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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Rural general practice

Definition

In addition to general practice as defined by The Royal Australian College of General Practitioners (RACGP)1, rural general practice provides its own diversity of contexts and characteristics of general practice.2

In rural and remote Australia, geographical and demographic features lead to great diversity in both the range of presentations general practitioners may encounter and the facilities that may be available to administer primary care.2

Rural GPs are more likely to: provide in-hospital care as well as private consulting room care, provide after hours services, engage in public health roles expected of them by discrete communities in which there are few doctors to choose from, engage in clinical procedures, engage in emergency care, encounter a higher burden of complex or chronic health presentations, and encounter larger proportions of Aboriginal or Torres Strait Islander patients in their overall patient load.2 3 4 5

The extent to which the GP will engage in any of these activities and roles, however, will depend on the rural or remote practice context and the range of general practice skills in which they are required. For example, some rural doctors in smaller rural towns are based primarily at the local hospital, but the practice they conduct is still predominantly primary medical care, even though some secondary and tertiary care is also possible due to the hospital facilities.2

Rural GPs often value:

  • professional autonomy3
  • the range of medicine practised
  • practising to the extent of their clinical knowledge and skills
  • value the communities in which they work
  • being valued by the community.6

In addition, rural GPs are more likely to experience professional and social isolation than their peers in urban contexts.

While rural practice requirements conform to the core curriculum set for the Fellowship of the RACGP (FRACGP), they will also involve specific skill sets appropriate to the rural and/or remote health context. These skill sets may be practised at an extended or advanced level, depending on patient requirements. These characteristics and practices are supported by the RACGP Standards for general practices and a curriculum developed and maintained by the RACGP and reflected in the award of Fellowship of Advanced Rural General Practice (FARGP).

Curriculum in practice

The following case illustrates how the rural general practice curriculum applies to general practice:

  • Emily, 23 years of age, has returned to your small country town following the breech birth of her fourth child, Ben. The baby has been identified with talipes equinovarus, which is twice as common in the children of smokers (like Emily). She has been told she needs to return for weekly assessment and treatment in the city, taking 2 days of travel each time. She tearfully asks if there is any way this can be avoided. The crop is about to be harvested and she will be desperately needed at home to run the financial part of the family business, as well as care for the other children. She also cooks for the contracted workers. The family simply cannot afford to have her absent, nor does she have anyone to stay with in the regional centre to help reduce the costs of travel and accommodation.

Rationale and general practice context

Australia is predominantly an urban society. In June 2010, of the estimated 21 951 736 people living in Australia, 68.7% of the population was living in major cities, 19.7% in inner regional Australia, 9.3% in outer regional Australia, 1.4% in remote Australia and 0.8% in very remote Australia.7 The supply of GPs per patient population is significantly lower in remote areas than in major areas, as is access to medical specialists.8 Geographical isolation and social accessibility are significant factors in the decision to attend a GP for rural patients.9

Health outcomes, such as death rates, tend to be poorer outside major cities.10 The main contributors to higher death rates in regional and remote areas are coronary heart disease and other circulatory diseases, chronic obstructive pulmonary disease, motor vehicle accidents, diabetes, suicide, other injuries and some cancers such as lung cancer – perhaps reflecting differences in access to services, risk factors and the regional/remote environment.

Rural areas have lower rates of some hospital surgical procedures, lower rates of general practice consultation and there are generally higher rates of hospital admission in regional and remote areas than in major cities.11 People from regional and remote areas tend to be more likely to smoke and drink alcohol in harmful or hazardous quantities than people in major cities.12 Environmental issues such as more physically dangerous occupations and factors associated with hazardous driving play a part in higher accident rates and related injury/death in country areas.12

Higher death rates and poorer health outcomes outside major cities, especially in remote areas, also reflect the higher proportions of the populations in those areas who are Aboriginal or Torres Strait Islander.13 14

Because rural communities in general have higher levels of morbidity and mortality, the rural GP has an important and evolving role, with the potential to influence change at the individual patient, practice and community levels within the healthcare system. Rural GPs are more likely to be key players in local hospitals and also be called upon by local authorities to play a public health role, such as a police medical officer. To optimise their effectiveness in providing primary healthcare to their communities, the rural GP needs to develop a detailed understanding of the particular sociopolitical, economic, geographical, cultural and family influences on the health of their patients.

Rural general practice training in addition to the FRACGP

All medical practitioners require an understanding of what may be helpful for working in rural and remote environments such as procedural skills and knowledge of Aboriginal health, hospital work and population health. A knowledge of rural health is an essential part of preparing a general practitioner for unsupervised practice anywhere in Australia. This curriculum will assist any general practitioner to understand the knowledge, skills and competencies helpful for unsupervised practice anywhere in rural Australia.

Doctors with a particular interest in rural general practice can integrate enhanced rural training with general practice vocational training toward the FRACGP under the formal framework offered by the RACGP FARGP.

These doctors may also wish to undertake advanced rural skills (ARS) training in curriculum shared with other medical specialties such as anaesthesia, obstetrics, emergency medicine and mental health. These have additional curriculum requirements to those of the FRACGP. Specific curriculum statements have been developed by joint consultative committees between the RACGP and relevant specialist colleges.

These advanced rural skills are not required for attainment of the FRACGP, or included in this rural general practice curriculum statement. However, 12 months of training in accredited ARS posts is required for attainment of the FARGP. Doctors planning to undertake ARS training are encouraged to integrate these into their general practice vocational training, under the FARGP framework. Medical students, postgraduate doctors and general practice registrars are encouraged to undertake as much of their education and training in rural general practice as practicable.

Most RACGP curriculum statements will refer to rural and remote contexts. This rural curriculum statement serves both as the rural statement of the RACGP curriculum in general and as the baseline curriculum for the RACGP FARGP.

As a qualification beyond vocational FRACGP, FARGP candidates, for which the full 12 months of ARS training is undertaken in the one ARS curriculum, can include that curriculum in their postnominals, ie. a 12 months ARS training post in obstetrics, the postnominal is FARGP (Obst). This assists the graduate in seeking visiting medical officer credentialing in rural hospitals.

Please check the FARGP information available on the National Rural Faculty page of the RACGP website for specific educational and assessment requirements of the FARGP.

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

RURT1.1

Understand that effective communication skills of the rural general practitioner need to take into account the likelihood of higher than average workloads and the greater reluctance of many patients to freely discuss problems they may experience.

RURT1.2

Recognise that in a local rural environment, where patients are friends and neighbours, special care is required to communicate with patients in a manner not likely to confuse professional, social and personal boundaries.

RURT1.3

Establish rapport and be empathetic with patients from different socioeconomic, occupational and cultural background within rural communities.

RURT1.4

Adopt verbal and nonverbal communication styles appropriate to the diverse needs of patients in rural communities.

RURT1.5

Incorporate a particular communication emphasis on health promotion and education to increase patients' willingness to look after themselves, especially in relation to major risk factors in rural communities.

RURT1.6

Communicate to patients appropriate doctor-patient boundaries associated with living within a close knit rural community.

RURT1.7

Develop a specific cultural awareness of the indigenous populations living within the boundaries of the medical practice.

RURT1.8

Manage communication sensitively on issues such as family arrangements during transfer to a major centre for treatment.

RURT1.9

Appreciate the different cultural norms of interpersonal communication for specific patient populations (eg. Aboriginal and Torres Strait Islander people, non-English speaking people), and acquire knowledge to be able to communicate effectively with these patient groups.

2. Applied professional knowledge and skills

RURT2.1

Recognise that rural GPs are likely to be called upon to manage a wider range of patient presentations including emergency treatment, obstetrics and minor and major procedures without referral.

RURT2.2

Recognise that rural communities place great reliance on the applied professional skills of their resident GPs whose response must be skilful and appropriate in order to instil confidence and trust.

RURT2.3

Recognise and manage the range of common and significant patient presentations found in rural communities.

RURT2.4

Demonstrate a comprehensive knowledge of relevant anatomy, physiology, pathology and psychology including related research findings in the management of conditions commonly found in rural practice.

RURT2.5

Competently manage the range of illness and disease occurring in their community, including possible serious illness, which may be inherent in many common presentations.

RURT2.6

Demonstrate enhanced clinical skills in the management of common conditions according to the communities needs.

RURT2.7

Demonstrate continual improvement in the repertoire of procedural and clinical skills required for effective general practice in their rural communities, and the ability to perform appropriate medical procedures under minimal, or no supervision according to the community needs.

RURT2.8

Demonstrate the ability to manage emergencies to the level of skill attained in recognised intensive emergency medicine courses such as the early management of severe trauma, advanced paediatric life support, advanced life support obstetrics, clinical emergency management program and emergency life support including the management of emergencies in the rural hospital setting.

RURT2.9

Demonstrate a level of competence in those aspects of medicine, surgery, paediatrics, obstetrics, intensive care and anaesthesia appropriate to the practice of a rural GP taking part in in–patient/hospital care.

RURT2.10

Demonstrate ability to take X-rays and use teleradiology facilities and ultrasound when necessary.

RURT2.11

Demonstrate competent implementation of procedures for evacuation, disaster, trauma management and retrieval.

RURT2.12

Recognise and take into account the factors that need to be balanced when arranging an evacuation, including family considerations.

RURT2.13

Implement appropriate protocols for arranging an evacuation and for undertaking the preparations required in a community for air evacuations.

RURT2.14

Demonstrate competent performance of appropriate diagnostic procedures relevant to the advanced skills of rural general practice.

RURT2.15

Make decisions with confidence and accept the outcomes of these decisions while working within their limitations.

3. Population health and the context of general practice

RURT3.1

Provide or contribute to ongoing health education and health promotion sessions for other rural health professionals and members of their rural community.

RURT3.2

Develop a detailed working knowledge of their rural community's patterns of morbidity and mortality, health services, and be able to participate in regional and national community based prevention and education strategies.

RURT3.3

Apply public health principles including disease control management and utilise the appropriate health and community service networks as part of their rural practice.

RURT3.4

Participate in a range of public health roles as appropriate.

RURT3.5

Understand the need for multidisciplinary teamwork with other healthcare practitioners and crosssectoral nonhealth organisations in rural areas.

RURT3.6

Deliver an appropriate level of care with an understanding of the limitations of resources in rural general practice.

RURT3.7

Involve consumer groups in the development of policies relating to health service provision.

RURT3.8

Utilise relevant protocols and guidelines and, where necessary, participate in development of these guidelines, both for acute and preventive care.

RURT3.9

Demonstrate an understanding of the environmental, social and cultural influences on illness, health needs and priorities of rural and remote people and their communities.

RURT3.10

Recognise the importance of the family unit and the home environment, in illness and health, and acknowledge the extended support structures.

RURT3.11

Utilise the extended role of other healthcare practitioners in rural areas, recognising the value of multidisciplinary teamwork.

4. Professional and ethical role

RURT4.1

Understand the duty of care and medicolegal issues of the rural GP, who may deal with more emergency cases and procedural medicine than urban based GPs.

RURT4.2

Understand the potential ethical dilemmas arising from the multiple roles that GPs fulfil in small communities.

RURT4.3

Improve skills in critical self reflection and evaluation of their practice to ensure that the needs of the rural communities they serve are met as effectively as possible.

RURT4.4

Develop skills in balancing the case load and demands of working in isolation in a rural practice with the associated social and personal responsibilities, self care and self reliance, family, and potential difficulties associated with professional and social boundaries in a small rural community.

RURT4.5

Establish professional networks and utilise available rural resources and referral agencies.

RURT4.6

Understand the difficulties and importance of maintaining confidentiality in small communities.

RURT4.7

Be skilled in providing mentoring support for peers and others in the rural GP learning life cycle.

RURT4.8

Know the procedures and level of response required for local emergency and disaster situations.

5. Organisational and legal dimensions

RURT5.1

Be able to work effectively as part of a multidisciplinary team.

RURT5.2

Articulate and maintain good working relationship with all members of hospital staff/ hierarchy.

RURT5.3

Balance time management between the demands of the consulting rooms and the community hospital as required.

RURT5.4

Demonstrate awareness of local issues that affect the GP's decision to treat the patient locally, or to refer onto other services, which may be distant from the practice area.

RURT5.5

Develop an understanding of the principles of small business management relevant to a rural general practice.

RURT5.6

Apply the principles of triage and disaster management in the rural setting.

RURT5.7

Apply appropriate protocols for hospital, home and hostel visiting.

RURT5.8

Understand the principles of public health, including disease control arrangements within their state and utilise appropriately public health infrastructure.

RURT5.9

Know the legal responsibilities regarding notification of disease, birth, death, autopsy, nonaccidental injury and substance abuse.

RURT5.10

Appropriately prioritise patient management in rural general practice, according to individual patient needs, time and other resources available.

RURT5.11

Recognise stress and grief symptoms in staff, patients, their relatives and friends, and provide empathic and culturally appropriate support and follow up.

RURT5.12

Be able to obtain informed patient consent during medical procedures in the rural setting and in emergency care.

RURT5.13

Be able to apply transfer and evacuation procedures from the rural community.

RURT5.14

Apply the principles of retrieval medicine.

RURT5.15

Establish and utilise a comprehensive professional emergency referral network.

RURT5.16

Be able to apply the jurisdictional legislation relevant to involuntary admission to a psychiatric unit, power of attorney, child protection and abuse and guardianship.

RURT5.17

Be able to access the metropolitan clinical, academic, research, literature, hotline and legal resources available.

RURT5.18

Keep comprehensive patient records and be able to articulate why this is important.

RURT5.19

Be aware of local issues that influence the GP's decision to treat a patient locally, or refer onto more distance health faculties.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

RURLM1.1

Demonstrate how to establish rapport and empathy with patients from different socioeconomic, occupational and cultural background within rural communities.

2. Applied professional knowledge and skills

RURLM2.1

Demonstrate the ability to recognise the range of common and significant patient presentations found in rural communities.

RURLM2.2

Outline the basic management of the range of illness and disease occurring in their rural communities including possible serious illness, which may be inherent in many common presentations.

RURLM2.3

Identify cross-cultural issues applying to rural general practice including Aboriginal and Torres Strait Islander health in rural and remote communities.

3. Population health and the context of general practice

RURLM3.1

Outline how the socioeconomic, environmental and social factors of rural and remote areas contribute to poorer health outcomes, including those of Aboriginal and Torres Strait Islander people.

RURLM3.2

Outline differences in basic public health issues relevant to rural communities such as access to clean water, adequate housing and sanitation.

RURLM3.3

Outline the structures and processes in place to address pandemic or epidemic disease, prevent general morbidities and preserve health and wellbeing in rural Australia.

4. Professional and ethical role

RURLM4.1

Describe the professional challenges and rewards of rural general practice and the role of the GP in addressing the rural health inequities.

RURLM4.2

Describe the professional role of a GP in a rural community, including community trust, and the responsibility to practice medicine safely, with due care and strictly within guidelines of professional conduct.

RURLM4.3

Outline ethical questions that arise specifically in rural practice and formulate potential responses.

RURLM4.4

Describe the ethical issues associated with maintaining patient confidentiality in the range of general practice contexts found in rural Australia

5. Organisational and legal dimensions

RURLM5.1

Describe local issues that influence the GP's decision to treat the patient locally or to refer to other services.

RURLM5.2

Outline the principles of triage or disaster management in the rural setting.

Prevocational doctor

1. Communication skills and patient-doctor relationship

RURLP1.1

Demonstrate use of appropriate verbal and nonverbal skills for a rural setting.

RURLP1.2

Demonstrate how to communicate to patients the restrictions of appropriate doctor-patient boundaries associated with living within a close knit rural community.

2. Applied professional knowledge and skills

RURLP2.1

Demonstrate development in the competent management of the range of common and significant patient presentations in the rural setting.

RURLP2.2

Demonstrate improvement in procedural and clinical skills required for effective general practice in their rural communities, including those skills required for the management of emergencies.

3. Population health and the context of general practice

RURLP3.1

Demonstrate application of public and population health principles (see also curriculum statement on Population health and public health) in a rural setting.

RURLP3.2

Observe and outline the relationship between socioeconomic disadvantage and poor health in rural communities, ideally through clinical experience in a range of rural health facilities.

4. Professional and ethical role

RURLP4.1

Describe the role of the rural GP in their community, including both primary and secondary, and sometimes tertiary secondary care.

RURLP4.2

Document exposure to, and work within, a rural environment to the professional limit of the skills acquired and supervision necessary.

RURLP4.3

Describe the ethical questions that arise in rural practice and potential responses.

RURLP4.4

Outline how best to balance the potential conflicts in a professional role and the ethical concerns arising both from the complexity of rural practice and patients, and from the multiple roles that GPs fill in small communities.

RURLP4.5

Demonstrate preliminary steps taken in ensuring a balance of work, self care and family both at present and for a future medical career.

5. Organisational and legal dimensions

RURLP5.1

Outline time management strategies to balance the competing demands of consulting rooms and community hospital commitments in rural practice.

RURLP5.2

Identify local issues that influence your general practice's decision to treat a patient locally or to refer on.

RURLP5.3

Articulate the operational principles of triage and disaster management relevant to rural general practice.

RURLP5.4

Appropriately prioritise patient needs, time and other resources available.

RURLP5.5

Demonstrate knowledge of patient consent procedures.

Vocational registrar

1. Communication skills and patient-doctor relationship

RURLV1.1

Demonstrate the adaptation of appropriate verbal and nonverbal communication styles to the needs of patients in rural communities.

RURLV1.2

Demonstrate a capacity to use health promotion and education to increase patient willingness to look after themselves, especially in relation to major risk factors in rural communities.

RURLV1.3

Show how to communicate to patients appropriate doctor-patient boundaries, associated with living within a close-knit rural community.

RURLV1.4

Demonstrate multicultural awareness of people from culturally and linguistically diverse backgrounds living within the patient catchment of the medical practice.

RURLV1.5

Demonstrate specific cultural awareness of the indigenous populations living within the patient catchment of the medical practice.

2. Applied professional knowledge and skills

RURLV2.1

Demonstrate the competent management of the range of common and significant patient presentations in the rural setting.

RURLV2.2

Demonstrate further improvement in procedural and clinical skills required for effective general practice in their rural communities, including those skills required for the management of emergencies.

RURLV2.3

Competently implement procedures for evacuation, disaster, trauma management and retrieval.

3. Population health and the context of general practice

RURLV3.1

Demonstrate participation in ongoing health education and health promotion in rural communities.

RURLV3.2

Describe local rural community patterns of morbidity and mortality, the health services available to address these and any improvement in services required.

RURLV3.3

Apply public health principles to disease control management in the practice and hospital setting.

RURLV3.4

Utilise the appropriate health and community service networks as part of rural practice.

RURLV3.5

Demonstrate an informed commitment to primary healthcare delivery through inter-professional cooperation.

4. Professional and ethical role

RURLV4.1

Demonstrate appropriate care, responsibility and respect for patient rights and a preparedness to act as advocate for patients.

RURLV4.2

Outline the difficulties and importance of maintaining confidentiality in small communities.

RURLV4.3

Describe the difficulties and potential ethical dilemmas arising from the multiple roles that GPs fill in small or rural communities.

RURLV4.4

Outline the avenues with which ethical concerns or professional conflict can be discussed and resolved, including referral agencies.

RURLV4.5

Demonstrate steps required to ensure a balance between work, self care and family, both during registrar training in the rural setting and beyond vocational fellowship.

5. Organisational and legal dimensions

RURLV5.1

Demonstrate an understanding of the principles of practice/small business management relevant to rural general practice.

RURLV5.2

Implement the principles of triage and disaster management in the rural setting.

RURLV5.3

Outline legal responsibilities regarding notification of disease, births, deaths, autopsy, non-accidental injury and substance use in the rural setting.

RURLV5.4

Establish and utilise comprehensive professional referral network appropriate to the rural setting.

Continuing professional development

1. Communication skills and patient-doctor relationship

RURLC1.1

Demonstrate a specific cultural awareness of the indigenous populations living within the boundaries of the medical practice in the rural setting.

RURLC1.2

Demonstrate improvement in the ability to manage communication with sensitivity when sensitive issues are involved in a rural setting, for example, family issues when a patient is transferred to a major centre.

RURLC1.3

Engage in periodic review or audit of communication skills.

2. Applied professional knowledge and skills

RURLC2.1

Demonstrate engagement with continuing improvement activities in all curricular areas including procedural and emergency skills.

RURLC2.2

Demonstrate ongoing competence in diagnostic and clinical skills appropriate to the rural setting including in telemedicine.

3. Population health and the context of general practice

RURLC3.1

Demonstrate the capacity to place special emphasis on health promotion and education to increase patients' willingness to look after themselves, especially in relation to major risk factors in rural communities.

RURLC3.2

Review the changing approaches to public health issues including changing causes of morbidity and mortality in the rural setting.

4. Professional and ethical role

RURLC4.1

Demonstrate critical assessment of the sources of learning and application of new managements/treatments/technologies with competence in the rural context where appropriate.

RURLC4.2

Provide a professional example to medical students, interns and registrars of the highest possible standard, especially in relation to respecting patient rights, advocacy and confidentiality within the community.

RURLC4.3

Facilitate exposure of professional and ethical dilemmas to medical students, junior doctors and registrars in a teaching environment.

RURLC4.4

Demonstrate ongoing critical self reflection and evaluation of rural general practice to ensure the needs of the rural communities are met as effectively as possible.

RURLC4.5

Demonstrate the ability to effectively use and maintain professional networks and utilise available rural resources and referral agencies in a context of continuous improvement.

RURLC4.6

Demonstrate a commitment to continuing self directed learning and professional development in rural practice sufficient to improve the quality of medical care provided.

RURLC4.7

Demonstrate ongoing improvement in balancing the demands of working in isolation in a rural practice with social and personal responsibilities, self care and family.

5. Organisational and legal dimensions

RURLC5.1

Demonstrate the delivery of appropriate level of care and prioritise patient management in rural general practice according to individual needs, time and the limits of resource in rural general practice.

RURLC5.2

Assist medical students, interns and registrars in understanding the role of the GP in the community hospital and in other public health roles found in rural contexts.

RURLC5.3

Demonstrate improving competence in the delivery of a combination of primary and secondary care.

RURLC5.4

Assist medical students, interns and registrars in understanding the local issues that affect the GP's decisions to treat the patient locally or to refer on.

RURLC5.5

Modify practice business models to maximise practice sustainability within the workforce constraints and higher and more complex patient demands of rural primary healthcare.

References

  1. The Royal Australian College of General Practitioners. 2011. Available at www.racgp.org.au/whatisgeneralpractice.
  2. The Royal Australian College of General Practitioners. Rural general practice – Definition. 2011.Available at www.racgp.org.au/rural/definition.
  3. Dickinson J, Hickner J, Radford S. The changing characteristics of rural GPs. Aust Fam Physician 1995;24(7):1272–8.
  4. Strasser RP. Attitudes of Victorian rural GPs to country practice and training. Aust Fam Physician 1992;21(6):808–12.
  5. Britt HMG, Valenti L. It's different in the bush'. A comparison of general practice activity in metropolitan and rural areas of Australia 1998–2000. Canberra: Australian Institute of Health and Welfare; 2011.
  6. Lawrance R. What symbolises rural and remote general practice: the practitioners' perspective. Infront Outback, 6th National Rural Health Conference; 2001; Canberra.
  7. Australian Bureau of Statistics. 3218.0 – Regional Population Growth, Australia, 2009–10. 2011. Available at www.abs.gov.au/ausstats/abs@.nsf/Products/3218.0~2009–10~Main+Features~Main+Features?OpenDocument#PARALINK8.
  8. Australian Institute of Health and Welfare. Medical labour force 2009. 2011. Available at www.aihw.gov.au/publication-detail/?id=10737419680.
  9. Humphreys JS, Mathews-Cowey S, Weinand HC. Factors in accessibility of general practice in rural Australia. Med J Aust 1997;166(11):577–80.
  10. Australian Institute of Health and Welfare. Rural Health. 2011. Available at www.aihw.gov.au/publication-detail/?id=6442468150.
  11. Australian Institute of Health and Welfare. Rural, regional and remote health: indicators of health status and determinants of health. 2008. Available at www.aihw.gov.au/publication-detail/?id=6442468076.
  12. Australian Institute of Health and Welfare. Rural health – demography. 2011. Available at www.aihw.gov.au/rural-health-demography.
  13. Australian Institute of Health and Welfare. Indigenous health. 2011. Available at www.aihw.gov.au/indigenous-health.

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