Green health Focus on 2024 | Transgender pathology, psychedelics, robotics & 3D food printers
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EDITORIAL BACK TO CONTENTS
Cathy O’Leary | Editor
2024 a year of change and action
By now, some people will be back at work trying to recover from weeks of over-eating, as they eye off the last of the Christmas ham in the fridge. Others will be lucky enough to be on holidays, making their way through a stack of books or their saved list of movies on a streaming service. At Medical Forum HQ, we’re back at our desks and starting the New Year with our first-ever January edition, which we think should go to the top of your reading list. In the spirit of fresh starts at the start of the year, we have a decidedly green theme, to reflect the push within the medical profession and beyond to do more to look after the world we live in.
It’s not rocket science to join the dots between environmental factors such as poor air quality, drought and heatwaves, and the health of the population.
Doctors inevitably have a special role because healthcare is where many of the problems will come home to roost. It’s not rocket science to join the dots between environmental factors such as poor air quality, drought and heatwaves, and the health of the population. The impact of a struggling environment will be felt at both the primary healthcare level, as well as the pointy end of acute medical care. We look at efforts to green-up our healthcare – which has been notorious for generating waste and disposables – as well as activism by local doctors who want a greater sense of urgency in efforts to protect our health. This month we also include extended versions of some of our most interesting clinical updates from 2023 – personally I was intrigued by the transgender implications for pathology. This year is going to be a big year for Medical Forum, as we continue to expand and offer our readers more across a range of digital platforms as well as our linchpin print magazine. Here’s to 2024! In the meantime, we wish you a happy and healthy start to the new year.
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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Inside this issue 10
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FEATURES
IN THE NEWS
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Editorial: 2024 a year of change and action – Cathy O’Leary
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News & views
System change to combat climate change Weighing up antibiotic harm What the doctor said Close-up: Dr Chan Chea
LIFESTYLE 48 Summer fun 51 Wine review: Capel Vale – Dr Louis Papaelias
In brief Hockey gala day Doctors warn of heatwave pain Post-pandemic asthma rise warning New beginnings – Dr Joe Kosterich
52 Bollywood our way 53 Christmas in pictures
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Our first doctors dozen wine winner for the year is Dr Derek Scurry, who collects a selection of premium wine from Cape Mentelle, featured in our November 2023 magazine.
CA PEL VAL
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This month, we have another great prize, a dozen bottles from Capel Vale wines, which are reviewed by Dr Louis Papaelias on page 51. For your chance to win, use the QR code on this page or go to www.mforum.com.au and hit the competitions tab.
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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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General surgeon’s transition into robotic surgery Dr Ruben Rajan
Reporting and interpretation of laboratory results for transgender people Dr Michael Page
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The promise and perils of psychedelic-assisted therapy Dr Jeremy Tannenbaum
3D food printing to nourish Australians with dysphagia Dr Liezhou Zhong & Amanda Orchard
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
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PAT needs urgent overhaul Dr Anthony Bloch
Bridging the equity gap Chris Kane
Science approach to losing weight Professor Richard Prince
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34 Traffic choking our cities and our citizens Emeritus Professor Odwyn Jones
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Supporting diverse colleagues A new staff-led health initiative is supporting neurodivergent colleagues and educating others to understand the benefits and challenges of a neurodiverse workforce. Neurokin, founded by physician Dr Sarah Bernard who has autism and ADHD, has grown thanks to the work of a committed neurodivergent leadership team, including nurse manager Kathryn Boon who has ADHD. The group is leading the way in the healthcare sector in WA to promote an inclusive workplace culture for neurodivergent colleagues. It provides peer support, connection, and advice as staff negotiate a busy workplace that is not always set up for them to flourish. The group launched at North Metropolitan Health Service and has now expanded to include nurses, doctors, project staff and admin and clerical staff from
Answering the call Edith Cowan University is starting a new course from this year to help ease the shortage of medical sonographers. At the end of four years, students will have undertaken more than 2000 hours of clinical placements and will graduate with an Australian Sonographer Accreditation Registry-recognised Graduate Diploma of Medical Sonography and be ready to enter the profession. ECU School of Medical and Health Sciences Executive Dean Professor Moira Sim said the course was established due to demand from industry, with ECU approached to help meet the workforce demand. She said the new course would help ease the burden on the healthcare system and provide better care for patients, including those in regional areas. “There is a shortage of medical sonographers in all states of Australia, with wait times for routine ultrasound examinations,” Professor Sim said. “People in rural and remote Australia in particular have difficulty accessing ultrasound services in a timely manner. “We have a very enthusiastic group of medical imaging providers on our course consultative committee, from metro and rural across the public and private health sectors.” 4 | JANUARY 2024
Dr Sarah Bernard and Kathryn Boon
East Metropolitan Health Service, as well as the Child and Adolescent Health Service. Neurokin has partnered with WA Disability Health Network and the Staff with Disabilities and Allies Network and welcomes any staff member who identifies as neurodivergent. The group meets regularly and has an active Microsoft Teams group.
Professor Sim said sonographers helped make medical diagnoses, enhanced by recent advances in ultrasound technology. A specialist in obstetric/ gynaecologic ultrasound could make assessments during pregnancy and of the reproductive system. Other areas of focus could include musculoskeletal assessments of joints, muscles, tendons, ligaments and bones, vascular examinations of blood flow and blood vessels, or paediatric examinations for childhood diseases.
New prenatal test A new Rhesus D non-invasive prenatal testing (NIPT) is being offered to King Edward Memorial Hospital obstetric patients, changing the management of Rhesus D negative pregnant women. RhD negative pregnant women booked to deliver and receive antenatal care at KEMH will be offered the new RHD NIPT at 20 to 32 weeks’ gestation: RhD negative women will not receive RhD Immunoglobulin (anti-D) during pregnancy if the fetus has been identified as being RhD negative using the new RHD NIPT. They are not at risk of developing antibodies to the RhD antigen. Those women identified as carrying a RhD positive fetus will continue
to receive anti-D as per current guidelines. Those pregnancies where the Rhesus status is unable to be determined using the RHD NIPT test will continue to receive anti-D as per current guidelines. The cord blood will be tested at delivery to confirm Rhesus status for all RhD negative women who deliver at KEMH, and RhD immunoglobulin will be given as per guidelines. It is not possible to order the RHD NIPT test outside of KEMH currently due to the specific processes involved. The RHD NIPT test is different to fetal aneuploidy NIPT. Potentially sensitising events before 20 weeks’ gestation will continue to be managed as per current guidelines, noting that anti D is not required for medical abortion less than 10 weeks’ gestation.
Vape controls tick The country’s peak body for public health has welcomed the announcement of the Australian Government’s new vaping regulations, which will come into effect this month. The changes include a ban on the import of disposable vapes, and an expanded access scheme for medical use from the start of 2024. continued on Page 8
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The Heart Foundation has awarded Edith Cowan University’s Associate Professor Josh Lewis a 2023 Future Leader Fellowship to further his research into abdominal aortic calcification.
NEWS & VIEWS
WAPHA’s Mark Cockayne, SJOG Health Care’s Tara Peters, MP Emma McBride, MP Matt Keogh, SJOG Social Outreach chief executive Susan Cantwell and WAPHA’s Rod Astbury.
The winner of the Minister’s Award in the 2023 WA Mental Health Awards was Professor Ashleigh Lin, an advocate for policy development related to suicide prevention and mental health.
The Mount Hospital sold for $147 million at the end of 2023.
ECU’s Exercise Medicine Research Institute has been given more than $700,000 by the World Cancer Research Fund International to study the effects of exercise on prostate cancer patients. Researchers include Professor Daniel Galvao, Dr Oliver Schumacher, Professor Robert Newton and Dr Jin-Soo Kim.
A study led by Professor Samar Aoun, Perron Institute Research Chair in Palliative Care at UWA, has found the community-based palliative care program Compassionate Communities Connectors led to better patient outcomes and fewer hospital admissions.
A WA-developed drug ARG-007 has been granted Orphan Drug Designation status by the FDA in the US to treat hypoxic ischaemic encephalopathy in babies, led by Dr Adam Edwards from the Perron Institute, UWA and SCGH.
6 | JANUARY 2024
More mental health support in Armadale A Head to Health adult mental health centre has opened in Armadale offering free advice, assessment and treatment for people with stress, anxiety and other mental health issues. Funded by the Australian Government, the Armadale centre was commissioned by the WA Primary Health Alliance and is operated by St John of God Social Outreach, part of St John of God Health Care. There are four Head to Health services in WA – Midland, Mirrabooka, Gosnells and now in Church Avenue, Armadale. WAPHA is also commissioning a Head to Health site in Northam, expected to open this year. Its Executive General Manager Commissioned Services Mark Cockayne said Head to Health centres provide a low stigma entry point for assessment and treatment for people who may be experiencing distress or crisis but may not need an emergency department visit or be eligible for State-level services. “The centres offer immediate, short-term and medium-term episodes of care and help connect people to ongoing services, when required,” he said. “Head to Health makes it easier for GPs and other health professionals to support the mental health of the people they look after, and those who support them, through improving access to, and coordination of, mental health services in their local community.” St John of God Social Outreach CEO, Susan Cantwell said the group had worked with consumers and carers from diverse backgrounds, local service providers, government and the wider community, including local Aboriginal people, to ensure the new centre reflected the needs of Armadale and surrounding areas. The Head to Health centres are part of a wider range of services available to the community, including the Head to Health Assessment and Referral Phone Service on 1800 595 212, and the website www.headtohealth.gov.au
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continued from Page 4 “The vaping epidemic has been mounting for years and has proven to be a threat to the health of our kids,” said Public Health Association of Australia CEO, Adjunct Professor Terry Slevin. “The government has listened to parents, teachers, health experts, and the community in taking strong action against the rapidly growing vaping industry,” he said. “Nicotine addiction, respiratory illness, acute toxicity, and mental ill-health are just the beginning of the harms we’re seeing these products cause. “If some smokers find e-cigarettes helpful to quit smoking, that pathway will still be open. But instead of being self-regulated, it will be under medical supervision where there’s a much higher chance of success.”
Old drugs, new MS hope The first-ever adaptive clinical trial for Australians living with MS will seek to reverse neurological damage caused by progressive multiple sclerosis. With an initial $4 million in funding, the trial – which starts this month – will enable researchers to investigate the potential benefits of several medications simultaneously, giving hope to people living with one of the most debilitating forms of MS who currently have extremely limited treatment options. Progressive MS is a clinical form of MS characterised by a progressive worsening of symptoms and disability without periods of recovery. This complex autoimmune and neurodegenerative condition manifests differently in people over time, but without treatment, disability steadily accumulates. Working with a national and international group of clinicians and researchers, the multi-arm, multi-stage adaptive design known as PLATYPUS – PLatform Adaptive Trial for remYelination and neuroProtection in mUltiple Sclerosis – will test two repurposed drugs alongside each other, providing quicker results about whether the treatments are working. MSWA is the leading funder of the trial, having contributed $3 million. Its CEO Melanie Kiely said the ambitious research project would transform the way treatments for progressive MS were tested. 8 | JANUARY 2024
Dr Sam South and Professor Bruno Meloni at the Perron Institute
Giving drugs a spray Biotech company Argenica Therapeutics, which is developing novel treatments to reduce brain tissue death following types of brain injury such as stroke, has been awarded a grant to develop a non-invasive way to administer the drug ARG-007. The $419,000 in funding under the WA Government’s Innovation Seed Fund Program will support research aiming to develop a new formulation of the drug that is suitable for use in an alternative therapeutic delivery route, making it more acceptable in chronic neurodegenerative conditions such as Alzheimer’s disease. The novel neuroprotective drug ARG-007, currently undergoing clinical trials for stroke, is from the laboratory of Argenica’s Chief Scientific Officer, Professor Bruno Meloni from UWA and head of stroke laboratory research at the Perron Institute. “We see value in having multiple ways the drug can be administered,” Professor Meloni said. “For acute conditions such as stroke, intravenous formulations are ideal and this is the delivery method we are using in clinical trials for stroke. “For people with chronic conditions, such as Alzheimer’s and Parkinson’s disease or concussion, therapies that are easy to administer personally or by a healthcare professional are generally preferred. “This may be as a tablet, nasal spray or an EpiPen-style, depending on the condition being treated.” “Typically, each administration method will require a different formulation of a drug to maximise its efficacy,” said Argenica Therapeutics’ founding director and project innovation lead, Dr Samantha South. “Next steps involve developing a new route of delivery of our candidate drug ARG-007 and optimising its dose in a preclinical Alzheimer's disease model to determine efficacy.”
Moving to improve Children with long-term health conditions ranging from cystic fibrosis to cerebral palsy have been hitting the surf in Scarborough this year, all in the name of research. Part of Move to Improve, an Australian-first project led by researchers and health professionals at Perth Children’s Hospital, the surf sessions offer an innovative approach to improving mental health through fun and fitness. MEDICAL FORUM | FOCUS ON 2024
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Getting into the swing of modern medicine An annual hockey event which started in Perth eight years ago to showcase the impact of modern medicine and surgery recently notched up another successful competition. The ChestRad Western Hockey Masters Gala Day was held in December 2023, highlighting how dozens of hockey players have been able to return to the sport they love after undergoing treatment for conditions ranging from cancer and heart disease through to hip and knee disorders. Its origins began with a ‘Hips versus Knees’ tournament in 2016, with 15 knee replacement recoverees playing against 15 players who had undergone hip replacements. It was such a success that it turned into an annual gala day, with four games played at the 2023 event, watched by more than 100 spectators. WHM president Tony Jones said the event began with a simple challenge from two mates playing hockey on a Wednesday in the Western Hockey Masters competition for men over the age of 50. “One had a hip replacement, the other had a knee replacement, and the idea initially was to field two teams with players from each of these medical recovery areas – and this became the first Hips v Knees competition, later to be named the Bionic Cup,” he said.
“A few years later, I asked if we could expand this to include other medical recovered ailments, and three years ago we started the Survivors Cup for those who had survived a heartrelated incident against those who had survived a cancer scare.” Last year, a women’s competition was added to include two teams of players who had recovered from a medical condition and were able to play hockey again, and for the first time an over-80s competition. “I'm not sure what other sports have two teams participating with players who are over 80 years old,” Mr Jones said. “It’s a true celebration of a sport that can be played by all ages – from childhood to very old age. “It shows how much medicine has moved forward, and how keeping fit and healthy is important so that people are still able to play an active sport like hockey.” This year’s results were: ChestRad OBE Challenge Cup (Golden Masters v White Knights): 2-0 Australian Orthopaedic Association Ladies Challenge (Nice N Kneesy v Breast Friends): 2-1 Perth Urology Clinic Survivors Cup (Cancer v Heart): 5-1 AOA Bionic Cup (Hips v Knees): 2-0
The project, funded by Perth Children’s Hospital Foundation and The Stan Perron Charitable Foundation, with support from other sponsors, is evaluating the physical and mental health impacts of increased participation in physical activity on children with chronic conditions and their families. The surfing intervention is led by PCH senior clinical psychologist Joanna White and colleagues at PCH, the University of WA and Telethon Kids Institute. Last year, more than 120 surf sessions were rolled out to WA children with chronic health conditions including MEDICAL FORUM | FOCUS ON 2024
type 1 diabetes, juvenile arthritis, burns, cerebral palsy and cystic fibrosis. In addition to surfing, from this year children will also be able to take part in personalised Move to Improve programs as part of their routine clinical care. PCH head of endocrinology and program co-lead Professor Liz Davis said one in five Australian children lived with a chronic condition that restricted their physical activity, and they were 2-3 times more likely to develop a mental health disorder than other children.
JANUARY 2024 | 9
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Systemic change faces climate change head on In WA, climate words are turning into climate and sustainability action, from advocacy to change of health practice.
Jan Hallam reports
10 | JANUARY 2024
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COVER STORY Doctors are playing an increasingly vocal role in highlighting the impact on health of the increase in global temperatures and its devastating ramifications.
concerns associated with climate change, so we are in the process of understanding that risk and ensuring that we've got a plan for adaptation,” she said.
In Australia, Doctors for the Environment (DEA), which has swelled in number and influence over the years, bringing in the support of many of the professional colleges and the AMA, have been advocating loud and long for climate action.
Big strides
Most lately, awareness campaigns against the contentious fracking project in the Northern Territory’s Beetaloo Basin in Canberra, and last month, representation on the steps of the WA Parliament calling on the State government to “say no to gas”, have put health at the centre of climate action. WA doctors have long been at the head of the climate charge. Currently, retired GP Dr Richard Yin is deputy chair of DEA and rehabilitation specialist Dr Emma-Leigh Synnott is chair of the WA chapter. Dr Synnott has also found herself at the centre of change in her day job at South Metropolitan Health Service (SMHS), where apart from her clinical duties, she was the inaugural Medical Lead for Climate Health and has been deeply involved in the development and the ongoing implementation of its sustainability strategy. SMHS has set the goal of achieving net-zero carbon emissions by 2040. This ambitious blueprint not only addresses the imperative of mitigating climate change but also encompasses myriad other goals aimed at transforming the healthcare system into an ecoconscious and resilient entity. Dr Synnott (right) is keenly aware of the impact the climate crisis will have on people’s health and the delivery of healthcare if changes are not made. “We know that patients will suffer increasing health MEDICAL FORUM | FOCUS ON 2024
The SMHS Environmental Sustainability Strategy, which is available on the service’s website, outlines its ambitious goals but also the numerous specific initiatives aimed at waste reduction, procurement, and energy efficiency. The core philosophy revolves around maintaining high-quality patient care while simultaneously fostering long-term well-being for current and future generations. Ironically, it was one of the biggest health challenges in recent times, COVID, that has sharpened the antennae, particularly around PPE, which created a single-use waste mountain not just here in Australia but everywhere else in the world. Addressing the question of reusable versus single-use items, particularly in light of challenges posed by COVID-19, the strategy acknowledges the complexities involved. While there is a growing interest in reusable options, barriers such as infection control, lack of facilities for reprocessing, and environmental considerations like energy and water usage must all be carefully navigated. SMHS is exploring innovative solutions, including bioplastics and biotechnologies, to source environmentally friendly alternatives for various medical applications. While the pandemic led to an increased use of disposable items, it also served as a consciousnessraising episode. The SMHS ‘Think Before You Glove’ campaign, initiated during Plastic Free July 2023, encourages healthcare professionals to critically evaluate the necessity of using non-sterile gloves in various situations. This initiative, along with others like it, aims to claw back environmentally detrimental practices adopted during the peak of the pandemic, emphasising the need for thoughtful and sustainable choices. “Glove usage is ubiquitous across the health system and during
COVID it became second nature. They are still, in some instances absolutely necessary, but in a vast majority of situations, they are actually more detrimental to hand hygiene and to infection control because they prevent you from doing the five steps of hand hygiene,” Dr Synnott said. “Using hand gels on unsoiled hands is the most appropriate step when managing a patient or their surrounds and has the highest evidence for infection control in healthcare settings. “The Think Before You Glove campaign asks SMHS staff to step back from that automatic reach for gloves, and to assess ‘do I actually need them?’.
Conscious care “Our nursing colleagues are acutely aware of the amount of waste that we create because they are on the coalface of this situation. They see it day to day. They're the people doing the dressings, the catheters, the bed linen. “The ‘Think Before You Bluey’ campaign, launched in July 2022, specifically targeted the prevalent use of the blue, triple-layered plastic lining sheets in clinical settings, known as blueys. “These seemingly innocuous sheets take about 450 years to break down, so our sustainability officer set about an exhaustive process looking for the opportunities for behaviour change, which has resulted in a 21% overall reduction in use, and a significant 56% reduction in bluey use in high use areas, demonstrating the power of small changes in practice.” Dr Synnott said that the staff have become the agents of change, urging more action. “The 2023 Department of Health annual Your Voice in Health survey is telling – about 80% of the workforce respondents said that they believe that hospitals and health services should be acting in environmentally sustainable ways. “This 80% is across the across the board, from every single health service. Everyone’s attention is on sustainability.” While waste is a visible and, in some ways, a tangible, if difficult, continued on Page 13
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Systemic change faces climate change continued from Page 11 problem to tackle, the SMHS sustainability strategy has also set some powerful targets in areas of medical practice and consumable usage, digital healthcare and inservice improvements. In a clinical setting there has been a successful project to eliminate the anaesthetic gas desflurane, a noxious greenhouse gas far more potent than carbon dioxide in terms of its global warming potential. “SMHS anaesthetists studied the evidence about three years ago and found that desflurane use versus some of these less polluting agents made little to no difference to patient outcomes, so as an act of environmental sustainability, we have stopped using desflurane. (ED: Desflurane was recently removed from the State-wide Medicines Formulary).
CO 2
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HFC s SF 6
STATIONARY COMBUSTION
PURCHASED ELECTRICITY
FOOD AND CATERING
PATIENT AND EMPLOYEE COMMUTING
PHARMACEUTICALS
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FUGITIVE EMISSIONS COOLING AND MEDICAL
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SCOPE 2 INDIRECT
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SCOPE 3 INDIRECT
OTHER PROCUREMENT
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Fig.1: This graphic demonstrates the Greenhouse Gas Protocol Scopes 1, 2 and 3 emissions based on the Greenhouse Gas Protocol. Source: Health Care Without Harm.
“This is a wicked problem, and wicked problems are really hard because in order to tackle them, you have to change “business as usual” behaviour,” she said. “But our recent experience with COVID has shown us how we can adapt,” she said.
SMHS supply chains will need to meet specific ‘green’ criteria by 2026 with a target of 80% of its suppliers having to have a net zero strategy by 2030, and the aim is to have the SMHS transport fleet fully electrified in the near future.
“We saw partnerships between government, non-government, inter-government and within the health system itself when a national emergency was upon us. Everyone went, ‘right, what do we need to do? Let's do this together and let's get it done’.
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There are ongoing LED replacement programs, the upgrade of Fremantle Hospital air conditioning and plant has delivered improved energy efficiencies, and SMHS participates in the National Greenhouse Energy Reporting Scheme.
This thinking has been gaining
EQUIPMENT
MOBILE COMBUSTION
Energy focus
Dr Synnott believes the Black Summer of bushfires in 2019-2020 was pivotal in changing public perceptions of the climate crisis, with the realisation that climate change was destructive and that it was intrinsically linked to health outcomes, including respiratory issues, fetal distress, and long-term chronic diseases.
MEDICAL
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traction in wider medical circles ever since and been responsible for the establishment of units and initiatives within health departments dedicated to sustainability and climate risk, which signifies a growing recognition of the health threat posed by climate change.
“That clinical evaluation was done by our own anaesthetist team. And there are many other teams within the service that are evaluating their practices and coming up with great initiatives – food organics recycling in patient catering is just one.”
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“The challenge with climate change is that many people still don't see the connection with health as tangibly as they do with infection, and we need a better public health campaign around climate change so that it is seen as a palpable health threat. “Because it is – from heatwaves to extreme events to air pollution
and water and food security issues to the infectious diseases that will emerge and with them the potential for civil unrest. “It will cause issues with supply chains and economic hardship and all of those other things that we saw unfold with COVID and they will impact on community and individual health and wellbeing.” And there will be no vaccine to help slow or halt it. “If we want to achieve regenerative change, where we are nourishing society, where we are connected with our communities and our communities are connected to the earth beneath their feet and the rich biodiversity around them, then we need to shift the way we interact with and within the world. “It necessitates an interdisciplinary way of working, which is collaborative and co-designed and not reductionist in its approach. It’s a commitment to sustainability that reflects a paradigm shift where environmental responsibility is not just a goal but a guiding principle.”
E/Professor Odwyn Jones explores traffic pollution and how it is choking our cities on page 34.
JANUARY 2024 | 13
Doctors warn on heatwave pain As Western Australia reaches the midway point of another hot summer, doctors are urging governments to take climate action to save the ailing health system.
By Cathy O’Leary A group of WA doctors has called on the State Government to protect the community and health system by stopping the expansion of gas projects and taking action to reduce emissions. It coincides with the recent introduction of the Climate Change Bill 2023 to State Parliament, which aims to contribute to goals for decarbonisation and the transitioning to net zero greenhouse gas emissions. However, the
government has been criticised for lacking a 2030 emissions target. The Doctors for the Environment WA branch said new health statistics from the Australian Institute of Health and Welfare showed heatrelated hospitalisations had surged. “Health statistics show Australia has had over 9000 hospitalisations due to extreme weather over the last decade,” according to DEA WA spokesperson and GP Dr Tim Leahy.
“Over this period, 700 Australians died directly from heatwaves, and the unprecedented WA November heat wave and international medical research demonstrate this public health challenge, and it is only going to get worse,” he said.
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FEATURE
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FEATURE “The WA health system is already under significant pressure, and we cannot afford a future where healthcare professionals are constantly forced to respond to climate change induced heatwaves.” Another DEA WA member, Dr George Crisp, also a GP, said the community had seen the direct consequences of climate enhanced heatwaves and bushfires. “This is precisely what we have been warning policy makers about, with report after report documenting how we are failing to reduce fossil fuel use in line with agreed ‘safe’ targets,” he said. “Yet our government is continuing to support increasing fossil fuel emissions even as the human cost is escalating.” DEA WA is calling upon the State Government to: • stop fossil fuels expansion, including Burrup Hub and fracking in the Canning basin • urgently implement the recommendations of the 2020 Climate and Health WA Inquiry Report • include the setting of ambitious
2030 and interim targets in the new WA Climate Change Bill The international medical journal The Lancet recently released its annual climate health report, finding that for WA: • adults older than 65 years and infants younger than one year, for whom extreme heat can be particularly life-threatening, are now exposed to twice as many heatwave days as they would have experienced in 1986-2005 • Over 60% of the days that reached health-threatening high temperatures in 2020 were made more than twice as likely to occur due to man-made climate change • heat-related deaths of people older than 65 years increased by 85% compared with 1990-2000. Dr Leahy said doctors were trained to make decisions based on science and evidence, but elected leaders were ignoring the science and putting health at risk when it was politically convenient. Meanwhile the Royal Australasian College of Physicians has called for the urgent adoption of the recently released National Health and Climate Strategy to improve the resilience
of Australia’s healthcare system and promote population health and wellbeing. College president Dr Jacqueline Small said that if implemented fully, the plan could save lives. “The call for healthy and climateresilient communities is being answered and acted on, which is a great first step to ensuring a healthy climate future for our healthcare system and the populations it serves,” she said. “This strategy should not just tick a box. It needs long-term funding and resourcing, commitment from governments at all levels, and a transparent governance and accountability structure to see it through. “This is an opportunity to strengthen our communities and protect them from further harm from climate change.” Dr Small said Indigenous knowledge and guidance were also critical to the success of a national climate strategy.
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JANUARY 2024 | 15
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FEATURE
Weighing up the harm from antibiotics While Australia’s antibiotics use has fallen overall in the past four years, experts are warning doctors to remain vigilant about the threat from antimicrobial resistance.
By Cathy O’Leary
The good news is that rate of antibiotic prescribing in Australia is reducing – the bad news is that it is still one of the highest among developed countries and there is evidence of increasing resistance to E. coli. Each year hundreds of people in Australia die because of drug-resistant infections – a problem exacerbated by misuse and overuse of antimicrobials. Globally, the World Health Organization estimates that antimicrobial resistance could result in up to 10 million deaths each year by 2050. Close to home, the issue has been a hot topic in recent months, with the RACGP WA hosting a forum which raised concerns about an ever-increasing range of serious infections impervious to antibiotics, while underlining the role that primary care plays in safeguarding the appropriate use of antimicrobials. The event coincided with the release of a national report by the Australian Commission on Safety and Quality in Health Care, which found that many people are still being prescribed antibiotics to treat common infections when the medicines often have little or no benefit. According to the AURA report, Australia ranks seventh for the highest antimicrobial community prescribing rates compared with European countries, the United Kingdom and Canada, while our hospital antimicrobial use is nearly three times that of the European country with the lowest use, the Netherlands.
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FEATURE In 2022, 21.8 million prescriptions for antimicrobials were dispensed in the community, down from 26.6 million in 2017. One in three Australians had at least one antibiotic dispensed – higher than many similar countries. While overall Australia’s antimicrobial use in the community has fallen 18% since 2019, with a significant 25% decline in 2020 and 2021, this was followed by a 10% increase in 2022.
High hospital use The report found that hospital use of antimicrobials has remained high, with continued inappropriate use for surgical prophylaxis, and lower compliance with prescribing guidelines in private hospitals. Rates of critical antimicrobial resistances (CARs) in hospitals are rising, particularly carbapenemaseproducing enterobacterales (CPE). Aged care homes have seen sustained high rates of inappropriate antimicrobial use, with 35% prescribed 'just in case' and 42% prescribed for greater than six months. Common pathogens such as Staphylococcus aureus, Escherichia coli and Neisseria gonorrhoeae are increasingly resistant to major drug classes, and some organisms resistant to last-resort treatments, such as CPE. Several specific types of bacteria are key emerging issues for antimicrobial resistance, including community-acquired methicillinresistant Staphylococcus aureus (MRSA), E. coli and Clostridioides difficile infection. Senior medical advisor for the commission Professor John Turnidge said COVID had a major impact on antimicrobial use, as it was the first time the slow downward trend in prescribing was significantly accelerated with the help of GPs, who did not prescribe as many antibiotics. “AURA 2023 highlights the need to get smarter about our prescribing of antimicrobials. In the community and in aged care homes, we can ensure that prescribing for urinary tract infections, skin infections, chronic obstructive pulmonary disease and other respiratory infections is based on guidelines,” he said. “Everyone has a role to play in MEDICAL FORUM | FOCUS ON 2024
this – doctors and other healthcare workers, as well as patients. “In hospitals, we need to focus on appropriate use of antibiotics for surgical prophylaxis, manage the increase in organisms resistant to last-line antimicrobials such CPEs, and monitor for emerging antifungal resistance.” The report warned that if antimicrobial resistance was not managed better it could affect the ability of doctors and hospitals to perform medical procedures such as organ transplants, chemotherapy, diabetes management and major surgery.
Risk not recognised RACGP WA chair Dr Ramya Raman told Medical Forum that it was encouraging that the number of antibiotics being prescribed in primary care had reduced due to a lot of education and patients being made aware of antibiotic resistance. But it was still a huge threat because the community, and even governments to some extent, were not fully aware of the gravity of the situation. And she pinpointed pharmacy-prescribing as a potential vulnerability. “The WHO declared that antimicrobial resistance is one of the top global public health problems and it has led to many antimicrobial infection deaths – in 2019 it was about 1.27 million, so the misuse and overuse of antimicrobials is still quite a serious concern,” she said. “When we look at that AURA report 2023, it actually highlighted that the antimicrobial stewardship efforts by GPs has improved, but we need further and better education on this, and we hold concerns about introducing nonmedical prescribers of antibiotics in Australia because this puts at risk antimicrobial stewardship. “We have to keep it in perspective for the long term, and with the pharmacy prescribing projects that are happening, the reality is that with diagnostic skills in the clinical
setting, there are skills, knowledge and experience that a medical practitioner has gained through their career to manage these conditions. “Also, when a patient does come in for a consultation, opportunistically we can relate to all other matters that may arise out of that, including family and domestic violence.” Dr Raman said that with the urinary tract infection pharmacy prescribing project, the State Government had listened to GPs and infectious disease doctors about their concerns, and safeguards were put in place, and after consideration the antibiotic cefalexin was removed. “We’re trying to highlight some of the public health risks to this problem, and every year we have these discussions about antimicrobial awareness and resistance patterns, but at the same time we need to keep in mind the public health perspective of the policies that are being designed,” she said.
Private scripts missed The AURA report also found there was an increasing proportion of private prescriptions for antimicrobials not subsidised under the PBS or RPBS which meant there was limited reporting and monitoring. The average number of antibacterial prescriptions in participating MedicineInsight practices more than halved from 16 per 100 GP visits in 2019 to 7 per 100 GP visits in 2020 and 2021. As well, antibacterials were prescribed at a lower rate in telehealth consultations compared with face-to-face consultations in those practices. Away from primary care, private hospitals came in for specific criticism, with a concerning higher use of antibacterials with high resistance potential in private hospitals compared to public hospitals. There was also an ongoing lack of improvement in the appropriateness of prescribing in both public and private hospitals, the report found.
JANUARY 2024 | 17
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FEATURE
What the doctor said… What you learn when the tables are turned By Eric Martin
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FEATURE Doctors, just like many other professionals who undergo years of training, tend to take their gained knowledge for granted. So, when their patient’s eyes start slowly glazing over as the list of prescriptions and associated instructions inevitably roll forth at the end of the consultation, it can be hard to gauge just how effectively the essential facts were absorbed. Patients can be distracted by the pain or stress associated with their condition and trying to remember instructions couched in language they may struggle to comprehend. Given the importance of this pain point for patients, Medical Forum spoke with Dr Ahmed Kazmi, dermatologist by day and stand-up comic by night, and Tania Harris from the WA Health Consumers’ Council, to get some insights into this communication conundrum on the doctor-patient relationship. Ahmed was recently a patient with kidney stones and found the experience so enlightening that he has used it as the basis for his upcoming comedy show at Fringe Festival this month. Ms Harris helped Dr Sarah Doyle with her research project ‘What the Doctor Said,’ which explores the communication experiences of patients discharged from an emergency department with opiates, and is linked to a website platform. Ms Harris said that whenever the HCC talked to consumers about health, one thing that emerged was that people felt they were entering into a very siloed system and that
there was an urgent need for better communication.
No clear instructions For example, despite the serious potential for harm caused by opiates, the data gathered for ‘What the doctor said’ revealed that people were often being discharged from Perth EDs without any clear instructions. “Sometimes we heard of people having taken medication and then leaving by themselves, somehow finding their way home in situations that were really quite dangerous – like crossing super busy streets – because they just didn't know what was happening,” Ms Harris said. “We also heard of a few cases of medication being given to people with an intellectual disability, but then that information was not shared with their carers. People noted that, overall, there was a lack of sharing; of not including other people that were vital for supporting patients in those decisions; or even including them in the knowledge that this was what that person had been prescribed or given while in ED. “Yet opioids can have a terrible impact on people, especially if given without any real instructions or understanding of how dangerous they can be, or how often they should be taken. People just wanted information and they wanted it to be clear and relevant to their situation. You might get told something at discharge, but not necessarily remember it.” Given the pain associated with his diagnosis, Ahmed was also
Ahmed said that from his experience, everyone involved was as effective at communicating the diagnosis and treatment options as he had expected, though he did notice a slight difference depending on whether the treatment team knew he was a fellow practitioner.
prescribed opiates, though from his informed viewpoint, it was more a journey of confirmation than discovery. “They made everything better. One second, I was writhing in pain, the next I felt like Aladdin on a flying carpet showing Jasmin the sights,” he said. “I had a life moment – a moment of pride and insight. I thought 'wow these things really work' – everything I trained for, everything I learned, everything I tell patients – it’s real. Then I started retching from the opioids and was given an antiemetic – my nausea stopped almost instantly and, again, I was like 'wow, magic, Mashallah!'” Ahmed said that from his experience, everyone involved was as effective at communicating the diagnosis and treatment options as he had expected, though he did notice a slight difference depending on whether the treatment team knew he was a fellow practitioner.
Always a doctor “It is a tough job and time is often a precious commodity and sometimes the volume can cause empathy fatigue, so I give people some grace, but everyone was fine. There was one young urology registrar I hope will find some time to practise softening his communication skills. I said I was worried of the long-term impact on my kidney function from having had hydronephrosis for six weeks and he informed me you can cut a dog’s ureters and it’s fine for six weeks. I think he thought this would reassure me. It didn’t. I then felt bad for myself...and the dog,” Ahmed said. “I deliberately didn't mention my background at the ED check-in because I didn't want anyone to think I was using it to jump the queue. For the more elective things I went with colleagues who knew me and who I had collaborated with professionally and who I trusted, though I still made sure it was done the proper way – with referrals. “However, sometimes I had to announce my qualifications and contribute to the diagnostic or treatment process. Everyone does their best but sometimes things get missed or fall short of what you would like.
continued on Page 20
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What the doctor said… continued from Page 19 “It was uncomfortable for me at first, but I did get more assertive and used being a doctor to help me get the care I needed more easily when it wasn't happening. I found it just made people listen harder – there are lots of ways for selfadvocacy and for me this was one of them.” One of the things that surprised Ahmed the most about his experience as a hospital patient was how hard he found it to fully relinquish control to someone else. “I was actually quite happy to be led by the doctors and nurses looking after me, as in some ways it was a relief, but it’s hard to switch off. You can’t silence the constant
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commentary in your mind: 'I hope they get the canula in the first time', 'I hope they don't forget to write up an antiemetic,’ 'I bet the consultant is off site and won’t see me until the morning'. “It’s like seeing a film where the audio and the subtitles are on at the same time and you end up reading while you are listening” he said. “The worst part for me was the general anaesthetic, I wept before I had it. ‘How can I have autonomy of my body if I am unconscious?’ ‘What will happen if I don't wake up?’ I don't know if that is ‘doctor think’ though, or just specific to me.”
What about alternatives? Ms Harris said this feeling was a common experience reported by patients, exacerbated by a lack
of insight and an ignorance of alternatives that could potentially meet their needs. “It was clear that people don't like medication, with little understanding about opioids,” she said. “It made me wonder whether there's enough conversations happening with consumers about what opioids are, how they work, and what else you could do if you didn't want to take one? “People can't ask for an alternative if they don't even know what it does in the first place.” “The other aspect is that people can go online and Google nearly anything, which can be good if they’re getting high-quality information from trusted sources, but it's one thing to search for
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FEATURE
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FEATURE ‘what is this pain in my left toe’ and another to know, ‘what should I actually be looking for?’ “The best thing about the ‘What the Doctor Said’ platform was that it was personalised to that person's condition and what they had been prescribed. They didn't have to read through volumes of information that wasn't relevant to them – which often just becomes a huge overload.” Ms Harris said that during the pandemic, most people wanted official information from government sources and in normal times, GPs performed the same crucial role – as trusted providers who could help guide patients through their current situation with clarity. “People often reported that their GP should be included more effectively in the communication process, and this was particularly true for people with a chronic health condition – especially one which was already being managed by their GP,” Ms Harris said. “Yet when they went to hospital, their GP was not getting the most relevant information updated in time for their next appointment. At the end of the day, it was often the patients who were supposed to remember what the specialist or registrar said and take notes.” Ahmed said half the joy of a consult was the doctor was supposed to be the advocate in your corner, someone to witness your pain or fear or sadness and someone to facilitate your decisions.
Try being a patient His key piece of advice for other health professionals was to “give being a patient a go.” “It has totally transformed me as a doctor. I have so much more empathy for patients, and I have tested so many things I had prescribed or seen, now I know what it feels like from the other end,” he said. “It’s scary being moved around on a hospital gurney, the immodesty of a hospital gown, the odd sensation of compression hosiery.” Ahmed said doctors often found it easy to defer seeking proper review for their own health but were somehow still surprised when patients acted the same way. MEDICAL FORUM | FOCUS ON 2024
“One study from the UK found that only a fifth of doctors were registered with a GP compared to 90% of the general population, and while changes in legislation and indemnity have meant that doctors do a lot less self-prescribing and self-diagnosis now, simply going without care and the notorious 'colleague corridor consult' are still very much a part of doctor culture,” he said. “Yet one of the tips I give my colleagues is 'take the advice you would give a patient.’ I think it’s imperative we do – healthy doctors are needed first if we are to have healthy patients – and being on the other side of the stethoscope occasionally will only improve your ability to communicate with your own patients.” Ms Harris said that even though the relationship that people have with their GPs had changed over the years for a variety of different reasons, consumers still saw it as vital.
through all the ups and downs – they're such an important part of the support process,” she said. “We did a workshop with consumers in Kalgoorlie, and they reported that the best consultations were the co-operative appointments; patients really appreciated being able to visit their GP and then have the GP ring the specialist at the hospital so that they could review the information together. “If there was any kind of physical examination that needed to happen, the GP could perform that under the specialist’s guidance, and the specialist could tell the patient and the doctor why. People didn’t have to travel to Perth and wait for a half hour appointment, and most importantly, they got to hear the relevant explanation and they got to ask questions.” For more details go to www.whatthedoctorsaid.com To book Ahmed's show go to www.fringeworld.com.au
“Consumers really see and value the relationship they have with the GP, which can often go on for years, throughout their whole lives and JANUARY 2024 | 21
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CLOSE-UP
A champion for trial access Haematologist Professor Chan Cheah is driven to give Perth the best access to world-class trials and research around lymphoma and leukemia.
By Ara Jansen Studying medicine seemed like a solid and sensible place to start for a young Professor Chan Cheah. He liked chemistry, its logic, precision and how things made sense. He’d start with that and figured, if he didn’t like medicine, he’d just move on to something else. After a bit of a dusty start, somewhere along the line though, medicine did capture his heart. He became enamoured with haematology and ended up specialising in lymphoma and chronic lymphocytic leukemia. Then Chan became determined to give WA patients every fighting chance through his championing of prioritising access to clinical trials. Graduating from medicine in at UWA in 2003, Chan did his post-graduate training at Fremantle Hospital and the Peter MacCallum Cancer Centre in Melbourne, followed by fellowships in lymphoma at Peter MacCallum and Houston’s MD Anderson Cancer Center.
22 | JANUARY 2024
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to Perth but what he learnt through his work interstate and overseas only served to confirm that he wanted to bring his knowledge home with the desire for it to benefit people in the state he was born and grew up in. Chan came back to Perth in 2015 and three years later founded Blood Cancer Research WA. The charity supports fellows and nurses employed at Sir Charles Gairdner Hospital, Linear Clinical Research and Hollywood Private Hospital. It has drawn talent from around the world to work in Perth and catalysed the rapid expansion in access to clinical trials for WA patients, delivering the most promising new treatments, years before commercial availability. It has improved the lives of patients living with these disorders. “The first few years of medicine were very dry and textbook based and I didn’t get to see patients,” says Chan. “I took a gap year and taught English in Japan. I felt refocussed after that and the last three years were really clinical. I got into the hospital environment and that’s when I really started to like it, because I really liked the people side of it.”
his years at the Peter MacCallum Cancer Centre like finishing school.
He didn’t know what specialty he wanted to go into but he knew it wasn’t surgery or emergency medicine. After being exposed to haematology, he was hooked. Working at Fremantle Hospital he looked after people with acute leukemia, gaining hands-on experience.
He wasn’t certain he would return
“It was a fantastic experience. It introduced me to the world of research and was a big part of what made me. I made connections there which led me to the US and the biggest cancer hospital in the world, the MD Anderson Cancer Center.”
Chan is also a Clinical Professor of Haematology at UWA and immediate past chair of the Australasian Lymphoma Alliance. Last September, he was named Cancer Council WA’s 2023 Cancer Researcher of the Year for his outstanding contribution to cancer research. “I came back to make thing better here,” he says. “I wanted people continued on Page 25
“We would treat them with chemotherapy, and they would come to clinic six months later. I don’t think there’s anything in medicine that comes close to how satisfying that is. I personally find that haematology is one of the areas where you can make the biggest impact on someone’s life. You can take someone at death’s door and give them their lives back. “With haematology you can be a clinician or laboratory based and the variety can be interesting. It is one of the most research-heavy specialties – and that is what I am really interested in.” While Melbourne has recently been considered the country’s haematology centre of gravity, Chan was naturally drawn there during his training. He considers MEDICAL FORUM | FOCUS ON 2024
JANUARY 2024 | 23
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A champion for trial access continued from Page 23 to have access to as many clinical trials as possible. Our work has given people here access to trials equal to anywhere in the world. It has also put Perth on the map in terms of being a centre for research excellence in this area. People notice what we are doing here now and that is leading to more money for further research.” Chan suggests there are other cities where it would have been much easier to set up shop. But as a first generation Australian to ChineseMalaysian parents who migrated to Perth, Chan had a “great place to grow up” and the city has given him a lot. He also saw a need clamouring to be filled. “Not long after I took my first consultant job at SCGH, I had a young patient with terribly aggressive lymphoma. I had a strong connection to him and his family. His chemotherapy didn’t work and neither did the only trial I had available at the time.
fellow medicos. Mixing work and pleasure, he’s cycled in different parts of the world, usually in places he’s attending a conference. It’s Chan’s way of keeping fit, bolstering positive mental health and staying connected.
“Unfortunately, he did not survive his lymphoma. I remember thinking ‘this isn’t how it should be’. We should have had six trials to offer him, not just one. I’m going to create something to give the next person that.”
Family Cheah – Kylie and boys James and Miles – enjoy adventuring around WA in their caravan. The family all have bikes, the boys also like to game and, on the whole, Chan says, they probably do what every other family does.
While not easy, he says the key to a successful foundation involves plenty of vision and elbow grease. That’s combined with a great team and plenty of support on all fronts. He’s also had to become good at PR and talking about his work. “My wife says when I get focussed on something, I develop tunnel vision and become oblivious to other things. This is something I am passionate about, so I am a bit like a dog with a bone. “In my experience, tenacity and determination are often more important than talent. The persistence to keep at it in the face of adversity is probably my greatest asset. If one path is closed, then I look for another.” An intrinsically shy and quiet guy who is largely an introvert, Chan says medicine and his desire to help people have brought him out of his MEDICAL FORUM | FOCUS ON 2024
shell. Speaking in public, talking about the foundation and dealing with people from all walks of life are skills he had to learn and says they are aspects which have had a big influence in shaping his personality. “There’s no point being the best at anything if you can’t tell the story. Life is about telling stories.”
“We try and model good behaviour, healthy eating and exercise. We teach them to be able to express themselves well. We’re big on values and communicating what our core values are. We also teach them to be kind to themselves and each other, their friends and family. Kylie and I have lunch together every Friday – and I look forward to that every week.”
Part of Chan’s story is being an avid cyclist. He loves riding and is up at 5am most days to hit the road. He usually rides in groups and says there’s no shortage of people to ride with across Perth, especially JANUARY 2024 | 25
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GUEST COLUMN
PAT needs urgent overhaul The rules around the use of psychedelic medicines are not fit-forpurpose and need an urgent review, writes Dr Anthony Bloch. On July 1 last year, the TGA enacted changes to the classification of psilocybin and MDMA to enable prescribing by authorised psychiatrists for treatment-resistant depression and PTSD. To prescribe, psychiatrists must submit a complex research-like proposal to a Human Research Ethics Committee to then be considered under the Authorised Prescriber Scheme by the TGA. While I support the safe and effective use of psychedelic-assisted therapy (PAT) in Australia, there is an urgent need for a comprehensive review of the current rules and regulations that govern it. Such a reassessment is necessary to ensure that these medicines are used safely and responsibly and that their full potential as a therapeutic tool is realised. This call to action is echoed by medical and healthcare practitioners within the Australian Multidisciplinary Association for Psychedelic Practitioners (AMAPP). This is a registered organisation and charity comprising psychedelictrained health practitioners, including doctors, psychiatrists, psychologists, nurses, paramedics and social workers. AMAPP exists to provide governance to this multidisciplinary space and to provide education and leadership. While PAT is a promising tool for the treatment of mental illness, there is work to do to ensure a rollout that is safe, accountable, effective and accessible to those who will benefit. At present, those goals are in doubt due to an uncoordinated response from the parties involved. At AMAPP, we believe that there is a need for practical guidelines that are fit for purpose. Our members, many of whom have extensive experience understanding and working with psychedelic medicines for the treatment of psychiatric disorders, have united to MEDICAL FORUM | FOCUS ON 2024
develop safe, efficient and practical guidelines for the use of PAT as well as educational resources for general practitioners and the public. We feel that some of the current regulations and recommendations made this year by the TGA, the RANZCP and some State governments need review. While made in good faith, some are contradictory or fail to achieve intended goals, and some may cause harm. The TGA decision in February 2023 was unexpected in its timing, but it followed the (albeit nascent) science. However, some of the subsequent guidelines do not. The premise of psychedelic therapy is that after intensive preparation over days to weeks, which explores issues and builds deep trust with the therapists, a patient is then offered a drug in a very tailored environment with every aspect from furnishing to music carefully curated to achieve a state in which the psyche’s usual protective mechanisms can loosen or disappear for a few hours. This altered state of consciousness allows for profound shifts in thinking and perception, which by themselves can heal. These shifts can then be leveraged by subsequent therapy (integration) over the next weeks and months to help form these new insights into a more permanent and healthy psychological state. Harm is more likely if these practices are not followed. In the right hands, a challenging experience can yield great change and benefit. The flip side is a “bad trip” with long-lasting harm. Given these nuanced needs, the current regulatory system is virtually unworkable, overly conservative and cumbersome. It needs to evolve with the help and input from all the practitioners with appropriate knowledge and experience working in the psychedelic field. AMAPP is proposing an urgent
collaboration so that all those involved in this work can come together and develop comprehensive and consistent guidelines and regulations. For us, what is most important is the best possible patient outcomes, with safety and accountability at the core. We do not feel that current guidelines are explicit in these goals. Language is vague and, at times, falls outside of the remit and expertise of the writers. At other times, it sacrifices access to the treatments without a safety benefit, or sacrifices safety due to ignorance of the nuances mentioned above. The current TGA requirement for a psychiatrist to be physically present at every therapy session and personally administer medication to clients, regardless of their role within the therapy team, is an impractical and cumbersome practice, which could adversely affect the carefully curated environment, so essential to safety and success. Most psychiatrists would be unable to comply with this in their current practice model. This then limits capacity. In some cases, it would be inadvisable and may contribute to worse outcomes in clients who have had to have prolonged and careful preparatory sessions with therapists they have come to trust. Several other issues also need to be clarified, such as appropriate qualifications for therapists, advertising, clinic locations and types, the need for uniform national HREC standards, and the future collection of accurate treatment and research data. We are proposing that the TGA, State health departments, HRECs, research institutions, the RANZCP, Aboriginal mental health organisations and the colleges representing our members get together and formulate ways of continued on Page 29
JANUARY 2024 | 27
PSYCHIATRIC PRACTICE OPPORTUNITY ALBANY (WA) Consultant Psychiatrist
I am retiring in March 2024 and offering an opportunity to a Psychiatrist to take over my well established practice of 16 years. I currently work only 4 days per week, leaving enough time for myself to enjoy this enchanting and historical town. Albany offers breathtaking beaches, wonderful walking trails and the best nature can offer.
The city sparkles with a variety of art forms and a lively music scene. It is the home of many writers, artists and musicians. The State of the Art Albany Entertainment Centre attracts International and National artists. If you have a passion for people, nature and the art of psychiatry, this might be just the opportunity you have been waiting for. There are no after hours, no hospital patients and every weekend is a long weekend. If you are interested, please contact me (see details below).
Dr Piet Claassen | Consultant Psychiatrist Great Southern Psychiatric and Psychological Services 28 | JANUARY 2024
43 Aberdeen Street, Albany WA Email: admin@gspps.com.au | Phone: 9847 4900 MEDICAL FORUM | FOCUS ON 2024
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Bridging the equity gap Health equity is non-negotiable, argues Chris Kane from the WA Primary Health Alliance. Health equity is not the same as health equality. It’s the notion that everyone should have access to the health care they need regardless of their income, postcode or ethnicity. It recognises that everyone has different needs and may need different resources and opportunities to reach their optimal health. With the rising cost of living, health equity continues to pose a challenge. We’re seeing issues with deferred care or people not accessing care at all if they can’t afford it, many of whom have complex health care needs and chronic health conditions. In WA, there are several population groups at greater risk of poorer health outcomes, including Aboriginal people, multicultural communities, LGBTIQA+ communities, people experiencing socioeconomic disadvantage, and those with limited access to health care. While not every person in every group has the same experience, some groups as a whole are more likely to experience inequities in health and wellbeing due to social determinants including place-based disadvantage, stigma, discrimination and the unequal distribution of resources. Evidence also shows that, in
general, the lower an individual’s socioeconomic position the worse their health. Health equity can only be achieved through addressing this wide range of interconnected issues. WAPHA has always approached the work we do with an access and equity lens, however, over the next few years, we will be focusing on these far more explicitly and refining our priorities to ensure alignment. As a commissioning body, achieving health equity means more than just funding health services. It’s about ensuring the services we commission reach the right people and are delivered in a way that meets their needs and comes closer to matching their aspirations. The challenge is balancing an equity lens with what we can commission and where. We can’t simply replicate a service across WA. There are finite resources, and it is not necessarily about more, but better integration and connection. GPs are often the gateway to other health care services. Bridging the gap between general practices and primary health care services will result in more people from priority populations accessing services in their local communities. We are working closely with GPs to raise awareness of services we
commission and encourage referrals into them. Health service providers also have a role to play in managing health inequities through understanding the needs of the population they serve, how the people within that population can access their services and what they can do to ensure their services are provided in a way that is culturally responsive to an individual’s needs. We are working with our commissioned service providers, general practices and other primary health care services to improve their provision of equitable, accessible, integrated and culturally responsive services. We know we can’t be all things to all people. Our focus is on what we can do within our remit of primary health care so we are reaching those people who are at greater risk of poor health outcomes. We have an opportunity to make a meaningful difference to the health and wellbeing of Western Australians, and it all starts with our eyes being firmly on the North Star of health equity. ED: Chris Kane is executive general manager of strategy and engagement at the WA Primary Health Alliance.
PAT needs urgent overhaul continued from Page 27 significantly improving the current inadequate state of play. Failure to address these issues may also push desperate, vulnerable patients unable to gain access to unregulated therapists where actual harm is more likely. We know that PAT is a very MEDICAL FORUM | FOCUS ON 2024
promising treatment modality in this era of increasing mental health morbidity, which is overwhelming our resources – from GPs to tertiary psychiatric institutions. Like everyone else, we want it to be introduced safely and carefully, but the current situation in Australia does not meet the potential treatment needs of many of our patients.
The current regulations are counterproductive and limited by obfuscation and too much bureaucracy. We demand change for the sake of our patients. The world is watching. ED: Dr Anthony Bloch is a Queenslandbased rural generalist senior medical officer and chair of AMAPP.
JANUARY 2024 | 29
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Flagging a science approach to losing weight GPs should consider referring their patients to a weight management research trial using new technology, says UWA’s Professor Richard Prince. Lifestyle studies of weight management have identified clinically useful losses of between 5kg and 10 kg over one year administered by health professionals. This is the first step in all expert advice on dealing with the chronic disease of obesity. Unfortunately, access to such resources is limited, so many people do not get access to evidencebased weight management advice to improve patient outcomes. But there is a current study which provides direct telehealth support and has been designed to be translatable into ongoing affordable lifestyle modification – the basis for all other interventions.
Intervention
involves taking pictures of their meals and uploading them to an app that can identify healthy and unhealthy foods. All participants receive a specially prepared weight management booklet and have their biochemistry and DXA body composition monitored. The primary one-year outcome is the degree of weight loss in the two groups. The study design provides benefits to both the control and intervention groups so both groups will learn how to improve their dietary intake before considering other interventions such as medication or surgery if necessary.
Benefits
To assist in developing a practical, effective approach for patients and clinicians in Australia, my Curtin University colleague Dr Deborah Kerr, Professor of Dietetics, has secured a MRRF research grant to assist in improving lifestyle management options for patients living with obesity.
The advantage to your patients is that either way they receive appropriate free advice that is the initial treatment for the chronic disease of overweight. Secondly, you may be contributing to a ground-breaking primary care study to improve management of your patients using new technology.
This real-life, ethically approved research is looking to recruit patients to take part in a 12-month randomised study of a) standard care or b) a novel telehealth intervention led by dietitians that
Your role is essential to ensure that during the trial the intervention is appropriate for your patient. Although not part of the study, this may include normal, clinically determined, follow-up appointments.
After one year, you get detailed feedback on the results, including the biochemistry and body composition data, to provide ongoing advice. Interestingly, many patients living with obesity do not have a regular primary care physician to manage their many potential comorbidities. This study, needing 400 participants, is a simple straight forward way to get them involved in a therapeutic pathway under your supervision.
Who can participate? The study is likely to be suitable for people who: • are living with obesity (body mass index ≥ 30 and ≤ 45) • are aged between 18 and 65 years and in reasonably good health • have access to a smartphone (iPhone 7 or above or Android) • are able to take part in telehealth video conferencing calls. Your patients can contact the study coordinators directly themselves at https://chat2study.com.au/ or phone 0401 100 224 More details can be obtained from Professor Kerr on 0417 964 466 or myself on 0419 937 100, or visit the study website https://chat2study.com.au/
Numbers stack up for medical research Every dollar invested in WA medical research returns more than double that amount to the Australian population, a landmark review has found.
of the Health and Medical Research Sector in WA, was the first detailed analysis of the benefits of WA’s health and medical research to the State economy and beyond.
The WA Chapter of the Association of Medical Research Institutes said the report, The Economic Impact
It found that every dollar invested in WA medical research returns $2.61 in benefits to Australia. The
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global return was estimated at $7.58 for every dollar invested. AAMRI WA Chair Professor Jonathan Carapetis said the report confirmed what was intrinsically known in WA – that medical research gave back significant value to the community and economy.
JANUARY 2024 | 31
Bethesda Clinic is a voluntary, adult only, 75 bed clinic that provides multidisciplinary clinical services to aid recovery from mental health issues through inpatient and day patient programs. Services Bethesda Clinic provides: Inpatient care and therapy programs managed by a multidisciplinary team. Day patient therapy programs in the Wellness and Recovery Centre. Psychiatric and psychological services for those experiencing mental health issues. Specialties: DVA-accredited Trauma Recovery for veterans, military and first responder communities. The first designated women’s-only ward in Western Australia, providing a safe recovery environment. Alcohol and other drug use. General mental health. How to refer to Bethesda Clinic: Download the referral direct from our website bethesdaclinic.org.au/referrals Find us on HealthLink: Bethesda Clinic Contact Bethesda’s Triage Officer on (08) 6378 4999 or BC.Triage@bethesda.org.au
Bethesda Clinic 1 Honour Way, Cockburn Central WA 6164 Phone (08) 6378 4900
bethesdaclinic.org.au 32 | JANUARY 2024
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NEWS
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Post-pandemic asthma rise warning By Cathy O’Leary Asthma deaths are once again on the rise in WA – especially for men – and could be linked to fewer people seeing their GP and taking their prescribed preventer medication. The increase follows an earlier fall in the number of deaths, which was attributed to better hygiene standards during the height of the COVID-19 pandemic. Australian Bureau of Statistics data shows that 22 female and 18 male West Australians lost their lives due to asthma in 2022, with the highest increase recorded for men aged over 75, jumping from one death to 12 in just one year. Across Australia, there were 467 asthma-related deaths recorded in 2022, made up of 299 females and 168 males. This was a jump of over 30% from 355 asthma deaths in 2021.
“Women tend to require higher doses of inhaled corticosteroids, suffer more frequent attacks with worse day-to-day asthma control.”
Professor Wark said most asthma deaths were preventable and many related to undertreatment, especially in regard to the use of inhaled corticosteroids.
The ABS data also shows that in 2022 male deaths increased in almost every age group and jumped from 109 in 2021 to 168 in 2022 – the highest number of male deaths in Australia over the past 10 years.
“Commonly called a ‘preventer’, inhaled corticosteroids remain the only treatment that clearly reduce acute asthma attacks and asthma deaths for people in all asthma age groups six years and older and should be used by the majority of people with asthma,” he said.
In some cases, men who experienced asthma attacks were less adherent to regular asthma preventer treatment and were less likely to visit their GP for poor asthma control compared with women.
“However less than a third of people with asthma are regularly prescribed a preventer and of those, many fail to regularly take it as prescribed by their GP.
National Asthma Council Australia director and respiratory physician Professor Peter Wark said the deaths of hundreds of Australians each year from asthma attacks would continue until good asthma control was the norm.
The increase in deaths has prompted National Asthma Council Australia to remind people with asthma to ensure it has been correctly diagnosed with a lung function test.
“In addition, uncontrolled use of relievers or ‘puffers’ purchased over the counter without a prescription has been strongly associated with an increased risk of asthma death.
“Deaths were down in 2021 as a result of the hygiene standards in place and the lockdowns that occurred with the COVID-19 pandemic, which led to fewer respiratory infections and fewer asthma attacks,” he said.
Those who have ever had an asthma attack or need to use a reliever more than one or two times per month should be taking an inhaled corticosteroid preventer.
“Until these issues are addressed, we will not see improvements in asthma hospital admissions or mortality.”
“However, asthma attacks have now returned to pre-pandemic levels
National
“Adult onset asthma or a return of asthma symptoms in adults is associated with more troublesome asthma that is more severe and more difficult to control and affects more women than men,” Professor Wark said.
and may even be slightly higher and the upward trend of asthma deaths is due to the return of outbreaks of viral respiratory infections such as influenza and respiratory syncytial virus in the winter of 2022, both of which are associated with increased winter hospitalisations from asthma.”
It is also urging people who have mild asthma to talk to their doctor about budesonide/formoterol.
The ABS statistics show that women over 75 are still the most at risk making up almost half of all asthma deaths in Australia.
NSW
VIC
QLD
SA
WA
F
M
ALL
F
M
ALL
F
M
ALL
F
M
ALL
F
M
ALL
F
M
ALL
2022
299
168
467*
100
47
147
78
37
115
55
33
88
29
20
49
22
18
40
2021
246
109 355*
98
41
139
48
30
78
37
14
51
17
9
26
27
8
35
2022 *28 deaths outside QLD, NSW, VIC, SA, WA (no state stats done for Tas/NT/ACT). 2021 *26 deaths outside QLD, NSW, VIC, SA, WA (no state stats done for Tas/NT/ACT). nationalasthma.org.au
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JANUARY 2024 | 33
Traffic is choking our cities and our citizens Air quality in our cities is becoming a real health hazard and needs greater attention from the regulators, writes Emeritus Professor Odwyn Jones. A recent article in the Guardian Weekly (‘Choke point’, 29 September, 2023) prompted me to write about this very important community health issue. The article states that Europe is facing a “severe public health crisis, with almost everyone across the continent living in areas with dangerous levels of air pollution.” It quotes some startling facts: • In Germany, three quarters of the population live with more than twice the WHO guidance. • In the UK three quarters of the population live where exposure levels are between one and two times the WHO guidance. • Close to 30 million Europeans live in areas with small particle concentrations of at least four times the limit. • Traffic, industry, domestic heating and agriculture are the main sources of PM2.5 (particles with diameters 2.5 micro-meters or less) and the impact is often felt disproportionately by the poorest in the community. Traffic has the greatest overall impact, simply because of its greater geographic extent, and the fact that its pollution travels with the motor vehicle, cargo ships or aircraft. The exhaust fumes occurring by the burning of petrol or diesel in motor vehicles are composed of a mixture of gases as well as fine and ultrafine particulates. The gases include carbon dioxide (CO2), carbon monoxide (CO), nitric oxide (NO), nitrogen dioxide (NO2), oxides of sulphur (SOx) and polycyclic aromatic hydrocarbons (PAHs), with the particulates being predominantly solid elemental carbon (EC)
Some facts The greatest health hazard of dust particulates lies in the potency of the smallest ultrafine particles, e.g those of aerodynamic diameters 34 | JANUARY 2024
less than 100 nanometres (nm). These aerosols are unseen solid or liquid particles and can be sourced naturally from volcanoes, or bushfires etc., or from anthropogenic sources such as fossil fuel powered generating stations or from various forms of vehicular traffic powered by fossil fuels. Dusts are usually categorised as coarse, fine and ultrafine particles – the smaller the particles, the more dangerous they are to human health and the bulk of these aerosols (approximately 90%) occur naturally. However, the remaining 10% or so have anthropogenic sources, with high local concentrations in and around urban and industrial areas and airports. Such aerosols can remain suspended in the air and transmitted over long distances in moving airstreams. They can also be inhaled into the deeper portions of the lungs, and a proportion of them can translocate through the
alveolar lining into the bloodstream and on to ur various bodily organs, such as heart lungs and liver etc., causing them harm, especially if the particulates carry on their surfaces, toxic and/or carcinogenic substances.
Importance of the microenvironment It is important to realise that the ultrafine particles (UFPs), while having negligible mass, are by far the most numerous in polluted atmospheres, and are best defined by their number concentration. Diesel engine fumes, which contain the most dangerous mix of pollutants, once released into the atmosphere, contain both solid ultra-fine particles (a portion of which can be removed by filtration) and semi-volatile organic compounds (SVOCs) which bypass the filtration system in the vehicles’ exhaust pipe. When these SVOC vapours condense the resulting UFPs are toxic organic aerosols. Consequently, those working in close proximity to diesel-powered MEDICAL FORUM | FOCUS ON 2024
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GUEST COLUMN equipment, even when equipped with an oxidation catalyst, are exposed to these toxic SVOC-UFPs. It follows that the breathable air in close proximity to the tailpipe exhaust of diesel-powered mobile equipment, carries with it a mixture of some solid UFPs, and some condensable gases that escape the filtration systems in the exhaust pipe. These toxic SVOCs are usually in the size range < 20nm and form as the exhaust fumes are emitted into the ambient air, where they are cooled and condense onto existing solid and/or liquid aerosols. Thereafter, the UFPs coagulate to form larger particles, which apparently have short atmospheric lifetimes of a few hours at most, and their concentrations quickly diminish with increasing distance from emission sources. It is desirable therefore, that: • Individual exposures to UFPs be assessed in the microenvironments where people live, work or pass through. • Condensable UFPs must, if at all possible, be accounted for in assessing the total burden of UFPs. • Occupations involving people working near sources of diesel engine fumes, such as miners, heavy equipment operators and those involved in tunnelling etc., who are exposed to high concentrations of these newly formed condensed UFPs need special attention. • It is also important to sample the state of the air breathed by such workers in real-time, if at all possible. Unfortunately, methods of detecting and accounting for condensed particulate matter (CPM) are not well developed. A Japanese study noted that inclusion of condensed particles from stationary combustion sources resulted in a seven-fold increase in the emission rates of organic aerosols. It is therefore appropriate to emphasise the importance of UFPs in assessing the health hazard of those living and/or working in close proximity to stationary or mobile fossil fuel combustion sources. It is also important to note that the solid carbon-based UFPs from combustion sources can have
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strong adsorption capacities which means they can carry with them toxic and carcinogenic compounds on their surfaces.
Occupational and public health challenges At the first global conference on air pollution and health organised by the World Health Organization (WHO) in 2018, in Geneva, Switzerland, its Director General, Dr Tedros Adhanom Ghebreyesus, stated that air pollution was the “new tobacco” adding that it kills an estimated 7 million people each year and harms billions more. He went on to say that “no one, rich or poor, can escape air pollution". Indeed, as Dr Maria Neira, WHO Director for Public Health, states, the scourge of air pollution is increasingly affecting all of us, but children are the most vulnerable. There are many sources of air pollution, but the most pervasive is vehicular traffic, which is predominantly powered by petrol or diesel engines. Whereas dieselpowered engines are more efficient and emit less CO2, they generate significantly more NOx and produce particular matter at about 20 times the rate of petrol engines, and both have significant health effects. Much of this particular matter is in the ultra-fine range and is largely composed of active elemental carbon, which has high adsorptive capacity for a wide range of toxins, including toxic condensed compounds, many of which are carcinogenic. These ultrafine toxic particles can translocate across the alveolar lining of the lungs, thus causing many life-threatening diseases, including pulmonary and cardiovascular illnesses and possible damage of the genomic DNA, leading to mutations and ultimately tumours. There is increasing evidence, as stated by Professor Frank Kelly, “that the impacts of air pollution on health are seen far beyond the lungs” and suggested it could increase the risk of people developing dementia. Yet another important development is evidence of the influence of increasing levels of CO2 in the air we breathe on our cognitive ability. Indeed, it is claimed that at levels of 1000 ppm of CO2, human
cognitive ability reduces by 21% and as reported by the researcher, P.N. Bierwirth of the Australian National University (2018), “there is general agreement that levels of CO2 in many classrooms exceed 1000ppm and sometimes reach levels as high as 6000ppm for extended periods.” As far back as 2015, the UK Government’s modelling showed that “pollution from diesel traffic is not limited to large metropolitan centres, but also threatens the health of children and young people in towns and cities nationwide.” For example, the study found over 2,000 schools, nurseries, further education centres and after-school clubs throughout England and Wales were within 150 metres of roads with illegal levels of NO2. Based on these findings, Professor Chris Griffiths of Barts Hospital and London School of Medicine stated: “Research on exposure to traffic fumes and children’s lung growth reveal that such exposure reduces lung growth, produces long-term ill-health and can cause premature death, and we should be outraged exposing our developing children to these obvious problems.” A scientific paper (CalderonGarciduenas et al, 2014) published almost a decade ago claimed that “millions of children in polluted cities are showing brain detrimental effects” and that “protecting children and teenagers from neural effects of air pollution should be of pressing importance for public health.” Their research looked at the decreased cognitive function of verbal and non-verbal intelligence and memory in nine-year-olds. According to numerous scientific authors there is an association between autism spectrum disorders including attention deficit hyperactive disorders and air pollution. At about the same time, the Air Quality Group’s Report of the UK’s Department of Environment, Food and Rural Affairs concluded that there is “strong evidence” that diesel engine exhaust pollutants affect the cognitive function of children. It is vitally important for those responsible for the health and wellbeing of the general public and continued on Page 36
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Traffic is choking our cities continued from Page 35 industry employees, and especially young children and youths, to realise the serious dangers to the health of those inhaling vehicular exhaust fumes for extended periods. This challenge is emphasised by the mayoral proposals to ban diesel vehicles in Paris, Madrid, Mexico City and Athens.
National Environment Protection Measures The Commonwealth “National Environment Protection Council Act 1994” and complementary State and Territory legislation allow the Council to make National Environment Protective Measures (NEPMs). These measures include ambient air quality, and such measures, as decided by the various government Federal and/ or State Ministers are registered on the Federal Register of Legislative Instruments (FRLI). At a meeting of the National Environment Protection Council in April 2021, amendments were approved, taking account of the latest scientific evidence about health impacts which include amongst others: • Establishment of an 8 hour average ozone (O3) standard of 65ppb. • Strengthening the NO2 reporting standards for 1 hour and annual average of 80 ppb and 15 ppb respectively. • Strengthening the SO2 reporting standards for 1 hour and 24 hour SO2 to 100 ppb and 20 ppb respectively, making them some of the most stringent measures in the world. The 1 hour SO2 standard will be strengthened again in 2025 to 75 ppb. The 24 hour NEPM standard for PM2.5 is 25 micrograms/m3. To meet this standard the PM2.5 levels on every day of the year must be below this standard, and in recognition of its impact on human health this standard will be reduced in 2025 to 20 micrograms/m3. Bearing in mind none of our capital cities meet the current NEPM standard indicates, that there is 36 | JANUARY 2024
much remedial work to be dione.in reducing PM2.5 concentrations.
Ozone Ozone (O3) is a gaseous secondary pollutant formed by chemical interactions between nitrogen oxides (NOx) and volatile organic compounds in the presence of sunlight. Stratospheric ozone (6 to 30 miles above the earth) however, is formed naturally by the interaction of solar ultraviolet (UV) radiation with molecular oxygen (O2), which reduces the amount of harmful UV radiation reaching us humans on the earth’s surface. Tropospheric or ground level ozone, on the other hand, is formed differently by the photochemical reactions between two air pollutants, volatile organic compounds (VOCs) and nitrogen oxides (NOx) in the presence of heat and sunlight, resulting in higher ozone concentrations in summer months. The main sources of VOCs are chemical plants, petrol stations, auto-body shops etc., whereas NOx forms as a result of high
temperature combustion in motor vehicles, power plants and industrial furnaces etc. Ozone contributes to the creation of “smog” or haze, which is also more prevalent in summer. At ground level it is also damaging to our health, even at low levels, and it can travel long distances from its original sources. It causes reduced lung function and exacerbates asthma and chronic respiratory diseases. Children are at greatest risk because their lungs are in the process of developing, and because they are more likely to be outdoors when ozone levels are high.
Perth’s air quality By and large Perth enjoys healthy air quality most of the time, albeit it suffers occasional short-term, extreme air pollution episodes, due mainly to wildfires and thermal inversions, caused by a blanket of warm air trapping pollutants in the colder air below. However, historically, the main pollutants of concern in Perth are “photochemical oxidants” (measured as ozone), and MEDICAL FORUM | FOCUS ON 2024
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GUEST COLUMN particulate matter pollution” (Perth Air Quality index etc., IQAir, November, 2023). Exposure to high levels of ozone can cause irritation to a person’s airways, and minor lung function changes whilst elevated ozone levels have also been associated with increased hospital admissions and premature mortality (Perth Air Quality Management Plan,. WA Government, Dec. 2000).” As we know exposure to airborne particulates of size less than 2.5 or 10 microns in diameter (PM 2.5 to PM 10) are equally hazardous to health with the smallest material < PM 2.5, as mentioned previously, being able to enter the bloodstream, thus causing unwanted health effects to any of our many bodily organs. Perth’s ozone levels are, most likely, highest during the summer months, whilst particulate matter is usually more problematic in winter months due largely to the popular use of wood heaters etc. The WA Government currently operates a network of 15 air quality sensors throughout WA, with 9 of them located within the Greater
Perth Region, in the suburbs of Caversham, Duncraig, Quinns Rock, South Lake, Swanbourne and Wattleup as well as at Mandurah, Rockingham and the more inland location of Rolling Green.
Furthermore, a recent review of 38 relevant published articles (Khalaf E.M. et al, 2022) also showed that elevated levels of SO2 can also be a contributor to the development of Type 2 diabetes.
Subsequently, the measurements from these monitoring stations are reported to the public using a Perth Air Quality Index, which follows the Australian air quality index guidelines. They are published as a percentage of their respective standard, e.g. an AQI of 100 indicates the maximum level of that pollutant, whilst an AQI of 200 represent a twofold exceedance.
As the RAC has pointed out: • Whereas in Europe, Japan and the United States, the maximum level of sulphur permitted is 10 parts per million (ppm), in Australia it is 55ppm for premium unleaded, and 150 ppm for regular unleaded; 15 times the international standard. • Australia is also the only developed country that does not have a mandatory carbon dioxide (CO2) standard for new light vehicles.
The quality of fuel at our bowsers One area of particular concern in Australia, not mentioned hitherto, is the quality of fuel sold at our bowsers, and in particular its sulphur content. Sulphur is a natural component of the fuel, which can, when emitted from vehicular exhausts, as SOx, play a part in enhancing photochemical smog, it also acidifies the ecosystems and is harmful to our respiratory, cardiovascular and nervous systems.
As a result of lobbying by the RAC, and possibly others, the Government recently committed to reducing the maximum sulphur content in fuel from 150ppm to 10ppm by 2027, albeit the RAC is calling for that date to be brought forward. ED: References are available on request to the editor.
Here to Help Assoc. Professor Harsha Chandraratna General and Obesity Surgeon
Consulting at: SJOG Murdoch Medical Centre Suite 27 St John of God Medical Centre Murdoch, 100 Murdoch Drive, Murdoch WA 6150 Garden City Specialist Centre 537 Marmion St, Booragoon WA
Dr Bill Gong
Dr Steve Watson
Surgeons House 162 Cambridge St, West Leederville WA 6007 St John of God House 117 Anstruther Rd, Mandurah, WA 6210
Office Phone: (08) 9332 0066 | Mobile Phone: 0401809255 | Fax: (08) 9463 6202
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JANUARY 2024 | 37
“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 places 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 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.
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 38 | JANUARY 2024
E info@freshstart.org.au T 08 9381 1333 65 Townshend Road, Subiaco, WA 6008 MEDICAL FORUM | FOCUS ON 2024
OPINION BACK TO CONTENTS
Dr Joe Kosterich | Clinical Editor
New beginnings Most people have heard of Warren Buffet, the head of Berkshire Hathaway and investment guru (notwithstanding he does not accept that description). His long-term business partner, Charlie Munger, who is less of a household name, died in November – a month shy of his 100th birthday. In the same month, Henry Kissinger died having reached his ton, to use cricket parlance.
February 10 marks the start of the Chinese year of the wood dragon, described as a time for new starts, great beginnings, hard work, and power to growth and prosperity. Wood can create passion, creativity, invention, and introduce new things.
An obituary of Munger in the Wall Street Journal described him a “moral exemplar” – someone who showed how to think clearly, deal fairly and live life fully. Those who knew him well said he displayed epistemic humility which is a profound sense of how little anyone can know and how important it is to open and change your mind. In medicine we know a lot more than at any time in history. However, this remains dwarfed by what we do not know and cannot explain. Yet there has been a trend to increasing dogma and less willingness to consider that we could be wrong. To be honest, this is more at an official body level than in actual day-to-day practice. This is most notable when studies come out questioning current beliefs. The default position is to claim that the study is biased, wrong, faulty or even better there is something bad about the authors. Cochrane reviews are not immune from damnation if they find what is currently believed is not actually correct. Let’s collectively aim to adopt some epistemic humility in 2024. While WA is not scheduled for an election this year, we move into that part of the cycle (both state and federal) where everything is done with a view to the next election. With the same party in power at both levels it is harder to blame each other for the failings of the health system. Expect lots of promises as the year progresses. While on predictions, February 10 marks the start of the Chinese year of the wood dragon, described as a time for new starts, great beginnings, hard work, and power to growth and prosperity. Wood can create passion, creativity, invention, and introduce new things. This sound pretty positive and given the start we had to the decade and the problems of late 2023, we could use some positivity. This is our first January edition and the clinical section features four popular articles of 2023 updated and expanded. Everyone observes that time is flying by! January is a good time to recharge the batteries for what lies ahead.
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The general surgeon’s transition into robotic surgery By Dr Ruben Rajan, Colorectal Surgeon, Subiaco The first question is – what is robotic surgery? The advent of robotic surgery is certainly not new. With its origins in trauma surgery, being initially developed for deployment in the battlefield and surgeons operating remotely, it was eventually developed for civilian use. So how does it work? Robotic surgery essentially works as a master-slave manipulator. The operating surgeon works from a console unscrubbed while robotic arms perform his or her movements. Limited artificial intelligence eliminates tremor and fulcrum forces of the endoscopic instruments against the body wall. Articulated robotic arms allow the surgeon to perform fine tasks in limited spaces facilitating surgical dexterity while maintaining a minimally invasive approach. The next question is why is it relevant? The uptake of robotic surgery in the general surgical space has been met with varying enthusiasm. The presence of advanced skills among the general surgeons means that most tasks achievable with robotic surgery can be achieved by hand, albeit with difficulty. While laparoscopic surgery has very much overtaken open surgery in most general surgical fields, the prohibitive cost of robotic surgery has meant that it has not followed suit. With several platforms now available on the market, we can expect the transition to be exponential. The availability of this tool has now meant that surgeons are able to push the limits of minimally invasive surgery and strive for what was previously deemed impossible.
Advantages Let’s start with optics. The current generation of robotic endoscopes boast high definition, three dimensional views allowing surgeons to see planes and levels of detail not 40 | JANUARY 2024
previously appreciable. The ability of the operating surgeon to be in full control of the operating camera greatly improves vision and ease of operating. Depth perception also allows for efficient suturing of tissues and dissection. Some robotic platforms allow for near infra-red vision. This allows surgeons to easily identify ureters, bile ducts, vascularity of tissues with the assistance of indocyanine green. The combination of better optics and articulating instruments means operating in tight spaces and around corners can be achieved with relative ease. As a colorectal surgeon, this is relevant to me operating in a male, android pelvis, particularly with increasing rates of obesity in our population. The intuitiveness of the robotic controls allows for dexterity which is unparalleled. This becomes immediately apparent when dissecting along vessels for lymphadenectomies during bowel resections and in the difficult pelvis. The ability to control bleeding vessels and the presence of a third operating arm gives the operating surgeon the confidence to perform radical oncological surgery with the ability to mitigate its risks. This has also allowed us to
venture into intracorporeal bowel anastomoses which can even be handsewn, and transanal resection of large polyps or early cancers. Newer iterations of the robot have revisited single port minimally invasive surgery which can facilitate an entire operation through one port-site, an example being the ability to perform a total colectomy through a future ileostomy site as the only incision. Augmented reality has also been implemented into surgical planning such as that for complex pelvic surgery and for hepatobiliary resections such that the surgeon may be able to orientate themselves to preoperative imaging in real-time. As a training tool, the robotic platform allows for training exercises and even simulated operations so that a trainee surgeon may perform an entire operation before doing one on a real patient. These operations can also be rated by software for efficiency, accuracy, and timing. The ability with some platforms for a dual console robot also facilitates training at a level never seen before. Surgical instructors will have the ability to instruct with pointers, demonstrate techniques to trainees and take control of an operation at any time, much like a driving instructor’s dual controls. Having MEDICAL FORUM | FOCUS ON 2024
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Key messages Robotic surgery is not actually new having been developed for military use Take up in civilian surgery has been slow for a variety of reasons Its advantages, coupled with possible AI, will see increasing prevalence in upcoming years.
been taught on a dual console platform myself, I am able to vouch for its immersive experience and its ability to facilitate technical training. While all of these advantages have been available as individual technologies, the robotic platform provides an entire package of tools to add to a surgeon’s armamentarium. The combination of these factors results in surgery which is less of a physiologic insult to the patient and affects postoperative outcomes. Reduced length of stay, length of incisions, post-operative pain and the ability to complete procedures in a minimally invasive fashion are but a few advantages these confer.
These factors are particularly important in the sphere of colorectal surgery as more focus is put on patient reported outcomes and quality of life. Added to this is the reduced physical toll and increased ergonomics for the operating surgeon.
Obstacles You may wonder, if such technology exists and has done for a while, why it is not more commonplace. Unfortunately, as alluded to above, cost is a major barrier. With this comes many additional barriers. Consumables for this platform come at a premium. Access to robotic training for surgeons and nursing staff is also limited. Perceptions from patients and even healthcare professionals about what exactly robotic surgery entails are also varied. Like with any new technology these factors have resulted in a much slower uptake of this modality of surgery in Australia when compared to the advent of laparoscopic surgery.
particularly with the release of multiple new platforms which have now made it a competitive market. This will make robotic surgery more accessible by driving costs down and allow earlier access to surgical trainees. We may even see an increased presence of artificial intelligence in these platforms. While always a polarising topic in itself, I see artificial intelligence as an adjunct which we will eventually learn to embrace and take advantage of as we have already done in many other fields. We are already seeing an increased use of robotic surgery in colorectal, upper gastrointestinal, hepatobiliary and gynaecological operations. This has also recently been expanded to hernia surgery and emergency general surgery. The future is bright with robotic surgery, so watch this space. Author competing interests – nil
Into the future I see a steep uptake in robotic surgery in the coming years,
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
Robotic-assisted joint replacement
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
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JANUARY 2024 | 41
Reporting and interpretation of laboratory results for transgender people By Dr Michael Page, Chemical Pathologist Generalisation in medicine is sometimes necessary. We largely determine what is ‘abnormal’ by comparing findings (be they clinical, radiological, pathological or other) with what is deemed to be ‘normal’. In the interpretation of laboratory results, this is a principle underpinning the use of reference intervals (the pedant’s preferred term for “normal range”). These are determined from individuals deemed free of relevant disease, with cut-offs chosen to represent some percentage of that cohort. For example, a reference interval might be determined such that 95% of individuals free from disease fall within its upper and lower bounds. Of course, this means that a small percentage of individuals free of disease will fall outside the interval, so their results will be flagged as being potentially “abnormal,” despite the absence of disease. This is a well-recognised limitation of such generalisation. Generalisation can also lead to systematic biases, which can affect the quality of patient care in specific groups. In the US, a correction factor for the determination of estimated glomerular filtration rate (eGFR) in patients of African American ancestry, who were presumed to have higher creatinine concentrations owing to greater muscle mass, has historically been applied. The intention of the correction factor was to make the eGFR more accurate in such patients. However, it has been found to overestimate it in some patients, leading to delayed initial investigation and nephrology referral of those with earlier-stage kidney disease, and delayed consideration of renal replacement therapy in those with late-stage kidney disease. Therefore, the ancestry-based correction factor is now falling out of favour across North America. 42 | JANUARY 2024
distributions substantially overlap. Assumptions about sex-based biological differences will not hold true in every individual. For example, an athletic female could have a creatinine concentration that exceeds the female upper reference limit but might sit within the male reference interval, without it implying any pathology.
Key messages Laboratory software providers, like many other medical software providers, have not adequately catered for issues arising from serving transgender patients For many laboratory values that are sex-dependent, reference intervals for transgender patients are not well-established.
The healthcare sector has also been slow to keep up with the needs of transgender (including non-binary) people. The evidence base for transgenderspecific reference intervals permitting accurate interpretation of laboratory results is also lacking. Many reference intervals published on laboratory reports are sex specific. Some of these are widely divergent with no overlap. For example, serum testosterone concentrations in healthy cisgender adult females are expected to be lower than those in cisgender adult males, without any overlap of values such that a female reference interval might be < 2.0 nmol/L and a male reference interval might be 10 - 35 nmol/L. Others exhibit significant overlap. Examples include haemoglobin and creatinine, which are on average both higher in males, but the
Nonetheless, sex-specific reference intervals are thought to be mostly valid and broadly useful. A diagnosis of colorectal cancer causing borderline low haemoglobin in a cisgender male could be delayed if a female reference interval were used, or a polycythemia vera diagnosis delayed in a cisgender female patient in the reverse scenario. However, reference intervals for transgender people are not wellestablished. A greater degree of physiological heterogeneity might exist in transgender people than in cisgender people, especially in those who have recently started genderaffirming hormonal therapy (GAHT). This makes reliable reference intervals more difficult to establish. For any parameter likely to significantly change with GAHT, the duration of therapy required to do this and the point at which the change becomes stable need to be determined. For some tests, data (albeit limited) exist to support the use of the cisgender reference interval for transgender patients of the corresponding gender after a certain duration of GAHT. High-sensitivity cardiac troponin results in healthy transgender men and women after at least 12 months of GAHT approximate those of cisgender men and women, respectively. This means, for example, that the ‘male’ reference interval could be used for transgender males whose sex assigned at birth was female, after an appropriate duration of GAHT. This is also true of haemoglobin. Prostate specific antigen (PSA) MEDICAL FORUM | FOCUS ON 2024
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The promise and perils of psychedelic-assisted therapy By Dr Jeremy Tannenbaum, Psychiatrist, Perth & Fiona Stanley Hospital Psychiatric research has seen a resurgence of interest in psychedelic-assisted therapy (PAT) over the past two decades. The US Food and Drug Administration designated MDMA and psilocybin as ‘breakthrough therapies’ for post-traumatic stress disorder (PTSD) and treatment-resistant depression (TRD), respectively, in 2018/19, in a field where response and remission rates have been stagnant for decades.
Key messages Research in psychedelics has been resurgent. Since July 1, 2023, psychiatrists can apply to be authorised prescribers of MDMA and psilocybin. Hype needs to be tempered but there is genuine promise.
From the 1950s until criminalisation and the ‘War on Drugs’ in 1970, over a thousand clinical papers on the therapeutic uses of psychedelics (mainly LSD and psilocybin) were published, and several international conferences held. Psychiatrists prescribed and often conducted treatment, including group therapies. Common indications were ‘neurosis’, OCD, and alcoholism. Many psychiatrists had personal experience with psychedelics as part of their training.
The TGA’s February 2023 announcement of the rescheduling of MDMA and psilocybin was an unexpected global first, and in opposition to recommendations from peak bodies and most clinician-researchers active in the field. There are widespread concerns about the role lobbying, political and community interests played in the rescheduling decision, which erodes due scientific process.
testing in trans women is another area in which evidence is lacking. Given that oestrogens and antiandrogens used in GAHT suppress PSA, what cut-off should be used to determine the need for further investigation (such as MRI or prostate biopsy) in a trans woman who wishes to have PSA testing, given the standard thresholds are likely to be too high? Some advocate further investigation above a PSA concentration of 1.0 ug/L in this setting, but the evidence for this approach is poor.
often see more than one doctor (for example, a general practitioner and an endocrinologist), and the documented gender can vary from one request form to the next, causing uncertainty for the laboratory as to the correct gender.
While better data about reference intervals for transgender people that correspond with the presence, type and duration of hormonal therapy received could enable more accurate interpretation of results, implementation would be difficult. The clinical laboratory may not be provided with sufficient clinical information to provide the most appropriate thresholds. Furthermore, transgender patients MEDICAL FORUM | FOCUS ON 2024
Rescheduling allows authorised
Consistent with many types of medical software, inflexible laboratory information systems are unable to record that the patient’s preferred gender and sex assigned at birth might differ. Being able to record this information and have it readily transmitted between systems would be helpful. It would facilitate the provision of richer interpretive information by the pathologist alongside the result on the report. Furthermore, given the increasing ability and desire of patients to access their own pathology results directly, the potential for psychological harm by unintentionally misgendering the
psychiatrists to prescribe MDMA and psilocybin, in conjunction with psychotherapy; so-called MDMAassisted therapy (MDMA-AT) and Psilocybin-assisted therapy (PsilAT). MDMA-AT will be indicated for PTSD and Psil-AT for TRD and must be supervised by the psychiatrist and conducted in controlled clinical settings. Since July 1, psychiatrists can apply on a case-by-case basis to a human research ethics committee and then the TGA to become an authorised prescriber. Authorised prescribers must have experience, which at this stage is likely only accessible through participation in clinical trials. Therapists must also have additional training. New groups are vying to be the first to establish professional standards and accredited training organisations. Several phase 3 randomised control trials of MDMA-AT for PTSD have continued on Page 45
patient is also a consideration. This would be reduced if information systems were better able to record this information. All patients deserve the same high standard of healthcare. There are many facets to achieving this. In laboratory medicine and the interpretation of pathology results, the effort to provide an equivalent service to transgender patients has not yet been sufficient. Providers of medical software and assays to laboratories, and health services more broadly, should commit to addressing the particular needs of transgender people with respect to pathology testing and reporting. This must be respectful and inclusive, and wherever possible incorporate evidence bases equivalent to those taken for granted for cisgender people. Author competing interests- nil
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Psychedelic-assisted therapy is no clarity on training requirements for clinicians.
continued from Page 43 been conducted in recent years, with initial results indicating higher rates of response and remission compared to placebo. MDMA, a ‘serotonergic amphetamine’, induces mood elevation, fear extinction and pro-affiliative social behaviour, which can enhance the patient-therapist relationship. MDMA may reduce adverse physiological, cognitive and affective responses in patients with PTSD, enabling them to revisit and work through traumatic experiences in therapy. However, there are concerns regarding the potential risks of MDMA, including neurotoxicity, medication interactions and cardiovascular effects. Concerningly, there have already been reports of patienttherapist boundary violations in clinical trials. Psil-AT for TRD has also shown promise in recent clinical trials, with some studies showing significant improvements in symptoms lasting up to six or more months posttreatment. Partial or full agonism at the post-synaptic 5-HT2A receptor, characteristic of psilocybin and the other ‘classic’ psychedelics, induces neuroplastic changes and may destabilise the usually rigid, negative thought patterns characteristic of depression (and perhaps other mental disorders). Psychotherapy may harness transient neuroplasticity and cognitive shifts to allow patients to develop insights, change behaviour and hopefully enable recovery. Ketamine, a dissociative anesthetic, is increasingly used off-label for TRD and acute suicidality. Many trials are underway investigating ketamine-assisted therapy (KAT) for psychiatric and nonpsychiatric indications. Ketamine’s antidepressant effects have been attributed to NMDA receptor antagonism and other multimodal effects of s and r enantiomers and various active metabolites. Unfortunately, relapse typically occurs after 7-10 days following a single dose, so repeated dosing may be required to see a benefit and maintain effectiveness. MEDICAL FORUM | FOCUS ON 2024
We have already seen the exploitation of vulnerable patients in clinical trials, and there are significant medicolegal risks for clinicians. Rigorous safety protocols and clinical guidelines do not exist, and peak bodies are yet to release updated position statements.
The widespread emergence of unregulated ketamine clinics managed by health professionals without psychiatric expertise raises many concerns. Psychological risks of psychedelics include 'bad trips’, flashbacks, and deterioration of mental state, for example, psychosis, or complications from withdrawing medications due to a potential drug interaction with psychedelics. Medical risks may include cardiovascular toxicity (MDMA and ketamine), and hepatotoxicity, bladder injury and cognitive impairment with ketamine. Many of these risks are established in long-term recreational users, although the risks within therapeutic contexts are poorly understood. These risks may be minimised with robust screening, psychotherapy, safety and monitoring processes. PAT trial results must be interpreted cautiously in confronting unrealistic expectations amplified by media hype. PAT trials are typically limited in size, scope, and duration. Participants may not be representative of clinical populations, and maintaining the blinding of participants and researchers has been challenging, introducing significant bias. Further, PAT trial therapy protocols are unrealistically intensive and usually involve two clinicians. Crucially, significant challenges remain in translating PAT trial protocols into clinical services. These protocols are incompatible with the conventional, individual psychiatric/psychotherapy practice, and most other existing clinical services and funding models. There
Having two therapists per patient in a dosing session is not feasible from a workforce or payer perspective and, therefore, is not viable as a business model. Dosing sessions alone can last half a day or more, which is exhausting for patients and therapists. This would reduce therapy access for other patients, and is a financial opportunity cost for therapists, and psychiatrists depending on the level of supervision required of them by regulators. In my opinion, MDMA and psilocybin rescheduling was premature. Nevertheless, this reality is fast approaching. While PAT offers exciting opportunities for treating psychiatric disorders, it is important to approach these treatments with cautious optimism, given the potential risks and challenges involved in translating these therapies into clinical services. This will require large-scale accredited training and education programs, the development of clinical guidelines, clinical service restructuring and digital transformation, a national framework for monitoring and outcome evaluation, and a commitment from payers to develop adequate funding models. Despite these challenges, I remain hopeful that person-centred care principles are compatible with sustainable and accessible PAT programs and that we will see these treatments integrated safely and effectively into mental health services. References provided on request. – Author competing interests - Dr Tannenbaum has consulted for Emyria and Reset Mind Sciences and is engaged in several industry-sponsored clinical trials of psychedelic-assisted psychotherapy.
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3D food printing to nourish Australians with dysphagia By Dr Liezhou Zhong & Amanda Orchard, Edith Cowan University Poor nutrition contributes to more global deaths than any other factor, including smoking and inadequate physical activity. It is estimated to be responsible for 7% of Australia’s disease burden. Despite the perception that it is ‘an issue of the past’ in Australia, malnutrition is disproportionately common in various vulnerable groups such as people who have difficulties chewing (e.g. tooth loss, dry mouth, gum disease) and swallowing (dysphagia). It is estimated that 8% of the population worldwide has difficulty swallowing. Speech Pathology Australia suggests that over one million Australians are affected by swallowing disorders, including people with motor neurone disease, multiple sclerosis, Parkinson’s disease, Alzheimer’s disease, cancer/ stroke survivors, the geriatric population and children with cerebral palsy. Texture modified diets are clinically prescribed for these vulnerable populations.
Texture modified foods: a delicate balance of safe eating and nutrition Texture modified foods are generally minced, pureed, or thickened foods to reduce the risk of aspiration and choking. In Australia, the International Dysphagia Diet Standardisation Initiative framework, which describes standardised texture classification terminologies and testing methods for eight levels of texture modifications, is well accepted as the standard for texture-modified foods. The foods are commonly overcooked to achieve the required textures, severely destroying and diluting nutrients and flavour due to the extra water and food gums added. In addition, texture modified foods have been found to often lack visual and/or taste appeal. They are regularly presented in ‘blobs’ and ‘ice cream scoops’, making people feel ‘left out’. 46 | JANUARY 2024
modules provided by Maggie Beer Foundation, free recipes: https:// texturedfoods.com/recipes-3 and cooking instructions: https://www. iddsi.org/Testing-Methods) to help people prepare nutritious and safe texture modified foods. However, preparing texture modified foods that are safe for swallowing but also appealing is still a huge daily challenge for chefs and caregivers. Figure 1. The Future Foods & Digital Gastronomy Lab at ECU uses 3D food printing to transform ‘blobs’ into beautiful food presentations.
Poor food visual quality impacts food intake, physical health, mood and mental well-being. Above all, people on texture modified diets face persistent, severely restrictive food varieties, and have reported lower appetite, vitamin A & E intake, protein and fluid intake, and higher weight loss than those on a standard diet. Food is for pleasure. Food texture is one of the key food attributes used to define food quality and acceptability, whilst eating for pleasure and health in communities on texture modified diets is often sacrificed in favour of safe eating. As a result, a range of commonly eaten foods, such as fresh fruits and vegetables, are largely absent from the plates. However, higher fruit and vegetable intake is inversely associated with cardiovascular diseases, cancers, frailty and cognitive impairment. It has been estimated that a 10% increase in vegetable consumption in Australia will reduce health care expenditure by $100 million annually. Yet people on texture modified foods typically experience additional fruit and vegetable consumption barriers, with fruit and vegetable intake often reduced in favour of a ‘protein first’ nutrition priority. There is an increasing number of free resources (e.g. training
3D food printing for healthy and pleasurable eating Malnutrition in people on texture modified foods is not an inevitable consequence of eating difficulties. Enhancing normal food intake through food-based nutrition interventions has been suggested as a cost-effective approach to preventing malnutrition and improving associated health outcomes. 3D food printing technology is an innovative solution to improve food enjoyment in groups requiring texture modified foods by rebuilding the foods into aesthetically pleasing dishes. It can fabricate food objects layer by layer, from the bottom to the top, to achieve designed shapes and is being recognised as a new frontier in the food industry. It has been rendered as a ‘magic bullet’ to enable rapid prototyping, customised food design, and personalised nutrition (based on food preferences, health conditions, specific dietary requirements, and social context). Extrusion-based 3D food printers are the most common as their relatively simple operation and easy material handling is compatible with a wide range of foods. Typically, these materials for extrusion-based food printing should flow through a nozzle and then be self-supporting after being deposited on a surface. This includes chocolate, fats, dough, pureed or mashed fruits and vegetables, edible gels (gums, starch and protein), hummus, creamy cheese, icing, spread, surimi and meat slurry. Thus, texture modified MEDICAL FORUM | FOCUS ON 2024
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Key messages Poor nutrition contributes to more global deaths than smoking Texture modified foods often have lacked nutritional value and aesthetic appeal 3D printing of foods offers a solution.
foods are ideal for extrusion-based 3D food printing. The most apparent advantage of 3D food printing is its freedom to achieve appealing food presentations. It has inherent advantages in achieving more appealing plate presentations as compared to moulding. Beyond shapes, food sensory properties, such as colour, taste, smell and mouthfeel, can be precisely manipulated using 3D food printing and the food materials used can be fortified or even medically tailored for those vulnerable communities who often have a wide range of health conditions. Of note, by constructing different inner and outside food structures
and shapes, we can control the nutrient release of the 3D printed food products (i.e. releaseretardation food). The digestibility of 3D printed foods can also be modulated, which can further affect satiety and food intake. This strategy has also been used to deliver probiotics. In addition to health-related applications, 3D food printing technology can offer a unique opportunity to improve food sustainability. Aesthetically imperfect and underutilised fruits and vegetables that otherwise end up in landfill can be freeze dried to be high-value, nutrient-dense food ingredients, by removing water in raw fresh produce at very low temperatures. The ingredients can then be used to fortify texture modified foods through 3D food printing. To this end, together with freeze dried food ingredients that are upcycled from imperfect fruits and vegetables, 3D food printers can be a powerful kitchen appliance helping families prepare safe, nutrient-dense and appealing texture modified foods.
and Medical Research Council, the WA Health Department and Future Health Research & Innovation Fund, the Future Foods & Digital Gastronomy Laboratory at Edith Cowan University has brought together world-renowned researchers in aged care, multiple sclerosis, autism, nutrition, food science and technology, speech pathology, public health and implementation science to develop appealing, flavourful, nutrient-dense 3D printed food options, focusing on protein-enriched fruit and vegetable-based food choices. Using real-world residential aged care settings as an exemplar, the team has been evaluating the feasibility and effectiveness of implementing the developed 3D printed food choice to improve physical and mental well-being in aged care residents. ED: Dr Zhong & Ms Orchard are researchers at ECU’s Nutrition & Health Innovation Research Institute References available on request – Author competing interest- the authors have been involved in developing the technology described.
Funding from the National Health
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.
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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Summer-salting through the sunny season There’s plenty to do to fill your days and nights over summer.
By Ara Jansen This year Perth Festival (February 9 to March 3) celebrates the sun and our shared humanity in a varied arts program from theatre and performance to music and visual arts. It includes the world premiere of Black Swan State Theatre Company’s The Pool – a deep dive into the heart of community life and exploring the intimate, intersecting stories between a diverse group of attendees. Sit around the pool at night at Bold Park Aquatic Centre with headsets to hear, first-hand, authentic conversations, and observations of the everyday. You’ll also be able to step inside a 70s Aussie film in Stunt Double, hear Norway’s Kings of Convenience perform, be part of The Invisible Opera and Courtney Barnett play at The Rechabite, enjoy Paul Kelly and Angeligue Kidjo at the Concert Hall, see world premieres or see our city with different eyes thanks to Nightwalks with Teenagers.
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Evergreen Lotterywest Films run until March 31 under the pines at the Somerville while the Writers Weekend happens at the State Library on February 24 and 25. Enjoy panels, take part in workshops and binge on words, books, thoughts and ideas. Tempt your tastebuds and pique your curiosity at the markets happening across Perth and its surrounds almost every night of the week. They include the Inglewood Night Markets on Monday, Scarborough Sunset Markets on Thursday nights and Friday night’s Twilight Hawkers Markets in the CBD. Head away from the city to the Kalamunda Markets on Sundays, plus carnival-style night markets on the last Friday of every month. Sculpture by the Sea celebrates its 20th anniversary this year. From March 1-18, Cottesloe Beach will once again be taken over by sculptures in one of Australia’s largest free public events, which attracts more than 250,000 local, interstate and international visitors each year. In 2024, more than 70 artists from 15 countries will be exhibiting. Since the exhibition began back in 2005 with 25 sculptures on the iconic white sands of Cottesloe Beach, 592 artists from 44 countries have exhibited a total of 1,298 sculptures. Promising Perth a summer packed with full-flavoured live performance fun, Fringe World Festival (January 19 to February 28) is bursting with surprise and delight. A delectable array of comedy, cabaret, dance, circus and theatre shows awaits. There are more than 500 events to choose from, including shows such as Matt Hale's Top Fun: 80s Hypnosis Spectacular – The Remix, The Hairy Godmothers, Circus: The Show and the awardcontinued on Page 50
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Summer-salting through the sunny season continued from Page 49 winning DJ Groove Terminator and Soweto Gospel Choir presenting The History of House. Downstairs at The Maj welcomes back a full Fringe program with Aces at The Maj, including shows by Prinnie Stevens and much-loved locals Ali Bodycoat and Libby Hammer, a chaotic cabaret about a drag queen accountant and Australia’s favourite grammatical comedy Comma Sutra. Tickling a funnybone at Fringe is award-winning writer and comedian Kirsty Mann. Turns out she’s also a doctor and hasn’t told everyone because she wants to be taken seriously as a comedian. She’ll be debuting her Skeletons show at The Little Palais in the Pleasure Garden from January 19 sharing a ridiculous and hilarious true story featuring many characters, including Dom – an arrogant but delicious doctor with whom she has an ill-fated affair – and her best friend, Joe, a wild and accident-prone musician. She confesses how her double life came about and the challenges of actually living it. Visit the multi-sensory experience Monet in Paris – The French Impressionists Alive at Crown Perth. Step back into the dazzling world of 19th century Paris where Monet and the Impressionist masters led an unprecedented period of cultural and artistic flourishing. Housed in the purpose built 2,500-metre square Le Grand Palais, it features artworks projected at enormous scale in an immersive display of light, colour, sound and fragrance – for art lovers of all ages. Add to that the opportunity for painting classes, endless photo opportunities, chefprepared high tea with champagne, delectable French cuisine at Le Bistro and Monet by Moonlight sessions with DJs, specialty cocktails and art activations. Escape the hustle and indulge in the Busselton’s relaxing vibes and good times as the South West Craft Beer Festival returns to Signal Park on March 16. A great way to celebrate the St Patrick’s Day weekend, the festival brings together the region’s best craft 50 | JANUARY 2024
they’ll prove that laughter really is the best medicine.
beers, live local music, gourmet food, wine and cider. Perth Comedy Festival (April 22 to May 19) will have you in stitches as the best funny people take the stage. From an ogre-inspired burlesque and drag parody called Swamplesque to shows from Wil Anderson, Peter Helliar, Tommy Little, Connor Burns, Olga Koch, Felicity Ward and many more,
For those who like to plan ahead, the Blackwood River Arts Trail (March 23 to April 7) showcases the talent of local artists, artisans and performers. It also includes the Blackwood River Film Festival, featuring filmmakers from across Australia. The annual trail covers Nannup, Boyup Brook, Balingup and Bridgetown and is a fantastic opportunity for audiences to experience the beauty and culture of the region and connect with the local arts community. There’s also the Margaret River Readers & Writers Festival from May 17-19. Last but not least, consider trips to the WA Museum in Perth or Fremantle, visit a gallery or the Art Gallery of WA, local galleries and check in with any monkey business at the zoo.
MEDICAL FORUM | FOCUS ON 2024
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LIFESTYLE
Time, experience reaps class WA wine pioneers Dr Peter Pratten – a radiologist – and his wife Elizabeth planted their first vines in 1974 on a site by the Capel River, Stirling Estate. The first vintage was in 1980. They also had the foresight to recognise the quality of other West Australian regions, and went on to plant vines in the premium districts of Mt Barker in 1985 and in Wilyabrup in the Margaret River region in 1999, becoming the first producer to have holdings in three different wine regions. A reputation for quality wines quickly followed. Their total vineyard area is 52ha. In 1986, the Capel Vale Riesling was named the Australian Dry White Champion. More recently, the 2020 Scholar Vineyard Cabernet and the 2020 Whispering Hill Shiraz won gold medals in the Decanter World Wine Awards in 2022. The 2021 Whispering Hill Riesling was also awarded gold medal and three trophies at the WA wine show in 2021. Their son, Simon, took the reins of the company in 2007 and has clearly maintained and refined the overall quality of the product. The value of having access to three distinct viticultural sites has allowed for sourcing grape varieties most suited to the particular region. Hence, riesling and shiraz are from Mt Barker, cabernet and chardonnay from Wilyabrup, and merlot and malbec from Geographe where the winery is located just out of Capel. Vinification and viticulture here is first order. The wines tasted show great finesse and balance and I believe are in the “world class” category.
Review by Dr Louis Papaelias
2021 Capel Vale Whispering Hill Riesling Whispering Hill is located between Mt Barker and the Porongurup Ranges. From 40-year-old vines and a cool, low-yielding vintage, this has all the hallmarks of a great Australian dry Riesling. Lifted aromatics of citrus, honeysuckle and talc flow into lovely generous crispness on the tongue and all the way down. Lingering aftertaste. No aggressive phenolics here. Lovely with white fish or just before dinner as aperitif (12% alcohol, $39.99)
2020 Margaret River Cabernet Sauvignon Black Label This Cabernet is for lovers of fine Bordeaux. From a low-yielding vintage, the cassis, olive, chocolate, cedar aromas and fine grain tannins come together seamlessly. The wine is long on the palate and beautifully balanced. Delicious and approachable now because of its balance but will certainly open out further in five U M W IN years-plus (14% alcohol, $49.99) EMI
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It is hard to pick a favourite, as both are lovely wines. It is certainly well-worth stopping by the winery in Capel!
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WINE REVIEW
CA PEL VAL E
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JANUARY 2024 | 51
All the colour of Bollywood, our way Bollywood films have a colourful history in Australia, and now a documentary celebrates the genre and explores some of the more difficult aspects of its life here.
By Ara Jansen Believe it or not, Perth has a very early link to Indian cinema. Her name was Fearless Nadia and she was India’s first female superhero. Born in Perth, Mary Ann Evans moved to Bombay at age five in 1913. As a stuntwoman and actor, she made more than a dozen films and knew how to ride a horse, hunt, fish and shoot as well as having circus skills. It’s just one of the fascinating things you’ll discover about Australia’s links to Bollywood in the documentary Brand Bollywood Downunder. Packed with famous Bollywood types and Australians talking about the influence and impact the genre has had on Australia. You might recognise Anupam Sharma’s face and voice from the intellectual property ads at the start of DVDs talking about piracy, alongside former cricketer Brett Lee. He also directed Lee in the film un-Indian. An Australia Day Ambassador for a decade, a film director and producer, writer and actor, Anu is acknowledged by Australian and Indian media as a producer who has been pioneering films links between India and Australia since 1997. Named one of the 50 most influential people in the Australian film industry, he founded Films and Casting Temple, a Sydney-based production company. 52 | JANUARY 2024
Brand Bollywood Downunder was a project he started working on when so much of his industry was halted due to COVID. It became the perfect time to explore Australia’s love for Bollywood films, its history and where it stands today. “This is my homage to the world’s most prolific, followed, colourful, enchanting, ridiculed, engaging and celebratory film industry,” he explains as the doco’s writer, director and producer. “The film is a look at the confused, well-meaning, chaotic, unpredictable Australian reaction to the equally chaotic and confused Bollywood, as it invaded iconic Australian locations.” The doco features interviews with Indian stars Anupam Kher, Farhan Akhtar, Fardeen Khan and Harman Baweja, alongside former state premiers Ted Baillieu and Mike Rann, domestic film personalities and local film locations. While there’s plenty of glitz, glamour, chaos and colour, Anu doesn’t shy away from some of the more bitter moments of Bollywood in Australia, such as issues of racism, abuse of a film crew on set and the bewilderment of officials with a chaiwallah (tea maker) on an inbound crew list. As a migrant Anu was “looking for ways to combine the Australian in me, the Indian in me, the film professional in me and the Bollywood crazy fan in me”.
“I grew up watching many Bollywood films shot all over the world and now in Australia. It has been the most bizarre experience to see it all materialise from scratch as Australia, my adopted country, becomes an important part of the world’s biggest film industry. “As a filmmaker, and someone who is experiencing this amazing journey, I am very keen to share it. As an Australian, I have always been an ardent supporter of diversity, before it was a buzzword, in front of and behind the camera. It has been interesting to see Australian film professionals embrace diversity and heart-warming to witness them overcome their own prejudices and stereotyping.” Anu holds a number of board and advisory positions, but most recently became the inaugural board chair of the Australia India Film Council. He hopes the council will forge closer and even more productive film links between the two countries – and slake our thirst for more Bollywood-style films which honour Bollywood but have a distinctly Aussie flavour. For those who can’t get enough of Indian movies, check your local cinema – many are now regularly screening movies from across India. www.brandbollywood.film
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SOCIAL PULSE
Doctors farewell 2023
Doctors’ Christmas parties were back in full swing in Western Australia in 2023 when, for the most part, people shrugged off the remnants of the worst of the pandemic.
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Ramsay: Ramsay’s chief operating officer for hospitals Greg Hall, chief financial officer Martyn Roberts, national CEO Carmel Monaghan and WA government relations manager Peter Mott, joined by cardiologist Dr Phillip Currie.
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Ramsay: Chris O’Keeffe, anaesthetist Dr Rebecca Kelly, Leila Maddison, retiring urologist Dr Sydney Weinstein, urologist Dr Jessica Yin and Andrej Percic.
Ramsay Health Care, known for its high-end Christmas parties, celebrated at Fraser’s in Kings Park, with more than 500 specialists and their partners attending from its five WA sites – Hollywood Private Hospital, Joondalup Health Campus, Glengarry Private Hospital, Attadale Rehabilitation Hospital and Peel Health Campus.
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SJOG Mt Lawley: Dr Charles Armstrong and Louise Forbes
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SJOG Mt Lawley: SJOG Mt Lawley Doctor of the Year Greg Hogan, his wife Kate Hogan and hospital CEO Vanessa Unwin.
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SJOG Murdoch: SJOG Murdoch CEO Ben Irish presents Dr Sanjay Mukhedkar with his Doctor of the Year 2023 award.
It was hosted by Ramsay State Manager WA Dr Shane Kelly, with Ramsay Australia’s chief executive officer Carmel Monaghan flying over for the event. At St John of God Hospital Murdoch, the annual doctors’ catchup was used to announce its Doctor of the Year 2023, oncologist and cricket devotee Dr Sanjay Mukhedkar. The hospital’s CEO Ben Irish presented the award by the lake on the hospital grounds, in front of Dr Mukhedkar’s family and colleagues. Heading north-east, St John of God Mt Lawley held its doctors’ soiree at Moana Hall, where 130 specialists and managers enjoyed gourmet food while listening to vocalist Allira Wilson and a jazz band. Hospital CEO Vanessa Unwin presented its Doctor of the Year Award to orthopaedic surgeon Dr Greg Hogan, who was recognised for 21 years of service.
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52 | APRIL 2021
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
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
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
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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.
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
UNIVERSITY OF WESTERN AUSTRALIA, CRAWLEY Position vacancy for GP part/full time with no AHPRA restrictions. UWA Health and Medical Services is presently seeking a VR General Practitioner (Non-DPA) to join our multidisciplinary team of health professionals. 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; and the management of student and staff mental health. Sessions negotiable - attractive retention. Please contact Sharon Almeida (Practice Manager) sharon.almeida@uwa.edu.au or phone 6488 2118
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
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
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
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
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medical forum CLASSIFIEDS
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
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 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
PERTH Breast Clinic seeking VR GP Perth Breast Clinic is seeking an enthusiastic VR GP to join our expert team of breast physicians, 1 – 2 days per week. Located in the Mount Hospital Medical Centre, Perth Breast Clinic offers a comprehensive service for women, from breast screening and diagnosis through assessment of symptoms, diagnosis and management of breast cancer and benign breast disease. The clinic is led by our specialist breast physicians who work as part of a multidisciplinary team comprising radiologists, surgeons, pathologists, oncologists, nursing and support staff. We offer • Comprehensive training and mentorship by highly experienced breast physicians • Flexible work hours, 1-2 days per week • Mixed billing, low service fee • Onsite parking Requirements • AHPRA registration / Medical Indemnity insurance • Previous experience in women’s health • Advanced communication skills For further information, please contact Tasha Pratt by email tasha.pratt@healthscope.com.au or phone 0477 961 871
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
Contact Andrew, classifieds@mforum.com.au or phone 9203 5222 to place your classified advert
Opening October in WATERFORD
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
New patients welcome 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
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
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
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
General Practitioner Join our friendly Health Services team to provide quality care and make a difference in Curtin Community’s health and well-being at our Bentley campus. Part-time and full-time contractor/temp opportunities available Excellent working conditions and room facilities Administrative and Nursing support provided JOB REFERENCE Are you a caring and experienced General Practitioner? Join our friendly and collaborative team of general practitioners, nurses, medical receptionists, and a Practice Manager to make a difference to our Curtin Community’s health and well-being within our busy Medical Centre at our Bentley campus. Our Medical Centre is a well-established and fully equipped practice with a total of 7 consulting rooms, a procedure room, treatment, and onsite pathology. The Centre is open Monday to Friday between 8:30 am and 4:30 pm. It is well-served by public transport and has ample parking. We offer mixed billing (70% bulkbill) with flexible consulting hours. Our GPs are fully supported by a practice manager, registered nurses, administration staff and a mental health nurse practitioner. Our Medical Centre has high volumes of patient demands and full-appointment books during semesters. This is a large and diverse patient base offering lots of interesting work, plus walk-ins, opportunities for Healthcare Plans Health Assessments, and procedures.
Make tomorrow better
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BENEFITS 70% of the billing/mixed billing Work full-time or part-time with flexible hours. You choose! Excellent working conditions and room facilities Walk into a full & immediate patient base, OR create your own, with walk-in presentations Best Practice software in use throughout the practice REQUIREMENTS MBBS or equivalent Current AHPRA registration as a General Practitioner Vocationally Registered (VR) No restrictions To learn more about this opportunity, please contact Nandita Nadkar, Team Leader on 08 9266 7345. For more information about our university, please visit www.curtin.edu.au Applications close: 15 December 2023
curtin.edu.au
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
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medical forum CLASSIFIEDS Positions - Stress Test Supervising Physician Perth and suburbs
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
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. 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 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
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 109318.
Applications close 4.00PM (Christmas Island local time) (CXT) (UTC+7), 9 November 2023
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