rural medicine griffith university lecture mbbs 2016 cohort

RURAL AND AGRICULTURAL MEDICINE LECTURE SERIESProf Scott KitchenerClinical and Academic Lead, Rural Health

Teaching at Education HUB Day at the Darling Downs Clinical Training Centre (DDCTC)

Studying Rural & Agricultural Medicine

Lecture series by Year Introduce Rural Medicine Rural Medicine in practice – Year 2 Introduce Agricultural Medicine – Year 3

Introduction to Rural MedicineFirst Year Learning Objectives

Define Rural Medicine Become aware of the socio-

economic issues in rural communities

Appreciate the epidemiology of Rural Australians

Understand the nature of health care in Rural Australia including briefly discussing current issues

Outline of further lectures

Clinical Scenario at Education HUB Day at the Darling Downs Clinical Training Centre (DDCTC)

Studying Rural & Agricultural Medicine

Introduction to Rural MedicineOutline of further lectures

Rural opportunities in Griffith program

Cancer, Mental Health, Prevention in Rural

Agricultural health, Zoonoses, Tropical Disease

The Queensland Rural Generalist Program

Rural Medicine What is it? Why is it different? Is rural health different? Why?

Clinical Scenario at Education Day on Jilliby Woolshed, Tenterfield

Studying Rural & Agricultural Medicine

Clinical Scenario at Education Day on Jilliby Woolshed, Tenterfield

Studying Rural & Agricultural Medicine

Clinical Scenario at Education Day on Jilliby Woolshed, Tenterfield

Studying Rural & Agricultural Medicine

Where is rural? http://www.doctorconnect.gov.au/

internet/otd/Publishing.nsf/Content/locator#

ASGC-RA are not designed for health

Rural Medicine

Defining Medical Specialities

by organ system? Gastroenterology

by the procedure used commonly? Surgery

by geography? Tropical medicine

by the nature of medicine practiced? Primary care physician

Generalist practice (ACRRM) Undifferentiated acute and chronic

health problems Un-referred patient population Continuing care for individuals Preventative activities Population health interventions Responding to emergencies as

appropriate; Hospital-based secondary care Obstetric care

PNG Health Project

Studying Rural & Agricultural Medicine

Melbourne RCS “concepts” of rural practice Rural-Urban health differentials Access (to health care) in rural Confidentiality issues peculiar to rural Cultural safety – understanding rural

culture Team practice

The Domains of Rural MedicineACRRM Core clinical knowledge and skills for

generalist practice; Extended clinical practice; Emergency care in generalist practice; Population health in generalist practice; Aboriginal and Torres Strait Islander

health in generalist practice; Professional, legal and ethical practice

in generalist practice; and Rural and remote context in generalist

practice.

Rural Longlook student with patient (Kingaroy Hospital)

Studying Rural & Agricultural Medicine

RACGP National Rural FacultyThe Faculty expects Rural GP to be more likely to:

also provide in-patient and after-hours care,

hold public health roles in discrete communities,

perform procedures and emergency care,

practice more complex and chronic health care, and

see more indigenous people.

Context of Rural Medicine Cultural competence Respect the community norms Respond to the community needs

develop extended skills to meet the community needs

Self awareness and personal/professional balance

You are rarely alone but it can be lonely

Rural Longlook student with patient (Kingaroy Hospital)

Studying Rural & Agricultural Medicine

Rural Medicine The health of rural Australians Rural Mental Health Mining and Rural Industrial medicine Agricultural medicine In-patient care Indigenous health Procedural obstetrics, anaesthetics and

surgery Retrieval and emergency medicine

In-patient care in Rural Practice

In-patient care tips & traps Who to admit, or not admit, How to bill, or not bill, Who to include in the care, How to treat the nursing staff, What treatment to start and what not to

start in rural hospitals, When to discharge, how to discharge, who

to help discharge, When to call, who to call, when to refer.

First Year Learning Objectives

Become aware of the socio-economic issues in rural communities

Rural Population Health 1/3 Australians live rural 2/3 of Indigenous Australians There are proportionately more

children Aged rural Australians go to

regional centres

Socio-economic issues in rural communities

Queensland

PROPORTION OF POPULATION BY REMOTENESS AREA - Census 2006 Major Cities 60.0% Inner Regional 21.8% Outer Regional 15.0% Remote 2.0% Very Remote 1.2%

Queensland has the greatest rural and regional population

Socio-economic issues in rural communities

Rural Health determinantsThe reality of rural health is that it is determined by a combination of: Socio-economic and cultural differences

in rural communities including both occupational and environmental exposures,

and rural lifestyle; and

Access to health care services.

Socio-economic issues in Australian R&A health <1% of Australians are farmers and this is

falling yearly Less diversity, mechanisation, mega farms Internationalisation

China, Brazil, Argentina, India Vertical integration Consumer awareness

Rise of niche markets, organic enterprises, GM issue Biosecurity (BSE, swine flu, bird flu etc) Food security, food safety

Socio-economic issues in Australian R&A health

Family farms – still the majority of farms Families in proximity to agricultural industry Migrant and seasonal workers Connectedness of the rural community

economic dependence Competing interests:

Mining, Subdivision of land Succession planning

Contemporary issues Flooding after a decade of drought & fire

– El Nino Ill-informed agricultural trade policy

changes Foreign ownership of AUS farms and

water Murray-Darling Basin allocation of water Concentration of food retailers in AUS Mining interests raising costs &

FIFO/DIDO populations moving

An ageing workforce

Socio-economic issues in rural communities

Click icon to add picture

Of self-employed

Socio-economic issues in rural communities

Click icon to add picture

With limited incomesReal farm cash income, broadacre industries, average per farm

Socio-economic issues in rural communities

Issues with mining rural landhttp://www.abc.net.au/news/2016-04-15/linc-energy-goes-into-voluntary-administration/7331154

Socio-economic issues in rural communities

Foreign OwnershipQIC purchase NAPCo

Socio-economic issues in rural communities

Foreign OwnershipQIC purchase NAPCo

Socio-economic issues in rural communities

Foreign OwnershipQIC purchase NAPCo

Socio-economic issues in rural communities

www.longpaddock.qld.gov.auThe Department of Agriculture and Fisheries, QLD

Socio-economic issues in rural communities

Retail control of milk on the dairy industry

Socio-economic issues in rural communities

The Social Determinants Of Health

Rural people have

Lower income, employment, education

Higher occupational risk (farming, mining)

More distances to travel Less access to fresh food (!!), and Less access to health services.

Australia’s Health 2010, p245

Hope4Health Education Day

Studying Rural & Agricultural Medicine

First Year Learning Objectives Appreciate the epidemiology of Rural

Australians Understand the nature of health care in

Rural Australia including briefly discussing current issues

Life expectancy is lower in rural areas

Rural epidemiology & nature of rural health care

Increased rate of death with remoteness from cities and being indigenous

Rural epidemiology & nature of rural health care

Preventable deaths in Queensland significantly greater in rural and remote areas and especially indigenous people

Rural epidemiology & nature of rural health care

Epidemiology of Rural Australians Healthcare amenable/treatable

most cancers, asthma, maternal/infant dis.

Preventable conditions lung cancer, injury, COPD, alcohol/drugs,

hepatitis, HIV/AIDS Preventable and amenable/treatable

coronary heart disease, stroke, diabetes

Epidemiology of Rural Australians

Rural burden of disease in Queensland

Overall 6% of Qld burden of disease (BoD) avoided if Rural rates = Metro rates Mental health disorders Cardiovascular disease Cancer3rd CHO Report, The health of Queenslanders, 2010

Epidemiology of Rural Australians

Rurality and chronic disease

Rural ♀ more likely to report diabetes

Yet less likely to report osteoporosis

Arthritis more likely to be reported

Asthma and Bronchitis more reported

Children have poorer dental health

20% more rural ♂ have a phys. disability

Epidemiology of Rural Australians

Excess deaths among rural Australians from:

Coronary heart & cardiovascular Δ

COPD MVA & other injuries Neoplasms – 7% excess deaths Diabetes Suicide

Epidemiology of Rural Australians

Rural cancer inequality

7% higher mortality = 9000 additional deaths in first decade of this century

Disparities greatest in oesophageal cancer and melanoma

Prostate cancer: >18% poorer survival

Epidemiology of Rural Australians

Rural cancer inequality - reasons

Rectal cancer survival in Queensland reduces 6%/100km from radiotherapy centres

Rural breast cancer patients more likely to receive suboptimal therapy – 84% higher mortality

Diagnostic delays with increasing rurality

Undersupply of medical practitioners Lesser early detection Fewer therapeutic services

Burden attributed to 14 selected risk factors, 2003

How do rural communities fare with these risk factors?

Rural Tobacco Use Causes 8% of Australian burden of

disease Rural Australians smoke more,

particularly females and younger

Rural physical (in)activity 6.6% of Australian burden of disease Rural men more likely to report being

sedentary but actually report sitting less Rural Australians are much more likely to

be obese and report more hypertension (7.6% BoD),

particularly indigenous Australians

Obesity in Rural QueenslandersRural Queenslanders are much more likely to be obese

Rural risk-taking behaviour Rural males more

likely to undertake risky behaviour while intoxicated with alcohol

Rural risk-taking behaviour Drug use

responsible for 2% of total burden of disease

Illicit drug use less common in rural Australia!

Poor nutrition in rural Australia Contributes to 2.1% of Australian BoD Rural Australians less likely to eat low fat

or fruit But eat more vegetables and report high

cholesterol less (possibly as less tested) Rural females report more food

insecurity

Rural cancer Incidence much higher among rural

Australians, particularly Melanoma (60% of excess cases) Colorectal Lip Lung

BUT Survival α 1 / distance to city, eg. Prostate cancer

Injury in rural areasDemography and health status - Injury: 7% of BoD in Australia Prevalence higher in rural Australians of

An injury in last four weeks A long term condition due to an earlier

injury Road transport death

Queensland 2006-2007

Road Transport Death Rates Differentials

Rural OHS Farming the land and seas is dangerous Families live close to where they work

Rural OHSOn-farm injuries – 60/100 farms/year Most dangerous (most claims):

Livestock and related grain farming Poultry Support services, then Dairy farming, Cropping, Horticulture, etal.

Rural OHS ~ higher than previous study findings

Involved CasesEquine 40Bovine 36Porcine 6Ovine 1Ornithine 1

Machinery 55Wood/timber

12

Gender NumberFemale 53Male 155Total 208Average age

39.8 years, SD: 17 years

Animals and machinery Gender

Rural OHS

Triage category Frequency PercentCategory 2 10 4.8Category 3 78 37.5Category 4 106 51.0Category 5 12 5.8No data 2 1.0Total 208 100.0

Agricultural injury presentations to rural hospitals on the Darling Downs, Mar-Oct, 2015

Rural OHS

Triage category Frequency PercentCategory 2 10 4.8Category 3 78 37.5Category 4 106 51.0Category 5 12 5.8No data 2 1.0Total 208 100.0

Agricultural injury presentations to rural hospitals on the Darling Downs, Mar-Oct, 2015

Nature of injury Frequency

Percent

Cut/laceration 59 28.4Puncture + penetrating wounds 8 3.8Bite 2 1Superficial abrasion 18 8.7Other wound inc. amputation 7 3.4Haematoma/bruising 32 15.4Haemorrage 2 1Inflammation/oedema/tenderness 6 2.9Burn – full & partial thickness 7 3.4Foreign body in soft tissues 10 4.8Crushing injury 29 13.9Fractures & dislocations 35 16.7Sprain/strain 48 23.1Poisoning 1 0.5Aspiration or respiratory difficulty 2 1Electric shock 2 1Concussion 12 5.8

Skin trauma 60%Musculoskeletal injury 30%

Agricultural safety and health? 77% of farmers visited their GP in last

12/12 15% - Qld farms reported lost days to

injury 9 working days per farm to on-farm

injuries

The rural GP is very relevant in Ag OHS

Rural Mental Health Epidemiology

Should you be expecting a differential between urban and rural incidence?

Outcomes differential Shortage of resources, esp. MH

professionals Access to preventive & Rx MH services Perception of access

Rural Mental Health

Factors in mental ill-health: Poverty, unemployment, SE class Female, unmarried, separated Alcohol Significant life events recently Perceived social support

Social disadvantage more common in rural Rx benefit being closer to the community

What factors operate locally?

Post-disaster mental health

“Significant Life Events” in rural Qld as opposed to higher prices in Woolies

Rural coping: Problem focused, Optimism, positive appraisal Cognitive dissonance, denial, avoidance Community cohesion

Time in a community increases diagnostic sensitivity and awareness of management options

Specific local contemporary factors

What about the health care provided?.

So there are lots of rural Australians they are less well off, less well, and have higher risk factors for ill health.

The nature of health care in rural Australia

Cloncurry Hospital

Primary care based

QH primary care + GP integrated

Marginal viability

Clifton Medical Practice

ABS, 2013

No. specialists and GP/100,000 people by remoteness

Employed medical practitioners (FTE/100,000 population)

Major c

ities

Inner

region

al

Outer re

giona

l

Remote

/Very_

x000d

_remote

(d)0.0

100.0200.0300.0400.0

Clinician General practitioner (GP)(f) Specialist

Rural & regional specialty services

Health Expenditure per person

00.10.2

0.30.40.5

0.60.70.8

0.91

RA1 2 3 4 5ASGC-RA

Medicare services Pharmaceutical benefits

Medical & Dental practitioners by remoteness area, 2005 (AIHW)

0

50

100

150

200

250

300

350

MajorCities

Inner Reg. Out Reg. Remote

FTE/100,000GP/100,000Dentists/100,000

Take home message

Overall First Year Learning Objectives

Take home message - Rural HealthThe reality of rural health is that it is determined

by:1. Socio-economic and cultural differences in rural

communities including both a. occupational and environmental exposures,

and b. rural lifestyle; and

2. Access to health care services.

The strengths of Rural Medical practice are:3. Rural cultural competence and local

epidemiology knowledge4. Longitudinal diagnosis and management

NOT

Second Year Learning Objectives Rural Medicine in practice

Socio-economic issues of rural and agricultural health updated

Contemporary issues in Rural Medicine & health care delivery, that you should know

Rural Mental Health Cancer in Rural Australia Preventive health in rural generalist practice

QRMLP

Third Year Learning Objectives Contemporary issues in Rural and

Agricultural medicine Introduction to Agricultural Medicine

Agricultural occupational health and safety Clinical agricultural medicine

Zoonoses; Agricultural Respiratory disease OR LIVE IT: Longlook 4th year Rural GP

terms, Selectives, Electives (incl. OS) Training pathways to Rural Medical practice

The Rural Generalist Pathway; FARGP

Research opportunities in the Rural Program

Longlook research projects Year-long in supervised research groups Report to the HHS – can go on your CV Presentation at RDAQ or other

conferences Publication

Research opportunities in the Rural Program

Summer Scholarships (also look good on your CV)

Can begin in first year summer if available

Longitudinal across summers if you wish Presentable, publishable Free accommodation Some are funded scholarships

Queensland Rural Medical Longlook in 2017-18-19

Clifton

Blackbutt

CherbourgGympie

Maleny

QEII Hospital+ Nathan Campus

Opening Gympie Hospital with a comprehensive LIC

Expanding blended LIC to Maleny and JandowaeOpening an amalgamative LIC between Goondiwindi + Nambour

Dalby Clinical Education Centre

University Hospital

Sunshine Coast UniversityPre-Med

Continued blended LIC

Continued comprehensive LIC

Rural Centre

Devolve Hub teaching to Warwick and Kingaroy (MMM4)

Third year Longlook with patient

Any questions