Maybe a chink of light?

Today I presenting to a group of medical students from Melbourne University who are about to embark on their rural placements.

Why do I do this? Because I want to be involved in teaching and at the moment I have been invited to be a part of the medical students rural placements.

The learning objectives of the rural health module are:

1. To understand the impact of local context for rural people on their journey through illness and the healthcare system.
2. In terms of Aboriginal health to:

• understand the social determinants of Aboriginal health outcomes and how history impacts on Aboriginal People's current health and wellbeing
• develop an obligation to address the gap between Aboriginal and non-Aboriginal health outcomes at a personal, professional, institutional and community level.

1. To understand the expertise and experience of rural health practitioners, particularly in relation to six key themes.

The six key themes that underpin rural and remote healthcare are:

1. Patient access to care
2. Overlapping relationships
3. Cultural safety & cultural security
4. Generalist health care
5. Community-based models of health care
6. Interprofessional team practice

The Case
This is the case that was designed to examine and challenge the students to consider these six key themes:

You are a doctor in a small Victorian town of 3 500 people. Local facilities include a small cottage hospital with nurse led A&E assessment unit, to which you provide back up. There is also a birthing unit there, in which 500 births a year occur.

            You are having lunch in your favorite café. The manager approaches you, she has found out you are one of the local town doctors having seen your VISA card details.

            She approaches you saying that “She has heard you are really nice and a good GP obstetrician." She is 8 weeks pregnant and says she wants a home birth this time, saying her GP was dismissive of her request.

Discussion:

Overlapping boundaries

Confidentiality

Potential conflict with the other GP

Need to maintain professional approach even when your confidentiality is breached in a public setting

You see Mrs S 2 days later in your clinic.

She is requesting a home birth.

She is G3 P2.

Past Obstetric history

1.     full term birth Emergency C Section for failure to progress in labour. BW 3.4kg, no peri or post natal problems

2.     Full term normal vaginal birth. BW 3.87kg no post natal or peri natal problems.

She is a non smoker

She owns the local coffee shop.

She is very unhappy with her previous birth experiences. The midwives and doctors referred to these as deliveries which really upset her.

She says she only had a C section due to the fact that her doctor was very tired and it looked as though she would have her baby at 5am.

She also says the local birthing unit is impersonal, she wants 1 on 1 care during childbirth and to know the people looking after her in labour. She also wants birth attendants who respect her wishes.

This is her final pregnancy and she wants her mum, sister, husband and children to be present which the hospital will not allow.

She is medically fit & healthy

She does not drink alcohol.

Discussion

Involve respect for patient’s views

Need to explore risks vs benefits of home birth

Possible criticism of a professional colleague ?do they have  a problem, could involve conflict

?Criticism of local hospital policy

Where do you draw the line here?

Rights of patient to choose place of birth

Risks of refusal ie free birthing loss of reputation in community

Referral pathways to midwives/ home birth doctors

You referred this woman to a colleague who birthed at home successfully.

She comes back asking you to look after her family as you listened to her concerns.

This lady originates form the Cook Islands.

The place of birth and role of family is sacrosanct to her values & is thankful you supported her in this.

What other cultural aspects around birth are you aware of?

 Facilitating learning around evolving themes

The key to this mornings session was to be prepared as a facilitator of learning to adapt and evolve in response to the themes thrown up by this discussion. I did not rigidly stick to the script and in fact a 30min discussion turned into an hour.

My previous interactions with Australian medical students have been in stark contrast to my contact with New Zealand medical students. New Zealand medical students I have tutored have been warm and responsive individuals in contrast to, until today, feeling the arrogance and superior attitude of the Australian medical students. It was because of this attitude I was slightly nervous about the presentation this morning.

The medical students today I found were very interested and motivated to contribute to the discussion about this case. I discovered that we set of down a track and explored many of the issues facing rural pregnant women today. I was able to draw on my knowledge of the National Guidance on Collaborative Maternity Care document published by the Australian Government.

It also gave us the opportunity to explore the issues around mandatory reporting and the potential effects and also how it may be used as a weapon as well as protecting the public.

Chink of light

The chink of light that came out of the session for me was the medical students themselves stating that there needs to be a change. The change to more women centred care and less fighting between health care professionals in relation to pregnancy and birth. They wanted to see the culture changed at student level and expressed a wish to be more exposed to midwifery philosophy of care.