rural medicine griffith university lecture mbbs 2016 cohort
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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