We have just finished our first experience for a long time with a 4th year student,  Tea Williams.  We thought the experience worth sharing as a good example of a positive experience of undergraduate exposure to rural health albeit a short one.

The Auckland University in New Zealand has just reinstituted a 2 week rural GP placement for 4th year medical students. The curriculum goals are broad – their experience is supposed to give them an idea about the issues faced by health care providers and patients living in rural communities.

Our goal was to expose him to as much of the rural community here as we could to get a feel for the place a rural primary care centre takes in the provision of health care to a community.

His first day was aimed at understanding the patient experience – he shadowed a patient from the waiting room through the consultation, sat with our reception staff, and accompanied a patient from the treatment room to the Whakatane hospital by ambulance. Later in the week he saw a patient on a home visit, admitted to Opotiki hospital and after investigation and management of her hip pain, returned to her home.

We also aimed to expose him to the wider primary care team and arranged sessions with the local optometrist, pharmacist, district nurses, Whanau Ora providers, ambulance crew, and physiotherapist – he accompanied them on home visits and on a day long journey up the East Cape delivering medicines.

We wanted him too understand the risks and challenges of a lived experience in a rural community and arranged for him to spend a day with the Vet – he helped castrate several horses apparently, and he was also taken by truck and helicopter into the remote East Cape bush where he helped with “deer retrieval” – he can now gut a deer in about 5 minutes he tells me – a skill he never thought he would learn in his life.

We need to thank the various health providers and community members involved who were very willing to share their time freely to support Tea and us.

They gave Tea a unique exposure to rural health issues that we hope he will reflect on in whatever future career role he has in medicine.

We think this broad experience and open ended curriculum for 4th year students has a lot to commend it to others – a positive experience of a rural community goes a long way to opening the mind of young professionals to the idea of living and working rurally at some future point in their career.

Perhaps Tea will maintain and improve his deer gutting skills – you never know !

There follows a copy of his reflections on the experience and some photographs he took along the way…

Jo Scott-Jones

Reflections on the 2 week 4^th Year Rural Placement at Church Street Surgery, Opotiki.

By Tea Williams.  June 2015.

The mention of rural health tends to evoke the extremes of opinion amongst the modern medical student. On the one hand there are those sure-set on a career practicing as far as possible from the big cities and on the other the medical student who shivers at the thought of leaving the comforts of the urban metropolis.

Admittedly my initial thoughts on rural health leaned towards the latter. Being a born-and-bred Auckland boy I was unsure what to expect coming in to my rural general practice attachment in Opotiki.  Would I have to milk a cow before indulging in my morning flat white? Did I need to review my notes on leprosy? Would there by WIFI?

Prior to this placement I was not naïve to the unique challenges around the provision of primary health care in a rural setting. We learn in medical school about geographic isolation and limited access to resources and services, but for me the real implications of these issues were not understood until undertaking this placement.

In my first taste of rural health I can gladly say that I gained valuable insight into what rural health means for me and changed the way I will practice medicine and interact with patients in the future, especially with regard to my three lessons in rural health.

First lesson in rural heath: Isolation matters

The extent of geographic isolation faced by rural communities could not have been more evident than during my trip down the East coast with a pharmacist, delivering medicines to family homes, dairies and service stations as far as Cape Runaway. Coming from the city it was quite a foreign concept that one may have to drive two hours to a GP clinic for a consult or a repeat prescription and I really gained an appreciation for what isolation means in terms of healthcare provision.

Similarly, on a trip 3000ft up into the mountains on deer retrieval I saw first-hand how occupational hazards in a rural environment differ from those of the city. The office related back-pain and osteoarthritis of the typist now gave way to the bovine tuberculosis of the hunter and the compound fracture of the helicopter marksman.

Second lesson in rural health: The GP is not the only healthcare provider

Coming from the larger urban hospitals it is very easy to lose track of where medicine sits in the spectrum of healthcare. For me it was vital to see how the GP fits into the wider community and how each facet of healthcare works together to provide a comprehensive primary health service.

I initially thought the attachment would consist of me sitting in on consultations, taking a blood pressure here and a flu jab there, perhaps a ride in an ambulance if I was lucky, fortunately this was not the case. Whether it be sanding down the excess skin of hyperkeratosis with the podiatrist, diagnosing keratoconus with the optometrist, or discussing sexual health and rheumatic fever prevention with the school nurse, I gained valuable experience in all the cogs of the rural health machine.

With the growing burden of chronic disease and the ageing population I think this integrated model of primary health care is essential.

Third lesson in rural health: Innovation is key to success

It became apparent to me on this placement that the unique health challenges faced in a rural community merit equally unique and innovative solutions. Telehealth is a programme used at the practice whereby on-call rural doctors can see and talk to their patients in real-time over video. For the rural communities this means improved after hour’s access to clinicians. Furthermore the GP’s at the practice are involved in the PRIME (Primary Response In Medical Emergency), which involves accompanying the ambulance services to assist in emergency situations. I was fortunate enough to assist in an emergency call-out during my attachment and witness the process from initial call-out through to booking up a follow-up appointment.

The whole my short stint in rural health proved to be a serendipitous one. The myriad of opportunities presented to me in Opotiki were one of a kind and the empirical knowledge gained along the way was priceless and will serve to make me a better doctor when 2017 finally rolls around.

I would like to thank Jo and Lailani and fantastic team of nurses and administration staff at Church Street Surgery for their hospitality and for providing me with the invaluable experiences along the way. The patients of Opotiki are in great hands with such a dedicated, innovative and progressive practice.

Tea Williams

 

 

 

He had an agenda, he wanted others who read the story of his day to see the joy and satisfaction that can be derived from a life in General Practice, through the passage of 24 hours in his life he wanted to inspire and sustain, to draw in new people and affirm those who had chosen this life.

He knew this to be an impossible task, every day has it’s pleasure and it’s pain, there would be nothing believable about a perfect day in General Practice, just as no-one would accept that driving a train or being an astronaut was a daily round of bountiful excitement.

But he had been asked to write his story.  One day in his life, “in detail” she had said, everything.

3.00am

He woke, not in his usual state – bladder full – but this time hunted by a giant silver ball in his head –  anxious about the task ahead.

The French philosopher Montaigne wrote, amongst his serious contemplations of the mysteries of life,  a detailed account of his thoughts and actions, of his nagging wife, of his bowel habits and boredom, surely she did not want that detail ?

Maybe more like Samuel Pepys’ reports of his appointments and visits to important people sometimes distressingly bland of detail. But even he spattered the texts with a love of the theatre and ‘pretty things’, being caught in flagrante delicto and heavy drinking – would she want to know everything..really ?

Solzhenitsyn’s Ivan Denisovitch had also woken feeling sick on his day. A day in the gulag had more than a fair share of pain, but by the end of it even there, he had found satisfaction, even pleasure; in his fellow man, and in finding the necessities of life.

Perhaps it would not be so hard, to inspire and sustain, inform and entertain with the tale of a day in the life of a rural GP.

4.00am.

He checked his emails..six..none for Viagra or penis enlargement – the spam filter was working well .. one from a patient telling him about the latest specialist appointment and the surprise offer of further shoulder surgery.

He read between the lines. This man was telling him off, he should have been prepared, the months of waiting, the physio, the pain and suffering had been wasted, he could have been fixed so much sooner if only his GP had been a better diagnostician and decided to refer him sooner.

Shuffling off  self-recrimination, he replied all “jolly hockey sticks”, it never paid to read between the lines of an e-mail, face value communications at best – the modern equivalent of tipping one’s cap from a passing carriage “hale fellow – well met.” At least the mail would show he was doing this in the early hours.

Another  .. a paper had been rejected from another journal – this work was supposed to be fun. That weekend it had been – talking to the practice nurse conference “From Maids to Masters” about standing orders. He had left in all the jokes and taken out all the graphs, a good move given that they had put him on first thing Sunday morning after “the Maids” had had a heavy conference dinner and danced all night.

He believed standing orders would help expand patient services and could help practice team development, it was important to spread the word, enthuse people and provide good tools for their use.

His brother in law was researching a cure for AIDS and TB in Kenya – he tried not to live a comparative life, but it was hard sometimes.

The dog needed walking, an hour’s stroll along the beach whilst the sun rose, listening to his iPod. His playlist compiled as he “walkied” a rather ambitious blend of Hamish and Andy – two loveable Ozzie lads –  BBC Friday Night Comedy, Scientific American and The Archers – an ancient UK radio soap opera about the lives of people in the small fictional town of Ambridge – the local stately home estate is planning a horse race, scandal !

Podcasting was his entertainment life, iTunes fired up whenever his computer booted and updated each of his 51 chosen programmes. These self selected radio shows and educational broadcasts made up his listening diet whenever he was alone. He wore huge hearing protectors over his ear pieces whilst he mowed the lawns, so the noise of the machine did not drown out the “Best of Today” or “Health Matters.” NASA, National Geographic, TED talks and New Yorker Cartoons entertained him in waiting rooms, on flights and in the bath.

Reading was confined to bedtime Harry Potter with his daughter – the final book, the final chapters, the final daughter, a whole lifetime of bath, books, bed.

During breaks in work he would dip into BPAC, NZ Doctor, Obs and Gynae Journal, JPHC and NZMJ and BJGP- but probably not enough.

7.00 am

Home for breakfast, he woke the wife with a coffee, showered and the frantic school preparation began- lunches to make, teeth to brush, clothes to find and shake free of yesterday’s mud  – for his daughter not himself – cheque in an envelope – whatever happened to state funded education?

Mobile coffee made, he bundled off to work, a 25 minute drive with Garrison Keillor reciting poems over the car stereo.

8.00am

Check in on his computer and go over results, patients already waiting whilst he greeted the staff with a cheery grunt and lit his oil burner. The washed who came in after the great unwashed appreciated lemongrass and lavender generally.

(One patient had been horrifed “You don’t have that going all day do you ?“ Quack  “It’s very dangerous to have lemongrass in such concentration it will give you cancer” Quack.)

Fifty three results and scanned letters to view.  For many years he had been building a knowledge of these people, some of course were new to him, but many names triggered brief life histories in his head.

A poor HbA1c- man with a wife and a fishing addiction, overweight and under exercised mentally and physically, in town for years but still hankering after the busy town life that economics had driven them from.

A normal FBC – a busy woman with a family and an unmotivated husband -trialed for years by an illness that was getting better but would take many more months to overcome.

He greeted the GP registrar, shared news of the night on call, a few phone calls from the nurse but nothing major.  He settled in to his patient-filled day.

His morning was punctuated with three phone calls. Two from the chemist checking that the prescription he had just written for the medication he had just arranged to give the patient he had just seen was the medication that he intended to give and in that dose.

He had taken to writing “This is deliberate -I know what I am doing” on scripts the week before as this was not in uncommon occurrence. They needed a meeting.

The other call was from the hospital, the Sparky Young House Surgeon transferring Mr Cellulitis back to the cottage hospital, apologetic as the old school consultant had put him on IV Penicillin and Flucloxacillin, a very old school combination, but it had worked, “surprisingly” or so it seemed to Sparky.

Fifteen patients before lunch, another fifteen booked for the afternoon. A full “blue” book. But the day’s “blue” appointments gradually turning “yellow” as extra patients were fitted in…

08.30am  Morning:

Mr Diabetes Review.  Mr Stop Smoking (day 7.)

Mrs Back Pain Off Work.  Miss Infected Eczema.

Messrs Scabies and Lice and Sores and Snotty Nose.

Mr Cough. Miss Buckled Up With Abdominal Pain.

Mrs Medication review. Mr Erectile Dysfunction.

Mrs Discharge Transition Admission For Stroke.

Master Earache.  Mr Testicle swelling.  Mrs Sprained Ankle. Mr Arthritis.

Mr My life Is Shit, Cough, Cough, Cough, Cough.

Mr Man in A Wheelchair Insurance Form.

Mr Funny Mole On The Ear And My Wife’s Affair.

Did she want him to write the details ?

Roger Neighbour talked about the 2 other people in the room in each consultation: the subconscious doctor and the subconscious patient, searching for what is unsaid.

Listening to those inner voices whilst Earache’s mum talked, revealed anxiety about the MMR vaccine. Testicle swelling had a cancer fear, Infected Eczema feared a DVT.

No-one had only one problem and his own voice needed constant attention to keep it focused:

“When he asks for an off work certificate why does the hair on my neck go stiff ?” “When abdo pain screeches try not to let your face show you think it sounds funny.”

The pleasure and the pain.

He chatted to the GP registrar. Her morning had been much the same, she told him of the exemplary management of all her cases.  He felt his contribution was to listen and affirm, to reassure, but was this education?

Teaching theory would talk of apprenticeship learning.  His burden was sharing the decision making vicariously.  Perhaps a CXR would have been good, maybe think about the unexpressed fear of dementia next time.

12.30pm  Lunch.

Half an hour in the local café. Alone with the paper, a bacon wrap and a cup of strong coffee, head down, he avoided eye contact with yesterday’s Chlamydia out of fear of triggering an embarrassed response. He made no decisions.

1.00pm  Afternoon.

Mrs Review The Drugs – Stop The Beta Blocker.

Mr Carpal Tunnel Syndrome And A Funny Mole.

(Discuss new vaccine schedule with nurse.)

Master Heel Pain . Mr Impetigo.

Mr Severe flank pain – admit to hospital.

(Discuss 2 patients with rest home manager.)

Mrs Atrial Fibrillation Counsel About An Operation.

Miss Infective Exacerbation Of Asthma.

Master Epididymal Abscess.

Mrs Review The Drugs And Chase Up Surgery.

Mrs Depressed and Fat For Sickness And Loan Form.

( Telephone from chemist are the rest home scripts right?)

Mr My Wife Says I’m Cold To Her Touch.

Mrs Worried Well Results. Miss Spots and Flu.

Miss Urinary Tract Infection and Medication  Review.

He checked his e mails. Twenty Four. None for Viagra or penis enlargement – strange.

Two from the Professor – put the papers to a different journal, apply to a different ethics committee.

One from the DHB – a newsletter from the GP liaison – One from the college asking for volunteers to do a Cornerstone visit, minutes of the PHO Board meeting to approve,  PHONZ asking for expressions of interest in a new pilot project, Australian students confirming their elective, Swiss friend asking how goes it, BMJ and NZMJ and NZ Doctor and Medscape, MOH minutes of a Taskforce meeting.

He went through his in tray – insurance forms to complete.

Would he put them off until another day?

Does the pope wear a funny hat ?

ECGs to review, Spirometry results, newsletters from ACC and plastic covered bumpf from the drug companies, he discarded into  the rubbish 50 % of the mail after a cursory glance, completed a questionnaire for a university researcher about the elderly, and switched off his computer.

5.30pm.

He chatted to the GP registrar, the afternoon had thrown up a problem, literally in the form of a child who had been vomiting repeatedly and become sufficiently dehydrated to warrant admission, the hospital doctor had been obstructive but she had stuck to her guns, confidence growing, what else could  have been done ?

He discussed a planned trip to the local amateur dramatic production for the staff outing.

The receptionist stopped him as he left.

Venison had been left by ‘My Life Is Shit, Cough, Cough, Cough, Cough’ freshly butchered from a newly slaughtered beast.

A bag of beans had been left by Mrs Review the Drugs.

He popped over to the hospital. Mr. Cellulitis was happily settled into the ward, eating what could have been a roast dinner at one time, but was now what could only be called ‘hospital food’ – the amorphous gray green slime collected into pockets on a harshly cleaned plate that always reminded him of the film “Soylent Green.”

He drove home, listening to Stephen Fry, and part of Agatha Christie’s Radio Mysteries.

He stopped to check no-one was hurt at a minor crash, a car spun off the road in the gorge, just around the corner from where he had written off his own car two weeks previously answering his cell phone whilst driving to an out of hours clinic.

6.15pm

He arrived home just after the family and asked his wife “How was your day?” He wandered off the bedroom to change whilst she expounded upon the daily grind of a teacher in a high school. He mistakenly thought she was oblivious to his absence.

A cycle ride, “Health Matters” and “TED Talks” on the iPod, and then tea.  Venison steaks and fresh green beans.

Bath, Harry Potter, Bed for the daughter and the Food Channel to numb the brain for his wife before bed.

He wrote it all down.

He wondered about you. Inspired ? Sustained ? Informed ? Entertained ?

He thought “there is joy in each day and that’s not bad.”

He contemplated the list of conditions he had dealt with. The human contact and connections that he had made. The lives he had changed. The people he had helped.

He had not found a cure for AIDS and TB in Kenya, but every day was different, every pain and cough had a unique story, he was making a difference atom by atom, doing what he could.

He loved his work.

He thought of an empty chair in an empty room and fell asleep.

Jo Scott-Jones

(A version of this story appeared in NZ Doctor Magazine in 2008)

Implementing Change Workshop. #woncarural2015. Dubrovnik. 

Facilitator Martin London NZ / Scribe Jo Scott-Jones 

The workshop was well attended by people from South Africa who were effecting change for small rural communities, from Canada – who were facing government imposed changes and wanting to learn ways to change for others, from the USA seeking international perspective on change, from Ireland having undertaken significant change looking for more ideas, and from the UK  a work renowned expert able to share expertise about change through organisations. 

The process was one of “snowballing” discussion starting with pairs and building to larger groups, than sharing generated ideas to the whole group. 

To draw out initial ideas The facilitator made each pair speak to each other for two minutes without interruption starting each sentence with “One thing that has changed for the better in my practice has been… ” there were two iterations of this until the larger group feedback. 

Our workshop findings are below: 

Critical Landmarks on the Journey to Change 

There is a need for persistence, patience and time to enable change 

5-10-18 years is not uncommon. Be ready for rapid change because when it comes it will happen quickly. 

In terms of workforce problems train in rural for rural, a culture of learning is a fertile ground for change. 

Courage and Critical Mass 

Once there is opportunity there needs to be enough people in place to move with the cascade of change, face to face meetings work well, the people need a shared courage to make the move. Use IT resources to maintain conversations in between meetings, they can especially be helpful for the diaspora of people in rural communities. 

Demonstrate value

There will be barriers to change financial, or political keep the dream you have for your patient in focus. Cost effective change is a key to enabling change so you need to understanding “value” you can bring to the table. Resources go to what is measured. 

Cost effective discussions are hard, seek advice. 

Build on your strengths, we often circle the drain and focus on problems – celebrate what you do well. 

Opportunity prefers the prepared mind – having a vision and sharing it is important even if it is not implemented straight away it is part of the preparation for others. 

In South Africa, private practices often need to shift into government policy, a lightbulb moment has been that the private practice is demonstrating great care it can drive the government to change. 

Sometimes it is important to make a step change away over major structural barriers but sometimes major structural barriers can be changed if the right people understand. Elevate the conversations to the people above the barrier – use the organisations. 

Resistance is futile

You can always go up, down, round, or through – remember the shadow system in complexity theory – the shadowy power brokers if exposed can be extremely helpful. 

Identify the shadowy powerful people, get to know them, bring them into the rural areas, allow them to taste the vulnerability of distance, demonstrate hospitality and they will be friends for life. 

Rural Health Hero Test (after ZeFrank) 

It is safe here. 

Imagine We are surrounded by a soundproof glass bubble that protects us from all outside, only you and I are here and you and I can be honest with each other without fear. 

This test is designed to show if you are a rural health hero or not. 

Your only task is to answer honestly, by sitting down if the answer to the question is “yes”. 

Have you ever trodden in cow shit on your way to a home visit? 

It’s OK. You are with friends. 

Have you ever been chased by a gravel path by a goat, goose, dog, cow or chicken? 

Have you ever fallen over a wire fence at the scene of an accident and heard police, ambulance and fireman laugh  ? 

it is OK, you are with friends here,you are a rural health hero

Have you ever been on a home visit and had to have your car rescued by a tractor because it fell off the side of the road because the road was narrow and your reversing skills too poor? 

Have you ever fought with a manager or government official over the future of a service to your community? 

Yes. You are a rural health hero. 

Have you ever tried to match up skin edges ragged by a chainsaw? 

Have you ever fallen asleep in front of a patient on a warm afternoon after a busy  weekend on call?  

Have you ever spent an afternoon persuading a patient the trip to town to get healthcare is worth it? 

Have you ever seen a man, a barn, a gun, his blood and brains? 

Have you comforted a spouse in a kitchen left behind to deal with the debts? 

Be calm, you are safe here, you are a rural health hero. 

Has your spouse ever been asked by a stranger in the street if you have the results of their Chest X-ray ?

Have you ever sat at a family dinner party with your best friend and his wife who you have just treated for an STI that she caught from someone who is not at the party? 

Have you seen someone’s inner thigh in the cereal aisle of the local shop? 

You are safe here. It is OK. You are with friends. 

Do you live in a most beautiful house ? Is the view from your window amazing? Do you breathe clean air and walk in forests, fields, beaches, or mountains after work ? 

Have you ever thought your was the best job in the world ? 

Have you ever wondered what will happen next and smiled? 

It’s Ok, I see you have all passed the test, well done, you are all rural health heroes. 

Jo Scott-Jones 

(More on rural heroes can be found here  Rural Heroes) 

http://www.nationalruralhealthconference.org.nz/nrhc15 

 People who have an interest in the health and wellbeing of rural communities will find substantial benefit from spending time at the National Rural Health Conference 2015 in Rotorua this year. 

 Rural communities are high needs communities, they have populations that are characterised by a high proportion of Maori, and poor socioeconomic profile. 

New Zealander of the year Lance OSullivan’s opening keynote will highlight some of the positive things that are being done in rural communities to address the gaps between mainstream and Maori New Zealanders.  This will be followed by Health Minister Jonathon Coleman who I am sure will talk about the current direction of travel of government policy and how initiatives like Alliancing are impacted on the way services are delivered. 

 The conference has clinical, research, management, hospital and community streams that reflect the pressures and issues that face rural health providers and communities.

Farmers, local government officers, rural business owners, NGOs and others will find specific conference presentations that will open opportunities and address the pressures they face in their daily lives. 

 Dr William Rolleston , National President of Federated Farmers will chair two presentations and workshops  about health and safety reforms implemented by WorkSafe NZ and the implications for rural businesses and workers, and around mental health issues, which remain a significant pressure in rural New Zealand. 

 Rural Communities in New Zealand have been referred to as “zombie towns” recently by an influential economic expert, to counter this world view Dr Ernesto Sirolli is coming back to New Zealand to present and run a workshop focussed on building community resilience and developing the economies of small communities.  Ian Proudfoot of KPMG will present on how rural communities can best equip themselves to deliver to global food markets. 

 New Zealand relies heavily on rural communities for its economic health, and the health of those  communities is vital to enable an effective workforce. All rural communities need to look at ways of futureproofing their rural health provider teams and leading rural educationalists will talk about how we ensure that we maximise training opportunities in rural communities. 

 What is amazing is that this is all on day one, and it represents only a small reflection of the opportunities the conference will offer to delegates. 

 Day two has more opportunities to work with Dr Sirolli on how to grow local economies,  inspiring stories from rural health students, developing sustainable health services, shifting services closer to home, challenges for Maori providers, technological advances in rural communities,  and how we best advocate for equitable sustainable services. 

 It is going to be a busy weekend – if you have an interest in the health and wellbeing of your community and want to socialise and network with like minded others – make time to be there !