Some of the clinical team that few up to Brewarrina for the day have been visiting ‘Bre’ for over four years, and have developed strong relationships with the small hospital’s staff, including Aboriginal Health workers, and regular patients who often travel hundreds of kilometres into Bre for an appointment. The team made it clear though that while the need for specialist services is present, having a consistent primary care physician seems to be the principal concern of most people. In the last twelve months, there have been twenty different locum physicians in Bre. As the only physician for a community of 1,500 it is often difficult to find and maintain long-term doctors. Like most Indigenous communities, Brewarrina heavily values long-term relationships, which makes it all the more challenging when a new doctor comes in every fortnight. One patient summed up the situation: “We change our GP just about as often as we change our underwear.”
The importance of long-term relationships was no more clear than when return patients visited the clinic. With the constant turnover of GPs, record taking and documentation often falls through the cracks. To combat this, the visiting cardiologist I spent the day with had developed a separate set of notes for the hospital. This helped ensure that any changes to their care between his visits were noted. Many patients only come to the clinic regularly now that they’ve developed a rapport with the cardiologist. Visiting Brewarrina for the first time, an Endocrinologist soon realised this fact when many of the scheduled patients didn’t initially show up. Thankfully, being a tightknit town, the hospital staff and Aboriginal Health Workers actively sought out patients who had missed their appointment and brought them into hospital.
Spending time in a remote setting provided numerous opportunities to see pathologies rarely seen in urban centres. The opportunity to spend time with the visiting cardiac sonographer was especially informative. She was keen to teach and explain the function of sonography and how it is a vital tool in medical care. While the patient’s care is always the priority, without being able to closely monitor changes in medication or treatment, the visiting specialists are often forced to maintain the status quo. This is done in order to avoid the possibility that the patient may experience adverse effects without having someone close by to help.
I was encouraged by the visiting cardiologist to take some time and walk into town over lunch. As I was leaving, I ran into one of the Aboriginal Health Workers who was going to drop her car off at the local mechanic, and she offered to take me on a quick tour. Located on the outskirts of town, we visited the Brewarrina fish traps, which are believed to be amongst the oldest surviving human-made structures in the world, and have been dated to be at least 40,000 years old. The traps are formed from river stones arranged in a complex pattern to trap fish swimming upstream. The abundance of fish from the traps made Brewarrina amongst different communities who used the riverbanks as a meeting place for millennia. As we pulled up to the traps, it was amazing to see how the riverbanks are still frequented by locals looking for a place to meet with friends.
I not only learned a lot about cardiology and endocrinology, but also developed a deeper understanding and appreciation of the challenges faced in rural and remote Australia, and how they impact Aboriginal health. It was striking to see the parallels with Canada. Despite being thousands of kilometres away, there are many of the same issues present. I had some excellent conversations with the hospital staff and Aboriginal Health Workers about these problems, and know that what I learned will be unrivalled by time spent in a lecture theatre. Where our metropolitan teaching centres provide us with clinical skills and attempt to instil competence, a day spent far removed from the city shone light onto what it meant to be someone’s doctor.
Sean Hassan, Stage 3 Medical student
The patient population was a well balanced mix of Indigenous and non-Indigenous Australians with myriad of cardiac concerns. The most striking thing I learnt was the absolute requirement for structure and support in order to provide medical care to these people. Something the Poche Centre is striving to facilitate through programs like this. I was exposed to excellent teaching clinically, from both the cardiologist and sonographer. But without doubt the highlight of the trip for me was meeting local indigenous staff at the health centre and discussing the complex interaction between cultural views, health, social demographics and funding. This is an experience that will continue to resonate with me and allow me to better appreciate the circumstances of the patients I will undoubtedly meet throughout my studies and future career. As a medical student I will never again underestimate the importance of clear and accurate documentation provided to patients upon discharge and how fortunate we are to have access to the metropolitan Australian healthcare system. Thank you to the team at the Poche Centre and Brewarrina Health Centre for allowing me to join them in this incredible experience. It is something that I believe every medical student who intends to work in Australia will benefit from.
Neill Kiely, Stage 3 Medical student
Once at the clinic I spent a good early portion of my time with the sonographer as she performed patient bedside echocardiograms. This was a fantastic opportunity for a student, as ultrasound and echocardiograms are not often fully covered in medical school and rarely, if ever, on such an individual basis.
The patients were wonderful and I was able to marry physical signs to echocardiogram features to cardiac pathology. I also spent time with the pacemaker and ICD technician and was able to learn about the management of these devices, with input from both the technician and feedback from the patients.
I also spent time with both cardiologists and saw several patients in clinic. Patients presented with some wide-ranging pathologies, as well as some broader cardiovascular diseases which affected them in varied ways and earlier stages. I was able to see several physical signs on examination and speak to the physicians with regards to the patients seen for feedback and learning. The patients in clinic were again wonderful and open to my being present and participating in the consultation.
As it was very busy through the morning, I moved around between sonographer, clinic and technician. The cardiologists were wonderful and came to grab me when they thought I should see a particular patient, and I was able to experience the full breadth of the fly-in clinic that day. I did not sit down for a minute other than to grab a sandwich for lunch.
The entire day was inspiring to the extent of and effectiveness of rural medicine, specialty health care in more removed settings and the variability in health and healthcare of Indigenous people. It fortified my interests in rural and Indigenous medicine and I thoroughly enjoyed every aspect of the day. I will continue to look forward to spending more time in rural health, hoping to work with Indigenous patients again.
Alexandra Garland, Stage 3 Medical student
Brewarrina, the town affectionately known to locals as ‘Bre’, is home to fewer than 1500 people, with the majority of residents (about 70 per cent) identifying as Aboriginal. The cardiology clinics are held at Brewarrina District Hospital and Health Services, a twenty bed public hospital and community health centre providing general inpatient, outpatient and emergency care with haemodialysis and residential care facilities.
It seems from first impressions at least while driving down the main street, one would envisage the stereotype of an Indigenous Australian country town with a strong sense of culture and friendliness but also with an over-representation of unemployment, crime and substance use, replete with the issues you have come to expect. However, as we moved into the clinic setting, I felt as though we were painted a prettier picture. As I walked past the waiting area, the majority of patients appeared to be Caucasian as opposed to my preconceptions of a predominantly Aboriginal patient population in after all a predominantly Aboriginal town. And I grew hopeful that perhaps, the statistics had it wrong, that the medical issues faced by Indigenous people are no different to those faced by the general population.
But after sitting in on several consultations, it was obvious that the medical issues faced by Indigenous Australians are substantial and unique. From a population medicine perspective, the clinical presentations seen in Brewarrina seem fairly similar to those in the city, with the exception of increased cardiovascular risk associated with being Indigenous.
One example involved a young Aboriginal man in his twenties receiving primary prophylaxis with a combination of aspirin, statin and antihypertensive after one of his five siblings suffered an acute myocardial infarction in their mid-thirties. The incidence of rheumatic valvular disease is also more prevalent, as are the common themes of aging and obesity. Sedentary lifestyle also appears to be a particular health risk in these individuals, with a memorable quote from one man: "I live in Bre, what else is there to do around here?"
Then it finally dawned on me why only half the patients seen by the cardiology clinic were Indigenous despite it being a service that targeted this patient population. Perhaps the uptake of these culturally targeted services are still gaining recognition or acceptance within the Indigenous community and perhaps more needs to be done to raise awareness to ‘close the gap’. Nevertheless, it is clear that there has been some positive progress made to address the health inequalities between Indigenous and non-Indigenous Australians. It is now a matter of continuing the trend.
Above all, the people of Brewarrina face issues typical of many rural communities. There is only one full-time GP who is responsible for the care of patients at the local hospital as well as his community clinic. Astounded as I was by this revelation, I still find it hard to believe that a sole GP is able to serve the primary care needs of 1500 people yet is also expected to play the role of a general physician when those people became acutely unwell, even administering thrombolysis, perhaps something unheard of in metropolitan practice and what would commonly be considered as outside the scope of practice for a GP.
The closest town, Bourke, 100km away is larger in population terms but offers little much more in way of specialist medical services. I wonder about the effectiveness of current rural incentives and whether there is something that can be done on a non-governmental level to attract doctors to these areas of need. Equality of access to health services is undoubtedly a challenge in these geographically disadvantaged towns. Even with a regular roster of visiting specialists, undertaking further investigations such as an exercise or sestamibi stress test is a struggle, with Dubbo, Orange and Sydney being hundreds of kilometres away.
Personally, this trip has been a special journey and an invaluable learning experience as I have now seen first-hand a snapshot of the unique health problems faced by people living in rural Australian townships such as Brewarrina paralleled by their good humour and sense of camaraderie. In particular, it was encouraging to see the impact of collective will in addressing the health inequalities between Indigenous and non-Indigenous Australians and that progress is being made to 'close the gap'. I would like to thank the Poche centre and the clinical staff for making this most worthwhile experience possible.
Caran Cheung, Stage 3 Medical Student