AI’s superhero viruses New approaches | New thyroid test, kids’ diabetes, resistant depression & obesity
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EDITORIAL BACK TO CONTENTS
Cathy O’Leary | Editor
Time up on seven-day results wait We live in a world with real-time access to all matters of health information, including Dr Google where I suspect there is a significantly higher risk of misinterpretation than any results on MHR.
A big talking point in recent months has been the Federal Government’s plan to scrap the seven-day delay for patients wanting to access pathology and diagnostic imaging results on My Health Record. Several medical groups representing GPs and pathologists have raised concerns that patients could be unnecessarily alarmed if they don’t have a health professional on hand to explain or interpret the results. Their argument is that no one should be a medical gatekeeper or deny patients access to their results. But if that’s the case, then that is a solid argument for removing the seven-day hiatus. We live in a world with real-time access to all matters of health information, including Dr Google where I suspect there is a significantly higher risk of misinterpretation than any results on MHR. I speak from recent experience, as someone who had multiple blood tests and imaging over several months. It was frustrating to see the results pop up on MHR – sometimes within a few hours of the test – but padlocked from my access for seven days for no particular reason. As each cache of results became available – some positive, some not – I felt more informed. Some were later discussed with doctors. There have been calls for exceptions to the axing of the seven-day delay, such as genetic test results, and the Government has already paved the way for this discussion, which might have merit. But denying most patients timely access to their own results seems a lost opportunity, especially when we have real-time digital technology and people are being urged to take a more pro-active role in their health. We have to remember the ‘My’ in My Health Record!
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 Medforum Pty Ltd (Publisher) as an independent publication for health professionals in Western Australia. Neither the Publisher nor its personnel are medical practitioners, and do not give medical advice, treatment, cures or diagnoses. Nothing in Medical Forum is intended to be medical advice or a substitute for consulting a medical practitioner. You should seek immediate medical attention if you believe you may be suffering from a medical condition. The support of all advertisers, sponsors and contributors is welcome. To the maximum extent permitted by law, neither the Publisher nor any of its personnel 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 and do not represent the opinions, views or policies of Medical Forum or the Publisher. 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 (Cth) as amended. All advertisements are accepted for publication on the condition that the advertiser indemnifies the Publisher and its personnel against all actions, suits, claims, loss or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Medical Forum has no professional involvement with advertisers other than as publisher of promotional material. Medical Forum cannot and does not endorse any products.
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CONTENTS | FEBRUARY 2024 – NEW APPROACHES
Inside this issue 10
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FEATURES
IN THE NEWS
10 Close-up:
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Editorial: Time up on seven-day results wait – Cathy O’Leary
4 9 19 24 30 37
News & views
Professor Britta Regli-von Ungern-Sternberg
14 Cover Story: Superhero viruses 20 Bowel Cancer Screening age lowers 26 Empowering women to tell
LIFESTYLE 50 Doctors show art style 52 Sculptures by the Sea
In brief AI in healthcare MyMedicare update Deep dive into protein research Transparency – a new approach – Dr Joe Kosterich
53 Spinnaker awards U M W IN
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The lucky winner of three bottles of boutique gin from Esperance Distillery Co is Professor Michaela Lucas, pictured with her prize.
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PUBLISHERS Fonda Grapsas – Director Tony Jones – Director tonyj@mforum.com.au
Clinicals
EDITORIAL TEAM Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Production Editor Jan Hallam 08 9203 5222 jan@mforum.com.au
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A new molecular test for thyroid nodules Dr Ben Dessauvagie
Rethinking diabetes in children Dr Sarah Black & Dr Craig Taplin
Treatment resistant depression Dr Carl Holm
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Innovative approaches in the management of obesity Dr Imran Badshah
Managing addictions differently Dr George O’Neil
Harnessing ‘brainpower’ to reduce pain Dr Myles Murphy
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Respiratory physiotherapy – what is it? Tamara Thornton
Telehealth: Changing landscape of regional healthcare Dr Vincent Lee
Journalist Eric Martin 08 9203 5222 eric@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Graphic Design Ryan Minchin ryan@mforum.com.au ADVERTISING Advertising Manager Andrew Bowyer 0424 883 071 andrew@mforum.com.au Clinical Services Directory Alice Miles 08 9203 5222 alice@mforum.com.au CONTACT MEDICAL FORUM Suite 3/8 Howlett Street, North Perth WA 6006 Phone: Fax: Email:
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Labour pain for maternity services Dr Lesley Kuliukas
Keeping the playing field fair Carolyn Hackett & Glenn Carroll
Thwarting a killer Ivor Campbell
Time to progress telehealth Cloe Benz
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Joint venture on orthopaedics A group of 24 Perth orthopaedic surgeons has joined forces with St John of God Health Care to build a specialist orthopaedic hospital on the SJOG Murdoch Hospital campus. Orthonova Orthopaedic Hospital will be the first of its kind in WA, with a private hospital operator and a group of surgeons working together to develop and operate the hospital. According to the developers, the hospital will be a centre of excellence for orthopaedics, featuring the latest in robotic joint replacement surgery and leading technology in sports surgery and will service growing demand in Perth’s southern corridor. Murdoch CEO Ben Irish said the new hospital’s bespoke design was aimed at providing patients with high-level clinical care and comfort beyond what was typically expected for a surgical patient. Key to the hospital design has been creating efficient pathways between the hospital’s day surgery suites, four operating theatres, recovery areas and 40-bed inpatient ward, all of which are focused on orthopaedic care. SJOG Health Care CEO Bryan Pyne said the positive response within the orthopaedic community and the anticipated growth in demand for orthopaedic services meant that planning for a second facility in Perth’s north was already underway.
St John of God Murdoch Hospital chief executive Ben Irish, left, SJOG Health Care chief executive Bryan Pyne and SJOG Health Care chief operating officer Ben Edwards.
High-end, contemporary finishes will feature throughout the lobby, patient lounges and private suites, and healthy meals will be served to patients via on-demand room service – a move which has been popular since its launch at SJOG Murdoch four years ago. A linking corridor will connect the Orthonova Orthopaedic Hospital to SJOG Murdoch’s existing 510bed hospital. The building will be constructed in partnership between St John of God Health Care and Hesperia on the eastern side of the Murdoch Hospital campus.
Uncovering the hidden wonder of cells Perth researchers have developed a technique to see inside cells with unprecedented detail, revealing a web of interactions that show how cells stay healthy. Lead researcher Professor Aleksandra Filipovska, the Lou Landau Chair in Child Health Research at Telethon Kids Institute and UWA, said the knowledge could pave the way for new treatments for a range of incurable diseases. In particular, it could help with debilitating mitochondrial diseases which affect up to one in 5000 babies born in Australia each year. Much like how the body needs organs to function, cells have inner ‘organs’ called organelles. Within each cell, these organelles collaborate, with each performing specific functions. 4 | FEBRUARY 2024
until now these relationships had not been systematically explored. In a multi-year study published in Nature Cell Biology, her team used a focused ion beam scanning electron microscopy to watch what happens in cells engineered to harbour mutations that damage organelles.
3D image of entire cell – threedimensional visualisation of cell components, mitochondria in red, Golgi in green, ER in blue and peroxisomes in yellow (vesicles are in brown and endosomes in grey). Image: Dr Ben Padman, UWA/Telethon Kids Institute.
The mitochondria produce energy, the rough endoplasmic reticulum makes and folds proteins that are exported from the cell, the Golgi apparatus processes proteins and fats, and the peroxisome deals with the destruction of fats no longer needed by the cell. Professor Filipovska said it was already well-known that the structures and functions of organelles in cells depended on each other for cell health, however,
“We showed that if one of the organelle team members isn’t doing their job, it can cause trouble for the whole cell – and that has implications for how diseases may be understood and treated,” she said. In particular, organelles rely on specific types of fats (etherglycerophospholipids) to function properly. The study found that when certain genes related to these fats were turned off in cells, it caused problems in various organelles. The study explored potential solutions and found that by providing the cells with specific fatbuilding blocks, they could partially fix the issues.
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ThyroSeq® v3 — a new molecular test for thyroid nodules Ensuring a definitive result for indeterminate cases and reducing the need for surgery. Clinipath Pathology is introducing ThyroSeq®, a new molecular diagnostic tool that uses nextgeneration DNA and RNA sequencing to classify thyroid nodules.
Thyroid nodules are common, with up to 50% of people experiencing them by the age of 60. However, it is estimated that only 5-10% of these nodules harbour disease.
• With ThyroSeq®, thyroid nodules with indeterminate cytology can be confidently diagnosed as either benign, avoiding many unnecessary surgeries; or neoplastic, with an assessment of risk of malignancy. • ThyroSeq® uniquely reports the probability of cancer and a prediction of cancer recurrence, informing personalised patient management and allowing for single stage definitive surgical management.
The cytology of a fine needle aspirate (FNA) from a thyroid nodule using the RCPA/ASC (Australasian) modified Bethesda system can confirm a diagnosis, and most FNA results can be confidently designated as benign (Category 2), or malignant (Category 6), with clear consequences for subsequent decision-making.
Developed by Professor Yuri Nikiforov’s world-leading thyroid research team at the University of Pittsburgh, ThyroSeq® is able to show with a high level of certainty whether a nodule is likely to be benign or malignant without the need for diagnostic surgery.
However, FNAs from about onethird of nodules do not provide a definitive diagnosis and are designated indeterminate (Category 3; 3-20% of FNAs), suggestive of neoplasm (Category 4; ~10%), or suspicious for malignancy (Category 5; ~2-3%). These indeterminate cases are resolved through performing diagnostic surgery that involves removing some or all of the thyroid gland. Diagnostic surgery allows for a definitive diagnosis, but an estimated 80% of the nodules removed by surgery are benign. This means that a great many patients receive what ultimately proves to be unnecessary surgery. Since diagnostic surgery usually involves the conservative removal of only about half of the thyroid, when cancer is found, a second procedure or completion thyroidectomy is often needed to ensure the removal of all malignant cells.
Utility • The ThyroSeq®Genomic Classifier uses genetic analysis of the FNA to clarify the risk of malignancy in nodules with Category 3-5 cytology. • It uses next-generation sequencing to analyse the DNA and RNA of 112 thyroid-related genes for four main classes of molecular alterations, including mutations, gene fusions, copy number alterations, and gene expression alterations.
By Dr Ben Dessauvagie Dr Dessauvagie is a histocytopathologist and head of cytology at CliniPath Laboratories with an interest in the power of cytology through the use of adjunct tests.
• It provides a reliable diagnosis of all types of thyroid nodules, including Hürthle cell nodules, medullary thyroid carcinoma, parathyroid, or other non-thyroidal lesions in a single workflow. • When the ThyroSeq® analysis shows no genetic abnormalities, the risk of residual cancer is about 3%—a rate equal to that of a benign cytology result. • ThyroSeq® is also used in Category 6 malignant nodules to assess the risk of recurrence and the need for adjuvant therapy such as radioactive iodine and targeted therapies.
Report The ThyroSeq® report is easy to follow. It provides a simple positive or negative result, indicating whether the genes associated with cancer are present or absent. When abnormalities are present, the report lists all genetic alterations and provides the associated cancer risk, thus informing the required extent of surgery and therapeutic options. To request ThyroSeq® with Sonic Genetics www.sonicgenetics.com.au/ our-tests/all-tests/thyroseq/
More information on ThyroSeq® www.thyroseq.com/ physicians/
Authors: Clinical Assoc. Prof. Benjamin Dessauvagie & Dr Rachael Chambers, Sullivan Nicolaides Pathology
Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200 Patient Results: 9371 4340 For our extensive network of Collection Centres, as well as other clinical information please visit our website at
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CT imaging is about to get a whole lot safer.
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Labour pain for maternity services With the recent closure of a Perth midwiferyled maternity clinic – hot on the heels of several hospital units also winding up – Curtin University’s Dr Lesley Kuliukas argues that the funding model is broken. When the Perth Pregnancy Clinic recently went into liquidation it was the case of another maternity care provider biting the dust. The loss of this clinic was due to a common failing of midwives – a desire to provide free care. Midwives provide essential care which should be the right of every woman and growing baby. However, midwives who bulkbill maternity care appointments are unable to make a living, demonstrated by the demise of Perth Pregnancy Clinic.
All maternity care should be bulkbilled. The government is missing a financial opportunity by not making it so. The future health of the nation could be determined by women receiving gold standard maternity care preconceptionally, through pregnancy, labour and until at least six weeks postpartum. Evidence demonstrates that continuity of care by a midwife provides best short-term outcomes with higher rates of vaginal birth, less intervention, babies born in good condition and lower rates of
pre-term birth. We also know the first 2000 days of life, including those in utero, impact long-term health outcomes. If the fetus received optimal care (through its mother), the incidence of obesity, diabetes and cardiac disease would reduce. With this knowledge all maternity care should start with a visit to the midwife. In 2008, then-Health Minister Nicola Roxon ran a national survey to discover what women wanted
Liver cancer relapse marker Perth scientists have identified a biomarker which can predict the likelihood of a liver cancer recurrence. A team led by Dr Ankur Sharma at Harry Perkins Institute of Medical Research discovered that patients with a high level of oncofetal cells are not only more likely to have an aggressive form of liver cancer return within six months but they also respond well to immunotherapy. Hepatocellular carcinoma accounts for about 90% of primary liver cancers and recurs within five years in 70-80% of patients. Five-year survival of liver cancer is only 18%. This makes it critical to identify patients at high risk of recurrence after surgery and the optimal treatment options at the time of diagnosis. Researchers analysed patient samples from Sydney, Perth and Singapore and found much higher levels of fetal-like cells in the patients whose cancer returned within six months compared to those who had recurrence in two years. “Even when all the cancer is surgically removed, liver cancer returns for half of all patients within two years and for some it comes back within six months,” Dr Sharma said. 8 | FEBRUARY 2024
“By analysing the microenvironment which surrounds and nourishes the tumour, we found some patients have high levels of fetal-like cells, and their presence predicts the likelihood of recurrence. “We also found that (these) patients respond well to a newly approved immunotherapy combination of Atezolizumab plus Bevacizumab, which works by targeting blood vessels and immune cells in tumours. “This suggests that if those patients were given immunotherapy as well as surgery at the time of diagnosis, rather than after the cancer has returned, their prognosis can be improved.” MEDICAL FORUM | NEW APPROACHES
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IN BRIEF from maternity services. Her results revealed that women wanted access to continuity of midwifery models of care. This led to the new role of the endorsed midwife, a midwife able to practice privately, order tests and prescribe.
educate, inform, refer to other professionals as appropriate – physiotherapists, sonographers, psychologists, obstetricians and anaesthetists – but being her mainstay throughout the whole childbirth journey.
Unfortunately, the Medicare rebates were set very low. Was it presumed that midwives would always charge a gap? Or was it presumed that midwives, a predominantly female profession, would prioritise caring over earnings? The collapse of Perth Pregnancy Clinic suggests the latter.
Postnatal care also affects longterm health. Women who attend hospital for the birth of their baby usually receive care from a midwife until the baby is five days old. The baby’s fifth day is the day that accumulative tiredness hits the parents, breastfeeding problems peak, visitors to the house become overwhelming, baby blues commence. It is not the day to discharge a woman from midwifery care.
Only a small percentage of midwives work as endorsed midwives. Most midwives work in the hospital system where antenatal care starts too late, at 16-20 weeks gestation. The midwife should be the first port of call for women when they discover they are pregnant. Privately practising endorsed midwives (PPEM), like those in Perth Pregnancy Clinic, Perth Maternity and many other small or individual PPEM practices, start maternity care much earlier in a pregnancy, which provides opportunity to inform on best health practices, both for general and maternity health. Midwives offer details of diet, gut health, effects of medications and supplements, dental, pelvic floor and back care, exercise regimes, mental health screening, general health history and screening, maternity history (including previous birth trauma), breastfeeding information, advice regarding addictive substances. They explain all available options of maternity care, not just public or private. This lengthy appointment can make the difference to early and ongoing fetal development and set a healthier future for women in terms of their ongoing health. Midwives would prefer women not to pay for this appointment, or any appointment or test over the childbirth journey. Women should not be deterred from seeking care because of cost. The impact of cost is felt most strongly by vulnerable women, to whom the biggest difference could be made if all care was bulk-billed.
Ongoing longer-term midwifery care would reduce attendance at emergency departments due to worries that could be investigated, treated or explained by the midwife. I have a dream that women receive home visits from a midwife until six weeks after the birth or for as long as it takes to fully establish breastfeeding and see women through any postnatal issues. Hospital readmissions would reduce and future health outcomes would improve. PPEMs provide this gold standard service, but often not bulk-billed. The closure of Perth Pregnancy Clinic highlights the need to consider governmental priorities. Is there true interest in improving maternity services? If so, midwifery care should be available for every woman at the start of pregnancy. If so, Medicare rebates should be adequate for midwives to make a living without being required to charge women a gap. If so, there should be no costs for tests, ultrasounds, classes. If so, all women should receive six weeks of postnatal midwifery care. The future health of the nation depends on it. Author’s note: While the word ‘woman’ has been used in this article, it is recognised that people have diverse gender identities and the aim of all maternity care providers is to individualise personal terms at point of care according to preference.
Australia’s last remaining Health Department director-general to have served throughout the entire COVID-19 pandemic, WA Health’s Dr David Russell-Weisz, will finish up in the role next month, after 28 years with the department.
Australia’s first RSV vaccine to be approved by the TGA is likely to be available on private prescription in time for winter. GSK’s Arexvy can be given to people aged 60 and over.
Taking out top gongs in the RACGP WA’s 2023 awards were GP of the Year Dr Andrew Leech, GP Supervisor of the Year Dr Fen Chin, GP in Training of the Year Dr Corey Dalton and General Practice of the Year Derbal Yerrigan.
The WA Country Health Service has welcomed a record 30 new medical interns this year, who are now well into their 12-month placements across regional areas.
Edith Cowan University Deputy Vice-Chancellor Regional Futures Professor Cobie Rudd says ECU has become the only WA institution to receive five nationally recognised Science in Australia Gender Equity awards.
Curtin University research led by Associate Professor Vin Cavalheri has linked five minutes of daily physical activity with prolonged life in people with inoperable forms of lung cancer.
I would like all women allocated a midwife at the very beginning of pregnancy, to monitor progress, MEDICAL FORUM | NEW APPROACHES
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Championing children’s safety She started her career as an ambulance volunteer and paramedic in Europe. Now living in Perth, Professor Britta Regli-von Ungern-Sternberg is a world authority on making children’s experiences with anaesthesia and surgery safer and more comfortable.
By Ara Jansen Paediatric anaesthetist Professor Britta Regli-von Ungern-Sternberg broke family tradition by studying medicine amid a family of German judges and lawyers. Curious about medicine, at the age of 14 she completed a nursing aide course after signing up with a friend who never showed. She started working as an aide and trained as an ambulance volunteer for St John Ambulance before starting her paramedic training during high school. She was the only female paramedic working in Freiburg in the Black Forest at the time. Britta gained experience with the ambulance service, working nights and weekends and continued while studying medicine. This also exposed her to many anaesthetists working as emergency doctors. “Because of my exposure while working within the ambulance team, I met a lot of anaesthetists and got interested in what they were doing,” says Britta. “They played a significant role in my decision to study medicine and later to complete my anaesthesia training. “One night, while working as a paramedic, I repeatedly bumped into an anaesthetist after dropping off patients in the intensive care unit. He was intrigued that I was a female paramedic and kept quizzing me about what I wanted to do and why. “By the night's end, I had agreed to start a medical research project and doctorates in experimental anaesthesia over several years in parallel to medical school.”
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CLOSE-UP While studying in Germany, she grabbed multiple opportunities to travel and work in different hospitals in Europe and overseas. During one of her electives in 2000, she found herself working in two adult hospitals in Sydney. One of the consultant anaesthetists invited her to The Children’s Hospital at Westmead as he thought Britta would love working with kids. He was right, she did. After obtaining her medical degree, she trained in Switzerland. Following her specialist training, Britta and her husband decided to move to Perth at the end of 2006 for a post-grad research year to finish her Swiss academic training. She worked at PMH in paediatric anaesthesia. They both enjoyed their work and the city so much, they decided to stay. Britta holds the Foundation Chair of Paediatric Anaesthesia at UWA, the first of its kind in Australasia, and now leads the newly founded Institute for Paediatric Perioperative Excellence. She is a specialist paediatric anaesthetist at Perth Children’s Hospital. She co-leads the Perioperative Care Program at Telethon Kids Institute with Professor Fiona Wood and leads the Perioperative Medicine Team at TKI. Her paediatric anaesthesia research program is highly active and one of the internationally leading research groups with a strong focus on continuously driving improvements in safety and quality of care along the perioperative pathway. Thanks to an interest in being able to look at a problem or an issue from every angle, Britta’s research team is multidisciplinary and includes anaesthetists, surgeons, physicians, nurses and allied health professionals, but also the likes of engineers, scientists, computer scientists, psychologists, statisticians and other professional groups. Together, they search for tangible, applicable practice changes with actual health benefits for young people. “It’s fantastic to work with people from a variety of backgrounds. My research team is relatively large and comes from different professions and schools of thought. Everyone brings a new or different personal and professional perspective to the table. That’s what makes our team effective at tackling complex issues.
Many different pieces are required to solve a problem. “In medicine, there is hardly ever only one way. Sometimes, you must try multiple ways to see if one is better. And more often than not, combined aspects from multiple paths lead to the best solution. Britta’s primary research interests relate to predicting and preventing respiratory complications in paediatric anaesthesia, lung function changes during anaesthesia, evaluating different airway devices, the impact of anaesthesia in early life on a child’s neurodevelopment as well as improving perioperative pain control and the overall perioperative patient experience. If there’s one thing you probably hear her say a lot, it’s that threequarters of critical incidents for children in surgery are related to breathing or that up to 80% of children are anxious or very anxious in the perioperative period. She wants to change that. “What gets me out of bed every day is to try and make sure that every time a child needs surgery, we make it as safe and comfortable as possible. It is important to work as a team, including the child, their family and all the health professionals involved in their care,
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to help make that happen. We can make a difference simply by how we interact with and listen to them.” She enjoys the variety and the challenge of working with children across a spectrum of presentations and children who range in size, age and weight. Becoming a mother has also lent added understanding and dimension to her work. “All my research and ideas come from my clinical work and listening to children, their families and my colleagues. I work closely with our consumers, both adults and children. To give some examples of our consumer involvement in my research program, we have a diverse Anaesthesia Consumer Research Reference panel and Youth Consumer Ambassadors. “We hold youth consumer conversations, meet the researcher sessions as well as perform kids’ voices projects where we talk to children as young as four years old about their own experiences in the perioperative period. Even my kids are often involved. They come up with many creative ideas from a child’s perspective. “In my mind, if you want to do clinical research, you must be an active clinician and listen closely to continued on Page 13
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Championing children’s safety continued from Page 11 consumers and staff. That’s how you learn what the real issues are. Unfortunately, it is not rare that people research or develop things that do not align with clinician or customer needs.” She is passionate about improving the overall outcomes for children and giving everyone the best chance to a happy and healthy start to life. “We can make such a difference in their physical and psychological health and how they interact with healthcare now and for years to come. We know if a child has positive healthcare experiences (even if they do have to have surgery, which is not necessarily nice), that as adults, they will be more likely to seek help and be calmer about the experience.” Britta’s husband is intensivecare specialist, Clinical Associate Professor Adrian Regli, and the pair have worked hard to balance two hectic careers with three children, aged 11, 12 and 14. It has been made that little bit harder by not having any immediate family in this hemisphere. She credits great friends for a support system and the couple sticking to one unbreakable rule – they are never on call or away at the same time. “We’ve stuck to that. We both work very long hours and are often away, but our family still comes first. There are those rules we don’t break. For example, if I promise to be somewhere, I will be there. We have clear boundaries with what we say yes and no to. “We have rules around travel, and I travel a lot less than many of my male counterparts. Luckily, some of my work is flexible – I work in a very collaborative, international environment around many different time zones. Some days, I talk to people until 2am, other times, I can be at home when needed.” Britta’s children have grown up being exposed to their parents’ work. She was doing a job interview for a new postdoc when her youngest was only a week old.
When the team writes documents to be read and understood by children, she gets her kids to roadtest them. They’ve also had some input into an app being created for children. Britta says they’re good at being honest critics of what she brings home to be tested. Equally, Britta says while she and Adrian are happy to expose their children to parts of their job, they’re cautious not to push medicine on to them as a profession. She’s determined to keep their pathways open for whatever they genuinely want to do, while being passionately conscious not to force any gender stereotyping on either her boy or the girls. “The gender stereotyping seems to be much stronger here than what I have ever experienced in Europe. So many things here are gendered, whether it’s the men gathering around the barbecue or this insistence of labelling it a girls’ night out rather than just a night out.” When there’s family time, the five make the most of it by going to the beach or river, enjoying a hike, or riding their bikes. Outside work,
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they travel for pleasure, visiting friends and family around the globe. Britta speaks a range of languages, including English, French and German, plus plenty of Latin and has a basic understanding of Italian and Spanish. The rest of the family are at least bilingual, and they only speak German or Swiss German at home unless they have visitors. “To me, it’s more than learning a language. It’s a vehicle to understand other cultures, other people,” she says. On meeting Professor Britta Regli-von Ungern-Sternberg, most people are highly curious about her name, which, in fact, is even longer. It’s a very old name with its roots in Baltic German nobility, long enough that she has to get special dispensation on her various passports and can hardly ever fit it onto forms. “It’s not a very practical name in everyday life, but I love the tradition and history of it,” says Britta.
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Superhero viruses, AI and the final phage Two big changes in different fields of technology stand poised to radically impact global health. One of them – the artificial intelligence revolution – could hold the key to help counter the other – the alarming spike in antimicrobial resistance (AMR).
By Eric Martin
14 | FEBRUARY 2024
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COVER STORY It is a trend that the World Health Organization predicts could see AMR become the leading cause of death in the next 20 years. Perth researchers, led by Associate Professor Anthony Kicic from the Wal-yan Respiratory Research Centre at Telethon Kids Institute and Curtin School of Population Health, have been using AI to explore the medical potential of bacteriophages as an alternative means of treating bacterial infection, harnessing machinelearning to sift through the organisms’ unique genetic structure and find the best, individualised match for pathogens. “We're on the doorstep of a similar scenario to COVID now in terms of global need,” Professor Kicic said. “We all need to take this quite seriously because there's dire consequences: in less than five years, infections we can currently treat might be killing people again because we don't have effective treatment options for them anymore. “It is a scary thing, yet it's not on everyone's priority list. Shining the light back onto bacteriophage, these superhero viruses, is fantastic. It may add another treatment option for clinicians.” Ironically, bacteriophages were first
identified as a potential treatment more than 100 years ago, in 1915, and were the subject of investigation until the sudden discovery of penicillin relegated ‘phages’ to the largely forgotten pages of medical history. “It's one of those pieces of history that has never found recognition because of everyone's embracement of antibiotics. They were developed at the same time and still work but their voice has just been lost in time,” Professor Kicic said. “However, their importance is clearly shown by the fact that they outnumber any other class of biological creatures on earth and are among the most numerous groups in the human virome.” Which is where the computational power of AI is helping to identify the correct phage in a fraction of the current time. “For example, we have about 3000 bacteriophages against a particular bacterial species called Pseudomonas aeruginosa, and when we have patient X come in with a particular infection type, we have to try and match them,” Professor Kicic said. “At the moment it's ad hoc and is not an efficient process. You start
from phage number one and go right through and see which one might be active against this bacterial species. We can look at some characteristics to provide clues as to which ones we think will work, but it's really a guessing game. “So, the goal was to address the bottlenecks of time-impacting processes. We wanted to pull this information that we're manually gathering now, feed it into a machine-learning algorithm and have it come up with a predictive list that will identify the most likely candidates that will be active against a bacterium. “We could prioritise our screening process against those the machine would find and have this turned over in a very time-efficient manner. Currently, it takes two to three weeks to screen about 100 phages. So, if you've got a thousand, that can take a lot of time that a patient may not have.” Professor Kicic said with philanthropic and State government funding, a specific machine-learning tool was being developed that would also continue to build on the whole genome sequencing data they were amassing, both locally and nationally. “The system is always improving itself and uses the continued on Page 16
Image: Telethon Kids Institute
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FEBRUARY 2024 | 15
Superhero viruses, AI and the final phage continued from Page 15 genetic sequences of both the bacteriophage and the bacteria as well, very much like bioinformatics, to search for the answers in that genetic code,” he said. “The screening and the genetic sequencing of the phage will identify whether it's a lytic versus a temperate phage, and whether the bacterial host has any prophage as well. We have also screened our library to only look at those that will be therapeutically applicable, as well as contributing to a nationwide network collective called Phage Australia. “All the data will then feed into this algorithm to increase its accuracy and diagnostic capability, and be rolled out across Australia, and hopefully internationally as well. “We already have colleagues at Westmead who have started successfully treating patients. But while they're a little bit more advanced than us in the application, their genome sequencing and matching is still conducted on a manual basis. “One of the main benefits is we've all had our own specific research interests, and we all bring repositories of bacteriophage here in Australia to the table. We also hope to have the ability to share manufactured phage and treat everyone on a national level.” Professor Kicic said Phage Australia’s international connections were also very diverse, enabling them to bring new phage into Australia, which was otherwise challenging as live biologics. “What we would like to do in countries that don't have the ability to generate their own phage libraries and algorithms is to provide that matching service for them. “If they supply us either with the genome sequences of the bacteria and the phage that they're trying to test, or in fact, ask us, ‘here's the bug that we've got a problem with, do you have any phage with it?’ Then we can actually get that manufactured to a medicinal level.” Professor Kicic said the other big 16 | FEBRUARY 2024
challenge was that the FDA had recognised phage therapy one way, while the European Therapeutics Council viewed it slightly differently. The TGA here in Australia still hasn't decided because it's so new, it's still not recognised as a therapeutic.
to being hospitalised and having an 8-12-week course of antibiotics to try and eradicate these bugs, and obviously, over a 30-40 year life span, you can often see that by their early 20s, they are starting to experience AMR,” he said.
“As such, the national network is providing the data that we're generating to the TGA so they can make a recognised decision that will then determine how we prepare these phage for human use at a medicinal level,” he said.
“We work in close partnership with the community, and they've raised it as a continuing issue, noting certain problematic bacteria in their adult populations that are extremely difficult to treat. That opened my eyes to the AMR crisis that we are facing globally.
“We also feel that being on the doorstep of Asia, which has the highest density population in the world, including numerous megacities, it is likely that they – and we – are going to see significant outbreaks of AMR in the near future.” Professor Kicic explained that his background as a researcher into respiratory conditions, particularly cystic fibrosis where those impacted tend to contract more viral, fungal and bacterial lung infections, set him on the search to find effective alternatives to antibiotics. “Maintaining lung health is a top priority for CF communities. Repeated lung infections lead them
“Even pharmaceutical companies are not investing in traditional antibiotics anymore. It's not beneficial. They're all off patent. There's no money to be made in it. We need to preserve the antibiotics that we've got available and look at new therapeutics, totally different to antibiotics, but which have the same effect.” However, Professor Kicic also pointed out that newest, alternative therapeutics had the same translation time to enter the market as antibiotics. “There will be a 15-20-year translational pipeline to make them readily available for the general public,” he said. “That's not going MEDICAL FORUM | NEW APPROACHES
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COVER STORY to help the current situation where we want to make an impact to this 20-year prediction of it being the leading cause of human death. “I needed to look at something that was going to be able to be implemented in clinics and help our doctors treat patients in the next two to five years. “Bacteriophage therapy was something that our CF community was aware of in terms of technology. Several Australian patients had been travelling overseas to be treated and the question was posed, ‘why aren't we doing this here in Australia?’ “As a result, I received a small grant to start a phage repository here in Perth against most of the bacteria that cause real problems for people with CF and begin the exploration process using AI. “AI has been adapted and implemented in many ways across medical research and assisting diagnostics, such as increasing the sensitivity and detection of cancer cells during screening. Even though it’s not mainstream yet in the clinic, the proof of principle is there.”
While the inclusion of pseudomonas, staphylococcus, and several other pathogens was respiratory related, Professor Kicic soon realised that his primary targets also caused infections at other sites. “For example, pseudomonas and golden staph can cause lung infections, but they also can cause skin infections and numerous complications after surgery, so you can imagine the potential,” he said. “However, we've got to be careful how we use it, it's not a golden bullet all the time. Once you have the correct phage that is active against the bacteria, you need to hit it hard, fast, and repeatedly to counter the active ability of the bacteria to develop resistance.” Horizontal gene transfer, a common trait associated with phage, can render an originally suitable bacteriophage suddenly ineffective for therapeutic treatment. “Once they start tolerating the bacterial genome, they become what we call temperate phage which, if internalised by the bacteria, will just integrate with their genome
host and grant the first signs of resistance,” he said. “As such, where we really place bacteriophage therapy currently is only when a patient identifies themselves as starting to develop problematic AMR. But eventually, we want to implement further upstream. Bacteriophage therapy is going to be prescribed as opposed to a course of antibiotics when you see your GP. “We're now at a point, some five years later, where even post pandemic, we've got the largest repository of bacteriophage against several prominent bacteria – the escaped pathogens – that are on the WHO priority list in Australia. “We have national ethics approval through our collaborators to start treating patients on a compassionate use basis where there is critical need, no therapeutic alternatives, and they don't have the luxury of time. “And finally, we have a small-scale manufacturing facility here in Perth where we can manufacture phage to the medicinal quality that we need.”
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AI
AI is here to stay By Eric Martin While the medical use of artificial Intelligence may currently appear confined to the labs and the realm of research in Australia, the reality is that many GPs in other countries are already using AI in the clinic. The funding pouring into areas of AI research and development is now often at rates outstripping traditional areas of medicine such as antibiotics. Last month, a European startup Nabla, which has already signed a partnership deal with a subsidiary of one of the biggest healthcare providers in the US – Kaiser Permeate – announced raising $24m to roll out the AI tool for doctors across its network. The Nabla Copilot was launched in March last year and is already being used by nearly 20,000 clinicians across the US and Europe. “Copilot is closely integrated with major electronic health records such as Epic and Nextgen and already handles more than 3 million consultations a year in three languages,” Nabla’s co-founder and CEO Alexandre Lebrun said. While Australian doctors may have glanced at the strategic recommendations made in policy statements by the various national medical groups, the sense of urgency behind the need for clear guidelines is now clear. While the AMA believes that AI may support the delivery of healthcare that is safe, high quality and patient centred – potentially advancing the healthcare system and the health of all Australians – the association has flagged a wide range of concerns that have serious legal and policy implications for healthcare providers. “The integration of AI into models of healthcare delivery will create unforeseen consequences for the safety and quality of care and privacy of patient, as well as for
the healthcare workforce and the medical profession,” the AMA said.
nationally and ensure that adverse outcomes are reported.
It has repeatedly stressed that a human must always be ultimately responsible for communication throughout the patient’s journey, noting that “regulation must ensure that clinical decisions are made with specified human intervention points during the decision-making process.”
“Our regulatory environment must ensure that AI tools developed by private profit-oriented companies do not undermine healthcare delivery nor trust in the system. If patients and clinicians do not trust AIs, their successful integration into clinical practice will ultimately fail,” the AMA said.
“The final decision must always be made by a medical practitioner and never by a person in a non-clinical role with the aid of AI, and this decision must be meaningful, not merely a tick-box exercise.
The need for extensive education for doctors and other health professionals on the ethical and practical application of AI in a clinical setting, has been highlighted by every medical organisation in Australia, and the dean of Harvard’s Medical School, Dr Bernard Chang, recently gave an insight into how this training could be incorporated into future programs.
“Increasing automation of decision making such as this could result in adverse outcomes for groups with diverse needs, particularly if the data used have systemic biases embedded in AI algorithms.” Given the high level of vulnerability to potential legal claims already faced by doctors, the AMA has highlighted the need for regulation that clearly establishes “responsibility and accountability for any errors in diagnosis and treatment.” “There will be many instances where a practitioner determines that the appropriate treatment or management for a patient is different from the suggestion of an AI or automated decision-making tool. In the absence of regulation, compensation for patients who have been misdiagnosed or mistreated will be impossible to achieve.” Healthcare organisations – from hospitals to individual practitioners – need to establish robust and effective frameworks for managing risks which ensure patient safety and guarantee the privacy of all involved. The AMA has recommended registering AI-based software as a medical device with the TGA as one way to enforce robust standards
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Dr Chang told JAMA that students would need to be more ‘human’ in their doctoring skills than ever before, “working at the highest levels of cognitive analysis, engaging in the most personally nuanced forms of communication, and remembering the importance of the actual laying on of hands.” “We [must] quickly move our students toward doing even higher levels of cognitive analysis, higher levels of understanding the individual patient nuance, which I think might still be difficult for AI to handle,” he said. “This includes higher levels of compassionate and culturally competent communication, which we know AI might have some difficulty with, and returning students to the primacy of the physical exam, which as far as I know, AI is not going to be replacing in the next few years.” Dr Chang said that as AI’s accuracy and efficacy increased with development, it would allow more time to be spent on doctor/patient interaction and personalised forms of treatment. FEBRUARY 2024 | 19
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FEATURE
Red alert for lowering bowel screening age In Australia, 45 is the new 50 when it comes to bowel cancer screening. But could that age recommendation go even lower, and how can GPs help?
By Suzanne Harrison Six years ago, mother-of-three Louisa Gardener had just reached her 50s when she was told she had late stage 3 bowel cancer. Not long beforehand, Louisa had suffered an accident when she was kicked by a horse – and suffered multiple injuries to her upper body. “It wasn’t until I was in hospital having further surgery after the accident that a nurse said I should have a further check of my bowels,” Louisa, now aged 57, told Medical Forum. “What this showed me was that cancer doesn’t play by our rules and can have different signs and symptoms. “I am one of the lucky ones. My surgeon did say that my decision to have a hysterectomy at the same time as the removal of the area where the tumour was made his job a lot easier. I am now monitored every three years for the rest of my life.”
20 | FEBRUARY 2024
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FEATURE Naturally, it was a challenging time for the former ski instructor. Her children were then aged 18, 16 and nine. And as far as she knows, there is no history of bowel cancer in her family.
at Parliament House, bringing together 50 early-onset bowel cancer patients plus medical experts to raise awareness and advocate for important policy change.
“My cancer did not show the classic signs of bleeding, weight loss and bloating, but a rather uncomfortable tummy. I also tried a change in diet as some foods disagreed with what was described to me as ‘women’s pains’.”
They called for increased Federal, State and Territory funding for colonoscopy services to ensure the public healthcare system meets the clinically recommended (<30 day) target as part of a ‘wait time guarantee’ as well as investment and improvement in primary care awareness of age bias and development of early-onset guidelines and referral pathways to ensure timely triage, diagnosis, and treatment for younger people.
Not that she hadn’t done the right thing and checked at the age of 50, either. A routine free screening test at that time came up clear. To learn that bowel cancer screening in Australia is now starting from the age of 45 for people of average risk is good news for those who have experienced the disease firsthand. It’s no wonder. Bowel cancer is the deadliest cancer for those aged 25-44, according to Bowel Cancer Australia (BCA).
Updated guidelines As a result – and after a five-year campaign by BCA – a milestone was reached in October last year when updated clinical practice guidelines were endorsed by the National Health and Medical Research Council (NHMRC). For the first time in Australia, population screening (for people at average risk of developing bowel cancer, i.e. those without symptoms) is now recommended every two years for people aged 45-74. Previously, it was 5074, along with a lowering of the National Bowel Cancer Screening Program start age from 50 to 45. “People aged 40-44 (previously 45-49) are also able to request screening via their healthcare professional before receiving their first NBCSP invitation,” the BCA said. Previously, only Australians aged between 50 and 74 were sent a free test kit by the NBCSP. It comes as a faecal occult blood test, or iFOBT. BCA CEO Julian Wiggins said an increase in young people being diagnosed with bowel cancer was the drive to lower the screening age and launch its #Never2Young. Of the 1,716 Australians diagnosed with early-onset bowel cancer each year, people aged 40-49 accounted for 56% of new cases and 64% of
deaths in those diagnosed under age 50. People under the age of 50 had an increased risk of developing bowel cancer when they experience one or more symptoms of abdominal pain, rectal bleeding, diarrhoea and iron deficiency anaemia between three months and two years prior to diagnosis. BCA recently launched its Never2Young advocacy agenda which seeks to improve care experiences and health outcomes for younger people by championing: • Greater awareness: among the community and health professionals of early-onset bowel cancer. • Lower screening age: in response to the increasing rates of bowel cancer in younger people. • Prompt GP referral: to a colonoscopy for all younger people who present with symptoms that may be consistent with bowel cancer. • Improved pathways: that ensure timely triage, diagnosis, and treatment for younger people. • Better understanding: the challenges of early-onset bowel cancer to improve and tailor treatment, support, and care for younger patients. • Further research: into the causes of early-onset bowel cancer, which has the potential to improve survival and/or help build a path toward a cure. Last year, the charity hosted the inaugural Call on Canberra
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They also urged that screening start from the age of 40 as part of the current Clinical Practice Guideline Review. Another Call on Canberra event is planned for June this year, and BCA is developing resources tailored to early-onset patients and GPs about the importance of investigating symptoms and prompt referral so bowel cancer can be ruled out as an underlying cause in younger Australians.
WA support In WA, Dr Hooi Ee, a gastroenterologist at Sir Charles Gairdner Hospital where he is director of endoscopy and clinical adviser to the WA Health Department on bowel cancer screening, said the recent news from BCA was welcome. Dr Ee was involved in the working party that contributed to BCA’s push to make the change. However, he says there is still a way to go to ensure that this change flows through to disadvantaged groups, namely those in need of further education and advice on bowel cancer. “I am pleased about the lowering of the age to 45, but we need to ensure that previously recognised inequities, that is, reduced participation and difficulties with colonoscopy access in certain groups, are not amplified, for example, among continued on Page 22
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Red alert for lowering bowel screening age continued from Page 21 socially disadvantaged, Aboriginal populations, remote areas, culturally and linguistically diverse groups,” Dr Ee said. “This requires more targeted education, greater focus on strategies to improve participation in these groups, and more directed pathways to access colonoscopy.” But with bowel cancer posing such a risk to younger people, does 45 go low enough? And where does this leave GPs, a group always at the frontline of such diagnosis? “Offering screening from age 40, in accordance with the updated guidelines, has the potential to maximise impact, saving more lives through early detection,” Mr Wiggins said. “In addition to screening, however, GPs have a critically important role in symptom assessment in younger patients.”
Recent research, headed by Dr Klay Lamprell from the Australian Institute of Health Innovation at Macquarie University, investigated advice from people with earlyonset bowel cancer on managing health service barriers to diagnosis.
“Early-onset bowel cancer patients are different from later-onset bowel cancer patients in their diagnostic trajectories; time to diagnosis can be 60% longer with a greater number of missed diagnostic opportunities; and younger people are more likely to be diagnosed in later stages of the disease.”
The research revealed younger people with bowel cancer symptoms found themselves selfadvocating as the only consistent and reliable source for overcoming age bias, barriers to diagnosis, and optimising outcomes for the deadliest cancer in those aged 25-44.
Late-stage diagnosis increases the likelihood of aggressive treatment with physical, psychosocial, and quality of life outcomes that are uniquely challenging for this under-50 patient population, especially with regard to fertility and ostomy management, he said.
Younger people may spend between three months and five years seeing multiple doctors before diagnosis. They may make 10 or more visits to GPs.
Role of GPs
“Even when younger people experience blood in their stools or rectal bleeding, GPs may not immediately refer them to specialists for further investigation,” Mr Wiggins said.
Dr Lamprell’s research found that patients perceive their GPs’ low suspicion of cancer, given their age, as a bias that shapes the nature of clinical assessments, influences the investigations conducted and referrals given, and creates tensions which obstruct shared decisionmaking.
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FEATURE
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FEATURE Eventual referrals and lengthy wait times for non-urgent colonoscopies were also a common theme of delayed diagnosis and a cause of patient dissatisfaction with GPs. Additionally, young people seeking diagnosis are also challenged by limited clinical awareness of earlyonset bowel cancer. “The researchers found with the rising incidence of bowel cancer in people aged under 50, there is a mounting imperative for GPs to receive more information and clinical guidance on early-onset bowel cancer diagnosis,” Mr Wiggins said. Cancer Council Australia said in a report that a recommendation from a GP has been shown to be the most significant factor in encouraging people to screen for bowel cancer with (iFOBT). One survey showed more than 90% of respondents would be ‘likely’ or ‘very likely’ to have an iFOBT every two years if advised by a doctor. Pilot program invitees who did not participate reported a greater likelihood of doing so if it was recommended by a GP, the council said.
“GP involvement is, therefore, critical to optimal participation in bowel cancer screening programs. While there is evidence that GPs support bowel cancer screening, they have articulated a need for further education on the issue.” Elsewhere, lowering the screening age to 45 was implemented in the US in 2021. Recommendations to begin screening from the age of 45 were first introduced there in 2018, when the American Cancer Society updated its guidelines in response to rising rates of the cancer and mortality in young and middleaged populations. BCA says that by 2021, the American College of Gastroenterology, the US Preventative Task Force and the US Multi-Society Task Force on Colorectal Cancer had all joined the ACS in updating their guidelines to the recommended 45 rather than 50. In the UK, it is being lowered, but from 60 to 50.
the screening age is one step forward, it doesn’t address the rise in early-onset bowel cancer,” said BCA medical director Associate Professor Graham Newstead. “Younger people need to be aware of, and act on, these potential signs and symptoms and have them investigated to rule out bowel cancer as an underlying cause.” This is not news to Louisa, who can’t stress enough the importance of being on top of screening, especially with modern dietary habits. “My feeling to testing now is that we are very good at being aware of what we can see on the outside and then doing something about it. But what we can’t see, we sweep under the carpet and forget about,” Louisa said. For more information: www.bowelcanceraustralia.org
But what else needs to be done in Australia to combat such a serious disease in younger people? “While we recognise lowering
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MyMedicare – it’s off, but slowly
The registration phase of MyMedicare is in progress but WA doctors want to see better education of patients of its benefits.
Eric Martin reports The MyMedicare system was rolled out as the start of the Federal Government’s new plan for improving primary care for patients with chronic conditions, yet nearly six months later, it has been hard to gauge its impact beyond the sign-up figures touted on occasion by the Federal Minister for Health and Aged Care Mark Butler. “Around 2600 general practices have registered with the government’s new voluntary patient enrolment service MyMedicare, representing nearly 40% of the 6500 practices in Australia,” he said in October. His figures matched those in recent survey findings by GP education provider HealthEd, which revealed that 55% of respondent practice owners said they had already registered with MyMedicare (39%) or intended to do so (16%). That left nearly half of practices across Australia ambivalent about the supposed benefits on offer or too busy to complete the extra paperwork. Tellingly, the survey also asked GPs whether MyMedicare was likely to have sufficient engagement from practices or patients to be successful – a pointed question to which 68% of doctors surveyed said ‘no,’ which begs a further question, is MyMedicare just another stop-gap technological solution, or could it really provide value for the registered practices and patients with chronic conditions?’
24 | FEBRUARY 2024
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FEATURE
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FEATURE Medical Forum spoke with Dr Ramya Raman, a GP and Chair of the RACGP WA, about the feedback the college has been getting from their members and how to encourage more engagement from the medical community – not just GPs – to make it more effective.
RACGP was still working with the government to establish a time frame for the rollout and highlighted the need for timely and effective communication by the Health Department to address the known pain points for registration.
“The concept of MyMedicare is there to support GPs, to enable them to provide more comprehensive care to patients with chronic conditions who will benefit from a long-term relationship with their usual GP – the level of access is probably the key to it,” Dr Raman said.
“It has become clear very early on that GPs need to educate their patients about MyMedicare. That was a real pain point for me as a GP on the ground and the college is calling for the government to learn from these personal experiences and work more collaboratively towards a scheme that is going to be effective, but at the same time is appropriately paced for general practice.
“The intent is to ensure that there is continuous care by the general practice multidisciplinary care team and, I would say that, from a patient's point of view, it enables their opportunities to access their GP in more than one way, not just a face-to-face consultation.
“It's really important to take the patient with you as a GP, because their first question is often, ‘why would I want to?’, ‘Why do I want to do this (signing up for another government initiative) again?’ ‘What is the difference between this program and my current situation?’
“Ultimately, it will reduce the number of hospital presentations and the level of stress on the State health system – there's been several studies to show that a patient who has a longitudinal relationship with their GP has fewer hospital presentations.
“But we're not able to give many details out beyond the intent to have better coordinated care and make sure that patients see their GPs more regularly.”
“Practically, the tripling of the bulk billing incentive for the longer C, D and E telehealth items for registered patients means that there's going to be better access for our rural and remote patients.” However, Dr Raman said the college was still trying to understand all that is entailed in the MyMedicare package. “As to exactly how the system is going to ensure regular follow-up for those patients to keep them healthier in the community, provide better management and treatment options, and keep them out of hospitals – those are the details that are still being progressed,” she said. “We know it's a phased model that's being rolled out and right now it's still just the registration process. And that's where the college has been in consultation with the government to ensure that the policy is practical and uses our feedback to determine the best implementation model – one that will be the most appropriate for the GP, the practice, the patient and the community.” Similarly, Dr Raman said that the
Currently, the main advantage of signing up early is access to Medicare rebates for telehealth consultations longer than 20 minutes – the aforementioned consults C, D and E – which were scrapped for non-registered patients last year. This means that Medicare will cover almost half the consultation fee for long telehealth appointments for registered patients, further supported by the highly praised tripling of the bulk-billing incentive for these consultations when provided to children under 16, pensioners and concession card holders, which came into effect on November 1, 2023. However, Dr Raman said that one of the main questions facing GPs was the exact nature of the other comprehensive care on offer, and how GPs and practices would coordinate it, noting that as the rollout was planned to take place over three years, the government has already indicated that two more benefits for registered patients would be announced by mid-2024. While the exact details (just like everything else) are still sketchy, the Department of Health revealed that
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one will be an Aged Care Incentive, which would partially reimburse doctors for making regular visits to MyMedicare registered patients in residential aged care; while the other, the Frequent Hospital Users Incentive, would pay a similar bonus (the value of which is still unknown) for providing comprehensive, multidisciplinary care for these patients in the community, reducing their number of visits to hospital. “But what are the incentives around that and how can we manage their care with other non-specialists and specialists if needed?” Dr Raman asked. “I speak to non-GP specialists and colleagues who have highlighted that patients often have several touchpoints in the system and everyone in that system needs to know about that patient’s MyMedicare registration so that they can direct the patient in the most appropriate way. “That's why it's so important to not just make it a GP issue. It's about being aware system wise as well and I think governments need to get that messaging out to non-GP specialists as well.” Dr Raman pointed out that the necessary education about MyMedicare needed to come from multiple levels to be effective. “There's a certain level of education that occurs from a GP and a GP practice. And then there's education that needs to come from external sources, such as the media and the government, and this is the area where we would currently like to see more definitive action,” she said. “We have a lot more work to do to ensure that the community actually understands what this means and how it's going to be beneficial for them.” Patients can register using their Medicare online account, the Medicare app or in person at their GP practice, and while selecting one particular clinic and one preferred doctor does not prevent patients from making appointments elsewhere, they will only be able to access the benefits of the MyMedicare scheme at their registered practice. Patients are free to change their preferred practice or GP at any time but will need to attend two face-to-face appointments before their telehealth benefits resume.
FEBRUARY 2024 | 25
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FEATURE
Letting women know it’s ‘safe to tell’ A WA educational program aims to equip doctors with the tools they need to tackle an often-invisible form of abuse.
By Cathy O’Leary Violence against women is a global public health and human rights issue, with one in three women experiencing in their lifetime physical or sexual violence by an intimate partner. Many experts believe that screening in primary care offers the ideal opportunity for often-invisible abuse to be identified because GPs are trusted and well-placed to connect survivors with counselling or other services. It is estimated that full-time GPs see up to five women a week who have experienced some form of intimate partner violence (IPV) or reproductive coercion and abuse (RCA). However, research suggests that typically only one-third of women experiencing intimate partner abuse disclose this to their GP. Some women find it difficult to spontaneously disclose their experience for a range of reasons, including fear that they will not be believed, concerns about how they will be treated by the health or justice systems, or particularly the fear of reprisals from their partner. And while some healthcare providers report significant personal discomfort in broaching the subject, research shows that many women want their doctor to raise the issue and would in fact disclose their experience of violence if directly asked.
26 | FEBRUARY 2024
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FEATURE As a result, Northbridge sexual health clinic SHQ was prompted to develop educational tools for health professionals to help them provide women with a safe and private environment for disclosure and timely referral to appropriate services.
Successful pilot After a pilot program showed its benefits, the program Safe to Tell was rolled out more widely to provide education, training and support to professionals across the health sector, including GPs and specialists. It has self-paced modules to increase health professionals’ knowledge and build skills in recognising signs of intimate partner violence and reproductive coercion and abuse – and how they can refer appropriately.
launched a few years ago, it had provided online and faceto-face education for GPs but it was important that more doctors were aware of the resource. She said there was a recognised link between negative sexual health outcomes and intimate partner violence and reproductive coercion, but the behaviour was often not picked up in general practice or elsewhere. “It is something that is easy to miss and people don’t necessarily raise it if it’s happening to them,” she said. “One of the barriers recognised in the literature is not knowing what to do or being aware of the resources, so overcoming this by providing some
SHQ medical educator Dr Alison Creagh said that since the project
education and resources can allow GPs to help their patients.” RACGP’s WA chair Dr Ramya Raman, who is on the Clinical Education Advisory Group running the project, said women affected by intimate partner violence and reproductive coercion needed to feel safe to speak up. She said the Safe to Tell team had developed tools, programs and educational resources, and when the e-learning tool was launched, many GPs in remote and rural areas reported back saying it had been very useful in their clinical practice. “Initially, a key reason that the education advisory group took my interest was because on ground level as a GP this is a really challenging area and subject to actually raise with patients,” she said. continued on Page 29
What’s the problem? Family domestic violence includes intimate partner violence and reproduction coercion and abuse, which both impact on women’s health and safety. Intimate partner violence is a pattern of abusive, coercive, or controlling behaviours experienced by someone in an intimate relationship. In Australia, IPV disproportionately affects women, who are nearly three times more likely than men to experience violence from an intimate partner, and almost four times more likely than men to end up in the hospital after an assault from a partner or spouse. It is behaviour by someone in an intimate relationship that causes physical, sexual or psychological harm to those in the relationship. This includes current or past marriages, domestic partnerships or dating relationships, and can present as: • acts of physical violence, such as slapping, hitting and beating • sexual violence, including forced sexual intercourse and other forms of sexual coercion. Reproduction coercion and abuse is when someone’s reproductive health is controlled by their partner. It is a serious public health issue which often goes unnoticed by many health care providers and unrecognised by the women who experience it. RCA can refer to many behaviours, including: • contraceptives being sabotaged so they won’t work • threats or use of physical violence if a contraceptive is requested, • emotional blackmail around sex, pregnancy, and termination, • controlling one’s freedom to seek help without the presence of the partner, and • sexual assault.
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FEBRUARY 2024 | 27
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FEATURE
Letting women know it’s ‘safe to tell’ continued from Page 27 “And equally so, many patients don’t come in presenting with the complaint that things are not okay at home, and might not even recognise that what is happening at home is a form of domestic violence.
An open mind “So, trying to have that open mind, and that knowledge and ability to help the patient appropriately and in a timely fashion, takes a bit of training on the part of the GP – and that’s the reason why I got involved.” Dr Raman said working in a lower socio-economic area for some time and being of Indian heritage meant she saw a wide range of patients from ethnic diverse populations. “There is sometimes a sense of taboo or shame, or maybe even a sense of acceptance, in certain cultures and backgrounds, so we have to adapt our conversations and clinical consulting style for the patient’s needs because they might not recognise there is a problem,” she said. “It’s about educating and empowering them, and then if and when they’re ready, enabling them to break out of that cycle. “It’s a two-way channel, and that journey takes time, and the GP is well-positioned to go through that timeframe and journey with the patient.” Dr Raman said there were often complex family dynamics that had to be considered too. “For women, who are the majority in this area – which is not to say it doesn’t happen to men – there are some circumstances and financial implications which can be a barrier (to taking action),” she said. “For example, grandparents might live with them, or the husband’s family members might live with them. “There are also differences in thinking between western culture and eastern culture, and the expectations, so when these situations arise, they might occur
in a family scenario where’s there more than a partner and their kids involved, which makes it harder to call it out. “Family sexual violence is difficult, and we don’t know what emotional turmoil is involved behind the scenes, and that’s why we need to get the message out to doctors, and it’s not just for GPs. “There are opportunities for emergency physicians or other hospital staff, and hopefully that non-GP specialist would pick up the phone to the GP and say ‘hey, this has just been divulged to me and can you look into it’.” Like many areas of primary healthcare, picking up problems was often opportunistic. “Around 90% of the time in my own clinical experience and teachings – women do not present with this complaint. You need to establish a sense of trust, and that takes time, and it may take opportunistic segues and the doctor needs to be well-informed to look out for that,” she said. “But having resources is so important because as a GP the worse thing is when you’re sitting there and you’re not sure what to do and what’s the best next step or resource.
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“With this project, the resources are WA-based, for metro, outermetro, rural and remote areas, and there are numbers and online resources, and some of it is about myth-busting things like controlling someone’s freedom, or contraception being sabotaged or emotional controls – the behaviours which women might not think are a problem.” For more information on the Safe to Tell project go to: www.shq.org.au/resources/safeto-tell/ Other referral points: 1800RESPECT (1800 737 732) National domestic, family and sexual violence counselling, information and support service. Women’s Domestic Violence Helpline (24/7) 9223 1188 or free call 1800 007 339 SARC (for recent sexual assault) (24/7) 6458 1828 or free call 1800 199 888 Mental Health Emergency Response Line (MERHL) (for suicide risk mental health assessment) 1300 555 788
FEBRUARY 2024 | 29
Secret life of proteins is now free for all An algorithm which has helped scientists around the world better understand how human proteins take shape has won a Perth researcher a prestigious international award.
structure of proteins made by all living organisms – knowledge that could help to supercharge research into diseases including cancer and dementia and viral infections such as COVID-19.
Telethon Kids Institute computational biologist Dr Timo Lassmann, whose work as a young PhD student more than 20 years ago helped to crack one of biology’s biggest mysteries, has been recognised for making his work available to the open-source community.
Proteins and the chains of amino acids they are made from are the essential building blocks of living organisms, existing in every cell in the human body. A protein’s shape helps determine its function in the human body but until recently, scientists have only been able to measure the shape of a tiny fraction of the estimated 20,000 proteins expressed by humans.
Scientists have long sought to understand how to predict the
developed and made freely accessible to scientists everywhere by Dr Lassmann, artificial intelligence company DeepMind largely solved this problem.
In 2021, with help from an algorithm
Now part of Google’s AI arm, DeepMind used the Kalign program created by Dr Lassmann to help build a breakthrough method known as AlphaFold. It is based on a concept called deep learning, with the structure of a folded protein represented as a spatial graph. AlphaFold was subsequently used to accurately predict the shape of thousands of proteins, achieving within days what might otherwise have taken years to establish through traditional laboratory methods.
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NEWS
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NEWS extremely large projects powered by the development of genome sequencing technologies,” Dr Lassmann said.
The artificial intelligence technology was able to determine the shape of many proteins with accuracy comparable to laboratory experiments.
“It is now being used across a wide range of applications, from constructing the human genome reference annotation to studying the mutational processes in SARSCov-2 and antimicrobial resistance genes, and virulence factors in bacteria.”
Dr Lassmann, now an internationally respected leader in the field of computational biology, said he had been surprised to discover that the DeepMind team had incorporated Kalign – albeit in a supporting role – into their groundbreaking AlphaFold method. “This is particularly gratifying, as I have been an ardent admirer of the DeepMind team since their pioneering AI work on Q-learning and AlphaGo,” Dr Lassmann said. Dr Lassmann recently received Google’s Open Source Peer Award for his work, which began 23 years ago when, as a first-year PhD student with the Karolinksa Institute in Sweden, he was trying to understand the evolutionary history and function of protein and DNA sequences. Confronted with the daunting task of manually analysing thousands of sequences, he opted to create an algorithm to automate the process.
Dr Lassmann said the achievement demonstrated the far-reaching influence of basic discovery science. “Initially, I underestimated the complexity of this task, but it forced me to deeply study the analysis of biological sequences and master advanced programming techniques, leading to a significant breakthrough,” he said. The work culminated in six firstauthor PhD publications, with Dr Lassmann releasing all his computer codes as open-source software – making them freely accessible to the global academic community.
“Discovery science is not merely a precursor to translational research – it is the principal driver of scientific innovation,” he said. Researchers around the world have now used AlphaFold to predict the structures of 350,000 proteins belonging to humans and other organisms.
“Fortuitously, the utility of Kalign grew due to its ability to scale to
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GUEST COLUMN
Keeping the playing field fair for all Doctors have a role in supporting special needs students at exam time, without giving an unfair advantage, according to education consultants Carolyn Hackett and Glenn Carroll. Each year, about 13,500 Year 12 candidates sit the Australian Tertiary Admissions Rank (ATAR) course examinations, which are run by the School Curriculum and Standards Authority in WA.
be considered in a consistent and equitable manner across the nation. To support this, it is important that recommendations being made for adjustments should also be consistent.
They are considered high-stakes, as the results are used for entry to university, identification of award winners and gaining scholarships. It is, to an extent, understandable that there are some students, or parents of students, or indeed schools, who seek to maximise students’ performances in the examinations to improve their results and gain advantage over other candidates. The School Curriculum and Standards Authority is committed to all students having access to curriculum and assessment that is appropriate to their needs. The authority recognises that for some students the impact of a medical condition, disability or impairment may be a barrier to accessing an assessment to demonstrate their knowledge, understandings and skills. Where the disorder significantly impairs access, such students may need adjustments to standard format assessments. The way that requests for adjustments are considered is outlined in the Authority’s Equitable Access to Assessment Policy. The underlying principle of this policy and its associated guidelines is to provide students with the opportunity to participate in and complete their assessment in an equitable manner. Adjustments are not intended to provide individual students with the opportunity to maximise their performance or gain advantage over others. Last year, the authority saw an increase in the range of
adjustments being requested, and this may have provided some individuals with an unfair advantage in the ATAR examinations. This included requests for extra working time and use of a computer. Some of the recommendations for these adjustments will have been written in response to student requests. Other recommendations may have been made unwittingly, and without knowledge of the policy and guidelines. In 2023, nearly 1200 candidates requested adjustments to the standard conditions under which they were to sit the examinations. This was a significant increase on previous years, especially in the areas of ADHD and anxiety disorders. Many of the requests were outside the scope of the policy and were not approved. In many cases, a lesser level of adjustment was demonstrated to be appropriate and was approved. The Equitable Access to Assessment Policy has been developed in consultation with other assessment jurisdictions around Australia to ensure a consistent approach to supporting students with identified barriers to assessment under standard conditions. As the examination results from each jurisdiction leads to the calculation of the ATAR, it is important that students’ needs and their requests for adjustments
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To assist medical professionals in Western Australia being asked by patients to support requests for adjustments, the authority is keen to ensure all practitioners have access to the same information, and that recommendations being made for adjustments remain within the agreed framework, considering the nature and severity of the student’s medical condition or disability. The authority therefore requests, before any recommendation is made regarding adjustments, medical practitioners consult the EAA Policy so that it remains within the guidelines. More information, including the policy, guidelines and support documents outlining the implementation of adjustments, can be found at https://seniorsecondary.scsa.wa.edu.au/ assessment/examinations/specialprovisions. Staff from the Special Provisions team are available to discuss reasonable adjustments and to provide guidance for unique situations that might not clearly fit with the published guidelines, by phoning 9273 6316 or emailing specialprovs@scsa.wa.edu.au. The assistance of medical practitioners in providing reasonable support for those examination candidates demonstrating special needs is appreciated. ED: Carolyn Hackett is Principal Consultant and Glenn Carroll is Senior Consultant – Special Provisions with the Education Department’s School Curriculum and Standards.
FEBRUARY 2024 | 33
Thwarting a killer and keeping trust Could medical technology prevent a hospital tragedy, asks med-tech consultant Ivor Campbell. The crimes of convicted UK serial killer Lucy Letby shocked the world, devastated the families of her victims and undermined confidence in a healthcare bureaucracy that allowed her to murder seven babies and attempt to kill six others, long after she should have been detected and stopped. The failings at the Countess of Chester Hospital, in the north of England, where she worked as a neonatal nurse between 2015 and 2016, were undoubtedly human. Central to the tragedy was a refusal by senior decision makers to believe that a woman trained to care for grievously ill, newborn babies was capable of murdering and injuring them. Of course, there is no completely foolproof way to ensure that disturbed and deranged people can never inveigle themselves into situations where they can perpetrate harm. Human nature will always ensure that the most deceitful perpetrator has an advantage over even the most sceptical gatekeeper. Letby exploited not only the naiveté of a credulous employer, but also the hospital’s refusal to countenance the possibility that it had a serial killer on its staff through fear of the reputational damage that would ensue. Healthcare professionals who kill patients are, thankfully, extremely rare but this case has implications for hospitals and health authorities throughout the world. The public inquiry which began late in November last year will consider all of these issues. Doubtless, many of the proposed changes it will make will concern tightening procedures around recruitment, management and clinical oversight, but how effective can they truly be? Could medical technology have been better deployed to detect 34 | FEBRUARY 2024
what Letby was doing? And could advances in artificial intelligence (AI) and diagnostics hold the key to preventing a repeat of her campaign of carnage? One of the first questions the inquiry will consider is Letby’s character. Was she a one-off, or was there anything in her past, or in the patterns of her behaviour, to indicate that she was capable of murder? While the crimes of the like perpetrated by Letby are rare, it is doubtful that a form of psychological profiling could have identified any risks in employing her, according to Dr Marissa Harrison, a professor of psychology at Penn State Harrisburg. In a profile of ‘typical’ female serial killers (FSK) compiled by Harrison and her team for The Journal of Forensic Psychiatry & Psychology in 2015, nearly 40% were nurses, nurses’ aides, or other healthcare workers. Their analysis showed that a FSK was likely to be white, Christian, average looking or attractive, and in her 20s or 30s – very similar to Letby but also to many of her colleagues. So, while profiling may have identified Letby as a potential serial killer, it would also have identified many other nurses or health professionals who would never dream of harming another human being. However, could advances in medical technology and diagnostics offer more effective possibilities to identify signs of malicious intent among healthcare staff, ensuring early intervention to prevent patient harm? Automated systems can already continuously monitor patient vitals, medication administration, and treatment responses, alerting clinicians to deviations from expected patterns.
Letby killed and harmed babies by injecting them with air and insulin and by overfeeding them. Dr Dewi Evans, a clinical expert who provided medical evidence that resulted in Letby’s conviction, reviewed clinical notes of more than 30 babies who had either died or collapsed between January 2015 and July 2016. In most cases, the cause of death was identified as natural explainable, for example after suffering a haemorrhage, infection or because of a congenital problem. However, in the cases of 15 babies, their collapse was unexpected and could not be explained as natural. Several of the babies had evidence of an air embolism, as if someone had injected air directly into their circulation. Others displayed signs of having had milk, or milk and air, injected directly into their stomachs, had high levels of insulin in their systems or they showed signs of having suffered direct trauma, with traces of blood found around their mouths or at the back of their throat. Evans said staff were only alerted to the insulin poisoning after reexamining a set of twins who had been harmed in other ways. It is clear that early detection of irregularities in medication administration, patient responses, or mortality rates should have triggered investigations and interventions earlier, potentially identifying anomalies and prompting timely actions to prevent further harm. Additionally, an earlier close examination of electronic health records (EHRs) could have provided faster tracking of patient care, providing an audit trail for every action taken by medical professionals. Machine learning, in such cases, will become increasingly more valuable because algorithms can analyse vast datasets to detect subtle MEDICAL FORUM | NEW APPROACHES
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Time to progress telehealth Telehealth can make a big difference for people with disabilities but access is the name of the game, writes Curtin University researcher Cloe Benz. Telepractice and telehealth have the potential to significantly improve access to disability and health services for people with disability, but only if they know how and why. People with disability often have more frequent and prolonged interactions with health and disability service providers. The integration of telepractice can improve their time and cost burden and provide a valuable delivery strategy to use in combination with in-person care. Telepractice in the form of videocalls refers to accessing services predominantly provided by disability support service providers, whereas telehealth is the term used for health and primary care interactions. In the context of this article when referring to telepractice, I do so for brevity and intend to include all interactions of people with disability both in the health and disability sectors.
Demystifying One of the biggest barriers identified in the use of telepractice is the limited understanding for both consumers and clinicians regarding how and when it can be beneficial. Access to information, both theoretical and applied case examples, are valuable in enabling potential users to relate the use of telepractice to their own situations. For example, in the case of a young child accessing multiple types of
patterns that might indicate foul play or negligence. However, while the prospect of using medical technology to identify malicious intent is promising, it also presents challenges. Context matters, and deviations from
weekly therapy, telepractice can provide the opportunity for them and their family to go on holiday while maintaining continuity of care. This hypothetical situation was specifically mentioned by a mother, who remarked that they would love a holiday, but it never seemed possible until telepractice became an option. Another example included enabling young adults to maintain regular working hours more consistently through accessing services remotely, decreasing travel time and improving flexibility in their location to access care. These two cases exemplify the opportunities of telepractice as a valuable addition to in-person care and personalised delivery of services.
Not a replacement Fears stemming from the COVID-19 pandemic, relating to telepractice becoming a replacement for all in-person services, are relatively common. The perception that telepractice is a last resort, and a substandard alternative to inperson care, significantly hampers positive progress in telepractice implementation which occurred during this period. Use of language which enables better understanding of telepractice, not as a replacement but an addition to in-person care, may help to alleviate these fears and facilitate better uptake. Telepractice and in-person sessions
are good for their intended use but not great as a replacement for the other. Separating telepractice from the notion of a poor in-person replacement helps to acknowledge what it is meant to be rather than focusing on what it is not.
Mutual understanding Telepractice as a way of delivering services is completely different to more familiar in-person methods, and as such it should be intentionally designed as a virtual service. Working directly with people with disability and clinicians to co-design how telepractice services are delivered, is crucial for its integration into everyday practice. Most current models were haphazardly implemented in the early days of the pandemic, and collaborative processes were not possible. Highlighting current strengths of these services and opportunities for improvement are essential to safeguard the sustainability and usability of telepractice moving into the future. Through processes such as mapping the consumer journey, better understanding of bottle necks and pain points can be gained, and solutions implemented. People with a disability want more accessible and integrated services, and telepractice is a prime opportunity to facilitate progress. ED: Cloe Benz is a PhD candidate at the Curtin School of Population Health
norms may arise due to genuine reasons such as workload, fatigue or personal issues.
and judgment remain crucial in interpreting data and making informed decisions.
Technology should serve as a tool to raise red flags, rather than as irrefutable evidence of malicious intent. Human oversight
ED: Ivor Campbell is Chief Executive of Snedden Campbell and a specialist recruitment consultant for the medical technology industry in the UK.
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FEBRUARY 2024 | 35
“One in five Australian adults are estimated to live with chronic pain.” (Commonwealth of Australia, Department of health, 2021)
Chronic pain can be debilitating and have adverse effects on work, sleep and relationships often leading to comorbidities such as, depression, sleep disturbances and fatigue resulting in worsened health and negative societal and financial impact. An increased reliance on pain medications and the concurrent disorders associated with chronic pain may place individuals at a higher risk of developing a substance use disorder.
Risk factors for Substance use Disorders: Recurrent and easy access to substances Stress and financial difficulties Any mental illness or impairment PTSD and trauma.
Signs & symptoms of a substance use disorder: Frequent requests for early prescription refills Social withdrawal or neglecting responsibilities Physical changes; weight, poor hygiene or skin problems Taking higher doses or more frequently than prescribed Patient requesting prescriptions on first visit, “doctor shopping” Changes in mood or behaviour; agitation, irritability and mood swings Defensive or evasive when questioned about medications.
We can help... If you suspect that a patient may have a substance use disorder, please refer them to Fresh Start, or a suitable specialist. Referral forms can be found on our website www.freshstart.org.au or call our clinic on 08 9381 1333 36 | FEBRUARY 2024
E info@freshstart.org.au T 08 9381 1333 65 Townshend Road, Subiaco, WA 6008 MEDICAL FORUM | NEW APPROACHES
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Dr Joe Kosterich | Clinical Editor
Transparency – a new approach Over 20 years ago freedom of information (FOI) laws were applied to medical practices. Doctors became legally obligated to provide their files to patients making an FOI request. There was significant concern at the time, which largely proved to be misplaced. Relatively few requests have been made.
Privacy is important. What we do in our personal lives, where it does not interfere with others, is nobody else’s business. What we do with our medical hat on does need to be transparent and this is regardless of whether we are in the private or public system, employee or selfemployed.
However, the idea that notes could be seen at any time by patients did lead to some changes in how notes were made. Transparency is a key part of accountability. As the local saying goes “don’t say or do anything you would not like to see on the front page of the newspaper.” America has similar FOI laws. The Free Press reports that The American Academy of Paediatrics (AAP) issued a directive to all members to stop using work emails due to concerns about subpoenas and FOI requests. The directive was broad: “…members who serve on the AAP Board of Directors as well as AAP committees, councils, sections, task forces, editorial boards, educational planning committees, authors of publications and policy, and other AAP advisory bodies are required to use personal email accounts for communications relating to AAP matters and may no longer use their work email.” Transparency was also out of favour here during the pandemic when health advice which impacted the entire State was kept secret and FOI requests stymied. The contrast with what private doctors are required to do if issued with an FOI about the advice provided to an individual patient is stark. Why the AAP is going down this path can only be speculated on and seems pointless, as emails from private accounts can also be leaked or subpoenaed. Some years ago I read a prediction that the further we went into the 21st century the harder it would be to hide. Actions of major institutions (previously hidden) have been revealed with some regularity. The internet has given whistle-blowers a tool previous generations lacked. Privacy is important. What we do in our personal lives, where it does not interfere with others, is nobody else’s business. What we do with our medical hat on does need to be transparent and this is regardless of whether we are in the private or public system, employee or selfemployed. This month we focus on “new approaches”. Medicine has a history of secrecy. In centuries past this was accepted. In the 21st century it is not and demands for transparency will only increase. The AAP has given us a good lesson in what not to do.
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FEBRUARY 2024 | 37
Rethinking diabetes in children By Dr Sarah Black & Dr Craig Taplin, Perth Children’s Hospital A 13-year-old boy presents to your rural GP practice with a sore throat, abdominal pain and general malaise. You note he is tachypnoeic. His mother mentions some weight loss over the past two weeks though she had not been concerned about this because his weight was >95th centile and BMI >98th centile. You prescribe amoxicillin but he re-presents the next day with his mother. After being asked directly, his mother recalls her son has had polyuria and polydipsia for a few weeks. A finger prick blood glucose level (BGL) reads ‘high’. A finger prick ketone level is 5.5. He is not his normal self, with breathing observed to be deep, rapid, and laboured. You send him to the emergency department. On arrival at the regional ED, he is drowsy and confused, with GCS 1315, pulse 130 bpm, and normotensive. Skin perfusion is slow at 3.5 seconds and his blood gas is: pH 6.85, PCO2 19, Bicarb 3, BE -30, Na 123, K+4.2, glucose 38, ketones 7. He is transferred via Royal Flying Doctor Service to a paediatric tertiary referral intensive care unit, treated with an IV insulin infusion and IV fluids according to the local diabetic ketoacidosis (DKA) protocol. Once his acidosis normalises, the boy is transitioned to subcutaneous insulin and – while in hospital with his family – educated about type 1 diabetes (T1D).
How many children have T1D, and how many have DKA at diagnosis? Over recent decades there has been a well-documented increase in the incidence of T1DM in WA, Australia, Europe and the USA. In WA the prevalence of moderate to severe DKA at the time of diagnosis has also increased. A recent WAbased study identified 2111 children diagnosed with T1DM <16 years of age over a 20-year period. Moderate-severe DKA at diagnosis 38 | FEBRUARY 2024
occurred in 25.3% of this group and may be associated with a more adverse long-term trajectory for glycaemic control.
When might DKA be more difficult to diagnose? Most clinicians can identify a classical history of T1DM in a school-aged child, presenting with polyuria, polydipsia, weight loss and hyperphagia. In Europe, public health campaigns focusing on new onset enuresis in previously dry children – a more subtle sign of T1DM – are having success in preventing DKA. Children <5 years of age, who may be variably toilet trained and in whom symptoms may be less clear or more difficult to distinguish from common early childhood illness, are a more challenging group to diagnose. Consider T1D in a young child with increasing lethargy, weight loss (or poor weight gain), or increasing frequency or heaviness of wet nappies. Another diagnostic conundrum is differentiating between T1DM and T2DM. Australian youth have high rates of obesity, and we now see similarly high rates of obesity in T1DM. Furthermore, T2DM remains uncommon in pre-pubertal children. It is important not to assume a
new diabetes diagnosis in obese youth is T2DM. While T2DM is increasingly common and important to consider, most youth presenting with symptoms consistent with hyperglycaemia will have T1DM. Without prompt diagnosis and treatment, they are at risk of severe clinical deterioration. Ketosis may also be seen in youth with T2DM, and a severe presentation with DKA, the hyperosmolar hyperglycaemic syndrome, or a mixed picture may certainly be seen in youth with T2DM. A general index of suspicion and prompt discussion with a paediatric tertiary diabetes service and referral to emergency services is important in all youth with newly detected diabetes.
Missed diagnosis and differentials Children with T1DM generally have symptoms for several weeks before diagnosis, becoming more obvious with time. A substantial proportion of children diagnosed with T1DM have interacted with the health care system and had an assessment by a healthcare provider at least once before a formal diagnosis of diabetes or presentation with DKA. A delayed diagnosis of T1DM or DKA may be explained by symptoms that MEDICAL FORUM | NEW APPROACHES
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CLINICAL UPDATE could be rationalised or diagnosed as something else. For example: • polyuria – urinary tract infections • Kussmaul breathing – the tachypnoea and respiratory distress of a respiratory tract infection • polydipsia – increased thirst due to heat or increased physical activity (i.e. in summer) • vomiting – gastroenteritis • abdominal pain (which can be caused by ketosis/DKA) – other common childhood illnesses • weight loss – intentional attempted weight loss in overweight children or accelerated linear growth, especially in adolescents. Weight loss in growing children should always raise concern and a diagnosis of diabetes be considered.
specific symptoms such as abdominal pain, nausea/vomiting or rapid, deep breathing (regardless of age or weight), get a blood glucose level (and a ketone level if possible). Patients with DKA can deteriorate quickly. Mortality is < 1% in Australia and due mainly to cerebral injury, but morbidity due to complications such as more subtle neurocognitive insult, acute kidney injury, venous thrombosis and pancreatitis can occur. All, however, are potentially preventable if hyperglycaemia in the differential diagnosis is considered early.
The next steps once you suspect diabetes?
If the BGL is >11 mmol/l (or fasting blood glucose >7 mmol/L in a less acute situation), the patient should be discussed immediately with the local on-call endocrinology team. Where there is any question about T1DM, the patient should be sent to the ED. Once stabilised, patients and families will undertake education with the multi-disciplinary diabetes team (nurse educators, dietitians, social workers and endocrinologists) with close outpatient support and follow-up to coordinate care after discharge home from hospital.
If a patient presents with non-
The international standard of care
Other less classical symptoms include behavioural disturbance, reduced school performance, blurred vision, impairment of growth and recurrent candidiasis.
is that all youth have access to at least quarterly diabetes clinic visits and 24/7 access to emergency phone support for diabetes-related acute concerns. All youth in Western Australia (approximately 1200 with T1DM and 100 with T2DM, with approximately 150 new children diagnosed annually) receive tertiarylevel care through the Diabetes Service based at Perth Children’s Hospital. Where possible this is provided every three months in agegrouped multi-disciplinary clinics. Approximately 40% of the service’s state-wide diabetes clinical care is provided in regional WA. These regional clinics are fully staffed by the Perth Children’s Hospital diabetes team. Partnering with our colleagues in general and community practice settings is highly valued and important for optimal outcomes for all youth with diabetes. – References available on request ED: Dr Black is an advanced trainee in paediatric endocrinology and Dr Taplin is a paediatric endocrinologist at Perth Children’s Hospital Author competing interests – nil
PERTH HIP & KNEE CLINIC welcome Dr Paul Rebgetz to our practice Paul is a locally trained surgeon who brings with him experience gained from several years of interstate and overseas fellowships, and specialises in: Hip & Knee replacement
Sports knee
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Foot & Ankle
Upper & Lower limb trauma
Perth Hip and Knee are a specialist practice focused on the treatment of all aspects of hip and knee pathology. From arthroscopy to complex joint replacement and revision surgery, we deliver excellence in care utilising state-of-art surgical techniques and cutting-edge technologies to achieve optimal outcomes for our patients. We are delighted to have Paul join Perth Hip & Knee and he is a valued addition to our group of experienced hip & knee surgeons. You can contact his rooms direct at rebgetz@hipnknee.com.au or on 08 6489 1766 Perth Hip & Knee Suite 1/1 Wexford Street
PHONE: 6489 1700 EMAL: admin@hipnknee.com.au
Subiaco WA 6008
www.hipnknee.com.au
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Treatment resistant depression By Dr Carl Holm, Psychiatry Registrar A new WA-based study aims to improve outcomes in treatment resistant depression. Major Depressive Disorder (MDD) is one of the leading causes of illness and disease burden in Australia. In the 2021 Australian National Health Survey, 8% of people surveyed had experienced a mood (affective) disorder in the previous 12 months.
patient outcomes. Genetic variants can contribute up to 50% of antidepressant response rates, with a recent meta-analysis of multiple studies showing a significant association between PG-informed prescribing and remission of MDD. A new WA-based study focuses on the clinical application of PG support tools in treatment resistant depression. The GLAD (Genetics Linked to Antidepressants) trial is recruiting adults with treatment resistant depression and offers free pharmacogenomic testing to participants eligible for the trial. Participants will have psychiatric assessment on screening and regular assessments with the study team throughout the 12-week trial.
General practitioners continue to treat the majority of depression in the community, with these disorders associated with significant disability, role impairment and substance use comorbidity. Antidepressants are used to treat moderate to severe MDD, with 74% of mental health prescriptions provided for antidepressant medication. Current antidepressants are often inadequate as approximately half of patients see no response and two-thirds fail to see remission of symptoms. The process of finding a suitable medication then becomes a trial-and-error approach but the chances of remission and response rates decrease with every subsequent medication trialled.
Key messages Patients with Treatment Resistant Depression are more likely to have lower remission rates, substantially lower quality of life and higher suicide rates compared with patients with MDD who respond to antidepressant treatment Pharmacogenomics-guided antidepressant treatment has the potential to change the widely adopted ‘trial and error’ approach
Treatment Resistant Depression (TRD) is defined as MDD which fails to respond to at least two different antidepressants. Patients with TRD are more likely to have lower remission rates, substantially lower quality of life and higher suicide rates compared to patients with MDD who respond to antidepressant treatment. Many patients spend years switching from one medication to the next in search of something that works. Finding more innovative and targeted approaches to help those with TRD is a critical unmet need in the health system. Personalised or ‘precision’ medicine models of care are increasingly effective for achieving better outcomes for the individual patient, instead of using a one-drugfits-all model. One approach to precision medicine is the use of pharmacogenomics (PG), which involves the study of an individual’s
GLAD is a WA-based clinical trial which is currently recruiting patients with treatment resistant depression for free pharmacogenetic testing. genetic make-up to understand how that influences their body’s ability to metabolise drugs and consequently their response to prescribed medications. Some of the variation in response rates and frequency of side effects can be attributed to variation in genes involved in the absorption, distribution, metabolism and excretion of specific drugs.
The aim of the study is to determine if treatment with pharmacogenomicinformed antidepressant therapy improves clinical outcomes in treatment resistant depression compared with today’s widely adopted ‘trial and error’ approach. The principal investigator is Professor Sean Hood (head of UWA’s Division of Psychiatry & Sir Charles Gairdner Hospital, North Metropolitan Health Service, WA). The research has ethics approval at the University of WA and registered on ANZCTR. Apart from the potential benefits of taking part in the trial, participants and their GPs will have access to their pharmacogenetic testing report at the end of the trial to guide the choice and/or dosing of any medications that may be relevant to their current or future treatment(s). Those who would like to express their interest in participating should email the GLAD study coordinator at gladstudy@uwa.edu.au Author competing interests – the author is involved in the research described
PG support tools provide information relevant for drug selection or dosing decisions and has the potential to guide drug and dose selection to improve
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FEBRUARY 2024 | 41
Exploring innovative approaches in the management of obesity By Dr Imran Badshah, Endocrinologist, Nedlands The management of obesity necessitates a comprehensive approach involving lifestyle interventions, potential pharmacotherapy, and/or bariatric surgery for certain individuals. Optimal care involves a multidisciplinary team addressing physical and mental health comorbidities. Primary care in conjunction with allied health is ideally suited for most obesity cases. More severe conditions and associated comorbidities may require treatment in secondary or tertiary care settings. Australian healthcare services fall short in meeting the requirements of individuals seeking treatment for obesity. There is a notable lack of diagnosis and treatment for obesity in both children and adults, with adults taking an average of nearly nine years to seek professional healthcare assistance to manage obesity. Most weight management interventions are not initiated within a healthcare framework until the condition reaches a more severe stage, leading to various complications (metabolic, mechanical or psychosocial). The Australian National Obesity Strategy 2022–23 underscores the significance of healthcare in addressing obesity rates and the pressing need for change. However, there is a need for more clarity on how this strategy will translate into practical changes at policy and budgetary levels, specifically addressing the impact on funding and delivery of services and treatments. Gender disparities in obesity treatment are influenced by complex factors. A notable majority of patients seeking clinical attention and undergoing bariatric surgery are women, despite comparable obesity rates in men and women. The pervasive nature of obesity stigma within healthcare systems further 42 | FEBRUARY 2024
Key messages Obesity remains poorly managed in Australia There are multiple barriers to treatment A new approach is being trialled.
compounds the situation adversely, affecting patients' well-being and hindering engagement with the system. There is also a lack of national obesity treatment guidelines. The absence of coordinated services and referral pathways across primary, secondary, and tertiary care is exacerbated by budgetary tensions between state-funded hospitals and federally-funded primary care. A shortage of services is evident. Public hospital waiting lists for specialised obesity services range from months to years, with services disproportionately concentrated in major cities. Multidisciplinary specialist obesity services are limited, often imposing stringent eligibility criteria, typically reserved for individuals with escalating complexity, further straining the system due to rising demand. Public and private health systems lack the capacity to adequately address the needs of adults who may qualify for bariatric surgery. The tangible consequence of this service inadequacy is the substantial gap in the provision of care for individuals with severe obesity without current significant physical comorbidities. This is a missed opportunity to deliver care and potentially intervene early. The rising prevalence of obesity, coupled with lengthy waiting lists for bariatric surgery in the public health system, has driven individuals to consider early access to their superannuation to selffund the surgery. Certain obesity medications, such as liraglutide
(Saxenda), approved for weight management are not subsidised by the Pharmaceutical Benefits Scheme (PBS), resulting in patients bearing a monthly cost of approximately $387. To address these challenges, establishing clear referral pathways and collaborative partnerships is crucial. Primary care should be empowered to manage individuals seeking obesity treatment, working in tandem with well-resourced secondary and tertiary care. Accessible referral options at both community and higher healthcare levels, along with funding for necessary bariatric surgery, are imperative. Building links between primary, secondary, and tertiary healthcare to ensure continuity of care and support for patients with severe obesity can be achieved through formal partnerships, such as collaborations between local GPs specialising in obesity management and hospital-based endocrinologists in obesity clinics. Scaling up services to meet the increasing demand requires innovative solutions. Self-directed weight loss and maintenance interventions through smartphone apps, for example, offer a scalable and empowering approach. We are currently conducting a trial involving a multifaceted approach encompassing lifestyle modifications and pharmacotherapy. The primary objective is to educate patients about their energy metabolism, recognising the considerable heterogeneity in responses to various treatments. While recent attention has focused on GLP-1 analogues in obesity management, it is essential to clarify that these do not offer a cure. The key is individualisation of treatment through specialised services, with pharmacotherapy constituting only a fraction of the comprehensive approach. The pivotal focus should be on comprehending one's metabolism and discerning the MEDICAL FORUM | NEW APPROACHES
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Managing addictions differently By Dr George O’Neil, Subiaco Stress causes release responses of adrenaline, noradrenaline, endogenous opioids, endogenous cannabinoids and endogenous benzodiazepines. Recurrent stress is known to cause damage at the various related receptors causing anxiety, depression, hypertension, disturbance of the HPA axis, and addiction.
The PHREE (pronounced free with an emphasis on EE,) model of treatment has been developed over 25 years. It stands for physiology, housing, relationships, empowerment, entry, education and employment, and represents a series of changes which are essential for recovery from the stress-related disease of addiction.
Each time you encounter a person with addiction think of the fact that you are seeing a person with a stress-related disease. The stressrelated disease affects not only those with the addiction. It also impacts their direct family and very quickly the whole community.
Physiology – Understanding and changing the physiology of a person with an addiction involves understanding that you are treating a stress-related disease and using appropriate treatment for each individual. This is a crucial stage to ensure that an individual is looked at holistically and that we are treating all possible underlying diseases and factors that may also be contributing to the stress-related disease of addiction.
The science related to addiction is that the repeated use of substances such as drugs and alcohol has the ability to change the structure of receptors in the brain so that eventually addiction leads to substance tolerance in the individual. The person may then be recognised as substance dependant.
Housing – In order to reach patients, encourage a safe and stable place to live where substance use is not present. When that is not
possible, one needs a short-term accommodation facility for preand post-detoxing. When detox is complete many can return home. However, others may progress to city housing or residential rehabilitation. Relationships – People with addiction have to rebuild relationships with family and the community. A team of GPs, psychologists, addiction counsellors, chaplains, clinical psychologists and psychiatrists as well as addiction specialists work to rebuild these connections. Entry and Empowerment – Only with confidence can an individual start a five-year plan to change their whole life. Change comes from developing confidence. Initial contact focuses on supporting the patient to work out a plan for this change to occur. From here, Entry is a goal for the patient to resume their role in a functional society. Education and Employment – Planning and supporting education and employment is essential to help these recovering patients and requires the entire team to be focused on these goals. With the implementation and development of the PHREE model we are seeing an increased percentage of successful rehabilitations. In turn, this helps support individuals, their families and the extended community. Author competing interests – the author is involved with Fresh Start which delivers the program described
specific substrates necessary for maintaining a healthy body mass.
substantial weight regain due to the metabolic adaptations of the body.
With the widespread availability of these medications, there is a concern that we may inadvertently exacerbate the issue by procrastinating in addressing the underlying problems. These drugs cannot be administered indefinitely, and upon cessation, there is a
The core mission of a specialised service is to scrutinise individuals, their phenotypes, and their metabolic responses within the innovative framework developed by our clinic. The commitment extends to conducting sponsored Phase 3 randomised controlled trials
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adding a research-based dimension and enabling first-hand experience with novel agents that may shape future advancements in obesity management. Author competing interests – the author is involved with the trial mentioned
FEBRUARY 2024 | 43
Harnessing ‘brainpower’ to improve function and reduce pain By Dr Myles Murphy, Edith Cowan University Musculoskeletal injuries and pain are a significant cause of disability. This is a worldwide problem. Just one common musculoskeletal issue, osteoarthritis, affects more than three million Australians. Osteoarthritis also has a formidable personal burden with more years lived with disability than type 2 diabetes, ischaemic heart disease or stroke. Osteoarthritis leaves people unable to manage basic activities of daily living. Pharmacological management is one of the most common strategies to assist people with osteoarthritis. However, pharmacological management has poor long-term outcomes and thousands of people progress to joint replacements every year. This results in a huge economic burden with osteoarthritis costing
the Australian economy hundreds of millions of dollars a year. Another example is the common musculoskeletal condition Achilles tendinopathy. Exercise rehabilitation is universally recommended as it has a significant effect on improving patient-reported function. However, even though exercise rehabilitation is accepted as the gold standard, it is clear that even after months of treatment, many patients still have residual symptoms even though they have significantly improved. Therefore, to ensure we can improve the outcomes of treatment for our patients to achieve complete resolution of symptoms, we need to understand why some fail to improve and how we can amend our management. It is the case that people with
Surgery for Heel Pain Heel pain is a frequent problem that presents to the general practitioner. Plantar fasciitis is the most common cause of under the heel pain. Most patients will improve with non-operative treatment but not all. Surgery is a very effective form of treatment for this condition in patients with long standing refractory symptoms. Before being considered for surgery patients should undergo at least six months of non-operative treatment that includes the following (in the appropriate order): • Rest, avoidance of activity • NSAIDs, stretching exercise program • Orthotics: off the shelf or custom • Cortisone injection (one only) • Shockwave therapy
Plantar fascia origin
Surgery can be open or endoscopic. The principle part of the procedure is release of the plantar fascia near its origin on the heel. Historically only the medial half was released but recent literature supports more complete release.
musculoskeletal injury are unable to fully activate their muscles. The brain acts like a car, an accelerator contracts a muscle, a brake stops it. We know that people with musculoskeletal pain cannot ‘release the brake’ (termed cortical inhibition) and even when contracting at their fullest, termed maximal voluntary activation, they are unable to generate what should be maximal force. In hip and knee osteoarthritis, large differences in voluntary activation exist between people with osteoarthritis and healthy controls, as well as moderate differences between the symptomatic and asymptomatic sides of the same person. This is a massive problem as this cortical inhibition is directly associated with osteoarthritis pain severity and disability.
By Mr Peter Ammon Foot Ankle & Knee Surgery
Open surgery is performed through a 3cm incision in the proximal arch and allows not just plantar fascia release but also decompression of the tarsal tunnel and Baxters nerve which is often implicated in heel pain. Endoscopic plantar fascia release is indicated for those without nerve compression symptoms and is done through a much smaller incision using a camera assisted cutting device much like a carpal tunnel release. Both open and endoscopic releases are performed as day cases and require approximately two weeks on crutches. Recovery is slightly quicker for endoscopic patients as you would expect. Patients can expect an 8090% chance of a good result from surgery. Complications are rare.
St John of God Medical Centre Suite 10, 100 Murdoch Drive, Murdoch WA 6150 Telephone: (08) 6332 6300 Facsimile: (08) 6332 6301 www.murdochorthopaedic.com.au Murdoch Orthopaedic Clinic Pty Ltd ACN 064 146 774 ABN 23 070 745 210
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Key messages People with musculoskeletal pain and injury cannot fully activate their muscles Inability to fully activate muscles is directly associated with pain and disability Innovative approaches such as electrical brain stimulation and peripheral nerve stimulation can improve exercise rehabilitation outcomes.
Electrical brain and muscle stimulation Non-invasive electrical brain stimulation (e.g. transcranial direct current stimulation) and muscle stimulation (neuromuscular electrical stimulation) are not new concepts. Electrical brain and muscle stimulation has been used safely for decades in other conditions (e.g. following stroke) to improve patient outcomes. Non-invasive electrical brain stimulation improves the cortical inhibition present following musculoskeletal injury, facilitating
peripheral muscle activation and improving overall motor output. Furthermore, non-invasive electrical brain stimulation has also been shown to activate the body’s natural analgesic mechanisms, directly reducing pain.
to sham brain stimulation and exercise. Therefore, non-invasive electrical brain stimulation should be considered as a legitimate option in the management of people with musculoskeletal pain such as osteoarthritis or tendinopathy.
However, despite this evidence electrical stimulation of the brain and muscle are rarely used in Australian clinical practice for people with hip, knee or ankle injuries or pain.
We know that our current outcomes for people with musculoskeletal pain are not good enough and we need to do better to reduce the number of people living with disability from musculoskeletal pain. However, electrical brain and muscle stimulation is an exciting avenue to address known impairments present in musculoskeletal pain. Utilising electrical brain and muscle stimulation should be encouraged due to the low side-effect profiles and evidence supporting its effects.
Improved clinical outcomes using electrical stimulation Recent research has been able to show that electrical stimulation to either the brain or peripheral muscles can improve the outcomes of exercise rehabilitation of people with musculoskeletal pain. Following anterior cruciate ligament (ACL) reconstruction, utilising peripheral nerve stimulation can improve outcomes following surgery with faster recovery of muscle strength. Pain, disability and function in people with knee osteoarthritis have also been shown to improve by as much as 60% when combining brain stimulation with exercise, compared
ED: Dr Murphy is a postdoctoral clinical researcher at the Nutrition and Health innovation Research Institute at Edith Cowan University. Author competing interests – The author is supported by a Raine Medical Research Foundation Priming Grant as well as a WA Department of Health Innovation Fellowship and a Near-Miss Award.
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Respiratory physiotherapy – what is it? By Tamara Thornton, Respiratory Physiotherapist, Nedlands Respiratory physiotherapists (PTs) are trained in providing specific skills and targeted techniques towards respiratory and breathing issues. Such skills can include airway clearance techniques, exercise advice and pulmonary rehabilitation, inhalation therapy and breathing retraining. PTs are well positioned to work alongside respiratory physicians and GPs in the community. The nature of this set-up optimises patient flow and continuity of care – patients can see a respiratory physician and physiotherapist in a timely manner avoiding issues such as loss to follow up or waitlists due to staffing and funding pressures that are a common occurrence in a tertiary setting. Pulmonary rehabilitation (PR) is one of WA’s best kept secrets that has potential large cost savings for the healthcare system. Research shows that PR is one of the most effective treatments for people with lung disease (particularly if they are limited by breathlessness) to improve their breathing and wellbeing. The 6-8-week evidence-based exercise and education program led by physiotherapists provides people with the skills they need to manage their breathlessness, stay well and out of hospital. PR programs involve a combination of resistance and aerobic exercises which can improve oxygen consumption and functional exercise capacity. Programs also serve to improve the psychological wellbeing of participants through providing a social support, bringing people with like conditions together, which can improve their ability to cope with their disease and positively influence health-enhancing behaviours. Currently, in the tertiary setting, among people with COPD who are suitable for a pulmonary rehabilitation program, referral is suboptimal. It is likely this is also true in primary care. Respiratory physiotherapists in the community have strong knowledge of PR programs and where not able to
Key messages Respiratory physiotherapists are well positioned to work alongside respiratory physicians and GPs in the community Airway clearance techniques should be considered for people with chronic suppurative lung disease Referral to a respiratory physiotherapist for pulmonary rehabilitation should be considered for people with lung disease.
provide PR themselves can act as a catalyst to finding appropriate programs in the community for people with lung disease. Airway clearance techniques (ACTs), colloquially termed ‘chest physio’ are techniques used to assist mucociliary clearance to move secretions in the airways when normal functioning is impaired. In chronic suppurative lung disease having a regular ACT regimen can assist in preventing exacerbations and optimise respiratory status. Airway clearance regimens should be individualised with consideration of the patient’s disease, pathology, age, preference and motivation. Respiratory physiotherapists are well trained in selecting appropriate techniques with the aim to achieve maximum efficacy with minimal treatment burden. There has been a paradigm shift in the selection of ACTs in adults over the past 30 years. Physiotherapists are no longer routinely recommending ‘tipping’ for postural drainage or ‘chest clapping’ as percussive therapy. New ACTs rely on modifying airflow to move behind pulmonary secretions and modulate expiratory airflow to move secretions proximally in the airways. Techniques such as the Active Cycle of Breathing Technique (ACBTs), positive expiratory pressure (PEP) and oscillating-PEP, and autogenic drainage (AD) are newer techniques
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that achieve superior outcomes with minimal side-effects. Inhalation therapy including nebulised saline can be considered as an adjunct to ACTs to promote airway hydration and alter the viscosity of secretions. Advances in equipment have seen hand-held portable mesh nebulisers introduced which allow for smaller medication particles to be delivered to the small airways of the lungs. These nebulisers are light weight and quieter than traditional compressor nebulisers enhancing the likelihood of adherence to treatment. The timing and order of inhaled medication when performed with airway clearance techniques is important in achieving optimal outcomes. Breathing pattern disorders (BPD) or dysfunction breathing are terms describing breathing disorders in people that have developed a chronic abnormal breathing pattern in the absence of any responsible organic causes. The development of abnormal breathing patterns can lead to a variety of sensations and unpleasant symptoms with the most common symptom being breathlessness. Currently, there is no gold standard diagnostic method for BPD. Cardiopulmonary exercise tests (CPET) can identify abnormal ventilatory responses, however, access to these tests is limited. More commonly used are questionnaires (Nijmegen) and outcome measures such as the Breathing Pattern Assessment Tool (BPAT). Physiotherapists trained in treating BPD can assist in restoring a normal breathing pattern. Through structured assessments they can identify triggers and contributing factors including musculoskeletal conditions and/ or postural control impairments for which they can then formulate targeted treatments. Author competing interests – nil
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Telehealth: Changing the landscape of regional healthcare By Dr Vincent Lee, Obstetrician and Gynaecologist, Mt Lawley We know that accessing healthcare in rural, regional and remote areas can be challenging, and with only six large regional hospitals in WA, there is limited provider choice and often significant travel and/or wait times.
show me the skin concern using their device camera and I can send a script to their local pharmacy, which saves considerable time and ensures a timely diagnosis and response. This system also allows me to deliver important results quickly.
Over the past 30 years of my career, I have seen many shifts in the healthcare environment and patient expectations. But I believe one of the most valuable shifts for those living in our regions is telehealth, which allows health providers to provide better and more timely access to care for those living outside the city centres.
For example, if I see a patient for a colposcopy and receive their biopsy result on a Friday, I can arrange a quick telehealth appointment on Friday or Saturday to allow us to discuss the results and arrange a follow-up in-person appointment on the Monday. I have found that this reduces the associated anxiety and the mental anguish that occurs when waiting for test results.
COVID-19 forces change If there was one blessing from the pandemic, it was that COVID-19 forced health professionals to think differently about the way we provide healthcare and telehealth became an acceptable form of care.
Key messages Telehealth is changing the landscape of regional and rural care, and is suitable in many settings for various appointment types
Fast forward four years, and telehealth is changing the landscape of regional and rural care. Gone are the days where patients are required to travel from Christmas Island or Shark Bay for every single obstetric or gynaecology appointment. Telehealth allows partners to ‘dial-in’ from mining sites to see the first scan of their baby in real time, and patients no longer have to experience the gruelling and stressful wait to receive test results at the next available in-person appointment.
So how does it work? From my experience, telehealth is suitable in many settings and for various appointment types. Take an obstetric patient living in Monkey Mia for example – I would request to see the patient in-person for their initial appointment to allow a physical assessment, build rapport and set expectations. The patient would then have the option to book the next appointment as an in-person appointment or via telehealth.
Patient demand for telehealth is increasing Health professionals have an integral role to play in offering services that meet patient needs.
This would continue until the eighth month of gestation, alternating with an in-person appointment every first month and a telehealth appointment every second month. By utilising local services such as general practitioners, nursing stations and pharmacies, blood pressure, weigh-ins and other tests can occur locally, reducing the need to travel. I order routine blood tests and urine dip sticks for protein and the patient tests themselves during the day and show me via video link.
An added benefit for the patient is that all telehealth appointments can be bulk-billed through Medicare.
The future of telehealth I believe telehealth is here to stay and offers an invaluable solution to the healthcare challenges faced by regional and remote communities. Today, patients are more health literate and expect more from their healthcare providers. While I do not advertise telehealth, I am finding more and more patients requesting this form of healthcare and am happy to oblige. As clinicians, we have a duty to our patients to evolve with the times and their needs, as this will lead to better care and ultimately, better patient outcomes. Together, we can build better practice beyond the walls of our physical practices to ensure we are effectively connecting with our patients, regardless of where they reside. Author competing interests – nil
If the patient needs medical advice outside of these times, say they develop a skin condition, they send me a photo of the rash and then we arrange to meet within the next few hours thanks to Zoom. During this digital meeting, the patient can
MEDICAL FORUM | NEW APPROACHES
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VISUAL ARTS
A gallery for healthy art From doctors to orderlies, medical specialist John Julius has opened a gallery to display artistic creations by those working in healthcare.
By Ara Jansen Watercolourist John Julius has gained so much from art in his life, he’s now helping other healthcare professionals show off their artistic talents. Owner of the John Julius Art Gallery at the west end of Hay Street in Subiaco, “JJ” is a painter and the gallery curator who uses a pseudonym to keep his artistic persona separate from his medical one. His gallery opened last July with a vision to exhibit work by healthcare professionals. To date the gallery has exhibited paintings in acrylic, pastel, watercolour and mixed media by registered nurses, a midwife, physiotherapist, medical illustrator, junior hospital doctor and JJ’s own pieces. A retired general practitioner and retired physio display metal work pieces and a speech pathologist has created dried flower arrangements. The exhibitors in the gallery range in age from people in their 20s through to retirees and come from across the medical spectrum in terms of professions. There are new and veteran artists, including those who have never exhibited before. All the works are for sale. Those who’d like to exhibit their work are welcome to get in touch.
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MEDICAL FORUM | NEW APPROACHES
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VISUAL ARTS
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‘Goldsworthy Road’ by Alison Thorpe, Physiotherapist (winner People’s Choice Claremont Art Awards 2023), Acrylic on Canvas, 103 x 103 cm
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‘Wildflower wonder’ by Ida Woodward, retired Registered Nurse and midwife, Watercolour and gouache, 18 x 12 cm
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‘When will it be summer again?’ by Susie Tait, Registered Nurse, Pastel, 65 x 32 cm
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‘Dried flowers’, by Holly Thong, Speech Pathologist
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‘Venetian flautist’ by John Julius, Physician, Watercolour 30 x 21 cm
2 Healthcare professionals spend their working life getting to know their patients. The gallery offers the opportunity to discover something of the lives of the people who care for us.
could exhibit and enjoy an outlet unrelated to medicine.”
A medical specialist, JJ started painting 20 years ago when his psychiatrist wife gifted him a book on watercolours for beginners. She clearly thought he needed an outlet outside work. Now in his early 60s, JJ has continued to paint to relax, escape, reflect and enhance his appreciation of nature. The gallery will eventually become his postmedicine retirement venture.
The owner’s choice of John Julius as a nom de plume comes from a family link to John Julius Angerstein, a Russian emigree to London in the 1700s. A merchant and banker he was a supporter of the arts and after his death in 1823, his collection – including works by Rubens, Turner, Rembrandt and Hogarth – formed the base of the National Gallery in Trafalgar Square.
“In the last five to 10 years, I thought it would be nice to have an art studio to retire to and to foster a bit of a social community,” says JJ. “Medicine is a very social experience. In our daily work, there’s all manner of things to talk to both patients and colleagues about. I wondered about creating a space where health workers
“I enjoy art. I find the painting process peaceful and you can lose yourself in a painting for two or three hours at a time, when time allows,” he says. “Medical work is a privilege. I worked in the public sector at RPH for many years and then moved to full-time private practice. Medicine and family have been the
MEDICAL FORUM | NEW APPROACHES
most important things in my life. However, with three children now in their 20s, it’s nice to be able to do a bit of painting. “We shouldn’t be surprised about the wonderful talent among our colleagues, given the dedication with which healthcare vocations are pursued. However, with the busy professional lives we lead, there are few who would dream of exhibiting their work in a gallery.” Now they have the chance to see their work on display. Opening hours work around JJ’s own medical practice, so check www.johnjuliusart.com. You’ll also find a pop-up gallery at Subi Night Market at Market Square on Roberts Road, Saturdays from 4pm-9pm until April 6. FEBRUARY 2024 | 51
Healthy repurposing to mark 20 years Perth artist Rima Zabaneh has taken an everyday medical disposable and turned it into art.
By Ara Jansen They are not the most obvious choice of material for an artwork, but when Rima Zabaneh came across a quantity of expired catheters, she thought she might have an artful use for them. The result is called Sinuous, and you’ll be able to see it at this year’s Sculpture by the Sea at Cottesloe Beach from March 1. Rima’s inspiration and idea came from thinking about changing the meaning of materials and what she calls a tipping point, when materials stop being what they are and become something different. In her case, how could the clear plastic of a catheter tube be combined with copper wiring to create a piece of art a world away from a vital medical device. “I like the idea of an object that you are aware of can be seen differently,” says Rima. “Materials like the catheters and copper wire are perfect.” A life-long artist and a professional one for 20 years, Rima says while experimenting in her studio, she started playing with both materials and they worked together well. Sinuous – an abstract piece – features them woven together and Rima says it looks like a body part. 52 | FEBRUARY 2024
“Everything has to have a reason for being. So, I started thinking about copper and its relationship to health and how the body needs it for important functions, like producing blood and healing. Then it made sense for me to work with these two things together. “There’s a tension between the pliable, you can twist the catheters while copper has a different tension.” It’s hard work on her hands and she had to experiment with different gauges of wire before she found the right fit and tensile strength. “Making is my main thing. I like using my fingers to make things and feel the tension of making things while I’m moving them. I also like to challenge myself with drawing and like to produce one drawing a day.” Rima will join more than 70 artists from 15 countries exhibiting at the 20th anniversary of the much-loved Sculpture by the Sea exhibition next month. Founder David Handley says Cottesloe Beach is undoubtedly one of the best sites for a sculpture exhibition in the world.
event that made visual art accessible – but I didn’t realise just how much the exhibitions would capture the hearts and imaginations of Australians and visitors to Perth,” says David. “Since the exhibition began in 2005 in Cottesloe, 592 artists from 44 of countries, including 146 artists from WA, have exhibited.” He says the people of Perth have made the Cottesloe exhibition their own, with up to 250,000 visitors each year, and together with artists from WA and around the world they have made it one of the most recognised sculpture exhibitions in the world. “One of the highlights at each exhibition is seeing the sense of wonderment on the faces of children. Now some of those children are part of the exhibition after being inspired to pursue a career as an artist, in part by Sculpture by the Sea.” Sculpture by the Sea is at Cottesloe Beach from March 1-18. Don’t forget to vote for your favourite piece.
“We knew that there was an appetite for a large community MEDICAL FORUM | NEW APPROACHES
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AWARDS
Southern research gets a boost Researchers across Perth’s southern hospitals and universities have won funding for studies into cancer, heart transplants, pregnancy, middle ear implants and ageing through the partnership of Spinnaker Health Research Foundation and the national charity the Hospital Research Foundation Group.
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Nine grants totalling $175,000 went to: Dr Collin Chin, Rockingham General Hospital (1) – for a new treatment for blood cancers, CAR T-cell therapy. A patient’s own immune cells are genetically engineered to create ‘supercharged’ CAR T-cells. This project will use a technology called ‘flow cytometry’ to study the impact on individual blood cells. Dr Andrew Fantoni, FSH (2) – This project will investigate the gaps in lung cancer testing and treatment in Aboriginal and remote populations, while also looking into whether biological features are more common in Aboriginal people to better plan treatments. Dr Marcus Voola, FSH (3) – Middle ear implants are effective hearing aids for many people, but programming them is complex and subjective, which can be hard for children or those with communication or intellectual challenges. This project aims to develop and validate a new programming method using activity of the brain, which has already proven effective for people with cochlear implants. Nicole Catalano, SMHS – Routine Group B Streptococcus testing is common during pregnancy. This study aims to test whether simple lifestyle and diet changes (such as taking vitamin D supplements and pre/probiotic foods, limiting sugar and increasing exercise) can prevent and reduce GBS rates. Dr Andrew Redfern, FSH, UWA (4) – Statins are being studied as a treatment for breast cancer, however, it is not clear which types of breast cancer (hormone sensitive, HER2 positive or triple negative) statins work for, nor side effects. This study will analyse 2500 breast cancer patients with varying types of breast cancer and statin use, to provide insights into who is best targeted for this treatment. Dr Tom Ferguson, FSH (5) –A radiation substance called Lu-PSMA is currently used to help treat metastatic castration-resistant prostate cancer (mPRPC), delivered intravenously every six weeks. For other cancers, oral capecitabin chemotherapy is used alongside Lu-PSMA. However, no one has tested this combination as a treatment for prostate cancer. This project will study if this combination can help men with mCRPC live longer and with better QoL, while also refining safe dosages. MEDICAL FORUM | NEW APPROACHES
Dr Warren Pavey, FSH, Heart and Lung Research Institute WA – Only one in three hearts offered for organ donation are transplanted due to damage suffered during the death of the donor. New therapies are needed to reduce this damage and this project will explore whether ergothioneine (EGT) – a naturally occurring amino acid – can protect hearts that have stopped beating or suffered stress during donation. Prof Merrilee Needham, FSH, Murdoch University, University of Notre Dame (6) – Inclusion body myositis (IBM) is a disease affecting older people, causing progressive loss of muscle strength, disability and falls. The immune system attacks the muscles and causes inflammation, in part due to B cells that produce antibodies which target the muscles. This project aims to identify the protein sequence making up these antibodies so new drugs can be developed to block them. Dr Yu Yu, Curtin University (7) – Primary brain melanomas are rare, extremely aggressive and don’t respond to current treatments. The family of a 34-yearold woman who died from a primary brain melanoma at Royal Perth Hospital has offered her tumour for research. This project aims to improve understanding of this melanoma through a technique that will allow the team to look at many tumour growth molecules in this patient’s tumour to find out which were responsible for the aggressive behaviour of her cancer. FEBRUARY 2024 | 53
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MEDICAL FORUM | CARDIOVASCUL AR HEALTH
medical forum CLASSIFIEDS FOR LEASE
DUNCRAIG Highly Sought Rare Medical Suite + Unique opportunity as long term tenant retiring + 98sqm medical consulting suite + Ample parking + 3 consulting rooms + Opposite Glengarry Hospital Asking Rent $34,300 pa + GST & Outgoings For further details please contact Rob Selid 0412 198 294
MURDOCH Murdoch Health & Knowledge Precinct Suite 3.10, 44 Barry Marshall Parade, Murdoch • Superbly located ‘A Grade’ suite within master-planned medical community • 195 m2 brand new tenancy • Corner suite, abundant natural light • 2 under cover car bays • Fit-out contribution available • Suite may accommodate 4/5 consulting rooms, reception/waiting area, kitchen/breakout area, store records room, and other zones. Be part of this brand-new complex and make your enquiry today. Contact Paul Farris 0424 888 778 or paulf@rfre.com.au
HILTON 44 Victor Street, Hilton • Well located whole building in a thriving Neighbourhood Commercial Hub • 93.2 m2* m2 lettable area • 3 consulting rooms, reception/waiting room, multiple toilets plus shower, store and tearoom • Abundant on-site parking • Ready for your practice now. Contact Paul Farris 0424 888 778 or paulf@rfre.com.au
NEDLANDS Hollywood Medical Centre Suite 36, First Floor, 85 Monash Avenue, Nedlands 87sq m – fully fitted, large reception, 2 consulting, 2 treatment & 2 store rooms. Contact: Irene 0409 688 339
Contact Andrew, classifieds@mforum.com.au or phone 9203 5222 to place your classified advert
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FOR SALE
JOONDALUP PREMIUM QUALITY JOONDALUP MEDICAL SUITE – FOR SALE • FIRST CLASS MEDICAL FITOUT • PRIME GROUND FLOOR MEDICAL SUITE Altegra Property Group are pleased to offer 8/189 Lakeside Drive, Joondalup to the market for sale. This newly refurbished ground floor medical/consulting suite comprises 98sqm consulting suite+ 3 car bays, located on the corner of Lakeside Drive & Reid Promenade, within walking distance of Joondalup Health Campus with ample street parking and easily accessible public transport links. ASKING PRICE: $630,000 + GST Contact Anthony Morabito at Altegra Property Group on 0430 101 385 or anthony@altegraproperty.com.au
RURAL PLACEMENTS
HARVEY Treendale Medical Group – GP Positions • DPA Area’s and MMM5 Available • FSP GP’s are welcome to apply • Busy & well established Medical Group with 4 Location in the South West of WA • Full time & Part Time GP Positions in Treendale & Harvey • Fully computerized and accredited modern practice with nursing and admin support • Well supported with large team of experienced GP’s • Situated in the beautiful South West Region surrounded by coast and forest and close to tourist areas in the south of WA • Only 1 ½ hrs from Perth • Family friendly working hours and no on call or hospital cover required • 65 – 70% of billings depending on experience Please forward CV and enquiries to Kylie Wilson kyliew@harveymed.com.au
METRO PLACEMENTS
DUNCRAIG Duncraig Medical Centre GP required Full time patient load available. Flexible hours seven days Excellent remuneration – $200 to $300 per hour. Predominantly private billing practice Modern fully computerised practice (Best Practice) Please contact Michael on 0403 927 934 or michael@duncraigmedicalcentre.com.au
LEEDERVILLE Opportunity for a VR GP to join our busy, long established private medical practice in Leederville. Fully computerised and well equipped GP practice with Pathology onsite Our practice is fully accredited and offers full support from a well-trained and collaborative practice team. Please call Lorraine on 0487 589 829 or email practice.manager@oxfordstreetgp.com.au to discuss. All enquiries will be kept confidential.
UNIVERSITY OF WESTERN AUSTRALIA, CRAWLEY General Practitioner (GP) – The University of Western Australia (UWA) Medical Centre UWA Health and Medical Services is presently seeking a VR General Practitioner (Non-DPA) to join our multidisciplinary team of health professionals. Part time or full time with no AHPRA restrictions. About UWA Health and Medical Services The University Medical Centre provides a range of professional, patient-focussed services in support of the University’s strategic objective to improve the quality of the student learning experience. Services are provided across a range of areas, including General Practitioner consultations; urgent medical care; immunisations; minor procedures; travel medicine; sexual health; and the management of student and staff mental health. About the opportunity At UWA Health and Medical Services, you’ll become part of a dedicated team of skilled and knowledgeable professionals who are deeply committed to patient well-being and contributing meaningfully to the community. We encourage a collaborative and innovative approach to primary health care. Working alongside a team of experienced general practitioners, registered nurses, mental health nurses, administrative team and other health professionals within the wider UWA community. What are the benefits • Mixed Billing Practice with an attractive retention percentage • Fully digital clinical practice • Fully equipped and up to date treatment room • Internal training and education to support your Medical Training and Governance requirements • Flexible working hours • Excellent work-life balance To learn more about this opportunity, please contact Sharon Almeida on (08) 6488 2118 or at sharon.almeida@uwa.edu.au This position is only open to applicants with relevant rights to work in Australia.
CANNINGTON PART TIME FEMALE BULK-BILLING VR GP REQUIRED IN CANNINGTON 85% OF MEDICARE BILLINGS OFFERED A unique and new opportunity for a female GP to be part of a team delivering holistic women’s health care. ESSENTIAL REQUIREMENTS • VR General Practitioner • Experience in antenatal / postnatal care • Experience in contraceptive technologies • Willing to work with interpreters • Current Police Clearance and Working with Children Check WHY WORK WITH US? Ishar Multicultural Women’s Health Services is a highly reputable, not-forprofit, charity with a 30 year history of delivering specialised women’s health services to women from a refugee and migrant background. • Flexible work hours • 85% of Medicare billings offered and no other on costs • Brand new clinic fit out • Experienced reception and administrative team • Focus on a niche area of women’s health • Work as part of a dynamic multidisciplinary team, comprising of a midwife, practice nurse, dietitian, psychologist, social worker and counsellor. This is a unique opportunity for the right person, if you are interested in finding out more about the role please contact: Kim Duong, Services Delivery Manager; Phone: 9345 5335 or Email: kim@ishar.org.au
BALCATTA Clinical autonomy The role would suit a new Fellow or GP who wants to curate their own patient base with a guaranteed minimum offered for 3 months. Work in a fantastic environment – a non-judgemental, respectful and safe space with a supportive nursing and admin team. Enjoy an innovative, modern practice with the latest equipment and software (BestPractice). Choose your hours – our clinic is open from 8am to 7pm Monday-Friday, 8-1pm Saturdays. Get to know your colleagues with quarterly team-building activities Sub specialise – for the right applicant, we’re happy to support your special interest. Central location - 15 minutes from the CBD, extensive parking available. Contact: PracticeManager@balcattafamilypractice.com.au or call Debbie on 08 6478 3955
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
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medical forum CLASSIFIEDS
JOONDALUP The Best GP Job in Perth – Hands Down! Here’s a job where you finally get Treated (and Paid!) like a Specialist. We are looking for a motivated GP in Skin Cancer Medicine. Join a clinic that puts you first and helps you excel in your career: • 100% Private Billed Skin Checks. No exceptions. • Procedures privately billed with high gaps • State of the art Mole Scanning Technology • Fast on boarding, training and mentoring • Happy staff and expert colleagues • Expand to Cosmetic medicine or Vein Sclerotherapy • $200 ph min • And more….. What are you waiting for? moleclinic.link/Best-Job Please contact Practice Manager on 08 9301 1825
EDGEWATER GP FT/PT Edgewater Medical Centre is an accredited, mixed billing, medical practice in Edgewater, Western Australia and seeking a General Practitioner to join our friendly, patient focused team. Work place: You will be working with a dedicated and professional team of administration, nursing and health staff supporting GPs within this busy practice, providing a full range of medical services. The focus is on personal care, attention and expertise. Role: As an experienced GP, this role will allow you to provide high quality primary health care services to the community, in keeping with best practice standards. Essentials: • Applied knowledge, skills and experience in general practice • Unrestricted VR GP qualification • Full Australian Work Rights What’s in it for you: • State of the art equipment, technology & facilities • Supportive team • Doctor owned practice • Nurse Support • Onsite Pathology • No call outs– Week Day 8-5 roster • Free parking onsite • Flexible arrangements • 70% of billings • Initial Guaranteed payment of $150.00 per hour in first 3 months For a confidential discussion, please contact Cecelia – (08) 9306 1899 or CeceliaC@edgewatermedical.com.au
Contact Andrew, classifieds@mforum.com.au or phone 9203 5222 to place your classified advert
HIGH WYCOMBE VR GP POSITION – Full time/Part time • A busy, well equipped, fully computerized and AGPAL Accredited GP Practice in Perth, WA is looking for a VR Doctor • Flexible days and hours tailored to your need • Excellent RN and reception team as well as managerial support and onsite pathology • Clinical full autonomy guaranteed • Mixed Billings, using Best Practice Software • GP private ownership • Good income potential and emuneration at 72%, negotiable. • $150 hourly minimum for the first three months. The practice provides general GP services including skin check and many more. For enquiries, Email: highwycombemc@bigpond.com Phone: 08 9454 6987
ATWELL Require VR GP’s Unrestricted for Part-time Positions: As an experienced GP, this role will allow you to provide high quality primary health care services to the community, in keeping with best practice standards. Essentials: • Applied knowledge, skills and experience in general practice • Unrestricted VR GP qualification • Full Australian Work Rights What’s in it for you: • Supportive and Experienced Admin team • Doctor owned practice • Nurse Support • Onsite Pathology • Flexible arrangements • AGPAL Accredited Practice • Located near FSH and SJOG Murdoch • Mixed Billing (mainly Private) If you are interested please contact our Practice Manager for further information on 9332 5556 or email: adminmetrogp@metrogp.com.au
FREMANTLE P/T GP required for our friendly practice in the heart of Fremantle. Young demographic with lots of student health, sexual health, women’s health and mental health. Fully equipped, accredited practice with full time practice nurse and onsite pathology, 2-3 days/week, days negotiable. Contact Stephen on 0411 223 120 or at stephen@westendmed.com.au
BULL CREEK Bull Creek Medical – VR GP opportunity We are seeking full time or part time VR GP to join our friendly team. It is a mixed billing well established practice providing quality health care for many years. It is located closer to world class public and private hospitals and near by top public and private schools. Flexible working hours and terms and conditions are negotiable. If you are interested in this exciting opportunity, contact practice manager via email: admin_pm@bullcreekmedical.com or call on 08 9332 0488
COMO
Opening for VR GP - F/time or P/time Full Private List available now from retiring GPs FRACGP essential Up to 70% private billings Unique opportunity to join our family orientated practice in one of Perth’s fastest-growing suburbs. Enjoy working for a doctor-owned, non-corporate, well supported, and accredited practice. Please contact the Practice Manager on 6165 2444 or email: reception@comogp.com.au
GREENWOOD Kingsley Family Practice We are seeking a part time or full time GP to join our well established, busy practice. You will work in a highly equipped AGPAL accredited practice, alongside GPs with extensive specialised skills, including skin cancer surgery (including flaps and grafts), cosmetic medicine, ultrasoundguided musculoskeletal PRP injections, IUD insertion, ENT operating microscope use, and much more. The practice itself is highly equipped, including on-site ECG, spirometry, ABI machine, ultrasound, digital dermoscopy imaging, ambulatory BP monitoring and a full time chronic disease management nurse. Mixed billing, offering our GPs 70%. All appointments privately billed on Saturdays. For more information please email kingsleypractice@gmail.com or call our Practice Manager Tracy Weare on (08) 9342 0471
Contact Andrew, classifieds@mforum.com.au or phone 9203 5222 to place your classified advert
NEDLANDS Niche, Boutique Medical Centre looking for a VR GP Fully Private Our practice is situated in the Golden Triangle in the Western Suburbs. Standard consult 23 - $100, 36 - $180 We are looking for a committed GP with excellent time management. Full-time practice nurse with outstanding administration support. One Saturday per month (AM only) with higher rates. Please send through your EOI to: manager@nedlandsmedicalcentre.com.au BURSWOOD/CLAREMONT 75% OF BILLINGS!! GP positions available in accredited mixed-billing clinics in Burswood and Claremont. Looking for VR GPs and non-VR GP’s on a full time/part-time basis for weekday and Saturday afternoon sessions. Fully computerised with on-site pathology and RN support. Please contact Dr Ang on 9472 9306 or Email: info@thewalkingp.com.au
Reporting to the Clinical Lead – Primary Health Care, we are currently seeking a General Practitioner, to provide service delivery to the RFDS WO traditional GP clinics including the provision of comprehensive routine and emergency general practice care to patients in remote communities and nursing posts. This is a permanent part time 0.8 FTE residential position based in Port Hedland and we would consider a job-share arrangement. The RFDS WO provides partially subsidised housing and vehicle as part of living in the community. Please contact peopleandculture@rfdswa.com.au for more information.
MOUNT LAWLEY VR GP - Mount Lawley WA - Privately billed After Hours practice GP After Hours Mount Lawley is a well-established, community-based after-hours practice. We privately bill and are GP owned and run. We are looking for an experienced VR GP to join our team of clinicians in providing quality after hours care to our patients. Our practice offers: • Modern facilities with a fully equipped treatment room • Fully computerised practice using Best Practice software • Percentage of the billings with a minimum hourly rate guarantee • All sessions are 4 hours in duration • Opportunity for weekend / public holiday sessions For all enquiries, please email Gina at gpahmtlawley@3rdave.com.au or call 0412760871
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
medical forum CLASSIFIEDS
Join our team at Bullsbrook Medical Centre where you will enjoy every aspect of general practice. We are a well-established clinic with a strong and loyal patient base. • Value driven, innovative, non-corporate GP owned medical centre with a highly competent administrative and nursing team, supporting the practice and allowing you to focus on servicing the patient demand. • Large patient base with broad demographics. • Team of GPs providing high quality care with a strong focus on comprehensive chronic disease management • Fantastic opportunity for GP’s with special interests • Friendly working environment of mutual support • On-site Practice Manager, pathology and allied health. • Fully computerised (Best Practice). • AGPAL accredited. • Training Practice for GP Registrars. • Independent Contractor Agreement with high income potential • Incentivised opportunity for FRACGPs interested in providing supervision to training GP’s. Requirements: Unrestricted AHPRA registration, VR/FRACGP
For a confidential discussion please contact Dr Raf Francikiewicz on 0424436663 or email raf@bullsbrookmedicalcentre.com.au
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Northbridge Medical Centre is looking for a VR General Practitioner to join our well-established private billing medical practice located between Perth CBD and Mt Lawley Owned and operated by doctors High patient load Taking over existing patient base from relocating GPs Full Time or Part Time Position available now 65% billings with minimum of $150/ hour for the first 6 months Joining a team of 6 Doctors with supportive Nursing, Management and Marketing team AGPAL accredited, well equipped and fully computerized with Best Practice software Doctor’s parking available Requirement: MBBS or equivalent, Vocational Registration / Fellowship, current AHPRA registration
If you are looking to practice quality medicine in a supportive environment, please contact Dr Alex Koh on 0408 037 290 for a confidential conversation or email at Alex@northbridgemedical.com.au
Positions - Stress Test Supervising Physician Perth and suburbs Park Centre, East Victoria Park Victoria Park Central, Victoria Park Waterford Plaza, Karawara
New patients welcome
Are you seeking a workplace focused on best practice and excellence in clinical care? At Perth Cardiovascular Institute we believe in providing more than just a diagnostic imaging service. Our team are committed to delivering an excellent patient experience along with clinically robust findings in a timely manner. Senior staff perform as leaders and assist with training, mentoring and development of less experienced team members. Much of our time is dedicated to ensure our trainees develop superior skillsets to tackle even the most difficult of cases. We foster an environment that promotes asking questions, seeking feedback and sharing of knowledge.
Positions available for suitably qualified Doctors and Nurses To apply please contact: practicemanager@parkmedicalgroup.com.au
To book your appointment
Call ☎ 9452 9999
or book via
or on-line via
We have world class, internationally renowned cardiologists within our group that support and develop individuals. Our cardiologists are approachable to discuss patient findings and encourage and enable team members to manage patients. In completing our daily duties we go above and beyond expectation with clients repeatedly providing outstanding feedback from their contact with us. If you wish to know more about the role, feel aligned to the way we do things and are excited by the unique opportunity Perth Cardio offers then we would be thrilled to hear from you.
Please contact Adam Lunghi on Phone (08) 6314 6881 or info@perthcardio.com.au
www.parkmedicalgroup.com.au Park Centre, U2, 779 Albany Highway, East Victoria Park Victoria Park Central, U24, 366 Albany Highway, Victoria Park Waterford Plaza, 230 Manning Road, Karawara
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
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medical forum CLASSIFIEDS
Gosnells Healthcare Centre has a great opportunity for General Practitioner to join a very well-established practice. The role would suit a new Fellow or GP who wants to curate their own patient base with a guaranteed minimum offered for 6 months. Wonderful, friendly practice Experienced Doctors Very Large existing and loyal patient base Mixed billing practice Enjoy an innovative, modern practice with the latest equipment and software (Best Practice) 70% of billings- plus attractive relocation package Choose your hours, Our Clinic is open from 8am-5pm Monday-Friday. On-site services include Pathology, Physiotherapy, Podiatry, Dietician Fully Accredited practice DPA Replacement Provider Number available Safety Net of $150 per hour for 6 months
If you are interested in the exciting opportunity please contact Phil at ceo@spectrumhealth.net.au Gosnells HealthCare Centre 2227A Albany Highway, Gosnells WA 6110
Hillarys Medical Centre is a very busy practice located 15mins from the Perth CBD along the coast. We have a strong focus on family & preventive health medicine. We are a team of 10 doctors with excellent administrative and nursing support staff. We have been in Hillarys for 20 years with dedicated GP owners. We pride ourselves with providing exceptional health care to our community of Hillarys. We have a modern purpose built well equipped 3 bed treatment room and 10 consulting rooms with quality equipment as well as a spacious staff & meeting room. We are also able to offer secure remote access and secure onsite parking. Pathology & Pharmacy are within our complex. There is a high-income potential as we are mainly a private billing practice. We would also encourage doctors to develop their own special interests Our patient base is varied as well as a strong family base practice including women’s & mens health, skin cancer medicine, iron infusions, aviation medicine and more. Our nurses are committed to support for care plans & health assessments. We are a 7 day a week (Mon to Thur 8am to 7pm, Fri 8am to 6pm, weekends 8.30 to 12.30pm) we have a variety of sessions available and the opportunity to share a Saturday roster with your fellow GP colleagues, with nursing support. We would require: Current unrestricted registration with AHPRA as a general practitioner Current medical indemnity insurance Full Australian working rights and No DPA restrictions For confidential discussion please phone Dr Rod Parker 0447 117 013 or Dr William Thong 0403 171 061 or by emailing admin@hillarysmc.com
District Medical Officer Christmas Island – Serving the local community Full time Ongoing Vacancy | Package is $400K+ and negotiable The Indian Ocean Territories Administration (IOTA) is currently seeking a motivated and suitably qualified professional to join our enthusiastic and multidisciplinary team as a District Medical Officer (DMO) within the Indian Ocean Territories Health Service (IOTHS) based on Christmas Island. The IOTHS delivers a primary and acute health care service in two of Australia’s most remote and most spectacular settings - Christmas Island (CI) and the Cocos (Keeling) Islands (CKI). The IOTHS includes a 24 hour eight bed hospital and primary care facility on CI and clinics on Home and West Islands in the CKI. The IOTHS is committed to “Working with our communities to keep us healthy for the whole of our lives”. The DMO works in a team and is primarily responsible for delivering comprehensive medical services to the community of Christmas Island using a culturally appropriate approach. The DMO provides general practice services and inpatient care as required, after hours’ emergency medical care and preventative health care. Our ideal candidate will have demonstrable and substantial experience working effectively in general practice in a rural and remote cross cultural environment, recent experience working in an Emergency Department and the ability to work independently, make sound medical judgements and manage the emergency environment. In addition, the successful candidate will be
committed to working collaboratively to deliver quality health outcomes and have excellent communication skills including experience in preparing reports. The successful candidate must hold a current ALS2/REST certification or equivalent, will be registered, or be eligible for full registration, as a Medical Practitioner with the Australian Health Practitioner Regulation Agency (APHRA) and hold a post graduate qualification. Further the successful candidate will hold a current driver’s license transferable to the Indian Ocean Territories, a valid Western Australian Working with Children Check and provide proof of vaccination or immunization as required by the IOTHS. For an application pack outlining how you can apply, please contact the IOTA Human Resources Team at IOTHRTeam@infrastructure.gov.au and quote position number 109161.
Applications close 4.00PM (Christmas Island local time) (CXT) (UTC+7), Monday 5 February 2024
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
An amazing lifestyle opportunity for GPs Our beachside practice in Albany is looking for new GPs
FRACGP preferred, flexible arrangements Relocation assistance offered Large and diverse patient base, mixed billing
Your own spacious room Fully computerised and Doctor owned No on call or after hours
For a confidential discussion about your next career move, call Jean at 0400 605 529 or email jean.paradise@breckenhealth.com.au