Australian College of Rural and Remote Medicine

Understanding the 'university of origin' of general practice and rural generalist trainees informs workforce planning.

Precision medicine tailors an individual's healthcare to their genetics, environment and behaviour. This has been driven by rapid advances in genomics, where an individual's entire genetic code can now be sequenced. General practitioners (GPs) are increasingly involved in genomics throughout the lifespan, including performing prenatal screening during pregnancy, requesting reproductive genetic carrier screening and arranging genetic referrals for cancer and other conditions. Patients are relying on their GPs to appropriately counsel, test, refer and manage genetic conditions, and provide genomic healthcare. This article provides an overview of the GP's expanding role in genomic medicine, some tools to assist GPs to navigate this landscape, and barriers to genomic uptake. GPs are integral to supporting patients and families in the genomics and precision medicine era. Resources specifically aimed at, and codesigned with, GPs are required to enable broader and equitable access for the benefit of all Australians.

Koalas (Phascolarctos cinereus) face significant threats from habitat loss and fragmentation, with South-East Queensland (SEQ) experiencing some of the most severe population declines. Current metrics used to assess conservation impacts often lack spatial resolution, transparency, or integration of diverse data sources. We propose a novel, spatially targeted metric, Koala Population Potential (KPP), to estimate the potential number of koalas that could inhabit a given area under ideal conditions. This metric is derived from a Bayesian Network model that integrates ecological, environmental, and threat data, including satellite imagery, expert knowledge, and stakeholder input. We developed and validated the KPP within an interactive online platform, the Koala Bayesian Network Platform (KBNP), enabling stakeholders to visualise and assess the conservation impact of various management scenarios at the land-parcel scale. Application of the KPP across SEQ revealed substantial spatial variation in potential koala populations. Regional areas like Somerset and the Scenic Rim exhibited high KPP scores, while urban LGAs such as Redland City and Logan had lower scores due to elevated threat levels. Model predictions of habitat support were strongly correlated with independent habitat quality assessments (R² = 0.803, p < .001), supporting the validity of the approach. The KBNP provides an accessible, evidence-based decision-support tool that empowers landholders, planners, and conservation managers to evaluate and communicate the likely outcomes of their actions. While developed for koalas, this framework is adaptable to other vulnerable species requiring localised, data-driven conservation planning under uncertainty.

Emergency Departments (ED) are critical components of the healthcare system, providing immediate care for acute conditions, injuries and trauma. Individuals who experience domestic violence (DV) face barriers accessing care in traditional EDs. These include fear of retaliation from an abuser, shame, isolation, logistical challenges. Virtual Emergency Departments (VED) have emerged as potential solutions to these challenges. Providing emergency care through telehealth offers an innovative way to meet the needs of patients who may otherwise hesitate or be unable to seek help. This article explores the intersection of VEDs and DV, examining the potential benefits and challenges of using telemedicine to support DV victim-survivors, as well as the ethical, legal and clinical considerations. By focusing on this emerging field, this opinion piece seeks to highlight how VEDs could enhance the way DV victim-survivors access care and the broader implications for healthcare delivery.

In 2023, a Diploma of Rural Generalist Anaesthesia (DipRGA) was implemented across Australia. Developed collaboratively by the Australian and New Zealand College of Anaesthetists (ANZCA), the Australian College of Rural and Remote Medicine (ACRRM) and the Royal Australian College of General Practitioners (RACGP), the 12-month qualification is completed during or following ACRRM or RACGP Rural Generalist Fellowship training. Focused on the needs of rural and remote communities for elective and emergency surgery, maternity care, resuscitative care for medical illness or injury, and stabilisation for retrieval, the DipRGA supports rural generalist anaesthetists working within collaborative teams in geographically isolated settings. The goal is a graduate who can anaesthetise American Society of Anesthesiologists physical status class 1, 2 and stable 3 patients for elective surgery, provide obstetric anaesthesia and analgesia, anaesthetise paediatric patients and undertake advanced crisis care within their scope of practice. Crucially, they also recognise both limitations of their skills and local resources available when considering whether to provide care, defer, refer or transfer patients. DipRGA curriculum design commenced by adapting the ANZCA specialist training curriculum with consideration of the training approach of both the ACRRM and the RACGP, particularly the rural and remote context. Curriculum content is addressed in seven entrustable professional activities supported by workplace-based assessments and multisource feedback. Trainees are supervised by rural generalist anaesthetists and specialist anaesthetists, and complete flexible learning activities to accommodate geographical dispersion. Standardised summative assessments include an early test of knowledge and an examination, adapted from the ACRRM structured assessment using multiple patient scenarios.

The health impact from alcohol is of recognised concern, from acute intoxication as well as increased risk of chronic health issues over time. Identifying factors associated with higher alcohol consumption when presenting to the emergency department (ED) will inform public health policy and enable more targeted health care and appropriate referrals. Secondary testing of blood samples collected during routine clinical care of 1160 ED patients presenting to the Royal Brisbane and Women's Hospital in Queensland, Australia, for 10 days between 22 January and 1 February 2021. Alcohol was measured by blood ethanol (intake in recent hours) and phosphatidylethanol (PEth; intake over 2-4 weeks). Zero-inflated negative binomial regression was used to identify demographic and clinical factors associated with higher alcohol concentrations. Males were found to have 83% higher blood ethanol and 32% higher PEth concentrations than females (adjusted rate ratio [ARR] 1.83, 95% confidence interval [CI] 1.37-2.45 and ARR 1.32, 95% CI 1.04-1.68, respectively). Blood ethanol concentrations were 3.4 times higher for those 18-44 years, compared to those aged 65+ (ARR 3.40, 95% CI 2.40-4.82) whereas PEth concentrations were found to be the highest in those aged 45-64 years, being 70% higher than those aged 65+ (ARR 1.70, 95% CI 1.19-2.44). Patients brought in involuntarily had eight-times higher blood ethanol concentrations than those who self-attended. This study used two alcohol markers to identify factors associated with higher alcohol concentrations in emergency presentations. The findings demonstrate how these biomarkers can provide informative data for public health responses and monitoring of alcohol use trends.

Digital games are among the treatment methods for speech disorders that serve purposes other than mere entertainment. These games have been used for different speech disorders at any age. This study aims to review articles that have used digital games for rehabilitating speech disorders. This study was a scoping review. PubMed, Scopus, and Web of Science were searched on February 28, 2022, to access the articles on digital games used in rehabilitation of speech disorders without any date restrictions. The search strategy was as follows: ("video game [MeSH term]" OR "computer game" OR "mobile game" OR "serious game" OR gamification [MeSH term]) AND ("speech pathology" OR "speech therapy [MeSH term]" OR "speech disorder [MeSH term]" OR stuttering [MeSH term]). Original interventional and observational studies in English were included. The data were extracted from the relevant articles, including the first author's name, year of publication, country, target group, participants, mobile device/computer-based, type of game design, language level, number of sessions, and outcome. Descriptive statistics were used to analyze the data. Of 693 retrieved articles, 10 articles were included in this study. Digital games were used for different speech disorders such as apraxia (20%), dysarthria (10%), articulatory hypokinesia in Parkinson's disease (10%), dysphonic disorder (10%), hearing disability (10%), phonological impairment (10%), and speech disorder in autism (10%). Most of the articles (60%) used a mobile device-based game. Phonemes (30%), words (30%), and sentences (20%) were the most frequently used language levels in designing digital games. All the reviewed articles reported the positive effect of digital games on speech and the patients' motivation in therapy. Digital games can improve patients' speech and motivation in therapy. Although studies showed the positive impact of digital games on speech disorders, personalized speech therapy should be considered in designing these games.

Clinical courage can be described as a rural doctor's adaptability and willingness to undertake clinical work at the limits of their training and experience to meet the needs of their patients. This article describes the in-house development of survey items to include in a quantitative measure of clinical courage. The questionnaire development involved two key concepts: a second-order latent factor model structure and a nominal group technique, used to develop consensus among the research team members. The steps taken to develop a sound clinical courage questionnaire are described in detail. The resulting initial questionnaire is presented, ready for testing with rural clinicians and refinement. This article outlines the psychometric process of questionnaire design and presents the resultant clinical courage questionnaire.

The Australian response to the emergence of human immunodeficiency virus and the acquired immunodeficiency syndrome (HIV/AIDS) has been rightly praised as being progressive for its time but also highly effective in preventing the virus from becoming established in the general population.1, 2 One of the factors identified for this success was the engagement of the community sector – activists, lobby groups and associations rather than a purely medically driven disease control model. In 2016, a joint statement3 from the Australian Federation of AIDS Organisations (AFAO) and researchers from the Peter Doherty and Kirby Institutes declared ‘the end of AIDS as a public health issue in Australia’; however, it is important to consider what this means. Certainly, HIV is now considered primarily an outpatient disease, and deaths from AIDS-related complications are so rare that the decision no longer to collect data on them is justifiable. However, in 2017 there were more than 27 500 people living with HIV and 963 persons newly diagnosed in Australia.4 The number of new diagnoses has been trending down since the peak in 2014; however, the overall statistic conceals many concerning trends. The proportion of diagnoses where male-to-male sex is identified as the primary risk factor is declining, also since 2014, while heterosexual exposure has increased in turn. This increase has been most marked in patients not reporting another high-risk marker (e.g. sexual contact with a partner at high-risk, or being from a high-prevalence country). The proportion of patients diagnosed with CD4 counts of <350 × 106 cells/L has increased from 28.5% to 35.9%, and <200 × 106 cells/L (i.e. those with late-stage disease) from 16.7% to 22.5% across the same period. Some of this change likely represents the successful implementation of new biomedical prevention methods – the increasing recognition of the success of ‘Treatment as Prevention’ (TasP) and Pre-Exposure Prophylaxis (PrEP), which have targeted individuals at highest risk of HIV infection – men who have sex with men, and particularly highly sexually adventurous men. Australia has also been progressive in its approach to biomedical prevention, with PrEP now available on the Pharmaceutical Benefits Scheme for persons at risk of incident HIV infection.5 Around 200 people are diagnosed with advanced HIV in Australia each year. Factors associated with late diagnosis in studies outside Australia include being from a marginalised population (including misuse of drugs or alcohol), older age,6 heterosexual acquisition7 and fear of stigma.8 Many of the reviews of late diagnoses find multiple missed opportunities for testing prior to the positive test – potentially allowing treatment when immune status was still relatively normal. Two papers in this issue of the Internal Medicine Journal address the issue of HIV testing in other diseases that, while not AIDS-defining, may be associated with HIV infection.9, 10 Lin and colleagues9 review Australian specialty guidelines for these indicator conditions and find room for improvement in the recommendations around HIV testing. The second paper by King and colleagues10 finds that a simple educational intervention is effective at increasing the rate of HIV testing in a general medical unit, but that rates of testing are still far too low, and calls for new strategies to boost these low testing rates. Opt-out universal HIV screening has been shown to increase the number of diagnosed individuals in both low-risk11 and high-risk12 settings; however, questions about cost-effectiveness and the ethics of universal testing in Australia remain. Critical to improving the rate of testing is normalising HIV screening for patients and for clinicians. For indicator conditions, this can be as simple as saying ‘when we see this condition, we routinely screen for HIV because it can be associated with your condition. Have you ever been tested? Do you think you could be at risk?’. The previous procedure for documenting formal informed consent and pre- and post-test counselling is no longer necessary for Medicare reimbursement of testing, but the perception of the complex counselling requirements around HIV testing persists. Treatment and prognosis for HIV have progressed so far since the 1980s that there is no longer any medical reason to treat HIV testing differently to any of the other tests routinely done every day. However, the other major barrier to HIV screening is stigma about the disease and fear. We may be reluctant to suggest screening patients who we do not identify as being high-risk because of fear of offending them, or concern that the patient will receive the wrong message. Of course, these fears and attitudes are themselves the result of stigma; those living in the mid-80s will no doubt remember newspaper headlines about the ‘Gay Plague’ or the Federal Government's Grim Reaper advertisements. Treating HIV as something that ‘other people’ get only reinforces stigma and contributes to people fearing undergoing (or offering) testing and will not help those people who are yet to be diagnosed. Ironically, the groups that are at greatest risk have been the quickest to engage novel testing methods like point-of-care HIV testing, outreach testing13 and even testing at home. To be able to say we have truly reached the end of HIV's time as a public health threat, education is critical, that HIV is now just another chronic disease, and that there is no shame in testing for it or in living with it.