Advocating for rural health across country Victoria and beyond

Gabriella Smith is a final year medical student at the University of Melbourne Rural Clinical School. As part of her studies, Gabriella spent most of last year undergoing placement at Cobram Hospital through the Extended Rural Cohort program. For her final year, she will be placed at the Wangaratta Rural Clinical School and based at Northeast Health Wangaratta for placement.

Gabriella Smith, final year medical student at the University of Melbourne outside of Cobram Hospital in 2022.

In amongst her studies and placement work, Gabriella is the newly appointed President of the Outlook Rural Health Club where she works with a committee of students advocating rural health from a student perspective. If she wasn’t preoccupied enough, Gabbi is one of the founding members of Halad to Health – a student-run program delivering mental health and counselling services to youth in rural Philippines. We spoke to Gabbi about her rural origins, her placement experience in a small country town and her vision for rural health in Australia and beyond.

From rural origins to the city and back to rural again

Growing up in Griffith and Broken Hill in New South Wales, Gabbi found her passion in rural medicine and began her medical studies undertaking an undergraduate degree in biomedical sciences at Monash University in Melbourne. It was in 2020 that she was accepted into the University of Melbourne, Doctor of Medicine, where she commenced the degree in Parkville. Gabbi spent her second year placed in Shepparton and, following two years of the pandemic and remote learning, her third year was based in Cobram in 2022.

Through the Extended Rural Cohort program – which will be replaced by the new Rural Pathway curriculum by the end of 2023 – Gabbi was offered a long-arm general practitioner placement at Cobram Hospital. Located 259 km from Melbourne and positioned on the southern banks of the Murray River; Cobram is a small, holiday destination and part of a rich dairy and fruit growing district. Operated by NCH Health, Cobram Hospital delivers healthcare to the town’s population of nearly 7,000 people under an 'urgent care' model. Through this format, the emergency room is predominantly nurse-run, with the doctors called in for acute presentations and ward rounds when required.

“I think the biggest difference between this placement and other placements is it’s so hands-on. From day one we were given our own patients; you’ve got to do the consult and you’re very active the whole time” says Gabbi.

“In a big hospital it is easy to get left behind or lost in among the big team. Often it is very passive learning and the consultants might not even know your name, whereas with this placement it is very active and hands on. We are seeing our own patients all day, maybe 10-15 patients a day so it quite full on.”

The University of Melbourne, Department of Rural Health.

Close-knit learning environment beneficial for students

Due to the nature of the workplace, Gabbi says working so closely with the nurses has been beneficial.

“It's really nice working so closely with the nurses, making friends with the other staff members and chatting over lunch - you just don’t really get that in a hospital as a student I think, unless you’ve got other students there.”

The close working nature between the doctors and nursing staff has allowed Gabbi to learn new skills from her colleagues, often leaning on the nursing staff to learn procedures such as dressing wounds correctly, removal of stitches and running through ECG results.

“You know people by their first name and you’re having lunch with them so it’s much more natural for these sort of teaching moments and engagements between different allied health to occur.”

Stepping out of comfort zone on rural placement

After her year on rural placement, Gabbi has many comparisons to her time in Melbourne – mainly stepping out of her comfort zone and gaining confidence in effectively communicating with patients.

“I’m one of these students who could have got easily lost in the system in a big hospital. If we’re on ward rounds, it’s easy to hang back and not ask questions - it’s a bit overwhelming. In the country you don’t have the opportunity to do that. It’s just you, the patients and the doctor.  It’s really pushed me out of my comfort zone.”

“It’s a bit of trial and error; things like explaining their results, explaining their drugs and the overall management plan. I don’t think those sorts of practices I would have picked up in a regular six-week GP placement that the metro kids get.”

A diverse and rich learning experience

With the urgent care set-up at the hospital, Gabbi would be preoccupied with clinic consults most of the day and within moments would find herself in the emergency room.

“That diversity is so rich, and I think it’s just so fulfilling” describes Gabbi.

“Even the broad spectrum of people you see; a sick kid in the morning, an older person in the afternoon – it’s so interesting.”

Gabbi explains the perception of general practice as a “less glamorous area of medicine” or that people think it’s the “easy option” if they want to have a good lifestyle. However, she makes it evident that they play a vital role in delivering high-quality primary care and preventing many patients from going to hospital by managing the conditions in a small town.

“You see the GPs in the country, and they’re worked to the bone. It’s not a nine to five job, there’s paperwork they stay back for, they’re on-call. Someone needs to be on call all the time when there’s only a small team.”

“I saw the need when I was a kid and we couldn’t get in [to see a doctor] and I think it’s just been reinforced so many times along the way. When living in Broken Hill, Dad was seeing a specialist in Mildura and he would have to drive three hours for his appointment - that’s six hours of driving plus an hour or two in the waiting room.

It definitely, without me knowing, planted the seed. Throughout my life I’ve done different work experience to see where I’d fit and the most rewarding things that I’ve been most interested in have been the rural and remote placements, that’s for sure.”

Rural origins: Gabbi has always loved living in regional and rural towns.

A new perspective and an eye-opening experience in remote Australia

Before stepping foot into Cobram hospital, Gabbi had already been exposed to a small hospital through the John Flynn Placement Program in the Northern Territory as one of the last cohorts before the program ended.

“I spent two weeks in a remote clinic which was nurse-run. I went to some of the local indigenous communities as well and that was a really eye-opening experience.”

“I know rural medicine because I grew up rural, and was exposed to it, but then going and seeing that type of remote medicine through the program was a nice lead-up to the year in Cobram. It’s obviously very different to the Northern Territory but it was nice to get that sort of perspective.”

The John Flynn Placement Program in the Northern Territory provided Gabbi with a first-hand glimpse into remote medicine.

Rural patients often fall through the gaps

Growing up in the country, Gabbi knew it would take a while to see a doctor however, didn’t understand why it was such an issue until she started rural and regional placement.

“You start to understand a bit in the hospital that if someone has to go to a catheter lab or requires some other medical procedure; they have to go to Melbourne or the bigger centres like Bendigo or Ballarat. But then on the actual fundamental primary care level you realise there’s a real issue. Even if someone needs a new script, it can take them weeks to get in.”

“Many patients say, it’s so hard to see a doctor I’ve been waiting for months or I’m so glad you’re here - and I think seeing that appreciation and that real disparity has had a huge impact on me.”

Often in a rural setting, GPs are at full capacity addressing high demands and are overworked. Long wait times in between appointments and the inability to see a GP can lead to potentially preventable hospitalisations, patients being transferred around and many falling through the gaps in the system.

“Patients are frustrated and feel like they have nowhere to go. They want to come in and have their medications explained to them or have that support or just have a general check-up. Our GPs just sometimes don’t have the time to do a general check-up. So, I think that lack of confidence that patients experience as well is really tricky.”

Commitment to rural health and the community

Despite the challenges, often it is the love for their community which keep doctors in rural medicine.  As a GP working in a small team of other GPs with limited hours, it’s not uncommon for doctors to travel from other towns or even from the city to help address the demand.

Dr Gihad Chabbou, who was Gabbi’s supervising doctor during her placement at Cobram Hospital, commutes from Melbourne to Cobram three days a week. After living and building a life in Cobram for a long period of time, he and his family moved to Melbourne yet he couldn’t quite give up the community he has become so fond of. His commitment to Cobram is strong and it’s clear his dedication and passion have translated well into his supervision, helping to shape Gabbi into a high-performing medical student.

“We are very impressed with her performance as a medical student at Cobram Hospital. I always receive positive feedback from patients after their appointment with Gabbi. She has excellent communication skills, builds good rapport, is very resilient and her clinical knowledge is very good. She’s amazing” says Dr Chabbou.

“It’s great for the community to have ongoing support from the University of Melbourne medical students.”

Cobram, a small rural town in Northern Victoria, provided Gabbi with plenty of outdoor activities including cycling.

The ‘outlook’ for the year ahead

Joining the Outlook Rural Health Club during her first year of Medicine and becoming Vice President in 2022, Gabbi will now take the reins as President for 2023 - a role previously held by graduate and Rural Medical Student of the Year, Jasraaj Singh.

For the year ahead, Outlook plan to continue delivering the vision from last year; focussing on rural health advocacy and building awareness in First Nations Health. This year there will be even greater emphasis placed on allied health in rural communities, with Gabbi describing the importance of advocating rural health for not only medical students but nursing and allied health students as well.

“Engaging with nursing and allied health is something that I’ve learnt in rural communities really matters. It’s important everywhere, but especially in rural communities.”

“When there is a lack of doctors, nurses are the ones that are really making up for it. So really engaging with allied health early, as medical students, is the way to go. I think it’s so beneficial to not only encourage medical students and future doctors to come to the country but allied health as well.”

Delivering health services to youth in remote Philippines

Beyond advocating for rural health in her home country, Gabbi and the Halad to Health team are also delivering health education in rural Philippines where she works as the Operations Manager. Joining as an establishing member in 2019 after being approached by the two co-founders, Eliza Li and Wilh Jacobin - Halad to Health was born. Operating as a not-for-profit provider, all funds raised from all services go towards the Halad to Health Foundation Philippines who are providing free mental health education and counselling services to some of the most disadvantaged communities in rural Philippines.

One such service is an innovative ‘safe space’ pop-up at the local mall in Bukidnon province – a space where young people can come for free mental health, counselling, education and coaching sessions. Entirely run by medical and allied health students to address depression and suicide among disadvantaged youth, Halad to Health is having a significant impact on young people in rural Philippines.

Halad to Health is a not-for-profit GAMSAT tuition, medical interview preparation and health volunteering experience (missions) provider.

Shifting the focus to young Australians in the country

With Halad to Health’s success in the Philippines; now standing on its own two feet and managed by local Filipino students - Gabbi plans to shift the focus to rural and remote Australia.

Starting with the Hume region, the program will aim to deliver health education in rural high schools, focussing on mental health, awareness of health careers and health promotion in the country.

“When I was a kid in a public school in rural NSW, I had a few year 12 subjects without a consistent teacher because of short staffing. I thought how am I going to get into anything or get a good ATAR? You couldn’t event sit the UMAT/UCAT to get into med school because you had to travel to Canberra.”

“My partner and I are both really passionate about creating awareness and outlining to students - okay these are the supports, you don’t have to go to a fancy school or receive the top ATAR.”

With plans to roll out the project within twelve months during her final year, the program has already received support by a consulting company who are researching how to implement the strategies. Education and community members are also now approaching and showing interest.

Gabbi at the Halad to Health pop-up in the Philippines who plans to deliver a similar model for young Australians living in rural towns.

Advice for future students considering rural medicine

As Gabbi embarks on her final year of the Doctor of Medicine in Wangaratta, she has some advice for students coming through the Extended Rural Cohort (ERC) and Rural Pathway.

“Although ERC is phenomenal, it’s hard work and you often put in more hours than are expected for the metro kids. It involves a lot of travel - I think it’s important to not hide that stuff. It’s the driving long hours that students need to prepare for.”

“But you do get used to it and is something to consider because if you’re a rural GP, you’re going to experience travelling a lot for work, it’s an important part of the job.”

When she wasn't commuting between towns, Gabbi enjoyed the Cobram University of Melbourne student accommodation being in close proximity to the hospital where she would often find her walk to and from her shifts as a way to decompress. Not only that, the tranquil surrounds of country Victoria and the Murray River provided an opportunity to unwind after a busy clinical day.

“I love the river. At the start of the year my housemate Hannah and I would do a lot of swimming, we’d go for sunset in the afternoon and have a picnic.”

“It’s really lovely to have that sense of community as well. Everyone’s willing to help each other and say hello. That type of lifestyle suits me, it’s sort of ingrained in me.”

Downtime at the river: Gabbi and her housemate Hannah, fellow Doctor of Medicine student at the Rural Clinical School, often enjoyed unwinding alongside the Murray River.

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