Rural dental health care and the workforce challenges

To the Editor: Rural Australians have poorer oral health than metropolitan Australians,1 and this oral health gap is not decreasing.2 Possible reasons for poor oral health among rurally located people are that they tend to be of lower socioeconomic status,3 which is known to be linked with a marked inequality in oral health,4 and that rural people have a different concept of health,5 which may influence their use of health services.

Another reason that has been suggested for poor oral health among rural people is poor access to dental care due to an inequitable geographic distribution of the dental workforce,6 with progressively fewer dentists as remoteness from major cities increases. It is not surprising, then, that dentists practising in non-capital city areas have been supplying more patient visits per year, and were more likely to be busier than they would like to be, compared with dentists in capital cities.7

Since 2005, four new dental schools have opened in Australia, at Griffith, La Trobe, James Cook and Charles Sturt universities; many of the existing dental schools have increased their student numbers; and there has been a large increase in the number of dentists coming from overseas. Anecdotal evidence indicates that rural dental practices, which have had trouble attracting dental practitioners in the past, are now receiving cold calls from new graduates looking for work. The problem of the rural undersupply of dentists may be correcting itself.

However, a continuous churn of highly skilled and experienced practitioners being replaced by less experienced ones could result, since practitioners tend to move back to capital cities once they gain some experience.8 A lack of experienced dentists could lead to rural patients being caught up in a repeat restoration cycle9 of having teeth filled and later having the same teeth refilled as restorations collapse or more decay occurs. Although ensuring that rural towns have fluoridated water supplies would be the most cost-effective way to reduce the incidence and prevalence of dental caries among rural people10 and to limit the repeat restoration cycle, enabling rural people to access dental care will decrease the effects of the disease, particularly if treated in its early stages.

Despite an increase in interest among new graduates and overseas-trained dentists in working in rural areas, there is still a great need for specialist dental services, such as oral and maxillofacial surgery, oral medicine specialist care, special needs dentistry, periodontics, endodontics and orthodontics, in rural areas. People in rural areas have high medical and dental needs and require access to experienced health practitioners. One way to provide this and to ensure a continuation of dental care in rural communities is to develop an advanced rural dentist program similar to the rural medical generalist program.11 The program could cover some procedures of specialist dental practice, some areas of practice outside of dentistry and research into rural oral health, and it could also teach the skills to create stronger links and cooperation between rural health care practitioners.

Patient safety and rapid response systems

In 1995, the Journal published its most cited article, reporting that some 18 000 Australians died each year in acute care hospitals and over 50 000 suffered permanent disabilities as a result of the effects of health care.1 About half of these were judged to be preventable or to have resulted from errors of omission or commission.

Two other highly cited studies from the United States, published 4 years earlier, showed a similar high incidence of potentially preventable deaths and stimulated interest in the level of patient safety in acute care hospitals2,3 which continues today. A crucial insight involved recognition that safety depends largely on the system within which care is embedded4 and that clinical error is the final link in a causal chain of antecedent events.5

In response to the high levels of adverse events, a patient safety industry that aims to overcome these problems has emerged. A national patient safety organisation, the Australian Commission on Safety and Quality in Health Care, was founded in Australia in 2006. There are similar organisations around the world. The patient safety movement now has its own journals, conferences and textbooks. Most health jurisdictions and hospitals have many staff devoted to patient safety.

Much of the subsequent research has focused on further defining the problem, rather than implementing and evaluating solutions. Various reasons for the incidence of potentially preventable adverse events have been advanced, including systems problems, treatment delays, not using evidence-based medicine, failure to order (and act on the results of) appropriate investigations, medication errors, inadequate staffing, fragmentation of care, information overload, and failure to use policies and protocols effectively.6 It has been hard to make progress.

Rapid response systems as a patient safety system

Most potentially preventable deaths in hospitals are a result of failure to recognise that a patient’s condition is deteriorating and failure to prevent further deterioration.7 Patients who suffer potentially preventable deaths are almost always in the general wards of hospitals. Such deaths are not common in areas such as intensive care units (ICUs). Most patient deaths in ICUs are a result of electively withdrawing and withholding further active management when such management is considered futile.8 The reason for the low incidence of potentially preventable deaths in ICUs is that patients are continuously monitored in an environment of high staff-to-patient ratios and where the staff are trained to care for seriously ill patients. In contrast, patients in general wards are monitored in much the same way as they have been for over a century and clinicians in general wards are not trained to recognise and manage patients who are seriously ill and whose condition is deteriorating.9

Rapid response systems (RRSs) are a unique patient safety system. They operate across the whole organisation and respond to all at-risk patients, regardless of the cause of the deterioration of a patient’s condition (Box 1).9 For example, the deterioration may be a result of the nature of the patient’s illness or a result of individual or system failure and errors. The RRS concept involves using vital signs and observations to identify at-risk and seriously ill patients early in the course of their illness. Once identified, a rapid response is triggered and the patient is then managed by staff with appropriate skills, knowledge and experience.9 The concept of RRSs was developed, implemented and evaluated by front-line clinicians in response to the high number of potentially preventable deaths and serious adverse events occurring in hospitals.9

The aim of an RRS is to provide a level of care which is similar to that delivered in areas such as operating theatres and ICUs. This type of safety net is becoming increasingly important because the population of patients in hospitals is changing dramatically.10 Patients are older, they have more underlying comorbidities, and they are undergoing interventions that have a high risk of complications. The risk of serious deterioration of a patient’s condition is therefore higher in general wards.7 Many patients in general wards can become as seriously ill as those in ICUs.11 There is no longer the easily identified distinction between patients being cared for in an ICU and those in a general ward. This trend is likely to become even more pronounced as populations age. Moreover, pressure to decrease hospital length of stay tends to result in an even more vulnerable patient population in acute care hospitals.

So, RRSs were developed to improve patient safety in acute care hospitals, aiming to provide a safer environment in general wards by urgently providing qualified staff from areas such as ICUs when they are identified. However, there is still the challenge that patients are not monitored in the same continuous way that they are in environments such as ICUs.

Measures of hospital safety

The concept of an RRS lends itself to standardised and comparable outcome measures which reflect patient safety across the whole organisation. As the goal of an RRS is to prevent deaths and major adverse events such as cardiac arrests, measuring the effectiveness of the RRS also measures the safety of the hospital.

Many factors have been used to measure patient safety in acute care hospitals (Box 2). However, there is a lack of agreement on definitions and measures. Hospital mortality is relatively easy to define and measure. Using it as a measure of hospital performance is therefore tempting, and researchers continue to flirt with the concept.12 One obvious problem with using mortality as a measure is that some hospitals treat more complex patients who have a lower chance of recovery than others. Another problem arises in ascribing mortality to a single doctor. For example, surgical outcomes depend on many factors apart from the surgeon, such as the treatment provided by physicians in the ICU, specialist consultations, systematic care from nursing staff, trainee medical staff and paramedical staff, and the systems within which the patient was managed. Despite problems with using mortality as a measure of hospital performance, crude mortality rates remain a common element in the way clinicians review their own practice.

More recently, there have been attempts to adjust mortality rates according to risk, by using a standardised mortality ratio (SMR).13 An SMR compares the actual death rate of a hospital with the expected rate based on the hospital’s particular population of patients. The inference is that if the actual mortality is higher than the predicted mortality, there may be a problem in the hospital. But it is difficult to identify and accurately measure the risk factors used for adjustment and the adjustment can exaggerate the very bias that it is attempting to reduce.14 Moreover, SMRs are a global measurement and do not identify where potential problems may be.

About one-third of rapid response calls are for patients at the end of life.11 These are patients who require an urgent response by appropriately skilled clinicians but who have not previously been recognised as being at the end of life.11 An often overlooked issue with using mortality as an outcome measure is that it infers that death is something to be avoided at all costs, contributing to the failure of acute care hospitals to recognise the many patients who naturally and predictably die in hospital. Concentrating on avoiding death can mean that patients may not die safely in hospitals.15 Inappropriate management of patients at the end of life has many patient safety implications, including a lack of transparency with patients and their carers, removing choice from patients, and being a major contributor to the unsustainable costs of health care. Reducing mortality is not necessarily an outcome that we should always aim for and by which we should judge a hospital.

For many years we have considered that patient safety, as a result of hospitalisation, should only be measured by outcomes derived during the patient’s admission. We are now learning that hospitalisation may, in itself, cause serious adverse events that occur after a patient has left hospital.16 Many patients, particularly older patients and frail elderly patients, may leave hospital alive but have a poor quality of life. They may require admission to a nursing home, and many suffer similar symptoms to post-traumatic stress syndrome, such as nightmares, anxiety and depression. Moreover, many die soon after discharge from hospital.16 Patient outcomes that result from a hospital intervention, and the implications for patient safety, can no longer be measured only during hospital admission.

Another often overlooked dimension in hospital safety is how safety and performance are viewed from a patient’s perspective — not just whether the meals are palatable and whether the staff are polite, but how appropriate the care was. This could include: whether information about the explicit aim of the hospital intervention was achieved; whether, in hindsight, the patient would undergo the same intervention again; and what information about the hospital experience was not made clear.17 There may be trends in certain diagnostic or procedural groups for which there is a high level of dissatisfaction and dissonance between the promises of interventions and the outcomes as determined by patients and their carers. A rigorous analysis of patients’ outcomes and their retrospective attitudes could become important when considering whether a hospital provided safe care.

Rapid response system outcomes that reflect hospital patient safety

While we still often measure crude rates of mortality and cardiac arrest, it is more relevant to exclude patients who have a do-not-resuscitate (DNR) order because an RRS is not designed to improve the outcome of patients for whom further active management is thought to be futile. For patients who have not been assigned a DNR order, deaths and cardiac arrests may be designated as “unexpected”.18 Instituting an RRS increases awareness of these patients and, as a result, the rate of DNR orders is increased in hospitals with an RRS.19

Similarly, it is clinically relevant to test whether an RRS is operating effectively by analysing data for patients who experience serious adverse events. In cases where a response to abnormal calling criteria within 24 hours of death or cardiac arrest did not occur, it is designated “potentially preventable”.18 Thus, unexpected and potentially preventable deaths and cardiac arrests become meaningful, standardised and easy-to-collect outcome measures of not only the RRS but also patient safety across the whole hospital.

Other hospital-wide indicators of RRS effectiveness include failure to rescue, deaths in low-mortality diagnosis-related groups,20 and number of rapid response calls per 1000 admissions. For the latter, the higher the call rate, the greater the reduction in deaths and cardiac arrests.21

Conclusion

Outcome measures associated with RRSs are clinically relevant, owned by those who deliver health care, and lend themselves to easy analysis and ways to improve the system. An efficiently functioning RRS can urgently provide the same level of expertise that is available in an ICU to patients in general wards of acute care hospitals. RRSs have been shown to significantly increase patient safety and decrease mortality and cardiac arrest rates, in adult and paediatric hospitals, and are widely employed around the world.21–23 The implementation of an organisation-wide patient safety system such as an RRS, then, lends itself to evaluating the safety of an acute care hospital by measuring the impact of its implementation on end points such as prevention of deaths and cardiac arrests in patients without a DNR order. The next challenge in the evolution of RRSs and their contribution to patient safety is to identify patients who require urgent intervention at an earlier stage in their illness. This could be achieved by providing improved technology that is capable of detecting clinical deterioration at an earlier stage.

1 Characteristics of rapid response systems relating to hospital patient safety

Operate across the whole organisation
Bypass traditional hierarchies and professional boundaries
Are constructed around patient needs
Are developed and operated by front-line clinicians
Are not externally mandated
Engage managers and policymakers from the bottom up
Aim to prevent the most serious adverse events from occurring in hospitals
Operate independently of the reasons for the deterioration of a patient’s condition
Contribute to real-time detection of safety events
Are associated with standardised and readily measurable outcome measures

2 Factors that have been used to measure hospital performance

Admission rates
Mortality rates and standardised mortality ratios
Length of stay
Numbers of visits to emergency departments
Waiting times in emergency departments
Numbers of outpatient visits
Numbers and types of operations
Costs
Patient satisfaction
Equity and access
Numbers of patients on waiting lists
Ambulance response times
Rates of return to theatre
Readmission rates

Leading the rebirth of the rural obstetrician

In 2002, 30% of all Australian births occurred in non-metropolitan hospitals, and 57% of these hospitals did not provide specialist obstetric cover.1 Antenatal care led by general practitioner obstetricians is offered in 50% of South Australian and Victorian public hospitals and is the only public sector model in most non-metropolitan hospitals.2 GP obstetric care has been shown to provide safe care for pregnant women at low risk of complications, and access to such services in rural Australia is essential.3–8

A looming crisis in the provision of rural obstetric services in Australia was identified in 2007.9 An important study of survey data from 2003 reported that Victorian GPs were becoming less likely to provide obstetric management and that half of the existing GP obstetricians intended to cease practising in the next 5–7 years. In addition, they found that 71% of GPs who completed a Diploma of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (DRANZCOG) did not then go on to practise independent procedural general practice obstetrics.9

Factors contributing to the forecast deficit in GP obstetric services included a rise in specialisation, centralisation of services, concerns regarding indemnity and litigation, rural workload and difficulty maintaining competence.9,10–13 The problem of maintaining competence in rural environments has been compounded by reported difficulties in accessing appropriate locum coverage to allow attendance at upskilling courses, in addition to the time and travel required to participate.10

The impending shortage of GP obstetricians and the need for strategies to train, retrain and retain GP obstetricians in rural practice have been the integral considerations in developing a comprehensive training and support program offered in the Gippsland region of rural Victoria. The Gippsland region lies east of Melbourne, covering a land mass of 41 524 square kilometres, and has a population of around 240 000.14 The program by Southern GP Training (SGPT) combines training for registrars and upskilling of GP obstetricians with strategies aimed at overcoming the professional isolation confronting rural GP obstetricians. The program (outlined in the Appendix) expanded registrar training at the larger regional (specialist-led) units to include a 3-month rotation on secondment to a metropolitan hospital. Further training was extended to include a state government-funded 6- or 12-month placement in a GP-led obstetric practice (bridging post) with secondments to larger centres; provision of a clear, individualised postdiploma pathway with supported placement in a GP-led, community-based obstetric practice; continued professional development; upskilling of existing GP obstetricians through the DRANZCOG Advanced qualification, which includes competence in performing caesarean sections; regular GP obstetrician meeting days attended by both registrars and practising GP obstetricians; specialist-led support and mentoring through a regular email forum; and specialist involvement in subregional GP perinatal education and morbidity meetings. In this way, the model provides a supported transition from specialist-led hospital obstetric units to GP-led, community-based obstetric services and integrates this with support for practising GP obstetricians.

The program is continuing to evolve, with new developments such as rotations to the Northern Territory and Pacific islands,15 to enrich the experience of the trainees. The implementation of this program has been matched by a period of recovery for Gippsland maternity services with an increase from 31 GP obstetricians in 2007 to 39 in 2013, including an increase from 10 to 23 conducting caesarean sections. This represents a reversal of the pre-existing trend in service closures.9,16 Of the 39 currently practising GP obstetricians, 18 received their training in the SGPT Gippsland obstetric training program.17 Another three trainees went on to practise GP obstetrics elsewhere, meaning that 21/33 program graduands were active in procedural practice.17

Recent government initiatives have supported GP obstetricians through funding professional development, incentive payments for upskilling, annual incentives for continuing GP obstetric practice and indemnity insurance support. These developments have removed some of the structural disincentives identified as barriers to procedural obstetric practice.

The aims of our study were to understand the factors influencing the decisions of rural GPs and GP registrars to practise obstetrics, and to understand the impact of this innovative GP obstetric training and support program on these decisions.

Methods

Our research was conducted in Gippsland in July and August 2013. Within the region, there are three specialist regional centres that offer a GP-led model of obstetrics, and five hospitals with GP-led services only, all with the facilities for caesarean sections.

Participants were identified from training records and the GP database of the past 5 years for the SGPT GP obstetrician and registrar training and support program. Letters of invitation, explanatory statements and consent forms were sent to potential participants.

We adopted a qualitative approach using semistructured face-to-face interviews.18–20 The research questions examined were:

What challenges face rural GPs in practising obstetrics?
What impact has the Gippsland GP obstetric program had on GP obstetric career decisions?

A three-stage framework method of data analysis (data display, data reduction and data interpretation) was applied,21 and measures were employed to augment the validity and reliability of this research. To ensure correct and detailed collection of participants’ experience and views, all interviews were audiotaped, and copies of the transcripts were provided to participants to check for accuracy. Recorded interviews were analysed by two researchers for credibility and validation of the analysis. Analysis of the transcripts, once uploaded into NVivo 10 (QSR International), was conducted independently by two researchers to check interrater reliability of the emerging themes.

Ethics approval was obtained from the Monash University Human Research Ethics Committee for this research.

Results

Of the 60 potential participants contacted, 22 agreed to take part. The sample included registrars, GPs who were upskilling and established GP obstetricians who supported registrars in training. Interviews ranged from 40 to 90 minutes in duration.

Six major themes emerged: isolation, work–life balance, safety, professional support, structured training pathway and effective leadership.

The first three themes relate particularly to the first research question.

The theme of isolation included the subthemes of distance from specialist services, access to assistance, and access to professional development. The challenge of isolation came with the awareness that it was critical to have the confidence and competence to handle difficult situations and that access to assistance and advice was important. When experienced GPs talked about the impact of isolation, their comments were focused on managing a situation, often in the context of access to assistance from a local team.

Neonatal Emergency Transfer Service (NETS) can come down, [but due to] the weather, it may be several hours before they can … the GPs rally around and can keep working on the babies, intubate them, and keep breathing for them. It is not ideal, but it works well most times. (Participant t)

Comments about isolation from registrars and GPs who were at an earlier career stage focused on how access to assistance with the guidance and information available through the SGPT program ameliorated this isolation.

I’ve got someone to call on at the drop of a hat if I am out of my depth at any point, even if it’s just for advice over the phone. (Participant e)

The theme of work–life balance included the subthemes of impact of after-hours call out, the demands of emergency situations, dealing with scheduled patients at the clinic after being at deliveries during the night, and family commitments.

Obstetrics interrupts the rest of life, both clinical, family life, and sleep. You know to be woken up in the middle of the night … isn’t a particularly pleasant thing, and try getting back to sleep after all the excitement. (Participant g)

Being part of a team of GP obstetricians assisted in achieving an acceptable work–life balance.

The theme of safety was mentioned more often by doctors who were at an early point on their career trajectory. This theme included the subthemes of patient safety and practitioner safety. Patient safety was related to backup and competence, while practitioner safety was about feeling supported and having confidence in dealing with the unknown. The SGPT Gippsland program was seen to contribute to improving safety.

Because (obstetrics) is a high-risk area and people burn out. They [SGPT] don’t want us having disastrous situations when we are junior. (Participant a)

The second three themes —professional support, structured training pathway and effective leadership — relate particularly to the second research question. Professional support was mentioned by all 22 participants. Participants from all groups within the cohort commented on the quality and availability of professional support within the Gippsland program. This theme included the subthemes of professional backup, professional networks and a respectful learning culture. With regard to professional backup, the availability of backup from specialists was described as timely and appropriate, as nominated mentors assisted with advice on practice in the clinic, and teams were built to support the training experience. Doctors in training and doctors in independent practice perceived they were well supported professionally.

When you are training you are always first on call, which is fantastic because you have to deal with everything that walks in the door. But you are paired with a consultant on the day. You basically run your assessment with them and see if they are happy with your plan, and for any instrumental deliveries or complicated issues you contact them to come in. So, it is very well supported. (Participant d)

Involvement in the Gippsland program made available both formal and informal professional networks to participants. The professional networks provided an environment where people at all stages of their career received support and timely, up-to-date information. Regular professional development opportunities were a valuable component, strengthening these networks and providing opportunities to reflect on best practice.

Ongoing professional development offered is fantastic, as it keeps you abreast of new developments as well as provides an opportunity for professional networking. (Participant v)

A respectful learning culture with an emphasis on empowering and enabling participants was an important component of professional support.

Respect is a huge factor; the leaders in the program lead by example and are very inclusive and respectful of individuals’ experience and needs. (Participant u)

The structured training pathway theme emerged as an important component of the Gippsland GP obstetric program. This included the subthemes of community-based bridging posts for registrars; secondment for additional experience; and continuous professional development. Registrars rated the bridging posts as critical to offering a safe transition.

I think it is about fostering supported practice and this is a particular time of vulnerability in terms of support … the movement from hospital-based practice to being a new person in community-based practice. (Participant g)

The theme of effective leadership was apparent across all interviews. There was clearly the perception of supportive, knowledgeable and respectful leadership within the program, and this was highly valued.

They are definitely good mentors and good role models and that is part of the reason … to want to keep going with this pathway. (Participant f)

Discussion

The themes of isolation, work–life balance and safety for the practitioners and patients emerged in our study as substantial challenges for rural GPs in practising obstetrics. These findings are consistent with the findings of other researchers who have studied the challenges of rural and remote medical practice more broadly.22,23 Work–life balance is particularly important for sustainable practice24 and is vulnerable to the demands of isolated obstetric practice. Our study indicates that the Gippsland GP obstetric program has contributed to a recovery and retention of maternity units in Gippsland founded on its success in helping doctors deal with these challenges.

Participants found the obstetric program to be professionally supportive, with meaningful backup, advice and support of professional development. The program has also been instrumental in building and supporting professional networks. Reliable, relevant backup and advice ameliorates isolation and enhances patient and practitioner safety. Professional networks remove isolation and enable cooperative rostering, which is a means to improving work–life balance. In this way, the SGPT Gippsland GP obstetric program would seem to have become fundamental for sustaining GP obstetric practice in Gippsland.

Our study suggests that the structure of the Gippsland GP obstetric training enables its trainees to continue into active, independent procedural obstetric practice. The bridging post after the primary training was highly valued. A large decrease in use of procedural skills 1 year after their primary procedural training has been reported previously.9,25 Supported transition after completion of hospital-based training has been found to be an important factor influencing recently qualified GPs to continue into independent procedural practice.25 Structured, respectful clinical supervision by senior role models is vital to effective postgraduate medical education,26 with the supervision relationship being shown to be more important than the supervision method.27

Leadership was clearly a major factor in the impact and success of the SGPT Gippsland GP obstetric program. This leadership was provided by committed specialist obstetricians and active GP obstetricians.

There was a notable absence in the data of mention of financial disincentives to practising GP obstetrics. This suggests that disincentives identified previously1 have been largely removed by recent government initiatives in this area.

This study was conducted in a particular geographic area, so transferability of the results cannot be assumed. In particular, this program was introduced where a shortage of GP obstetricians was forecast but not yet apparent. The participation of GP obstetricians was key to the success of the program. Therefore, this program design may not be as effective where GP obstetrician shortages already exist. However, themes such as isolation, safety and leadership are likely to be relevant in most rural settings, and the strength of these themes across the different practitioner groupings and towns suggests that the findings are generalisable. The stratified sampling method used was a strength of the study.

Our study also suggests that the Gippsland GP obstetric program has had a substantial impact on trainees continuing into active obstetric practice and on GP obstetricians continuing in their obstetric practice. This innovative program was made possible by state and federal government funding, the support of local and metropolitan hospitals, and ownership by both specialist and GP obstetricians. Leadership, organisational support and administrative support by SGPT have provided the scaffolding for the program. Key features of this training include a supported transition into community-based GP obstetrics; adequate clinical exposure through secondments; a culture supportive of GP obstetrics; building and sustaining professional support networks; and inspirational leadership. The increase in numbers of practising GP obstetricians has enabled more acceptable rosters and greater flexibility in accommodating personal commitments. These key features should be foundational considerations in replicating this successful model elsewhere.

The parable of Provence

Being the victim of a robbery highlights our inherent helplessness in an inexorably changing world

It was on the cusp of winter in southern France. As president of an international health care organisation, I had been in Geneva and decided to have a few days in a village near Avignon. Up to that time, the trip had had its moments.

One such moment was our flying out of Schiphol. Birds, probably geese, had struck the plane. It was thought that at least one engine had been involved. The plane returned urgently to Amsterdam with the runway lined with a welcoming display of fire tenders and ambulances. A daytrip from London had been transformed into the tedium of waiting into the early hours of the morning for a replacement plane. There was tension among the passengers given that, just a few weeks earlier, an El Al Boeing 747 cargo plane had crashed into a block of flats in the Bijlmermeer district of Amsterdam, killing at least 39 people on the ground and injuring many more. The plane had lost its engines in flight.

You put all that aside and have a relaxed time in Provence, shorn of tourists in this season. In the city of Orange on the way north, there is a famous Roman theatre, so we stopped in the city square, and went off to see it. From the end of the square I looked back and saw — nothing. The theatre was in a state of disrepair, much of it fenced off.

It must have been 30 minutes before we returned to our vehicle. Strange, the door on the driver’s side was unlocked. And then came the full realisation. The car was empty. The lock had been broken with a screwdriver.

We had not been robbed of everything. They had missed a couple of bottles of red wine that had rolled under the seat and a couple of scarves stuffed into a plastic bag. The fencing blades for my son were ignored, as was my board report that had been printed out the night before. The computers had been taken, but fortunately, we had been carrying our passports and money.

First, a sensation of helplessness paralyses any action. Then there is a period of intense anger of deprivation, fortunately, not of identity, but of those pieces of memorabilia that are surrogates for identity.

J’accuse! You look round as if the square is full of accomplices. Being lunchtime in late autumn there were few people. Those that were there had seen nothing. Where was the police station? The gendarmerie had been moved from the centre of town.

However, we first made a rapid trip to the pharmacy to get replacement drugs. No prescription, but the staff, with Gallic insouciance, gave me what I wanted, and then went back to dispensing — and no, they had seen nothing.

Eventually we found the police station. Lunchtime, and not a policeman to be seen. A young man was seated on the corridor bench where we sat down. There was nothing unusual about him, except he was handcuffed; no other restraint, no guard. We all waited together. The French lunch extended well past 2 pm. We were ushered into the presence of an inspector who conformed perfectly to the stereotyped caricature. He picked his teeth, had a moustache, spoke little English and, after taking down a short narrative, solemnly looked out the window and concluded it was the fault of the Algerians who were infesting the south of France.

Disappointedly, he said the thieves could be anywhere. Then suddenly he realised we were Australians and launched into a long paean about “Oran”. I knew Oran was in Algeria, but this was about a chap. The sou dropped. The subject of his adoration was Timmy Horan, the champion Australian rugby union centre. The interrogation was at an end; the subject was now Timmy Horan and the Australian world cup triumph the previous year.

The guy with the handcuffs was still there when we left. Our mood was now one of resignation. We got into the car, looked for any tell-tale signs of discarded booty on the way out of town, and drove back to Geneva to the same hotel that we had left just days before with a car packed with luggage. Now we returned with all of our goods in a plastic bag.

Hire cars at that time stood out like beacons, especially as our car’s headlights were perpetually on, common in northern Europe, but a real giveaway in the south of France. That we had been trailed by a gang of thieves waiting for the right moment to strike developed in both of us a distrust of leaving anything unattended. No longer was there carefree sightseeing. Taking in the sights became a matter of military precision. Go to the hotel, unload the luggage and then go sightseeing with an eye on the rear vision mirror and making sure any stuff in the car was scattered on the back seat to make robbery more difficult. It was said that a nimble burglar could empty a car in 30 seconds.

Insurance covered the loss, but the experience left a scar. I have not suffered having a gun held to my head, as happened to a South African friend, whose burnt-out car was found later near the Botswanan border. But still, there is a residue. One way to deal with it is by joking about the Clouseau-type inspector and his obsession with rugby — blocking the whole unpleasantness, and turning it into a conversational anecdote.

I was taught medicine by a raft of doctors who had experienced war and imprisonment, and had confronted their own mortality on many occasions as young men. Had they felt helpless? None of my generation ever asked. After all, being a doctor is about coping.

I have never been confronted by armed force or a terrorist missile — only by an empty car. I was a victim of random violation. Stolen goods are replaceable. Nevertheless, helplessness is no longer an anecdote to laugh off. We are now bombarded with matters beyond our control. Not just having to watch, but being able to cope with the apparent helplessness is a worldwide dilemma for all of those educated people who believe that there is a solution to everything.

I turned to the poet Milton. Are we lost in helplessness as was Samson, finding himself “eyeless in Gaza, at the mill with slaves”?1 By contrast, Paradise regained, Milton’s other work written concurrently, is a syntactical battle between the Tempter and the Other Guy, with Him eventually getting the ambrosia.2

Maybe in the final scuffle of stones, the trick is to realise that to counter helplessness, one needs to miss the mill and strive for the ambrosia. After all, the mill, which Blake expanded to “dark satanic mills”,3 compounds the misery of helplessness, whereas the concept of Milton’s Saviour partaking of ambrosia at the triumphant end of the ordeal indicates hope — surely a relevant message for this time of the year.

The impact on vulnerable Australians if the Government removes the Medicare bulk billing incentive items

GP services – bulk billing rate is 82.2%.

Metropolitan patients will have to pay at least $6.25 when they see their GP.

Rural patients will have to pay at least $9.25 when they see their GP.

Pathology services – bulk billing rate is 87.7%.

Metropolitan patients will have to pay at least $6 for their tests.

Rural patients will have to pay at least $9.10 for pathology tests.

Diagnostic imaging services – bulk billing rate is 76%.

Metropolitan patients will have to pay at least $6 for imaging.

Rural patients will have to pay at least $9.10 for imaging.

Commonwealth Medicare funding cut by least $632m per annum for the most vulnerable people in the Australian community.

The 4th Rural and Remote Health Scientific Symposium

Making the most of rural and remote health research through collaboration

Given its focus on ensuring that rural and remote health research leads to changes in policy, it was appropriate that the 4th Rural and Remote Health Scientific Symposium was held at Old Parliament House in Canberra on 2–3 September 2014.

It was an occasion when “data custodians” (an interesting term, much used throughout the 2 days) came together with rural and remote health consumers, service managers and researchers. With the National Rural Health Alliance as one of its organisers, the event was unashamedly focused on rural and remote health research and what it might do for health outcomes in those areas.

Members of the rural and remote health research sector are proud of what we have achieved. When it comes to providing specialist health services, there is an accepted dependence on large regional centres and metropolitan areas. But where research is concerned, there is an emotional and intellectual belief that the best work for rural and remote areas can only be done in those areas.

In the final session, several suggestions were made for inclusion in what might be seen as a plan of action:

regular meetings of the parties that attended the symposium would add value to the rural health research sector, particularly if they progressively include agencies responsible for data series relevant to the social determinants of health, such as those associated with the Department of Social Services. By including such interests, the health data and research sector can help demonstrate an approach to wellbeing based on the social determinants of health;
rural and remote health researchers should talk with data custodians early, to help shape their research proposals and to be clear about what data they really need;
policymakers can be enlisted to help identify “best bets”, including evidence about health interventions that do not provide good value for money;
the case for more focused investment through the National Health and Medical Research Council in rural and remote research should be pursued;
the rural and remote health research sector should consider producing a publication on best-practice approaches to Indigenous health research and play a leading part in ongoing work to promote the elements of such an approach;
a strong case must be made for the fourth phase of the Primary Health Care Research, Evaluation and Development (PHCRED) strategy (the first three phases of the PHCRED strategy have been described,1 and a review of PHCRED is being completed in anticipation of Phase 4); and
further consideration should be given to the establishment of a virtual academy of rural and remote health research.

The key element in this list is perhaps the last: an idea whose time has now come. A virtual academy would support health researchers working in rural and remote areas, and be a clearinghouse for research proposals and an advocate for resources. It would also support collaboration on ethics approvals, and help remove barriers to data access and sharing.

For information about the symposium, including the associated communiqué and links to the presentations, visit the symposium website at http://www.ruralhealth.org.au/symposium2014.

Rural clinical school outcomes: what is success and how long do we wait for it?

In reply: Garne and colleagues raise the important matter of whether the current quota of rural students in medical schools (25%) should be increased, given the positive impact of rural background on future rural practice. We agree that this warrants serious consideration, but suggest that there should not only be an increased national quota for rural students but also consideration of the distribution of these students between different medical schools.

Medical schools are not all the same. They have differing staff expertise and facilities, and also recruit students in a number of different environments and populations. These factors facilitate student recruitment and training, and hopefully influence students’ future career choices to serve in disadvantaged communities (such as underserved urban or ethnic communities), and also in underserviced subspecialties (such as dermatology and otorhinolaryngology) and other health priorities (such as public health and research leadership). Perhaps individual medical school quotas for rural students should vary depending on their staff expertise, facilities and environments.

We are not frustrated. We are proud of our achievement in training rural practitioners and congratulate the University of Wollongong on theirs.

Aboriginal and Torres Strait Islander medical students’ and doctors’ career intentions

To the Editor: In the past 30 years, the Aboriginal and Torres Strait Islander medical workforce has rapidly expanded. However, proportionally, there is still underrepresentation of Indigenous people in all areas of medicine.1 General practice has remained successful in attracting Indigenous people to undertake fellowships,1 but there are many specialties that have yet to see an Indigenous trainee or fellow.

Indigenous medical student numbers reached population parity for the first time in 2012.2 As these numbers increase, it is important to understand the demographics, career intentions and outcomes for this group, to achieve positive change for Indigenous health through improved support and reduced attrition of students.

The Medical Schools Outcomes Database and Longitudinal Tracking (MSOD) project collects data on Australian medical students and doctors.3,4 All students are invited to complete short questionnaires when commencing and finishing medical school and subsequent postgraduate years. Between 2005 and 2012, 36 244 participants completed the surveys.4

Up to 2012, 296 Aboriginal and Torres Strait Islander students had completed the commencing medical students questionnaire (CMSQ); 45 Aboriginal and Torres Strait Islander students had completed the exit questionnaire, and 26 Aboriginal and Torres Strait Islander doctors had completed the postgraduate year 1 questionnaire. Despite attrition in response rates, which may be attributable to a prolonged time to graduation, Indigenous students and doctors tend to be older, more likely to have children and more likely to identify as being from a rural background compared with non-Indigenous participants across all surveys (Box).

In all questionnaires assessed so far, general practice was the highest ranked preference for Indigenous medical students (Box). Overall, of all MSOD participants in the CMSQ, only 47 (0.2%) ranked Indigenous health as a first preference. This shows that improved pathways for Indigenous people into specialty training remain important, and that improved strategies to encourage both Indigenous and non-Indigenous people into Indigenous health should also be further developed. These results and future results of the MSOD project will provide a useful evidence base to guide policy development in Australia, particularly surrounding workforce, medical education and vocational training for Aboriginal and Torres Strait Islander medical students and doctors.

Demographic details of Indigenous and non-Indigenous survey participants in the Medical Schools Outcomes Database and Longitudinal Tracking project, 2005–2012

	Commencing medical students questionnaire		Exit questionnaire		Postgraduate year 1 questionnaire
Demographic characteristics	Indigenous (n = 296)	Non-Indigenous (n = 21 709)	Indigenous (n = 45)	Non-Indigenous (n = 8392)	Indigenous (n = 26)	Non-Indigenous (n = 4510)

Participant response rate	84.8%	91.0%	72.6%	83.0%	49.1%	67.0%
Women	55.1%	52.7%	48.9%	53.7%	61.5%	56.7%
Marital status (married)	9.1%*	3.6%	11.1%	10.4%	19.2%	20.2%
Have children (> 1 child)	16.8%*	2.8%	19.0%*	5.5%	15.4%*	8.7%
Mean age (years)	24*	21	28*	26	30*	27
Identify as being from a rural background	55.7%*	19.0%	48.6%*	17.9%	61.9%*	18.9%
First preference to pursue general practice	32.0%*	20.6%	25.0%*	19.4%	26.3%	26.4%

* P < 0.05 for comparison with non-Indigenous participants.

Newborn bloodspot screening: setting the Australian national policy agenda

To the Editor: Maxwell and O’Leary’s article1 and Wiltshire and Cameron’s letter2 provide insights into the current issues facing newborn bloodspot screening (NBS) in Australia. It is clear that we have world-class NBS programs, but there is a lack of national policy guidance agreed on by governments. It has been argued that this has affected the programs’ capacity to respond to the changing environment in which they operate.1,3,4 There is a need for clear national policies to support the programs’ continued success and growth, and a way to assess the benefits and harms of screening additional conditions through NBS.5 Since the aforementioned articles were published, there has been substantial progress towards achieving these goals.

Australian governments have recently agreed to develop a national policy framework for NBS. This will include a decision-making pathway, against which congenital adrenal hyperplasia and other conditions can be assessed for inclusion in NBS. The policy framework is being developed under the auspices of the Standing Committee on Screening, through a multidisciplinary working group. The project is due for completion by early 2016, and will be informed by broad consultation, due to take place in 2015. Further information can be found at http://www.genomics.health.wa.gov.au.

The current process is a genuine opportunity for policymakers, NBS programs, clinicians, consumers and others to come together to put in place a framework that builds on the successes of NBS, safeguards the programs into the future, and enables transparent and consistent decision making.

Medically assisted circumcision: a safer option for initiation rites

Culturally sensitive integration of medical circumcision could avert adverse effects at traditional male initiation rites

In many traditional cultures, male initiation rites involve circumcision practices that can sometimes result in medical complications. In a recent incident in the Northern Territory, three young men required airlifting from their Borroloola initiation site to Darwin for medical assistance.1 The risk of permanent harm and potentially fatal outcomes could be decreased if safer options were available during initiation ceremonies. In this article, we report that it is possible to provide safe circumcision at male initiation rites.

In December 2013, a traditional initiation ceremony was conducted in Drekikier District, East Sepik Province, Papua New Guinea (PNG). During the 4-week ceremony, circumcision, considered vital for transition from boyhood to manhood, is conducted in the first week. Previously, young initiates suffered excruciating pain and severe blood loss when a carved cassowary bone was used to cut the penis and foreskin. On this occasion, at the invitation of community leaders, a medical team assembled at the site to provide safe male circumcision for 34 initiates.

The team consisted of a medical officer, two community health workers, an HIV counsellor and the provincial HIV response coordinator. Consistent with local cultural traditions, the entire team consisted of men originating from the local cultural group who also participated in cleansing rituals as part of the ceremony. Medical supplies, surgical instruments and a portable steriliser were brought to the initiation site deep in the forest. A specially built traditional dwelling stood in the middle of a small clearing. The few bush tracks that led into the site were carefully concealed to be completely segregated from other villagers, especially women and children.

A small shelter that stood immediately to the back of and continuous with the main ceremony house served as the operating theatre. It had an opening in the roof to allow sunlight in. Two beds and two tables were assembled in the centre of this structure. The beds served as operating tables and the tables were used for medical supplies and surgical instruments. The medical officer and one community health worker performed complete foreskin removals with assistance from other team members. Five to 10 mL of 1% lignocaine was infiltrated around the base of the penis and the procedure was conducted using sterile technique.

Five or six circumcisions were performed per day. Of the 32 initiates who were circumcised, only two experienced adverse events. The first had slight bleeding, rectified by reinforcing the gauze bandage and gentle continuous pressure for 1 minute. The second experienced heightened pain despite having two 500 mg paracetamol tablets after the procedure. This pain resolved after further regular doses of paracetamol.

Two initiates had previous penile modifications and were refused surgery. The injection of substances (such as cooking oil) or insertion of objects (such as ball bearings) under the skin of the penis can cause extensive scarring and disfigurement.2,3 For the safety of the initiates with previous penile modifications, arrangements were made for their circumcision to be done in the district hospital.

A number of challenges were encountered. Health workers needed to be re-deployed from existing programs and some supervisors were reluctant to allow staff to participate. Surgical instruments and medical supplies were sourced from provincial health facilities and were provided with a degree of reluctance. The makeshift operating theatre did not have a good light source, nor was it enclosed by flywire to keep insects out. Sterilisation was challenging, with forceps and tissue scissors washed in water collected from a nearby stream, placed in kidney dishes and sterilised in a pressurised portable steriliser heated over a fire for 30 minutes. This took 1 hour and limited the number of procedures per day.

Despite these challenges, the service proved successful. Of the 32 initiates circumcised, all had successful healing and fully participated in the remaining activities, including instruction on responsible living, family planning, wealth acquisition and respect for one another. All initiates completed the 4-week ceremony with a rousing celebration on 15 January 2014.

Improving the evidence base and increasing the availability of safe male circumcision procedures was a major recommendation from a recent national policy forum in PNG.4,5 Providing safe circumcision at the initiation site meant that some aspects of traditional circumcision were adjusted. Circumcision was delegated and performed entirely by the medical team, albeit a team of local cultural origin. Penile foreskins were completely removed, and medically contraindicated procedures such as urethral poking or scarification were not performed. However, chants and recitals continued in the main ceremony house as initiates were being circumcised.

This experience has shown that it is possible to provide medically assisted circumcision within initiation ceremonies in cultures that traditionally practise male circumcision in PNG. A similar approach may assist cultural groups in Australia to reduce the risk of adverse effects from male circumcision during traditional initiation ceremonies.