Rural Medicine Griffith University Lecture MBBS 2016 cohort

RURAL AND
AGRICULTURAL
MEDICINE LECTURE
SERIES
Prof Scott Kitchener
Clinical 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 Medicine
First 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)

Introduction to Rural Medicine
Outline 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

Where is rural?
 http://www.doctorconnect.gov.au/internet/otd/P
ublishing.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

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 Medicine
ACRRM  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)

RACGP National Rural Faculty
The 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 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 determinants
The 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

Of self-employed

With limited incomes
Real farm cash income, broadacre industries, average per farm

Issues with mining rural land
http://www.abc.net.au/news/2016-04-15/linc-energy-goes-into-voluntary-
administration/7331154

Foreign Ownership
QIC purchase NAPCo

www.longpaddock.qld.gov.au
The Department of Agriculture and Fisheries, QLD
QUEENSLAND DROUGHT SITUATION
as at 1st
October 2016
Date created: 10th
October 2016
www.LongPaddock.qld.gov.au
Information contained in this publication is provided as general advice only. For application to specific circumstances, professional advice should be sought. The Department of Agriculture and Fisheries, Queensland, has taken all reasonable steps to ensure the
information in this publication is accurate at the time of publication. Readers should ensure that they make appropriate inquiries to determine whether new information is available on the particular subject matter.

Retail control of milk on the dairy industry

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

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
care

Preventable deaths in Queensland significantly greater in rural and remote
areas and especially indigenous people
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

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
 Cancer
3rd CHO Report, The health of
Queenslanders, 2010

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

Australians
Excess
deaths
among rural
Australians
from:
 Coronary heart & cardiovascular Δ
 COPD
 MVA & other injuries
 Neoplasms – 7% excess deaths
 Diabetes
 Suicide

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

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 Queenslanders
Rural 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 areas
Demography 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 OHS
On-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 Cases
Equine 40
Bovine 36
Porcine 6
Ovine 1
Ornithine 1
Machinery 55
Wood/timber 12
Gender Number
Female 53
Male 155
Total 208
Average age 39.8 years,
SD: 17
years
Animals and machinery Gender

Rural OHS
Triage category Frequency Percent
Category 2 10 4.8
Category 3 78 37.5
Category 4 106 51.0
Category 5 12 5.8
No data 2 1.0
Total 208 100.0
Agricultural injury presentations to rural hospitals on the Darling
Downs, Mar-Oct, 2015

Rural OHS
Triage category Frequency Percent
Category 2 10 4.8
Category 3 78 37.5
Category 4 106 51.0
Category 5 12 5.8
No data 2 1.0
Total 208 100.0
Agricultural injury presentations to rural hospitals on the Darling
Downs, Mar-Oct, 2015
Nature of injury
Frequenc
y
Perce
nt
Cut/laceration 59 28.4
Puncture + penetrating
wounds
8 3.8
Bite 2 1
Superficial abrasion 18 8.7
Other wound inc. amputation 7 3.4
Haematoma/bruising 32 15.4
Haemorrage 2 1
Inflammation/oedema/tenderne
ss
6 2.9
Burn – full & partial thickness 7 3.4
Foreign body in soft tissues 10 4.8
Crushing injury 29 13.9
Fractures & dislocations 35 16.7
Sprain/strain 48 23.1
Poisoning 1 0.5
Aspiration or respiratory
2 1
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

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)
0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
400.0
450.0
Major cities Inner
regional
Outer
regional
Remote/Very
remote(d)
Clinician
General practitioner
(GP)(f)
Specialist
Rural & regional
specialty services

Health Expenditure per person
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
RA1 2 3 4 5
ASGC-RA
Medicare services Pharmaceutical benefits

Medical & Dental practitioners by
remoteness area, 2005 (AIHW)
0
50
100
150
200
250
300
350
Major
Cities
Inner Reg. Out Reg. Remote
FTE/100,000
GP/100,000
Dentists/100,000

Take home message
Overall First Year Learning Objectives

Take home message - Rural
Health
The 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:
1. Rural cultural competence and local epidemiology
knowledge
2. Longitudinal diagnosis and management

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
Cherbourg
Gympie
Maleny
QEII
Hospital
+ Nathan
Campus
Opening Gympie Hospital
with a comprehensive LIC
Expanding blended LIC to
Maleny and Jandowae
Opening an amalgamative
LIC between Goondiwindi +
Nambour
Dalby Clinical Education
Centre
University
Hospital
Sunshine
Coast
University
Pre-Med
Continued blended LIC
Continued comprehensive LIC
Rural Centre
Devolve Hub teaching to Warwick and
Kingaroy (MMM4)

Third year Longlook with patient
Any questions

Rural Medicine Griffith University Lecture MBBS 2016 cohort

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