A life of globetrotting has given Professor Hans Nossent keen insight into rural rheumatology.
Professor Hans Nossent has enjoyed an adventurous rheumatology career, globetrotting some of the world’s most remote and beautiful locations.
In an interview with Rheumatology Republic, he shares insights from his journey.
Where have you worked around the globe?
I was trained and worked in the Netherlands and initially worked on multiple islands in the Dutch Caribbean. Then I worked in Tromso, Norway, before moving to Australia about seven years ago. I’m now a rheumatologist at Sir Charles Gairdner Hospital in Perth and do four clinics a year in Kalgoorlie and Carnarvon.
What made you want to practise in so many different places?
I have no idea! The travel bug? Inner unrest? I wouldn’t be able to tell you, so the usual story is going back to The Flying Dutchman. I can’t really explain it any other way.
What’s it like to work in the Caribbean?
The whole Caribbean lifestyle is different from the Australian lifestyle. Lying on the beach just outside the hospital in Curacao and Sint Maarten and having a siesta break in the early afternoon is quite handy for everybody. Everything shuts down. You then get a bit of energy back for the afternoon sessions and work a bit later into the evening when it cools down.
Any similarities between outback Australia and the Caribbean?
Yes, in terms of small communities and limited resources. In terms of people being quite hardy and used to being isolated and not getting a lot of help from outside. So that’s a clear shared cultural perspective.
There’s also a similar sort of Medicare arrangement.
But there’s a difference as well. In the Dutch Caribbean, there are larger private practices for people with health insurance – which means they can access services in the US or in one of the larger hospitals on the other islands – but that’s for more privileged people.
St Elisabeth Hospitaal, St Maarten c1988 
The Caribbean island of St Maarten c1988
What was it like to practise in Norway after the Caribbean?
Norway is a completely different story because it’s a fully funded public health system only. Everybody, every specialist basically, is employed by the hospital. So, there’s no private practice and there are larger hospital departments.
An interesting comparison would be that at Charles Gairdner, where I work. We have one-and-a-half full-time rheumatology positions for a population of 700,000. In Norway, the department where I worked covered a population of 300,000 people and we had eight rheumatologists, which is better than the recommended one specialist per 50,000 population.
What does that mean for your current practice?
At SCGH we have to prioritise very clearly which patients we offer appointments to. Our department would have approximately 5000 appointments a year available based on our staffing budget – which is, of course, completely insufficient to serve the whole population of Northern WA. Our hospital is funded by the state, but outpatient care, which we largely do in rheumatology, is funded by the federal government. So, our hospital isn’t very interested in funding rheumatology.
We even had one CEO of a hospital tell us: “We’re not obliged to have outpatient care.” But especially nowadays, with the biological treatments, we need to see the 1000 patients that we have on biologics at least twice a year. That’s 2000 appointments gone out of the 5000 we are funded for.
That sounds very frustrating.
As rheumatologists, we’re quite used to not being prioritised in many areas of the medical field. There are many studies showing that musculoskeletal conditions affect 10% of the population, and here we are in rheumatology getting 0.5% of the whole budget.
What surprises your city colleagues about the work you do in the outback?
Possibly the lack of resources. It means you have to improvise quite a lot; for example, in terms of imaging facilities. In Carnarvon, the nearest MRI is 400 kilometres away in Geraldton and they fly in sonographers once a month – this means that you can get imaging done but won’t necessarily have the answer at the time you need it. So, you need to go with your clinical best judgment and make a call on the appropriate way to manage these patients’ symptoms.
That said, I feel that clinical examination and acumen has a much larger role to play in whole-patient management than imaging or additional investigations – unless you’re talking very complex cases, such as complex vasculitis, interstitial lung disease or pulmonary hypertension. But you can manage standard rheumatology patients very well in remote communities just by your clinical findings.
What have you learnt from working with First Nations people?
There is a big cultural divide in terms of understanding how the world is. Being a foreigner to the country, it’s an amazing experience to see how their culture is so completely different from that of the Western world.
I’ve met a lot of Indigenous patients who have been fantastic in understanding their disease, and how it has to be managed, and even getting out to their communities and talking to people about how they could improve their health in a similar fashion. That’s a big inspiration.
What do you love about working in rheumatology?
The long-term relationships you build with patients. And the achievements over the past 20 years in being able to relieve symptoms and increase quality of life without much in terms of medication side effects. It’s wonderful to see how people improve nowadays, compared with, say, the early ’80s and ’90s when we gave them high-dose aspirin and poisoned their immune cells with gold injections.
I’m also very interested in autoimmunity and the way autoimmune diseases develop. Why is the antibody formation in one condition different from the antibodies that are present in other conditions? Why is rheumatoid arthritis completely different from lupus, although the abnormalities in the immune system seem to be largely similar? The world of immune studies is fascinating.
Any final words?
I find people in rural areas hardier than people in the cities. I see people in Carnarvon and Kalgoorlie with quite severe disease and they just get on with it, which is quite different to what we see in the city. I think that the spirit of the outback, or being isolated in a small city, and just going on with life in their work and family, is truly inspiring to see.
