Preparing doctors for working in remote health teams  

About 3% in remote, compared to 25-30% in rural (depending on classification system used) In Australia, there is a population density gradient from metropolitan to remote areas. Large rural centres have an average of 59.4 persons/sq. km, whilst ‘remote other’ averages 0.1 person/ sq. km (AIHW 1998 p6). Population dispersion is a very salient factor for health care planning and delivery.  

Australian Standard Government Classification

Population distribution

Socioeconomic status

Food prices

Percentage of young people entering university

Social determinants Decreasing SES with remoteness Increasing cost of living with remoteness Decreasing educational opportunity & outcomes with remoteness Decreased educational opportunity & attainment for Indigenous vs non-Indigenous Higher levels of unemployment for Indigenous people

Mortality

Outcomes: Mortality rates 1992 - 2003

NT life expectancy gap by GBD 1981-2000 Zhao & Dempsey 2006

Health outcomes Overall mortality rates increase with increasing remoteness Significant geographical variation in rates Mortality rates declining over time, especially in remote areas NT Indigenous mortality improving, but not declining at a comparable rate to non-Indigenous Australians except in 0-4 year old group This observation may result from health service development targeting this age group The biggest ‘gap’ in 35-64 year old group Increasing prevalence of chronic diseases Little information regarding social & emotional health

Practitioner to population ratios

Doctors – FTE/100,000 by ASGC

Access to treatment for IHD

There is a common perception that mortality increases with increasing remoteness. Recent analysis of mortality data across different geographical areas indicates that total population death rates are about 10% (1.1 times) higher in Inner and Outer Regional areas and Remote areas than in Major Cities, but 50% (1.5 times) higher in Very Remote areas (AIHW 2003 p 33)[i]. It is likely that the high Indigenous proportion of the population in remote areas makes a substantial contribution to the higher overall death rate. [i] This five-tired geographical classificatory system, known as the Australian standard Geographical Classification (ASGC), was developed by the Australian Bureau of Statistics, derived from the ARIA.

Remote medical practice Eight key features: salaried employment, not private practice isolation telehealth increased clinical acumen extended practice cross-cultural setting multidisciplinary practice emphasis on public health & personal security (Smith et al 2008)

Remote Health Remote Health is an emerging discipline with distinct sociological, historical and practice characteristics. Its practice in Australia is characterised by: Geographical, professional and, often, social isolation of practitioners; A strong multidisciplinary approach; Overlapping and changing roles of team members; A relatively high degree of GP substitution; Practitioners requiring public health, emergency and extended clinical skills.

Remote Health (cont.) These skills and health systems need to be suited to: Working in a cross-cultural context; Serving small, dispersed and often highly mobile populations; Physical environment of climatic extremes; Rapid technological change. (Wakerman 2004)

Integrated Training in Remote Medicine ACRRM Primary Curriculum ACRRM Advanced Remote Curriculum Endpoints: FACRRM Graduate Certificate in Health (Remote Health Practice) – Flinders University Graduate Diploma in Health (Remote Health Practice) – Flinders University

Integrated Training in Remote Medicine - curriculum Grad Cert (Core Year 1): Context of Remote Health Remote PHC RMP 1 RMP 2 Grad Dip: PH Principles & Practice Ethics Power & Practice Introduction to Research & EBDM Context: ENSURING SAFE PRACTICE. Concerned with the cultural, social and economic context of remote health care in Australia and will facilitate the development of the student's understanding of the people in remote areas and the major issues they face. The topic explores the definition of remote and examines significant issues remote communities face, as well as the concept of culture and racism within Australian society. There is an emphasis on indigenous health and how present health status is related to history. The topic also explores the adaptation process to living and working in remote areas, examines sources of stress associated with remote practice and suggests strategies to manage stress. The topic provides an opportunity for reflection on how services are delivered in remote areas; it proceeds from an examination of models of health, epidemiology and public health to an analysis of primary health care and introduction to HP. All topics have an emphasis on Aboriginal health

Graduate Certificate in Remote Health Practice (Year 1) Remote Medical Practice 1 Remote medical practice & teamwork Emergency skills in remote areas Consultation & communication skills Chronic disease in remote areas

Graduate Certificate in Remote Health Practice Remote Medical Practice 2 Mental health Management of STIs in remote areas Women’s health Child & adolescent health

Aboriginal Health RMP 1 + Context + PHC Adult Internal Medicine RMP 1: mgt of chronic disease Aged Care Anaesthetics Child and Adolescent Health RMP 2 Dermatology Emergency Medicine RMP 1 (EMST) IT/ IM Management Musculoskeletal medicine O & G /women’s health Ophthalmology Palliative care Research and evidence based practice Population health Principles of r & r general practice RMP 1 Psychiatry/mental health Radiology Renal medicine Strategic skills in rural medical practice Surgery

Graduate Diploma in Remote Health Practice Grad Cert (18 U) plus Public health principles & practice Ethics power & practice Introduction to research & EBDM This topic aims to develop the reflective practice of students in relation to their role within a multidisciplinary team and with the community where they work. The topic examines ethics, reflective practice, working in teams, power relationships, and indigenous health issues in a remote context.

Aboriginal Health RMP 1 + Context + PHC Adult Internal Medicine RMP 1: mgt of chronic disease Aged Care - Anaesthetics Child and Adolescent Health RMP 2 Dermatology Emergency Medicine RMP 1 (EMST) IT/ IM Management Musculoskeletal medicine O & G /women’s health Ophthalmology Palliative care Research and evidence based practice Intro research & EBDM Population health PH principles & practice Principles of r & r general practice RMP 1 Psychiatry/mental health Radiology Renal medicine Strategic skills in rural medical practice Surgery Ethics,power,practice;Context

Remote medicine advanced training Core clinical knowledge & skills Extended clinical practice Emergency care Population health Indigenous health Professional, legal & ethical practice Rural & remote context