The food at Boole Poole is continuous and one meal runs into the next. Looking for an alternative to eating, I decided to interview Miriam, the newest physician to work for the Aboriginal Cooperative and their first and only full-time physicians. My colleague, Rocky, had already spent time with her on his last journey to Australia when he consulted to the physicians who worked for the Cooperative. The rain drummed on the roof as we talked in the living room of the house while most everyone else watched films of aboriginal dancing from the community at Mullingimby, the home of Shadow and Lily.
"How long have you been at the Coop now?" I asked.
"Since last August, 2011. Now, it's six months." Miriam answered. She had trained in Brazil and had practiced for some time with aboriginal people there. In Brazil she had a catchment area of 4000 people. She worked for the public medical care system. In her clinic, she had four health workers, one nurse, and her. I wondered how it was to have that many families under your care. She said it was a matter of doing the match. In any given month, one expects 4% acute care visits. She used the morbidity tables for the percentages of chronic diseases in her practice to calculate how much time to allocate for chronic disease care. Time was very scientifically managed. Next I asked her what was her biggest challenge in coming to the Coop in her first week.
"My first week was one of introductions and cultural awareness. I was taken to the different sites I needed to know about; taken to meet the people with whom I would be working and whom I would be calling. They (the coop) introduced me to elders. That first week was also an introduction for the community to me. It was a pleasure. They believed it was fundamental for me to understand the geographical space in which the patients lived. They were open to all my questions. They introduced me to all the places that were important to know. The two aboriginal health workers did that -- Shane and Judi Ann. Judi worked with the midwife and could bring her all the issues with pregnancies in young people and what they need, their expectations. That was my first week." I was impressed with how culturally sensitive the Coop was to Miriam. I hoped we had contributed something to that awareness. Then I asked Miriam about her second week.
"During my second week I was in the unit of my mentor, Dr. Jane Greason. She was able to introduce me to the program and what they had been doing in the community. She has been there more than 12 years." Then I asked her what other doctors work for the Coop.
"Dr. Greason is my supervisor. There is Dr. Gene Wofurt who was raised in Bairnsdale, then Dr. Schoefeld, and Dr. Black. We have two offices at the health center. Usually only one session or two sessions occur at the same time." I learned that the other doctors had contracts with the Coop and did their own billings. Miriam was on a salary.
"My challenge is, not by the production, but to help people get well. I am not billing medicare like the other doctors who have to see patients one after the other, 1, 2, 3, 4. I have A, B, and C consultations. An A consultation is scheduled for 10 to 15 minutes. B is 40 minutes and C is one hour. Because we have the other doctors, if I have another doctor at the unit, the other doctor does their patients and I do the health assessments with the aboriginal health worker and do the gp planning." I hadn't heard the term "gp planning" so I asked what that was. Assessments are always category C consultations.
"After the assessment, you have at least some idea of the risk factors, medications, and social information. That supports the gp planning. We identify the patients with the chronic disease and the special needs. After that, you have to work in a way that you agree with the patients and negotiate with them what can be done and how. We set some goals between us. I have to write this down. That is the product we call GP planning. The Coop is a very special situation because they have more than just general practice. They have the family service, the alcohol and drugs follow-up, the midwifery service, and many more community outreach services. With these special services, it's easier for us to go further than a simple gp plan in mainstream medicine. There they have hard work because they don't have the facilities to refer as I have here.
"When I arrived in the heatlh center, I realized some of the aboriginal health workers were not having time with the doctors. Every doctor had a small time with the patient. I started doing the health assessments with the aboriginal health worker and the patient together. I also did the gp planning with the patient and the aboriginal health worker together. This seemed like a natural way to do this. It would be a longer appointment if we did it together, but we would get so much more done. It is the job of the aboriginal health worker to visit the patient in the community and to make sure the plan that we have negotiating is being implemented. If I cannot finish the gp planning with the patient, I will finish it with the aboriginal health worker. Sometimes that's necessary because I didn't have all the necessary background.
"We have a clinic coordinator who is a nurse practitioner and we have Leslie who is a nurse practitioner who is more responsible for immunizations and wound management. She's a more unit centered nurse. Another nurse does diabetic education. We have another midwife who works with Liz Boyer, who is one of the doctors responsible for antenatal care and deliveries at the hospital. The midwife is a nurse, too.
"After gp planning, I keep in contact with the aboriginal health worker to be sure every action that we have planned is happening. In that stage I had some concerns because the aboriginal health workers belong to the families. If I have a male patient, they have male business and they will be ok with these patients, but if they belong to other families, maybe they will not be ok. We lost one aboriginal health worker because she couldn't do the male business. Judi worked with the midwife and had good support in the women's business. It's very hard because you know they belong to their families and sometimes they don't want to get involved in other families' business. I have to be very careful, because I don't know where I am walking. Some of them are close to these patients. I have to be very respectful. Once I went to aboriginal health worker and said what I wanted to do with this patient and he said, doctor, I prefer not to work with this patient, because she is my wife. He could help her as a husband but not as a health worker.
"Patient confidentiality is minimal. Everybody is a relative. You have to be very careful what you have as a goal. What we have to do is ask the patient. I have the opportunity to talk with the patient myself before we discuss things with the aboriginal health worker. I explain what is a good aboriginal health worker and they agree with me. Then I ask them if they are ok with who will be assigned to them. Some of them don't accept the aboriginal health worker." I asked Miriam about the challenges to health in the community.
"People in the community want to be heard. They have a hard time with drug addiction, alcohol, domestic violence, but when you open the door, they go through it. If you listen to them, they will tell you things which will give them some relief. I remember one patient who was very upset. In their community, it's not normal practice to have an elder in a retirement home. She was very upset with that. She came for high blood pressure. She was very upset. She was fighting with the family because one of the sisters got the guardianship of their mother. The sister wanted their mom in this specific retirement home. I started to treat her blood pressure but I knew the stressful situation was part of what was raising her blood pressure. Part of my job was to be a problem solver strategist. To help her make small changes to cope with the situation was what I needed to do. She is still working through her issues but she is changing. She asked me to support her with her alcohol issue because that was why her mother was in the retirement home. She was not able to take care of her mother because of her drinking. She was then able to go to alcohol treatment. She could choose an alcohol counselor. " I have this problem and how can I solve with the resources we have here.' Now her mom is in the retirement home and she is struggling to cope with alcohol problems and she accepted the situation as transitory because she wants to recover so she can take care of her mother. She is in the middle of her process now. She has access to the consultations. Every time she needs to contact me, I have an agenda for her to come every week as a crisis like, trying to support her in this journey.
"Second I have a list of resources we can present to the patient. Patients can choose what they want. If it's housing, I have people who can help with that. One of her [the above patient] issues was that she didn't have a house. She got connected to the aboriginal legal services and I could do a letter supporting her for housing. It was important for her for the crazy stress.
"The aboriginal health worker is very important, because they know how to work the system. If the patient doesn't allow me to contact the aboriginal health worker, I have the list of the resources and I ask the patient how to help them. Sometimes they say it's impossible. They give me the limitations.