“I have learnt … a different way of looking at people's health”: an evaluation of a prevocational medical training program in public health medicine and primary health care in remote Australia

Abstract

The purpose of this study was to gain insight into what prevocational medical practitioners (PMPs) learnt during a six-month public health medicine and primary health care training program (the Program) in remote Aboriginal Australia in 2001–2002. The Program's curriculum objectives included clinical and public health management of sexually transmitted infections, immunization, clinical audit and quality improvement, primary health care in remote Aboriginal communities, and working as part of an interdisciplinary team with health and non-health professionals, and lay people. The mode and location of delivery of these objectives was determined by the healthcare needs of the Kimberley population, and availability of safe, supported workplaces. Qualitative data from a variety of sources, including PMPs’ reflective journals, were examined in the context of the Program's curriculum objectives and by conducting a content analysis of journal notes. Findings are presented using the curriculum objectives and other comments that emerged while examining the data. Preliminary data indicated that PMPs gained knowledge and practical experience in clinical and public health management of sexually transmitted infections, immunization and primary health care in poorly resourced remote Aboriginal settings. Deeper understandings of health and illness in a cross-cultural setting also developed, along with professional and personal growth, as illustrated by the following quotations from PMPs: “I have learnt … a different way of looking at people's health … I was encouraged to think more deeply than before about the whys and wherefores of medical practice, and thus consider the most effective ways of influencing patients’ behaviours for the better.” “I was encouraged to examine the thought processes behind the ways … healthcare was provided … [after leaving the Kimberley] I am constantly questioning the reason why we are practising medicine in a certain way in the big city hospitals—much to the consternation of my colleagues … .” The Program was successful in teaching its first four PMPs the basic tools of public health medicine and remote area primary health care.

Introduction

In 2001 the Kimberley Public Health Unit (KPHU), a state government body, which has statutory responsibilities for population health in a remote region of Western Australia (WA), established Australia's first accredited training program in public health medicine and primary health care (from now on referred to as ‘the Program’) for prevocational medical practitioners (PMPs) [1]. The 24-week program, described by Mak & Plant (2005), aimed to give PMPs practical remote area experience in public health medicine and primary health care in the hope that they would develop a career in one or both of these fields and return to ‘the bush’. It consisted of four weeks’ sexual health training at a metropolitan teaching hospital followed by 20 weeks in public health medicine and primary health care at KPHU and community and remote area health clinics. Geographic isolation from urban Australia, an unfamiliar sociocultural setting and a unique healthcare system in the Kimberley meant that PMPs were encountering a very different environment, often for the first time, when they arrived in the region fresh from a city tertiary teaching hospital.

As this Program is unique in Australia, an evaluation component was incorporated from the Program's inception. The twofold aim of the evaluation was to assess (a) the development of PMPs’ knowledge and understanding as a result of the Program, and (b) the Program's influence on PMPs’ medical practice and career aspirations six months to two years later.

Table

Practice points
•There are very few opportunities for Australian prevocational medical practitioners to develop knowledge and skills in public health and rural/remote area health.
•A six-month prevocational public health medicine and primary health care training program in the remote Kimberley regions of Western Australia was established in 2001–2002.
•Removed from their normal clinical workplaces, familiar geographical environment and social supports, PMPs not only gained medical knowledge and practical experience (in clinical and public health management of sexually transmitted infections, immunization and primary health care in remote Aboriginal settings), but also developed deeper understandings of health and illness, and experienced considerable professional and personal growth.
•More prevocational medical placements in public health medicine and remote area health should be offered.

Methods

Given that only two PMPs were involved in the Program each year, and the exploratory nature of this unique evaluation, we opted for a qualitative analysis comprising in-depth examination of the following textual materials collected between February 2001 and June 2003:

1. PMPs were asked to write a reflective journal every fortnight and to email this to the Program supervisor (author DBM). The journal not only served as a record but also helped to conceptualize questions related to their experiences.

2. PMPs were interviewed midway and at the end of the Program by author AJP using a 45- to 60-minute structured telephone questionnaire about curriculum objectives, teaching and supervision, social, collegial and workplace support and PMPs’ suggestions for improving the Program. AJP, the only person who had access to interview data, identified major themes from these data.

3. Reports and publications written by PMPs during and after completion of the Program (reports, conference presentations and newsletter articles) were also analysed.

4. PMPs completed a written questionnaire in May 2003 (six months to two years after completing the Program), about what they had learnt during the Program, how it had influenced their perceptions of working in public health medicine, primary health care and remote areas, and whether it had influenced their future aspirations.

These data, comprising PMP-authored journals, emergent interview themes, reports, presentations and post-Program questionnaire, were examined in the context of the Program's curriculum objectives. The raw data, except for PMPs’ interviews with AJP, were analysed by all authors. Any differences in opinions were discussed until consensus was achieved. Findings were then integrated and are presented below. Noting that the collected data are indicative only, but suggesting the need for further research, where possible, results are illustrated by anonymous quotations from PMPs [2].

Results

Curriculum objectives

STI clinical and public health management

All PMPs gained practical experience in the clinical management of patients with STIs, in both a specialist STI clinic and remote area primary health care settings, and identified this as one of the most important learning outcomes of the Program. They appreciated the differences between Fremantle Hospital Sexual Health clinic and Kimberley practices:

… in urban venereology … time, distance … and client comprehension seem to be on the clinician's side … . The chaotic nature of work up here seems worlds away from Fremantle [STI] clinic.

Despite these differences, PMPs seemed able to apply newly learnt skills to challenging situations. This was evident from the fact that one female PMP conducted STI screening on several males from a very traditional community, at their request, after their attendance at a sexual health education session. The journal of a male PMP reports a more informed position, which helped him to conduct STI consultations in a difficult situation:

[doing] STI check ups on four boys named as syphilis contacts in an alleged rape case, while remaining non-judgemental, maintaining confidentiality, and respecting [cultural] taboos … was challenging, character building and not something I would recommend to my friends.

The following journal entry reveals that PMPs also learnt why clinical sexual health skills are an important part of medical practice:

The stigma associated with STIs will only be reinforced … [and] Patients suffer when their doctors are too embarrassed or don’t have the knowledge and skills to deal with sexual health.

PMPs also learnt about the public health aspects of STI control through implementing and evaluating syphilis outbreak control strategies and doing at least one clinical audit on an aspect of STI control. Their ability to apply public health principles to real-life STI clinical management situations is evident here:

One of the new … syphilis cases was an itinerant woman from [interstate]. The doctor who had [tested her for syphilis] knew … that [the patient] was not going to be in [Western Australia] by the time the results were back … had no plan of how to follow-up the results and seemed to think that it was now my responsibility … in the past I have not thought of follow-up when doing tests, but when testing for things as serious as HIV and syphilis, I think this is a little irresponsible. A learning experience.

The lasting nature of improved knowledge and understanding, and the ability to apply skills in new situations is evident from the following PMP report, one year after completing the Program:

I introduced a [sexually transmitted disease] screening pack [in the infectious diseases department of tertiary hospital X] … [because] I discovered that [the hospital doctors] were doing literally hundreds of HIV tests … in at-risk [people] but never screened for [other] STDs unless someone was symptomatic. Most of [the hospital doctors] didn’t know what swabs to use … . So when I suggested a pack adjusted to … our pathology system's [requirements] … [the hospital doctors] said ‘great idea—can you do it!’.

Immunization

Practical immunization training was a new experience for PMPs, as the following quote makes clear:

Strangely enough doctors never have to give intramuscular injections in hospitals, so I was quite unfamiliar with the technique … from being completely incompetent at the start … to feeling as if I could almost run the clinic myself.

PMPs also learnt about the logistics of vaccine delivery in a remote area. When asked to organize rabies vaccination for a patient following a bat bite, one PMP initially thought:

This will be easy … [but] Things didn’t happen smoothly … the [vaccines] almost didn’t make it … . Another example of the difficulty of providing good quality health care to a remote region.

After completing their immunization accreditation, PMPs commented that they had previously never realized the complexities of delivering an immunization program, one commenting that if she became a general practitioner she would employ an accredited nurse immunization provider.

Clinical audit and the quality improvement cycle

Although most PMPs had no previous experience of conducting or disseminating the results of a clinical audit prior to commencing the Program, journal entries, verbal comments and audit reports indicated that they learnt about audit design, data collection and how to use Excel and SPSS software to analyse quantitative data:

I have found through the process of collecting the data and entering it that the deficiencies of the [audit design] and the potential biases are more obvious than they would be if someone else was doing this part and I was just analysing it.

Verbal and written feedback indicated that the process of writing up and disseminating their audit results was a powerful learning experience and one that might usefully be applied to other situations:

[I] learnt a lot about the process of report writing. Draft after draft … did a Powerpoint presentation of the results … to the [Town X] doctors, [the Town X Aboriginal Health Service] and to the midwives … although [the doctors] were fairly defensive … it made them think about their practice and may lead to some improvement. They also picked out a fault [in audit design] … so it was back to … collect more data.

Primary health care in remote Aboriginal communities

PMPs’ discussions and extracts from interviews with DM and AP, combined with content analysis of journal entries, show that working in an Aboriginal primary health care setting provided a rich source of learning. This was demonstrated clearly by comments relating to PMPs’ experiences in Area K, which is very remote, has a culturally and politically diverse population with high levels of morbidity, as described by Toussaint (1999), poor environmental health conditions and a paucity of primary health care resources—concerns noted by each PMP on his/her arrival.

On her first day in area K, one PMP saw a young man with acute psychosis being cared for prior to aeromedical evacuation by the clinic nurses, mabarns (Indigneous traditional healers) and a Catholic priest:

[I witnessed] an incredible process of healing … . For this man and his community each of the three parts [Western medicine, traditional healing and Catholicism] was considered as important as the other.

Later she wrote:

I was in [area K] to collect data for an] audit … but I ended up [being] a clinical doctor … and also ran mass syphilis screening to combat an outbreak. The whole week was a remarkable learning experience, and a week I will never forget.

Through working on primary health care programs and assisting with clinical work in small towns and remote Aboriginal communities, PMPs gained experiential insights into many of the access, cross-cultural and workforce issues influencing people's health and health service delivery in remote Australia. For example:

I did not take much food with me to [community X]. I thought I should eat whatever was at the store, to [understand] what kind of diet the average person … has. I found the standard of perishable food generally appalling.

Prior to doing this term, I was unaware just how isolated working and living conditions can be in Australia. [I now have] a better understanding of how much more difficult it can be to achieve things such as access to specialist care, performing investigations and even getting medications.

I saw the difficulties in reaching the people I was trying to screen [for diabetic retinopathy] due to lack of transport, phones and mail.

Almost halfway into the Program, one PMP expressed frustration that the process of consultation and obtaining approval to do his work (providing sexual health education for young males in the context of a syphilis outbreak) was taking much longer than expected, but he acknowledged that “my agenda is not necessarily the agenda of others”. Later he wrote about:

… the privilege of … [providing] sexual health education for young men [in area K] … [where] strategic community members were extremely helpful.

PMPs were also exposed to certain distressing realities of life in various remote Aboriginal communities:

… one of the nurses was badly assaulted … lucky not to be raped and killed … . I found this incident very sad and disturbing. Firstly because [nurse X] was badly hurt and traumatised … . But also because of the continual assaults … to the nurses … community leaders seem to be unable to prevent this … . If … services are withdrawn to try to force the leaders to do something … the health of these people will suffer … . But if things go on as if nothing had happened, does this … endorse … what has happened? I think of … a four-month-old baby [who needs long-term, daily antibiotics to prevent urinary tract infections]. If there are no nurses in the community how will he get these antibiotics? Will he end up like [a person in the same community], with a renal transplant at the age of 30? I see no easy solutions.

Fortunately, incidents such at these were outnumbered by more positive experiences of life and medical practice in remote Australia gained by PMPs, made possible because they lived and worked in remote towns and communities for sufficiently long periods, as the following extracts testify:

… women [were] camping [at Lake X] … for a cultural day … we put holes in gumnuts … and painted them with ochre … women were making baskets out of grasses … [then they] sang whilst [preparing for dancing]. A chant that was almost hypnotic. It was such a privilege to be [there].

[the Program] enabled me for the first time to work in [a remote area primary health care] setting independently and gave me a better understanding of what is involved and at least a partial understanding of what factors impact on how a [health] program will work.

Extracurricular learning outcomes

Deeper understandings of health and illness

By the end of the Program all evidence pointed to the conclusion that PMPs had developed an acute awareness that the determinants of health and illness lie largely outside the health system, and that there are no easy solutions to the complexities of promoting and protecting health, and delivering quality healthcare in remote area and Aboriginal settings:

It seemed ridiculous to tell people to put rubbish in the bin to help prevent trachoma, when there was no one to empty the rubbish bins. To fix the problem, it would not be sufficient to simply hire someone to do the job. No one needs to work as long as the pension cheques keep coming—who would want to deal with smelly rubbish just for a few extra dollars? … This is surely one of the reasons why Aboriginal [health is] in such a sorry state—the majority of Australians do not even realize that their fellow citizens reside in Third World conditions … I had not appreciated [this] myself before I … visited an Aboriginal community.

I have learnt … a different way of looking at people's health … I was encouraged to think more deeply than before about the whys and wherefores of medical practice, and thus consider the most effective ways of influencing patients’ behaviours for the better.

Personal growth

An unplanned, but not altogether unexpected, outcome was the personal growth that PMPs experienced during their relatively short time (20 weeks) in the Kimberley. The curriculum objectives may have contributed to this, but being out of their ‘comfort zone’ in terms of both work and social life probably contributed even more. As one PMP explained:

There's something about being isolated which makes you more aware of yourself and your surroundings.

Reflecting on the differences between Aboriginal people living in a traditional community and those living in a small town, one PMP wrote:

I thought it sad that the town people had given up or lost a large part of their culture. Then it dawned on me that I am no different myself. I know very little of the … cultures of which I am a descendant … at times I have felt as if I do not belong anywhere because of my mixed ancestry and upbringing. But, as yet, I have felt no strong compulsion to ‘discover my roots’.

PMPs recognized, but also gained from, the personal challenges of living and working in the Kimberley, as evident from these comments written at the completion of the Program:

Although I found parts of this term difficult … this will be an experience that will stay with me forever.

I have learned [that] The greatest rewards require the greatest investments … of your time, energy and your soul.

Professional growth

The following quotations hint at the professional growth experienced by PMPs:

I see things differently now especially with regard to … the commitment that is supposed [to be] in the rights and responsibilities of a medical practitioner.

By helping to administer and deliver real public health programs (and not just reading about them like in medical school) [I learned that] effective public health programs need to be continued … consistent efforts over long periods of time … this is difficult to achieve in a funding-driven health system, where the powers-that-be need to see results relatively quickly.

I was encouraged to examine the thought processes behind the ways … healthcare was provided. I worked in an environment where I could see directly the potential benefits and repercussions of individual projects. Consequently, this job HAS had a lasting effect … I am constantly questioning the reason why we are practising medicine in a certain way in the big city hospitals—much to the consternation of my colleagues … .

Future aspirations

At the time of writing, three of the PMPs had been accepted into general practice vocational training and another was gaining experience in obstetrics and paediatrics prior to entering vocational training in internal medicine. One of the PMPs accepted into general practice training undertook a four-month locum as a public health medical officer at KPHU, then relocated his family to Derby where he now practises in an Aboriginal-community-controlled health service.

Figure 1. Characteristics of Kimberley prevocational program in public health medicine and primary health care.

Their writings indicate that working in the Program opened their eyes to new opportunities:

I now have a stronger desire than ever to explore other remote parts of Australia—and not just as a tourist but as a contributing member of the community.

Limitations of the data

PMPs knew that their supervisor (DBM) had named access to all data sources, with the exception of the confidential mid- and end-of-term interviews. However, we believe that they felt safe enough to express themselves truthfully because several critical comments about the Program and the quality of teaching appeared in their journals.

The provisional nature of these data, based on the experiences of the Program's first four PMPs, means that ongoing evaluation of this and future similar programs is required.

Discussion

These preliminary data indicate that, through a problem-based, hands-on approach, the KPHU Program was successful in teaching its first four PMPs some of the basic tools of public health and primary health care and how to apply them in real-life situations both during and after the Program.

Despite witnessing some distressing and sad events, and at times experiencing frustration regarding their limited ability to contribute to improvements in health, PMPs were able to appreciate the importance of this ‘warts and all’ experience to their ability to develop a realistic and pragmatic approach to living and working in Aboriginal and remote area settings. This is consistent with the evaluation results of a Maori cultural immersion program described by Dowell et al. (2001).

PMPs’ isolation from their familiar clinical workplace, geographical surroundings and social supports was challenging for them, but it also undoubtedly contributed to their personal and professional growth. Similarly, Gibbs & Thalange (1999), dermatology and paediatrics registrars in the United Kingdom, who undertook a public health term during their specialist training, found “the cultural change from clinical doctoring … bewildering”, but also “[grew] and developed, professionally and personally” to the extent that they “have a sneaking suspicion that you’re not really complete until you’ve done something like this”, and recommended that “there should be more opportunities for ‘ordinary’ doctors to gain experience in public health”.

Another factor, not mentioned by PMPs, that may have contributed to personal and professional growth was journal keeping. Writing of reflective journals and field notes has been shown to contribute to the writer's development of deeper understandings about her/his study subjects and him/herself, as reported by Jackson (1990); Ashbury et al. (1993); Kerka (1996); Janesick (1999); Boyd (2002), and Anderson & Schiedermayer (2003).

The need for medical practitioners in Australia and overseas to develop knowledge and skills in public health and rural/remote area health has been well documented by Sidoti (1999); Pomrehn et al. (2000); Pflaum (2001); Howe et al. (2002) and the Postgraduate Medical Council of New South Wales (2002). Adult learning principles described by Knowles (1984) and experiences of medical educators (Osborn et al., 1986; Chickering et al., 1999; Dowell et al., 2001; Abramson, 2002; Wilkinson, 2002), indicate that the field experience can be an effective educational strategy, as well as positively influencing recruitment. So far, the Program seems to have been effective in recruiting doctors to work in public health medicine, primary health care and/or rural/remote areas. While it could be argued that only PMPs with a pre-existing interest in these areas were recruited, the Program's positive learning experience affirmed, rather than dampened, their enthusiasm.

Conclusions

The breadth, depth and intensity of personal and professional development that its first four PMPs experienced during the Program support its continuation and the need for ongoing evaluation. The words of one PMP characterize this imperative:

The opportunity to focus on populations not individuals is [one that] few doctors are afforded.

Disclaimer

The views expressed are those of the authors and may not reflect the views of the institutions which they were employed by, or affiliated with, during the writing of this paper.

Acknowledgements

Prevocational medical practitioners’ salaries and travel/accommodation expenses were funded by the National Indigenous Australians Sexual Health Strategy (administered through the Health Department of WA's Sexual Health Program) in 2001, and by the Commonwealth Government's Rural and Remote Area Placement Program (administered through) the Australian College of Rural and Remote Medicine in 2002.

Thanks are extended to the first four PMPs (Nadia Chaves, Graeme Johnson, Michael Light and Rebecca Quake) who participated in the Program, and to all the people, Aboriginal communities and organizations (Kimberley Health Service, Fremantle Hospital, Mercy Community Health Service, Prevocational Training and Education Committee of WA, Kimberley Division of General Practice) involved in their training.

Special thanks are offered to the Kimberley Public Health Unit's Disease Control team, community health and remote area health staff of the Kimberley, Dr Lewis Marshall and Dr Patrick Hertnon for their commitment and invaluable contributions to the Program.

Notes

Additional information

Notes on contributors

Donna B. Mak

DONNA MAK is a public health physician who has worked in general practice and public health for 11 years in the remote Kimberley region of Western Australia (WA) and has taught many medical students and junior colleagues. She is now an Associate Professor based in Perth, WA, working in communicable disease control and teaching population health to medical students.

Aileen J. Plant

AILEEN PLANT is a public health physician. She has extensive experience in general public health, especially infectious disease control, and in educating health practitioners in these areas.

Sandy Toussaint

SANDY TOUSSAINT is an anthropologist who has worked for several decades among Indigenous groups in the Kimberley region of Western Australia. She has published widely on health, legal and environmental issues.

Notes

1.  Prevocational medical practitioners are doctors who have not entered a specialist training program.

2.  In accordance with ethical requirements, PMPs gave written consent for the content of their journals to be used in preparation of this paper. PMPs were also invited to comment on this paper prior to its submission.