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Cape York ENT crew builds a pathway

13 July 2022

Treating patients across 14 remote Cape York Peninsula communities, JCU GP Registrar Dr Steve Johnston and his team have seen the impact their fledgling service can have on the lives of Aboriginal and Torres Strait Islander children with ear disease.

From facilitating urgent surgical intervention in Townsville for a teenager with mastoiditis to picking up rare malignant tumours with clusters of symptoms so subtle they would otherwise be overlooked, some of the outcomes have been dramatic and lifesaving. But just as important is the consistent, community-led ear, nose and throat (ENT) outreach care across the Cape, which is improving quality of life and preventing chronic conditions.

“Picking up ear disease and managing it early on is a big thing,” says Dr Johnston, a Weipa-based rural generalist trainee with ENT special interest skills. “A lot of kids would just track along. Some would get hearing aids, which is fantastic, others wouldn't. They get recurrent middle ear infections, they get scarring over the years, the bones in their middle ear stop working well.

“So their hearing is already down to a level where their education is being substantially impacted. But not only that, their hearing at home, their social development and their communication skills are all severely impacted. Providing definitive care early, improved pickup rates and management of these kids in community, the longer-term outcomes are certainly there, and we see that.”

Referrals increased by around 400 per cent in the first three months after the program was formalised in December 2020. “Getting the whole team together took us up until about July last year,” Dr Johnston says. “We built the program based on 200 referrals a year, and now we’re seeing over 600 new referrals a year. That’s on top of review patients and the surgical procedures that we were already performing.

“When you do sit back and you think about it, it's pretty awesome what we've been supported to do and the opportunities we've had. The communities have welcomed us all on board, TCHHS (Torres and Cape Hospital and Health Service) and the execs have been incredibly supportive of the program, ACRRM (Australian College of Rural and Remote Medicine) has been supportive.”

Dr Johnston’s colleagues in the TCHHS ENT team at Weipa are Clinical Oversight and ENT Staff Specialists Associate Professor Bernard Whitfield and Dr Ryan Adams from Logan Hospital, Peta Hamilton (ENT nurse practitioner candidate), Kristen Tregenza (audiologist) and Tanya Davis (ENT Aboriginal and Torres Strait Islander health practitioner).

A sustainable, specialised workforce 

The team’s next goal is to bed down a service that is not wholly reliant on the individuals who form its backbone, through developing credentialled career pathways in rural ENT medicine. Dr Johnston, A/Prof Whitfield and Dr Adams are picking up support from ACCRM and the Australian Society of Otolaryngology and Head and Neck Surgery (ASOHNS) as a subsidiary of the Royal Australasian College of Surgeons (RACS) in the consideration and development of nationally recognised Advanced Skills Training in ENT.

 “It's amazing what we're seeing and what we’re able to get out and do, but there's no point if it's not sustainable,” Dr Johnston says. “That reflects on the greater rural or remote workforce as well. It becomes a person-dependent system, so if you're not getting the right people up there, if you're not providing them with the skills they need, you're not going to have a workforce in five to 10 years.

“We're trying to build a pipeline where other people can develop the same skills that I have to not only do the same thing but also translate it across other health systems and areas where it's very much needed as well.

“We're using rural generalists with ENT skills, we're looking at using nurse practitioners with advanced ENT training and, similarly, Aboriginal health practitioners within their own skill sets. We're looking at the broader picture for sustainability of the service to try to provide the best care that we can for the community.

“But it's a process in that you're lobbying government structures, you need the colleges’ support, and there's a lot of paperwork because you're building a curriculum – that means exams and the time and money that's involved in the upkeep of that – all considerations I never thought I'd have to think about, not this stage in my career anyway. ACRRM have been amazingly receptive and are very supportive. They understand that it's a need and that's why they're hearing the conversations and considering taking this on board.”

Dr Johnston says primary care physicians do an excellent job of managing ear disease in community. “But their workload is huge, and they know if they send referrals to these larger centres, the patients aren’t going to make that appointment or they’re just not going to want to leave the community for a variety of reasons,” he says.

Tailoring your skill set to meet a need

On track to fellow with ACRRM in October, Dr Johnston is a product of JCU’s undergraduate-to-specialty pipeline for remote, rural and regional Queensland. After gaining his advanced skill in anaesthetics, he sought out ENT Special Interest training with A/Prof Whitfield with the goal of filling a need he saw as a junior doctor in Weipa.

“My first time in Weipa was as a sixth-year medical student at JCU and I absolutely loved it,” he says.

“It's a fantastic place to be. The team who was up here at the time were very dynamic in their own interest and specialty areas, and you had so much to learn from each of them. There was a great culture. Everyone got along, everyone was a team. That's when you realise this is where I want to come back to.

“The next step is coming back as a PHO (Principal House Officer) or relieving officer to see what's it like to work in the community and get a bit more of a feel for it. You need to know what skill sets are required by your community and what you can utilise.

“If you wanted to do GP anaesthetics or GP obstetrics, you could go anywhere, really. But if you're doing other subspecialties, you've really got to know what the skill set requirements are of the place that you go into. Anaesthetics was always on the cards from early stage. I've always loved it and that emergency style of medicine, but the ENT was a massive need. It wasn't a skill set that was being actively sought, but it was notably required in the area.”

Part of the family

Dr Johnston says his placement experiences as a JCU medical student and John Flynn Scholar shaped his interest in rural generalism. “Where your experiences have been is where you'll get on and where you'll go back to. It’s reflected in the JCU core curriculum – early placements and building those connections within community while you're there,” he says.

“John Flynn was a great program for the fact that you're taking medical students out to remote areas and giving them that both community mentor as well as a clinical mentor. So you're ensuring they do build relationships within those communities. Fair, you might not go back to those communities, but you have an understanding of how they work, and that's ingrained in your mind early.”

From his experience as a JCU GP Registrar Liaison Officer and as a member of the ACRRM registrars committee and the RDAQ Doctors in Training group, Dr Johnston believes supported places beyond medical school are key to recruiting and retaining rural doctors in their first few postgraduate years. 

“Supported places are places where you have strong local clinicians who know the area quite well, who are good with students and who are quite passionate about what they do,” he says.

“If we're trying to attract people to rural and remote sites, we've got to make these sites appealing for them as well. We've got to make them feel welcome and part of the family. I think that's what good supervisors, educators, clinicians, and good people really, do well. When you feel welcome in the community, you're much more likely to come back.” 

‘The work you get to do is amazing’

For Dr Johnston, the communities and the work make living in Weipa unbeatable. “I love to be able to go and do a shift in emergency, then the next day I'm doing a remote ENT clinic and then the day after that I'm doing general practice back up in Weipa,” he says.

“Then you're on call after hours, you’re seeing anaesthetics, you’re seeing emergencies, you're doing retrievals, you're on the roadside, you’re pulling people back from Mapoon and other remote communities. It's just unbelievable. The work you get to do is amazing. Then there’s coming back from that to home, having mates in the community.” 

Dr Johnston’s red heeler kelpie cross, Darren, enjoys Weipa life as much as his owner does. “The local ambos up here are fantastic, the teachers are great, the coppers are awesome,” Dr Johnston says. “We play Oztag after work, we go for a fish in the afternoon, catch up with everyone for beer when you can. It’s a community and it’s a big family. That's what makes the lifestyle so desirable.”

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