"[It's] more than just medicine": The value and sustainability of mandatory, non-clinical, short-term rural placements in a Western Australian medical school.

Introduction: In 2005, the University of Notre Dame School of Medicine (Western Australia) established a mandatory, non-clinical rural and remote (hereafter termed rural) health placement program delivered in 2 weeks over 2 years, largely resourced by voluntary human capital. Our study investigated whether the program: (1) encouraged medical graduates to seek rural employment; (2) enhanced their ability to meet rural people's health needs; and (3) was sustainable.Methods: A qualitative descriptive study collected data using semi-structured, in-depth interviews with graduates and placement hosts. Data were transcribed, coded and analysed using Framework Analysis to identify key themes.Results: Twenty-eight medical graduates and 15 community hosts participated. The program validated pre-existing interest in, or positively influenced graduates' attitudes towards, rural practice, and enabled empathy and responsiveness when caring for rural patients in urban, as well as rural, health services. Placement hosts unanimously supported the program and contributed social capital, to ensure its sustainability.Discussion: The program influenced a broad spectrum of students over 15 years and reflects a socially-accountable approach to medical education.Conclusions: This study demonstrates the sustainability and value of mandatory short-term community-based placements in improving medical graduates' responsiveness to the health needs of rural Australians.

'I can sit and talk to her': Aboriginal people, chronic low back pain and healthcare practitioner communication.

BACKGROUND: Chronic low back pain (CLBP) is a complex issue to manage in primary care and under-researched in Aboriginal populations. Good communication between practitioners and patients is essential but difficult to achieve. This study examined communication from the perspective of Aboriginal people with CLBP in regional and remote Western Australia. METHODS: Qualitative, in-depth interviews were conducted with 32 adults with CLBP who identify as Aboriginal. The approach and analysis were informed by clinical ethnography and cultural security. RESULTS: Barriers to communication related to communication content, information that was not evidence-based, miscommunications, communicative absence and the use of medical jargon. Enablers related to communication style described as 'yarning', a two-way dialogue, and healthcare practitioners with good listening and conversational skills. DISCUSSION: Health practitioners need to consider communication content and style to improve interactions with Aboriginal people with CLBP. A 'yarning' style may be a useful framework. Findings may be pertinent to other populations.

Disabling chronic low back pain as an iatrogenic disorder: a qualitative study in Aboriginal Australians.

OBJECTIVES: To determine the low back pain beliefs of Aboriginal Australians; a population previously identified as protected against the disabling effects of low back pain due to cultural beliefs. DESIGN: Qualitative study employing culturally appropriate methods within a clinical ethnographic framework. SETTING: One rural and two remote towns in Western Australia. PARTICIPANTS: Thirty-two Aboriginal people with chronic low-back pain (CLBP; 21 men, 11 women). Participants included those who were highly, moderately and mildly disabled. RESULTS: Most participants held biomedical beliefs about the cause of CLBP, attributing pain to structural/anatomical vulnerability of their spine. This belief was attributed to the advice from healthcare practitioners and the results of spinal radiological imaging. Negative causal beliefs and a pessimistic future outlook were more common among those who were more disabled. Conversely, those who were less disabled held more positive beliefs that did not originate from interactions with healthcare practitioners. CONCLUSIONS: Findings are consistent with research in other populations and support that disabling CLBP may be at least partly iatrogenic. This raises concerns for all populations exposed to Western biomedical approaches to examination and management of low back pain. The challenge for healthcare practitioners dealing with people with low back pain from any culture is to communicate in a way that builds positive beliefs about low back pain and its future consequences, enhancing resilience to disability.

Contributions of local knowledge to the physical limnology of Lake Como, Italy.

This article shows how local knowledge may be valuably integrated into a scientific approach in the study of large and complex hydrological systems where data collection at high resolution is a challenge. This claim is supported through a study of the hydrodynamics of a large lake where qualitative data collected from professional fishers was combined with theory to develop a hypothesis that was then verified by numerical modeling. First the fishermen's narratives were found to describe with accuracy internal wave motions that were evident in water column temperature records, which revealed their practical knowledge of the lake's hydrodynamics. Second, local knowledge accounts emphasized the recurrent formation of mesoscale gyres and return flows in certain zones of the lake in stratified conditions, which did not appear in the physical data because of limitations of sampling resolution. We hypothesized that these features developed predominantly because of the interaction of wind-driven internal motions with the lake's bathymetry, and the Earth's rotation in the widest areas of the basin. Numerical simulation results corroborated the fishers' descriptions of the flow paths and supported the hypothesis about their formation. We conclude that the collaboration between scientific and local knowledge groups, although an unusual approach for a physical discipline of the geosciences, is worth exploring in the pursuit of a more comprehensive understanding of complex geophysical systems such as large lakes.

'Even if we get one back here, it's worth it...': evaluation of an Australian Remote Area Health Placement Program.

INTRODUCTION: In 2006 the Kimberley Remote Area Health Placement Program (hereinafter the 'Program') was established at the University of Notre Dame's School of Medicine (Fremantle campus, Western Australia). The Program was developed as one of the strategies to achieve the School of Medicine's mission to graduate knowledgeable, skillful, dutiful and ethical doctors who will want to work in Australian areas of unmet need. The Program aims to immerse medical students in non-clinical settings to provide them with opportunities to learn life skills required for remote area living, and to introduce them to the myriad of socio-cultural, geographic, climatic and economic factors that impact on the health and wellbeing of remote area residents. To meet these objectives, the School organizes for students to live with, and do useful non-clinical work for, a host community or organization for up to one week. In 2008 the Program was evaluated to explore and assess its immediate and potential future benefits and limitations as perceived by Kimberley residents. This paper reports on the evaluation's findings via Kimberley-based narratives and raises some issues that are essential to training and retaining a 'bloody good doctor...' in a remote Australian setting. METHODS: Using a mix of qualitative, ethnographic methods, the Program was evaluated by an independent researcher during four weeks of field research in late 2008. The methods included a survey, structured and unstructured interviewing and participant observation to elicit data. Thirty-three formal interviews of at least one hour's duration were conducted. Data were also collected via 15 informal discussions. Both formal and conservational interactions occurred in a range of town-based and more remote settings. RESULTS: The majority of persons consulted generally highlighted the Program's benefits. The reasons for this positive evaluation varied, but a common thread was that exposure to the Kimberley introduced the students to local life, a quality that had the potential to result in a medical student returning as a qualified doctor. The Program was seen as beneficial because it provided a structured, constructive means for prospective doctors to appreciate the assets rather than the deficits of remote area living. Another positive implication was that the Program equipped future doctors (regardless of their eventual work location) to treat a person from the 'bush'. It also encouraged students to think and act cross-culturally. An important immediate benefit was that the Program offered human resource support to the host organization at a busy time of the year. In only three of the 33 formal interviews was a negative or ambivalent attitude toward the Program expressed. However, a common concern was the brevity of time students served with their host organization. CONCLUSIONS: The data collected revealed that Kimberley people believed that the Program held strong potential for the successful recruitment of doctors prepared to make a long-term commitment to the region. Never far from their minds, conversations and activities was the idea that the effort they put into accommodating, supporting and guiding the students was worth it because 'If only one good doctor comes from the Program, then that's a good thing. A good doctor would have a great impact - the implications are immeasurable...'.

"I have learnt ... a different way of looking at people's health": an evaluation of a prevocational medical training program in public health medicine and primary health care in remote Australia.

The purpose of this study was to gain insight into what prevocational medical practitioners (PMPs) learnt during a six-month public health medicine and primary health care training program (the Program) in remote Aboriginal Australia in 2001-2002. The Program's curriculum objectives included clinical and public health management of sexually transmitted infections, immunization, clinical audit and quality improvement, primary health care in remote Aboriginal communities, and working as part of an interdisciplinary team with health and non-health professionals, and lay people. The mode and location of delivery of these objectives was determined by the healthcare needs of the Kimberley population, and availability of safe, supported workplaces. Qualitative data from a variety of sources, including PMPs' reflective journals, were examined in the context of the Program's curriculum objectives and by conducting a content analysis of journal notes. Findings are presented using the curriculum objectives and other comments that emerged while examining the data. Preliminary data indicated that PMPs gained knowledge and practical experience in clinical and public health management of sexually transmitted infections, immunization and primary health care in poorly resourced remote Aboriginal settings. Deeper understandings of health and illness in a cross-cultural setting also developed, along with professional and personal growth, as illustrated by the following quotations from PMPs: "I have learnt ... a different way of looking at people's health ... I was encouraged to think more deeply than before about the whys and wherefores of medical practice, and thus consider the most effective ways of influencing patients' behaviours for the better." "I was encouraged to examine the thought processes behind the ways ... healthcare was provided ... [after leaving the Kimberley] I am constantly questioning the reason why we are practising medicine in a certain way in the big city hospitals-much to the consternation of my colleagues ... ." The Program was successful in teaching its first four PMPs the basic tools of public health medicine and remote area primary health care.

Patient views on the management of rheumatic fever and rheumatic heart disease in the Kimberley: a qualitative study.

OBJECTIVE: To describe, from a patient perspective, factors leading to suboptimal management of individuals with rheumatic fever (RF) and rheumatic heart disease (RHD) among members of the Kimberley population. METHOD: Qualitative in-depth semistructured and repeated interviews of seven Kimberley patients, or parents of children, with rheumatic fever and/or rheumatic heart disease, during 1998. RESULTS: Participants showed variable levels of understanding about RF/RHD, often relating to the need for secondary prophylaxis. Compliance with medication was closely linked with positive patient-staff interactions. From the perspective of health care, living in a remote location was frequently described as a negative influence. Participants desire more accessible and culturally appropriate opportunities for learning about their disease. CONCLUSIONS: Participants focused on issues closely related to effective and ineffective management of RF/RHD. The lessons learned are indicators for health staff attempting to improve the quality of management that people receive.