Medical Forum – February 2021 – Public Edition

What the World needs now

Innovations and Trends Imaging, Palliative Care, Metabolics, Tech Trends, Mental Health

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February 2021 www.mforum.com.au

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EDITORIAL BACK TO CONTENTS

Cathy O’Leary | Editor

Brave new world

It feels like I’ve come the full circle, writing this as the new editor after working as a newspaper journalist for decades (I started young!), reporting on all things health and medical.

As much as I loved that job, mainstream media seems to have far less appetite now for what I began my career aspiring to do – providing readers with independent and accurate news and information.

So not surprisingly I feel privileged to have found my way to Medical Forum – filling the big shoes of the multi-talented Jan Hallam and returning to do the journalism that I love best.

It’s appropriate that the first edition for 2021 has a theme of innovations and trends because we have never needed a breakthrough more than now.

And it’s appropriate that the first edition for 2021 has a theme of innovations and trends because we have never needed a breakthrough more than now, to help us claw back COVID-19 which has well and truly overstayed its welcome.

This is the time when the smartest minds need to come together, with party politics and turf wars put to one side, to find an effective and safe suite of vaccines that can steer the world out of the pandemic.

A single vaccine now seems wishful thinking but whatever regime works, it is likely to go down in history as one of the innovations of the century (please disease gods, no more challenges for a while).

But innovations are not just about laboratory breakthroughs. In this edition we have two great examples of thinking outside the box to tackle the complex issues of homelessness and loneliness.

The solution to our state’s homeless is not just about finding bricksand-mortar for this highly vulnerable population. It needs a multifaceted approach and strong political will.

Meanwhile, it’s encouraging that more doctors are signing up to social prescribing to connect their patients with non-health services in the community which – surprise, surprise – can actually improve health outcomes.

Medical Forum is also a fan of some innovation of our own, with the launch of a new weekly e-newsletter this month to keep our readers ‘in the know’ in between our print and digital editions. Welcome aboard.

SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission.

DISCLAIMER Medical Forum is published by Medical Forum WA as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Competition and Consumer Act 2010 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

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MEDICAL FORUM | INNOVATIONS AND TRENDS

FEBRUARY 2021 | 1

CONTENTS | FEBRUARY 2021 – INNOVATIONS & TRENDS

Inside this issue 10 24 14

18

FEATURES

NEWS & VIEWS

LIFESTYLE

10 Election Q&A –

1

54 Perth Festival – Made in WA 56 Motivator

Roger Cook and Zak Kirkup

14 Close-up: Dr Ramya Raman 18 Homeless healthcare 24 Script for life

Editorial: Brave new world – Cathy O’Leary

4 In the news 8 In brief 30 Silky eardrums 45 GP health of the nation 50 Better health oversight needed in mining

52 Mapping health care

Dr Katherine Iscoe

57 Spirit Review: The Gin Republic – Dr Martin Buck The annual Christmas party pictures will be published in the March magazine.

New Year, new cheer...

Check out our new weekly newsletter starting on February 5 for some exciting new wine and entertainment promotions.

The winner of the St Aidan Doctor's Dozen is Dr Suzette Finch.

See page 57 for our first spirits review with gin from the Republic of Fremantle.

CONNECT WITH US /medicalforumwa

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PUBLISHERS

Clinicals

Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au

ADVERTISING Advertising Manager Andrew Bowyer (0403 282 510) andrew@mforum.com.au

EDITORIAL TEAM

5

33

34

Customising cancer treatment Assoc/Prof Kynan Feeney

Innovation and hope Dr Joe Kosterich

Imaging of slipped femoral epiphysis Drs Richard Warne and Michael Mason

37

39

41

Knee OA – Mechanics v Metabolics Dr Daniel Meyerkort

Tech trends in health care Dr Marcus Tan

Keeping physical health in mind Dr Gordon Shymko & Louise Dobson

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45

49

BerlinCase Viewer: Covid-19 app Dr Yuranga Weerakkody

Current trends in palliative care

By Dr Logan Shemer

Voluntary Assisted Dying – what are the choices?

Dr Peter Beahan & Dr Richard Lugg

Editor Cathy O'Leary (0430 322 066) editor@mforum.com.au Journalist Dr Karl Gruber (PhD) (08 9203 5222) journalist@mforum.com.au Production Editor Ms Jan Hallam (08 9203 5222) jan@mforum.com.au Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au

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Medical students’ mental health Dr Helen Wilcox

WA disability plan champions inclusion Julie Waylen

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IN THE NEWS

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Crunching the data A deal between Perth medical researchers and supercomputers company DUG Technology promises to give extra data crunching capability that could speed up medical breakthroughs.

The partnership with the Harry Perkins Institute will provide researchers with the computer and storage capability needed to conduct analysis using genomics and other bioinformatics heavy technologies. Bioinformatics combines biology, computer science, information technology, mathematics and statistics to analyse and interpret biological data.

These high-performance computers will look for disease mutations and can help researchers analyse the behaviours of a particular cell type that may be causing disease or enable them to see the range of cells present in a patient’s tumour. The deal was welcomed by the institutes' associate director of research, Professor Alistair Forrest, who said access to additional high-performance computing significantly increased research capacity.

Predicting a killer A study led by Edith Cowan University has shown the build-up of calcium in a major artery outside of the heart could predict the risk of heart attack or stroke. The research, published in the Journal of the American Heart Association, could help doctors identify people at risk of cardiovascular disease years before symptoms appear. Analysing 52 previous studies, the international team of researchers found that people who have abdominal aortic calcification (AAC) have a two to four times higher risk of a future

cardiovascular event. The more extensive the calcium in the blood vessel wall, the greater the risk of future cardiovascular events, while people with AAC and chronic kidney disease are at even greater risk. Factors contributing to artery calcification include poor diet, a sedentary lifestyle, smoking and genetics. Associate Professor Josh Lewis from ECU’s School of Medical and Health Sciences said AAC was often picked up incidentally in routine tests such as lateral spine scans from bone density machines or x-rays. “This can signal an early warning for doctors that they need

Let’s talk about it Australian palliative care specialists are trying to take the taboo out of what many people still see as a dreaded topic of conversation – death. Teaching more positive ways to address this difficult conversation is the focus of a paper in PLOS ONE journal by palliative care experts across Australia. Led by Flinders University, researchers surveyed almost 1500 people on the use of language to express their feelings and insights into death and dying.

They found that a reluctance to think, talk or communicate about death was even more pronounced when people dealt with others’ loss compared to their own. However, either way, people tended to frame attitudes and emotions in a sad and 4 | FEBRUARY 2021

to investigate and assess their patient’s risk of heart attack or stroke,” he said.

Hive of activity Select patients at Royal Perth and Armadale hospitals will be watched by a second set of eyes, as part of a $22 million service to remotely monitor hospital ward beds. The Health in a Virtual Environment (HIVE) patient monitoring innovation operates inside the East Metropolitan Health Service Command Centre and uses artificial intelligence and technology to continuously track and monitor a patient’s condition. HIVE clinicians are alerted when a patient displays early signs of clinical deterioration, and can respond with the wardbased clinical teams using twoway audio and video. This year, HIVE will monitor 50 beds across 11 different wards and will be staffed by one clinician and two nurses continuously, operating 24/7.

Indigenous health boost negative way. Participants were then enrolled in a six-week online course course developed at Flinders to encourage open conversation about death and dying. Analysis of the emotional content of the words used by the participants showed that by the end of the course they were able to use “more pleasant, calmer and dominating (in-control) words to express their feelings about death.”

New national accreditation standards to boost Indigenous knowledge in psychology education aim to create a more culturally aware and responsive mental health workforce. The standards, resulting from a research project led by the University of Western Australia, will require Indigenous

continued on Page 6

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Case Study: Comprehensive pathology, histopathology and molecular typing in customising cancer treatment Clinical Features A 40-year-old female presented to the ED with intermittent abdominal pain of two to three months duration, as well as PR and PV bleeding. Her past medical history included an appendectomy two years prior, and primary hyperparathyroidism. She had no family history of malignancy. On examination, the patient had a tender abdomen with absent bowel sounds.

The patient’s initial laboratory test findings including full blood count, renal function tests and liver function tests were within normal limits, However, her CA125 was raised at 141KU/L. Chest x-ray showed a right-sided basal pleural effusion with right basal pulmonary opacification. CT imaging of the abdomen and pelvis revealed a large, predominantly cystic, mass lesion in the central pelvis measuring 13.5cm x 9.3cm x 16.4cm, appearing to originate from the left ovary, with features highly concerning for ovarian carcinoma.

There were significant ascites and infiltration of the omentum with features concerning for metastatic disease. The sigmoid colon featured an abnormal thick-walled segment, approximately 5cm in length. There were at least two ill-circumscribed lesions in the liver (10mm and 7.5mm) which were non-specific but concerning for the presence of liver metastases.

Pathological Findings The patient underwent an ultrasoundguided aspiration of ascitic fluid, which was found to be negative for malignancy on cytological examination.

She subsequently underwent surgery, which included a total abdominal hysterectomy/bilateral salpingo-oophorectomy, anterior resection, omentectomy and right hemicolectomy. At the time of surgery, the patient was noted to be free of any macroscopic peritoneal disease.

By Associate Professor Kynan Feeney MBBS (Hons), MPH, FRACP Assoc/Prof Feeney is the head of cancer services at SJOGH Murdoch. His clinical interests are in breast, gastrointestinal cancer and melanoma. He is principal investigator of clinical trials investigating new treatments spanning breast, melanoma, colon, gastric, esophageal, lung, bladder, pancreas and renal cancer.

The anterior resection revealed presence of a 35mm circumferential and partly stenosing tumour in the sigmoid colon.

The histopathological findings revealed a low-grade (moderately differentiated) adenocarcinoma of the sigmoid colon, penetrating the visceral peritoneum (pT4a), exhibiting lymphovascular and perineural invasion, intermediate tumour budding, and metastatic involvement of lymph nodes. The resection margins were clear of tumour.

Metastatic disease was evident on the serosal surface of the uterus and left ovary, while both the omentum and right hemicolectomy showed no malignancy. Immunohistochemistry for mismatch repair proteins showed no loss of staining for MLH1, MSH2, MSH6 and PMS2, indicating a normal pattern of staining.

Molecular analysis did not detect any mutations in the KRAS, BRAF, NRAS, PIK3CA, PTEN or AKT1 genes.

A peritoneal fluid sample was sent for cytological evaluation and while no overtly malignant cells were seen in the smears, the cell block contained occasional, better-preserved cells with hyperchromatic nuclei and irregular nuclear contours. These cells showed positive immunohistochemical expression for CK20 and CDX2, in keeping with involvement by metastatic adenocarcinoma of primary gastrointestinal origin.

Post-surgical management Post-surgical PET/CT imaging for staging purposes showed at least two FDG-avid hepatic metastases

involving segment IV, with other low-density lesions seen on prior CT imaging not appearing FDG-avid. The right-sided pleural effusion was noted to have reduced following drainage.

Tiny nodules were seen in the right lung but no definite pulmonary metastatic disease was demonstrated.

Subsequent MRI imaging of the liver showed five metastatic deposits in segments 3, 4 and 7, ranging from 2mm to 23mm, and a prominent inferior right internal mammary chain node.

The patient recovered well from her surgeries and underwent a six-month course of a combination of FOLFOX chemotherapy and Cetuximab monoclonal antibody treatment with plans for repeat staging scans at three and six months.

Post treatment PET/CT imaging showed complete metabolic response to therapy with the two previous FDGavid hepatic metastases no longer avid, and resolution of the right pleural effusion, internal mammary lymph node and tiny pulmonary nodules.

Overall, the patient has had an excellent response with a prognosis likely measured in years of excellent quality of life and disease control.

This demonstrates the importance of knowing the primary histology of a cancer which can then guide subsequent appropriate molecular testing. In this case, the patient’s extended RAS genotype was wild-type and predicted an excellent response to chemotherapy and EGFR-inhibitor monoclonal antibody therapy.

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continued from Page 4 knowledge be included in all levels of psychology education and training. It is also hoped this will lead to an increase in the number of Indigenous psychology students.

Lead researcher and Aboriginal psychologist UWA’s Professor Pat Dudgeon is working with partner universities to develop curriculum resources and educational materials and support professional development for academics teaching psychology.

New chief for HSS The WA Government agency which manages information and communication technology for the state’s public hospitals has a new chief.

Health Support Services has appointed Christian Rasmussen as Chief Information Officer. Mr Rasmussen is highly experienced in digital transformation, organisational change management and technology leadership. He was previously CIO at Lotterywest and will start with HSS on February 15.

Mr Rasmussen will be responsible for leading the modernisation of ICT at HSS and across the WA health

system. HSS supplies IT, purchasing and supply, workforce and financial services to WA’s public health care system and its 45,000 employees.

Tick for female testosterone Women’s health experts have welcomed the registering of a female testosterone cream on the Australian Register of Therapeutic Goods. Perth-based Lawley Pharmaceuticals has been given the tick of approval for AndroFeme, which is used to treat postmenopausal women experiencing low sexual desire with associated personal distress, also known as hypoactive sexual desire dysfunction or HSDD. An estimated one in three Australian women aged 40 to 64 are estimated to experience HSDD. Association Professor John Eden from the Women’s Health and Research Institute of Australia said that while natural oestrogen and progesterone products had been available for several years, only now did women have access to a female-appropriate testosterone approved by the TGA.

GPs not so wounded

the taskforce’s final report, after reviewing more than 5700 MBS items over the past five years. The ban on levying additional fees in bulk-billed consults has long been a sore spot with many GPs. The taskforce’s recommendation to the Federal Government argues wound care consumables should be covered under the same Medicare exemption used for vaccines.

Previous research has found GPs often lose money every time they provide a dressing.

Sobering limits Cancer Council Australia has backed guidelines which recommend people drink less to reduce their health risks from alcohol. Updated guidelines by the National Health and Medical Research Council recommend that in order to reduce the risk of harm from alcohol-related disease, Australians should consume no more than 10 standard drinks a week. Clare Hughes, who chairs the CCA’s nutrition and physical activity committee, said the evidence was clear that drinking was not good for your health.

Calls to hose down fake news

GPs may be finally allowed to charge for dressings given to patients in bulk-billed consultations, after the MBS Review Taskforce called for a rule change. It is one of more than 1400 changes in

The Consumer Healthcare Products Australia has backed

continued on Page 8

Interns find a home Twelve medical interns have started work with St John of God Health Care in WA, making up the second batch of newly-minted doctors to be directly employed by the group. Since last year, SJOG has been accredited to run its own medical intern program, allowing local medical graduates to access employment in a combined public and private setting. This year’s interns will be based at St John of God Midland Public Hospital and will also rotate to St John of God Subiaco Hospital. SJGHC CEO Dr Shane Kelly said there had been positive feedback from the inaugural interns about the teaching and training they received, despite the challenges caused by COVID-19.

6 | FEBRUARY 2021

Midland public hospital CEO Michael Hogan said over the next 12 months, the interns would gain experience across medical specialties including general surgery, emergency medicine, general medicine/acute aged care, paediatrics, intensive

care and neurology/stroke. “Since the hospital opened in 2015, we have supported more than 1290 medical interns, resident medical officers and medical registrars,” he said.

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IN THE NEWS

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RACGP WA winners for 2020 are: GP of the year Dr Ramya Raman; Supervisor of the year Dr Andrew Png; GP trainee of the year Dr Anastasia Isakov and the General Practice of the Year was Fulham GP. Telethon Kids Institute paediatric infectious disease expert and clinician-scientist A/Prof Asha Bowen has won the Eureka Prize for Emerging Leader in Science.

The WA Health Department is reviewing its Disability Access and Inclusion Plan 2020–2025 and is calling for comment and feedback on the its key strategies over the next five years.

Four advocates for LGBTIQ+ health have been appointed to WAPHA clinical councils or committees. Dr Belinda Wozencroft to Perth North Metro Clinical Council, Sandra Norman to Perth North Metro Community Advisory Council, Dr Andrew Wenzel to Great Southern Regional Clinical Committee and Bella Broadway to Perth South Metropolitan Community Advisory Council.

The 2020 Department of Health/Raine Medical Research Foundation Clinician Research Fellowship recipients are Osborne Park Hospital physiotherapist Jess Nolan, East Metropolitan Health Service staff specialist Dr Stephen Macdonald, and Perth Children’s Hospital Consultant Respiratory and Sleep Paediatrician Dr Mon Ohn. Dr Michael Gannon is MDA National’s new president.

IN THE NEWS

continued from Page 6 calls by doctors for strong government push-back on health misinformation peddled on the internet and social media. The Australian Medical Association wants the Federal Government to invest in ongoing advertising to challenge fake medical news and conspiracy theories, particularly about COVID-19. AMA president Perth-based Dr Omar Khorshid said people were increasingly turning to social media to learn about healthy choices but the internet had the potential to significantly magnify health misinformation campaigns.

CHP Australia has previously advocated for the development of strong measures to combat health misinformation, as well as increased and ongoing investment to improve Australia’s health literacy.

Higher CO2 may risk young lungs Perth researchers have helped in a world-first study which shows increased atmospheric CO2 levels could be damaging young lungs.

Their mice-based work looked at the direct health impacts of predicted carbon dioxide levels and found worrying results which they said highlighted the urgent need for more research. Researcher A/Prof Alexander Larcombe, of the Walyan Respiratory Research Centre,

said humans had evolved to breathe atmospheric carbon dioxide at about 300 parts per million.

“Current levels are just over 400ppm, and climate change modelling predicts that within our lifetimes it is likely to increase to about double that,” he said.

The study was conducted in mice, which are naturally able to better tolerate increased CO2 levels due to their burrowing habits. It found that exposure to about 900ppm of CO2 had a direct impact on both the lung function and structure of mice that had been living in that environment throughout pregnancy, early life, and into early adulthood.

The lungs of adult mice not exposed to elevated CO2 in early life did not show signs of impairment, which the researchers believe was because their lungs were fully formed before being exposed to the higher CO2 levels.

Study co-author UWA researcher Dr Caitlin Wyrwoll described it as important work because it offered the first insight into the fact that higher levels of CO2 exposure were affecting the health of developing lungs.

“The lungs are the first organs that we would expect to see affected, and it gives us a clue that other systems in the body might also be affected,” she said.

Welcome to the Weekly Forum Medical Forum has its own news with the launch this year of the Weekly Forum, an e-newsletter which will land in subscribers’ inbox first thing every Friday morning from February 5.

It’s designed to keep you up-to-date with the very latest health and medical news from our state and around the world, so you and your patients stay informed.

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Q&A

Election Q&A The people of Western Australia go to the polls on Saturday, March 13, to elect a new state government.

The incumbent Health Minister (and Deputy Premier), Roger Cook, and the opposition health spokesman (and leader of the parliamentary Liberal Party) Zak Kirkup address the pressing health issues that face WA in 2021 and beyond.

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CLOSE-UP

ROGER COOK

ZAK KIRKUP

MF: COVID-19 had an enormous impact on the WA community, particularly health services, in 2020.

How confident are you that the state can manage the pandemic in 2021?

MF: COVID-19 had an enormous impact on the WA community, particularly health services, in 2020. What would be your priority in managing the pandemic in 2021?

RC: I am quietly confident, but we must be cautious and vigilant about the year ahead. The fact we have been regarded as one of the world’s safest places in 2020 is testament to the quality of the teamwork and decisionmaking under pressure. This extends right across the political and health sectors, from the outstanding work in our hospitals through to the quarantine hotels and beyond. It has not happened by chance. The expertise honed during 2020 will continue to evolve and adapt during 2021 for whatever new challenges come our way.

ZK: A Liberal government will continue to back the Chief Health Officer’s advice to help keep West Australians safe from COVID-19. We will make sure we follow the expert advice and go a step further and actually release it publicly. West Australians have done all the heavy lifting and have made so many sacrifices during the pandemic to keep WA safe, so they deserve to know the exact details of the reasons why the government is making its decisions.

MF: If effective and safe COVID-19 vaccines are available, what is your view on making them mandatory for all Western Australians, or in some specific settings?

RC: We strongly encourage people who are eligible and able to, to receive COVID-19 vaccines that are approved by the TGA. MF: COVID-19 aside, what do you consider will be another major priority for the health portfolio in 2021?

One of the most difficult challenges of 2021 will be mental health. We know this is not just specific to WA. We are seeing a sharp increase in both the number and acuity of cases and patients are also younger. The priority is ensuring that we have the right balance and resourcing in mental health services across the WA community. We need to make inroads in preventing mental illness and providing the right level of care in the most appropriate setting.

MF: Do you support the push by WA pharmacists for a greater role in administering vaccines, including a COVID-19 vaccine?

RC: There is a role for pharmacists administering some vaccines where they are on the lower spectrum of risk, as they already do. With respect to COVID-19 vaccines, as we better understand the complexity and precautions required to safely administer them, we can determine any role that pharmacists may or may not play.

MF: Voluntary assisted dying legislation will come into effect in July. What do you say to people who still have strong reservations about its potential for harm or misuse?

RC: The Voluntary Assisted Dying Act 2019 includes rigorous criteria and safeguards throughout the process that prevent a person from being coerced or manipulated into engaging in the voluntary assisted dying process. In addition, the Act establishes a statutory board to ensure proper adherence and to recommend safety and quality improvements. The primary purpose of the legislation is a compassionate one, of giving people who are at the end of their lives the right to choose the timing and circumstances of their death, whilst ensuring strong safeguards against any possible undue influence or coercion.

MF: If effective and safe COVID-19 vaccines are available, what is your view on making them mandatory for all Western Australians, or in some specific settings?

ZK: The successful rollout of COVID-19 vaccines will require time, communication and trust. We will make all decisions based on what would undoubtedly be a nationally consistent approach, informed by the advice of the Chief Health Officer here in WA. MF: COVID-19 aside, what do you consider will be another major priority for the health portfolio in 2021?

ZK: We need to tackle ambulance gridlock across our state hospitals. We have record levels, which is putting the lives of West Australians at risk. Health professionals are telling us that our health system would not cope with an outbreak of COVID-19 in WA, which is alarming given the government has had nine months to develop a robust plan to protect the State. It proves that under its watch our health system has deteriorated and is now in crisis. Ambulance gridlock is getting worse and the Health Minister needs to stop making excuses and fix it now. Our doctors and nurses do an amazing job, and it is appalling that they don’t have the resources they need to keep West Australians safe. The priority should be to make sure every single ward is open and that every single bed is available. Our health system needs to be better resourced, starting with expansion of our emergency departments.

MF: Do you support the push by WA pharmacists for a greater role in administering vaccines, including a potential COVID-19 vaccine?

ZK: All decisions in relation to the rollout of any vaccine will be dealt with in accordance with the advice of the Chief Health Officer.

MF: Voluntary assisted dying legislation comes into effect in July 2021. What is your personal view on VAD? ZK: I was initially quite hesitant about this legislation because of not only the issue but also the significant undertaking with WA being only the second state in the federation to implement assisted dying as an option of end of life for the terminally ill. However, after speaking to thousands of people within my district and going over the legislation a number of times independently, it became

continued on Page 13

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WA Rural Health Conference 2021 LESSONS LEARNT FROM PAST DISASTERS

27 and 28 March 2021 | Perth Convention and Exhibition Centre

FIRES | PANDEMICS | EARTHQUAKES | FLOODS

l PRESENTATIONS

l CLINICAL UPDATES

l WORKSHOPS

l CONCURRENT SESSIONS

l CASE STUDY LEARNING

The 2021 WA Rural Health Conference will focus on learnings and effects from disasters that have impacted Australia and the world. It will explore how we can prepare for future adversities, focusing on dealing with the aftermath of natural disasters such as bushfires, floods and COVID-19.

Hear from ASSOCIATE PROFESSOR RUTH STEWART National Rural Health Commissioner

The role of rural health professionals in disaster preparedness

COMMISSIONER DARREN KLEMM

RABIA SIDDIQUE Australian Criminal and Human Rights Lawyer

Fire and Emergency Services Commissioner

Emergency management in rural Western Australia

Leading under pressure

Experience •

An outstanding line-up of keynote speakers

•

Rural Paediatrics Forum and Paediatrics Scientific Meeting

•

Networking opportunities with health professionals

•

Rural Psychiatry and Mental Health Forum

•

Clinical upskilling sessions

•

Long Service and Excellence Awards ceremonies

•

Pre-conference REACT+ and Toxicological Emergencies workshops

•

Special program for medical students and junior doctors

•

GP Obstetrics Think Tank

•

Fantastic family program

•

Generous travel support

REGISTER NOW!

TO FIND OUT MORE, OR TO REGISTER VISIT

ruralhealthwest.eventsair.com/2021-wa-rhc

For further information, contact the Events team on T 08 6389 4500 | E warhc@ruralhealthwest.com.au This education event is proudly delivered by Rural Health West in partnership with WA Country Health Service through the Better Medical Care Initiative 12 | FEBRUARY 2021

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Q&A

Election Q&A continued from Page 11

MF: Ambulance ramping at WA hospitals hit high levels in 2020, despite relatively stable patient demand. How can this be turned around?

RC: Our public emergency departments are under pressure currently, with higher than usual patient demand. Compared to the same three months last year we had an extra 3500 patients arrive at EDs. There has been an increase in mental health presentations, an increase in acuity and an increase in respiratory illness more common in winter months. As a result, the Department of Health has met with key stakeholders including St John Ambulance and is implementing a number of strategies. These include an extension of health liaison managers to assist patient flow, joint secondary triage initiatives, mental health peer support workers deployed in EDs and mental health community outreach to mental health patients to help prevent readmission via ED. Emergency departments are for emergencies. Recently, I was told about a presentation at a busy ED for a repeat prescription, which is a good example of why we are rerunning our advertising campaign for Urgent Care Clinics. In addition, 77 new ED beds are either under construction, or soon will be.

MF: Some health experts are worried that COVID-19 has created a ‘syndemic’ or perfect storm for rising rates of non-communicable diseases such as obesity, diabetes and heart disease. How can this be addressed?

RC: Non-communicable diseases have and will continue to be an issue of great concern. In addition to many health promotion and primary prevention interventions that the government currently employ and looks to expand, there is extra focus on providing support for people with chronic conditions to access care in the community so they can manage their health without needing a more intensive level of care.

MF: Mental health problems are also on the rise. How do you think this is best tackled?

RC: The WA Government has invested more than $1 billion in mental health and AOD service delivery but there is more to do. Prioritisation of investment will be focused on the areas and services of greatest need first as determined through previous consultations and reports. The WA State Priorities Mental Health, Alcohol and Other Drugs 20202024, highlight our immediate areas of focus and will form the priority work of the Mental Health Commission, Department of Health and health service providers.

quite obvious that the overwhelming majority of people in my community support voluntary assisted dying.

Accordingly, I supported the voluntary assisted dying legislation.

MF: Ambulance ramping at WA hospitals hit high levels in 2020, despite relatively stable patient demand. If you were Health Minister, how would you address this?

ZK: We need to open every ward and make every bed available in our state’s hospitals. We will also acknowledge the issues facing our state’s hospitals and not continue to make excuses and fail to substantially address the problem like the current government. The continual ignorance of the WA Health Minister on this issue is a shame on the government. At a time when we need leadership, the government has gone missing.

They are putting the lives of West Australians at risk. Our health system is in crisis now.

MF: Some health experts are worried that COVID-19 has created a “syndemic” or perfect storm for rising rates of non-communicable diseases such as obesity, diabetes and heart disease. How can this be addressed?

ZK: We need to double-down on our community and public health measures and campaigns to help respond to these concerns.

MF: Mental health problems are also on the rise. How do you think this is best tackled?

ZK: There needs to be a greater focus on community and preventative mental health services, and the government needs to fund these important areas accordingly. For example, the Auditor General last year revealed that investment in prevention of mental health illness had dropped to just 1% instead of the 6% recommended in the Better Choices. Better Lives: Western Australian Mental Health Alcohol and Other Drug Services Plan 2015-2025.

We will be releasing our mental health policy and it will be comprehensive and a key part of our campaign going forward.

MF: Do you support recent decisions by the state government to move away from the privatisation of services in the hospital sector, such as Serco’s contract at Fiona Stanley Hospital?

ZK: Once the government has made a decision in relation to commercial operations of any hospital, we won’t be changing positions. More important than anything else is the certainty and continuity of decision making in WA when it comes to our health system.

MF: What is the thinking behind the WA Government moving away from the privatisation of services in the hospital sector?

MF: What is an area of the health portfolio that you would personally feel keen to make your mark on, and why?

RC: We want to put public health in public hands to put patients first. In 2020, we brought some Fiona Stanley Hospital services back into public hands from Serco, and now we are looking to end privatised public services at Peel Health Campus. This will turn Peel into a truly regional hospital with extra benefits and services that the public system can provide.

ZK: We need to address ambulance gridlock and tackle the mental health issues in our community properly.

These are serious issues which the government has neglected. We need to acknowledge these concerns and do something substantial to make them right.

MEDICAL FORUM | INNOVATIONS AND TRENDS

FEBRUARY 2021 | 13

CLOSE-UP

GP – working with the whole person Dr Ramya Raman is a GP who loves connecting with her patients to nurture trust for their ongoing care and a lot of people are taking notice.

Dr Ramya Raman regularly feels humbled to care for people and to care for generations of the same family. As a GP at Skye Medical in Armadale, Ramya has embraced specialising in general practice because she loves the variety of the work and the connection to the community it creates.

“People bring their kids to see you and you become part of their family story, and that’s a special relationship and a level of trust they give you,” she says.

As an only child born to Indian parents who were posted around the world because of her father’s work in academia, Ramya considers herself a country girl after moving to Dubbo in New South Wales and spending her high school years in the town of Orange. She completed her undergraduate Bachelor of Social Science at Charles Sturt University before moving to Perth to complete her medical studies at the University of Notre Dame.

Ramya’s mother is an alcohol and drug counsellor, which is what piqued her interest in the health field.

Childhood inspirations “My interest in medicine was also triggered by going to a country school where not a lot of students showed interest in the area at the time. My dad noticed this interest and gave me the biography on Dr Ida Skudder. It was an inspirational story – an American missionary, she was the first female practitioner who built a medical college for women in India,” she said.

“Skudder worked against a lot of gender resistance in the mid to late-1800s.

Her having an Indian heritage was a real role model for me and showed me that medicine was a possibility. She has been my inspiration and fire for doing medicine. I have to thank my dad for that book.”

Curious about biology and how the body works as much as she is about the human condition, Ramya considers medicine a profession which offers both stimulation and the chance to build relationships with people.

“That’s what I’m really interested in. It’s probably why I’ve chosen general practice, so I can build those long-term relationships with people, which is a privilege. A GP in primary care helps build continuity and allows you to engage with people before a health issue becomes a problem.”

She recalls working with a GP in rural New South Wales who looked after a 14 | FEBRUARY 2021

MEDICAL FORUM | INNOVATIONS AND TRENDS

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Ara Jansen reports

CLOSE-UP could just come in and say hello, which is wonderful.”

Ramya joined the Armadale practice 18 months ago and many of her patients have moved with her. She’s enjoyed being able to have that continuity of care alongside meeting new patients.

“In terms of connection, it’s an extremely rewarding profession and my biggest driver as a GP is to be able to make a difference to people’s lives and to do that at a grassroots level in the community, treating kids through to adults.

“I enjoy the variety of having the opportunity to see patients of various ages and cultural backgrounds. No two days are the same.”

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The use of telehealth consultations has understandably risen greatly over the past year for Ramya and her colleagues. It has been a huge learning curve in terms of diagnosing as well virtual and online communication and connection. community of about 3000 people and had been doing so for nigh on 40 years.

“I thought that was amazing and nice to have that continuity of care at a family level, seeing someone through from birth to later in life.”

That level of comfort and assurance has gone a long way, especially at the start of COVID, when numerous patients came in to discuss issues such as whether to send their

kids to school. She says it puts GPs in a challenging situation to try and answer these types of questions beyond playing the role of providing medical advice.

Personal touch “As GPs you are a trusted source of information to parents and their families. During COVID, with some of my elderly patients, they just needed to come and see someone, and connect with a real human.

They told me they felt like they

“It’s going to have a huge impact on the way the GP system works.

It has been a long time coming and has its drawbacks as there are certain things you need to do in person, but there’s still a lot of work we can do this way. Hopefully, it also makes doctors more accessible to more people.”

Ramya has a special interest in women’s health and her patients come from diverse cultural backgrounds, something which she can relate to. Particularly for women, who for various reasons, culturally or otherwise, feel uncomfortable with a male doctor.

Hard questions “I’ve also done extra work in the area of family and domestic violence, trying to make women and men aware of it and being available to approach it. The numbers have gone up, particularly in the past year, and people still don’t know how to talk about it,” she said.

“That’s where relationships with patients is particularly important.

When you know a family, it gives insight into certain things going on. It makes it a little easier to navigate through and break the Ramya and husband Surakshan

MEDICAL FORUM | INNOVATIONS AND TRENDS

continued on Page 16

FEBRUARY 2021 | 15

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GP – working with the whole person continued from Page 15 ice with a patient. It gives women the opportunity to come and talk about it and for me to ask the right questions.

“I teach and supervise medical students from Notre Dame and these clinical encounters are the best way to show students how we approach delicate topics such as domestic violence in clinical practice.”

She suggests using opportunities like postnatal checks as a chance to gently find out how things are going at home. Who is home with the patient? Who is helping?

As part of last year’s postponed World Organisation of Family Doctors (WONCA) conference in Sydney, Ramya had planned to present a workshop on how doctors deal with the fourth trimester (a newly minted phrase for the three months after the

The Skye Medical team

baby is born). Hopefully, they can resubmit it to the WONCA World Conference slated for November.

may be able to see things as they are, and you can explore and work through them together.

“Women at this time can present with mental health concerns and physical issues but they can be physical, verbal, emotional or even financial. A GP’s role is really important at this time. When you’ve built up a trusting relationship, they

Next gen “These issues don’t necessarily present in a standard way. I’m hoping the workshop will be able to generate some insightful discussion to bring back to use here. I hope

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CLOSE-UP to use these in teaching sessions for my GP registrars in training at WAGPET and my students at Notre Dame.”

When she’s not hard at work, Ramya is slightly obsessed with recreational cycling, either out on the paths or enjoying her favourite television shows while pedaling a stationary bike. She also loves to dance and is a trained Barathanatyam dancer, though it has been a while since she danced.

Barathanatyam is a major form of Indian classical dance hailing from the country’s south and is one of its oldest.

She also enjoys flying with her husband, Surakshan, a product manager and private pilot. Together they also indulge their love of food by eating out around Perth. If it’s outdoors, even better.

In September, Ramya received the City of Fremantle Aspire Award, which offers a $5000 scholarship for personal and professional development towards an overseas conference. Thanks to nominations from her colleagues at Skye Medical, she was also named 2020 Western Australian GP of the Year

Ramya in full Barathanatyam dress

by the Royal Australian College of General Practitioners.

“It’s a huge honour and I’m grateful to my colleagues and the patients who nominated me. I’ve been incredibly lucky to have such a supportive family and colleagues, all of whom support my passion as a GP and in medical education.

“The way primary care is rapidly evolving thanks to technology – which has been particularly accelerated through COVID – there’s lot of space to contribute and participate in the journey.

“Teaching really helps with clinical practice. Teaching, writing and learning keeps you up to speed with new things, which I can use in my practice and as examples for my registrars and students.

Using clinical cases is immensely powerful and much more engaging than ‘death by PowerPoint’. It also forces students to work through something and figure out all the things that can happen.”

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FEBRUARY 2021 | 17

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FEATURE

Health care and the homeless Health care for the state’s homeless people has never been more critical.

Jan Hallam reports Pictures: Tony McDonough

18 | FEBRUARY 2021

MEDICAL FORUM | INNOVATIONS AND TRENDS

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FEATURE

Announcements of big government spending projects have become a regular occurrence in these COVID-19 times and as the state gears up for an election next month, the money is flying around from both ends of politics.

In health there has been promised funds by the incumbent government for a range of infrastructure and equipment projects, many in regional areas, mental health and research.

The $319 million social housing economic recovery package (SHERP), while not running through the WA Department of Health books, is expected to have longterm positive health impacts for some of the state’s most vulnerable citizens.

The Federal Government’s substantial increase in the Job Seeker payment and the Job Keeper subsidy have been credited for keeping a lid on the unemployment and homeless rates but there is a lot of breath-holding in the community sector as these supports are peeled back in the next couple of months.

Homelessness and rough sleeping in the CBD found controversial prominence during the Perth City Council election campaign in October and, in November, Noongar community leaders and activists marched on Parliament House demanding action on the availability of public housing and the plight of those sleeping rough.

Nowhere to go Tent cities have sprung up in the Perth CBD and Fremantle’s Pioneer Park, highlighting the urgent need for accommodation for thousandplus people.

Both sides of politics have pledged action.

For the medical and social support organisations that know this space best, they are bracing for what they expect will be a rocky 12 months to come.

One person who understands well the precariousness of the current situation is Dr Andrew Davies, who leads the Homeless Health Care (HHC) team and is also an integral part of the RPH Homeless Team.

In February 2019, UWA published its evaluation of the first two

and half years of the RPH team’s operations. It reported that in that time it had provided 2486 separate consultations during 1812 episodes of care to 1014 patients. The report provides a grim snapshot into the lives and health of people who are living rough on the streets.

“The majority of these patients were not known to HHC prior to their Homeless Team contact, demonstrating this cohort’s disengagement and lack of access to primary care in the community,” the report said.

Other statistics showed that patients had an average age of 44 at their first contact with the service and 86% of them were Australian born. Patients who identified as Aboriginal and/ or Torres Strait Islander were overrepresented compared to the general population, accounting for 29% of patients seen by the Homeless Team.

The report flagged that 73% of patients at first contact with the team were rough sleeping: “For the subset with self-report VISPDAT (Vulnerability Index Service Prioritisation Assistance Tool) data, it was found that more than 70% of patients scored above 10 indicating very high levels of vulnerability amongst the cohort.

MEDICAL FORUM | INNOVATIONS AND TRENDS

Multi-morbitities “Poor health and multi-morbidity are commonplace…[with] health conditions affecting these patients often exacerbated by their experience of homelessness. The most common physical, psychiatric and alcohol and other drug (AOD) related pre-existing conditions upon first contact with the RPH Homeless Team were hepatitis B and C (28%), depression (26%) and methamphetamine use (34%).”

Dr Andrew Davies has been caring for the Perth CBD’s rough sleepers since 2004 and his fledgling Mobile GP service began clinics in 2008 at drop-in centres around the city.

As the years have rolled on and the demand for GP and community nursing has increased, Andrew has broadened the scope of the practice to include a transition clinic and the work on the RPH team.

The RPH team, which is led by emergency medicine specialist Dr Amanda Stafford, is based on a program that has been implemented in 11 hospitals in the UK. Here, HHC GPs, nurses and caseworkers link homeless patients who attend hospital with primary care health services as well as community support and housing continued on Page 20

FEBRUARY 2021 | 19

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FEATURE

20 | FEBRUARY 2021

MEDICAL FORUM | INNOVATIONS AND TRENDS

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FEATURE

Health care and the homeless continued from Page 19 services. The idea, of course is to address their social needs alongside their health issues.

It is an opportunity for Andrew and the HHC to make contact with people who can so easily become lost in the bustle and carelessness of the CBD. The pandemic has given policy makers heightened awareness of the precariousness of these people's lives. Andrew’s team has been engaged to expand the service with extra outreach services having doctors and nurses accompany outreach workers on their rounds through the streets and to visit people newly rehomed.

Andrew said the outreach work was proving to be particularly useful.

“We are so lucky that one of the outreach workers in this area is indigenous and knows everybody on the street, so we are getting past engagement problems just by association.

“These visits have been a good way for us to see some people who just don't come in for appointments.

The project has been COVID funded and UWA is evaluating it.

I'm looking forward to seeing how that goes and that the evidence shows that it’s reducing people's hospital presentations as we hoped.”

Housing shortage Housing may be a big part of the solution, but it is not the only element for a successful transition from homelessness to homed.

“Those who have been rehoused in individual housing still have all the health issues and problematic relationships with services, so this visiting service is another piece of the puzzle that creates more options for homeless people to access primary health care.

The West Leederville transition clinic still accounts for about half of HHC’s workload and it offers more discreet general practice for people who are homeless or housed

and who just can't negotiate the mainstream.

Andrew said mental health and drug and alcohol conditions were the main health problems facing homeless people.

“Until about a year ago, what we were seeing most was alcohol dependence. Now meth has finally filtered through into homelessness more, but mental health is the most common – and that means all mental health problems, particularly trauma-based issues.

“The public mental health system tends to deal with psychosis and

MEDICAL FORUM | INNOVATIONS AND TRENDS

not much else. So, depression and anxiety and PTSD often fall through the gaps and they end up coming to see us.

“We have upskilled in these areas, but GPs in general have been doing that for years. The physical health issues are mainly complications of drug and alcohol use – it could be anything, but hepatitis C is probably the most common.

“The new direct-acting antivirals are absolutely fantastic – they have made such a difference.”

continued on Page 22

FEBRUARY 2021 | 21

FEATURE

Health care and the homeless continued from Page 21 With significant shifts in government funding and policy, does it give him renewed hope that real change can happen in these people’s lives?

“I'm optimistic by nature. I’ve been working in homeless health care for 17 years now. There have been a lot of announcements and the right things are being said, but let's actually see it happen because the numbers of people getting stuck on the streets just continues to climb,” he said.

“Once someone has been on the streets for six to 12 months, they have become so damaged psychologically and physically that it is really hard for them to maintain stable housing.”

While Andrew says HHC is currently seeing a lot of regulars, he is

bracing for a projected increase in homeless people when special federal funding is removed.

“These supports have kept people from falling completely into homelessness. That said, I reckon it takes about six months from a person losing their job and winding up on the streets because they have social contacts they can rely on for a bit. So, yes, we are worried about the possible blow out.

“An overriding concern for homeless people is permanency and security and it's that uncertainty that creates a lot of the issues. When you look at the different groups who are homeless, it is those who are chronically stuck on the streets who have the worst health outcomes.

“Those who have a single episode of relatively brief homelessness have the best health outcomes among the homeless cohort. Then

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Actions not words

FEATURE When times get tough, and in this area of healthcare they are numerous, what keeps staff going is the success stories.

“We can’t control bad outcomes particularly well, but the good outcomes are just phenomenal,” Andrew said. “And that's what keeps you going, in spite of everything else. All the doctors, nurse practitioners and nurses say the same.”

there are those who bounce in and out of accommodation and homelessness. These people don’t do well, health wise.”

Respite needed On Andrew’s wish list (and has been for the past five years) is a respite centre that would help recovery outside of a hospital setting.

“Unfortunately, without a home to stay in, homeless people cannot

access services that enable shorter stays in hospital, resulting in high rates of unplanned readmission.

A recovery centre can meet those health needs.

“Several US studies have shown that medical recovery centres are responsible for substantial reductions in hospitalisations and hospital re-admissions. Such a service would save the health system valuable taxpayers' money.”

“Just five years ago we were less than 10 people.”

And as Andrew comments, he’s not going to be short of work anytime soon.

ED: Authorised pictures supplied

by Raw Image

Read this story on mforum.com.au

“ When Annie lost her hearing, she began to lose her connection with Jack, too.

I just had to do something.

Nezha Delorme, Amana Living Client Services Manager

“

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HHC now numbers seven doctors, two nurse practitioners and about 25 nurses plus a couple of administration people.

“Annie had a stroke and lost her hearing. It became so hard for her to communicate with her friends and family, and it was especially hard on her husband, Jack, who loves her dearly and is her prime carer.

During my training I’d learned how relationships can become strained as physical or communication difficulties arise. So, with the help of our IT team, we created a solution.

We got an iPad for Annie and showed them how to use dictation software that converted Jack’s spoken words into text. It brought so much happiness back into their lives. And into mine.”

Professionally trained. Naturally kind.

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MEDICAL FORUM | INNOVATIONS AND TRENDS

FEBRUARY 2021 | 23

Social prescribing changing the paradigm The pandemic has exposed our need for social connection and GPs are especially well placed to write the community prescription.

Cathy O’Leary reports

Social prescribing is not radical, nor is it new. The concept has been simmering quietly on the backburner of Australia’s health policy hotplate for several years.

In principle, it seems a no-brainer.

Where appropriate, GPs and other primary health care workers write ‘scripts’ to refer patients to nonmedical services in their local community, such as the social running group parkrun.

And while progress has been slow to get social prescribing (SP) officially on the national agenda, COVID-19 could now be the catalyst that finally gets things cooking.

The pandemic’s all-pervading impacts on physical health, mental health and social wellbeing appear to have galvanised efforts to explore patient care beyond the boundaries of traditional medicine.

Prominent GP and consumer groups argue it is more important than ever to link patients to nonmedical activities which address underlying contributors to poor health, such as loneliness.

Twelve months ago, the push to get SP formally recognised in preventive health planning was 24 | FEBRUARY 2021

given a shot in the arm with the release of a landmark report off the back of a roundtable meeting.

Produced by the Royal Australian College of GPs and the Consumers Health Forum just as the coronavirus bullet was starting to ricochet around the world, the report highlights the need for better links between general practices and community services.

Now moves are afoot to see social prescribing included across several health plans this year including the Federal Government’s 10-year Primary Health Care Plan.

In the meantime, WA GPs are being encouraged to register their interest in tracking progress here and overseas.

Current models The call for more social prescribing comes after successful trials in Canada and Singapore as well as its widespread introduction in the UK. It has been used in a limited way in Australia with a 2019 survey of almost 3000 healthcare professionals, including 271 GPs, showing almost 70% had ‘prescribed’ parkrun to their patients.

MEDICAL FORUM | INNOVATIONS AND TRENDS

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FEATURE

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FEATURE But supporters of SP argue that while it is popular with both doctors and patients, the infrastructure and funding are lacking, and the practice needs to become a routine part of primary care in Australia.

Previous surveys of primary care doctors found that many did not have links to appropriate services, and 57% of consumers reported that their GP had never discussed SP-type approaches as part of their care.

Dr Mark Morgan, chair of RACGP’s expert committee on quality care, is now optimistic about progress.

“Things are moving quite rapidly,” he told Medical Forum.

The RACGP-CHF partnership has been joined by Mental Health Australia and by the end of last year they were finalising a budget submission to Federal Health Minister Greg Hunt, together with a detailed proposal for implementing a staged roll-out of a national social prescribing system.

“What we’ve been doing is taking the strong drive for social prescribing to work out how a policy might roll out in Australia, and some suggested funding around that,” Dr Morgan said.

“There have been discussions with community houses, or local providers of non-health services for people, which are part of the jigsaw to make social prescribing more accessible.”

Connection works A recent college survey with responses from 140 GPs showed a strong belief that referring people to community groups and services could improve health outcomes.

“We also know 20% of the primary reason for people to visit their GPs could be described as social issues rather than directly health issues,” he said.

“In fact, social issues form a component of most consults with GPs.” Dr Morgan conceded some people thought social prescribing sounded paternalistic, so it was important to define it because people tended to recognise it when someone

described it but not necessarily by the term itself.

“It’s where a GP or nurse might connect someone to a nonhealth service such as parkrun or a community group that can address loneliness and social connectedness, and provide opportunities for physical activity,” he said.

“It’s more than just sign-posting and that’s where the role of link-workers becomes very important, and that’s why models internationally and nationally have always had a link-worker role fulfilled by someone with local knowledge of the community.

“My vision is that the role in some instances would be done directly

by GPs and practice nurses, and at other times there would be an additional role for an appropriately trained, informed and supported link-worker, hopefully embedded in general practice to work closely with GP teams.

“GPs are very aware of community services available for their patients, such as those with chronic disease management, but what’s needed is a system that facilitates in providing information about what’s available and has an appropriate level of government safety.”

Clare Mullen, deputy director of WA’s Health Consumers’ Council, said it was encouraging to see work being done through the Compassionate Communities model focusing on improving the end-of-life experience.

“There are some interesting lessons emerging from the nine sites across Australia, including in the South West of WA, that have been applying that SP approach for a couple of years, but it’s still early days,” Ms Mullen said.

Change of focus “We are talking about a very different approach to delivering support than the traditional clinical model. It’s about moving from a ‘doing to community’ model, to a model based on ‘doing with community’ or even a ‘doing by community’.

MEDICAL FORUM | INNOVATIONS AND TRENDS

“One element of a social prescribing approach in the UK is the creation of a role that can support a consumer to navigate the fragmented system of care.

“This is something we hear at almost every community discussion about health services – that the system is confusing and difficult to navigate if you don’t have someone who can support you through it.”

Armadale GP and WAGPET medical educator Dr Ramya Raman is a fan of social prescribing.

She is concerned about increased rates of family domestic violence during the COVID-19 pandemic and argues it is crucial to make sure people have access to the right resources.

“I’ve become more familiar with the concept of social prescribing over the past 18 months and the use of it particularly in the UK to enable patients to target issues such as loneliness, chronic medical conditions and mental health wellbeing,” she said.

“I believe that as GPs we’re the primary care, the frontline workers, who are best placed to employ social prescribing to patients because I’d like to think we’re a trusted source of information.

GP strength “We don’t deal with the one patient, often we deal with entire families, so there’s a lot of traction we can potentially influence.”

Examples of social prescribing in action in WA were community choirs and parkrun, which could target patients who were feeling lonely and give them the opportunity to meet others.

“Parkrun a very non-competitive environment, it’s not about running marathons or being a gym junkie, and women can take their kids along,” Dr Raman said.

Dr Raman has a big culturally and linguistically diverse population of patients, so social prescribing could help them discover what activities were available in their local community.

Activities such as parkrun also allowed new mothers to be in a social environment while getting some physical activity which

continued on Page 26

FEBRUARY 2021 | 25

Better, not more

ultimately benefited their mental wellbeing.

Ms Mullen said the pandemic had shown that health services and the community could make positive changes quickly when needed.

“I think the biggest thing GPs hold is the trust of their patients, and when you put something on a script, even if it’s non-medical, it can help with engagement and commitment,” Dr Raman said.

“I think social prescribing and more holistic care of patients has great potential for helping to meet people’s needs that may not neatly fit into the box of either ‘clinical’ or ‘social’, she said.

“It’s not for everyone but as GPs our focus is on preventative health, to try to ensure our patients are well and keep them out of emergency departments, so social prescribing is an excellent tool.

“We regularly hear from people who want to be seen and treated as whole people.”

“If anything, most GPs are already incorporating this in their dayto-day practice, so it’s more about taking it to the next level, or a central hub to find more information and resources,” she said.

continued from Page 25

Holistic care “General practice is not just about prescriptions and examining the patient. We know our patients best, and the beauty is our continuity of care. We get an understanding of the family dynamics which gives us an insight into holistic care.”

Dr Raman said that during COVID-19 people had found new ways to communicate with each other such as online platform or deliveries. But she was stunned how many patients had come to see her once the lockdown eased up.

“It just drives home that we are social beings, and that exactly echoes the concept of social prescribing. We thrive on the social interactions and conversations we hold,” she said.

Dr Morgan agreed that COVID-19 had shown how reliant people were on community and contact with others. “We’ve woken up to how much we need and value community connectedness,” he said.

26 | FEBRUARY 2021

However, even supporters of social prescribing recognise some potential negatives and limitations.

Dr Morgan said it was not a onesize-fits-all, some people could benefit more than others, and some would not want to engage at all.

“It’s not a requirement, it’s just another opportunity to assist with both physical and mental health and take that bio-psychosocial approach that we all try take in,” he said.

“It’s about having more arrows in the quiver for patients.”

Dr Morgan said GPs had an enormous number of things to consider when seeing patients, especially those with multimorbidities, but they had more than one opportunity to intervene, unlike emergency departments which might have the one chance. GPs were also used to working in teams and sharing tasks.

“It’s a way to provide an extra level of health care, and affordable local services are features of social prescribing which make it stand out,” he said.

Dr Raman said she did not see social prescribing as an extra burden.

Ms Mullen said the HCC wanted to see more positive case studies about the benefits for the community, and more people lobbying their local providers for a more holistic approach.

“I think one of the potential pitfalls is looking ‘over there’ and thinking – we can do that here,” she said.

“From what I know of successful approaches, they’re quite specific to the local context.

“There may be lessons we can learn from others, but any model would need sustained community and clinical engagement in the local area right from the outset and throughout.”

Like any service, social prescribing could have funding implications for the health sector, but many believe it will be cost effective and even save money because it is not reinventing the wheel.

Dr Morgan said that while social prescribing was already happening in Australia, it was piecemeal and lacked the necessary support. Having a national arrangement designed properly would not create barriers or bureaucracies, it would just help things happen more smoothly.

MEDICAL FORUM | INNOVATIONS AND TRENDS

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FEATURE

FEATURE in the first place by tackling the upstream determinants of health including, for example, early years education, housing and employment, to reduce inequity which is what kills on a grand scale.”

which historically did not work well using integrated multidisciplinary teams, particularly outside the hospital system.

Allied health

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But he questioned how community connectors or link workers would be accommodated in the funding model if allied health services still struggled to attract rebates, underlining the need to change the GP funding model.

“It’s not about paying for services in an expensive way, it’s more about tapping into current health services, and perhaps a small ask in terms of supporting an organisation, instead of a massive commitment to create something from scratch.”

Public health physician Bret Hart said COVID-19 had provided a real opportunity to re-evaluate the healthcare system as a whole,

Dr Hart said some critics of social prescribing worried it was a smoke screen for change without addressing some of the more fundamental issues that contributed to health inequities, which had become even more stark with COVID-19.

“The massive investment in SP in the UK is a measure of its success but to obtain a prescription you have to visit a health repair shop,” he said.

Dr Hart said a whole of government response, which COVID-19 had shown was possible, needed to be applied to upstream strategies that protected and promoted the health of populations. While social prescribing was a vast improvement on the mainly downstream focus, it was not enough on its own because it was a midstream activity.

He said GP practices in WA were being encouraged to track the social prescribing trend in the UK and elsewhere by registering their interest at bret@hart-solutions.com.au.

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FEBRUARY 2021 | 27

Medical students’ mental health COVID restrictions have added to the already stressful lives of medical students.

Dr Helen Wilcox says more effort is needed to support our doctors of the future.

Medical school can be a stressful start to a professional career.

Medical students are particularly vulnerable to poor mental wellbeing, with higher rates of mental illness and psychological distress compared to the general population, and a 27.2% prevalence of depression during their studies.

Program-related stressors such as an intense academic workload, assessment load and the organisational structure of medical courses often coexist with financial and social pressures.

This can generate or exacerbate psychological distress and open the door to potential burnout and disruption or discontinuation of medical training.

Mental health promotion and early recognition and intervention strategies are not always integrated into each stage of the curriculum, nor consistently marketed to students, although a recent securing of government funding for mental health first aid training will be of value for early phase students.

Barriers to medical students seeking help remain, including the effect of stigma and self-labelling, the fear of a confidentiality breach and its possible effect on academic and career progress, and access issues relating to the costs of services and difficulty in attending services while studying a full-time course.

These issues have been brought into focus by the COVID-19 pandemic, which has had significant effects on delivery of the teaching curriculum across medical schools. The speed at which the community locked down and the subsequent changes to the medical course resulted in many students struggling to adjust to online learning and other curriculum changes.

The abrupt cancellation of previously timetabled face-to-face tutorials, clinical placements and patient contact further contributed to disruption of normal studies.

In addition to teaching-related 28 | FEBRUARY 2021

changes, other impacts include the loss of peer interaction and social connectedness, geographic isolation for rural, interstate and international students, and financial stressors including loss of parttime employment caused by the economic consequences of the pandemic.

At our university, survey data obtained in May 2020 showed a mean Kessler-10 (K10) score of 20.6 indicating moderate psychological distress, consistent across students in all years of the program.

Deterioration in mental wellbeing since COVID-19 onset was reported by 68% of students, with the main negative impacts being on social connectedness, studies and stress related to uncertainty about returning to normal study and the prospect of a delay in graduation.

Respondents outlined the mental wellbeing activities and strategies that they were using and finding effective, and identified resources or strategies that could be initiated by the medical school and student society to further promote wellbeing.

The strategies employed by current students are the same as those which have been shown to be effective in alleviating stress: having social support and emotional resilience; proactively participating in self-care activities such as

exercise, good diet and engaging in fulfilling interpersonal relationships; and deliberate practice of positive traits such as joy, self-efficacy and optimism.

Additionally, frequent accurate communication between the school and the student body was identified as crucial in allaying students’ concerns.

The survey findings are a valuable snapshot of the factors affecting student mental wellbeing, and provide an impetus to examine existing wellbeing and support strategies in order to inform a future cohesive and comprehensive support strategy.

This process will be greatly assisted by the recent release of the Every Doctor, Every Setting framework, which has been developed by a working group co-led by the Black Dog Institute and Everymind with representation from the AMA, AMSA, and Orygen, the National Centre of Excellence in Youth Mental Health. It provides an evidencebased strategy aimed at preventing and responding to mental ill health and suicidal behaviour, as well as supporting good mental health for all doctors and medical students.

The framework is built around five pillars denoting actions and targets, which can be adjusted to best represent medical student needs:

MEDICAL FORUM | INNOVATIONS AND TRENDS

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GUEST COLUMN

• Primary prevention Improve training and work environments to reduce risk.

From a medical school perspective, this means curriculum design that is both challenging and achievable, integrating teaching on work-life balance, self-care, and with flexible delivery where possible. Comprehensive orientation materials at the start of each year should address basic study skills, time management and goal setting, and provide access to specialist academic support strategies within the university. Opportunities should be sought to integrate case studies on doctor and student mental health into teaching and learning activities and reflective pieces. Lived experience examples from senior students and academics can be valuable.

• Secondary prevention Improve the capacity to recognise and respond to those needing support. Teaching on mental health literacy can cross disciplines, from general practice to psychiatry, and can be supported by curated e-mental health resources.

Student groups who may benefit from additional support and flexibility based on culture, geography or personal circumstances should be provided with targeted academic and peer support. Access to support services should be improved, potentially prioritising medical student access to university counselling and psychology services. Lists of doctors’ health advisory services and mental health professionals who are experienced with doctors’ health can be provided through student support channels. Policies relating to leave, deferral and special consideration should be promulgated, with clear pathways to access these provisions in a timely manner, especially around assessment periods.

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• Tertiary prevention Improve the support provided to doctors and medical students impacted by mental ill health and suicidal behaviour. Schools should develop student-in-crisis and postvention procedures in consultation with the broader university, which are consistent with other schools’ approaches locally and nationally. Mechanisms should be in place to assess when it is safe for students to study following an episode of mental ill health, facilitate their return and monitor their progress after their return.

• Mental health promotion Improve the culture of the medical profession to increase wellbeing. Schools should support co-curricular physical and mental health promotion activities in consultation with student societies.

• Leadership Improve accountability, coordinated action and monitoring to ensure success. This translates to school leaders acknowledging their roles as mental health champions, demonstrating a zero tolerance to bullying and harassment, and providing appropriate staff training so they can deliver on the initiative above.

Co-design of strategies with student representatives and with other schools is key to assuring suitability of the approach, sustainability of interventions and ultimately their success.

ED: Dr Helen Wilcox is Program Director and Head, Medical Education Unit, UWA Medical School and committee member of the Doctors Health Advisory Service of WA www.dhaswa.com.au

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GUEST COLUMN

helen.wilcox@uwa.edu.au – References on request

MEDICAL FORUM | INNOVATIONS AND TRENDS

FEBRUARY 2021 | 29

Hearing the good news Despite the tricky waters of 2020, the Ear Science Institute Australia managed to kick some big goals.

Jan Hallam reports In July last year, the Ear Science Institute Australia (ESIA) received nearly $1 million from the Federal Government to advance the commercialisation of the ClearDrum device, which, developed by ESIA and Deakin University researchers, incorporates silk in an ear implant.

after treating hearing loss. Current data suggests that hearing loss accounts for 8% of the modifiable risk factors of all cases of dementia,” she said.

The trial will also explore whether the correction of hearing loss with hearing aids results in less brain volume loss and improved cerebral metabolism, compared to those with uncorrected hearing loss.

The acoustically optimised silk fibroin (an insoluble protein present in silk produced by numerous insects) implant aids the treatment of chronic middle ear disease (CMED) by mimicking a human ear drum and promoting the patient’s own cells to grow.

"What our team found is that the tympanic membrane cells, called keratinocytes, actively proliferate and migrate across this scaffold, promoting the healing process,” Professor Marcus Atlas says.

The device is developed in two different formulations, which will allow ClearDrum to dissolve over time, addressing small perforations or acting as a long-lasting implant for larger perforations, with no need for further operations.

In 2019, ESIA became a World Health Organization (WHO) collaborating centre and as part of that work, according to the ESIA website, when clinical trials are complete, ClearDrum will change thousands of lives around the globe for people living with eardrum perforations.

The WHO estimates that 65-330 million individuals have CMED and 60% of them have a significant hearing impairment. CMED is particularly prevalent in Australian indigenous populations.

“Our plan is for ClearDrum to be available to patients in a clinical trial [in 2021],” ESIA CEO Sandra Bellekom said.

30 | FEBRUARY 2021

The RPH Research Foundation has put $600,000 into the study and a RPH Research Foundation grant will provide for an MRI and FDG—PET imaging study as well as looking at the health promotion aspect.

ESIA’s John Schaffer and Sandra Bellekom with 2021 ambassador Justin Langer.

Inset: The ClearDrum device.

In another initiative, the institute announced that it was launching a 24-month randomised clinical trial that will see a multi-disciplinary team of WA researchers and healthcare workers joining forces to find out if using hearing aids is an effective way to delay the onset of dementia symptoms.

The trial will be led by Dr Dona Jayakody, ESIA audiologist and research lead for the Cognition and Hearing Loss project. The concept was developed in 2015 when Dr Jayakody began researching the link between cognition and hearing loss.

“My research found that hearing loss is associated with cognitive impairment/dementia so I was interested in finding out whether this could be delayed or arrested

Other funding includes Oticon donating 400 hearing aids valued at $1.2 million, a Department of Health Research Translation Grant providing $237,000 to conduct a health economic analysis, and Dr Jayakody receive $100,000 from the Rebecca L Cooper Foundation.

Another boost on the health promotion front has been the appointment of Australian cricket coach Justin Langer signing on as the 2021 ambassador.

The 50-year-old Langer said he was looking forward to working with ESIA, given his own personal experiences with hearing and ear-related issues such as tinnitus, vertigo and vestibular migraines.

“These issues have had a natural impact on my physical and mental well-being. I know first-hand the difficulties related with hearing loss and vestibular imbalance and the importance of addressing ear and hearing issues early,” he said.

MEDICAL FORUM | INNOVATIONS AND TRENDS

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NEWS

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GUEST COLUMN

WA disability plan champions inclusion The WA government has added its weight behind people with disability. NDS WA State Manager Julie Waylen applauds the move.

All West Australians have the right to full citizenship of our community.

By that, I mean everyone is equally entitled to full social, economic and civic inclusion and the opportunity to lead a great life.

However, this is not always the case for the one in five of citizens who have a disability.

Creating a Western Australia in which people with disability are equally included has long been a priority, and while much has been achieved since the introduction of the Disability Services Act in 1993 to build accessible and inclusive communities, many people with disability still don’t have the same opportunities.

A Western Australia for Everyone: State Disability Strategy 20202030 was unveiled by Disability Services Minister Stephen Dawson in December and sets out a vision to make WA a place where people with disability have a fair chance, are engaged and feel empowered to live as they choose.

National Disability Services, which represents more than 100 disability service providers in WA, has long championed the creation of such a strategy to promote the social and economic participation of people with disability as well as investment in a strong disability services sector that can provide high quality and safe services.

The strategy outlines investment in a strong state disability ecosystem for those eligible for the NDIS as well as people with disability who are ineligible.

Importantly, the strategy will maximise the benefits of NDIS for West Australians with disability, providing opportunity to do more and build on what works, what can be improved and explore new frontiers and innovation.

In essence, it seeks to create a community where everyone belongs.

However, commitment to change is not only about what governments can do. The opportunity for people with disability to fully participate in the life of the Western Australian community can only be realised if it is matched with an increased capacity of communities to include people with disability in all facets of community life.

Disability is a part of everyday life.

More than 411,000 West Australians have a disability and 68,000 are carers for a friend or family member with a disability.

The strategy outlines a new 'whole of community' commitment to changing the lives of people with disability and is grounded in four foundational pillars of participation

First phase of the WA plan An action plan was launched alongside the State Disability Strategy with commitments including:

a $5 million innovation fund, increasing the number of specialist disability accommodation properties in WA by enrolling about 400 state-owned houses,

ensuring ACROD parking bays are better monitored and penalties enforced for parking infringements,

and contribution; inclusive communities; living well; and rights and equality.

The first pillar highlights key areas where change is needed to create a WA where people with disabilities can fully contribute and participate. These include greater support to access education and learning; equal opportunities for employment; and workplace cultures that make jobs sustainable and provide opportunities for advancement.

Creating more inclusive communities involves ensuring that public buildings, facilities and other community spaces are designed for everyone; that everyone is welcomed and included in recreational, social, cultural and economic activities, including tourism opportunities; everyone has a range of transport options and technology is accessible and available.

Thirdly, a focus on living well encompasses access to suitable housing options, quality disability services and supports and health and mental health services to ensure people with disability have good health and wellbeing outcomes throughout their lives.

Finally, rights and equality highlight that achieving equal rights for people with disability means being treated fairly and with dignity before the law, being safe from violence, abuse, neglect and exploitation, having a voice and, where required, support to communicate and make decisions and having access to the right information.

A Western Australia for Everyone is a good starting point to work toward improving the inclusion of people with disability in our state.

supporting women with disability with two new accessible family and domestic violence refuges, and

increasing the representation of people with disability employed in the public sector to 5% by the end of 2025.

MEDICAL FORUM | INNOVATIONS AND TRENDS

FEBRUARY 2021 | 31

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MEDICAL FORUM | INNOVATIONS AND TRENDS

OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Innovation and hope We generally start a new year hoping it will be an improvement on its predecessor. In 2021, this is probably more apt than any year since 1945 when there was hope for an end to war.

The rollout of COVID vaccines will require innovation as a program of this magnitude been never been undertaken before.

Albert Einstein reputably said that a problem cannot be solved at the level of its creation – the solution must come from a higher level. In the 1890s, concern grew about horse manure in city streets. A three-day conference to solve the issue ended with no plan. The problem was ultimately solved by Henry Ford. The car was not designed to remove horse droppings but solved the problem – from a higher level.

Conversely, lack of innovation can see problems persist.

The release of historic cabinet papers from 2000 revealed that a $500 million package to “improve regional health and increase GP numbers in the bush” was a key health policy. A strategy was advised to double the number of doctors working in regional areas over four years. The Aged Care Act 1997 was amended in 2000 following reports of residents being bathed in kerosene. The department noted that the public had concerns about the quality of residential care.

Sounds familiar.

Innovation drives human progress yet is often resisted at first. Hand washing when proposed by Ignatius Semmelweis was strongly opposed by the ‘experts’ of his day. Closer to home Barry Marshall’s ideas were far from welcomed when first raised.

This issue examines innovations and trends in medicine. There are articles on new methods of service delivery in mental health and also palliative care. Both are pivoting to a patient-centric model.

Technology trends are examined including an app which is assisting COVID diagnosis, which was developed collaboratively in Berlin, Rome and Perth.

In July, the Voluntary Assisted Dying laws, which were passed in late 2019, take effect and this is also examined.

The rollout of COVID vaccines will require innovation, as a program of this magnitude been never been undertaken before. If two shots are required and a target of 95% population coverage is set, then this means five to six times an annual flu vaccination season (based on a single shot in 30-35% of people). We will all need to be flexible.

History records that 1945 delivered on its promised hope. The promised hope for 2021 is that families are reunited, and we get our lives and freedoms restored. Let us hope 2021 delivers.

MEDICAL FORUM | INNOVATIONS AND TRENDS

FEBRUARY 2021 | 33

Imaging of slipped capital femoral epiphysis

By Drs Richard Warne and Michael Mason, radiologists, Wembley & Perth Slipped capital femoral epiphysis (SCFE), or slip, is a disorder of the proximal femoral growth plate leading to slippage of the epiphysis relative to the metaphysis. It is one of the most commonly missed diagnoses in children, which can result in delayed treatment and increased morbidity.

The peak age at diagnosis is 11 to 13 years in girls and 12 to 14 years in boys. The diagnosis needs consideration in younger children, particularly with coexisting endocrinopathies such as hypothyroidism, growth hormone deficiency and renal osteodystrophy.

Pain and limp are the most common presenting symptoms, but the pain can vary in severity and location, sometimes only being felt in the distal thigh and knee. The majority

within 18 months of a unilateral slip.

Key messages

SCFE is an important diagnosis to consider in the adolescent with hip pain

Delayed diagnosis leads to increased severity of SCFE and greater risk of complications

Radiographs are the best first-line investigation with MRI useful for very early slips (can be occult on radiographs) or other pathology.

of children with a SCFE are above the 90th centile for weight. The incidence is higher in African Americans, Hispanic and Pacific Islanders.

About 20% of SCFE are bilateral at presentation and there is risk of developing a contralateral SCFE

Radiographs are the imaging modality of first choice.

Diagnosis can be made on an anteroposterior (AP) pelvis view although, as the epiphysis usually slips posteromedially, the lateral radiograph is very useful for confirmation.

In suspected SCFE the diagnosis is made on radiographs, so MRI is generally not needed and does not alter treatment. MRI may be performed first because another diagnosis is suspected, and MRI is more sensitive for detecting other conditions causing the same symptoms. Slips are well depicted on MRI with increased fluid signal along the growth plate and abnormal alignment of the epiphysis in relation to the metaphysis. MRI can be useful to diagnose very early slip or ‘pre-

Figure 2a – lateral hip radiograph showing normal alignment of both the anterior and posterior aspect of the epiphysis in relation to the metaphysis (dashed lines). Figure 2b – posterior SCFE with offset between both the anterior and posterior aspect of the metaphysis and the corresponding epiphysis.

Figure 1 shows the signs of a SCFE on an AP view of the pelvis.

The normal line of Klein on the right (solid line) is a line drawn along the superior aspect of the femoral neck. Normally this intersects with part of the epiphysis but on the left the epiphysis has moved medially and the line of Klein (dashed line) no longer intersects with any of the epiphysis. As the abnormal epiphysis moves posteriorly there is widening of the growth plate (thick arrow) and the epiphysis loses apparent height on the AP view, (double headed arrows). The abnormally positioned epiphysis also overlaps with the metaphysis leading to the double density line shown by the arrow heads.

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Figure 3 – examples of different severities of slip. Morbidity increases with greater slippage.

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CLINICAL UPDATE

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CLINICAL UPDATE

Figure 4 – a pre-slip where the epiphysis is still normally positioned as highlighted by the normal line of Klein (solid line).

Abnormal fluid signal extends along the growth plate (arrow heads) with mild oedema in the adjacent epiphysis reflecting the abnormal sheer forces along the physis.

Figure 5 – complications that can occur secondary to a SCFE. The old internal fixation tunnels (*) are still visible but there are changes of osteonecrosis (circle) in the femoral head and associated degenerative change and cam deformity (arrow).

slip’ where radiographic findings may be normal or equivocal.

Trauma-related injuries such as ASIS/iliac crest avulsions (6a) or labral tears (6b) can cause similar symptoms to SCFE. Transient synovitis (6c) usually occurs in younger children than SCFE although overlap occurs. On imaging it presents as an isolated hip joint effusion (arrows) with a normal growth plate (arrow heads).

Perthes disease or osteonecrosis of the femoral epiphysis (6d) generally occurs in a younger age group.

Imaging shows loss of epiphyseal height with perfusion imaging showing loss of blood supply (*).

Children with osteomyelitis and associated soft tissue collections (6e circle) may have associated fever and raised inflammatory markers although in the early stages may present in a similar fashion to a slip. Bone lesions should always be considered, sometimes visible on radiographs but usually better shown on MRI (6f circle).

Figure 6 – common conditions that mimic the symptoms of SCFE.

Author competing interests- nil

MEDICAL FORUM | INNOVATIONS AND TRENDS

FEBRUARY 2021 | 35

36 | FEBRUARY 2021

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CLINICAL UPDATE

Knee osteoarthritis’s Battle Royale – Mechanics v Metabolics

By Dr Daniel Meyerkort, orthopaedic surgeon, West Perth Knee osteoarthritis leading to knee replacement increased 161% between 2003 and 2019, against population growth of 28% over the same period. This rise parallels the increasing prevalence of obesity in Australia with 89% of knee replacement patients being overweight to obese.

An interesting question to pose is: what is the cause of knee osteoarthritis?

Classical orthopaedic teaching suggests it is mainly a mechanical disease (malalignment, prior meniscal/ACL injury, trauma, increased joint force secondary to obesity etc.) with an incompletely understood genetic component.

Increasingly, it is being suggested in contemporary literature that the metabolic syndrome (hypertension, dyslipidaemia, insulin resistance and increased waist hip ratio) is an independent risk factor for knee osteoarthritis separate to weight.

Studies both suggest and refute metabolic syndrome as an independent risk factor when accounting for the known relationship between obesity and knee osteoarthritis.

We know that weight loss has a linear relationship between knee pain and function. The benefit starts with a loss as low as 2.5% of body weight. The metabolic syndrome has been linked with a low-grade pro-inflammatory state and increased levels of adipokines (leptin, visfatin and resistin), which have a negative effect on cartilage and joint tissue.

Currently, no evidence suggests a non-obese patient with metabolic syndrome and knee arthritis would have improved pain and function from treating their metabolic syndrome.

Hyperglycaemia a risk factor?

High blood sugars have strongly been linked with low-grade systemic inflammation, which potentially may be linked to osteoarthritis. Interestingly it

Key messages

Knee OA is strongly linked to obesity and metabolic syndrome/ hyperglycaemia

Optimising patients through diet and weight loss can result in significant pain relief and functional improvement

Hyperglycaemia after surgery is common and linked to poorer outcomes. Optimise diabetic patients through dietary and medication review before surgery.

has been shown that joint space narrowing (progression of knee arthritis) is higher in patients with Type 2 diabetes, independent of BMI. A separate longitudinal study of patients with BMI over 30 has shown that those self-reporting the use of metformin (i.e., independently commenced by their GP) had a 50% lower volume of cartilage loss as assessed on MRI scanning and a 70% risk reduction of requiring a knee replacement over a four-year period. This effect

MEDICAL FORUM | INNOVATIONS AND TRENDS

was after adjustment for age, sex, BMI and grade of osteoarthritis.

High blood sugars are common after joint replacement, being reported in 27% to 42% of patients in the literature. This is a risk factor for poor outcome, particularly infection. Weight-loss interventions, while avoiding nutritional depletion, are possible before surgery but have not yet been shown to improve surgical outcomes.

A prospective RCT between myself and Professor Grant Brinkworth from the CSIRO will assess if dietary change before surgery (commencing the CSIRO Low Carb Diet) results in improved perioperative glycaemic control, assessed by continuous glucose monitoring.

Author competing interests – the author is part of a study in this area.

FEBRUARY 2021 | 37

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CLINICAL UPDATE

Tech trends affecting health care in 2021

By Dr Marcus Tan, CEO, Health Engine When electronic records, online appointment booking and phasing out the humble fax machine are still considered ‘innovations’, that says plenty about the health care sector’s glacial adoption of technology.

Then 2020 delivered a global pandemic and the fear of not being able to deliver a service, concerns for the health and safety of practices and patients, along with hard-fought Medicare rebates led to the accelerated adoption of telehealth – albeit sometimes begrudgingly.

Was this the catalyst we needed in healthcare to explore and embrace the latest technology trends for our practices including machine learning (ML) and artificial intelligence (AI), the ‘Internet of Things’ (IOT) and 5G? Sci-Fi author William Gibson famously said, “the future is already here — it’s just not very evenly distributed”. This uneven distribution is most evident in laggard industries like healthcare where the combination of conservatism in our ranks and complex, often outdated regulations create an environment that delays adopting many technologies that more progressive industries have had in place for years, or decades.

Key messages

Healthcare innovation has lagged other industries.

2020 has forced a catch-up.

Be open-minded.

Predicting the future of healthcare is easy. Predicting when that future arrives is much more difficult.

It’s in our power to bring the change together by being open to emerging trends.

Three to watch ML and AI: Most radiologists would recognise the concurrent power and threat of artificial intelligence that is disrupting the diagnostic imaging sector. Many of the latest generation software applications are incorporating ML and AI to create insights and automation like never before.

IOT: Smart devices will become commonplace in health care as Cloud-connected sensors collect copious amounts of data to feed the voracious AI algorithms powering many of the aforementioned software applications. The quantified self-movement has grown as smartwatches record and track their users within an inch of their

MEDICAL FORUM | INNOVATIONS AND TRENDS

lives. The smartphone is now the ultimate IOT device with countless apps for diagnostic and even therapeutic benefits.

5G: Increased technology requires more performance and power for an increasingly connected society and practice. Telehealth, the requirements of IOT and latest AI-driven software needs greater bandwidth for efficient data transfer. 5G technology is another important step towards a more capable health care sector. That can only be a good thing for patient wellbeing, which we all can agree is the most important outcome of all health care systems.

With all this in mind, it makes sense to look for these types of features in any software or hardware you procure to ensure you are dealing with a leading-edge solution that will allow you to future-proof for at least a few years. The key takeaway is that more open-minded practices/practitioners who can stay a step ahead with technology – without overinvesting in the more esoteric stuff – will hold an advantage over those who default to wait and see.

Author competing interests – nil

FEBRUARY 2021 | 39

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CLINICAL UPDATE

Keeping physical health in mind

By Gordon Shymko, Clinical Director, and Louise Dobson, clinical practice nurse, Headspace Early Psychosis Individuals with mental illness have higher rates of physical co-morbidity and mortality than the general population. The association between mental illness and mortality from physical health conditions increases with the severity of the mental illness. Those with severe mental illness have a life expectancy approximately 25 years less than the general population.

Several factors contribute to this – lifestyle (e.g. smoking, poor diet and relative lack of exercise), relative lack of access to general practice and specialist care and the prescription of psychotropic medications, the side-effect profile of which often includes metabolic disturbances.

This essentially represents risk factors for cardiovascular disease including weight gain, hypertension, hyperglycaemia and hypercholesterolemia. These metabolic risk factors and lifestyle issues are critical to screen for and intervene against.

A relevant factor is that patients primarily seen within mental health settings may be less likely to have their physical health care considered in their overall management plan.

Key messages

Physical health is a critical but often overlooked issue for mental health patients

Prescribed medications can contribute to metabolic disturbance

Prevention, screening, early

There is now an increasing understanding and policy direction for holistic models of care addressing both mental and physical health. Mental health services need to structurally and culturally function to provide this care and as a psychiatric profession we must continue to take more responsibility for the physical wellbeing of our patients including promoting collaborative care with general practitioners.

six monthly thereafter. Baseline fasting serum glucose, lipid levels and prolactin should be obtained and repeated at three months and then every six to twelve months thereafter. A baseline ECG for QTc interval repeated yearly is advisable.

The initial focus has been screening patients prescribed psychotropic medications, especially antipsychotic medication, for baseline weight, Body Mass Index (BMI), waist circumference and blood pressure. These should be monitored at least monthly to bimonthly in the first six months and

This early monitoring is accompanied by education and early transition away from weightinducing medication if possible.

Increasingly, the focus is prevention including prescribing more metabolic friendly antipsychotic medications (e.g. aripiprazole, lurasidone) and avoiding

detection and early intervention are paramount, ideally in shared care with GPs.

MEDICAL FORUM | INNOVATIONS AND TRENDS

more metabolically unfriendly medications (e.g. olanzapine, quetiapine). Medications such as risperidone and paliperidone sit in the middle.

Early intervention is increasingly recognised with the early prescription of metformin (500mg daily) to reduce the likelihood of, or offset, initial weight gain. Dietician and exercise physiology referrals can be very helpful.

Finally, increasingly, mental health services are embedding physical health nurses into the workforce who carry responsibility for ensuring the mental health service attends to screening and assists in connecting patients with general practitioners as part of their ongoing care.

Having general practitioners contracted to work within mental health services has also been another effective way to facilitate physical health measures for our mental health patients.

Author competing interest - nil

FEBRUARY 2021 | 41

Different equipment produces different quality images.

Not all radiology equipment is the same.

So for the highest quality results, refer your patients to the specialists using WA’s leading imaging technology.

www.envisionmi.com.au 42 | FEBRUARY 2021

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CLINICAL UPDATE

BerlinCase viewer: Covid-19 educational app

By Dr Yuranga Weerakkody, radiologist, Perth* The BerlinCase viewer: COVID-19 imaging educational app was designed as a multicentre collaborative effort between Western Australia, Germany and Italy during the initial heavy outbreak in Europe in early 2020.

With increasing use of imaging in aiding diagnosis and the heavy burden on health systems at that time, it was released as a free app for iPad and iPhone for radiologists and appropriate frontline clinicians to better familiarise themselves with the CT imaging spectrum of COVID-19.

The app drew on the clinical and programming experience and expertise of the three radiologists and their clinical and technical support staff.

Prior to this collaborative effort, BerlinCaseViewer had been a medical training application, mainly focusing on musculoskeletal rheumatic diseases. It shifted its focus in times of need on the lung manifestations of COVID-19. As a socially responsible gesture, all versions are released as a free-touse app.

For better user engagement, the app was designed as a questionand-answer case-based interactive platform with links to important radiology journal publications embedded up to the level initial

Key messages

An imaging app was collaboratively developed in early 2020

It enables radiologists and appropriate frontline clinicians to aid COVID-19 diagnosis

The app remains free to use. release (April 2020). These cases are presented as easily scrollable stacks as well as annotations as the user progresses through a case.

A large number of COVID-19 positive cases from Italy (generously made available by Dr Fabio Macori) were selected.

Several mimic cases are also carefully selected to help clinicians realise the differences and similarities with certain overlap of non-COVID-19 cases.

The app is currently pitched at high-level hospital clinicians. Several revisions and upgrades planned.

Imaging was not used as a firstline diagnosis in Australia due to low manageable numbers of critically ill patients. However, it was indicated under guidelines by several international bodies such as Fleischner Society for medical triage of patients suspected of

Example case of the COVID19 quiz with a multiple choice question. Further series of the CT scans are only shown after the questions are answered.

MEDICAL FORUM | INNOVATIONS AND TRENDS

having COVID-19 who present with moderate-to-severe clinical features and a high pretest probability of disease in resourceconstrained environments such as Europe in early 2020.

Regardless of circumstances, our view was that better familiarisation with the imaging spectrum of COVID-19 would prove beneficial to appropriate frontline clinicians and radiologists generally. The app is currently available in English and free to download from the AppStore and with the full version using 470MB of file space and with a light version using 80MB. So far, there has been a very positive response worldwide both in terms of downloads as well as reviews. It recently highlighted as a feature Article in AuntMinnieEurope. com in October 2020.

To learn more about this project and to download the app visit www.berlincaseviewer.de/covid19-on-ct-scans/. Feedback is highly appreciated. *The author acknowledges Prof KayGeert Hermann, Professor of Radiology, CharitĂŠ Medical School, Berlin, and Dr Fabio Macori, Radiologist, Ospedale Santo Spirito, Rome.

Author competing interests - the author helped develop the app

Imaging findings depicting features annotated by coloured overlays in some cases.

FEBRUARY 2021 | 43

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CLINICAL UPDATE

Current trends in palliative care

By Dr Logan Shemer, palliative care registrar, Albany Over the past year I have been privileged to work with the Great Southern Palliative Care Service as a registrar in Albany. From this vantage point I see some emerging trends.

First is managing patients in the community setting, especially rural and regional patients. By integrating naturally occurring community networks with specialist palliative care, patients can remain at home for as long as reasonably possible.

Increased awareness and education of the normal dying process improves patient and family experiences by bringing greater meaning in their last days and reducing unnecessary hospital attendances. Providing early palliative care to patients with lifelimiting disease improves quality of life measures. Discussing Goals of Care and Advanced Health Directives empowers patients and families in treatment decisionmaking.

Regional WA has increased funding for palliative care and improved clinical nurse availability to provide practical support for patients and their families. This enables patient assessment in their own communities and access to specialist palliative care through telehealth, regional clinics and onthe-ground clinical nurse expertise.

Quality community palliative care requires collaboration between a patient’s general practitioner, wellequipped and skilled community

Key messages

Managing patients at home is now more enabled.

Novel methods for pain and dyspnoea are available.

A collaborative approach is essential.

palliative care nursing service and a versatile specialist team.

Technology If COVID-19 has brought us anything, it is video conferencing.

This has particularly helped assess and manage patients in rural and regional communities and rapid integration of video conferencing and the WA Country Health TelePalliative Care program (operational before COVID-19) has been a game-changer.

Rural patients can access specialist care “in the moment” without leaving home. This has helped change their quality of life in providing patient care in the comfort of their own environment, implemented and monitored by skilled nursing.

A growing trend is utilising novel methods to help with pain and dyspnoea. In 2019, morphine sulphate was TGA-approved for the treatment of chronic breathlessness providing a valuable pharmacological tool.

Patient-controlled analgesia has been adapted and changed

for subcutaneous use. Those with difficult to control incident or breakthrough pain can selfadminister subcutaneous opioids.

A continuous ambulatory delivery device (CADD) with opioid cassettes lasting up to five days can deliver ongoing analgesia.

These methods improve symptoms, reduce the burden on community nursing and allow patients more freedom.

Voluntary Assisted Dying (VAD) will become operational in Western Australia in mid-2021 and continues to divide the palliative care community. WA Health is working on processes for how patients will navigate through the assessment process, how and where medications will be dispensed and how we will support staff through this significant change.

Key stakeholders such as hospices, community palliative care providers and private facilities will have to work towards their VAD position and consider its impact on their staff, fundraising supports and community opinion.

Many believe firmly that the core essence of palliative care is neither to hasten or postpone death and therefore hold that VAD has no place in the palliative care. But keeping a patient’s choice central and providing a safe space for patients with life-limiting illness will need to guide the specialty.

Author competing interests – nil

GPs and the health of the nation The RACGP has released its 2020 General Practice Health of the Nation Report. In the survey, GPs recounted some of their major concerns treating patients during the pandemic. They said the most common patient presentations during COVID-19 were: • psychological (eg depression, sleep disturbance) • preventive (eg immunisation/vaccination, diet) • respiratory (eg cough, asthma, sinusitis, suspected COVID-19) • musculoskeletal (eg back/neck pain, arthritis) MEDICAL FORUM | INNOVATIONS AND TRENDS

GPs told the college that they wanted the Australian Government to prioritise primary care funding, mental health and telehealth with action on: • Medicare rebates • Mental health Telehealth/ePrescribing • Creating new funding models for primary healthcare • Pandemic/disaster preparedness • Obesity health equity and equality • Climate change and health.

FEBRUARY 2021 | 45

46 | FEBRUARY 2021

MEDICAL FORUM | INNOVATIONS AND TRENDS

MEDICAL FORUM | INNOVATIONS AND TRENDS

FEBRUARY 2021 | 47

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CLINICAL UPDATE

Voluntary Assisted Dying – what are the choices?

By Dr Peter Beahan, retired anaesthetist, & Dr Richard Lugg, retired public health physician Depending on jurisdiction, a person eligible for voluntary assisted dying (VAD) may have a choice from one of three possibilities: • Self-administration, oral • Self-administration, intravenous, by self-activation • Practitioner administration by intravenous injection No overarching principle favours one route of administration over another. The choice is best left to the person, or to a combination of person and practitioner.

One possible advantage of oral selfadministration is home storage in a locked box. A significant proportion of those keeping the medication at home never get to use it. Ready availability can reassure and reduce anxiety levels.

Occasional side-effects of oral administration are generally regarded as not significant if explained to family members.

Though rapidly unconscious, the time to cessation of breathing is significantly longer than with intravenous administration.

Precautionary measures include fasting for three hours and early provision of anti-emetics before ingestion. The aim is to gulp the medicine down quickly and follow it with a strongly flavoured beverage,

Key messages

Attitudes to VAD are changing Education of patients and families is critical

Professional services will emerge.

as the former has a bitter taste.

Occasional side effects of intravenous administration (e.g., discomfort on injection) are also regarded as not significant, if explained to the subject and family members.

With oral administration, it is prudent, in advance, to place a cannula in a forearm vein, and to explain to the subject, and to family members, the possibility of varying the plan in the unlikely event of mishap.

One advantage of intravenous selfactivated administration is that it allows the patient to be completely in control both of timing and of conversation, without interruption caused by the process. A state of composure is promoted. Activation is a simple matter. Onset is quick and effective.

Important considerations Any kit supplied by pharmacy services for assisted dying should be sufficiently comprehensive to cover all foreseeable clinical requirements and eventualities. The simplest way to meet this need is to have only one kit for all modes of administration. This allows for the full range of responses that may be required, depending on the case circumstances. Such a kit should be checked, cleaned, and refurbished after each return to pharmacy services.

With the intravenous route, it is prudent, in advance, to place a second cannula in the opposite forearm, covering dislodgement of the primary cannula.

During deep unconsciousness, airway obstruction may occur. It may be advisable to remedy this by means of a Guedel airway or laryngeal mask airway, a range of which should be available.

While we would consider these practices to be sound in principle, they do present some difficulties in the context of the Victorian and WA Acts, which treat oral and intravenous administrations as if they were mutually exclusive.

A three-lead ECG is recommended to give everyone attending a visual display of the heartbeat. Cessation of the heartbeat is easy for all to see and is a convincing way to determine the end of life.

Once established, VAD will become a professional service provided by doctors who develop a special interest in it, as a branch of medical activity. Such a progression is facilitated by respecting the competence and integrity of those in the field. Doctors should be allowed to develop their work as they see fit, with access to the medications they choose, within the provisions of the law, and with guidance from the colleges – as in all other branches of medicine.

Oral self-administration

Intravenous physicianadministration

Intravenous selfactivated administration

Default status, as selfadministration

Special rules apply to practitioner administration

Default status, as selfadministration

Medication can be kept at home and used at any time

Practitioner provides and administers the medication

Practitioner provides medication and set up

Unconscious 3-5 min; cessation of breathing 20‑30 min, sometimes longer

Rapid onset of unconsciousness and cessation of breathing

Rapid onset of unconsciousness and cessation of breathing

Occasional side effects – gagging, airway obstruction

Occasional discomfort on injection

Occasional discomfort on infusion

Timing determined by subject

Timing determined by subject and practitioner

Timing determined by subject

Presence of medical practitioner may not be considered essential

Practitioner presence required for injection

Practitioner required for set up and availability, but not for activation

Further reading, email peter.beahan@outlook.com

Composure interrupted by process (ingestion)

Composure interrupted by process (injection)

Composure and conversation not interrupted

Author competing interests – nil

MEDICAL FORUM | INNOVATIONS AND TRENDS

FEBRUARY 2021 | 49

Better health oversight needed in mining sector E/Professor Odwyn Jones and C/Professor Bill Musk put the case for WA to instigate more rigorous oversight of the health of WA mine workers.

There is a considerable good material available on the need for, and operation of, health surveillance schemes for Western Australian and Australian workplaces. In the WA mining sector, current guidance is provided in the Risk-based health surveillance and biological monitoring, which supports a suite of legislative and regulatory requirements.

However, problems potentially arise if such programs are not overseen regularly, which plunge them into neglect and potentially put mine workers at risk.

Sodhi-Berry et al (2017) have identified that WA mine workers are still succumbing to worksite induced illnesses such as lung cancer and susceptibility to other cancers, and cardiac and respiratory illnesses.

A review of the health surveillance regulations in 2012 removed the industry-wide requirement to report data to the regulatory authority and placed the onus on principal employers to maintain their own health surveillance systems for workers engaged in “specified occupational exposure work”.

The revision removed the opportunity for early health-based intervention by the regulatory authority.

Health surveillance of nonmineworkers engaged in “specified occupational exposure work” in WA is governed by the Occupational Safety and Health Act, 1984 and Regulations, 1996. These requirements have similarities to those applicable to mineworkers, but have some important differences which bolster the health surveillance system: • It is the employers’ responsibility to provide health surveillance, and to do so at no cost to their employees. The employer should also appoint a medical practitioner to supervise health surveillance of their employees.

50 | FEBRUARY 2021

• The purpose of surveillance is to identify possible excessive exposure to hazardous substances such as diesel engine exhaust fumes and/or silica and/ or any other carcinogenic dusts in the workplace atmosphere.

Hopefully, by so doing, the surveillance system will prevent illnesses occurring and promote improvements to safe work practices.

• Health surveillance must be supervised by an “appointed medical practitioner” (AMP), who is registered with the regulatory authority.

• The AMP must be appropriately experienced and understand the toxicology of hazardous substances.

• The AMP will provide a recommendation on the required frequency of health surveillance in accordance with the Guide for Medical Practitioners provided by the DMIRS. For example, a baseline health surveillance examination of a worker exposed to silica dust is recommended before commencement of work, followed by annual health surveillance with two-yearly imaging tests.

Arguably, the health surveillance of mine workers would benefit from similar provisions.

A Queensland Audit Office report in 2019 examined mine dust lung disease to assess the uptake of the recommendations of independent reviews – Black Lung – White Lies – and a review of respiratory components of Queensland coal workers’ pneumoconiosis. The select committee found that: • Coal mine operators did not have clear or consistent guidance from inspectors about actions required to demonstrate dust monitoring compliance.

• There was a culture of complacency within the industry regarding the serious risk posed by respirable dust exposure.

• There was an absence of

any regulated oversight of monitoring or mandatory reporting of dust exceedances.

• The regulator was primarily focused on mine safety, rather than on miners’ health and the risks posed by exposure to respirable dust.

• The regulator did not have a dedicated occupational physician to oversee the health surveillance scheme, as recommended by the select committee.

Subsequently, a new digital occupational surveillance solution is being implemented to support the regulator in operating its coal mine workers health scheme. It is intended to: • Digitally capture fitness for work health information from employers, workers and clinicians, • Provide electronic storage of health assessments, • Provide access to previous records by medical practitioners, employers, coal workers and others, • Enable data analysis and reporting of health assessment data, • Provide for clinical data exchange with other health management systems, • Strengthen the approval of appropriately trained and qualified doctors who can provide health assessments of coal mine workers, • Use ‘dual read’ chest x-rays for identifying early signs of dust lung disease.

Notwithstanding that improved diagnostic tools, which provide better results than chest x-rays, are available, the response by the Queensland Government to the crisis has been emphatic.

In WA, the contemporary legislative structures for health surveillance of mine workers does not allow for holistic observation by the regulatory authority, disavowing the opportunity for early intervention if ill-health trends develop.

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GUEST COLUMN

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GUEST COLUMN As pointed out by Stewart A.G. et al., (2019) few diseases are unifactorial, and pneumoconiosis is a term which defines a range of dust-induced lung diseases including CWP, as well as asbestosis and silicosis.

Indeed, it would be highly unusual to have mine workers exposed to only one type of dust. CWP, for example, is affected by the presence of silica, whereas hardrock miners’ silicosis would be adversely compromised by the presence of asbestiform or nickel sulphide mineral dusts and/or environmental tobacco smoke (ETS).

As indicated by the Queensland Audit Office report, the increased incidence of any dust-induced respiratory disease may well be due to inadequate regulatory control and/or failure of the operator’s risk assessment and/or supervisory regime.

The only way to circumvent such human failings is to ensure the effectiveness of the regulatory system.

WA legislation In WA, the health surveillance system was revised in January 2012, following two reports indicating its apparent ineffectiveness. The role of the regulatory authority was diminished, with the lion’s share of responsibility for health surveillance resting with the principal employer.

However, an updated health assessment and surveillance systems need to be urgently reestablished in WA and following is a draft proposal for such a system: • The WA mining industry legislation should adopt the APM system as provided for in the OSH Act and Regulations.

• A pre-employment medical health assessment be carried out including recording occupational history, radiographic imaging of the chest using low-dose CT scan and assessment of lung function using forced expiry volume in one second (FEV1) and forced vital capacity (FVC) performed by an accredited lung function technician. This will provide an excellent baseline for future health assessments.

• A similar health assessment should be carried out when changing employers, with appropriate reference being made to past assessments.

• Every underground miner should undergo periodic health assessments, carried out by an AMP every three to five years.

• Health assessment information and lung images must be stored centrally and be assessed independently by qualified medical and health science personnel.

• AMPs responsible for such health assessments are required to undergo an “industry induction program” prior to registration.

• All health assessment records should be collated and analysed independently in order to allow interpretation of lung damage in its earliest stages, before it may be clinically apparent.

• It is also suggested that consideration be given to establishing a sub-committee of Mining Industry Advisory Committee (MIAC) composed of independent mining professionals, health scientists and statisticians to oversee the operation of the scheme.

Work Health and Safety Bill 2019 was passed by the WA Legislative Assembly on 20 February 2020 and subsequently introduced to the Legislative Council, which referred it to a Standing Committee for further consideration. This Bill will replace the existing Occupational Safety and Health Act 1984, and other legislation including the Mines Safety and Inspection Act 1994.

Conclusions Regardless of the ever-encroaching digital era with its automation

MEDICAL FORUM | INNOVATIONS AND TRENDS

of industrial activities and use of data analytics and robotics, there is nothing more important than providing employees with a safe and healthy place of work, as included in the WHS Bill currently before the WA Parliament.

The lessons from the Queensland CWP experience should be salient for the WA mining industry. The Select Committee observed “in the field of occupational health and safety, there is often a distinction between efforts to address safety issues which involve more immediate risks of physical danger, and health issues, which typically involve longer term or chronic risks and effects”. However, “… the results are no different – deaths, illness and enormous changes in working and family lives. Miners and their families are never the same again”.

The mining industry, being one of the most hazardous industries, places considerable responsibility on employers and their officers to discharge their duty of care for all employees. Learning from the Queensland experience, an important component of the duties is to establish, maintain and periodically review a health assessment and surveillance” scheme within the matrix of organisational management at every mine site.

ED: The authors are grateful for the assistance of the DMIRS, Mines Safety Directorate, in proof reading this article.

– References on request

FEBRUARY 2021 | 51

Mapping the world’s access to health care Easy access health facilities is assumed if you live in a big city.

Local researchers say most people are not so lucky.

Dr Karl Gruber (PhD) reports

When you or a loved one is sick, reaching the nearest hospital is all that matters. But, for many people in the world, the nearest hospital may be out of reach.

Researchers at the Telethon Kids Institute and Curtin University have created the first global map of access to healthcare facilities. The map shows who can quickly reach a hospital or healthcare clinic and who might need extra help trying to get there.

This is the first map of its kind, identifying major healthcare facilities from every corner of the world and making global estimates of how long it would take people to reach their closest health care facility.

The study, led by Telethon Kids’ Dr Daniel Weiss, builds on a previous study he published in 2018, showing global access to cities. The 2018 study showed that, worldwide, only 50% of people 52 | FEBRUARY 2021

living in low-income settings were more than one hour away from a city, compared to 91% of people living in high-income settings. This study showed significant disparities in terms of wealth and accessibility but did not go into detail about important factors such as access to healthcare.

In this new study, Dr Weiss shows just how far away some people are from a healthcare facility.

Key findings A major finding of this study is that most people around the world have quick access to a hospital or healthcare facility – as long as they can hop into a motorised vehicle.

If this is the case, 60.3% of world’s population can reach a healthcare facility within 10 minutes, and 91.1% within about 60 minutes or less.

However, when you remove the motor vehicle from the picture, things change dramatically.

“For people who are only able to walk to their nearest healthcare facility, our map shows that just 16.3% of people around the globe can reach a healthcare facility within 10 minutes, and for 43.3% it will take them one hour or more,” Dr Weiss said.

For a substantial number of people, it can take much longer than an hour.

“For example, if there is access to a motor vehicle, about 300 million people live in a place where it would take them more than two hours to reach a hospital or clinic.

If there is no access to a motor vehicle, the number of people living two or more hours away from a healthcare facility rises to 1.8 billion.

“The reality is somewhere between these numbers, meaning hundreds of millions of people around the world require a long journey to reach a healthcare facility. This is critically important from a public

MEDICAL FORUM | INNOVATIONS AND TRENDS

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FEATURE

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FEATURE health perspective because we know that the longer people must travel to receive care, the less likely they are to do so.”

The story is not much different in Australia. People in rural areas are generally further from major hospitals and major healthcare facilities.

How was this map done?

The global map was built by a process of amalgamating multiple global and publicly available datasets, including data from OpenStreetMap, and Google Maps.

Data included information on road locations around the world, as well as location of healthcare facilities.

“We took our methodology (from our 2018 paper) and built on it to make it a travel map to healthcare services. The motivation behind our research was that we know from other research that people who live farther away from healthcare facilities are less likely to seek care when needed. We wanted to quantify this,” he said.

“It was quite the undertaking but one of the marvels of living in this era where there are powerful global datasets available. It becomes our job to capitalise on them and turn the data into useful information.

One potential limitation of the study concerns the definition of healthcare facilities.

“We relied on other people’s definition of what a hospital or clinic was and one country’s

definition of a clinic might be slightly different from another country’s definition,” Dr Weiss said.

“Also, these maps are only as good as the inventories of healthcare facility locations. The quality and completeness of these data varies between countries, and data also change through time as facilities open and close.

“Another important caveat is that the time it takes to reach healthcare is only the first hurdle people face.

Other factors, such as cost or how busy a facility is, can also limit people's ability to receive care.”

Why these findings matter?

While these global maps are reassuring for many, they also show that significant numbers of people are likely to struggle to reach a hospital or other major healthcare provider when they need it.

“These inequities are understandable because facilities are placed in areas where most people live and therefore are in most demand, but people living far from facilities still need care,” he said.

“The maps may help policy makers direct resources to underserved communities, perhaps through programs such as mobile clinics, community healthcare workers, or telemedicine.”

The maps are free to download and use and Dr Weiss has also created an online tool, accessible to anyone with internet.

“We didn't just make a set of maps, but also an online map-making system that enables users to upload facility locations and generate custom travel time maps. In doing so, we allow anyone to make maps using the most up-to-date facility lists they have,” he said.

The road ahead Now, Dr Weiss is looking at making more detailed maps that show the transportation services which are available for people needing to reach a healthcare facility.

Beyond mapping access to healthcare, Dr Weiss has also used his mapping skills to track the burden of malaria around the world, with the Malaria Atlas Project (MAP). Malaria is still a major healthcare problem in many countries, affecting 218 million people and killing more than 400,000 in 2018, mostly children.

The largest burden of malaria is disproportionally allocated in the African continent. The WHO African region has more than 93% of all malaria cases.

With help from the MAP project, researchers have been able to obtain global data on malaria incidence, prevalence and mortality since 2000.

“The Malaria Atlas Project has been able to track the success of malaria reduction in key countries where this disease is a major problem,” he said.

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FEBRUARY 2021 | 53

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ARTS

Made in WA This year’s Perth Festival could only have been made right here – and it is world class. Ara Jansen speaks to festival director Iain Grandage.

The 2021 Perth Festival is a love letter. It’s also an anthem celebrating what makes Perth and our fair state a wonderful place to live and create in.

“These works could be on a stage anywhere in the world but the stories could not be made anywhere else but here,” says festival artistic director Iain Grandage. It’s a big statement but it’s also a clarion call for an ambitious festival made under the most extreme of circumstances.

He’s right though, these stories could only be made here. They are our stories, inspired and influenced by the place that is uniquely Western Australian – our links to the land and river, to each other, to First Peoples and history.

This is your one warning: box up your perceptions and banish any cultural cringe. The 2021 Perth Festival is a glorious outpouring and celebration of creative energy.

For Grandage – who grew up in

54 | FEBRUARY 2021

Perth – this year particularly felt logical as the holder of the beacon to oversee a festival celebrating us.

Old friendships were reignited and new ones made to bring together inspiring and uplifting events.

“I think cultural cringe is a moot point now, it’s in the past. There’s an absolute sense that the created work is of international quality and that what we have is the opportunity to celebrate and show the public that’s the case. What we’re doing here is also making an investment for people to be at their best.

“It’s not an act of parochialism.

It’s an act of collaboration born of necessity and we’ve done that as strongly as we can. The breadth of artistic practice here is huge.

“When the art is good here, it’s good on the world stage. I have long had that sense of knowing when we do something really beautiful and celebrated here, it is world class. I hope that a lot

of these stories eventually get to travel out to the world.”

The program also features numerous world premieres including the ‘escape room meets The Truman Show’ production of Whistleblower, Barking Gecko’s House, CO3’s contemporary dance piece Archives of Humanity and the theatrical and musical piece, Black Brass.

This year, the locations of events in the festival program are also included in Noongar – Kaarta Koomba (Perth CBD/Kings Park), Yandilup (Northbridge) and Gumap (Government House). As part of the festival’s commitment of Indigenous-led art, Grandage hopes this opens new language doors and that people will start to use them more regularly in their everyday speech.

“I hope people will want to at least become familiar with the language of this place – the tones, the sounds, the rhythms. It’s something

MEDICAL FORUM | INNOVATIONS AND TRENDS

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I think the sense of belonging is more infinitely profound as a result.”

The festival commission Witness Stand is an invitation to gather and spend time learning together as sound works pay homage to the ancient stories of Whadjuk country.

Bruce Lee’s classic kung-fu film, Fist of Fury, is the first feature film to be revoiced in an Australian language with English subtitles. Yirra Yaakin Theatre Company presents its first queer work with an all First-Nations cast revisioning the warm comedy, The Sum of Us. This year’s festival theme is Bilya – river. Whadjuk Noongar custodians call the Swan River Derbal Yerrigan and is an important part of the creation story of this place. Not only does the river run through our city and provide all sorts of symbols, outlets and an enduring presence in our lives, metaphysically we’re connected by rivers of histories, energies and bloodlines which run through us all.

Throughout this year’s program, there’s an opportunity to explore cultural history through events like Galup, an interactive walking performance which happens just before sunset on the banks of Lake Monger. It brings to life largely unknown histories of the area in an intimate truth-telling performance.

and WA Youth Orchestra honour country with new work by Noongar musicians and performers alongside classics from Sibelius and Stravinsky.

“I think there’s a thirst in the audience and the community to hear these stories. It’s an opportunity to put ideas forward and to learn,” Iain said.

“I have always been in love with this place, more the fact that it’s as large as it is. With the festival, I love that we get to put on so many different things and we get to tell so many different stories. We don’t feel like a small cultural community, we really are in the best sense a metropolis.

“We’re part of a broad and wonderful movement that is emblematic of the community knowing itself and part of knowing itself is knowing that if you put on a story about this place it will be culturally and artistically as good as something from elsewhere.”

ED: The Edward Street Baby Farm, Fremantle Press

Gina Williams and Guy Ghouse present the world premiere of Koort (Heart), the second of their four-part song cycle which follows the singer’s personal journey as a child of the Stolen Generations.

In Dreams of Place, the Western Australian Symphony Orchestra

Read this story on mforum.com.au

City of Lights:

The Cherry Orchard:

Ballet at the Quarry:

Take the family to the Perth Cultural Centre for immersive lighting projections. Free.

Chekhov’s classic gets an ’80s Australiana makeover and takes place in the grounds of Dalkeith’s Sunset Heritage Precinct. Ticketed.

The West Australian Ballet presents As One, a series of works exploring physical and emotional connection under the night sky. Ticketed.

One & Many:

Literature Weekend in the City:

Under the blue whale in the WA Museum Boola Bardip, soprano Sara Macliver and violinist Shaun LeeChen offer joyous chamber music performances. Ticketed separately.

Features speakers such as Julia Gillard, Craig Silvey, Shaun Tan, Trent Dalton and Kate Grenville.

Ticketed – pay what you can.

powerful and functional and helps makes the language accessible.

“I remember being in Wales and watching the public exploration of the Welsh language. It felt palpable as all the bilingual signs went up.

SUGGESTED FESTIVAL PICKS:

A Forest of Hooks and Nails: The install crew at Fremantle Art Centre, normally unseen in a gallery, turn the tables and become the artists for an intimate behind-thescenes experience. Free.

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FEBRUARY 2021 | 55

‘Move over, self!’

Dr Katherine Iscoe uses a varied life experience alongside a healthy dose of academic research to mentor people to find their potential. She tells Ara Jansen sometimes people just need to get out of their own way.

During her life, Dr Katherine Iscoe has been a pastry chef, owned a restaurant and seen it go bust, worked through an eating disorder, moved countries and was medicated for depression.

There were of course plenty of highs and successes too. Importantly they have all been part of ongoing and valuable lessons which have made Kat who she is today – confidence mentor, author, speaker and shoe addict.

Born in Canada to two academics, Kat moved around a lot. Combined with her parents eventually splitting up, Kat’s relationships were constantly changing as was her sense of identity.

“I’d look at magazines like Vogue and thought maybe that’s what I needed to do or look like to be loved and popular,” says Kat or Dr Kat to those who have worked with her. “These days people look at influencers the same way.”

“Often people just need to get out of their own way. I wanted to develop something which worked quickly. Eventually I developed a program that sums up my life experience of 42 years and helps expedite people’s potential.

“As I started working with people I realised they wanted to look good and feel good but 99.9% wanted to feel really confident about themselves. That drove me to work on my own development because there’s always another level to reach.”

Her bespoke and strategic method of mentoring is designed to build internal strength, mental flexibility and adaptive resilience.

“Any expert who says they are not changed by their work is either lying, not human or not doing their job. You can’t help someone to change and not be changed 56 | FEBRUARY 2021

yourself, even in a very small way,” she said.

Just over a decade ago, Kat moved to Perth and threw herself into study and discovery by doing a Bachelor of Arts in Health Sciences, a Master of Science in Exercise Physiology and Health Sciences, a Doctorate in Exercise Physiology and Biotechnology and a post-graduate certificate in counselling.

“I wanted to be someone who was positive, and more than that, understands that everyone has a story; never to be judgmental or take things for granted. To live the best life, you have to do it with love and gusto. I never teach what I haven’t learnt or use myself.”

This led her to create a unique science-based process which is informed by extensive research, personal experiences and academic qualifications. It’s the basis of the work she does with clients who want to unlock their potential to achieve their goals and dreams.

Along the way she’s also written a cookbook and one on body confidence and created several education programs as well as becoming a professional speaker.

She’s also co-founded a company that has developed a smartphone app to accurately track body measurements.

In her programs and mentoring work, self-talk and creating positive self-talk is one of the cornerstones. A technique she uses with her clients is to have them text her each time they have a disparaging thought about themselves or their actions.

“It offers an objective way to look at your thoughts, because typically you don’t notice the nice thoughts.

The negative thoughts are insidious.

I do this over seven days and I’ve never had someone who hasn’t had a lightbulb moment. It often creates a chance for a reset and snaps you into being more conscious.

“Change is hard but everyone has a unique recipe that’s sitting right in front of them.”

MEDICAL FORUM | INNOVATIONS AND TRENDS

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LIFESTYLE

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SPIRITS REVIEW

Republic of Fremantle Welcome to the first Medical Forum distilled spirits review with the Republic of Fremantle, an urban distillery located in the historic heart of Fremantle. I was able to visit the distillery before its formal opening last year and was impressed with the Muller still and their process of producing spirit.

Oliver Kitson, Chief Distiller, has a pedigree of working at the Sipsmith Distillery in the UK and bringing his love of all things spirits to Western Australia. Using grapes to produce base spirit is not unique but does involve considerably more time and effort. Having the choice of some amazing West Australian wines to distil and impart their unique flavours to your gins and vodka is rare in the world of distilling.

The Republic of Fremantle has made a big splash in the harbour city with their grape-based spirits and I look forward to trying more of their unique styles of gin and vodkas.

Review by Dr Martin Buck

Republic of Fremantle Signature Vodka

Republic of Fremantle Aromatic Gin

Republic of Fremantle Full-Bodied Gin

Making vodka from wine is a challenge as any small imperfection in the wine is going to run into the spirit. The Signature Vodka is double distilled in batches and non-filtered. There are some subtle citrus aromas and floral hints from the glass, the palate is impressive with a luscious feel and flavours of citrus and apricots. Definitely best consumed ice cold to fill the mouth with flavour. Certainly a vodka to consume straight or would make an awesome cocktail.

The first gin is the Aromatic Gin using Great Southern riesling as the wine base and distilling a concentrate, which is then blended with grape spirit and water to obtain best flavour profile. Tasted neat, the grape aromas are soft and mixed with some ginger, on the palate there is good mouth-fill and roundness to the spirit with grapefruit and ginger flavours.

A splash of tonic liberated the juniper and ginger but retained the signature grape origins. Perfect for a summer cocktail.

The Full-Bodied Gin is a bolder style and distilled from West Australian shiraz adding some barrel complexity. I found some oak, rosemary and juniper aromas and the palate had some persisting heat from the pink peppercorns. For me this was my favourite, and the textural palate was well balanced, the splash of tonic helped bring out the rosemary and shiraz fruit. A gin style well suited to Vermouth based cocktails and of course a Negroni.

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FEBRUARY 2021 | 57

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