Margaret from Morgan’s Lagoon

‘Margaret from Morgan’s Lagoon’ is a case study featured in online modules developed by the Royal Australian and New Zealand College of Psychiatrists (RANZCP).  It explores the options to medical practitioners when a patient presents after clinic has closed for the day.  It features in Module 1: Interviewing an Aboriginal or Torres Strait Islander Patient.

You are about to head to the airstrip after a quiet and unremarkable outreach clinic at Morgan’s Lagoon, your second visit to the community (the first was even quieter). It is 4.00pm and the pilot wants to get off well before last light.

The nurse on duty, Tracy, approaches you and relates that an elderly Aboriginal woman, Margaret, wants to talk to “the head doctor”, adding that she doesn’t think that Margaret has a “mental problem”. She adds that Margaret is a frequent attendee at the clinic, a “big worrier” and that the biggest worry is her adult children. Margaret had been in the clinic earlier in the day, but had not raised anything about mental health issues. Tracy comments that the community had been informed that the specialist was only going to be in the community this day and that Margaret could have come earlier if her issue was important. Tracy kindly offers to “settle her down” instead of seeing you so that you can get into the air early.

Fly in / fly out outreach clinics to remote communities are not ideal means to provide services. For residents of these settings, the alien nature of such practice is compounded by the high turnover of practitioners, particularly when this complex work is allocated to registrars who are necessarily short term. Indeed the same problems bedevil primary care and, in this instance the primary care nurse is herself an agency employee with probably a less than full understanding of local issues and knowledge of community members. It is not surprising that, on your first visit there were few presentations, or that this person has presented late in the day. There may well have been lengthy discussion after your first visit and Margaret may well have been “checking” you out when she came to the clinic earlier in the day. Although Tracy is trying to be helpful while there may well be some pressure because of the approaching last light, allowing Margaret to be put off risks more than missing a mental health issue. It may well also reinforce doubts about the degree to which health care service workers care about community members. Indeed there is a long history in Australia of medical practitioners involvement in discriminatory, race-based practise – for instance in the treatment of leprosy and sexually transmitted infections – the legacy of which remains real in many areas of remote Australia. Even if a consultation with Margaret is necessarily short, it is important as recognition of Margaret’s problems, an affirmation of her needs and as a building block in developing a relationship with this community. Be sure that discussion about you and how you have responded to people’s needs will continue after you have left.