Medical Forum February 2020 - Public Edition

Forward thinking LEARN, UNLEARN, RELEARN

Innovations & Trends issue | Phenomics, AI, Digital Health, Whole Person Care, Radiology

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EDITORIAL BACK TO CONTENTS

Jan Hallam | Managing Editor

New year, new tricks This isn’t just about accepting what technology can do to improve outcomes. It’s about returning to what is essential – our compassion for each other and the planet, and let that be the guide.

As we prepared for this annual Innovations and Trends issue, I stumbled on this little ‘disruptor’ triptych: LEARN, UNLEARN, RELEARN. Now, usually this sort of stuff is confined to Facebook along with the truly adorable stories about lost cats and dogs, but this has seeped into my brain, somewhat, and partially because this is no longer a clever thing to say, it is becoming a lived experience – and a necessity.

This bushfire season in Australia is a living lesson for the world. Not simply because Australia was on fire, that in itself is no surprise when it hasn’t rained properly in years and our waterways are being drained, but this tragic episode has sent tangible shock waves through local and international political circles.

The loss of life – four legs, two legs, feather, fur, scales, leaves, seeds and spores – has been on an unprecedented scale. Air quality has never been so poor. People are scared of what the future holds, but even more scared that there is no policy direction or leadership to navigate them through this new landscape.

Climate change is as real as the burden of largely preventable chronic disease which is slowly killing our citizens and choking our health system. No one can deny either.

However, all this is an opportunity … cue the relearn phase.

There are very smart, capable people out there in all walks of life – there are more than a few in the medical profession. People prepared to undergo the painful unlearning phase to allow in new ideas and methodologies.

This isn’t just about accepting what technology can do to improve outcomes. It’s about returning to what is essential – our compassion for each other and the planet and let that be the guide.

This new thinking is reflected in the articles we publish this month, in Medical Forum’s first edition for the year, itself refreshed and in the process of relearning.

The views are from clinicians, from researchers, from government. The views are forged from lived experience and embracing the best of the new.

It will be an exciting year of change.

MEDICAL FORUM | INNOVATION & TRENDS ISSUE

FEBRUARY 2020 | 1

CONTENTS | FEBRUARY 2020 – INNOVATION & TRENDS ISSUE

Inside this issue 16 18 8

22

FEATURES

NEWS & VIEWS

LIFESTYLE

8 Q&A: Dr Andrew Miller

1

51 Wine Review: Sittella

16 WA Digital Health Strategy 18 Clinician-led technology 22 Australian National Phenome Centre

Editorial: New year, new tricks – Jan Hallam

– Dr Martin Buck

52 Arts & Entertainment:

4 Opinion: Overdiagnosis – Dr Joe Kosterich

10 WA News

War Horse

53 Out & About 54 Social Pulse Christmas:

11 Local Brief

SGJ Midland Hospital, SJG Murdoch, SJG Subiaco, Ramsay, Bethesda Health Care; SJG Mt Lawley

12 Global News 14 Research Briefs 32 Superannuation – Rob Pyne

CONNECT WITH US /medicalforumwa

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info@mforum.com.au

MEDICAL FORUM | INNOVATION & TRENDS ISSUE

CONTENTS

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

Clinicals

ADVERTISING Marketing Manager (0403 282 510) mm@mforum.com.au EDITORIAL TEAM Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au

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Genetic Testing in Cancer A/Prof Mirette Saad

35

Real World Research Dr Michael Winlo

36

Stereotactic Body Radiotherapy Dr Sean Bydder

37

39

Research Support A/Prof Sue Skull

41

Women’s Care Dr Stuart Prosser

42

AI in Medicine Dr David Playford

Implant 44 Breast Update

Diabetes Testing Dr Cameron Gent

48

US Prostate Testing Dr Weerakkody

49

AI in Radiology Dr Brendan Adler

Journalist James Knox (08 9203 5599) james@mforum.com.au Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au

Dr Tim Cooper

GRAPHIC DESIGN Thinking Hats studio@thinkinghats.net.au INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Mark Hands (Cardiologist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon)

47

Knee AO Dr JP Caneiro

Guest Columns

CONTACT MEDICAL FORUM Phone: 08 9203 5222 Fax: 08 9203 5333 Email: info@mforum.com.au www.mforum.com.au

6

Whole Person Care Dr Sarah Moore

26

Silicosis E/Prof Ifan Odwyn Jones & Prof Bill Musk

28

Vaping Dr KC Wan

30

Working on your Zen Dr Talia Steed

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MEDICAL FORUM | INNOVATION & TRENDS ISSUE

FEBRUARY 2020 | 3

Cracking open overdiagnosis Treating symptomless conditions can be a slippery slope. Dr Joe Kosterich reports some of the discussion from a recent conference.

Ultimately it comes back to physicians and patients seizing back control from public health academics…

We need to return to treating people, not populations.

Sometimes the most obvious gets forgotten. Medicine’s goal is to alleviate suffering. To quote Arturo Catiglioni “[Medicine was] born with the first expression of suffering and the first desire to alleviate this suffering”.

Today we focus more on what does not cause suffering – certainly not in the immediate sense. The problems that mass screening, population health programs, commercial drivers and litigation have caused were considered at the seventh annual Preventing Overdiagnosis Conference held at Sydney University in December.

Professor Jin-Ling Tan from China deftly contrasted how medicine has changed in the past generation.

Previously, we saw people with symptoms. The patient could indicate whether they were getting benefit from treatment and “had a say in what was done”.

Today we treat symptomless conditions such as raised cholesterol or blood pressure. The patient cannot tell whether they are getting benefit – only we can do that through measurements. The patient may give informed consent but arguably has less of a say in what goes on.

Prof Tan gave the example of treating moderate hypertension. The estimate is that 7% of the average Chinese hypertensive population will develop a CVD event over 10 years. Hence only 7% can potentially benefit from interventions for preventing CVD events and 93% will be treated for no net benefit to themselves.

Furthermore, of the 7%, only 30% will benefit from anti-hypertensive drugs.

Only two out of 100 people treated for moderate hypertension will actually benefit from the treatment!

This is astounding. Now, I am sure others have different statistics which

4 | FEBRUARY 2020

come to different conclusions. As doctors we don’t think much about the harms (personal and economic) of treating people who will not benefit from treatment.

A Danish paper estimated that 43% of frail older people had no reason to be on one or more of their medications.

Of course, treatment follows diagnosis. Lowering of thresholds and commercial drivers of increased testing and treating were examined.

Again, the common view that there is little or no downside. The problems of tainted guidelines and how they are often not applicable to real world patients was discussed.

Some sessions examined the overdiagnosis of cancer. Paul Glasziou et. al. presented a paper estimating that each year in Australia more than 11,000 women and 18,000 men are over diagnosed. This means they are found to have and be treated for something which would never have manifested clinically, nor affected life expectancy.

Necessarily such a conference cannot come up with all the answers.

However, it can get us thinking.

Both patients and doctors need to better understand that testing and treatments have downsides and that more is not always better.

Ultimately it comes back to physicians and patients seizing back control from public health academics. It is about individualised care not ‘best practice’ when such practice may be irrelevant to the individual. We need to return to treating people, not populations.

– References available on request Author competing interests. The author attended the conference on a media pass but self-funded airfares and accommodation.

MEDICAL FORUM | INNOVATION & TRENDS ISSUE

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OPINION

Major Partner: Australian Clinical Labs MAJOR PARTNER

Update on Genetic Testing in Cancer and Targeted Therapy

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About the author

Assoc. Prof.

Mirette Saad

Speciality: Chemical pathology and molecular genetics Areas Of Interest: Cancer genetics, antenatal genetic screening and fertility, medical research and teaching Phone: (03) 9538 6777 Email: mirette.saad@clinicallabs.com.au

MBBS (Hons), MD, MAACB, FRCPA, PhD Lab: Clayton VIC

Associate Professor Mirette Saad is a Consultant Chemical Pathologist and the National Clinical Director of Molecular Genetic Pathology at Australian Clinical Labs. At Clinical Labs, A/Prof Mirette Saad leads the Molecular Genetic testing for Non-Invasive Prenatal Testing (NIPT), genetic carrier screening, personalised drug therapy and cancer. She is a Chair of the RCPA Chemical Pathology Advisory Committee, Member of the RCPA Genetic Advisory Committee and a Chair of the Precision Medicine Services at Australian Clinical Labs.

Cancer, a leading cause of mortality, is associated with aberrant genes. The world of molecular profiling in cancer has undergone revolutionary changes over the last few years as knowledge, technology, and even standard clinical practice have evolved. Broad molecular profiling is now nearly essential for all patients with metastatic solid tumours. New agents have been approved based on molecular testing instead of tumour site of origin.

Driver Mutations Guide Treatment Decisions The introduction of targeted therapies in lung, colon, melanoma and breast cancer have contributed to a significant increase in overall survival (OS) related to these diseases.

Genetic variants identified in cancer are known to be associated with increased or decreased sensitivity to targeted therapy. For example, while PIK3CA and EGFR mutations are sensitive to tyrosine kinase inhibitors (TKIs), RAS and BRAF are known to be resistant.

Crizotinib is an ALK/ROS1/MET inhibitor that is already FDA approved in ALK-positive or ROS1-positive NSCLC but also has proven clinical activity in cases of MET exon 14 alterations and MET amplification. PD-L1 expression in metastatic NSCLC can benefit from FDA approved pembrolizumab monotherapy under specific criteria.

Recently, a third-generation EGFR TKI, which is effective in tumours harbouring the p.T790M EGFR mutation was approved in Australia for patients with NSCLC following progression on an EGFR TKI. In breast cancer, mutated PIK3CA has become an attractive therapeutic target. While anti-BRAF inhibitors (BRAFi) remains the first-line treatment for melanoma tumours that harbour a BRAF mutation, particularly in Australia, other oncogenic driver mutations such as cKIT mutations may guide the selection of KIT TKIs (imatinib and sunitinib) for the melanoma treatment.

New Guidelines; Broadening Molecular Profiling Boundaries Recent NCCN guidelines recommended additional genetic biomarkers for different types of cancer tissues.

In lung cancer, the new NCCN guidelines recommend testing for EGFR, ALK, ROS1, BRAF, and PD-L1 for all patients with NSCLC at baseline before treatment.

Universal Microsatellite instability (MSI)/DNA mismatch repair (MMR) testing at the time of initial diagnosis for all stages of colorectal tumours is now recommended to determine whether patients have a germline

mutation indicative of Lynch syndrome. For additional treatment options, testing for KRAS/NRAS/BRAF in un-resectable left-sided stage IV metastatic colorectal cancer (mCRC) tumours is also recommended.

In addition to breast and ovarian cancers, germline mutations, mainly BRCA1/2, along with somatic mutation testing are recently recommended by NCCN guidelines for both pancreatic and prostate cancers. In prostate cancer, BRCA1/BRCA2 can occur in 20-25% of all advanced prostate cancer. Although ATM testing is not yet recommended by the NCCN as a predictive measure, Na et al., showed that germline BRCA2 and ATM mutations distinguish lethal from indolent prostate cancers and are associated with shorter survival times and earlier age at death. While tumour mutation burden (TMB) is certainly an interesting emerging biomarker, evidence of its importance is growing.

ctDNA identified the emergence of polyclonal and heterogeneous patterns of mutation in KRAS, NRAS, BRAF, or EGFR with mutations found in 96% of panitumumab- or cetuximab refractory patients.

Subsequently, Misale et al., were able to illustrate a way to use this information to overcome treatment resistance.

Furthermore, studies demonstrate better outcomes when no tumour-derived DNA is found in patients following surgery or chemotherapy in colorectal cancer patients, whereas those with whom tumour DNA is still present do better with the addition of more aggressive targeted treatment or chemotherapy.

In melanoma, several studies showed the utility of ctDNA as a diagnostic, predictive and prognostic biomarker for patients on anti-BRAF treatment.

Liquid Biopsy: Circulating Tumour DNA (ctDNA) Testing The variety of validated technologies emerging enables more precise and robust analysis of circulating tumour-derived DNA (ctDNA) extracted from blood with sufficient sensitivity and specificity to accurately detect cancer biomarkers.

Moreover, ctDNA can also ease the decision in the daily clinical practice when radiological evaluation is problematic especially for patients receiving PD-1 inhibitor immunotherapy. In this context, an important advantage of ctDNA is the possibility of non-invasive serial testing for monitoring treatment response and resistance to therapy.

It is clear today that a single biopsy from a single metastatic site does not seem to be representative of the metastatic cancer. The advent of molecular profiling overcame the limitations of traditional solid tumour classification methods, which relied on the morphology of tumour cells and the surrounding tissue.

Finally, precision medicine in cancer is moving that quickly specially in the malignant heme space and is now a part of our standard practice. While with new challenges, it will continue to move forward with more discoveries to come.

References on request

While considered the gold standard, tissue biopsy-based tumour diagnosis has many limitations.

For instance, tumour heterogeneity, the detection of early-stage tumour or residual lesions is unsatisfactory, and its application in the evaluation of treatment efficacy, resistance, relapse and prognosis is also limited.

The use of liquid biopsy profiling has proven useful in selected clinical scenarios. The first ctDNA liquid biopsy approved for use in clinical settings was in lung cancer patients for the identification of EGFR mutations for first line therapy or identifying resistance mutations that will allow for treatment with third generation EGFR inhibitors.

In colorectal cancer, ctDNA could also be used to track clonal evolution and targeted drug responses.

In patients with metastatic colorectal cancer who developed resistance to EGFR antibodies, analysis of

Building better health partnerships MEDICAL FORUM | INNOVATION & TRENDS ISSUE

Contact a local pathologist near you

Dr Shona Hendry MBBS (Hons), FRCPA Lab: Subiaco Speciality: Anatomical pathology Areas Of Interest: Molecular pathology, Gastrointestinal pathology, cytology, bone and soft tissue and urology.

Phone: (08) 9213 2173 Email: shona.hendry@clinicallabs.com.au Dr Hendry is an Anatomical Pathologist with special interests in molecular pathology, gastrointestinal pathology, cytology, bone and soft tissue and urology. She is an Honours graduate of the University of Western Australia medical school who completed much of her pathology registrar training in Perth, gaining her FRCPA in 2016.

1300 367 674 | clinicallabs.com.au FEBRUARY 2020 | 5

Care – for the Whole Person Busselton GP and educator Dr Sarah Moore takes a journey around mindful medicine.

In October 2019, I was fortunate enough to travel to Montreal to spend two weeks on sabbatical at McGill University, based in the Programs in Whole Person Care in the Faculty of Medicine. This was as a consequence of my successful application for a Fay Gale Fellowship, which the University of WA awards annually to an early career academic.

While there, I attended the third International Congress in Whole Person Care, chaired by my sabbatical supervisor, Dr Tom Hutchinson, and the program included inspiring keynote speakers, practical workshops and presentations focussing on whole person care approaches to addiction, compassionate health care and culture change in health care.

One of the most powerful speakers was Dr Rana Awdish, who is a critical care physician and faculty member of Wayne State University School of Medicine in Detroit, Michigan.

She completed her medical degree at Wayne State in 2002, her residency at Mount Sinai Beth Israel in New York, and her fellowship training at Henry Ford Hospital where she currently serves as the Director of the Pulmonary Hypertension Program. She also serves as Medical Director of Care Experience for the entire health system.

At the conference, she shared her experience of being seven months

pregnant and finishing her critical care fellowship, only to experience a life-threatening intra-abdominal haemorrhage.

She described in detail her experience of arriving on the obstetric ward at the hospital where she worked and being greeted by a resident who admitted he didn’t have much experience with ultrasound. She reassured him she would help.

When she told him there was no fetal heart beat to be seen, he asked her “can you show me where you see that?”.

Next, she was rushed to theatre for emergency surgery, and she remembers hearing the anaesthetist say, “We’re losing her, she’s circulating the drain”. Then she arrested and the next thing she remembers is waking up very debilitated in ICU, having had a cerebellar stroke.

Her first thought was getting hold of a pen so she could ask, “am I dying?”. Her family wouldn’t give her one because they thought she was going to ask “is the baby alive?” and they feared that if they told her the baby had died it might impair her healing.

Later, she recalled overhearing her medical team discussing her management, and the resident said “she’s been trying to die on us” to which she thought, “I am not! Why

do we have to be on different sides – I’m part of the team too!”

She then had an experience of bleeding into her legs and had to ask her treating medical team to examine her because not once had they done so, relying instead on blood tests and CT scans to determine her management. She went on to endure 12 months of slow recovery, experiencing further episodes of discoordination of care, inability of her treating doctors to attend to human suffering and poor communication.

However, she was able to report one positive interaction with her surgeon. He could see she was anxious about having a residual abdominal hernia, so invited her in for a consultation. He asked her “what are you most afraid of?” to which she responded “having an ostomy bag”. He replied, “I’ll do everything I can to avoid that”.

There was no data he could give her to reduce her fear, but he could demonstrate rapport and trust, which is what she needed.

As a consequence of her experience, Dr Awdish has become passionate about improving the patient experience across the health system.

Dr Awdish has also developed a model for healing, which she shared with us. It is simple yet powerful.

• Mutuality Doctors, patients and their families working together as a team, not in opposition

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MEDICAL FORUM | INNOVATION & TRENDS ISSUE

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OPINION

OPINION

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Visual thinking strategies

Sarah strolls the grounds of McGill with her children.

• Proximity Getting close to what makes us uncomfortable and sharing this, exposing our vulnerabilities in order to build rapport and trust • Resilience Putting time and effort into the “rewards” of medicine, including meaning, healing, autonomy and gratitude, to allow us to endure and bounce back from the impact of the many stressors, including suffering, monotony, responsibility and blame.

• Humility Understanding that we do not know it all, but if we are open to different perspectives we can learn from others and deepen our wisdom.

CLEAR conversations When eventually Dr Awdish returned to work, she sought training in Vital Talk, a communications training program for health professionals. She then established a workshop program to train faculty and trainees in relationship-based communication skills. These workshops are run in

small groups of eight physicians who take turns in giving bad news to a patient-actor following which doctors receive feedback from the actors. The aim is mastery through experiential and transformational learning. The values are CLEAR – Connect, Listen without judgement, Empathise, Align with patient values and Respect.

Coaching Dr Awdish believes that every doctor needs a coach, even after they complete their fellowship training. Atul Gawande has written a lot on this topic and much of the training that has been developed at Henry Ford Hospital is based on his work. One example of how coaching can be provided is encouraging medical staff to use reflective statements when talking to their patients and to each other. For example, It sounds like what you value most is…

What I hear you saying is…

It seems you may feel…

What appears to be most important to you is…

What is Whole Person Care?

Dr Hutchinson has written a number of books on the subject, and below is his definition, paraphrased from his most recent publication MD Aware: A Mindful Medical Practice Course Guide.

Whole person care is about being a doctor who will provide competent medical care and relate to the patient a whole person, who has preferences and needs that need to be considered as part of their treatment. Whole person care contrasts the reductionist view of medicine that sees doctors as technicians who repair broken bodies. Whole Person Care focuses on the fact that even though a patient may not be cured, they may still be healed.

In summary, whole person care requires that the doctor recognises their own whole personhood, including their valuable medical knowledge, skills and attitudes but also their own human limitations, ignorance, lack of skill and unhelpful attitudes.

MEDICAL FORUM | INNOVATION & TRENDS ISSUE

At Henry Ford Hospital, all multidisciplinary teams go to the art museum together at the beginning of a new rotation. A trained facilitator takes them to a painting and asks the following questions: What do you think is happening here?

What do you see that makes you say that?

What else could you see?

All members of the team share their insights and through this process realise that everyone sees things slightly differently, illustrating the importance of shared decisionmaking. The purpose of the exercise is to demonstrate implicit bias and the importance of mutuality with the intention of building a positive team structure.

Narrative writing Henry Ford Hospital runs practical workshops where medical staff read literature and poetry and watch films then share what they notice, either verbally or in writing. These reflective exercises encourage doctors to get in touch with their emotional responses and the value that comes with communicating these responses.

In closing, Dr Awdish stated that she set out to change herself but ended up transforming the culture of her hospital. A powerful and inspiring message for us all.

Now that I am back in Australia and reflecting on my learnings from Montreal, there are a number of actions I intend to take.

I already have an (almost) daily meditation and yoga practice, which I will continue. I have read MD Aware: A Mindful Medical Practice Course Guide and will be facilitating this seven-week course with my 10 Rural Clinical School (RCS) medical students in Busselton in 2020 under the guidance of Dr Hutchinson. I plan to establish a “Whole Person Care” interest group with academic colleagues from the RCS. I also anticipate facilitating regular debriefing sessions with my medical students to discuss the challenges they face, both personally and professionally.

I hope that each of these actions will allow me to strengthen my ability to provide whole person care and inspire my students to master this essential clinical skill.

FEBRUARY 2020 | 7

Q&A with...

Dr Andrew Miller, President of the Australian Medical Association (WA)

MF: Reflecting on the year just past, what have been the highlights for Dr Andrew Miller – both professionally and personally?

AM: 2019 held some of my best and worst days. The arrival of our daughter Ava, in late 2018, has brought wonder and renewal, as only a baby can do. There is nothing like a fresh new person to motivate us to improve the world that she, and her adoring older siblings, will inherit.

She won't remember though, that in her first few months she spent some short but wonderful time with my closest friend, fellow anaesthetist Andrew Olney, just before he died from renal cell carcinoma. How valuable he was. Such huge a loss can only be digested over a very long time, if at all. I can’t get his voice out of my head. though, so I still have his disrespectful advice on hand.

My son graduated high school late in the year, deploying what could only be called an extremely healthy work-life balance, and my elder daughter continues to inspire with her adventurous approach to study and life.

Being elected to the AMA (WA) Presidency was a great honour.

I have high hopes for what the organisation can become, and what doctors can do, when our collective intellect is coordinated. I am so proud of this profession, when it is at its best, and I relish the opportunity to change things for the better and to point out all the good medicine has done and can do. Science must win out over whatever it is that is going on now with democracies and online information.

MF: What were the most significant issues you had to face as AMA (WA) President in 2019?

AM: The big-ticket items were: - the public health system perfect storm.

8 | FEBRUARY 2020

Sky rocketing demand rendering new facilities already too small, poor staff engagement, junior doctor leave and rosters, difficulty getting subacute patients placed, and mental health languishing.

- general practice suffering chronic Canberritis Under-funding and bureaucracy, lack of training applicants, pharmacy nonsense, pathology rent issues. WAPHA leading on the Urgent Care pilot was a plus here, and WAGPET leading on Rural Generalist pathways.

- voluntary assisted dying, palliative care, and the whole of end of life.

- public health skirmishes Obesity, vaping, with chronic outbreaks of smoking, alcohol and gambling industry push back.

Getting the balance between public policy and personal responsibility right.

- internal renewal of the AMA (WA) to set it up for the next generations.

MF: How did you and the organisation approach them?

AM: I have refined my view of how the AMA can move forward after being on the state and federal Councils for some years, observing and learning from doctors whom I admire. I took time to see what works and what doesn’t. We need a laser-like focus on what doctors and their patients need from the AMA to make our lives easier and outcomes better. In 2017 I started a process of renewal at AMA (WA) and we changed the constitution then to have a professional board, modern governance, and to start a professional seamless transition to our new CEO. That has now been successfully delivered.

In advocacy, actively soliciting

opinions of members and all doctors is the most effective way to represent the profession. Seeking and listening to the various opinions is vital to staying sensible. Though doctors take issue with some decisions, and that is inevitable, they do seem to appreciate the opportunity to be heard and treated with respect.

MF: Do you measure the outcomes in terms of success, or in a more multi-dimensional way?

AM: Outcomes are always multidimensional as the question suggests. Sophisticated analysis of any issue will reveal the level of priority, the stakeholders, the impact, and how it all interacts with culture and politics. Were we listened to?

Was change made? How have doctors and patients been affected?

It takes a while to find these things out, but we have to decide objectively if advocacy has resulted in improvement then try again.

The AMA has to be both reactive and proactive and also agile enough to respond quickly when the issues arise. All this on a limited budget, which is why our businesses must also be run professionally to effectively support our underlying aims.

MF: Assuming that Voluntary Assisted Dying was one of those issues, are you content with the outcome?

AM: We aren't finished with that one yet, in the sense that the impending implementation of the Act has both risks and opportunities. However, we were listened to and we can now continue to discuss with doctors and represent the views of those who will be directly affected by its implementation. In many cases that will be Specialist GPs who provide a lot of end of life care.

When there are disparate views

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Q&A

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Q&A

within the medical community it is important to acknowledge that, and we did. The commitments made to palliative care by the government are an important outcome and will be closely watched and reported on independently by the AMA. MF: Looking towards 2020, what are the issues that pose the greatest challenges for the AMA, specifically, and the membership more broadly?

AM: The increased demand on public hospitals has rendered the construction of new facilities already insufficient. Subacute care – placement for rehabilitation and long-term care – is failing in WA, as in other states. It contributes to ambulance ramping as the problem of access is the ED-to-ward interface, not the ED itself.

GP Medicare rebates are a disgrace, to be frank. They have not moved much since I was working in Marangaroo in the early 1990s.

Demonstrating the value of primary care in preventing high-cost, later intervention and closing the loop back to higher GP rebates so that high frequency medicine is discouraged, will not be hard but requires a more sophisticated advocacy than we have managed so far. Charging gaps to avoid high frequency medicine will help in some places, but puts the economic burden on those already doing it tough in many cases.

The culture in public hospitals is on the improve in some, but still all of them can do much better.

The problems are a combination of process (eg leave access) and people (clever bullies) and it takes some time to determine which is contributing most.

The implementation of VAD will need to be carefully considered and involve as much direct doctor communication as possible.

We want permanent tenure contracts for our state employees – this will be the sticking point in the new EBA. Some years ago, there was a pay rise, now whittled away, in return for five-year contracts. These contracts have contributed to poor cultural practices and facilitated bullying in some places. All other states have tenure and similar pay, so we want the same deal as a way of improving culture.

WA could be a medical hub with our unique ability to fund medical research. If we can fix the morale problem, and putting clinicians in control of their own destiny again, then we can make it a great state in which to start and complete a medical career.

MF: The current bushfire dilemma has put climate change firmly in the centre of the national debate. The AMA has formally recognised climate change as a health emergency. In what ways will the AMA make that recognition tangible?

AM: The AMA will advocate and facilitate members to do all sorts of things on climate change. We are confident in backing the science on this, as we do on vaccination.

When the CSIRO, BoM, Academy of Sciences and universities state the case as clearly as they have, we have no problem accepting that. It is a public health issue and therefore very high on our agenda along with all the social determinants of health.

MF: The WA branch of the AMA heads into 2020 with a new CEO, what does this new era promise to bring its members, specifically, and the WA health sector, generally?

AM: The AMA is having a reboot in WA and federally, with a new CEO there as well. It is a time of great change building on the good things we have, and reminding all doctors that the AMA belongs to the whole profession. It has incredible influence and its independence is very important at a time when the media is increasingly partisan.

The AMA is a general forum for members to express, argue, resolve and advocate. Even when we have differences, it is essential we stick together to advance the cause of science and medicine.

For individuals, the AMA is a union that can go into bat, not just with an employer, but in many circumstances where doctors tend to run into trouble. Along with medical indemnity insurance the AMA membership is an important (and relatively inexpensive) piece of risk management.

It resonates with all doctors when the AMA emphasises issues of professionalism and the primary role of science, so there is much that unites us. The Doctors-in-Training

MEDICAL FORUM | INNOVATION & TRENDS ISSUE

will lead the way on membership.

Combining the organisation’s corporate knowledge and their enthusiasm, the AMA will be a force for good in the medical and wider community MF: What is on your health system wish list for the coming year?

AM: Improved culture and permanent contracts for public system doctors.

The adoption of a single employer, a career agency, by Health in WA would reduce so much transactional cost, stress and uncertainty for doctors. We know we need doctors for the long haul so we should be offering cradle-to-grave support with the deal being: we will help you and employ you throughout your medical life, if you come dedicate yourself to the WA Health system.

Reducing duplication of mandatory modules would be a good place to start.

A better approach to the methamphetamine issue, with consideration of all harm reduction and rehabilitation methods being apolitical. The recent WA parliamentary report is a valuable place to start.

Banging some sense into the metaphorical heads of the MBS Review.

Implementing VAD in a safe, equitable and workable way that listens to the patients, families, GPs and others who actually care for the dying.

Avoidance of more IT mega project waste. I believe there will be a temptation for governments to listen to the multinational spruikers of AI who promise that a massive investment in deep data will solve their health system problems and reduce reliance on doctors. It won’t.

Positivity from the AMA. We will fearlessly point out problems and nonsense, but follow up with solutions.

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FEBRUARY 2020 | 9

WA NEWS

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Interns for Midland January saw a new crop of interns start their hospital placements and, for the first time, St John of God Midland Public Hospital has accepted an intake.

The 12 interns will spend the next 12 months in general surgery, emergency medicine, general medicine/acute aged care, paediatrics, intensive care and neurology/stroke. They will do an intensive care rotation at St John of God Subiaco Hospital. Group CEO Dr Shane Kelly said the interns wold benefit from being part of a small cohort, “further supporting individualised training, education and mentorship.” “As a direct employer of interns, we can expand the career pipeline for the next generation of doctors in WA. Dr Kelly said there were plans to expand the intern program to include other St John of God hospitals in WA. The Midland hospital late last year released its annual report which reflects increased activity in the eastern health service from the previous

Emerald’s IPO Emerald Clinics, which specialises in the prescribing of medicinal cannabis, will launch on the ASX this month, reportedly seeking to raise at least $6 million and up to $8 million through the issue of 30-40 million shares at $0.20 each. This offer indicates a market capitalisation of about $37-39 million upon completion. Managing Director and CEO Dr Michael Winlo has written about the value of high-quality realworld data collected from Emerald’s patients in this issue of the magazine.

He told Small Caps business website that the acceptance of real-world evidence was gaining significant momentum in jurisdictions through Europe and North America with substantial investment being made by big pharma. He said Emerald planned to use the IPO funds to expand its clinics and grow patient numbers with additional clinics being considered across Australia and the UK. The company also plans to boost investment in its data platform.

LGP floats Also heading for the share boards is medicinal cannabis grower and manufacturer, Little Green Pharma (LGP). It is offering 22.22 million shares at an issue price of $0.45 with the hope of raising $10 million.

LGP chairman Michael David

10 | FEBRUARY 2020

SJG Midland Public and Private Hospitals CEO Michael Hogan with the group’s first intern intake.

year. Its ED saw 71,181 presentations in 2017-18 which grew to 76,585 in 2018-19; the number of public patients was slightly fewer public admissions down to 33,290 from 33,477; there were 77 more babies born than previously with 1888 for the past financial year; staff grew from 1983 to 2236; the number of bed days grew from 97,816 to 103,618.

Lynch-Bell wrote in the prospectus that the company’s “first mover advantage” and “highly scalable production” were key factors that position the company to “capture value” from the emerging medical cannabis industry. Last month the company and Curtin University announced that they would be working together to develop a range of new medicinal cannabis products that have the potential to deliver more accurate and targeted treatment for a range of medical conditions. Curtin has provided an exclusive worldwide licence to LGP for the micro-drug delivery system ARISE (Atomised Rapid Injection for Solvent Extraction) and will use raw cannabis extract to start an 18-month development program to generate new medicinal cannabis formulations.

tests which slash the time taken to identify the cause of infection, enabling earlier treatment and reduced severity of infection. One of the new tests is used like a home pregnancy test, with the appearance of two lines in a panel providing almost immediate confirmation of infection. The second test, which has been developed by PathWest, not only reduces the wait for a diagnosis by hours or even days but also predicts antibiotic resistance.

This added feature means the treating doctor can prescribe the right antibiotic upfront rather than rely on the use of a broad-spectrum antibiotic to cover all possible infections. Up to 100 PD patients are expected to take part in this study which will employ the two novel tests alongside standard existing tests.

School’s in for Recovery

Dialysis in the field SCGH nephrologist Dr Aron Chakera is leading a study on two tests that have the potential to minimise complications of the more lifestyle friendly form of dialysis.

Peritoneal dialysis (PD) can offer patients a better quality of life than conventional haemodialysis because it can be delivered outside the clinical setting but is often shied away from due to a heightened risk of peritonitis. Anton and his team believe the solution could lie in two

The Mental Health Commission has appointed NFP Helping Minds to establish the state’s Recovery College with hubs located around the state. The WA government has invested $3.6 million to the project, which will involve local organisations around the city and in regional areas. The college will offer courses co-designed and co-delivered by people with lived experience of mental health, alcohol and other drug issues. The college will operate using a hub and satellite design.

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LOCAL BRIEF Courses are expected to kick off in the second half of the year at a Perth hub (as well as locations north, south and east of the CBD); three locations in the Kimberley (Broome, Kununurra and Fitzroy Crossing) four locations in the Pilbara (Karratha, Hedland, the Shire of Ashburton and Shire of East Pilbara) while planning is underway for the Mid-west, Wheatbelt, Goldfields, South-West and Great Southern.

Joondalup expansion Christmas came early for the Joondalup Health Campus in December with the announcement the WA government intended to invest $96 million to provide 30 mental health beds, two new operating theatres (including a cardiac catheter laboratory), an extra 90 inpatient beds and six new critical care beds. Also due for upgrade is the emergency department with 12 more bays and the establishment of an Urgent Care Clinic to treat drug and alcohol-affected ED patients.

Parking will expand by 362 new bays. Construction is due to begin in mid-2020 with the expanded car park and the ED first cabs off the rank. The entire build is expected to be completed by July 2025. The $96 million commitment brings the estimated total cost of the expansion project to $256.7 million, of which the Commonwealth has committed $158 million.

The researchers kept blood sample tubes taken from the women at room temperature (usual clinical practice), on ice (research grade) and in FC Mix tubes. They found the sugar results didn’t change in the blood samples that were put in FC Mix tubes, which were easier to use than putting samples on ice to stop sugar results from dropping. The research team is now planning to meet the Royal College of Pathologists of Australasia to discuss updating its guidelines for blood sample collection for sugar testing.

A/Professor Julia Marley from UWA’s Medical School said it was possible that two out three women with gestational diabetes, and who lived in rural and remote areas, may have been missed due to problems with the collection tubes. “To get correct sugar results, the blood tubes need to be put straight on ice until they are tested and testing needs to happen within one hour of the last blood sample taken but this is not part of usual practice in Australia,” she said. “Instead blood samples are put in tubes that contain an additive (fluoride) to stop cells in the blood sample from using sugar. However, this takes four hours to work so when the blood gets tested there is less sugar. We wanted to explore this further to see if usual practice affects sugar results and if we are missing women with gestational diabetes.”

In December, the WA Department of Health called for EOIs for new members of the boards of PathWest and Health Support Services. HSS provides information and communication technology, financial, procurement and supply and employee and payroll services to the health sector, areas of intense scrutiny over the past 18 months.

Medications on record The Australian Digital Health Agency and Webstercare have launched a new clinical document within My Health Record (MHR) to reduce medication-related problems, especially in the elderly.

The Pharmacist Shared Medicines List (PSML) is a consolidated list of medicines prepared by a pharmacist and uploaded to a patient’s MHR. The list will compile both prescription and non-prescription medicines, including over-thecounter and complementary medicines, such as vitamins and herbal remedies. The move was in part to combat the growing number of medication-related admissions to hospitals, which numbered about 250,000 last year.

Teller of Tales

Changes to testing?

Dr Neale Fong has become the new CEO of Bethesda Health Care after being its executive chair for 11 years. He took up his position last month.

We alerted readers to the release of the third edition of Dr John Murtagh’s Cautionary Tales, with the added legal input from GP Dr Sara Bird, who is also MDA National’s executive manager of professional services. It came to our attention by the publisher that the small commentary might have been misconstrued when we alluded to the “odd mistake” or two as being those made by Dr Murtagh in composition. This is, of course, definitely not the case. His ‘cautionary tales’ continue to be invaluable and entertaining reading and learning for doctors, students and the general public alike.

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Curtin Medical School has a new dean replacing its foundation dean, Prof William Hart.

Prof Sandra Eades will become the first Indigenous Dean to an Australian medical school. Prof Eades joins Curtin from the University of Melbourne, where she was Associate Dean of Indigenous Maternal and Child Health and Professor at the Centre for Epidemiology and Biostatistics.

Still with Curtin University, it celebrated the official opening of its new Midland Campus, which will act as a base for Curtin Medical School students in their fourth and fifth year of study and students studying other Curtin University health science disciplines. The State Government committed $22 million in funding and reserved land to support the establishment of the new campus.

It ties in nicely with increased training involvement by SJGHC. Dr Mark O’Brien has been appointed to the board of St John of God Health Care. Dr O’Brien is a co-founder and medical director of the Cognitive Institute, an organisation which helps health care leaders and their teams with enhanced non-technical skills, such as communication and leadership.

FEBRUARY 2020 | 11

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Mozzie manipulation Researchers at CSIRO's Australian Animal Health Laboratory may have found a solution to curtail the spread of dengue virus (DENV) by genetically engineering mosquitoes to reduce their vector competence, thereby restricting their capability to acquire and transmit pathogens.

The findings offer a proof-of-concept of the capability of genome engineering and the reduction of arboviruses.

The genome-engineered mosquitoes, Aedes aegypti, are reported to be 100% resistant to the four DENV serotypes – a world first.

Although the lab-based findings are compelling, the journey from the laboratory to the real-world has just begun for the modified mosquitoes, as a genetic drive mechanism will need to be demonstrated to ensure future generations of mosquitoes continue to supress DENV serotypes.

Human cooling The mean human body temperature has decreased in the United States since the industrial revolution according to researchers at the Stanford University School of Medicine. In 1868, the mean body temperature of 37°C was established as by German physician Carl Reinhold August Wunderlich.

The researchers analysed three population datasets ranging from 1862 to 1930, 1971 to 1975 and 2007 to 2017, which featured 677,423 temperature measurements According to the researchers, the human body temperature decreasing at -0.03°C per birth decade for men and -0.029°C for women. Men of today were reported to have -0.59°C body temperature decrease as compared to men born in the early 19th century, while women of today were reported to be -0.32°C cooler.

The authors suggest the body temperature changes could be causal to a decrease in metabolic rate, which is hypothesised to a population-level reduction in inflammation since the 19th century.

Billions slashed Johnson & Johnson Pharmaceutical will be breathing a little easier after an appeal for a review of an $8 billion damages verdict was upheld and reduced to $6.8 million.

12 | FEBRUARY 2020

The New York Times reports that a Philadelphian judge slashed the jury verdict over the marketing of the antipsychotic drug Risperdal, manufactured by J&J subsidiary Janssen. In October the jury found the company had played down the drug’s risks, which could lead to breast growth in boys. The lawsuit was filed by a Maryland man, Nicholas Murray, who sued the company in 2013 after he suffered gynecomastia after he began using Risperdal in 2003, at age nine, to treat symptoms of autism.

Bugs alive!

The WHO has called on governments to intervene in the pharmaceutical industry’s inertia when it comes to R & D of new antimicrobials. It estimates that without government help, resistant infections could kill 10 million people a year by 2050. Apart from the human suffering that would have a severe impact of the global economy. But it’s not all bad news from the UN agency. In its report on potential innovative therapies, the WHO identified 252 agents in development that target 12 pathogens declared ‘grave threats to humanity’ including multidrugresistant E. coli, salmonella and the bacteria that cause gonorrhea. On the other hand, WHO reports that only eight new antibiotics have been approved since 2017, most

of which are derivatives of existing drugs. Of the 50 new antibiotics being tested in clinical trials, only two are active against the most worrisome class of bugs, called gram negative bacteria, that can prove deadly for newborns, cancer patients and those undergoing elective procedures such as hip and knee replacements.

AI accuracy Further evidence supporting clinical efficacy of artificial intelligence (AI) systems has been published in the journal Nature. Researchers from Imperial College London, Deep Mind and Google Health designed the study to compare the accuracy of mammogram interpretations between six radiologists and an AI system. The radiologists and the algorithm were presented with anonymised and randomised imaging datasets from the UK and USA. Findings from the study demonstrate the effectiveness of AI systems when compared to highly trained, specialised humans with the AI outperforming the doctors with reductions of false positives reported as 5.7% and 1.2% (USA and UK data) and false negatives 9.4% and 2.7%.

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Superhero CBG Canadian scientists are hopeful that a compound from cannabis plants may wipe out drugresistant bacteria. Five cannabis compounds have been screened for their antibiotic properties and cannabigerol (CBG), was particularly potent at killing methicillin-resistant Staphylococcus aureus (MRSA), one of the most common hospital superbugs. The Guardian reported that CBG, which is not psychoactive, killed common MRSA microbes and ‘persister’ cells that are especially resistant to antibiotics and that often drive repeat infections. The compound also cleared up hard-to-shift biofilms of MRSA that can form on the skin and on medical implants.

The study is under review at the ACS Infectious Diseases journal.

In the worm hole Lifespan extension is a topic we covered in the November edition, with a particular focus on gene-editing in mitochondria.

Researchers have since identified two major pathways that modulate aging in C. elegans, a type of nematode worm frequently used in research on ageing as they have short lifespans of around three to four weeks and share many of their genes with humans. By identifying and manipulating the synergistic cellular pathways which are responsible for longevity of the worms the researchers were able to extend their lifespans. The equivalent lifespan extension for humans would be around 400-500 years.

Shine a light Researchers at the Massachusetts Institute of Technology are putting a new range of polymer devices to the test. Not to see how well they stand up, but if they can in fact break down inside the body with the introduction of LED light. Instead of surgical removal, researchers are finding that devices made form hydrogel break up when an LED light is inserted.

The team say the approach could be extended to a broader range of medical equipment, as well as offering a new approach to delivering drugs to the right 14 | FEBRUARY 2020

RESEARCH BRIEFS location at the right time. Writing in the journal Science Advances, researchers report how they applied their study to gastric balloons, which are removed after six months with an endoscope. Rather than fill the balloon with fluid, the porous shell was filled with a material that rapidly inflates when wet, and sealed it with a pin made from specially designed light-responsive hydrogel. An hour after inserting the gastric balloons into the stomach of three pigs and checking they had inflated, the team passed an endoscope bearing an LED and shone light onto the hydrogel pin for 30 minutes. Six hours after the balloon was inserted, scans showed it had reduced to almost 70% of its original inflated size, suggesting the pin had broken down and the balloon’s contents released.

Silver for Golden Oldies The RACGP’s updated clinical guidelines for the care of older people for the first time covering issues such as elder abuse and concerns in the care of older marginalised groups. College president Dr Harry Nespolan said the RACGP aged care clinical guide (Silver Book) Part B, had been significantly expanded in scope. Dr Nespolan said it was a vital document for the profession.

“Statistics show that already, more than one in three GP-patient encounters are with people aged over 65 years, and the proportion of people aged over 65 will more than double in the near future,” he said. Dr Mortin Rawlin chaired the Silver Book review said the Royal Commission into Aged Care and Quality Safety highlighted the issues in aged care and unique concerns of marginalised group.

Things needed to change. “There is a huge opportunity for GPs to make a difference – they have a central role to play in creating a more inclusive environment for all, and in doing so promoting health and wellbeing for everyone in our community.”

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Fidelity of translation initiation is required for coordinated respiratory complex assembly A discovery from researchers at the University of WA, Harry Perkins Institute of Medical Research and Curtin University have discovered how gene regulation in mitochondria could assist in identifying targets for drug treatments in energy-based morbidities such as cardiovascular disease.

Pictured: PhD students Danielle Rudler and Laetitia Hughes who are working on the gene regulation study

Bile acid bio-nanoencapsulation improved drug targeted-delivery and pharmacological effects via cellular flux: 6-months diabetes preclinical study Researchers from Curtin University have created miniscule capsules with bio-nanotechnologies, filled them with bile acids and a lipid-reducing drug to target the liver and pancreas which can reduce the inflammatory effects of type two diabetes.

Decreased Physical Working Capacity in Adolescents With Nonalcoholic Fatty Liver Disease Associates With Reduced Iron Availability Edith Cowan University researchers have found a correlation between individuals with non-alcoholic fatty liver disease (NAFLD) and functional iron deficiency. The researchers suggest the iron deficiency could lead to people with NAFLD being physiologically incapable of exercising.

T cell receptor cross-reactivity between gliadin and bacterial peptides in celiac disease An international team of scientists in conjunction with Monash University and and the Australian Research Council have identified a link between gluten proteins and proteins found in some bacteria as a potential environmental risk factor in the development of coeliac disease, suggesting the immune response is the same for bacterial or gluten proteins as they are indistinguishable.

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DRAF

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FEBRUARY 2020 | 15

WA's digital future Work has begun to digitally connect the many parts that make up the WA Health system.

James Knox reports

A roadmap for the Western Australian health system has been outlined in the WA Health Digital Strategy 2020-2030 and features a plethora of initiatives planned for not only the system, but also clinicians, and ultimately, health consumers.

The impetus for the strategy came from the final report of the Sustainable Health Review, which was published in April, 2019. The report recommended a long-term digital strategy including a 10-year digitisation plan.

According to Judith Stewart, Executive Director of Strategy, Policy and Planning at the WA Department of Health, the strategy follows on from the digitisation plan and a “vision for how to use

innovation and technology to transform the health services and the way that they deliver care over the next decade.”

The strategy has been developed with a clearly defined personcentred focus to ensure the outcomes are beneficial for the end-users by including them in the development and implementation of the proposed initiatives, Judith told Medical Forum.

The person-centred approach encompasses six key areas of focus to be integrated into all aspects of the strategy: empowered consumers; informed clinicians; optimised performance; supported workforce; enhanced public health; and embedded innovation and research.

Crucial to the strategy’s success, says Judith, is a unified electronic medical record (EMR) for WA Health and it is currently in the early stages of mobilisation. The EMR will be bespoke to WA with the intention

of interoperability with My Health Record.

In the cloud Implementation will take place in four distinct phases, with Judith emphasising the importance of the first, foundation phase, which will focus on modernising and increasing the capability of the information and communication infrastructure, as part of the HealthNext project. In essence, a migration from physical to cloud-based infrastructure.

While the strategy can be read as a document long on ambitious objectives and possibly risk alienating those with little interest or aptitude in technology, by it taking a person-centred approach, the enduser’s digital capability is a priority across the board, Judith said.

“We have some great expertise in clinical execution, but we need to make sure that all of our staff are supported and enabled to provide modern, digital care, so we need to

The Big Six Empowered consumers: ‘Improve equity of access and empower consumers to become true partners in their own care.’

Supported workforce: ‘Support and foster workforce engagement through connectivity and communication.’

Informed clinicians: ‘Ensure clinicians are informed to make effective decisions that support high value health care.’

Enhanced public health: ‘Protect, maintain, promote and improve the health of individuals and their community through a combination of safeguards, policies and programs.’

Optimised performance: ‘Optimise health system performance with user-centricity, modernisation and interoperability.’

Embedded innovation and research: ‘Embed innovation and research into core business and promote the adoption of rapidly-evolving technologies.’

16 | FEBRUARY 2020

MEDICAL FORUM | INNOVATION & TRENDS ISSUE

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have an understanding of what their digital capabilities are, and consulting with those key clinical groups,” she said.

Forward planning for digital innovation can be undone by the advancement of the technology itself. What could be considered fit-for-purpose and future-proof could also be redundant before it is even implemented, so it will require flexibility to adapt.

Judith said the strategy has been designed with that flexibility in mind, particularly beyond the first phase.

“When we undertake a horizon scan and assessment, we need to ensure that those initiatives can adopt transformational change that may be ready for that initiative,” she said.

Accessing Home Care can be confusing To help we’ve created this simple guide Step 1.

Successful implementation of the proposed strategies, such as the EMR, will be dependent on the malleability of the infrastructure and the usability of the interfaces, as the end-users need to be able to experience the benefits of adopting the new systems.

“The people that really make the difference are the ones who adopt and use these systems. We need to ensure that we are constantly in dialogue with them and we have the right feedback mechanisms to understand what the clinicians and the users on the ground are experiencing, so that we can be agile and adaptable,” she said.

“Our measures of success will be what are our stakeholders are feeling and experiencing about their delivered outcomes. It has to be something that is at the forefront of our minds as we move through implementation.”

Artificial intelligence (AI) and machine learning are rapidly advancing in clinical applications, especially imaging, yet one area where this technology could be revolutionary is in predictive informatics, which Judith highlights as an area of interest.

You, the GP, refer them for an ACAT assessment via www.myagedcare.gov.au/health-professionals OR Ask your

to call us and we will conference call MyAgedCare with them to arrange the referral.

Step 2.

Your will be contacted by the ACAT to arrange to visit them and work out the amount of help they may need.

Step 3.

“It’s our intention to take further advantage of automation and robotics, which we already use, such as TeleHealth, considering how we can use some of these existing tools differently, not just in WA Health but across the whole health ecosphere. That could lead us to looking at opportunities in aged care, for example, using Telehealth for consultations, which could be more convenient for the patient rather than from a purely clinical perspective.”

“We have this great opportunity to work meaningfully with clinicians on the ground, capitalise on some of those fantastic projects around capability already underway, and discuss with consumers how technology can deliver for them. Ultimately, to do something useful that is tailored for WA and that meets our unique needs.”

with Department of Human Services (DHS) The can call us on 1300 26 26 26 and we can mail the form to them.

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1. ACAT approving their care level. with their income assessment.

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Being clever with AI “There is evidence to show that predictive and analytical capability not only changes some of the dimensions of care but also helps predict demand capacity. This is really meaningful where it can transform clinical care – when AI intervenes and predicts patient outcomes earlier, such as patient deterioration. This could allow our clinicians to respond sooner than they do currently.

ACAT referral.

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FEBRUARY 2020 | 17

Communication is the key What the health world needs now is ways to connect and communicate. James Knox talks to clinicians how tech can work.

Information and communications technology (ICT) in healthcare can reap significant benefits for clinicians and patients when successfully scoped, designed and implemented.

The pitfalls of ICT projects, however, are often due to poor governance, as we have witnessed at all government levels, and that can lead to massive financial blowouts, not to mention wasted opportunities to deliver better health care.

Successful implementations require a bottom-up approach, guided by clinicians on the ground, yet our current experience has seen digital technology usually engineered from the top-down, and the tools and projects that result languish from lack of participation.

If health care revolves around patients and the ICT systems revolve around the clinicians, then Occam’s razor would suggest that the most effective systems should be developed by clinicians.

To get a snapshot of where transformational technology is heading, Medical Forum spoke to some of the leading figures in the industry to hear their perspectives.

The human element Innovation is not necessarily synonymous with digital technology, yet they are often intertwined, especially in medicine, where algorithms and artificial intelligence (AI) are forging ahead at a rapid pace.

Innovation goes beyond the creation of advanced tools and comes back to their user; how they utilise the benefits to assist clinical decision making and ultimately to provide patients with better care.

That speed, according to Professor Moyez Jiwa, Associate Dean of

18 | FEBRUARY 2020

Notre Dame’s Melbourne Clinical School and formerly of Curtin University, is putting pressure on a critical aspect of care – especially at the primary level – the “art of doctoring”.

“That skill involves getting information from people. If we ignore that, everything else becomes a distraction, a toy, a program in the consultation over and above the actual business of forging a relationship with a patient and getting that information from them,” he said.

Moyez sees technological innovation as an important part of medicine, but cautions on top-down designed applications.

“Innovations can become distractions largely because they're not fit for purpose. When they are designed by somebody who has not ever stepped in the doctor’s shoes and hasn’t been in a consultation, where you've got literally 10 to 15 minutes to make a diagnosis, they are not going to work.

The technology, whatever it happens to be, has to fit into those confines.

“We need to design innovations that doctors themselves have tested in real life, not in a randomised control trial, and shown that this actually will speed up the process of making a diagnosis in often very difficult circumstances.”

Moyez describes a doctor-led innovation, of which he was a part, that involved switching the seating position of the doctor and patient in a mock consultation room. The simple act of the patients being provided with the larger and more comfortable chair significantly improved the patient’s experience.

“The impact was enormous, absolutely astonishing,” he said.

The footage from the videoed consultations was analysed for non-verbal communication between the doctors and patients and, according to Moyez, the patients who were given the doctor’s chairs demonstrably changed their behaviour.

“There was much more of a connection. Patients were more open to ideas and accepting information coming from the doctor and more open to saying what was bothering them.”

For all of the advancements with AI in medicine, such as in imaging, where an algorithm can be more effective than the human eye, the intangible elements of the patientdoctor relationship cannot be so easily replicated.

“When it comes to the business of doctoring, when it comes to how we respond to people who are distressed, who are anxious, who are in pain, you can’t beat the best technology we have – the human touch, the human interaction,” he said.

“I'm not decrying robotics or artificial intelligence in other fields, but when it comes to the interaction between the doctor and patient, we can’t do better than what we have already.”

Clinicians lead The healthcare industry is going through a phase of rapid development in a whole range of areas and the traditional boundaries of where technology and healthcare intersect are being redrawn, says Dr Daryl Cheng, paediatrician and clinical informatician from the Royal Children’s Hospital Melbourne.

Echoing Moyez, Daryl says the successful integration of advanced technology relies on the architects being from a health care background with an interest in technology and vice-versa, so as to ensure the development of these tools actually reflects the clinical needs of the end-users.

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FEATURE He said clinicians sit on an adoption curve – where they sit determines their response to and adoption of new technologies.

“There are those who want technology to sit side by side with care and will use it when they need it, but their interaction is as minimal as possible. Then there is the majority of clinicians who have come to terms with technology as an integrated part of practice and are trying to balance the technological inputs with the rest of the impacts on their clinical workflow,” he said.

“There are also those who love technology and want to make this not only part of their workflow, but their entire workflow.

“Depending on where you are on that continuum, your responses will be different. Take the electronic medical record (EMR). We have a small group of clinicians who refuse to engage with it, they use it because they're forced to, they log on because they have to, and they are required by their hospital or clinic to document certain things.”

“The vast majority will use it on an everyday basis, they get used to and like some features, they complain about certain things, they know that the EMR is not perfect and they want more out of it.

“Then there's the group that are really at the forefront of optimising and trying to champion it. And even though it's not perfect, they try to harness its power and integrate it more closely with their clinical workflow.

Daryl also said the top-down engineering approach can foster tolerance rather than acceptance of tech tools, which was a rational response to what was considered a good solution in theory, but unworkable from a clinical workflow perspective.

“We might have a tool, say in an EMR or a predictive analytical score, which doesn't consider the nuances of how we want to use it in daily practice.

That's why the adoption is poor,” he said.

When a technology project is delivered by someone who speaks the language of tech and clinical practice, there is a significant difference to the adoption, engagement and development of the product or solution.

The integrated EMR/EMT proved to be hugely beneficial with a high uptake of users. In the first three years since it was deployed, over 135,000 tasks had been requested, with anywhere between 50 and 75 tasks being generated an hour.

With so many tasks being requested, the hospital has been able to analyse the data to measure demand and predictively scale resources, which has been one of

continued on Page 20

However, technology is not quarantined from the silos that inhibit other areas of medicine.

“You may have one communication app between nurses and doctors, another between doctors, another for allied health, another for between clinical and service staff.

You end up with 10 different ways of communicating, which in any other corporate organisation outside of health care would not be acceptable.

There would be one platform for everyone to communicate,” Daryl said.

“That's where the gap is at the moment and what’s preventing healthcare technology from really being at a tipping point where we see it as the bread and butter of what we do. Many clinicians will see it as a bolt on, or as an efficiency optimiser, but not the primary way of practising.

The Royal Children’s Hospital Melbourne has deployed an integrated electronic medical task board (EMT) – an electronic whiteboard for the nurses to record non-urgent things, and to communicate to the specific doctors.

“There's still concern that machine learning, AI and predictive analytics while accurate, may not be fully accurate. It may give false outcomes that don't have clinical nuance. It may turn medicine into a science rather than an art. And it's really finding the balance between the human touch, context and the clinician's knowledge of healthcare, and how to blend it all with the power of the analytical tools we now have.”

When the hospital transitioned to an EMR, they integrated the task board into it, which according to Daryl provided staff with unprecedented access to patient history.

“It’s very helpful, especially for after-hours care in the hospital where you may be covering patients that you don't usually see during the day,” Daryl said.

“At a glance you can see anything about any patient that has been tasked.”

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FEBRUARY 2020 | 19

Communication is the key continued from Page 19 the unintended benefits of this type of integrated system.

Daryl offers an example of the system in practice.

“We noticed that in the cardiology ward, nurses were continually requesting orders that were not particularly appropriate. And that allowed us to push for some education to manage that better.

“We’ve also been able to rejig the workload. The cardiology and oncology wards have a particularly high workload with a number of tasks between specific hours because the daytime staff have gone home and extra coverage is needed. Being able to respond to the demands just by looking at the data has been something we've not been able to do before we had the EMT integrated into the electronic medical record.”

Daryl believes widespread adoption of technology will come when clinicians realise the significant overall benefits that expand beyond what they're able to do currently, and how that translates to better health care and reported patient outcomes.

“That's the challenge, he said. “We can develop a system that predicts when a child is going to deteriorate from sepsis or infection but until we have the clinical data showing its benefit, its effectiveness and timeliness and that it’s more efficient than our current way of doing things, it won’t fly. Significant patient and clinical benefits such as preventing morbidity or mortality will be the significant driver for acceptance.”

Daryl says the new EMR/EMT system at the Royal Children’s is doing just that.

“The mortality rate has dropped by greater than 20%. These types of outcomes show technology is not only making health care more efficient, but safer and better for patients.”

Other implications Myriad issues can arise with EMR implementation, according to A/ Professor of Digital Innovation in Health and Health Pedagogy at the 20 | FEBRUARY 2020

University of Tasmania, Dr Kerryn ButlerHenderson.

primary health care providers and the individual can communicate virtually to monitor progress, and the individual’s quality of life is improved.

“The main factor is good project management, including strategy, communication, risk management, consultation, and evaluation. Often when things go wrong, you can identify that one of these things has not been done well,” she said.

“However, our biggest missed opportunity is in closing the gap in primary health care. In a country as geographically large as Australia, it is the structure of our health system and poor telecommunications that are creating the silos and barriers to innovation driving system performance.”

The sticking point is often one of engagement.

“Not everyone has to be on the project team, but all stakeholders should be engaged, and the project team should ensure it’s done at the right time. I’ve seen large scale implementations held up by months simply because the right questions were not asked of the right people,” she said.

“Conversely, I’ve seen small- and large-scale projects go very well where there has been strong and continuous engagement and communication with all stakeholders throughout the project.

“We need to stop seeing digital health as a project, a time-limited activity with a definitive start and end date. Even once a system has been implemented, there is system management and maintenance until eventually a system is decommissioned and the cycle starts again with the new system.

“Viewing digital health as a timelimited activity, and budgeting it as such, contributes to the barriers and its siloing, when it should be ubiquitous in-service provision. In a system that is still separated into federal versus state-funded services, and focused on activity instead of outcomes, the effectiveness of digital health will continue to be constrained.

“Innovation is observed in those who transcend these boundaries, with reportable positive outcomes at the individual and population level observed. A good example is where Telehealth is used to support someone and enabled them to return to their remote location much earlier than in the past. Acute and

Digital workforce Kerryn said a digitally capable health workforce was imperative to enable innovation in the sector.

“Currently, we have disparate levels of digital capabilities with the literature showing that there is a generational impact. Our younger health care professionals are largely more digital capable, but as educators, we need to support and increase these capabilities, to produce capable and competent graduates, she said.

“These capabilities are not related to using a certain system, but in their soft skills. Our research has shown that increasing a digital worker’s attributes across four areas – awareness, creativity, agility, and learning orientation – will enable them to be prepared better for digital service provision.”

To achieve this, we may need a specialist digital health workforce beyond what we already have.

“Currently, many areas of this workforce do not have or require formal qualifications, and many people simply slide into roles that they have an interest in, as opposed to a formal career structure. The specialist digital health workforce is undersupplied, underdeveloped, unregulated, and unmonitored,” she said.

“Government, industry, educators, and peak bodies need to continue to work towards the formalisation of this workforce to support digital health into the 21st century.”

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A Phenome Future Phenome mapping is set to make WA a hub for health innovation.

Jan Hallam reports

It’s probably fair to say that Australia’s Cultural Cringe has come a long way down the recovery path in the past couple of decades. As a knowledge nation, we have become more confident in our capabilities, and within those confines, have made some amazing, life-changing discoveries.

“That’s when the concept of the Olympic legacy came up,” Jeremy told Medical Forum. “The drug testing facility was absolutely enormous, so I wrote to the Chief Medical Officer with an idea to take that equipment and put to it broader use for large scale population phenotyping to better inform on people’s health,” he said.

Think Marshall and Warren; Wilton and Fletcher; and numerous researchers of significant standing at institutions dotted around Perth and the country, all working on finding solutions to save lives.

“It ended up on the Prime Minister's desk and, three months later, we had £10 million from the Medical Research Council and another £11 million from industry to build transfer laboratories. When politics and science align, you can do something that's quite amazing.”

However, news several years ago that the state government and local universities, in particular Murdoch, were not only going to build a state-of-the-art phenome centre south of the river, but attract two of the world’s most respected names in the field to run it, sent more than a ripple or two within national and international research circles.

Not least at Imperial College London where the now leader of the Australian National Phenome Centre, Professor Jeremy Nicholson, was head of the Department of Surgery and Cancer.

He was one of the prime movers of Imperial’s phenome centre (the UK National Phenome Centre), which came into being as a happy indirect consequence of the enormous multi-billion pound spend on the London Olympic Games.

22 | FEBRUARY 2020

Those stars aligned in southern skies several years on, when other collaborative phenome centres were established in Hong Kong and Singapore, creating some seriously big health data capacity in the southern hemisphere. The idea was to have these large-scale facilities harmonise technology and approach so that the studies on the biology of disease could have global consequences.

“About four years ago, this Australian guy came bouncing up to me at a lecture I was giving in the US and announced ‘we’d like a phenome centre, too’. That guy was A/Professor Rob Trengove who was running the metabolic laboratory here at Murdoch,” Jeremy said.

Talks with the Murdoch hierarchy about the scientific possibilities of a WA phenome centre quickly moved on to the Chief Science Officer, Prof Peter Klinken, and the Health Minister, Roger Cook, who had made no secret that on his watch he wanted to see an overburdened MEDICAL FORUM | INNOVATION & TRENDS ISSUE

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What is phenomics?

It’s the study of how the environment and a person’s lifestyle interact with the expression of the genes to influence their health and risk of disease.

Australian National Phenome Centre

WA health system move towards sustainability.

Professor Elaine Holmes, who was head of Computational Systems Medicine at Imperial. She was awarded the WA Premier’s fellowship in phenomics in 2018 and her work will revolve around maternal and infant health, liver and gastrointestinal disease and metabolic diseases such as diabetes and dementia.

Jeremy had his first brush with antipodean boldness when asked why didn’t he come to sunny WA to lead the operation.

“I’d been at Imperial for 21 years and was running its biggest department with 300 surgeons – they can be difficult buggers – and about another 900 other staff in cancer, obstetrics, gynaecology, critical care, hepatology, gastroenterology, systems medicine and ophthalmology. My budget was double that of Murdoch University.

“I had spent nine years dealing with just about every conflict, with almost every sort of clinician and personality. Certain branches of medicine really do attract a certain phenotype!

“It was an invaluable experience, but it did encroach on my ability to do science, particularly. So, the opportunity to establish an integrated laboratory from scratch, that is now the best in the world, with a brief that not only encompasses health but agriculture, food, nutrition – it is an adventure coming here.

“It is also a much more collaborative environment with universities and government. It’s a small pool and people have to get along and I like that. And then there’s the lifestyle of WA. “But the real driver was the opportunity for the first time to study humans in the total environment.”

Accompanying Jeremy is his colleague, the computational biologist

“We love the lifestyle here. It's important for people to be happy in their environment as well as in their work and the move has proved to be infectious. We now have 10 former Imperial researchers here, so I’m not so popular at Imperial right now,” he said.

“I was just saying to Elaine the other day, we’ve got the group together again, and we’ll have that excitement we used to have 10, 15 years ago.”

The location of the ANPC is at the Perkins South building opposite the Fiona Stanley Hospital campus just in case anyone should forget the primary focus – the patients.

“I've been a head of a clinical department and the patient always comes first. It is important to do good science but imperative to make sure that it's going to be something that really makes an impact on somebody’s life,” he said.

So, what can we expect of the ANPC, which has the potential to do so much? In clinical terms, the list is long.

“We can help in straightforward, precision medicine – stratifying diseases into different subclasses to try and optimise therapies. We can support clinical trials

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What is a phenome?

A person’s phenome is a snapshot of their unique biology results from the complex interactions between environmental, lifestyle and genetic factors. by understanding responders and non-responders to drugs and new interventions. We've got technology that can be used in real-time during surgery. And there is the potential to revolutionise clinical chemistry and chemical pathology.”

Broader projects are looking at the environmental impacts on the body, which open up areas of food production and nutrient composition.

“We have a Cooperative Research Centre (CRC) project – part of a $150 million study on precision foods – that is the first out of the bag. This is being funded by the ministry of Agriculture and links to about 50 different companies. Our technology will define more accurately the composition of food, particularly nutrient composition, so that a brand quality can be attached to it and, of course, its value increases.

“The powerful thing is, though, you can take those very highly characterised foods and do clinical nutritional trials so we know more accurately the chemicals that go into the body and record different continued on Page 24

FEBRUARY 2020 | 23

A Phenome Future continued from Page 23 responses. This raises clinical nutrition to a totally new level of molecular science.”

“We would not have been able to fund a project like that in London, or even the UK, but you can get it done in Australia because the agricultural industry is so important here. So, economically the research is significant.”

However, food is critical for human health and projects such as precision food will become a cornerstone in preventative medicine. With the acute sector facing an increasing burden from treating people with chronic disease, keeping people healthier is the key to sustainability.

“If you think about preventative medicine, it involves some very simple things. Don’t smoke, don't eat too much, get some exercise.

It can keep you healthy for a long

time. Unfortunately, most people don't do this very well. So, the precision food CRC project is really interesting,” Jeremy said.

sensible one. We have a big food project that comes in which is relevant to preventative medicine.

Now what's not to like about this.”

“We not only better understand food and how it works, which improves its value as an Australian product, it also becomes a preventative medicine because we can start to understand, in a broader scale, the individual effects of different foodstuffs on people, and not everybody is the same.

And then there is the treasure trove from WA’s and Australia’s history of quality epidemiological studies.

“People are all very different in the way they respond to diet or drugs or anything for that matter.

And that's what a phenome centre is about. It is understanding that variation in biology which allows you to make predictions for the future.”

“So, for me, it was like all the planets aligned because we have the Phenome Centre right next to the hospital. We've got a change in the strategy for healthcare in Western Australia, which is a very

Prof Tim Davies’ diabetes study, the Telethon Kids’ Origins, Prof Bu Yeap’s HIMS project and, of course, the Raine Study, and, in Victoria, the Barwon study – all have longitudinal grunt.

“There are biological samples that go back years, so we can go back and do retrospective analysis of the phenotypes of people in epidemiological studies knowing after 20 to 25 years what their clinical outcomes have been. This allows us to model disease risk in a retrospective-prospective way,” he said.

“I have some big ambitions for this laboratory. I would like to phenotype everybody in Western

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CLOSE-UP Australia – and genotype them as well – to create a biobank that is relevant to our population. It’s not possible to do that somewhere like the UK. It would only be a small sample of a large population and that wouldn’t be representative.

“Places where digital health care works, this sort of personal health care has made some advances, but the electronic records have to be good because we’re trying to take new chemistry and new science and match it with events which are against the conventional clinical metrics and wisdom.

“WA has 2.4 million people, it’s quite a lot people, but it's doable.

You could do a much more statistically relevant proportion of the population here and have deep insight into the biology that affects their future health.

“Western Australia's really lucky in that it has the right sort of infrastructure, the right sort of money, the right sort of size, a population where you could

actually make personalised health care and preventative medicine more efficient and more effective than anywhere else in the world.

“Here we are in a very high-tech environment in one of the best labs in the world with immense firepower but that doesn't help Aboriginal people in the north of the state, or people in sub Saharan Africa. For me, it's very much a duty of science to serve everybody.”

“One of things we're going to be developing very soon is new, smaller, cheaper devices that can basically measure things in location.

Our exploratory lab here is the Formula One of technology, but people in the field need technology they can take to the shops.”

What is metabolic phenotyping?

It is the analysis of biological tissue and fluid to uncover the specific interactions of genetic, environmental and lifestyle factors on a molecular level. The techniques used to perform metabolic phenotyping combine mass spectrometry, nuclear magnetic resonance spectroscopy and

“Ultimately there'll be things that come out of what our work, that will be with your local GP in the next 10 years.”

advanced data modelling. The metabolic ‘signatures’ revealed enable researchers to understand the complex underlying factors causing disease and to develop preventions and treatments at both an individual and

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FEBRUARY 2020 | 25

When Will We Ever Learn?

Silicosis is emerging as the decade’s most problematic occupational health threat.

E/Professor Odwyn Jones and C/Professor Bill Musk, explain why.

We well recall that beautifully poignant song, Where Have all the Flowers Gone and the refrain about the young men’s lives lost in droves during the last world war.

The futility of wars was wonderfully captured in that other line, which asked the eternal question, “when will we ever learn?”

The same can be said about the terrible toll some of our industries have on the lives of their employees, most of them young men. Let us, therefore, relate the sad story of the situation prevailing now in our artificial stone (AS) benchtop industry and, sad to say, even in some of our operating mines.

Wherever there’s silica dust in the air breathed by employees or contract workers, there is always the risk of silicosis, a dreadful disease which at the very least is debilitating and, at worst, a death sentence, and yet it’s totally preventable.

The onus is on our regulators and employers to carry out their duties as defined in the OSH Regulations 1996, efficiently and with real purpose.

Current situation WorkCover Queensland has recorded 164 worker compensation claims for silicosis from workers in the AS benchtop industry. In Victoria there have been 28 claims for silica-related conditions since 2018, and 15 workers have died from the disease since 1985; SafeWork NSW has had 12 silicosis claims and Tasmania has had 5 cases (The Guardian, August 17, 2019).

In WA, six workers have been diagnosed with the disease, so far, five from the benchtop industry and one from the mining sector (UNIONSWA/ adsa, July 2019), but the portents are that many more are in the pipeline both here and nationally.

The current workplace exposure level for fine silica dust of 0.1 mg/ m3 of RCS (< 5 microns) has been in place since 1983. However, SafeWork Australia, knowing that AS contains around 90% silica,

26 | FEBRUARY 2020

operations by carrying out these tasks in an enclosed area with its own exhaust system.

Compensation claims

roughly double that in normal granite, is currently in the process of reducing the limit to 0.05 mg/ m3, to be implemented across all industries as soon as practicable.

However, the Victorian Trades Hall Council has recently released an even more stringent approved safety standard of 0.025 mg/m3, as an eight-hour TWA (in keeping with the USA silica exposure standard).

Control measures There is a suite of precautionary measures which employers should have in place, and their implementation and use should be overseen by government-appointed regulators. These measures include: • Water suppression as practised in wet cutting.

• Good local exhaust ventilation to minimise the exposure of workers to RCS dust.

• The use of appropriate personal protective equipment such as respirators etc.

All states and territories, apart from the ACT, have already banned the practice of dry cutting, which has led, in large measure to the recent spate of AS accelerated silicosis (The Guardian, August 17, 2019).

Without complicating matters, the solution is as easy as making sure workers, be they employees or contract workers, do not inhale the very fine RCS dust, and consideration should be given to isolating the workers from the cutting, grinding and polishing

WorkCover WA’s fact sheet points out the hazards to workers who are exposed to RCS from dry cutting, grinding, sanding and polishing stone benchtops and during installation. It also advises that to obtain compensation, workers need the independent Industrial Diseases Medical Panel (IDMP) to make a final and binding determination on various questions, including the diagnosis of work-related silicosis, the extent of the worker’s capacity for work and level of impairment.

Furthermore, the initial steps to make a workers’ compensation claim requires the claimant to: • Obtain a Certificate of Capacity from the worker’s GP with a provisional diagnosis of silicosis, • Complete a workers’ compensation claim form, and • Give the claim form, Certificate of Capacity and medical test result to the employer, who will then forward the claim to their insurer within five days.

Support for workers diagnosed with silicosis and those who suspect they are developing symptoms of the disease can obtain support services and/or advice from a range of organisations including Beyond Blue, MensLine Australia, Lifeline Australia and Silicosis Support Network (an offshoot of Asbestos Disease Support Society).

The Silicosis Support Network can provide sufferers access to its own social worker, as well as a range of information ranging from medical specialists, lawyers and allied health care professionals. The network has published some detail of the situation in Queensland where among the 168 diagnosed with the disease, more than 20 men, including one 22 years of age, have been diagnosed with “progressive massive fibrosis” (PMF), often referred to as “end stage disease”, which is a death sentence.

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GUEST COLUMN Regulatory system The general industry in WA is regulated by WorkSafe, in keeping with the Occupational Safety and Health Act, 1984, and its subsequent Regulations of 1996 with outline the responsibilities of employers and surveillance.

Every employer, main contractor or self-employed person should seriously consider establishing a WorkSafe Plan, which involves an assessment process that rates safety and health management systems and directs attention to areas that need close scrutiny and could possibly be improved. Such plans can be drawn up by appropriately qualified assessors listed in the directory supplied by WorkSafe.

When inspectors become aware of non-compliance with requirements of the Act and/or regulations they may issue advice, improvement or prohibition notices or a combination of these.

It appears, therefore, that if all of these precautions are in place and adhered to there should be very few, if any, unsafe workplaces be they construction sites, workshops or AS benchtop manufacturing and processing workshops etc.

However, as stated in a recent article (Hender S., 2019), “it doesn’t matter what is written in the regulations if the stated requirements and practices are not policed”.

Indeed, the same article refers to a 33-year-old Queensland tradesman with progressive massive fibrosis saying “he can’t recall a regulator ever attending any of his work sites to check on compliance”.

Government initiatives On 26 July, 2019, the Commonwealth Chief Medical Officer, Professor Brendan Murphy, announced the establishment of the National Dust Disease Taskforce to develop a national approach to the prevention, early identification, control and management of dust diseases in Australia.

The federal government has committed $5 million to support this taskforce, including establishing a National Dust Diseases Register and new research to understand, prevent and treat preventable occupational lung diseases such as silicosis.

It was due to provide interim advice to the Minister for Health by December 2019, and a final report is expected no later than December 2020.

Conclusions We all have a duty of care for our fellow workers, but employers have a duty of care for all their employees.

It is also assumed employers and their on-site management team have sufficient knowledge and information to enable them to carry our risk assessments relating to the health and safety of their employees.

Also, the Government’s appointed regulators and inspectors have the responsibility to ensure that such health effects risk-assessments have been carried out and all necessary control measures are in place.

Let us therefore finish by reiterating the title. “When Will We Ever Learn”, bearing in mind silicosis has been a totally preventable disease for the past 50-years or more?

– References on request

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FEBRUARY 2020 | 27

To Vape or Not to Vape?

Occupational health consultant Dr K C Wan poses the question which is troubling policy makers and doctors alike.

Last year, I was invited to speak at the symposium on Environmental Pollution Harm Reduction in Thailand to report on what we know are the health risks, from current medical and scientific information, of tobacco smoking compared with e-cigarettes and vaping. And to review the outcomes of vaping for harm minimisation in countries such as the UK, US, France, Sweden, Norway, Iceland, Korea and Japan.

Of the more than 7000 chemicals in tobacco smoke, at least 250 are known to be harmful and at least 69 can cause cancer. Electronic cigarettes (e-cigarettes) work by heating a solution of water, flavouring, propylene glycol (or vegetable glycerine) and, typically but not always, nicotine. The

28 | FEBRUARY 2020

composition of the resulting vapor varies but the majority of toxic chemicals found in tobacco smoke are absent in ecigarette aerosol.

Those present are mostly below 1% of the levels in tobacco smoke.

There is also an electronic delivery system that heats but not burn tobacco to deliver nicotine and less toxic compounds that has been permitted for sale by the United States Food and Drug Administration (FDA) in April 2019.

The modern e-cigarette was invented in 2003 by Chinese pharmacist Hon Lik and as of 2015 most e-cigarettes are made in China. Since first sold in 2004, their global use has risen exponentially.

According to Action on Smoking and Health (ASH) in the UK, in

2017, the number of people using e-cigarettes there had risen to 2.9 million (5.8% of the population).Of this number, 52% were ex-smokers, 45% continued to smoke tobacco alongside e-cigarettes and 3% had never smoked.

Public Health England reported in 2015 that best estimates showed e-cigarettes were 95% less harmful than tobacco and there was no current evidence to show they were renormalising smoking or increasing the uptake of tobacco.

Cancer Research UK-funded scientists found that people who swapped smoking cigarettes for e-cigarettes or nicotine replacement therapy (NRT) for at least six months, had lower levels of toxic and cancer-causing substances in their

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GUEST COLUMN body than people who continued to smoke tobacco. The Royal College of Physicians agreed that e-cigarettes were the most effective way of getting smokers to quit.

Despite the high cost of smoking and best practice treatment of professional counselling and quit medication, cessation rates are low with 75% still smoking a year later.

In 2018, the Royal Australasian College of Physicians’ (RACP) expressed concern that there was a lack of clear and robust evidence to inform policy makers, clinicians and the public about e-cigarettes.

The RACP acknowledged that e-cigarettes may help in tobacco harm reduction and smoking cessation.

Smoking rates in Australia have been declining steadily since the 1970s but have recently slowed, while rates are now declining faster in other countries where tobacco harm reduction strategies are available. Cigarette sales in Japan decreased by an unprecedented 27% during 2017-2018 after heated tobacco products were introduced.

The NHMRC, the TGA and the WHO currently do not recognise e-cigarettes as smoking cessation aids and there are concerns that they normalise the act of smoking. Three meta-analyses and a systematic review suggest they are effective for smoking cessation and reduction.

The long-term health effects are not known. A systematic review of case reports showed that e-cigarettes can have a negative impact on respiratory, gastrointestinal, cardiovascular, neurological and immune systems. Experimental data suggest that e-cigarettes can induce lung inflammation.

Nicotine is a Schedule 7 poison under TGA and while it is legal to buy vaping devices, it is not lawful to buy, sell or use devices containing nicotine. It is also illegal to possess nicotine liquid for vaping without a doctor’s prescription.

However, smokers can readily purchase tobacco cigarettes.

There is a need for regulation of e-cigarettes. Ten ‘nicotine-free’ e-liquids purchased online and over the counter from Australian suppliers did not disclose ingredient information. They were analysed quantitatively by gas chromatography (GC-MS)

which showed that apart from the excipient and nicotine, 16 known chemicals were identified and a further seven could not be.

Most Australian states and territories regulate sales, advertising and promotion of non-nicotine e-cigarettes. However, there is no specific regulation for packaging or labelling, nor requirements to list the ingredients and make the packaging child-or spill-proof. This is problematic as some e-liquids resemble drinks or confectionary that may appeal to children.

Action is necessary to improve the safety of e-cigarettes, particularly in view of the recent reports of fatalities from vaping identified by CDC in the US. Based on the evidence, the answer to my question is "yes" from the perspective of harm minimisation.

Vaping is at least 10 times less hazardous than tobacco smoking.

However, the answer is "no" from the ideological perspective.

Vaping is a habit that should be discouraged.

– References on request

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Working on your Zen NeuroSpine Institute

neurospineinstitute.com.au

GP registrar and yoga teacher Dr Talia Steed urges colleagues to take a little time to reflect on the year that was and the year ahead.

Now Offering: Specialised Physiotherapy Treatment

We welcome Dr Yee Hein to the team. In addition to general physician services, Dr Hein provides perioperative

Service for patients in need of treatment inwards towards ourselves, As we start 2020, we give time or yogis. Whatever it is ourtojob support complement ourswimmers surgical services. for back and neck pain, rehabilitation or for reflection – where we consider that we are drawn to is what we is incomplete. recovery following injury or spinal surgery.

whether we have achieved our goals for the year that’s been and consider how we might move forward.

should keep up throughout the Dr Yee Hein It is important to take care of Consultant Physician year. It’s important to keep active. ourselves on all levels – physical, • Be aware of our alcohol mental, emotional and spiritual. consumption. Alcohol has a Multi-disciplinary Our uniqueness and diversity mean depressant effect on the body As doctors, we are often used to that it is up to each of us to find and can exacerbate feelings specialist practice offering high levels of intellectual stimulation the things that make us come alive, Dr Paul Taylor Drof Andrew Dr anxiety.

Michael Kern low Miles mood or We and being on the go.

The absence Surgeon Neurosurgeon Neurosurgeon bringing a sense of joy andSpinal vitality advice and treatment across also need to be mindful of the of a regular routine leaves more to our lives. physical effects of too much space for contact with our the full range ofown spine and alcohol; the kind we spend the Dedicated Acute Disc Service Once we know what they are, we emotions and psyches. We can be rest of our year educating our brain conditions. faced with the re-emergence of have to consciously choose to seek We prioritise patients with newly referred arm or leg pain with proven patients about! uncomfortable feeling states that out and implement these things, nerve compression on CTto or MRI. have been overshadowed by our Mentally optimise the re-energising function outside world pursuits. of time off work.

• Socialising: It is important to 3 CONVENIENT LOCATIONS maintain a social network to This is aAlso time where it is helpful offering outlying clinics in Mandurah, Vasse,Physically Albany and Geraldton.

APPOINTMENTS avoid the negative effects of to cultivate an attitude of self• Regular exercise: This helps to Perth MurdochWe spend our working Wembley social |isolation.

The amount and P 1800 NEUROSPINE F (08) 6147 8200 compassion. keep us Suite 7, Level 4 Suite 77, Level 4 Suiteenergised 10, First Floorand uplifted.

(1800 638 767) frequency of this varies for us all, lives providing care Centre and compassion 140 Mounts Bay RoadIt doesn’t Wexford Medical 178 Cambridge matter Street whether weE info@neurospineinstitute.com.au but, ultimately, we are relational to others, butMarshall unless this is directed Perth WA 6000 3 Barry Parade Wembley WA 6014 are regular walkers, runners, Murdoch WA 6150

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GUEST COLUMN

GUEST COLUMN

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profound impact on our psyche.

Yoga, Tai Chi and Pilates are just some of the other more active practices that incorporate this element of mindful meditative movement. When we are focused and engaged in any activity, it can be a form of meditation, even things such as watching sport or surfing, for those of us who normally shy away from formal mediation practices.

beings that require some level of social connectedness. If you are someone with few family members or friends, getting involved in the community can be helpful. Even volunteering your time to do something for others can be an uplifting experience.

• Letting go: We often hold on to so much of our past that can function to weigh us down and keep us stuck. The old year as passed and we can consciously

let it go. We create new and fresh energy in our psyche, ready to open to new experiences.

Emotionally • Meditation: This is something that is always useful in cultivating a sense of inner wellbeing and peace. We can do this anywhere, alone or in the company of others. However, when we unite with like-minded people, it can have a deeper and more

Spiritually • This is something unique to each and every one of us, but we are all spiritual beings having a human experience here on earth. We are not our thoughts.

We are not our body. We are not our emotions. By allowing things to flow through us, rather than become consumed or taken away by ruminating thoughts, overwhelming emotions or physical sensations, we can become free to experience our life in its totality and fullness in the present moment.

ED: Dr Talia Steed is a GP registrar and a yoga teacher.

NeuroSpine Institute Now Offering: Specialised Physiotherapy Treatment

Service for patients in need of treatment for back and neck pain, rehabilitation or recovery following injury or spinal surgery.

neurospineinstitute.com.au

We welcome Dr Yee Hein to the team. In addition to general physician services, Dr Hein provides perioperative support to complement our surgical services.

Dr Yee Hein

Consultant Physician

Multi-disciplinary specialist practice offering advice and treatment across the full range of spine and brain conditions.

Dr Paul Taylor Spinal Surgeon

Dr Michael Kern Neurosurgeon

We prioritise patients with newly referred arm or leg pain with proven nerve compression on CT or MRI.

Also offering outlying clinics in Mandurah, Vasse, Albany and Geraldton.

Perth Suite 7, Level 4 140 Mounts Bay Road Perth WA 6000

Neurosurgeon

Dedicated Acute Disc Service

3 CONVENIENT LOCATIONS Murdoch Suite 77, Level 4 Wexford Medical Centre 3 Barry Marshall Parade Murdoch WA 6150

Dr Andrew Miles

Wembley Suite 10, First Floor 178 Cambridge Street Wembley WA 6014

We get spines working.

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APPOINTMENTS P 1800 NEUROSPINE | F (08) 6147 8200 (1800 638 767)

E info@neurospineinstitute.com.au

FEBRUARY 2020 | 31

Secure in Retirement Doctors work hard and often spend only a small proportion of what they earn.

Time to think superannuation, writes financial planner Rob Pyne.

Frank* is a 58-year-old doctor with income of $555,000 a year and net wealth of $7 million. His current workload sees him at 20% of full time equivalent (FTE) in the public system, and 60% FTE in the private system.

Frank loves his work so he works a lot and spends far less than he could resulting in a large proportion of his disposable income going unspent and building up in his bank account.

Frank was aware that his built-up cash could be working harder for him elsewhere, but he wasn’t sure where that ‘elsewhere’ was.

Here are some recommendations.

Given restrictive superannuation contribution limit, when people like Frank have a significant pool of assets outside of superannuation, it’s important to devise a contribution strategy over a number of years to get as much into superannuation as possible. These funds will eventually fund a tax-free income stream in retirement.

Frank has the added benefit of having a GESB West State Super Account. (This fund was closed

to new members in 2007 and is irreplaceable.) West State is unique in that it is an ‘untaxed fund’ where tax on contributions is deferred until funds are accessed (via rollover or withdrawal at retirement). This enhances compounding investment returns as they can generate returns on the deferred tax amount.

Given Frank’s high disposal income, he maximised the tax-free salary packaging benefits and salary sacrifice a significant portion of his income ($1,500 fortnightly).

Contributions to GESB West State are counted towards the general cap of $25,000 a year applying to Frank’s other standard ‘taxed’ superannuation fund.

The recommended salary sacrifice in addition to private practice employer contributions received by Frank’s ‘taxed’ superannuation fund means Frank’s total contributions will breach the cap, requiring additional tax payment. This can be paid personally or from a superannuation account. In Frank’s case he paid the tax from his ‘taxed’ superannuation fund given

the deferred tax treatment on all investment earnings enjoyed by GESB West State accounts.

The net benefits of the above strategies are: • An extra $300K in retirement savings which are now more tax-efficient and compounding in value year on year.

• Yearly tax savings as salary sacrificed funds are not taxable at the maximum tax rate of 47% but are subject to a deferred tax of 30% within super (30% rather than 15% applicable to individuals earning more than $250,000 per year).

• Maximising the value of funds invested in the ‘untaxed’ superannuation account, enhancing Frank’s returns overtime.

These strategies should ensure Frank a comfortable retirement whether that happens in two years’ time, or 10.

ED: Rob Pyne is managing director of HPH Solutions. This is an actual case study but for privacy reasons, the client’s name and details have been changed.

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32 | FEBRUARY 2020

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FINANCIAL PLANNING

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Clinical Update Innovation & Trends 35 REAL WORLD RESEARCH

Dr Michael Winlo

42 AI IN MEDICINE

36 STEREOTACTIC BODY RADIOTHERAPY

Dr Sean Bydder

44 BREAST IMPLANT UPDATE

37 AI IN RADIOLOGY

Dr Brendan Adler

39 RESEARCH SUPPORT

A/Prof Sue Skull

41 WOMENâ&#x20AC;&#x2122;S CARE

Dr David Playford

Dr Tim Cooper

47 DIABETES TESTING

Dr Cameron Gent

48 US PROSTATE TESTING

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49 KNEE AO

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Dr Stuart Prosser

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FEBRUARY 2020 | 33

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CLINICAL UPDATE

New models for evidence generating care

By Dr Michael Winlo, Researcher, West Leederville Ever looked at an old photo and winced at your clothes? For me – hyper-colour pants in primary school. Only later can we see how awkward our choices are. Ideologies and traditions can be fashions which encourage us to look for fashions in conservative places like clinical research. The limitations of our most trusted evidence-generating apparatus – the randomised control trial (RCT) are being exposed by recent studies.

Clinicians face the challenge of trying to apply the take-aways from an RCT manuscript to the patient who, not infrequently, neither looks, nor behaves, like the carefully selected trial participants. And, what if the trial, itself, is flawed?

Diana Herrera-Perez et al released a study in 2019 examining the stability of the findings of more than 3000 RCTs published across three major medical journals. Her team found 396 cases of “medical reversal” – that is, where a newer and methodologically superior clinical trial produced a result contradicting existing clinical practice and the older trials on which it was based; 13% of published studies were eventually reversed.

Key messages

RCTs are not the only form of evidence

The digitisation of health data provides new sources of evidence

Real world evidence opens doors.

Evolving statistical models play a role. A 2018 study exposed the lack of concordance in modern statistical analysis. The research team gave the same data to 29 teams of statisticians; 69% produced analysis that was for the null hypothesis but 21% of teams produced data supporting the opposite result.

Remarkably, all teams presented internally validated and rational statistical approaches. Deciding whether to include data outliers is a good example of where differences can emerge (are they aberrations or ‘real’ phenomena worth including?).

The study demonstrated how subjective, yet defensible, analytical choices could influence research results.

In response to these tensions, major regulators such as the FDA and EMA are increasingly interested

in real world evidence (RWE) as a complement to, or in lieu of, traditional clinical trial evidence.

RWE is clinical evidence derived from the careful analysis of realworld data (RWD) such as insurance claims, electronic health records, disease registries and patientgenerated data.

It is an exciting trend. Firstly, it’s becoming easier to incorporate digital health technology into our own practices and thereby contribute to the body of RWD. Secondly, as the analysis of this data improves, we can more effectively evaluate the efficacy and safety of treatments directly in the line-ofcare and provide patients access to new treatments sooner.

As the limitations of RCTs become better understood, more pragmatic evidence-generating methods that absorb the real-world variances of patients and care delivery are welcome and, with luck, this kind of evidence-generating care can help expose our fashions a little earlier.

– References on request Author competing interests - nil

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FEBRUARY 2020 | 35

Stereotactic body radiotherapy for prostate cancer

By Dr Sean Bydder, Radiation Oncologist, Nedlands For suitable patients, Stereotactic Body Radiation Therapy (SBRT) allows shorter treatment courses, fewer side effects, and better treatment outcomes. Until recently patients with even relatively favourable prostate cancers, who were unsuitable for surgery or who opted for radiotherapy, were treated with seven- or eight-week courses of radiation.

SBRT is highly accurate, allowing larger doses of radiotherapy to be given with each treatment (fraction), while minimising the dose to surrounding normal tissues. Entire radiation courses can be given in five treatment ‘fractions’ over 11/2 weeks. Prostate cancers are now thought to be more sensitive to larger fractions of radiotherapy than normal tissues, so using larger fractions relatively spares the rectum and bladder for equivalent tumour effects.

SBRT can be given with modern radiotherapy machines or purpose-built systems such as the CyberKnife, which uses a linear accelerator mounted onto a robotic arm to deliver 100-200 precisely targeted radiation beams. It tracks and automatically adjusts for prostate movement throughout treatment.

Key messages

SBRT using larger yet fewer, more accurate radiotherapy fractions is producing good results in prostate cancer Robotic radiosurgery systems can track prostate movement throughout treatment, increasing accuracy PSMA PET scans identify sites of failure earlier than before and help stage patients planned for radical treatment.

A randomised trial in 874 patients from 38 UK centres comparing prostate SBRT with conventional radiotherapy (or radiotherapy with moderately larger than conventional fraction sizes) has been completed.

Acute side effects of treatment were mild in both groups. Late side effects and cancer outcome results are awaited. Longer term results of prostate SBRT of 2,142 patients (pooled) from phase two studies showed low-risk patients had a 5% rate of biochemical recurrence (i.e. a PSA rise suggesting prostate cancer remains) at seven years and intermediate-risk patients had a 10% rate of biochemical recurrence at seven years. Rates of late side effects were low.

SBRT can also be used to treat nodal or bone metastases from prostate cancer (especially with few metastases), in combination with hormonal therapy, or as a strategy to delay hormonal therapy or when disease is hormone refractory (castrate resistant).

PSMA PET scans can identify sites of metastatic disease earlier than conventional scans. These metastases might be suitable for SBRT. Urologists can place SpaceOAR, a gel that dissolves over a few months, between the rectum and the prostate, which can reduce the risk of rectal complications from low to very low for standard patients (and may be especially useful with previous radiotherapy).

For less favourable prostate cancers, hormone therapy may be required, and for aggressive, but still localised, cancers, SBRT is being investigated as a boost to follow a course of conventional IMRT radiotherapy, much like brachytherapy needles placed in the prostate were used as a boost (but without that surgical procedure).

Author competing interests – Dr Bydder declares a financial benefit from patients treated with Cyberknife stereotactic radiation

36 | FEBRUARY 2020

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CLINICAL UPDATE

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CLINICAL UPDATE

AI, machine learning and radiology

By Dr Brendan Adler, Radiologist, Wembley Artificial intelligence (AI) will eventually extend universally into health care, but this has been perhaps faster in radiology due to the combination of rapid development of graphic analysis software and easy accessibility to large imaging datasets.

AI will become an integral part of requesting, performing and reporting diagnostic radiology tests.

Analogous to the extensive data mining from social media platforms or improved voice recognition from home devices and facial recognition from widespread imagery, the development of picture archiving and communication systems (PACS) has provided a large body of labelled radiology data.

While AI encompasses a large group of software solutions, machine learning implies software solutions with the ability to independently learn and make predictions without being explicitly programmed to do so. As with humans, there is continual improvement with experience.

Key messages

AI will become integral to radiology workflow, organisation, data management and analysis AI may be incorporated as a diagnostic tool assisting tasks such as oncology follow-up Ethical and medicolegal issues will need addressing.

Given that substantial amounts of diagnostic radiology are largely pattern recognition, it is not surprising that it has been at the forefront of development of deeplearning techniques.

There have been substantial expectations versus actual practical solutions, but this is rapidly changing.

Multiple software can automate detection and interpretation of images, currently largely confined to less complex problems such as fracture assessment, pneumothorax, and mammography. Long-standing

Figure 1. AI Rad Companion Chest CT generated summary and images from ultralowdose unenhanced non-gated CT thorax (a) demonstrating automatic detection of small middle lobe micronodule in virtual bronchogram (b), automatically segmented and measured aortic diameters (c) and automatically segmented thoracic spine fracture assessment (d). Reproduced with permission from Siemens Healthineers.

computer-assisted diagnostic tools (e.g. pulmonary nodules) are being improved to provide guidance as to malignancy risk.

Post-processing of images is also under review. Much work is being done in automated segmentation and interpretation in evaluating brain parenchymal disease, cardiovascular abnormalities and liver metastatic disease. (Figure 1).

These solutions will be combined with automated radiology analysis to provide standardised reporting.

Further solutions are available to improve current technologies such as diminishing noise in low-dose CT scans and optimising radiation dose.

Intelligent scheduling, screening of referrals and automated triaging are being evaluated.

There is huge potential for coordinating radiology imaging analysis with a patientâ&#x20AC;&#x2122;s clinical and pathological data in a digital health record. This may be significantly delayed until My Health Record becomes a truly digital archive and the population perceives benefit from inclusion.

While disrupting radiology practice, these techniques are unlikely to replace radiologists but improve what they currently do, as occurred with picture archiving and communication systems two decades ago. The term augmented radiology has been coined.

There are also ethical and legal issues in regard to responsibility for the report.

While driverless trains and trucks are currently being used, there are concerns analogous to aircraft, for which despite the ability currently to take off, cruise and land autonomously, pilotless commercial air travel is still some time away.

Similarly, radiology reporting in the absence of any, albeit brief, review by the radiologist responsible for the report is unlikely to occur in the foreseeable future.

Author competing interests â&#x20AC;&#x201C; nil relevant disclosures. Questions?

Contact the editor

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FEBRUARY 2020 | 37

38 | FEBRUARY 2020

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CLINICAL UPDATE

WA leads the pack

By A/Prof Sue Skull, Paediatrician, Clinical Epidemiologist Having a basic knowledge of research methods is key to providing the best for our patients and clients, whether it’s through undertaking clinical audits or randomised controlled trials, critically appraising the latest evidence efficiently, understanding ethical and governance issues related to research, or translating results into policy and practice.

Embedding research in all aspects of clinical care is cost effective and central to evidence-based best practice. But while many clinicians are keen to be involved in research, they may not have had access to training in research methods, and can be unsure how to get started or avoid common pitfalls.

The Child and Adolescent Health Service (CAHS) Research Education Program, supported by the PCH

W E S T E R N

Foundation, provides high quality, free and open-access resources designed for busy clinicians and students of any health discipline or level of experience.

These include more than 20 onehour seminars across the research process, along with accompanying comprehensive handouts with additional resources, a Clinical Audit Handbook and some inhouse workshops. The seminars provide short, distilled overviews of a broad range of topics and link to other resources and available training opportunities.

The program aims to improve quality, impact, efficiency and outcomes for research projects, reduce risk associated with research, and encourages the embedding of research in all areas of clinical practice.

O R T H O P A E D I C

C L I N I C

Neurotization

N E R V E R E PA I R - A l e x O ’ B e i r n e One of the biggest advances in the repair of nerve injury is Neurotization or nerve transfer.

This is the technique of splitting a healthy nerve and redirecting it to a damaged nerve so that the healthy nerve now powers both its original function and the function of the damaged nerve. This can be utilized for both motor nerves and sensory nerves and trials are underway for autonomic nerves. The application of this technique has been gradually expanding over the last 10 years and it is now used for the repair of • High or extensive peripheral nerve injury • Brachial plexus nerve injuries • Spinal cord injuries • Single level spinal root injuries The technique involves splitting up to 20% of the donor nerve and then suturing it into the recipient damaged nerve. This is usually performed on the nerve in an area that is away from the site of injury, close to the end target organ (muscle or sensory area). The advantage of this technique allows for the surgery to be performed in healthy tissue, which improves success rates up to 90% in some series, speedy recovery of the nerve, activity usually begins within 3 months, and no donor deficit.

-

F I V E

M I N U T E

The program’s popularity across WA Health since it began in 2013 has grown to involve many WA health sites via video link and Telehealth. Program resources are currently used by staff and students from every major health service provider, university and research institute in WA, and increasingly more broadly throughout Australia and beyond.

Access to seminars is possible on the day of delivery in person, via video conferencing on individual devices, via Telehealth linked into shared teaching spaces, or later via recordings on the CAHS website.

Materials are regularly updated to reflect current national standards and changing methodologies.

continued on Page 43

C L I N I C A L

Some of the limitations of this technique are that the procedure should be performed within six months of the injury, technically very difficult as the topographical anatomy of the peripheral nerves is still not fully known and there is significant individual variation. It can take up to one year before full recovery from the procedure, thus outcomes are uncertain for quite some time.

The donor nerves are at risk and potentially the patient has a lot to lose.

Some examples of nerve injuries that have been repaired • Restoring elbow extension and hand function to C6 level quadriplegics to grade 4/5 power • Restoring shoulder and elbow function to C5, 6, 7 brachial plexus injuries • Restoring dorsi flexion of the ankle in L5 radiculopathy post disc prolapse • Restoring sensation to the hand after resection of the sensory component of the median nerve • Restoring the trapezius function CN XI post neck dissection and resection for tumour Future applications of this technique are restoration of arm function after strokes. This is an exciting area in orthopaedics and nerve injuries are no longer the devastating injury they once were.

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U P D AT E

Western Orthopaedic Clinic is a multi-centre orthopaedic group, with rooms across Perth. We are committed to bringing the newest techniques and are involved in research in many areas.

Phone: +61 8 9489 8700 Email: woc@wocwa.com

wocwa.com

FEBRUARY 2020 | 39

WA Rural Health Conference 2020

BEYOND2020 health innovations 21 and 22 March 2020 | Pan Pacific Perth

OPEN TO ALL MEDICAL PROFESSIONALS Explore the technological, societal and environmental forces that will shape the future of healthcare in coming years.

KEYNOTE SPEAKERS SHARA EVANS

Technology Futurist Shara Evans is globally acknowledged as one of the world’s leading futurists. Shara’s address will imagine the concept of better living through technology.

DR KEITH SUTER

Dr Keith Suter is an economic and social commentator, thought leader and author. Keith will examine the future challenges and opportunities of aged care.

This conference is proudly delivered by Rural Health West in partnership with WA Country Health Service through the Better Medical Care Initiative

Visit ruralhealthwest.eventsair.com/2020-wa-rhc to register, and to view the Preliminary Program 40 | FEBRUARY 2020

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CLINICAL UPDATE

Continuity of care – everything old is new again

By Dr Stuart Prosser, GP, Midland For 25 years, the trend in medicine has been towards specialisation. In practice, rather than medical care being provided or managed by generalists who knew ‘something’ about many areas, care was provided by specialists who knew a lot about their specific area.

This sounded good in theory but ultimately led to the creation of silos in medicine – fragmentation of the medical care delivered with the patient becoming responsible for coordinating their own care.

The profession has recognised that fragmentation delivers sub-par clinical outcomes for patients and we are now seeing a trend back towards continuity of care.

This can mean: • Multiple providers in one location to facilitate communication between providers, with the patient no longer having to project manage their own care.

• A team-based approach allowing for the integration of new information and the ability to make decisions from a wholeperson perspective efficiently, without extensive investigation or record.

My clinic is taking this approach to maternity care, and it’s shown me how desperately crucial it is when dealing with complex presentations that don’t fit neatly into one box.

Take the example of a patient with an unsettled baby in the postnatal period. Complex feeding issues are contributing to the baby being unsettled, and the baby is starving.

But it is also premature. And this too is contributing to the feeding issues. Overlaying this is the anxiety and postnatal depression which may have occurred independently to the unsettled baby, but is definitely worse with the unsettled baby.

Who is best to address this patient’s issue? Is it a neonatal paediatrician?

Is it a psychologist? Is it a child health nurse?

The truth is, for this situation and others like it, a team-based

Key messages

Medical specialisation has had pluses and minuses

Fragmented care delivers below par outcomes

Continuity of care invokes the skills of many in a team-based approach. approach and carefully coordinated care are needed to meet the patient’s needs effectively.

A clinic that intends to deliver strong continuity of care, needs to be: 1. Patient-centred: one where the care is individualised to the patient’s unique needs and the patient is actively involved in the decision-making process 2. Comprehensive: all care provided in one location, barriers between providers to be minimal and if the patient is referred to

MEDICAL FORUM | INNOVATION & TRENDS ISSUE

another provider, they do not want to repeat their history, they want the provider to have full knowledge of their condition.

3. Relationship-based: True continuity of care, in which the patient and the provider develop a trusted relationship, leads to significantly improved outcomes, both clinical and patient experience.

Moving beyond a system where patient presentations have to be fitted to the individual subspecialties is a positive trend in medicine and one that patients want. I hope it gains increasing acceptance in the profession. Like in sport, a champion team performs better than a team of champions.

Author competing interests – nil

FEBRUARY 2020 | 41

Doctors, big data and AI

By Professor David Playford, Cardiologist, Perth Will doctors be replaced by artificial intelligence (AI)? The answer is a resounding, NO! However, doctors not using AI may be replaced by those who do.

Multiparameter Space – how AI thinks

AI means a machine with humanlike intelligence. Machine learning is one form of AI, which (after training) enables the software to make simple predictions based on associations it identifies within complex data. It does not rely on simple equations.

A person instantly recognises a cat, dog, or horse. For a computer to recognise different animals, it requires computer training or recognition system. It could create a formula based on identifying two ears, two eyes, a nose, a mouth and some whiskers, which will reliably identify all three as being the same animal.

In contrast, machine learning is analogous to training a small child.

The software is shown many images of a cat (labelled ‘cat’), ‘dog’ and ‘horse’. The software performs its

Key messages

AI and big data are here Well-used AI can enhance medical practice Doctors will need to embrace and manage AI.

42 | FEBRUARY 2020

own feature recognition (using an ‘artificial neural network’) identifying aspects unique to each known label. More advanced feature recognition systems can classify unlabelled data first, simplifying the AI training process.

Machine learning does not involve the system being directed which features to identify. The software identifies these for itself. Exactly how and which features are used, is not revealed (‘black box’). This is similar to human learning.

We need AI Strategically applied, AI is ideally suited to organising the large amounts of seemingly disparate data

generated from medical testing. We cannot do this ourselves. Relative to a computer, humans have poor memory, poor mathematical skills, innate bias, poor recall accuracy and poor capacity to analyse big data in a multidimensional space. Humans can see in three dimensions and only imagine a multidimensional space.

AI can work in as many dimensions as it is given. Humans are superior to computers in other areas (e.g. capacity for abstract thought, consciousness, empathy). It makes sense, therefore, that the best application of AI to medicine should to extend our capacity, not compete with it.

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CLINICAL UPDATE AI has been applied around image recognition and analysis of big data. Our research in cardiology has focused on analysis of big data and automation of the process of diagnosis, to improve efficiency, accuracy, and consistency. Our AI system for automated diagnosis of arrhythmias (e.g. AF) is just reaching human-level accuracy but with greater consistency and speed.

Our automated system for interpretation of echocardiographic data has impressive accuracy in automatic diagnosis of aortic stenosis, including the phenotype of abnormalities associated with AS and future mortality.

ADVANCEMENT OF COCHLEAR IMPLANT TECHNOLOGY

In this emerging area we need to be ready and willing to embrace AI, train it to perform complementary tasks, and then in turn, learn from what the AI can teach us. Then we can truly be synergistic with this exciting technology.

Author competing interests – Prof. Playford is Medical Director of Alerte Digital Health, a medical AI company. He is principal investigator of the national Echo Database Australia.

continued from Page 39

WA leads the pack Since 2013, the program’s resources across 23 topics have been accessed more than 22,000 times. In addition, many have attended in-house workshops, and resources have contributed to university teaching programs. The Royal Australasian College of Physicians (RACP) links to the program’s content as an additional resource for their Online Learning Research Projects course. The program also actively cross-promotes next-level research skills training opportunities.

The following are currently available via the CAHS website at pch.health.wa.gov.au/ ResearchEducationProgram: • The schedule for the 2020 Research Skills Seminar Series • Recordings of all 2019 seminars, plus handouts • The Clinical Audit Handbook – also useful for other types of surveys • Subscription to the mailing list for upcoming events and registration for upcoming seminars Site coordinator access – individuals with videoconferencing facilities can organise group access to seminars on the day, with materials sent in advance, including evaluation forms and handouts.

• Workshop-related online resources eg: Research Electronic Data Capture use.

The CAHS Research Education Program continues to add new topics and resources and welcomes content suggestions via ResearchEducationProgram@health.wa.gov.au.

ED: A/Professor Skull is a paediatrician, clinical epidemiologist, public health physician and head of the CAHS Research Education Program.

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Anne Gardner

Andre Wedekind

Post Dip. Aud., BSc

M.Clin.Aud., BHSc (Physiotherapy)

Cochlear implants (CI) have been at the edge of bionics innovation for 30 years, providing hearing to those with very severe hearing losses through direct stimulation of the auditory nerve.

There are two components of a cochlear implant.

The implant Internal, implantable structures of a CI system are becoming smaller and, together with surgical advances, build on a trend towards atraumatic surgery and increasing structure preservation.

Cochlear implantation no longer means losing all residual natural hearing. For many, it simply replaces the speech frequencies for which hearing aids are no longer sufficient.

This has led to an unprecedented growth in candidacy. Recipients with a combination of natural and CI hearing show best performance in understanding speech in noise, music appreciation and sound localisation. With more candidates, the known benefits of implantation from a young age, and a growing likelihood for an MRI over a lifetime, MRI compatibility is of increasing importance. Some current models are now compatible with a routine 3 Tesla MRI without the need for surgical magnet removal.

The sound processor Sound processing in the externally worn component has improved significantly. Manufacturers have drawn from the technological advancements from within the hearing aid industry and utilised innovations for better speech-in-noise listening, automatic responding to changing environments, and connectivity to wireless devices.

In addition, some CI processors can connect directly to smartphones allowing listeners to stream to a compatible hearing aid in the opposite ear at the same time, maximising the benefits of binaural hearing for a full range of multimedia. Compared to people with normal hearing, cochlear implant recipients still require significantly higher signal-to-noise ratios to achieve the same understanding.

To improve comfort and performance in noise, the processor automatically detects, analyses and reduces non-speech sounds such as wind, traffic or clanging dishes. They combine multiple microphones and frequency analysis to zoom towards the dominant speech signal and away from potentially distracting speakers in a crowd.

51 COLIN STREET WEST PERTH WA 6005 P: 08 9321 7746 F: 08 9481 1917 W: www.medicalaudiology.com.au

FEBRUARY 2020 | 43

What to know about breast implants

By Dr Tim Cooper, Plastic Surgeon, Nedlands Women with breast implants are increasingly concerned about the risk of developing cancer or implant-related illness. They may be experiencing breast pain or other unexplained symptoms and access information online and in the media.

contracture and are positionally more secure.

The TGA and the FDA have withdrawn macro-textured implants from the market. Allergan, one of the implants most commonly involved with ALCL, voluntarily withdrew its product. The TGA has mandated implant manufacturers report any episodes of ALCL but has not recommended that all textured implants be removed in the absence of ALCL diagnosis.

Gathering information regarding breast implants has been advanced by the ABDR (Australian Breast Device Registry) for all implantrelated surgery.

There is considerable confusion as to the difference between BIA ALCL (Breast implant associated anaplastic large cell lymphoma), breast cancer, and BII (breast implant related illness). Many women with implants may well be concerned about a silent rupture.

BIA ALCL is a rare form of nonHodgkin’s Lymphoma, first classified as a distinct clinical entity by the WHO in 2016. It typically presents as an unexplained swelling of one or both breasts 5-10 years post implantation. ALCL has never been reported in smooth implants and appears related to more textured implants.

The more coarse, or macrotextured, implants have an incidence as high as one in 2000 breast augmentations, whereas the micro-textured products (all listed on TGA implant hub) have an

ALCL is diagnosed by cell cytology and immunohistochemistry of seroma fluid from US-guided aspiration. incidence of 1 in 80,000. This needs to be put in the context of the high lifetime risk of developing breast cancer.

Tissue expanders and anatomically shaped implants only come as textured products. Textured implants are often preferred as they have a lower risk of capsular

Evidence supports the development of a low-grade infection with the formation of a bacterial biofilm attached to the textured surface of the implant in someone who is immunologically compromised. Recommendations have been made to minimise bacterial contamination in implant surgery.

Beechboro Family Practice High patient volume at busy centre • Full time/part time position available • Large and modern practice • Collegial environment

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To learn more, contact Sandy McNab on 0419 917 010 or sandy.mcnab@ipn.com.au for a confidential discussion 44 | FEBRUARY 2020

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Key messages

Cancer associated with implants is rare and treatable

Implant-related illness is not clearly defined. Empathy is key

Rupture is detected on US and warrants removal.

The majority of these tumours are fluid, not solid. Hence mammography, MRI and /or PET CT are reserved for investigating diagnosed ALCL. Once diagnosed, patients should jointly be under the care of a plastic surgeon and a haematologist with a special interest in ALCL. Typical treatment involves entire removal of the implant and capsule.

Adjuvant therapy is rarely required.

The majority of patients suffer no long term effects. However, there have been three reported ALCL fatalities in Australia in the past decade.

Breast implant illness (BII) Increasing numbers of women with breast implants self-identify and present with various systemic symptoms (e.g. fatigue chest pain, brain fog, rash, anxiety) believing these to be related to their breast implants.

There is no medically accepted diagnostic testing for BII. The potential link between silicone breast implants and autoimmune disease has been extensively studied for over two decades

with no causal link found. Medical grade silicone is an entirely inert substance created by hydroxylating silica to form polymethoxylsiloxane. with all traces of antioxidants, dyes and plasticers being removed.

Many concerned patients present with multiple tests organised by their naturopath and much information about their condition and how to manage it. This includes further lab testing, request for samples and instructions on â&#x20AC;&#x2DC;en blocâ&#x20AC;&#x2122; capsulectomy to remove all traces of silicone.

My approach is empathetic despite the lack of scientific evidence.

If they wish to proceed with removal, then I will do so. If they are uncertain, I will perform an US to exclude a rupture. Anecdotally, many of these patients get better and remain grateful following explant surgery.

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The majority of implant ruptures are silent (clinically undetectable), but may be accompanied by a shape or consistency change, capsular contracture or axillary lymphadenopathy. Implants should not be considered lifetime devices nor be routinely changed at 10 years (where rupture rate should be less than 10%).

An US is recommended if rupture is suspected. MRI is only necessary in equivocal circumstances. Rupture is not a medical emergency and many patients will have had the rupture for some time. However, there remains a significant degree of patient anxiety with confirmed rupture.

Author competing interests - nil

FEBRUARY 2020 | 45

CLINICAL UPDATE

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Gaining health through innovation

By Dr Cameron Gent, GP, Wembley Approximately two thirds of the adult population are either overweight or obese, posing arguably the biggest threat to public health. The federal and WA state governments have become increasingly interested in ways to decrease this figure. Why? Money.

The Food Fix report, a state government inquiry into the role of diet in prevention and management of diabetes (released April 2019), estimated the cost to manage the complications of diabetes in WA to be between $880 million and $1.2 billion in the public system alone.

That’s about 10% of the state health budget. The cost federally, quoted in the same report, is estimated to be $20.2 billion as of 2018.

The major risk for type 2 diabetes is obesity. The Food Fix recommends information and education in regard to low-carbohydrate diet, consistent with CSIRO recommendations, be distributed to GPs in WA. If the nation’s adults reduce both carbohydrate intake and, in turn, body weight, they and the governments’ coffers will be healthier.

GPs, be innovative Science is about objectively testing whether new ways are effective in achieving goals and questioning, “Is it so?” Science is not, “I want it to be so, so it is so” (the latter becoming all too common in our society).

The eCal device being used in our practice (and the UK NHS) measures exhaled gases of patients via indirect calorimetry providing, via software integration

Key messages

To improve health outcomes, we need innovation

The food fix report recommended a low carb diet be supported Technology and a team approach can allow patients to gain health. an estimation of metabolic rate at the mitochondrial level and an indication of whether a patient is ‘burning’ carbohydrate or fat for energy in the fasting state.

The use of eCal is based on a new old idea that had been buried for many decades. That is, low carbohydrate diet can lead to reversal or cure of diabetes type 2 and may be the most effective nonsurgical way of combatting obesity.

The ‘new way’ of testing is to have a specific, on-site multidisciplinary primary care team to combat obesity in our patient population.

We have developed a process that is GP-workload neutral at worst, and less work, if possible, by having GPs direct a primary healthcare team of experts (nurse, psychologist, exercise physiologist, physiotherapist) within the practice to screen, motivate, educate and support patients to gain health by losing weight.

The goal of the program run by the exercise physiologist is for significant, sustained weight loss of 5% or more of initial body weight at 12 months from start of the program. The bias of the program

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is to educate patients about low carbohydrate diet, how they can take charge of their body weight by metabolic manipulation and give them the tools to do this in a sustainable, lifelong way.

Successful behavioural change is more likely with non-judgemental medical and paramedical advisors, regular coaching and positive feedback both subjective and objective. We do this all on-site.

The exercise physiologist measures the usual biometrics including body mass composition but, in addition, I have found the availability and their use of the eCal device developed here in WA to be pivotal in motivating patients to enter the program and stay in the program.

My experience is that patients love the fact they get a ‘one-stop shop’ for healthy weight loss in a nonjudgemental environment with people they know and trust. They get regular coaching, objective feedback and, if appropriate, professional psychological support.

We are engaging with several partners to help us undertake meaningful, ethical and significant research on our program to inform the management of this carbohydrate driven obesity epidemic. All this is taking place in a general gractice, where the battle should be owned, fought and driven.

Author competing interests – nil

FEBRUARY 2020 | 47

Ultrasound-guided freehand trans-perineal prostate biopsy

By Dr Y. Weerakkody, Radiologist, Perth The ultrasound-guided transperineal freehand prostate biopsy service was initially introduced into WA in the late 1980s by Dr James Anderson at the Royal Perth Hospital radiology department and progressively refined over the next few decades to improve patient tolerance. The service currently runs within the radiology department with clinical support and collaboration by the urology department.

Patients are initially assessed by a specialist urologist with increasing numbers of patients now also undergoing multiparametric MRI prior to biopsy. For first three decades, systematic sampling of the entire prostate was performed. With the advent of multiparametric MRI, a considerable portion of significant cancers are now discovered with targeted approaches i.e. directing the biopsies to areas in the prostate which appear suspicious on MRI. Random systematic sampling can also be performed but tends to be performed less frequently in those with a definite MRI positive lesion with the majority of samples taken through the region of concern with a lesser number of sampling done elsewhere. The procedure can be done as an outpatient rather than a day case or main theatre, saving time and cost to the patient. There is a lower risk of sepsis and no need for routine antibiotics.

Key messages

Ultrasound-directed transperineal prostate biopsy can be an outpatient procedure MRI can guide to biopsy site(s) Sepsis is considered less than that with transrectal biopsy.

The prostate ultrasound and biopsy technique is relatively straightforward and done with the patient in the left lateral position, a bi-plane ultrasound probe is introduced into the rectum where diagnostic ultrasound images are initially taken and the prostate measured.

After obtaining consent from the patient, the perineum is cleaned with iodine. The skin, subcutaneous tissue, pelvic floor musculature and prostate capsule are then anaesthetised using local anaesthetic and under direct ultrasound guidance. Administration of local anaesthetic takes about two minutes and, after checking for numbness, the biopsies targeting the prostate are taken.

All biopsies are performed as planned procedures. Compared with a traditional trans-rectal biopsy, a trans-perineal method does require a longer period of training to acquire the sufficient skill with about 15-20 minutes procedural (on table) time and about 30-45 minutes

Figure 1​: Pre-procedure MRI showing a lesion of concern on the right side of the prostate.

48 | FEBRUARY 2020

peri-procedural time. Patients are discharged soon after but requested to remain in the hospital precinct for half an hour (usually while partaking of a beverage).

Occasionally patients do experience a vaso-vagal reaction requiring nurse supervision. Rarely, bacteremia can become manifest usually becoming clinically overt in the first 24 hours and patients are instructed to contact the referring urologist and or general practitioner if they experience symptoms.

The author acknowledges the input of Drs James Anderson, Mikhail Lozinskiy and Tanya Ha, Royal Perth Hospital Radiology Department and Urology department.

Author competing interests – nil

Figure 3: ​Intra-procedural ultrasound showing biopsy device extending towards the region of concern.

Figure 2​: Dual probe device showing the corresponding lesion at a similar position (magnified images of prostate).

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Knee OA – joint damage or joint health

By Dr JP Caneiro PhD, Specialist Sports Physiotherapist, Shenton Park “It’s bone on bone…caused by wear and tear”, This is the common understanding of knee osteoarthritis (OA) affecting 9% of Australians.

Key messages

OA changes on imaging do not solely explain a person’s pain experience Exercise is safe and strengthens a knee with OA changes without causing harm Address the multiple biopsychosocial factors affecting pain and disability.

Best-practice guidelines recommend first line non-surgical interventions such as education, progressive strengthening exercise and weight loss. Evidence supports these interventions as effective at reducing pain and disability, lessening use of medication and surgery.

However, common misconceptions about knee OA negatively influence clinicians’ referral to, and patients’ acceptance of, nonsurgical management. Australian GPs are three times more likely to refer patients with knee OA for surgical opinion, than nonsurgical management.

When OA diagnosis is given based on imaging, patients are generally told their pain is due to ‘bone on bone’. This may lead many patients to disregard exercise-based interventions believing it would further damage their joints.

A person’s knee pain experience is influenced by biological (imaging findings, inflammatory processes, muscle weakness), psychological (low confidence, belief that exercise will cause damage, emotional stress, depressed mood), and social (work and sport demands), and lifestyle factors (poor sleep, low or excessive physical activity, obesity) that can mediate neurophysiological and inflammatory processes, sensitising knee structures and driving disability behaviours such as avoiding activity.

Clinicians should move from labelling knee OA as purely ‘structural damage’ towards understanding it as a ‘whole person condition’ with pain as a modifiable symptom related to sensitised knee structures.

Thus, we should adopt a personcentred approach, educating the patient about knee health, encouraging progressive exercisetherapy, regular physical activity

and weight loss, and reassure that it is safe to exercise and strengthen their knee without harm.

This helps patients build a positive mindset, adopt a healthier lifestyle and confidently manage pain flareups. Surgery is then reserved for patients with advanced OA, without adequate response to non-surgical care, and who are predicted to have a good response to surgery.

To change the view about OA towards joint health, changes need to occur at a public level through media campaigns, at the health system level with funding, and better reimbursement for exercise and education programs, and at a clinician level with the provision of evidence-based care.

References available on request The author acknowledges the input of Prof Peter O’Sullivan Author competing interests – nil

Management can be individualised with a physiotherapist or in a group environment. Group rehabilitation programs such as GLA:DTM (Good Life with Arthritis: Denmark) developed by researchers in Denmark is an evidence-based option for OA patients.

GLA:DTM is a physiotherapistled treatment consisting of two group education, and 12 group exercise-therapy sessions for people with OA. Research in Denmark reported pain reduction by 35%, reduced analgesic consumption; and improved function and physicalactivity level at one year.

This program is available across Australia (https://gladaustralia. com.au/), including Perth.

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FEBRUARY 2020 | 49

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WINE REVIEW

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Review by Dr Martin Buck

Sittella Shines in the Valley Sittella Wines has been a Swan Valley success story having been established by Simon and Maaike Berns in 1993 with plantings of Verdelho, Chardonnay and Shiraz, and later expanded to become one of the premier destinations in the Valley.

They have consistently helped to lift the profile of the Swan Valley and their current wines reflect great fruit selection and some clever winemaking. Make sure you drop past on your next visit to the Swan Valley.

NV Sittella Sparkling Chenin Blanc $21.50 (cellar door)

2017 Sittella Reserve Cabernet Malbec $26.10 (cellar door)

2018 Sittella Frankland River Reserve Shiraz $26.10 (cellar door)

Sparkling wines are in the Sittella blood and the Chenin Blanc Brut is made using Methode Traditionelle with 15 months on lees and giving the wine some delicate yeast flavours. In the glass there is a fine bead with bready aromas and some citrus. A well-balanced offdry palate with soft acid and lively Chenin flavours. A great example of the flexibility of the Chenin Blanc variety.

Sitella has sourced some Wilyabrup fruit for this Reserve Cabernet Malbec and it is a Bordeaux blend with a difference. A cooler vintage, picked later than usual, has produced more intense flavours. A deep purple in the glass with aromas of ripe blueberries, plums and spice.

By using more mature French oak, the fruit structure shines through some soft tannins. A great wine with exceptional fruit and balance that will cellar very well.

Frankland River is becoming the go-to region for big-bodied Shiraz and the 2018 Frankland River Reserve Shiraz ticks all the boxes. Once again, the clever use of mature oak has let the Shiraz express more fruit characters and the cool characters of pepper and plum. A dark purple wine overflowing with big berry aromas and fruit flavours with a soft tannin influence. If you love cool climate Shiraz, then look no further. Plenty of cellaring potential.

'S EWER REVI

PICK

2012 Sittella Museum Release Silk $28.80 (cellar door) Aged Swan Valley white wines have a special place in West Australian wine history with the iconic Houghtonâ&#x20AC;&#x2122;s whites showing great ageing potential. The 2012 Sittella Museum Release Silk is a blend of Chardonnay, Chenin Blanc and Verdelho that were all hand-picked and whole-bunch pressed with a minimum cellar age of seven years. An amazing example of what the Valley can produce with aromas of balanced older fruit with a smooth, mature palate.

Crisp acid, a silky, vibrant palate that still has freshness. Limited to 60 dozen and will continue to excite.

MEDICAL FORUM | INNOVATION & TRENDS ISSUE

FEBRUARY 2020 | 51

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ARTS & ENTERTAINMENT

A large dose of theatrical magic transforms cane, leather and metal into War Horse. Ara Jansen reports Theatre turns truly magical when it convinces you to suspend your disbelief. Nowhere is that more obvious than War Horse, which starts at Crown Theatre on March 24.

When horses prance and gallop across the stage we know they aren’t real horses, yet the puppets have been so cleverly handled we simply believe.

Based on Michael Morpurgo’s 1982 book of the same name, War Horse is the story of courage, loyalty and friendship between a young boy named Albert and his horse, Joey.

At the outbreak of World War I, Joey is sold and shipped to France to help with the war effort.

Caught in enemy fire, fate takes the beloved horse on an extraordinary journey, serving on both sides before finding himself alone in No Man’s Land. Albert cannot forget Joey and he embarks on a treacherous mission to find him and bring him home.

The stage adaptation has created a powerfully moving and imaginative drama which features groundbreaking puppetry created by South Africa’s Handspring Puppet Company.

The award-winning War Horse stage production has since been 52 | FEBRUARY 2020

seen by more than seven million people worldwide in almost 100 cities and a dozen countries.

The job of making sure War Horse’s puppets make us believe they are real falls to Resident Puppetry Director Gareth Aled.

“If our puppeteers focus on the puppet directly, the audience are encouraged to look at the puppet,” says Gareth. “Somehow it’s simple and yet incredibly powerful.”

The second aspect which brings the puppets to life is breath. “Our puppets breathe. So, if something is breathing it conveys life and the rhythm of that breath will suggest thought and emotion, which is what we want the puppets to do.”

Thirdly, the way the puppeteers convey the muscularity and weight of the puppets helps bring them to life. Convincing audiences the puppets are the weight of a real adult horse is an ongoing challenge.

The horse puppets are made of cane, mesh, leather, aluminium and steel. Each section of the horse – the head, heart and hind – works independently and each has a technical task to achieve, like the twitch of an ear or the bend of a leg.

Gareth started working as a puppeteer with War Horse seven years ago and was then made Resident Puppetry Director to travel with the show. Having worked on the inside of the horses, he has intimate knowledge of how to make those three sections work in harmony. Now on the other side, part of his work is to make sure that the audience is totally convinced by the horses.

“War Horse is an incredible alchemy of the individual parts,” says Gareth. “When everyone is present in the moment, anything this physical demands that you listen, trust and respond. The puppets in this show respond to what’s going on in the story but how they move is up for grabs each time they are on stage.”

Win...

War Horse is at Crown Theatre from March 24. For you chance to win a double ticket, go to www.mforum.com.au and click the 'Competitions' link.

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ARTS & ENTERTAINMENT

Out & about Each month Medical Forum review what's on in Perth. If you want to win tickets to our features, simply visit mforum.com.au and click the 'Competitions' link

Movies: Alliance Francaise French Film Festival

Movie: Bloodshot

Sculpture by the Sea

Presented by the Alliance Francaise de Perth, the festival showcases the best in contemporary and classic French Cinema at Palace Cinemas Paradiso (Northbridge) and Luna Palace Cinemas (Windsor in Nedlands and Luna on SX Fremantle). Find out more at www.affrenchfilmfestival.org

Vin Diesel leads a cast including Outlander’s Sam Heughan and Guy Pearce in the movie adaptation of the comic book of the same name. Diesel is Ray Garrison, a soldier recently killed in action and brought back to life as the superhero Bloodshot by the RST corporation. With an army of nanotechnology in his veins, he’s an unstoppable force.

Next month’s Sculpture by the Sea festival at Cottesloe Beach is the 16th year WA has hosted this celebration of sea, sand and sculpture. It is always fun and often surprising.

This year, the work of more than 70 artists form 20 countries will be showcased.

Various cinemas,

In cinemas, March 5

The curatorial panel for the 2020 exhibition is artist Olga Cironis, Dr Michael Hill, Head of Art History and Theory, National Art School, Sydney, Professor Ted Snell, Chief Cultural Officer, Cultural Precinct, University of Western Australia and Gemma Weston, Curator, Cruthers Collection of Women’s Art, Lawrence Wilson Art Gallery, UWA, and program associate for the Perth Festival.

March 11 – April 13

Movie: Peter Rabbit 2 In the new film, Bea (Rose Byrne), Thomas (Domhnall Gleeson), and the rabbits have formed a makeshift and loving family – but when Peter (voiced by James Corden) and his love for mischief spreads beyond the garden and his family is at risk, he must decide what kind of rabbit he wants to be.

In cinemas, March 19

Movie: I Still Believe From the makers of I Can Only Imagine comes this biopic of Christian country music star Jeremy Camp. Jeremy's first wife died at the age of 21 of ovarian cancer and he embarks on a journey that tests his faith in all things.

In cinemas, March 12

November Winners Movie: Jumanji Next Level Dr William Tee, Dr Brendan Connor, Dr Chong Kwah Movie: Like A Boss Dr Jarrad Paul, Dr Christine Lee-Baw, Dr Dian Harun Movie: Playing With Fire Dr Michelle Rooke, Dr Yim Kong Wong, Dr Julie Copeman Movie: Mrs Lowry & Son Dr John Van Bockxmeer, Dr Michael Hart, Dr Fred Faigenbaum, Dr Monica Keel Choral: Handel’s Messiah Dr Ben McGettigan Doctors Dozen: Millbrook Winery Dr Annette Finn

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FEBRUARY 2020 | 53

SJG Midland Public and Private Hospitals SJG Midland Public and Private Hospitals celebrated a big 2019 at Sandalford Winery.

1 Dr Andrew Crocker, Dr Dianne Sunderman, Rudi Seebach & Dr Melissa Gildenhuys 2 Caroline Murphy, Ross Hunter & Dr Jonathan Agunwa

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3 Dr Sayed Ali, Dr Siao Hoon & Jason Bertram 4 Dr Edward Fysh, Fiona Fysh, Natalie So & Dr Kenji So 5 Ian Maddox, Dr Mary-Anne Maddox, Dr Ilse Swart & Corrie Swart 6 Dr Jonathan Spencer, Claire Spencer, Midland CEO Michael Hogan & Dr Amanda Boudville 7 Dr Kelli Hanna, Dr Michele Genevieve, Dr Joel Stein & Dr Mary Theophilus 8 Loreen Lee, Dr Mark Lee, Midland CEO Michael Hogan & SJG Chair Hon Kerry Sanderson 9 Dr Megan Foster, Dr Simone Bartlett, Dr Michele Genevieve & Dr Mary-Anne Maddox 10 Dr Nelson Loh & Dr Tee Ching Hun 11 Dr Sayanta Jana, Sohini Haldar, Sarah Tegeler & Katherine Wray 12 Dev Makesar, Royce Vermeulen, Dr Matthew Summerscales & Gareth Jones

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SOCIAL PULSE

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SOCIAL PULSE SJG Murdoch Hospital The annual doctors Christmas event traditionally held in a marquee on the Murdoch hospital grounds saw oncologist A/Professor Kynan Feeney named Hospital Doctor of the Year for 2019. His family joined him for the presentation. Murdoch CEO Ben Edwards said Kynan,

who is head of the Oncology and Haematology, was instrumental in the establishment of the Cancer Centre and clinical trials into breast, melanoma, oesophageal, gastric, colorectal, lung, prostate, renal and bladder cancers.

1 Elaine Thomas, Dr Alan Thomas, Dr Krishna Epari & Dr Emelyn Lee 2 Dr Alex Oâ&#x20AC;&#x2122;Beirne, Sapna Sharma, & Uma Kanna 3 A/Professor Kynan Feeney (centre) with family members Aziz and Monir Zarandion, Kazuko, Farah & children Haifa and Noah.

4 Dr Rupert Ledger, Nadia Ledger & Dr Farah Tan 5 Dr Soni Narula, Brenda Narula & Dr George Sim

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6 Dr Alapana Kulkani, Sapna Sharma & Dr Ashwini Davray 7 Dr Volker Mitteregger, Dr Beate Harrison, Dr Ian Jenkins & Dr Craig Schwab 8 Heidi and Dr Jeff Thavaseelan & Jenny and Dr Chris Gunnell 9 Dr Peter and Brigit Ammon & Dr Harsha Chandraratna

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10 A/Prof Kynan Feeney, Dr Navid Hashemi, Dr Emelyn Lee & Dr Ed Debenham 11 Dr Nick Butterfield, Dr Ann Lynn Kuok, Sanne Butterfield, George Millovski & Dr Andrea Ang

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SJG Subiaco More than 400 doctors attended St John of God Subiaco Hospital’s annual Medical Practioners’ Christmas Soiree held this year at the Royal Freshwater Bay Yacht Club.

1 Dr Peter Robins, Katie Robins, Salley Chaney, Prof Gervase Chaney

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2 Dr Mariam Bahemia-Gannon & Dr Michael Gannon 3 Dr Jo Colvin & Dr Mangesh Deshmukh 4 Julia Allen, Jenny Davies & Dr Robert Davies 5 Loretta Baker, Hon Kerry Sanderson, Dr Shane Kelly & Dr Steve Baker 6 CEO Prof Shirley Bowen, Geena Kelly, Dr Eva Denholm & Dr Milly Wong

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7 Dr Rachel Collins & Dr Fiona Langdon 8 David Foti, Dr Michelle Ammerer, Dr Jurgen Passage & Kylie Passage 9 Petrina Burnett & Dr Lee Jackson 10 Dr Matt and Tania Rucklidge 11 Dr Rob Storer, Trish Clarke 12 Dr Tim Gattorna, Prof Brendan McQuillan

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SOCIAL PULSE Ramsay Health Care Ramsay Health Care said farewell to 2019 and thanked doctors and supporters at a function at Fraserâ&#x20AC;&#x2122;s.

1 Dr Maina Kava, Dr Ravisha Srinivas Jois, Dr Jason Tan, Dr Zoe Smythe, Dr Jamie Tan, Carly Tan & Dr Desiree Silva 2 Dr Stefan Ponosh & Anna Roberts 3 Dr Steve Rodrigues and Dr Rita Malik 4 Dr Andrew Wesseldine & Peter Mott

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5 Dr Andrew & Eloise Finlayson 6 Dr Maria Kladnitski, Lauren Neppe & Dr Cliff Neppe 7 Leila Maddison, Dr Syd Weinstein, Dr Jay Natawala & Dr Kah Lim Tay 8 Katie Nicol & Dr Arash Taheri 9 Danny Sims, Dr Rita Malik, Kate Munnings & Dr Peter Smith 10 Dr Paul Sprague, Christine & Kevin Cass-Ryall

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Bethesda Health Care Bethesda Health Care held its Christmas Party for 200 staff, doctors and supporters at the Claremont on the Park function centre.

1 Marion Bowater and Penny Charleston 2 Maria Lozinsky & Dr Mikhail & Lozinsky, Dr Neale Fong, Samantha Goebel & Dr Sven Goebel, Priscilla McLellan & Dr Duncan McLellan 3 Marie Bryson & Bruce Hua 4 Peta Fong & Dr Neale Fong 5 Gloria Cook & Gabby Chainey 6 Emma Whyte, Angela Turner, Freda Casey, Roisin Brennan

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SOCIAL PULSE St John of God Mt Lawley Hospital The SJG Mt Lawley Medical Practitioner Soiree was held at the Westin Hotel in the CBD with more than 150 specialists, SJG Health Care executives and senior Hospital Senior Leadership team celebrating.

The annual Doctor of the Year award went to former

Director of Medical Services, Dr George Eskander, who was instrumental in successfully leading the hospital through its 2019 ACHS Accreditation Survey. Also recognised and celebrated was retiring O&G Dr Bruce Thyer who was presented with the Dr Ellis Pixley Award.

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1 SJG Health Care Chair, Kerry Sanderson, Dr Leon Cohen and Caroline Cohen 2 SJG Mt Lawley CEO Mr Paul Dyer and daughter of Dr Ellis Pixley, Dr Fiona Pixley 3 Brian Meharry, Dr Suzanne Meharry and Chris Harris.

4 SJG Mt Lawley Mr Paul Dyer, Dr Fiona Pixley and Dr Ellis Pixley Award winner Dr Bruce Thyer 5 GP Liaison Officer Melissa Wilson, Dr Luca Crostella and Petrina Crostella.

6 Grand Joldes, Dr Ros de Wet and Dr Pierre Smith 7 Director GP Liaison Dr Erin Horsley and Aaron Barwood 8 SJG Mt Lawley Mr Paul Dyer and 2019 Doctor of the Year Dr George Eskander

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9 Dr Warren Thyer, Dr Anurag Goel, Dr Wendy Chong, Dr Joo Teoh, Dr Kwok Hor and Meggie Hor 10 Alan Francis, Clinical Nurse Shannon Francis, Nicole Bairstow and Dr Brett Bairstow 11 Dr Graeme Clarke

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You don’t buy a practice every week, but we do

It’s a big decision, Huge. For most, it’s a once in a lifetime proposition.

We take this very seriously too.

So much so, that over the last 25 years we’ve developed a process for medical professionals looking to go out on their own.

But we don’t just look at you, we look at the business as a whole. We act as your partners in ensuring that it is a viable and profitable opportunity. We assess everything - location, competition, client-base and growth potential.

Then, and only then, we tailor a loan to meet your needs.

Forgive the pun, but we have a lot of practice when it comes to buying a practice.

Visit us at boqspecialist.com.au or speak to your local finance specialist on 1300 131 141.

Car loans | Commercial property | Credit cards | Equipment finance | Fit-out finance | Foreign exchange | Home loans | Personal loans | Practice purchase | Practice set-up | Savings accounts | SMSF | Transaction accounts | Term deposits | Vehicle finance The issuer of these products and services is BOQ Specialist – a division of Bank of Queensland Limited ABN 32 009 656 740 AFSL no. 244616 (“BOQ Specialist”).