumatised by it.”

Dr Jones has seen survivors with deep personal wounds that will never truly heal.

He remembers pulling back the blanket covering the second patient he treated at the scene and being shocked by her distorted stomach.

She was eight months pregnant, had a ruptured uterus and was bleeding to death. Her father was a Brisbane GP. She’d been living overseas, but was on her way home to have her baby.

Dr Jones and the hospital intern kept the patient alive with eight units of Haemaccel.

He travelled with her in an ambulance to hospital and remembers the distress of feeling every bump increase her blood loss.

The patient survived. Her baby didn’t.

Years after the accident Dr Jones was reunited with another woman who had survived the crash but lost eight members of her family.

“They were all going on a holiday of a lifetime to the Whitsundays to go sailing. The children and relatives were all killed,” Dr Jones says.

The woman and her husband had been sitting on the side of the bus that wasn’t ripped off. She lost consciousness during the crash and was flown from the scene in a helicopter.

Her husband, who witnessed the horror, struggled to sleep properly after the accident. He passed away 12 months later.

Dr Jones’ trauma has faded, but not gone.

“I guess I suffered from post traumatic stress disorder,” he says.

“I had professional counselling for some years. It was a very significant issue for me, psychologically. It traumatised me severely. My marriage ended up folding up and the accident was a factor in that.”

Before Grafton, Dr Jones conducted autopsies in Grafton and across the rest of the Clarence Valley.

He continued the work for nine years after the bus crash, before realising he could no longer cope with it.

“It reminded me of things I’d seen in the accident,” he says.

 

DOCTORS UNITE FOR ACTION

Doctors for a Safe Pacific Highway want a dual carriageway from Port Macquarie to Ballina.

The group of 70 GPs, specialists and nurses has distributed 4000 bumper stickers calling for action, presented a petition of 3000 signatures to State Parliament, erected signs on unmarked blackspots, generated significant media coverage and held a public rally.

The lobby group’s members come from the many towns dotted along the highway on the mid north coast, as well as small inland settlements like Bellingen and Dorrigo,  which rely on the highway to reach larger centres. They are mindful there is no alternative route from Port Macquarie to Coffs Harbour, or between Woolgoolga and Ballina, and that they live in the key fatigue zone between Sydney and Brisbane.