Reflections

Indigenous children are seen as an intrinsic, systematic foundation of hope in Aboriginal conceptualisations of hope, yet are grossly overrepresented in Australian suicide statistics. Despite being a target of the Australian Government's almost 20-year-long Closing the Gap campaign, the numbers are only getting worse. ‘It's not depression, it's despair’ are words that echo a sentiment so ghastly for parents of Indigenous children who only hope to bestow them with the gift of exactly that: hope. It is only sensible to counteract this with holistic, culturally empowered, strengths-based well-being programs to both develop Cultural strength while concurrently instilling a sense of Cultural pride and identity.

Rudi Louis Taylor-Bragge

This commentary examines the cancellation of the author's keynote talk at a scientific conference in 2023, which referenced her work with Médecins Sans Frontières in Palestine. It evaluates challenges and perceived barriers to medical organisations and individuals speaking at the intersection of politics and health. As powerful bodies and individuals trained in rigorous interpretation of information and challenging communication, with a disproportionate amount of social and political capital, healthcare professionals and medical organisations should at least permit, and aspire to lead, a humane and nuanced discourse on current affairs that deeply impact health. Avoiding silence, and silencing of clinicians, can be an important contributor to humanisation, which intersects with the provision of equitable and safe access to health.

Natalie Thurtle

This is an article written by a doctor about their experience of navigating seronegative immune-mediated necrotising myositis

Jennifer G Mowbray

Long COVID affects society in many ways, including the workforce and voluntary roles

Karlie M Flannigan · Gerard M Flannigan

In this article, I share my journey of being a medical student, in which I seized rural health student opportunities to develop both personally and professionally. This culminated in my being elected as chair of the National Rural Health Student Network (NRHSN) for 2022. The NRHSN (https://nrhsn.org.au/) is a grassroots movement that started as a single university‐based rural health club (RHC) for rural medical students. It is now a federally funded network of 29 RHCs, the peak multidisciplinary body for 12000 health students, and one of Australia's largest student organisations. I never imagined that I would be a rural medical officer cadet studying in the New South Wales city of Bathurst. Before this, I spent years wandering and searching for a community; I grew up on Reunion Island off the coast of Africa, experienced a chikungunya epidemic and its impact on under‐resourced remote health care,1 moved to Western Australia as an international student to study English, and worked in roles such as breakfast chef and tour guide, taking international students on tours of the outback. At 29, I decided to become a factor for change for those who need it most and moved to Sydney to study medicine. At orientation week, I met an executive member of the local RHC who mentioned that the club is required to engage rural high schools as part of their funding requirements. This sparked my interest, and we discussed my previous experience working with students from low socio‐economic backgrounds. This simple conversation took me on an unexpected path of national leadership and advocacy. My journey included a detour to Central Australia, as I completed six weeks of life‐changing placement in Northern Territory communities during the summer holidays of my pre‐clinical years. I realised that the social determinants of health have a crucial impact in remote Australia. Some of my fondest memories are of the first day of rain after 18 months in Tennant Creek, helping a nurse change a LandCruiser tyre in a remote community with no mobile reception, and being taught how to eat honey ants in Yuendumu. My early and repeated exposures to rural and remote health have been the most memorable parts of my medical journey, and this is reflected in publications on future rural practice intent.2 As I started my clinical years, I felt that I needed to be a part of the solution to the problems I witnessed during my placements, and the only way I could enact change was through grassroots movements. This led to my role as chair of the NRHSN in 2022. The council of the NRHSN is formed by the presidents of the 29 RHCs and 11 executives, who are led by the chair; it gathers biannually for a national in‐person forum. My purpose became ensuring the post‐pandemic sustainability of this organisation which, through my local RHC, had put me on my path. As chair of the NRHSN, I was a member of the Advisory Network to the National Rural Health Commissioner. I was also a council member for the National Rural Health Alliance and the Royal Australian College of General Practitioners Rural Council. The NRHSN is a key rural stakeholder — for example, it was invited to participate in a budget meeting with the Minister for Regional Health. Also, it is the only student delegation to the Ngayubah Gadan Summit, a national rural health meeting held in Cairns which led to the development of a consensus statement on multidisciplinary rural teams (as yet unpublished). As a fourth‐year medical student, finding myself in crucial discussions on the future of rural health care was daunting but incredibly rewarding. The ability to advocate on behalf of students, and to take information and lessons back to the student body, was invaluable. As research is also a crucial part of the NRHSN's role, I was able to present the work of the NRHSN at the 16th National Rural Health Conference and at RMA22 (the Rural Medicine Australia 2022 conference). At these meetings, I advocated for further investment in short term rural placements for allied health, nursing and midwifery students, as it is well documented that non‐medical students are consistently underexposed to rural settings, and longer placements are not an option in many shorter degrees.3,4 I also presented this work at the 14th National Rural and Remote Allied Health Conference, where I won the Best Student Presenter award. The predictors of rural practice are varied and conflicting. Rural origin is a major factor, but regardless of origin, repeated exposure to rural communities throughout training is paramount in producing future rural practitioners.5,6,7 Another significant influence is student‐led movements by engaged and passionate leaders. Their many individual stories are reflected in my journey, which started with a simple discussion at my local medical school orientation and led to my role as chair of a national organisation. I finally found the community of like‐minded individuals I had been seeking and I look forward to a lifetime of future involvement.

Jean‐Baptiste H Philibert

The burden of disease in Aboriginal and Torres Strait Islander people is stark, occurring at two to three times the rate of non‐Indigenous Australians.1 The provision of culturally appropriate and safe health care is imperative in addressing this imbalance.2 One strategy to enhance cultural competency of health care services is to increase the representation of Aboriginal and Torres Strait Islander people working within the services.1 I have personally witnessed a cultural shift in the provision of health care services and the increased number of Aboriginal people who access health care when they are being cared for by an Aboriginal doctor. I am a Gija woman, born in Derby and raised in Halls Creek, less than four hours’ drive from my current home in Kununurra, in the East Kimberley region of Western Australia. I am a general practitioner who has worked at Kununurra District Hospital since 2011; first as a GP registrar (having completed all my training in Kununurra) and then as a District Medical Officer, having attained a Fellowship in General Practice in 2013. My role as a District Medical Officer gives me the opportunity to provide culturally safe and appropriate health care to my family and “countrymen” in the two largest First Nations communities in the East Kimberley in various clinical settings, including emergency, inpatient, palliative care, and remote clinics via the Royal Flying Doctor Service. In 2013, I commenced working for the Rural Clinical School of Western Australia as a Medical Coordinator and then as Lead Medical Coordinator. These roles complement each other and align with my personal and professional belief that the disparity between the number of rural medical practitioners and community needs will be addressed by enhancing the pathways of education and training, which assists in growing our own workforce. This workforce may come from people originating in rural and remote areas, or from city residents, who have an opportunity to immerse themselves in a rural/remote community while completing a clinical placement. Since working in Kununurra, I have supervised and mentored many medical students from both rural/remote and urban backgrounds, and have seen the transition students undertake, from one of reluctance or apprehension in working in rural/remote communities, to being able to see themselves returning to the country to practise medicine once qualified. I attended the special Aboriginal school in Halls Creek. Recognising the importance of a good education, my parents then sent me to boarding school in Perth, 3000km away. I was 11 years of age and I still consider that year one of my most challenging. Missing my big, close family in Halls Creek was tough, but learning to navigate this new world was daunting. The success of my secondary education was principally due to my parents providing me with the love, support and encouragement needed, while remaining steadfast in their resolve that I remain at boarding school to complete my education. On leaving high school, I completed a Diploma of Nursing at Edith Cowan University and graduated in 1991. I returned home and worked at Halls Creek Hospital before returning to Perth to convert my qualification to a Bachelor of Nursing in 1992. Although I loved working in the hospital setting as a registered nurse, I felt my need to contribute to addressing the health disparities of my community would be best achieved working within the community, so I embarked on a Graduate Diploma of Community Health Nursing. I had given up the idea of becoming a doctor way back in primary school because I thought those who studied medicine were far more intelligent than I! I also completed a Postgraduate Diploma in Clinical Nursing – Midwifery, which gave me the opportunity to move to Kununurra in the Kimberley, where I undertook consultancy work with Dr David Atkinson, who was developing the Kimberley Aboriginal Health Plan. On our many trips, we talked about a career in medicine for me. I respect, trust and admire David, and his belief, advice and support was instrumental in my embarking on my journey to become a doctor. I did not act on his advice and encouragement immediately, but over the next two years conversations about a career in medicine kept coming up. One day my husband said I should do it but forewarned me that I needed to really want to do so, because I would be the one doing all the hard work. The decision to apply to the School of Medicine at the University of Western Australia in 2002, with two children under two, at the time seemed reasonable. On reflection, I think we must have been a little nuts! In 2003, I was accepted and survived with the help of a scholarship and cadetship, my husband working full time, and with support from beautiful family and fellow students. The Medical Rural Bonded Scholarship assisted with our day care costs and thus my attendance at university. Without this financial support, my medical journey would not have started, despite my husband working full time. A cadetship offered through the Princess Margaret Hospital (now Perth Children's Hospital) also assisted us greatly. I was their first cadet and this was made possible by another one of my distinguished mentors, the late Dr Paul Carmen. Dr Carmen was a brilliant clinician, an amazing academic, and a kind and caring person, and to have had his unwavering support and belief in my ability to become a doctor was invaluable. The Centre for Aboriginal Medical and Dental Health at Shenton House is the Aboriginal student support program at the University of Western Australia and its support was excellent. For me, studying at home with two small children was challenging, so on the weekends I would retreat to Shenton House, leaving home at 5.30 am and returning around lunchtime to spend the weekend with my family. With my circumstances, there were periods of self‐doubt, but at Shenton House there was always someone to say, “Sure, the going is not easy – and yes, with two young children, your background and lifestyle are different from others, but that's OK”. I had a safe environment where I could go, somewhere I could have time out, and somewhere I could speak to other students and staff and receive reassurance. Although I had the opportunity to apply to the Rural Clinical School during my undergraduate degree, I did not do so, as I always intended returning to the Kimberley and felt my time was best spent gaining valuable experience and exposure in the tertiary settings in Perth. I remained in Perth for my internship and postgraduate training, despite having been accepted into the GP training program. Aware of the areas where I needed additional clinical knowledge and experience, and in readiness to return to the Kimberley, I spent my second postgraduate year gaining this experience. I completed a Diploma of Child Health while working at Princess Margaret Hospital, followed by working in a tertiary emergency department. In addition to acquiring sound clinical knowledge, I also developed an understanding of how tertiary hospitals function, which has been essential in my navigating and accessing health care services while advocating for and preparing patients who need these specialty services. Soon after returning to the East Kimberley in 2011, I began working for the WA Country Health Service at Kununurra District Hospital, where I have been since then. No two days are the same, and having the opportunity to provide health care that is tailored to meet the specific needs of the patient, in collaboration with the patient in a culturally safe environment, is why I work where I do. An example of this success was the rollout of the COVID‐19 vaccination program in Warmun Community at the end of 2021, where 83% of the eligible community members were vaccinated over two days, and then providing the clinical lead in the rapid response team when COVID‐19 arrived in the community in early 2022. The highlight of my journey has been returning home, armed with my medical degree and a steadfast resolve to help abate the burden of disease in my community and the region. The goal of providing best practice, with my ongoing education keeping me abreast of changes, places me in a unique position. My inherent knowledge assists in enhancing the health literacy of Aboriginal people by bridging the language, knowledge and cultural gaps of my Aboriginal patients, their families and the community, thereby ensuring the provision of culturally appropriate and safe health care.

Catherine Engelke

As Australia's first regional education commissioner, I want all people in regional, rural and remote Australia, regardless of where they live, to be able to access the education and career opportunities they need to reach their full potential. Having spent most of my life in country Australia, I know that some challenges can be greater in the regions compared with the cities, such as going to school or university or moving your family for work. Much is made of offering financial and other incentives or subsidies to encourage students to relocate to, or eventually practise in, the country, and there is certainly a place for that. But I like to think that rural living offers its own rewards. Regional towns have a strong sense of community, where you know and support your neighbours, and they know and support you. Unfortunately, not enough people are asking themselves “is a career in rural health a great option for me?”. This needs to change, because health professionals are central to rural communities — by providing essential services, they are valued and indispensable parts of the regional fabric. We know that there are challenges for health professionals who practise in the regions, such as vast distances from peers and colleagues. But there may not be enough focus on the many opportunities for health professionals in the regions. Practising in the regions can help health professionals develop broad skills, self‐reliance and confidence earlier in their career than they might otherwise. It also offers them the chance to provide health and wellbeing services to their own community, and to become respected leaders and trusted mentors. Unsurprisingly, the National Skills Commission identified care sector occupations as some of the most important in terms of future skill needs for Australia. To give a sense of the scale of future demand, the National Skills Commission has projected that an additional 100000 health professionals, at least, will be needed across Australia over the next 5 years.1 So, what can be done to attract students to a career in rural health? In discussions with stakeholders across the education sector and industry groups, a recurring theme is the importance of information for young students who are making decisions about the careers and pathways that suit them. The role of locally informed career advisers is critically important. Equally important is exposing regional students to industries and potential career pathways throughout their education, in a relatable way. As the adage goes, you cannot be what you cannot see. Industries like health should inspire the next generation of skilled workers by getting involved at the school level and letting students know about the opportunities to work in health care. Industry ambassadors — such as rural dentists or pharmacists who travelled away from home to learn before returning to regional Australia — can share their experiences at schools, making the pathway feel more attainable and lifting aspiration in regional students. Flying doctors and speech pathologists who practise by telehealth can demonstrate the potential for exciting careers that apply technology to make a difference in communities. Attending university can be a daunting experience. For a young person who needs to leave their home and community to study, it brings additional challenges and expense. Indeed, some of our future health professionals may well be the first in their family to go to university. Successive reviews prepared for the federal government — such as the Review of Australian Higher Education (Bradley review)2 and the National Regional, Rural and Remote Tertiary Education Strategy (Napthine review)3 — have shown that financial barriers for regional and remote students, particularly those relating to relocation, are a persistent problem. When regional students have no choice but to leave home to study, because local training options are not available, they need support to do so. More broadly, universities should consider the support they provide to regional students, to help them achieve their educational goals. Support services need to be visible and accessible; universities need to ensure that students are aware of the support available, and they should establish proactive methods to identify and support students who require assistance. When a student has the opportunity to study closer to home, this benefits their community. We know that health students from regional areas, and those who undertake extensive training in a rural setting, are more likely to take up practice in the regions.4,5 I remember talking to a high school principal in Albury not long after the announcement that there would be university medical schools in regional areas, where students would be able to do their entire degree. He had been speaking to three of his students, who were all very excited because they would not have to leave home and move to a city to study medicine. The smile on his face said it all. It is also important to offer health students the opportunity to train in rural and remote communities. One example is the Rural Health Multidisciplinary Training program, which aims to improve the recruitment and retention of medical, nursing, dental and allied health professionals in rural and remote Australia. Many years ago, when I was visiting the University Centre for Rural Health in Lismore, I spoke to a young student from Sydney who was studying there. She said that being in Lismore had completely changed her view of where she wanted to be. From the experience, she was sure that her future was not going to be in the city — it was going to be living and working in a regional community. Sharing the opportunities of working in health industries in regional, rural and remote Australia with young people, and making these professions attainable and relevant to them, will go a long way towards creating aspiration and vision for future career pathways. Balancing inspiration with investment will equip our future health professionals to meet the needs of their patients for decades to come. And if we get that inspiration and investment right, many more people will answer “yes” when they consider whether a career in rural health is a great option for them.

Fiona Nash

Acknowledging the loss can go a long way towards healing the complex grief related to ectopic pregnancies

Sarah Saunders