Rural workforce challenges: Why not rural psychiatry?

OBJECTIVE: The Australian psychiatry workforce is under-subscribed and highly urbanised. Currently, 90% of psychiatrists work in the cities, and there are significant projected workforce shortages of psychiatrists throughout Australia, particularly in rural and remote locations. This qualitative study explores factors influencing medical students and junior doctors' decisions to pursue a career in rural psychiatry. METHOD: Using a phenomenological approach, data were collected through semi-structured interviews and focus groups and subjected to thematic analysis. RESULTS: Sixteen participants were interviewed, 11 interviewees and five participants from two focus groups. This study identified enablers and challenges in pursuing rural psychiatry training in Australia. Clinical exposure to rural psychiatry, personal factors, rural lifestyle and workforce shortage awareness were identified as enablers. The lack of rural infrastructure, the attractiveness of urban psychiatry and the stigma toward rural psychiatry were identified as barriers. CONCLUSIONS: Australian rural psychiatry workforce remains a complex issue. Reinforcing enablers and addressing barriers identified in this study would benefit future rural workforce initiatives.

Exploring barriers to domestic violence screening among culturally and linguistically diverse and migrant women in a regional midwifery setting.

BACKGROUND: Women are at an increased risk of experiencing domestic violence (DV) from an intimate partner during the antenatal and post-partum period, contributing to poorer health outcomes for mother and baby. The antenatal period presents a critical window of opportunity for screening and intervention. In Australia, screening guidelines vary across state and territory health departments. NSW Health has introduced compulsory antenatal DV screening, however, screening appears to be more commonly deferred for women of CALD and non-English speaking backgrounds suggesting barriers to screening. AIM: To identify barriers to undertaking DV screening of culturally and linguistically diverse (CALD) and migrant women in a regional setting METHODS: Qualitative semi-structured interviews were conducted with midwives who undertook antenatal DV assessment at a regional hospital in rural New South Wales serving a high CALD and migrant population. FINDINGS: Eleven midwives participated in the interviews. Four emergent themes were apparent as barriers to DV screening: communications challenges, including literacy and use of interpreters, issues with maternity services including lack of flexibility and continuity, a woman's family issues and cultural difficulties. CONCLUSION: The antenatal period presents a critical window for screening and intervention for those living with intimate partner violence from CALD and migrant groups. While it is acknowledged that there are complex language, maternity service, family and cultural barriers that impact on the ability to undertake screening in a regional setting, recognising these is the first step in addressing them and being able to intervene to break the DV cycle.

Giving birth in the Murrumbidgee region: A quantitative and qualitative approach to general practice obstetrics in a rural region.

OBJECTIVE: There is public concern regarding rural workforce shortages and closure of smaller obstetric centres. AIM: To identify whether safety is a concern for Murrumbidgee hospitals that fit primary medical care models and ascertain general practitioner (GP) obstetricians' perspectives regarding the benefits and challenges to practising in the region. DESIGN: Mixed-method retrospective analysis of selected outcomes in the NSW Mothers and Babies Reports 2012-2015 and semi-structured interviews with GP obstetricians. SETTING: Murrumbidgee Local Health District. MAIN OUTCOME MEASURES: Evaluation of the safety of smaller hospitals (i.e. discharge status at birth, neonatal resuscitation and admission to intensive care); and iterative thematic analysis. RESULTS: This study provides evidence that smaller hospitals are providing safe obstetric care. Fewer babies were transferred, with fewer stillbirths, at the smaller hospitals and no difference in newborn deaths. There were more normal vaginal births in the smaller hospitals (70.0%) than in Wagga Wagga Base Hospital (57.2%) or Griffith Base Hospital (58.6%). There were fewer neonatal resuscitations in the smaller hospitals than in Wagga Wagga Base Hospital or Griffith Base Hospital. More than one-quarter of babies were admitted into the special care/neonatal intensive care for both Wagga Wagga and Griffith Base Hospitals; however, the rate was <3% in the smaller hospitals (p < 0.001). GPs were overwhelmingly positive about the professional rewards of GP obstetric practice and the importance of continuity of care, despite barriers such as workforce shortages, loss of facilities and other staff (midwives and anaesthetists). Possible solutions included fostering support systems, proactive succession planning and improving training support. CONCLUSIONS: GP obstetricians are providing a valuable, safe service in MLHD with both personal and community benefits.

Evaluation of a Lifestyle and Weight Management Program Within Rural General Practice.

INTRODUCTION: Australia has one of the highest rates of obesity in the developed world. In response to increasing rates of overweight and obesity in rural Australia, one regional primary health network commissioned the development of a multi-faceted weight and lifestyle management program, addressing nutrition, physical activity, and psychological approaches to behavioral change. This study evaluated the success of the program that was implemented in multiple general practices within regional New South Wales. METHODS: De-identified data were received from 16 general practices that participated in the Murrumbidgee Lifestyle and Weight Management Program (MLWMP). Patient weight outcome and functional status measures were determined using descriptive statistics (SPSS). RESULTS: Mean body mass index (BMI) of the 1217 participants was 37.4 kg/m2 and 75% of participants were female. Almost 40% of participants who had a BMI ≥ 40 kg/m2 had been diagnosed with a mental health condition. Upon completion of the program at 6 months, participants had lost an average of 3.2 kg. Over 31% of participants had lost at least 5% of their initial weight and 40% had reduced their waist circumference by at least 5 cm. Overall health and functional status measures were significantly higher upon program completion. There were significant improvements in quality of life measures regardless of level of weight loss during the program. CONCLUSIONS: The MLWMP, implemented in general practices within rural and regional Australia, had positive effects on both practices and participants demonstrating the value of intervention programs in primary care. Participants achieved a modest reduction in BMI, waist circumference, and weight. Further work is needed to determine the longer-term success of the program.

What influences trainee decisions to practise in rural and regional Australia?

Although international medical graduates (IMGs) make up a substantial part of the Australian rural general practice workforce, most research on factors associated with rural practice has focused on Australian medical graduates (AMGs). This study aimed to determine whether there were differences between IMGs and AMGs in terms of these factors. Registrars in training and recent fellows (Fellowship of the Royal Australian College of General Practitioners/Fellowship of the Australian College of Rural and Remote Medicine) who participated in training in rural and regional Australia were surveyed about practice models and rural practice. Almost two-thirds of participants were practicing or intending to practice in rural areas, with no difference between AMGs and IMGs. None of the variables associated with rural practice for AMGs was found to be associated with rural practice in IMGs in univariate binary regression analysis. Two key variables that are strongly associated with rural medical practice in the current literature, namely rural background and rural exposure, were not significant predictors of rural practice among IMGs. Due to the significant number of IMGs in regional training programs, any future incentives designed to improve rural recruitment and retention need to address factors relevant to IMGs.

A preliminary report on the awareness and knowledge of seafood-borne parasitic diseases among medical doctors in Australia.

Despite the increasing popularity of seafood in Australia and various reports of infection with transmissible parasites in Australian edible aquatic animals such as fish, the number of reported cases of human infections in the country is low. This raised the question that Australian medical doctors may not be fully aware of the presence of these parasites in Australia, which in turn can lead to misdiagnosis of infections. This also may lead to an underestimation of the risk seafood-borne parasites may pose to public health. This preliminary study was conducted to determine the awareness and level of knowledge among Australian medical practitioners in New South Wales, the most populated and multicultural state in Australia, about seafood-borne parasitic diseases. Medical doctors, both general practitioners and gastroenterologists, were surveyed through an anonymous questionnaire (n = 376). Although the response rate was low at 11%, participants represented a diverse group in terms of gender, age, nationality and expertise. Despite several publications on occurrence of zoonotic parasites in Australian fish and other edible aquatic animals, and also in humans in the country, all respondents said no seafood-borne parasite had been reported as being seen within Australian or overseas practice. Although, due to low response rate, we are unable to confidently comment on the level of awareness, the findings of this study clearly suggest that further research is needed to investigate the extent of unawareness among Australian medical doctors about these highly important parasites and understanding the underlying issues in medical education that lead to the unawareness.

General practitioner and registrar involvement in refugee health: exploring needs and perceptions.

Objective Despite the recognition that refugees should have equitable access to healthcare services, this presents considerable challenges, particularly in rural and regional areas. Because general practitioners (GPs) are critical to resettlement for refugees and play a crucial role in understanding their specific health and social issues, it is important to know more about the needs of GPs. Methods In-depth interviews were conducted with 14 GPs and GP registrars who trained with a New South Wales regional training provider with the aim of assessing the needs and attitudes of GPs in treating refugees and the perceived effect that refugees have on their practice. Results The interviews, while acknowledging well-recognised issues such as language and culture, also highlighted particular issues for rural and regional areas, such as employment and community support. International medical graduates identified with resettlement problems faced by refugees and are a potential resource for these patients. A need for greater information for GPs regarding services available to help manage refugees in rural and regional areas and greater access to those services was demonstrated. Conclusions Issues such as time, costs, language and culture were recognised as challenges in providing services for refugees. GPs highlighted particular issues for rural and regional areas in addressing refugee health, such as finding jobs, problems with isolation and the effect of lack of anonymity in such communities. These social factors have implications for the health of the refugees, especially psychological health, which is also challenged by poor resources. What is known about the topic? Providing refugees equitable access to healthcare services presents considerable challenges, particularly in rural and regional areas. Time, language and culture are commonly reported barriers in providing services for this population group. What does this paper add? There are particular issues for rural and regional areas in addressing refugee health, including finding jobs, problems with isolation and the effect of lack of anonymity in rural communities. These social factors have implications for the health of refugees, especially psychological health, which is also challenged by a paucity of services. The findings of this study suggest that international medical graduate doctors identified with resettlement problems faced by refugees and may be an important resource for these patients. This study highlights the awareness, empathy and positive attitudes of GPs in regional and rural areas in their approach to treating patients with a refugee background. What are the implications for practitioners? International medical graduates often identify with resettlement problems faced by refugees and are an important resource for these patients. A need for greater information for GPs regarding services available to help manage refugees in rural and regional areas and greater access to those services was demonstrated.

Accuracy of multiparametric magnetic resonance imaging to detect significant prostate cancer and index lesion location.

BACKGROUND: Multiparametric magnetic resonance imaging (mpMRI) of the prostate appears to improve prostate cancer detection, but studies comparing mpMRI to histopathology at the time of radical prostatectomy (RP) are lacking. This retrospective study determined the accuracy of mpMRI predicting Gleason score and index lesion location at the time of RP, the current gold standard for diagnosis. METHODS: Between April 2013 and April 2016, a database of all men aged more than 40 years who underwent RP after positive transrectal ultrasound biopsy by an experienced urological surgeon was collated at a single regional centre. This was cross-referenced with a database of all men who had mpMRIs performed at a single centre and reported according to Prostate Imaging Reporting and Data System (PI-RADS version 1) during this period to generate a sample size of 64 men. A Spearman's rho test was utilized to calculate correlation. RESULTS: Median age of patients was 64 years, the median prostate-specific antigen at RP was 6.22 ng/mL. mpMRI was positive (≥PI-RADS 3) in 85.9% of patients who underwent RP. More than 92% of participants had Gleason ≥7 disease. A positive relationship between mpMRI prostate PI-RADS score and RP cancer volume was demonstrated. An anatomical location correlation calculated in octants was found to be 89.1% accurate. CONCLUSION: mpMRI accurately detects prostate cancer location and severity when compared with gold standard histopathology at the time of RP. It thus has an important role in planning for future prostate biopsy and cancer treatment.

Increasing the knowledge, identification and treatment of osteoporosis through education and shared decision-making with residents living in a retirement village community.

OBJECTIVE: This pilot study explored whether individual goal setting in a retirement village setting could improve strategies to strengthen bones in an ageing population and help prevent osteoporosis. METHODS: A two-phased osteoporosis prevention program was developed, piloted and evaluated involving a group education session followed by the development of individualised Bone Plans based upon personal understanding of individual fracture risk and lifestyle factors. RESULTS: A significant improvement in knowledge and understanding of factors to prevent and manage osteoporosis was achieved, and changes in lifestyle behaviours were sustained at six months. CONCLUSION: Success was due to education by specialist medical and health personnel, flexibility of goal setting, use of group sessions and location of the program within the retirement community setting. The 'Mind Your Bones' program is a feasible and acceptable way to translate preventative bone health messages to a large number of people via the retirement village network.

Using electronic medical records to assess the rate of treatment for osteoporosis in Australia.

BACKGROUND: Despite available Medicare Benefits Schedule subsidies, it has been suggested that screening and treatment for osteoporosis are under-accessed in Australia, particularly in patients ≥70 years. This study describes the rate of osteoporosis treatment in those aged ≥70 years in regional New South Wales as identified in the electronic medical records (EMR) of 11 general practices. METHODS: EMR data were extracted using a Canning Tool adaptation. The prevalence of osteoporosis, fracture and bone-active medication prescriptions were described, and associations examined. RESULTS: Osteoporosis was identified in 728 patients (20.9%) - 28.6% females and 9.4% males - with 70.6% of these patients prescribed active medication. Diagnosis increased with fracture history (odds ratio [OR]: 6.65; 95% confidence interval [CI]: 5.22, 8.47), female gender (OR: 3.38; 95% CI: 2.73, 4.16) and each year older (OR: 1.04; 95% CI: 1.02, 1.05). Treatment was negatively associated with patients aged ≥90 years versus patients aged 70-79 years (OR: 0.5; 95% CI: 0.3, 0.9). DISCUSSION: This study suggests that treatment for osteoporosis is suboptimal. The use of EMR data could be used for audit or monitoring of interventions in general practice.

Orthopedic surgeons' attitudes to osteoporosis investigation and management after minimal trauma fracture (MTF).

A study of orthopedic surgeons in rural and regional Southeast Australia to determine attitudes to investigation and management of osteoporosis found they believe follow-up in regard to osteoporosis after MTF is important; responsibility for follow-up diagnosis and management lies with primary health care and current communication systems are poor. PURPOSE/INTRODUCTION: The investigation and treatment of osteoporosis after minimal trauma fracture (MTF) is regarded as sub-optimal. There is strong evidence of the benefit of identifying and treating osteoporosis after MTF, and there has been discussion of the possible role that orthopedic surgeons might play in the management of osteoporosis after MTF. The study surveyed orthopedic surgeons in rural and regional Southeast Australia to determine their attitudes to investigation and management of osteoporosis, the role health professionals should play, and the communication and co-ordination of follow-up care. METHODS: A survey was developed and piloted prior to being posted to 69 orthopedic surgeons asking for their opinions about the general management of osteoporosis, and the roles and responsibilities of health professionals in dealing with osteoporosis following an MTF. RESULTS: Responses were received from 42 participants (60.8%) with the majority of respondents agreeing that it is important to treat osteoporosis following MTF. Less than 15% of respondents felt that it was their responsibility to initiate discussion or treatment or investigation after MTF. No respondent felt that the coordination of osteoporosis care was good and 45% stated it was poor. Communication after discharge is mostly left to the hospital (30%), while 20% stated they did not follow up at all. CONCLUSIONS: This study shows that many rural orthopedic surgeons believe that follow-up in regard to osteoporosis after MTF is important, that responsibility for follow-up diagnosis and management of osteoporosis lies with primary health care and the current communication systems are poor.

Improving the management and care of refugees in Australian hospitals: a descriptive study.

Objectives The aim of the present study was to investigate healthcare provider perceptions of the impact of refugee patients at two public hospitals, one rural and one urban, in designated refugee resettlement areas. Healthcare professionals' views regarding improvements that could be made in this area were also sought. Methods Two-page anonymous questionnaires containing demographic, quantitative and open-ended questions were distributed to 150 healthcare providers at each research site. Results Response rates at the rural and urban sites were 50% and 49%, respectively. Refugees were seen at least monthly by 40% of respondents. Additional support was requested by 70% of respondents. Confidence was associated with being born overseas (P=0.029) and increased time working with refugees (rs=0.418, P<0.001). Only 47% of respondents felt confident managing social and psychological needs of refugees. Midwives saw refugees more than nursing and allied healthcare staff combined, and this was significant at the rural hospital (P<0.001). Rural respondents reported that working with refugees enhanced their practice (P=0.025), although felt significantly less confident (P<0.001) than urban respondents. Themes that arose regarding barriers to care included language and cultural barriers, paucity of knowledge and issues accessing available services, including appropriate interpreters, Medicare eligibility and patient factors, including lack of patient trust in government systems. Desire for support was more pronounced in the rural setting (P=0.001). Conclusions Refugees were seen frequently in both settings and most respondents requested additional support, highlighting that caring for refugees in Australian hospitals is a significant challenge. Additional support and education should be targeted to those caring for refugees most frequently, particularly midwifery services, to reduce barriers to care. What is known about the topic? Refugees are a vulnerable group, often with complex health needs. These needs are often unmet because of issues including language and cultural barriers. What does this paper add? Refugees were seen frequently in the two public hospital settings involved in the present study and most often by midwifery services. Healthcare professionals require more support, more information about available services and better access to interpreter services. These issues were more pronounced in the rural setting where very limited research exists. What are the implications for practitioners? Implementing additional support and education regarding refugee health needs could increase knowledge and confidence when managing refugees, reducing barriers to care and improving quality of care.

Accuracy of Screening Tools for Pap Smears in General Practice.

BACKGROUND: Data extraction tools (DETs) are increasingly being used for research and audit of general practice, despite their limitations.Objective This study explores the accuracy of Pap smear rates obtained with a DET compared to that of the Pap smear rate obtained with a manual file audit. METHOD: A widely available DET was used to establish the rate of Pap smears in a large multi-general practice (multi-GP) in regional New South Wales followed by a manual audit of patient files. The main outcome measure was identification of possible discrepancies between the rates established. RESULTS: The DET used significantly underestimated the level of cervical screening compared to the manual audit. In some instances, the patient file contained phone/specialist record of Pap smear conducted elsewhere, which accounted for the failure of the DET to detect some smears. Those patients who had Pap smears whose pathology codes differed between time intervals, i.e. from different pathology providers or from within the same provider but using a different code, were less likely to have had their most recent Pap smear detected by the DET (p < 0.001). CONCLUSION: Data obtained from DETs should be used with caution as they may not accurately reflect the rate of Pap smears from electronic medical records.How this fits in DETs are increasingly being used for research and audit of general practice. This study explores the accuracy of Pap smear rates obtained with a DET compared to that of the Pap smear rate obtained with a manual file audit The DET tested significantly underestimated the level of cervical screening compared to manual screening. Data obtained from DETs should be used with caution as they may not accurately reflect the rate of Pap smears from electronic medical records.

General practice registrars' intentions for future practice: implications for rural medical workforce planning.

The models of practice that general practice registrars (GPRs) envisage undertaking will affect workforce supply. The aim of this research was to determine practice intentions of current GPRs in a regional general practice training program (Coast City Country General Practice Training). Questionnaires were circulated to 220 GPRs undertaking general practice placements to determine characteristics of ideal practice models and intentions for future practice. Responses were received for 99 participants (45%). Current GPRs intend to work an average of less than eight half-day sessions/week, with male participants intending to work more hours (t(91)=3.528, P=0.001). More than one-third of this regional cohort intends to practice in metropolitan centres. Proximity to family and friends was the most important factor influencing the choice of practice location. Men ranked remuneration for work as more important (t (88)=-4.280, P<0.001) and women ranked the ability to work part-time higher (t(94)=3.697, P<0.001). Fee-for-service payment alone, or in combination with capitation, was the preferred payment system. Only 22% of Australian medical graduates intend to own their own practice compared with 52% of international medical graduates (χ2(1)=8.498, P=0.004). Future general practitioners (GPs) intend to work fewer hours than current GPs. Assumptions about lifestyle factors, practice models and possible professional roles should be carefully evaluated when developing strategies to recruit GPs and GPRs into rural practice.

GP and registrar involvement in refugee health - a needs assessment.

BACKGROUND: General practitioners play a crucial role in understanding the specific health and social issues of refugees, as they are often the first contact that refugees have with the healthcare system. Providing equitable access to healthcare services presents considerable challenges, particularly in regional areas. METHODS: A purposive sample of GP supervisors and general practice registrars was selected from a regional area of southern New South Wales and the Australian Capital Territory. General practitioners were surveyed to assess their needs and attitudes in treating refugees, and the perceived impact of refugees in practice. RESULTS: There were significant differences between GP groups, between domestic and internationally trained medical graduates, and between genders in their needs and attitudes relating to refugee health. DISCUSSION: There is a strong sense that there are benefits in dealing with refugee health. More research is needed to identify the supports and education required to be able to effectively help refugees.

Away from the mainstream: medical women in one region of rural New South Wales.

Despite recent research on the difficulties associated with attracting women to the rural medical workforce, and the perception that the image of the rural doctor is male, women have had a history in rural medicine in southwest New South Wales that spans a century. This paper explores the contribution to medicine of women medical practitioners working within one geographical area of rural New South Wales. It traces these women, documenting the diversity of women's medical work and some of the challenges faced. Based largely on data from contemporary reports in two local newspapers, the Daily Express and The Daily Advertiser, this paper shows that some of the silence associated with the role of women in rural medicine could be attributed to them holding positions at the margins of what is depicted as 'real' medicine, in fields that include public health and education.

Rural student doctors top city colleagues: representation of a rural clinical school in the rural press.

OBJECTIVE: To describe the way in which the rural press portrays a rural clinical school and its staff and students. DESIGN: Textual analysis of a collection of newspapers kept by the local campuses of the University of New South Wales Rural Clinical School (UNSW RCS). THE STUDY: The UNSW established a RCS in January 2000. This study sampled a total of 225 articles from eleven rural newspapers, a collection held by the campuses of the rural clinical schools. The major themes of the articles were identified; the descriptive terms the newspaper articles used for medical students, the UNSW RCS and rural doctors were also identified. The way in which clinical schools, their staff and students, are portrayed in the rural press has the potential to influence recruitment and retention. CONCLUSIONS: The study showed that the rural press was strongly supportive of the rural clinical school in their local region. This was particularly true for medical students, the school itself and the potential impact on workforce. The newspapers provided information for future students, depicting work-experience programs and current students. They were less illustrative of current medical and academic staff, with the exception of the Head of School.

Comparing patients' perceptions of IMGs and local Australian graduates in rural general practice.

BACKGROUND: Despite criticism of the clinical performance of international medical graduates (IMGs), little is known about the views of patients within a general practice setting. METHODS: A survey was conducted to measure the responses of 1127 patients of 10 GPs, five IMGs and five Australian graduates. The General Practice Assessment Questionnaire was used to assess the attitudes of patients towards attributes of the consultation and how the patient felt in terms of understanding and coping with their problem or illness. DISCUSSION: No statistically significant differences were found in any of the reported categories, although there were some responses that approached significance and warrant further investigation. The level of patient satisfaction with, and acceptance of, received care was similar whether the GP was an IMG or not.