Medical Republic
New scripts needed for these key medications
Rural DPA changes have GPs baffled
New contraceptive, endometriosis and fertility medications will be subsidised through the PBS, the federal government has announced.
Speaking to The Medical Republic, vice president of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists Dr Nisha Khot said that patients would need new scripts to qualify for the reimbursements.
“These changes will allow doctors to prescribe the most effective medications for their patients without financial barriers limiting access,”
Rural and remote practices will be disadvantaged by the government’s decision to make places like Noosa and Surfers
Paradise eligible to recruit overseastrained doctors, GPs from all walks are warning.
The federal government this month opted to adjust Modified Monash Model and Distribution Priority Area classifications on a “no losers” basis.
Areas that became more rural or were deemed to have a GP workforce
shortage had their rurality increased on the Modified Monash scale or were upgraded to DPA status, but areas that became less rural or that may have resolved workforce shortages kept their classifications.
Some of the areas that now qualify as DPA – i.e. have the power to attract international medical graduates serving out their 10-year rural moratorium – include popular coastal Queensland tourist destinations Surfers Paradise and Noosa.
“It’s ridiculous to believe that these very metropolitan, very coastal locations [qualify] … there should be a reasonable degree of embarrassment on the allocation of those areas as DPA,” ACRRM president Dr Rod Martin told The Medical Republic
During the last election, one of
Labor’s health pledges was to loosen the criteria governing DPAs to encompass all MM2 areas and above, as well as some MM1 areas.
It delivered on this promise in July 2022; in the following 12 months, 73 internationally trained doctors moved from an MM3-7 area to an MM2 area, up from around 40 in previous years.
Dr Martin said the incoming changes were discouraging, especially as interest in rural medicine starts to bounce back.
“We predicted this [in 2021] when all of the DPA changes were touted to come, and people fairly rapidly moved to ostensibly outer metropolitan areas – you could see the tall buildings in the city from where you were practising,” he said.
“The same thing is going to
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PA ‘zombie policy’ an ‘all around bad deal’
There’s no convincing evidence that PAs add value to UK primary care, the BMJ says LAURA WOODROW
Physicians’ assistants are a “poor policy being imported from the UK” with “no coherent strategy”, according to RACGP Queensland chair Dr Cath Hester.
Earlier this month, the BMJ published a piece authored by Professor Trisha Greenhalgh and Professor Martin McKee which found no convincing evidence that physicians’ associates added value in UK primary care or anesthetics.
Of the 29 papers which met the inclusion criteria for the review, some preliminary support was found for ward-based work by PAs when appropriately supervised.
But studies reported that PAs struggled in primary care in the more autonomous roles where decisions were more uncertain and support was limited.
“Very few UK studies have assessed the clinical competence and safety of physician associates or anaesthetic associates,” the authors wrote.
“Findings of apparent non-inferiority in non-randomised studies may obscure important unmeasured differences in quality of care.”
In October last year, Queensland Health closed a statewide consultation on the role of physician assistants in the state’s workforce, after a proposal to expand PAs at some Queensland hospitals attracted outrage online.
The results of the consultation remain under wraps.
Dr Hester told The Medical Republic that expanding the role of PAs in the Australian health system was a “zombie policy” that resurrected when things were looking dire.
“It just keeps bubbling up every few years when our health system seems desperate enough for workforce solutions, but there’s really no coherent strategy that I’ve seen so far,” she said.
“It seems to be a reaction to workforce challenges that many health systems, including Queensland Health, are facing.”
Dr Hester said the findings from the recent BMJ paper were not surprising.
“The PA model is not a particularly wise or a particularly efficient one ... it’s actually a little bit reckless and I think at this point it’s probably clutching at straws,” she said.
“PAs [are] not registered as healthcare practitioners ... In Australia there’s no current established training model for PAs, nor is there any established clinical governance around the use of PAs, either in hospitals or in the wider health system.
“We’ve also seen episodes where
➥ Rural DPA changes have GPs baffled – from Page 1
happen again. We’ll see more and more people that might have been staying in rural and regional areas moving back because the rules allow them to.”
Australia is currently short about 2400 fulltime equivalent GPs, with that figure likely to surpass 4000 FTE by 2030.
Dr Martin acknowledged that the DPA system was not perfect and that it would be preferable to have an incentive for doctors to work
rurally, rather than a mandate.
RACGP rural chair Associate Professor Michael Clements told TMR it had been a challenge for the college to articulate the importance of workforce levers for rural health while aiming for a better system.
“Even just writing a document saying what we think about it was difficult, because our general college position is that we don’t like sticks to try and force people to go rural, because rural communities deserve
PAs have demonstrated profound unconscious incompetence, particularly those alarming reports that have been reviewed by the coroner in the UK, around some very tragic deaths of people who otherwise could have been safely managed.”
PAs have had an ever-expanding role in the UK health system since 2003.
Dr Hester said that there was little use for PAs in Australia and that they were an “all around bad deal for the health system”.
“[The PA model] is another example of very poor policy being imported from the UK,” she said.
“[PAs] have clearly not solved the workforce issues in the UK. I would be of the opinion that their health system is not the better for their use, I’d be very unhappy to see that dilution of the quality of our healthcare system in Australia.
“The answer is really basic, but really clear: we need to train, support and retain high-quality health professionals.”
Dr Hester said that there was a concerning potential for PAs to “cannibalise” some of the work of other health professionals such as
nurse practitioners, allied health and clinical pharmacists.
“The PA role has been very poorly defined and it’s got very poor boundaries. We do see encroachment or scope expansion, which is quite dangerous, but I would say in our healthcare system, especially given the fact that they’re not registered as healthcare practitioners ... their utility is very, very low,” she said.
AMA Queensland president Dr Nick Yim told TMR that the BMJ paper showed that research into PAs was “minimal, outdated and inconsistent in quality, providing inadequate evidence of their safety”.
“Physician’s assistants and other health workers are not a substitute for medical officers,” said Dr Yim.
“AMA Queensland has opposed Queensland Health’s proposal until we can access the workforce data and clinical evidence that supports expanded use of the role.
“Such proposals risk patient safety and essential training opportunities for junior doctors who are our future medical leaders.
“We are also concerned that there is no current training system within Australia to produce physician’s assistants and we would be recruiting an unknown skill set that is not registered nor regulated by AHPRA.”
Dr Yim said ongoing consultation with AMAQ, ASMOFQ and other stakeholders was necessary if PAs were to be implemented to ensure their scope of practice was clear.
“Any expansion of physician’s assistants must be considered as part of a future evidence, data and needsbased holistic workforce plan and not rolled out as another ad-hoc, band aid solution to our medical workforce crisis,” he said.
“The LNP has committed to a health workforce strategy, but we need to see the details.”
somebody that wants to be there,” he said.
“We support incentive programs and support packages that are designed to increase the attractiveness of rural communities … but we’ve got DPA.
“We don’t have a better system yet.
“If we didn’t have DPA, there’s no doubt that our city locations would fill up very quickly.”
RACGP president Dr Michael Wright, who has previously worked in Surfers
Paradise, told TMR that if too many places were classified as priority areas, the program would likely fail.
“The workforce priorities there are different than what they would be in Emerald or Broken Hill, and so having a similar classification makes less sense,” he said.
Former RACGP president Professor Karen Price, meanwhile, criticised the DPA changes on social media, calling the move “disappointing” and a “populist political sideshow”.
PAs may cannibalise some of the work of other health professionals
Union seeks increase for all salaried docs
NSW Health’s biggest fear is coming true as award proposal to the IRC looms
LAURA WOODROW
The Australian Salaried Medical Officers’ Federation plans to submit a draft award proposal that would raise the base rate of all salaried medical practitioners working in the NSW public health system to the Industrial Relations Commission on 4 April.
“We are seeking a single award to cover all salaried medical practitioners [in the public system], not just staff specialists,” ASMOF NSW executive director Andrew Holland told the IRC hearing this month.
The IRC hearing to resolve the ongoing dispute between NSW public psychiatrists and the NSW Ministry of Health began 17 March.
Psychiatrists have called for a 25% pay rise, as well as a commitment to addressing critical workforce issues. NSW Health has offered a 10.5% wage increase over three years, noting that a 25% increase was not affordable.
According to the most recent numbers provided by the government, 206 intentions to resign have been tendered so
far, with 62 processed, 38 withdrawn and 109 deferred.
A total of 72 staff specialist psychiatrists agreed to transition to VMO roles, but only 27 are acting.
The cost of these changes remains undetermined.
Speaking at the hearing, Mr Holland rejected suggestions that the union campaigned for the mass resignation of staff specialist psychiatrists.
“We did not advise, instruct or recommend to submit a resignation,” he said.
Mr Holland said that the 25% pay increase that the union was seeking on behalf of the psychiatrists was “to do with the crisis of a specific subset of specialists” and that there was “no demand for it” and “no claim for it at all” among other specialists.
“Our absolute assertion is that there is no intention to try and seek 25% allowance
➥ New scripts needed for these key medications – from Page 1 she said. “It’s important for all doctors, including GPs and specialists, to note that from 1 May 2025, patients will need a new prescription to qualify for PBS reimbursements.
“Doctors may need to inform their patients about this requirement to ensure access to reimbursement.”
From 1 May, endometriosis medication relugolix with estradiol and norethisterone will be subsidised for patients who cannot get sufficient pain relief from other treatments.
The government estimates 8500 patients, that would otherwise be paying around $2700, will benefit each year.
Speaking to media after the announcement, federal health minister Mark Butler responded to criticism that the government had waited 12 months to act on the PBS recommendation to list the endometriosis medication, which was made on 13 March last year.
“I want to clarify that although the advisory committee did issue a recommendation in March last year, the company exercised its right to take the
matter back to the advisory committee,” he said.
“They weren’t happy with the scope of the recommendation, and so a final recommendation was only listed by the Pharmaceutical Benefits Advisory Committee in January this year.”
Fertility medication follitropin alfa with lutropin alfa is currently subsidised for patients with low levels of reproductive hormones – known as severe folliclestimulating hormone and luteinising hormone deficiency – in late-stage IVF cycles.
It is currently used by an estimated 6000 patients.
The medication will now be subsidised for use earlier in patients’ IVF journeys.
The maximum number of doses per script will also be increased from two to four.
Four doses currently cost more than $3500.
Fertility Society of Australia and New Zealand president Dr Petra Wale said Australia was facing a “fertility crisis”.
“The total fertility rate has fallen to 1.5 babies per women – the lowest
for any other member, staff specialists or otherwise,” he said.
Mr Holland said that the provision was intended as a 12-month “stop gap” to deal with the crisis and that it would be tied to ongoing discussions over improving conditions in public mental health care.
He said that he believed the proposal was drafted in such a way that it would eventually be replaced by a longer-term award agreed to by the commission.
Mr Holland said that, given the media coverage of this dispute, other specialists would be “knocking on our door” if they wanted the union to pursue similar action on their behalf.
“The majority of our members understand the specific, distinct crisis that our psychiatry members and the mental health system are facing.”
Mr Holland said ASMOF was finalising a new draft award proposal that would apply to all salaried medical practitioners working in the NSW public health system.
“We are seeking a single award to cover all salaried medical practitioners, not just staff specialists,” he said.
It is understood that the draft award would include a base rate increase to bring pay parity with other states and on top of that a pay increase that would increase over three years.
Mr Holland said he had to clarify whether the total proposed increase exceeded 25% but to his knowledge the base rate would
be less than 25%. The proposal will be filed with the Commission on 4 April.
Mr Holland said that, should an interim wage increase be granted to staff specialist psychiatrists to resolve the dispute, it would not be intended that the interim pay increase would “double up or double dip” with any eventual base rate award increase.
“I expect it would be the award that provides the more generous provision [that] would apply,” he said.
It is understood that the new proposal would include a “non-private practice option” that would offer a higher base rate but remove the right to private practice.
“It was our attempt to bring to the table the opportunity to say there is money to be saved if you engage with us on effectively removing the current rights of private practice structure,” he said.
There are also ongoing discussions by the union concerning possible industrial action which may occur next month to bring the government “back to the bargaining table”.
Mr Holland said these might include work stoppages.
Senior psychiatrist and clinical director at Royal North Shore hospital Dr Prachi Brahmbhat said that there was competitiveness between states over psychiatrists as a limited resource.
“Unfortunately, [NSW] are losing in that race.”
ever recorded and well below the replacement rate of 2.1,” she said.
“The cost of assisted reproduction remains a major barrier for many families, particularly amid the ongoing cost-ofliving crisis.”
Around 20,000 babies a year are born in Australia though IVF.
National medical director at Adora Fertility Dr Paul Atkinson said the announcement was a “big win” for patients with fertility issues.
“Our patients will now be able to access [the drug] from the get-go, rather than having to first go through the anguish of multiple cycles,” he said.
“More cycles mean more time, and for women up against their biological clock this adds another challenge to the IVF process.”
Drospirenone, a progestogen-only-pill, currently costs around $320 a year.
From 1 May, the contraceptive, which is an alternative for those who can’t take estrogen, will also be subsided on the PBS.
This is expected to benefit around 100,000 people.
Sexual health physician Dr Terri Foran said that that contraception was a fundamental reproductive right.
“Progestogen-only pills are especially suitable for older women, women at increased risk of blood clots, those who suffer migraine attacks, breastfeeding mothers, those who smoke, are overweight, or have high blood pressure,” she said.
“With greater education about contraceptive options and the risks and benefits associated with each, we are seeing increasing use of both progestogen-only birth control methods and the longer-acting methods in this country.”
When asked about the cost of the new announcements, Mr Butler said the numbers would be presented in the budget papers in due course.
“Some of those are subject to commercial negotiations, but this will be covered by the usual PBS budget arrangements,” he said.
Dr Knot renewed calls for a gendered review of the MBS, the PBS and the private health funds.
Union denies campaign for resignations
AHPRA access to PSR records ‘reasonable’
The RACGP has found little fault with the latest round of proposed amendments to health legislation, while still processes can be “stressful” for providers. The Health Legislation
Medicare CEO role grows
Medicare Integrity and Other Measures) Bill 2025 contains a swathe of planned changes, some of which will directly affect GPs.
These include reducing the timeframe to make a bulk-billing claim from two years to one year, allowing
by the Professional Services Review to be used as evidence in other investigations and expanding the powers of Medicare’s chief executive.
According to the bill’s explanatory notes, the current investigative powers are so narrow as
exercise of powers to detect, investigate and refer potential fraud matters”.
The RACGP submission to the Senate Community Affairs Committee inquiry on the bill raised no major red flags on any of the potential changes.
nor the explanatory memorandum went into detail on exactly how the PSR evidence sharing would work, but the RACGP appeared to have a clearer picture.
According to the college, the bill would change the circumstances for when information obtained by the PSR could be used as evidence in other investigations, such as those initiated by AHPRA to allow sharing when there was a significant threat to life, health or non-compliance with professional standards.
These provisions, the RACGP said, “appear reasonable”.
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It did, however, request more information on how the expanded Medicare chief executive powers would work.
“The bill will improve the ability of Medicare’s chief executive to obtain information about potential non-compliance and to more readily ascertain amounts that should not have been paid,” the college said.
“It is intended that this information-gathering power could be relied upon in a broader set of circumstances (e.g. in the early stages of inquiries).
“While the RACGP requests further information about how this expanded power will work in practice, we understand it will not change current compliance timeframes regarding when providers are issued with a notice to produce (i.e. this would not occur before the audit stage).”
The college also noted that the majority of doctors submitted MBS claims either immediately or in the weeks and months following the provision of a service, and would likely be unaffected by the lodgement timeframe being lowered to one year.
The Medicare chief executive and the health minister will also have discretion to allow claims to be made outside the timeframe in extenuating circumstances.
HOLLY PAYNE
Why microdosing GLP-1s is not OK
At best patients will be wasting their money, and there are risks for prescribers too
HELEN TOBLER
Experts have warned against the practice of microdosing GLP-1 receptor agonists to make a single injector pen last longer, saying patients risk losing clinical benefits, compromising the stability of the medication and wasting their money.
Many patients have reportedly reacted to the cost of the popular weight-loss drugs by shrinking their doses to extend the lifespan of one GLP-1 injector.
But patients who microdose or “clickcount” and use a pen device for two months rather than one were doing so “outside the recommendations of safe and effective use of medications”, said Dr Terri-Lynne South, chair of the RACGP’s obesity management specific interest group.
Dr South said microdosing to extend the lifespan of one GLP-1 pen was “definitely” happening in Australia and was absolutely offlabel use.
“There are theoretical risks in regards to stability, shelf life and effectiveness of the medication if it’s used outside what has been a registered therapeutic device and use of medication,” she said.
“And if people are doing this without the recommendations of a healthcare professional,
Microdosing flies in the face of the evidence of the efficacy trials, doctors say
the concern is that they’re not actually getting what they need clinically.”
Dr South noted that there was a “huge variability in clinical response” among different patients to GLP-1 medications.
“Some people can still have significant clinical response, whether that’s weight loss or cardiometabolic risk factor reductions, at lower doses than what has been shown in the trials or promoted as TGA recommendations of prescriptions,” she said.
“If an individual prescriber is saying, ‘Hey, you don’t need to go up on your Mounjaro because you’re having a fantastic clinical response’, that’s within normal prescribing guidelines and is supported.”
But Dr South said that was an entirely different situation to a patient independently deciding that they wanted to have a very small dose for weight management.
“I don’t recommend it. If someone came to me and told me what they were doing, as
a healthcare professional it’s about harm minimisation, and for that patient in front of me to understand what the pros, cons and risks are in that respect,” she said.
“In some clinical situations, I might agree that they don’t need a higher dose for what they’re trying to achieve, but I wouldn’t be recommending that people are trying to get more medication out of their device outside those recommendations.”
Dr South said clinicians needed to be aware of the potential medicolegal risks if they continued to prescribe GLP-1s knowing that patients were taking lower doses than recommended.
“I think there can be some medicolegal risks around a prescriber who willingly is prescribing a greater dose than what the patient is taking in order to manipulate the pen devices, but that’s a very different clinical situation to prescribing lower doses that are still having an appropriate therapeutic effect.”
Dr Gary Deed, chair of the RACGP’s diabetes specific interest group, said microdosing “flies against the evidence of the efficacy trials”.
“The indications not only show the efficacy and the type of patients you should use it on, but also the doses that have been proven.”
Dr Deed said microdosing was not scientifically validated.
“Basically, you’re addressing cost rather than the clinical condition for which it’s indicated,” he said.
There was no evidence that microdosing had non-glycaemic or cardiovascular benefits in overweight or obesity or people with cardiovascular disease, he said.
“The clinical benefits of these classes in emerging studies have not been validated at microdosing,” said Dr Deed.
Dr Deed said the “least harmful outcome” for patients would be a waste of money.
“The risk is that you’re financially impairing yourself for minimum benefit and outcome and exposing yourself to side effects without any benefits.
“When we use any medication, we’re balancing the risk versus benefits, or risk versus efficacy. And if you’re going to reduce the efficacy by using inappropriately low doses, you reduce the risk-benefit ratio, and you’re having to still pay some considerable amount of money to obtain the medications.
“It may emerge over time that studies may support this, but currently, as they’re indicated in the Australian environment, there isn’t evidence to support people microdosing.
“We certainly wouldn’t start a microdosing of medications unless there was some extraordinary indication for it, but that would be under a specialist or clinical trial situation.”
Renewed push for ADHD prescribing rights
HOLLY PAYNE
The RACGP has doubled down on its push for GP-led prescribing of “essential medicines for people with ADHD”, even as the specialist psychiatry college calls for caution.
Earlier this month, the RACGP called on all political parties to commit to allowing GPs to prescribe stimulant medicines for ADHD in the lead-up to the federal election.
The call specifically cited the election, although it should be noted that it is state and territory legislation that governs which prescribers are permitted to prescribe which medicines in each jurisdiction.
As such, GP prescribing powers vary across borders.
Late last year, the federal government
GP prescribing varies across borders
did support a recommendation that the commonwealth use the health ministers’ meeting to expedite the development of uniform prescribing rules to ensure consistency.
The health ministers’ meeting has not released any communiques or meeting minutes for 2025 so far.
“In some states, people can get treatment for ADHD from their GP, which means less frequent visits to the psychiatrist or paediatrician, while those living in other states experience delayed care due to long
specialist waitlists,” RACGP president Dr Michael Wright said.
“We recently applauded the West Australian government for committing to the reforms we called for to allow specialist GPs to diagnose and prescribe stimulant medication for ADHD.
“In Queensland, skilled GPs can prescribe ADHD medications for four- to 18-year-olds, and we’re calling for better access to care for adults.”
GP care for ADHD is a move that the Royal Australian and New Zealand College of Psychiatrists supports, up to a point.
“The best care is shared - multidisciplinary, holistic, and tailored to the individual,” RANZCP president Dr Elizabeth Moore told The Medical Republic.
Treatment, she said, went beyond just medication.
“This is where psychiatrists play a crucial role as they are uniquely trained to assess,
diagnose, and manage the condition, especially when comorbidities like anxiety, depression, or substance use disorders are involved,” Dr Moore said.
“Given the complexity of ADHD, any move to expand prescribing must come with specialised training for GPs and ongoing clinical oversight from psychiatrists with ADHD expertise.
“That way we can ensure that people get the right diagnosis, the right treatment and the right support from their treating practitioners at all times.”
She also cited state-by-state inconsistencies in ADHD management and ongoing medication shortages as barriers to care which required considered reform.
While neither of the major parties has made a commitment on ADHD, the Greens have pledged $181 million for ADHD and autism assessment items, which would be billable by GPs.
Treat men to prevent bacterial vaginosis
Sexual transmission really does play an important role in recurrence
MARIELLA ATTARD
GPs should start treating male partners of women with bacterial vaginosis who are in a heterosexual, monogamous relationship, the RACGP chair of the sexual health special interest groups has told The Medical Republic
The evidence from a new study conducted at the Melbourne Sexual Health Centre and published in the New England Journal of Medicine is enough to change treatment immediately, Dr Sara Whitburn, who was not involved with the research, said.
“If you are seeing someone who’s having recurrent, relapsing bacterial vaginosis, and if they are in a monogamous heterosexual relationship, I do think that this article supports a change in treatment,” Dr Whitburn said.
The change will also require some patient and pharmacist support.
Bacterial vaginosis affects at least 12% of nonIndigenous and 30% of Indigenous women in Australia, and more than half of those treated will have a recurrence within three to six months.
The condition increases the risk of acquiring
HIV and STIs, and, in pregnancy, early labour, low birth weight and miscarriage. It affects quality of life and is a significant burden on the health system.
The standard treatment has been to give the person presenting with bacterial vaginosis metronidazole or clindamycin 2% vaginal cream.
But the new research confirms the condition is sexually transmitted, and giving male partners oral and topical treatment (both are required) can interrupt the cycle of reinfection.
The researchers compared recurrence of bacterial vaginosis in two groups of female partners in monogamous heterosexual couples within a period of 12 weeks.
In 81 couples, females were given standard treatment and males were given concurrent oral and topical treatment – metronidazole 400mg tablets and a 2cm diameter volume
of 2% clindamycin cream, applied to glans penis and upper shaft, under the foreskin if uncircumcised, both twice a day for seven days.
In the control group of 83 couples only women were treated.
The trial was ended after 150 couples (69 in the treatment group, 68 in standard care) had completed the 12-week follow-up because the control group results were clearly inferior. The infection recurred in only 35% of the women in the treatment group, and in 63% of women in the group where the men were not treated.
Recurrent infection took a mean of 74 days to show up in the treatment group and just 56 days in the control group.
All the women and 86% of the men took at least 70% of their prescribed doses, with the lowest rate of recurrence in the partners of men who took all their treatment.
No serious adverse events were reported.
“Efforts to increase the likelihood of cure have been hindered by an incomplete understanding of the pathogenesis of bacterial vaginosis, although epidemiologic and microbiologic data show that it has the profile of a sexually transmitted infection,” the authors write.
Previous interventions in male partners which didn’t show a reduction in recurrence for the female partner used small samples, didn’t assess adherence to treatment and, importantly, used only oral antimicrobial agents to treat the men, “which may not be sufficient to clear cutaneous penile carriage of bacterial vaginosis-associated organisms,” the authors said.
“In order to promote clearance of BVAB (anaerobic BV-associated bacteria) from the male partner both oral and topical antibiotic therapy will be required. BVAB are detected in the distal urethra of males, a location well accessed by oral but not topical antibiotics. In contrast, the sub-preputial space and coronal sulcus (under the foreskin and in the groove under the head of the penis) are poorly reached by oral but well accessed by topical antibiotics.”
The topical treatment for men, clindamycin, was the same as the cream used for women, Dr Whitburn said.
“But you’re actually prescribing it for the person with the penis to put on their penis. So there will be some patient education required because of the way the prescription looks.
“Also, we’ll be wanting to support our pharmacy colleagues with information around what it says on the prescription.
“What I’m planning to do with my change of practice is probably print out the information from the Melbourne Sexual Health Centre and give it to the patient, or send a note or ask them to say to the pharmacist to give me a call, because I do think there will have to be some communication around this change.”
The evidence currently supports a change of practice only for that specific group of patients – those with bacterial vaginosis, who are in heterosexual, monogamous relationships – but Dr Whitburn said that studies were coming in the LGBTQI+ population.
“And it is probably worth discussing this study with people that don’t have monogamous relationships,” she said. NEJM, 5 March 2025
New clotting disorder defies anticoagulants
A new blood clotting disorder has been identified, with Australian researchers playing a vital part in determining the underlying mechanism.
The research, published in the New England Journal of Medicine, describes five patients who displayed unusual and persistent blood clotting after receiving high doses of blood thinners while being treated in New Zealand, Germany, Spain, France and Canada.
All patients displayed low serum levels of antiplatelet factor 4 antibodies similar to those seen in cases of vaccineinduced immune thrombocytopenia and thrombosis (VITT) – which had previously been linked to the AstraZeneca covid vaccine – for over a year.
The ongoing presence of the antibodies suggested there was an underlying pathological process involved, rather than these patients experiencing a shortterm reaction to a vaccine or adenovirus infection.
Dr Jing Jing Wang (PhD), a senior research fellow from the Flinders Health and Medical Research Institute and co-first author on the new publication, led efforts to examine the antibodies to determine how the new clotting disorder was different from “classic” VITT cases.
“By using our proteomic approach developed at Flinders Proteomics Facility, we [proved] that the monoclonal (M) proteins are the pathological VITT-like antibodies,” Dr Wang told media.
“Low-level serum M (monoclonal) proteins are often identified in patients who have VITT-like MGTS [monoclonal gammopathy of thrombotic significance]. Despite these M proteins being in
relatively low concentrations, they are highly pathological VITT-like proteins, which explain the patients’ severe symptoms.”
“We all remember those difficult times during the pandemic when the vaccine was linked to the rare, sometimes lethal clotting complication called VITT,” said SA Pathology’s Professor Tom Gordon, a clinical immunologist, rheumatologist and immunopathologist.
“This was initially thought to be selflimiting over days and weeks. [But] the major jump in knowledge coming from this new study is that a highly similar chronic condition – over months and years – can occur with patients presenting with intermittent clotting episodes.”
While thrilled by their discovery, the team is already looking forward to what happens next.
“By understanding how to diagnose
VITT-like MGTS, we can develop more effective treatment strategies that go beyond traditional anticoagulation,” said co-first author Emeritus Professor Theodore Warkentin, from McMaster University in Canada.
Researchers anticipate these findings will change how doctors test and treat patients who present with unusual or recurrent blood clotting, which may lead to improved outcomes.
“We propose that diagnostic testing for unexplained chronic prothrombotic disorders be expanded to include testing for anti-PF4 antibodies, as well as testing for M proteins,” the researchers wrote.
“[The anti-PF4 monoclonal paraproteins] are usually detectable on standard, commercially available PF4dependent ELISAs, but they cannot be identified on rapid assays for heparininduced thrombocytopenia antibodies.”
NEJM, 12 February 2025
LINCOLN TRACY
Change will require patient support
Which of these four bulkbilling models is right for GPs?
Doctors trying to work out if the new bulkbilling incentive will work for them, now have a few groups out there trying to help
JEREMY KNIBBS
CATE SWANNELL
Within weeks of prime minister Anthony Albanese announcing $8.5 billion of new Medicare money, largely to entice GPs to shift back to doing more bulk billing, we have so far counted four separate models (one not publicly available unfortunately) competing for GPs’ attention.
The models have been created by groups with very different backgrounds in finance and modelling: the Department of Health and Aged Care (which unfortunately isn’t being made available to anyone to check or to use to help assess the worth of shifting a practice’s private billing/ bulk-billing profile; a technically and potentially financially adept interested GP (Dr David Fong); a business analytics platform subscribed to by the majority of GP practices in the country (Cubiko); and a long-time (and sometimes controversial) practice advisory principal and accountant, David Dahm.
All the models have the same premise: GPs can use this to work out to what extent, if any, they shift the profile of their practice, or their sole trader business if they are an independently operating tenant doctor, to more or full bulk billing.
DOHAC’S MODEL
The DoHAC model is the easiest to dispense with because for reasons so far not explained, and which certainly put some sort of cloud over the whole policy, the department will not make their model or methodology available publicly.
All that DoHAC has so far released are some very high level examples for three sizes of practice, with no real input variables for anyone to get a sense of what they are doing to arrive at the conclusion that everyone is going to love this new incentive and switch over time to the point where nine out of 10 consults are bulk billed by the year 2030.
There’s a very obvious question here of why not be transparent and release the model if you think it’s so great, which, so far, hasn’t been answered.
On this basis, the DoHAC model can’t and shouldn’t be used. It’s not a model that anyone can trust or assess until the department lets everyone know what it is actually doing.
If GPs trust this model, they will essentially need to rely on the word of a politician: “Trust us, this works, we modelled it …”
The only reason the government might be able to get away with this is that before the prime minister even finished his grand announcement press conference in Launceston, the opposition had come out and said they’d match the policy.
It’s not exactly the blind leading the blind, but it’s certainly the opaque and cunning leading the blind, none of which helps a practice owner or tenant GP work out sensibly what to do about the offer.
A GP’S MODEL
Dr David Fong is a smart and engaged GP who took an immediate interest in the new policy and developed and published his own model providing a lot of detail on inputs and methodology and a chance for a GP or practice owner to use their own inputs to come up with some actual insight into what they might do.
Dr Fong says that his model “demonstrates the effect of pre-existing gap-fees, the proportion of patients which would normally be privately billed and the inclusion of different non-referred general practice service items into the estimated profitability of adopting the proposed bulkbill incentive program”.
He provides some pretty good examples
,The DoHAC model can’t and shouldn’t be used. It’s not a model that anyone can trust or assess until the department lets everyone know what it is actually doing.
for everyone to get a sense of what he is doing and how – generationally better and more informative than DoHAC’s go at providing us with examples.
Dr Fong goes into quite a bit of detail on how his model works and has published his model code for anyone to take and try their inputs for themselves.
We make a couple of observations here, and did reach out to Dr Fong for clarification but had not heard back by deadline:
• The model seems to only focus on the revenue side of a switch equation. It doesn’t take into account costs, which other models do. We are not saying this is better or worse.
• The model only appears to be for those making a decision on whether to go back to full bulk billing or not, nothing in between. This is useful but for some practices, tweaking their mix between private and bulk billing will almost certainly be a consideration they will be thinking about.
• You need to understand how to run and execute software code (not a lot but some, which might be an issue) to test the model using your own inputs.
Dr Fong’s model feels like a useful one to look at and try, especially if GPs can run the code themselves or have an IT friend.
He is at least giving GPs the basics of his methodology and inputs, and with that he’s miles ahead of anything DoHAC has put out.
All the models have the same premise: GPs can use this to work out to what extent, if any, they shift the profile of their practice
PRACTICE ADVISORY AND ACCOUNTANT
Long-time practice advisory principal, accountant, and chief payroll tax stirrer, David Dahm, has taken the view that you can’t model the real-world impact unless you take into account costs along with revenue, and then more.
In particular, he takes into account the tax implications for a practice or tenant doctor in changing the profile of how much they mix bill, but he also goes into some interesting detail on other key metrics such as volume of bulk billing to FTE ratio.
The other reason an owner or tenant doctor might want to try Mr Dahm’s model is that he isn’t asking anyone to run stuff through software. He is publishing a series of benchmarks on costs and revenues per FTE that someone can simply take and do their own maths on, pretty easily.
The only question someone might have of Mr Dahm’s modelling is: “Where did all these benchmarks come from, and can we trust them?”
Mr Damn told The Medial Republic the data comes from 30 years of working with literally hundreds of practices and thousands of doctors – all de-identified of course.
In other words, he seems to be making public a lot of his accounting IP over the years, which is something he couldn’t have done on a whim, and which looks like it is the polar opposite to DoHAC’s secret-squirrel approach to modelling the new incentives.
Mr Dahm’s view of DoHAC’s decision to not to release its modelling is pretty dim.
“What possible reason could they have to cloak their methodology and inputs?” he asked.
“Surely on something so systemic and important to the future of Medicare everything should be on the table so owners and GPs can make the best decision for the future of their businesses.
“That’s one reason I’ve been happy to make a lot of hard-earned IP public in my modelling. Decisions around what you do as a result of this policy will make or break a lot of practices into the future is my feeling.”
Spoiler alert: Mr Dahm has run the model on a lot of practice and tenant doctor scenarios, and he doesn’t like what he sees.
Some David Dahm detractors might point to his obsession with the effect of changes to GPs’ bulk-billing profile that this policy is clearly incentivising and tax.
But any owner or tenant doctor who thinks that potentially serious tax cost implications might arise from this new policy probably should have a good read through the commentary Mr Dahm provides with his model and then decide what they think.
BUSINESS ANALYTICS PLATFORM MODEL
Cubiko, which is a subscription-based business analytics platform integrated into most major practice management systems, has also launched its Medicare Incentive Modelling tool.
Cubiko’s data analysts have developed a dashboard that models the potential impact of those new incentives on practice revenue.
According to the company announcement, the tool analyses a practice’s actual historical billing data, applying the new incentives at the individual item level.
The other question is: Does Cubiko model costs comprehensively as well as revenue, as Mr Dahm claims his model does, and does Cubiko go anywhere near trying to model potential tax impacts?
It’s unlikely, but that does not necessarily make the Cubiko model flawed in any way.
It feels like it will be another interesting
This provides an assessment of how these changes could impact practice revenue and long-term financial sustainability.
Additionally, the new dashboard provides practices with a perpractitioner view of bulk billing and service mix.
“One of the biggest things we’re finding is that while having the numbers and the model is important, it’s just as crucial to understand the impact on practice culture,” founder and CEO Chris Smeed told TMR
An interesting aspect of Cubiko’s modelling product is that the group told everyone it was working closely with DoHAC on developing their model.
Was this a good thing or bad thing, though?
If DoHAC won’t release its modelling to anyone, and so far every interested GP, expert and analyst in town who has done the numbers can’t come up with what DoHAC has come up with – that masses of practices will change their mixed billing profile and bulk billing will make a huge comeback – what did they tell Cubiko to model?
and useful point of input for owners and tenant GPs out there who are starting to worry that the government pitch of “relax, change your profile and let the good times flow…” might be a tad simplistic.
NON-MODELLING CONSIDERATIONS
There are some things that are impossible to model, but which are vital to consider anyway.
Top of that list is: does anyone think that, given the track record of both the government and the opposition on indexing Medicare rebates properly, that this new splash of bulk-billing money will be indexed properly as we move forward? History says no it won’t.
In fact, you could look at the last 20 years, look at how it has been indexed against the total CPI in that time, inject that into your own model, and you should be able to do a calculation of how long it might be until whatever financial advantage you gain from changing your profile to get maximum advantage from the new policy is denuded by this problem.
Does anyone think this new splash of cash will be indexed properly over time?
PBS system an ‘unnecessary brake’ on good health care
A lack of bilateral agreement is causing authorisation to stagnate
EUAN KIELLY
The inefficiency of the PBS authority system is slowing down GPs and having a collateral impact on patients, the National Audit Office says.
The current system has faced nationwide criticism for its inefficiency for some time, with a recent audit by the ANAO making seven recommendations designed to streamline the system.
Newcastle GP Dr Max Mollenkopf told The Medical Republic reform was long overdue.
“The government wants to have the PBS go through a series of steps to provide purposeful friction points to stop what they would see as over-prescribing or an abuse of the system,” he said.
“What you find is speaking to an operator, they will override whatever problem is stopping you. So, on the digital system, when you come to a roadblock, you have no choice. I have no override. I have no way to get past it.
“It’s still a handbrake. It’s still an unnecessary brake. It wastes huge amounts of time.
“It’s entirely unnecessary, and every time I have to get on the phone or two-factor authenticate my way through a series of screens to then somehow satisfy a random bureaucrat, a non-clinician, is a waste of time that I could be spending with patients.”
The reported inefficiency stems from the administration of the system, with it requiring repeated log-ins with various levels of authentication before actual usage.
This has caused stagnancy in the system with the ANAO reporting that PBS suppliers have uncertified claims totalling over 1.5 billion as of June 2024.
This has been caused by a lack of bilateral agreement from Services Australia end with Health Australia having agreed to answer authority requests within 30 seconds.
In contrast, Services Australia reported in its annual performance statement that the measured performance target for answering said calls was within 15 minutes.
Services Australia also reported that, for monthly quality checking of authority approvals, 0.5% of approvals were selected for investigation.
,Dr Max Mollenkopf
“On the digital system, when you come to a roadblock, you have no choice.”
The agency’s telephone system recognises a completed call as when it has been transferred.
This means that a single phone call, from a caller’s perspective, may be counted as two or more phone calls for performance reviewing purposes, each measured at individual wait times.
The PBS measure does not account for this miscalculation.
The PBS system is designed to provide cheaper medication, with the authorisation system being used to regulate the process.
While it is effective in that respect, many GPs have expressed frustrations with the system’s lengthy processes that many feel are hindering their productivity in patient care.
The RACGP’s Health of the Nation Report found that dissatisfaction with the amount of administration for GPs increased from 60% in 2023, to 70% the following year.
This comes alongside 62% of GPs expressing how improved and streamlined administration services would benefit innovation.
The system previously ran entirely via phone before the introduction of a digital system to reduce user congestion and, in theory, shorten wait times.
Most GPs embraced the digital processing, with the phone system use dropping from 70% in 2022-23 to 54.5%.
However, this digital alternative has created further hinderance for some, with the rejection rate for digital applications being more than double compared with phone applications (5.6% vs. 2.3%).
Outside of GPs, this administrative friction is having a collateral impact on patients, especially those with repeat prescriptions.
Melioidosis cases surge after flooding
Sixteen people have died in Queensland from melioidosis and more than 100 cases have been reported – three times the number in the same period last year, according to Queensland Health.
And in the wake of tropical cyclone Alfred, more Australians could be at risk and should take precautions, Dr Thomas Jeffries, senior lecturer in microbiology from the School of Science at Western Sydney University, told media.
Living deep below the soil, the bacterium Burkholderia pseudomallei comes to the surface during flooding, becoming airborne in heavy rain, and infecting people through sores, cuts, inhalation or through drinking water.
Melioidosis symptoms include headache, fever, chest and muscle pain, trouble breathing, confusion and seizures. The bacterium is resistant to many commonly used antibiotics and treatment requires hospitalisation.
While the disease is rare in Australia, it kills around 90,000 people around the world each year and has a 20 to 50% fatality rate.
The recent deaths happened in the Townsville and Cairns regions, where there has been major flooding. Most of the fatal infections were due to inhalation of airborne droplets, Dr Jeffries said.
“Generally speaking for tropical diseases, we’re seeing a southward and a northeastward spread because of increasing temperatures due to climate change. So there’s no reason that I see why that disease couldn’t be spreading in a southward direction to the subtropics.”
The bacterium that causes melioidosis is endemic in the soil and water across northern Australia, including parts of Queensland.
“Thanks to tireless public health campaigning, residents of the NT’s tropical Top End, a global melioidosis hotspot, are very familiar with melioidosis – they know that cases spike following severe wet weather events, similar to what north Queensland has experienced this wet season,” Associate Professor Erin Price, a principal research fellow at University of the Sunshine Coast, said.
But while the current rate of cases in Queensland was “a cause for concern but not alarm”, it was also “unprecedented”, she said.
“Increased public awareness about melioidosis risk factors and symptoms, coupled with rapid diagnosis by public
health laboratories, are crucial for rapid diagnosis and effective treatment of this potentially fatal disease,” she said.
People with diabetes, kidney problems, take immunosuppressants or were heavy drinkers were more at risk, Dr Trent Yarwood, an infectious diseases physician at the Australian Society for Infectious Diseases, told media.
“If patients (particularly vulnerable ones) are not getting better after seeing their GP, then it is worth considering melioidosis during the wet season,” he said.
There were three melioidosis vaccines in train, Dr Jeffries said, but human trials had not yet taken place.
Meanwhile, experts advise wearing protective clothing such as gloves and boots when around mud and to avoid pressure-spraying hard surfaces without a mask.
MARIELLA ATTARD
The rejection rate for digital applications is more than double that of phones
Urgent care clinics are forever, says Butler
The minister isn’t willing to sit on his hands while awaiting an independent evaluation
LAURA WOODROW
Medicare urgent care clinics will “continue well into the future”, says federal health minister Mark Butler, arguing that cost-effectiveness should be modelled against emergency departments not general practice.
“This program is working, there is no doubt about that,” the minister told media earlier this month. “This program is going to be a permanent feature of Australia’s healthcare system. Whether the evaluation comes to us with some suggestions about changes to the way in which the program operates, remains to be seen.”
The federal government this month announced it would invest $644 million in opening 50 new bulk-billing UCCs during the 2025-26 financial year, despite the lack of evaluation of the 87 currently in operation.
According to the government, 80% of Australians will live within 20 minutes of a UCC once the new clinics are opened.
As reported by The Medical Republic, the RACGP has maintained its stance against continued investment in UCCs.
The college raised concerns around the cost
So far, evidence of the benefits of UCCs has been largely anecdotal
of UCCs compared to general practice.
Speaking at a media conference, Mr Butler said the college was using “the wrong comparator” and referenced a HealthEd survey published last year.
“With respect, I have a disagreement with the college of GPs on this,” he said.
“I want to point out that in a big survey last year, 70% of GPs said this program was a good program, and 80% of GPs said it was having a good impact on local emergency departments.
“I think the college of GPs is wrong about this.
The proper comparator is not the price of a standard consult a GP might have on a weekday.
“The proper comparator is what it is costing for people to end up at emergency departments ... because we know the vast majority of people who go through these UCCs tell us they would otherwise end up at a hospital ED, particularly on the weekend or after hours.”
When asked why the government was spending millions more on a policy that had not yet been evaluated, Mr Butler said “because there’s a clear demand for this”.
“I have no doubt this program will continue well into the future in Australia. We [were] one of the very few countries without an urgent care clinic program.”
The minister noted the 15,000 UCCs in the United States – arguably not the health system to use as a benchmark.
“The UK, New Zealand and Europe operate them as an integral part of the healthcare system, that sit between a standard general practice and a fully equipped hospital emergency department,” he said.
“The evaluation will help us tweak the program or provide some changes to its design, as would be appropriate given this is a new model of care for Australia, but I’m not going to sit on my hands and see this enormous demand for urgent care
out in communities ... while we await that independent evaluation.”
So far, evidence of the benefits of UCCs has been largely anecdotal.
However, Mr Butler said some semi-urgent and low-acuity ED presentations had decreased by as much as 10 to 20% in areas with UCCs.
When asked by TMR where the data came from, DoHAC said: “ED hospital data is publicly available on the AIHW website.
“Publicly available AIHW hospital ED data shows there has been a decrease in semiurgent and non-urgent ED presentations across a number of hospitals that are supported by Medicare UCCs.”
The office was unable to provide a list of said hospitals, or examples, prior to the publication deadline.
Mr Butler said he was confident in the attractiveness of the UCC model to staff but was working to address shortages.
“We just had a terrific discussion with the operators of this UCC [in Wyong] about some of the challenges they have – not because of the attractiveness of this model; it’s a really attractive place to work as a doctor or a nurse; I get that feedback all over the country – but some of the system barriers and hurdles that communities like this have in attracting GPs,” he said.
“We don’t have enough people coming into general practice, and certainly that provides downstream challenges in staffing areas like the emerging UCC network.
“But we’re working very hard to make sure that in addition to more UCC and more bulk billing, we are delivering more doctors.”
DoHAC targets GLP-1 docs for compliance
Doctors prescribing semaglutide on the PBS for patients who haven’t previously accessed the PBS for type 2 diabetes drugs are on the receiving end of the DoHAC’s latest compliance campaign.
The targeted education campaign has gone out to around 1000 doctors representing the top 10% of semaglutide prescribers whose patients have no prior history of diabetes, the department confirmed with The Medical Republic.
Semaglutide, which is part of the GLP-1 receptor agonist class of drugs, has been available on the PBS as Ozempic (Novo Nordisk) since mid-2020, for type 2 diabetes only.
The PBS listing is authorityrequired, with clinical criteria stating
that semaglutide must be used in combination with either metformin, a sulfonylurea or insulin, that the condition must be inadequately responsive to either metformin, a sulfonylurea or insulin and that the patient must not have achieved a clinically meaningful glycaemic response with an SGLT2 inhibitor.
Patients who have a contraindication or intolerance to SGLT2 inhibitors also fit within this cohort.
PBS treatment criteria also require that patients not be undergoing concomitant PBS-subsidised treatment for diabetes with an SGLT2 inhibitor, DPP4 inhibitor or another GLP-1 RA.
RACGP diabetes spokesman Dr Gary Deed told The Medical Republic there was concern about PBS prescribing of a restricted medication that did not fit the funding model.
“The PBS has limited funding … [and
while this] doesn’t reflect the efficacy of the medications, it reflects the fact that there are high costs-per-unit,” he said.
“In the explosion of prescribing of these agents – possibly around the efficacious nature of them in diabetes, but also their indication for overweight and obesity – the government’s funding has found some problems, and we need to put a cap on it, because it can run into millions of excess expenditure.”
Dr Deed stressed that the DoHAC letter was not punitive and instead represented an opportunity for education.
Alternative semaglutide formulation Wegovy (Novo Nordisk) is TGAapproved for weight loss, and is not listed as being in shortage in Australia. It is not on the PBS.
“That’s a reminder to people that [semaglutide formulations are] still available on private script, at a
significant cost to the person,” Dr Deed said.
“At the end of the day, it’s something you have to work with on a clinical basis with each individual patient … [and also note that] none of the studies of these agents in type two diabetes or in overweight and obese … involved some lifestyle change or calorie restriction where appropriate.”
Lifestyle interventions for pre-diabetic patients, he said, “well exceeded” the effects of pharmaceutical agents.
Semaglutide’s famed weight loss side effects, coupled with manufacturing issues, put the drug into shortage worldwide from 2022.
The Therapeutic Goods Administration predicts that it will remain in shortage in Australia throughout 2025, although the US Food and Drug Administration has recently declared its shortage as resolved.
HOLLY PAYNE
Spine injections are no benefit for chronic pain
No well-informed patient would want to undergo such an intervention, a new guideline suggests
LINCOLN TRACY
An international expert panel has called for a list of interventional procedures for chronic spine pain to be used only in research settings. Interventional procedures such as epidural injections and nerve ablations have become common in the management of chronic spinal pain, yet the evidence supporting their use is tenuous at best.
Now, a new set of clinical guidelines, published in the BMJ, concludes that 13 commonly used procedures for spinal pain offer little to no benefit on pain relief and other important outcomes when compared to sham treatments.
“Despite the common use of spine injections in pain clinics around the world, it has been hard to come up with evidence that strongly supports this practice when applied to chronic back pain... The research and guideline recommendations are worthy of attention,” Professor Jane Ballantyne, an anaesthesiologist from the University of Washington, wrote in an accompanying editorial.
The international panel consisted of 10 healthcare professionals with experience in managing chronic spinal pain (a mix of anaesthesiologists, rheumatologists, physiotherapists, rehabilitation specialists, and epidemiologists), as well as four people with lived experience of chronic spinal pain. The individuals with lived experience
had undergone a range of interventional procedures for their pain.
Importantly, no panel member had any financial conflicts of interest or had any strong opinions on the use of interventional procedures for chronic spinal pain at the outset of the process.
The panel undertook a systematic review of more than 130 trials – and network metaanalysis of some 8000 patients across 80-plus trials – of 13 different interventional procedures on eight outcomes, including pain relief, physical functioning, return to work, opioid use and opioid events.
Procedures examined as part of the review included epidural, joint-targeted and intramuscular injections of local anaesthetic and/or steroids, dorsal root ganglion radiofrequency and certain nerve ablation procedures.
“There was no high-certainty evidence of
,Professor Jane Ballantyne “It is never easy to change entrenched culture, and injections have undoubtedly become entrenched as a key component of pain clinic treatments.”
important pain relief (or benefit on any other effectiveness outcome) for any intervention for either chronic axial spine pain or chronic radicular spine pain,” the panel concluded.
“[In addition,] all interventional procedures supported by moderate or low-certainty evidence showed little to no pain relief compared with sham procedures.
“All or nearly all well-informed people would likely not want such interventions. Such interventions should not be offered outside of a clinical trial.”
Professor Ballantyne felt the findings brought into question whether it was reasonable to continue to offer these procedures to patients.
“Chronic back pain is highly prevalent, a great deal of money is spent on the injections and a lot of patients’ hopes and expectations are vested in this type of treatment,” the former chief of pain medicine at Massachusetts General Hospital in Boston wrote.
“[But] it is never easy to change entrenched culture, and injections have undoubtedly become entrenched as a key component of pain clinic treatments.”
However, Professor Ballantyne noted that broader changes to healthcare funding systems might help change how spinal injections were viewed and used.
“There are many pressures on providers to keep doing spinal injections, and on payers for paying for them, but the more the evidence fails to support the widespread use of these injections, the less inclined healthcare systems will be to fund them,” she said.
“[These findings] will not be the last word on spine injections for chronic back pain, but it adds to a growing sense that chronic pain management needs a major rethink that is perhaps best achieved by a better balance of reimbursements between procedural and nonprocedural chronic pain treatments.”
BMJ, 19 February 2025
AI scribe could rival the trusty stethoscope
LAURA WOODROW
Clinicians are harsh critics when it comes to AI technology.
Speaking at the Australian Healthcare Week conference earlier this month, Tom Kelly, CEO and co-founder of AI scribe service for doctors Heidi Health, said the margin for success as a tech producer in healthcare was slim.
“If doctors have to edit their notes more than about 5%, they never use the tool ever again,” he said.
“It’s completely visceral.”
The only way to work out if a product would fly was by getting it in the hands of doctors, he said.
“The really tricky thing about building a product in this space is that the differences between the products are invisible to everyone except doctors.”
Mr Kelly said that due to the technical nature of the output, only doctors were able to effectively recognise the accuracy.
He said the reason for the success AI scribes were that they took on a task that doctors were really opposed to.
According to Mr Kelly, one in five GPs in the UK were using Heidi every day.
“The UK is one of the slowest adopting
technology markets, it’s extremely difficult,” he said.
“The NHS is centralised and complicated to sell into.”
Mr Kelly said that the pace of uptake was broader among GPs than in hospitals.
“That level of adoption is unheard of, there aren’t many tools that doctors use that often. Maybe a stethoscope but not much else.
“I think the reason that we’ve seen so much adoption is fairly straightforward.
“The burden to provide really good health care for a patient is always growing, because we’re getting better and better at figuring out how to micromanage different conditions, how to diagnose different
variations and do genetic testing and find things earlier than we used to.”
The number of care hours per patient was therefore increasing, Mr Kelly said.
“You combine that with longer living populations and clinicians being burnt-out in general, it’s not that surprising to see that people are looking for solutions,” he said.
“I think in the future, AI will obviously be ubiquitous. It will be in every product, tool, service that we use.
“I’m very excited to see which solutions or approaches win. There’s lots of different opinions. I think so far from our experience, there’s definitely a lot of room to make a better product.”
Dr Tim Senior
Remember your colleagues working at the Deep End
GPs can provide extraordinary care for their least well off patients, but not if they’re drowning themselves
At a time of undervaluing and uncertainty for general practice, we all need some inspiration.
I got mine last year when I visited GPs in England, Scotland and Ireland on a Churchill Fellowship, courtesy of the Winston Churchill Trust.
My unusual opportunity was to talk to many GPs in depth about their work and to sit in and watch them with their patients.
It wasn’t the state of the health systems in these countries that inspired me, it was that these GPs found ways to keep working with their patients despite the system. They loved their work, and the possibilities that it gave for keeping their patients and communities well. They were passionate, and they were highly skilled. They had a profound respect for their patients, and were supported by expert teams of other health professionals.
I was visiting GPs working in different socioeconomically disadvantaged communities – so called Deep End GPs. As Professor Graham Watt, who founded the first Deep End GPs network in Glasgow, told me, “GPs don’t think so much about health equity. We think about how much we could do for our patients if we had enough resources.”
This hits on a truth. No GPs are doing it easy at the moment, either in the UK, Ireland or Australia.
However, health systems across the world consistently operate on the inverse care law – that those who need health care the most get the least. In Australia’s health system, unlike England’s or Scotland’s, GPs can charge patients directly to make up the shortfall in funding available from governments.
This is why my focus has been on Deep End GPs, working in socioeconomically deprived communities, often Aboriginal and Torres Strait Islander, often rural and remote. Imagine what we could do for those patients if we had the resources.
I returned to Australia with optimism. We really do have highly skilled GPs here, who want to provide really high-quality care to their patients and frequently, are doing this even without adequate support from the health system.
We need to respect the expertise of Deep End GPs, and by extension all GPs
This is especially true in disadvantaged communities. I’m also optimistic because the RACGP Health of The Nation report has consistently showed that GPs, like myself, working in Aboriginal Community Controlled Health Services have the most job satisfaction among all GP settings.
This shows that GPs aren’t the greedy, substandard professionals we are often portrayed as in the media, but that with the right setting and teams around us, including programs that act locally to alleviate adverse social determinants of health, we provide really high-quality care in complex circumstances, valued by our patients and our communities.
There’s that elusive quintuple goal that health policy experts are aiming for – right under our noses!
Many of the people I heard from and the services I observed in fact reiterated the value and values of primary health care time and time again.
Effective care was relationship-based: GPs knew and understood their patients well, and they knew the local areas’ geography and services. They provided comprehensive care and were the first point of contact, managing the vast majority of their patient’s problems in the community. They worked in teams and co-ordinated care across the complex health system.
We know all this, of course. Seeing it in action, though, is what inspires me. The sudden smile on a patient in Plymouth fed up in hospital when she realises the person coming towards her on the ward is the GP she knows well.
A patient in Dublin visibly relaxing when told by the GP he knows well, “I’m not going to tell you off. I’m not your grandma.” The GP able to
maintain rapport with an 18-year-old woman recently out of prison, who isn’t changing her drinking habits – yet.
So I’ve returned to Australia optimistic because I’ve seen the effectiveness of the principles of primary health care and general practice, and I know these principles are understood and acted on in Australia, certainly across the Aboriginal Community Controlled Health sector, but also in good quality general practice anywhere in Australia.
My recommendations for my Churchill Fellowship report are made so we can provide GP care in socioeconomically disadvantaged communities.
This is important because these are the communities that need us most, but where general practice is least sustainable, and where the Australian health system struggles the most. If the recommendations are widely understood and implemented, then all of general practice and all of our patients stand to benefit.
One of my recommendations is one that we can and should be doing straight away. It’s to look out for our colleagues. We should recognise our colleagues who are working in the Deep End, as well as others who are in danger of becoming overwhelmed. We should be aware of those who are struggling to recruit colleagues, who might be submerged by their daunting mental health workload, who are doing most of the housing forms and Centrelink certificates, who have many patients with complex multimorbidity, and who see most of the patients who don’t have enough money for co-payments for specialists or even for the GP.
We need to recognise these GPs, we need to make sure they are supported and helped. Just
being acknowledged and recognised doesn’t solve these problems, but it certainly helps.
Many of my recommendations are for those of us and our colleagues with roles in PHNs, academia, education, the colleges and advocacy and policy work.
Health policy needs to have a socioeconomic lens, as well as looking at Aboriginal and Torres Strait Islander health or rural and remote health on its own.
There’s a lot of overlap, but we do run the risk of leaving those of our colleagues working in poorer areas of rural towns or the poorer areas in our cities completely unsupported if we don’t do this.
We need to be able to support local action on social determinants of health.
PHNs may be ideally placed to do this, but there’s a growing movement relating to social prescribing in Australia which can contribute, provided the social infrastructure and third sector are resourced in deprived areas too.
We need to develop a skilled Deep End workforce, developing the skills specifically useful in disadvantaged communities – skills in multimorbidity outside of the elderly, disability care, multicultural consulting skills, psychological effects of poverty, dealing with Centrelink requirements, individual patient advocacy, extended mental health and trauma informed care all spring to mind.
We need to recruit workforce specifically to disadvantaged communities, and support them so they stay.
Finally, my most important recommendation is the one that shouldn’t need saying. We need to respect the expertise of Deep End GPs, and by extension all GPs.
We are regularly talking to our patients.
The skills we use to manage the complex combination of physical, mental and social circumstances, manage undifferentiated symptoms which could be anything from life threatening pathology to no pathology at all, and to do effective preventive health care, all while intentionally developing rapport with someone who doesn’t want to be there and doesn’t trust the health system.
That is skilled work, and it saves lives.
This is why I remain optimistic and proud of my profession. I invite you all to join me, in looking out for our colleagues and advocating for changes that will benefit us all.
Tim Senior is a GP at Tharawal Aboriginal Corporation, the Aboriginal Community Controlled Health Service at Campbelltown in southwest Sydney, and co-chair of the RACGP’s specific interests group on deprivation and poverty. He travelled on a Churchill Fellowship last year.
2 INDICATIONS, 1 VACCINE1,2
INFANTS via maternal immunisation*
ADULTS aged ≥60 years†
ABRYSVO is recommended in the Australian Immunisation Handbook to help protect both infants,* via maternal immunisation, and adults aged ≥60 years† against respiratory syncytial virus (RSV).2
NOW NIP-FUNDED FOR PREGNANT WOMEN 3
*Active immunisation of pregnant women at 28–36 weeks gestation. 1,2
†Active immunisation of adults aged ≥75 years, Aboriginal and To rres Strait Islander adults aged ≥60 years, and adults aged ≥60 years with risk fact ors for severe RSV disease. 1,2
Help protect 2 populations at risk of RSV with 1 vaccine1,2
Scan to view RSV recommendations
This vaccine is subject to additional monitoring in Australia. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse events at www.tga.gov.au/reporting-problems.
ABRYSVO is listed on the NIP for pregnant women (28–36 weeks gestation) only and is not listed on the PBS.
Before prescribing, please review the Approved Product Information by scanning the QR code. ABRYSVO should be used in accordance with official recommendations.1,2
ABRYSVO® (recombinant respiratory syncytial virus pre-fusion F protein) 120 micrograms/0.5 mL bivalent vaccine powder for injection vial and diluent syringe
Indications: Active immunisation of pregnant women (24-36 weeks gestation) for prevention of lower respiratory tract disease caused by RSV in infants (birth through 6 months); Active immunisation of individuals (60 years and above) for prevention of lower respiratory tract disease caused by RSV. Use ABRYSVO in accordance with official recommendations. Contraindications: Hypersensitivity to the active ingredient or to any of the excipients. Precautions: Appropriate treatment and supervision must be readily available in case of a rare anaphylactic reaction. Consider the risks of intramuscular injection in thrombocytopenia or coagulation disorders. Postpone in acute febrile illness. Anxiety-related reactions including syncope can occur following/before any vaccination. Immunocompromised individuals, including individuals receiving immunosuppressant therapy, may have a diminished immune response. No studies in pregnant individuals <24 weeks gestation. Protection may not be conferred in all individuals. Not for active immunisation in children. See PI for details. Interactions with other Medicines: Can be administered concomitantly, at different injection sites, with seasonal influenza vaccine and COVID-19 mRNA vaccines. Immunogenicity data indicated non-inferiority in immune response to RSV, diphtheria and tetanus components compared to ABRYSVO or dTpa administered alone. Immune response to the pertussis component of dTpa was lower in concomitant administration than dTpa administered alone. The clinical relevance of this is unknown. See PI for details. Adverse Effects: Headache, myalgia, vaccination site pain, vaccination site redness, vaccination site swelling, Guillain-Barré syndrome, hypersensitivity. See PI for details. Dosage and Administration: Single (0.5 mL) dose. For intramuscular use only. See PI for details. V10324.
References: 1. ABRYSVO Approved Product Information. 2. Australian Immunisation Handbook. Respiratory syncytial virus (RSV). Available at: https://immunisationhandbook.health.gov.au/ contents/vaccine-preventable-diseases/respiratory-syncytial-virus-rsv. Accessed February 2025. 3. National Immunisation Program Schedule. Available at: www.pfi.sr/nipschedule. Accessed February 2025.
Abrysvo® is a registered trademark. © 2025 Pfizer Australia Pty Ltd. Sydney, Australia. All rights reserved. Pfizer Medical Information: 1800 675 229. PP-A1G-AUS-0270. ABR-003122-16. February 2025.
Peter Breadon
Health system needs to target the consumers who can’t pay
Linking health funding to the needs of people and populations is something many other countries do much better than Australia
To make profits for shareholders, ASX200 companies work hard to maximise value. They target consumers who can pay.
To maximise value for taxpayers, Australia’s health system must do the opposite: target consumers who can’t pay.
Those are the people who need healthcare the most, and where healthcare can make the biggest difference.
Without it, they will get sicker, which means more suffering, more healthcare, fewer productive years of life, and ever-growing costs for government budgets and the economy. Annual taxpayer investment in healthcare dwarfs the revenue of any listed company. Governments spent $179 billion on healthcare in 2022-23 – that’s more than the revenue of BHP, Woolworths, and Qantas combined.
But while corporations get ever more sophisticated, using data and advanced models to zero in on niche markets and set individualised prices, governments allocate capital for healthcare in much the same way as they have for decades.
In a persistent and perverse pattern, taxpayerfunded care is skewed towards the healthiest and the wealthiest.
Disadvantaged areas have around twice the level of psychological distress, compared with the richest. But the richest neighbourhoods get about twice as much mental health care funding from the Medicare Benefits Schedule.
In GP deserts – the places with the lowest level of primary care, such as parts of Canberra –people are twice as likely to go to hospital with a condition that might have been prevented with primary care.
And the parts of the country where people die earliest get less care from specialist doctors than richer, healthier places.
In the 1970s, a Welsh GP, Julian Tudor Hart, described the problem as the “inverse care law”. He observed that when healthcare is a commodity, it is distributed like champagne: rich people get lots, and poor people get none. Health is far from a commodity in Australia, with our mixed public-private market, but we still have champagne problems.
The public sector must get much better at investing for the biggest impact.
The bulk of public funding either follows the clinician, wherever they prefer to live and work, or the hospital infrastructure, wherever it’s been built. And the billions of dollars in subsidies for private health insurance don’t shift care to those who need it most.
This approach hasn’t changed much since the 1970s, when we lacked the tools to identify and meet need with pinpoint accuracy.
But governments are increasingly awash in data about illness and healthcare. It’s time to start putting it to work and to focus funding on individuals and communities.
Primary care is a prime candidate.
Today, about 90% of funding for general practice comes in transactional, fee-for- service payments.
Payments are tied to GPs’ time, not patients’ needs or the best way to deliver care. The AMA has just called for more than a billion dollars a year to be added to GP fee-for-service payments.
But two expert reviews have recommended that 40% of funding be shifted from those payments to flexible budgets for each patient a GP clinic cares for.
This would let clinics spend more time planning and improving care, deliver care in
new ways, and fund a wider range of clinicians, such as allied health workers or pharmacists.
The budgets would be adjusted for individuals’ needs: higher for patients who are sicker and have greater health risks, such as being poor or old.
This would allow clinics to expand in areas where patients can’t afford to pay fees but have higher rates of chronic disease – exactly those with the most to gain from better primary care.
The federal government has made a start, providing small additional payments for clinics that care for patients who live in aged care homes, or visit hospital frequently. But much bolder change is needed to make the system fairer, and more efficient, and to get to the 40% target the expert reviews recommended.
There are plenty more examples. Many parts of Australia have extremely low levels of specialist care, vaccination, and GP care. All of that is clear in data that governments hold.
Yet we persist with obstinately data-blind, broad-brush approaches to allocating funding across the system.
To fill those gaps, we should allocate health budgets according to the needs of the populations in different areas.
In a persistent and perverse pattern, taxpayer-funded care is skewed towards the healthiest and the wealthiest.
To start, governments should draw a line in the sand and set a minimum acceptable level of care, then allocate money to fill the gap in areas that miss out year after year.
Increasing productivity is the enduring economic challenge for Australia, and for the health system. There is a lot to do, from making sure healthcare workers use all their skills, to harnessing AI to improve care and make it more accessible, to pivoting to prevention policies to keep people healthier. But making the health system fairer is a productivity fix that rarely gets mentioned.
Linking health funding to the needs of people and populations is something many other countries do much better than Australia. It represents both good values and a good investment, so it’s time to take the blindfold off.
This article was originally published by the Grattan Institute.
Peter Breadon is the Health Program Director at Grattan Institute. He has worked in a wide range of senior policy and operational roles in government, most recently as Deputy Secretary of Reform and Planning at the Victorian Department of Health.
Disadvantaged areas have twice the level of psychological distress than the richest
David Gardner
AHPRA is flawed and fallible — but not out to get you
It’s not faceless bureaucrats who are the harshest judges. The quest for reform must start elsewhere.
Grey’s Law tells us that: “Any sufficiently advanced incompetence is indistinguishable from malice.”
Those words seem uniquely well attuned to health practitioner regulation, because the decisions can have such substantial and adverse effect on an individual, practitioners feel that the decision must be personal and the result of some sort of deliberate malice.
That could not be further from the truth.
The better explanation is a combination of the difficulty of the job, combined with government inefficiency and ideological differences, and with some incompetence sprinkled in for flavour.
It is also because you are a faceless name on a spreadsheet. You are an invisible person whose entire existence has been boiled down to a handful of issues that have been “identified for investigation”.
You are not a human, you are a notification number.
It is not that the system is tainted by hatred, malice or bias – rather, it is that the system is not human enough.
Sometimes when I read outcome letters from AHPRA, it feels very much like ChatGPT has determined the outcome, because it feels so impersonal and so detached from the individual whom it concerns – a practitioner who I know to be caring, skilled, and thoughtful.
The reason I say all of this is that so often I see people advocating for things that won’t fix the system at all. To know what sorts of reforms might work, we need to accept a few truths before we can move forward.
MOST OF DECISIONMAKERS ARE DOCTORS
There are exceptions, such as the Ombudsman and the Health Care Complaints Commission, where decision-makers may not be doctors – but the medical boards are always comprised primarily of doctors. They are not bureaucrats. Seeking to put power back in the hands of doctors will not work, because the power is already in the hands of doctors.
Doctors are the harshest decision-makers about other doctors. Some apply impossibly
high standards to their colleagues, and do so without any legal training that might assist in making their decision-making more impartial and fair.
REGULATORS THINK THEY ARE DOING THE RIGHT THING
This applies to all regulators – the staff at AHPRA (I have been one) and the decision-makers on medical boards believe that they are doing the right thing. They want to help and they want to protect the public. They are not doing this out of malice, or to harm doctors.
This is really important to know. Often people threaten to go to the media with something that AHPRA has done – but this is never effective against someone who believes they are doing the right thing. If you have done something good, why would you care if someone runs to the media about it?
I say this as I have been the person on the other end of the phone with an upset practitioner telling me I had bad intentions and was trying to cause them harm. When they told me I was “a shill for Big Pharma” (sadly my cheques must have been lost in the mail), I would simply switch off – because I knew that this was not true. I was there because I believed what I was doing was for the benefit of society. The same is true of almost all of my former colleagues there.
I can assure you – it is very rare that anything that AHPRA or the Medical Board do is as a result of actual malice.
Rarely it will happen, typically with higherprofile matters. The case of Dr William Bay is a good example of where there appears to be a level of deliberate targeting (the Supreme Court found that there was an “animus” towards him), and I will be writing about that case soon – but it is the exception, and not the rule.
SYSTEM DOES A LOT OF GOOD
I have previously written about this, but it’s important to remember. The National Register is one of the most advanced public registration systems for health practitioners in the world. The vast majority of registration matters are dealt with very quickly. Most notifications have the appropriate outcome, in a reasonably timely manner. Our health regulation system is one of the safest in the world.
These successes mean that we should not simply burn the whole thing down and start again – we did that already with the statebased boards in 2010. If AHPRA is abolished, something else will need to rise in its place –and then that regulator will take many years to work out what its job is and how to do it (AHPRA has been in place for 15 years and often still does not know what it is doing).
SYSTEM CANNOT DEAL WITH COMPLEX MATTERS
Complex matters are the ones that damage the whole system.
Many performance matters are complex, and they are the ones that I have observed as being the most problematic.
For example, it can be exceptionally hard to determine whether a complication that arises in surgery is the fault of the practitioner or not. I have seen matters where experts line up on both sides and give unequivocal evidence that the practitioner is absolutely at fault, and that the practitioner is absolutely not at fault.
What is a regulator to do in that circumstance?
IDEOLOGY PLAYS A MAJOR ROLE
If there is a particular approach to an area of medicine that is favoured at board level, practitioners who disagree with that approach and use another approach are likely to be treated far worse than others. This leads to ideological “wars”, such as the forceps vs vacuum debate in obstetrics.
This means that practitioners who practise in certain areas of medicine, or in certain ways, are far more likely to suffer adverse outcomes because they do not have a seat at the table.
SO WHAT DO WE DO?
I propose that we focus less on the people involved in the system, and more on the system itself.
We should look at the specific outcomes that we find problematic, and work through what kind of systemic changes will fix those problems – rather than focusing on the individual people making decisions. This makes finding solutions much harder, because we cannot simply replace individuals in power – but my hope is that by attacking the root systemic causes of the problem, we will be able to effect change that is lasting, and can help remove the fear that practitioners feel when they see an email from AHPRA land in their inbox.
I’d be interested to know what you think are the most problematic outcomes that we need to tackle.
For me, it is delay, weaponisation of complaints, and the poor management of performance-based matters – but let me know your thoughts in the online comments section.
David Gardner is a lawyer, and a former manager and investigator at AHPRA. In addition to his legal practice, he is the director of AHPD, a new CPD provider of high-quality education to doctors on largely neglected nonclinical topics.
Doctors identified for investigation are not human, they are notification numbers
LIFE
Associate Professor Louise Stone MODERN
Stuff I know about doctors’ health
Here are a few things that should be demanded of anyone who is responsible in the health system
As the editor of an international text on sexual harassment in medicine, I’ve learned a few things about doctors’ health.
I also have a few decades of experience mentoring, treating and working with doctors who are struggling. I’ve just spent a day at a meeting discussing the psychosocial health of doctors. At the meeting, we saw an impressive framework, comprehensive documents and a lot of focus on large organisations. However, it seemed to me that we failed to respect the role of power in maintaining poor behaviour at the top of the health edifice.
There are good reasons why young doctors are overworked and underpaid, and it has nothing to do with their individual skills, capacities or resilience.
I used to love the book Everything I ever needed to know I learned in Kindergarten by Robert Fulgham.
He has a way of reducing things to their essence. He talks about the “simple rules” we learn at kindy, which are in fact “the distillation of all the hard-won, fieldtested working standards of the human enterprise”.
So here is my take on some of the things Fulgham describes. This is what we should demand of everyone who is responsible for the healthcare system.
DON’T HURT PEOPLE
Teaching by humiliation is not on, and neither is humiliating others to make yourself seem more important. Stop arguing, stop criticising each other in public and for goodness’ sake, make sure any romantic relationships you have with colleagues are consensual. And none of this senior-to-junior-relationships nonsense. It’s just not on.
There has been too much nastiness, and it’s not helpful. Stop the insults. No more “clinical marshmallows”. No saying GPs are “twits”.
How on earth does an intern feel safe if
the leaders of the health system are so, well, rude? If you can’t say something nice about health workers, don’t say anything at all.
CLEAN UP YOUR OWN MESS
I was listening to the discussion about psychosocial safety, and GPs were mentioned twice.
GPs were there to look after the students’ health needs and provide GP terms to help residents detox from lousy hospital culture. The rest of the time they were invisible. Hospitals, health departments and other large institutions don’t get to shove the trauma they inflict down the garbage chute to the GP swamp.
It is not our job to sweep up when the parade of hospitalists have created an unholy mess. We have enough emotional labour to manage as it is.
I am exceedingly happy to see medical students, and doctors in training. But don’t see me as the solution to psychosocial safety throughout the entire health system.
PLAY FAIR
If you’re a leader, manager or policy maker, don’t bite off more than someone else can chew.
There is a nasty tendency to make sweeping announcements of new, shiny,
services before shattering public trust by delivering an understaffed, under-resourced pale shadow of the promised nirvana. It just means the politicians get the praise while the clinicians cope with the blame.
The public and the media eviscerate clinicians who fail to live up to an impossible standard, and I wonder whether this is the point. By promising the impossible, the politicians get to be magnanimous to the voters, and can scapegoat the professions, implying their failure to deliver is due to a lack of education, motivation or moral fibre.
Shoving more into the GP curriculum, announcing a new item number or implying that GPs have an attitude problem (I’m looking at you, Ged Kearney, with your “medical misogyny” bandwagon) is a nasty strategy. Be fair. Don’t promise something you won’t resource.
And for general practice?
Don’t promise bulk-billing GPs and then reduce our resources, reallocating our budget and the more lucrative jobs to others. That’s just nasty.
DON’T TAKE THINGS THAT AREN’T YOURS
Don’t redirect money, from, say, public psychiatry and redirect it to appease the lobbyists in other areas.
There is only so much money to go around, and it is a government’s responsibility to allocate this as fairly as possible. Playing favourites with taxpayer money is wrong.
We all know a celebrity with a common, visible disease like breast cancer will drive all sorts of philanthropic and government investment. However, diseases that are invisible, embarrassing, stigmatised or rare, like ulcerative colitis, hepatitis or anal cancer will struggle to get appropriate funding.
I was reminded of this when I realised the falling-down weatherboard building that housed a truly world-class respiratory team at my medical school was razed to make way for the cancer centre car park.
To give you an even better example. My PhD looked at medically unexplained symptoms. Trust me, there will never be an invisible ribbon day or a fun run for people with medically unexplained symptoms. It’s all a problem of prestige.
High-prestige diseases get more funding. People who treat high-prestige diseases with high-prestige technologies are well supported and well paid (think neurosurgery for brain cancer).
People who treat low-prestige, lowtechnology chaos (think general practice) are overworked, underpaid and undervalued. And while some are celebrated
for their procedural skill, others are undervalued for hands-on caring, which to me is a gross misunderstanding of the skills required for both. Overworked, undervalued teams are not psychosocially well. After decades of underappreciation, some eventually become quite nasty.
So, how about someone has the guts to stop overconsumption of resources for the rich and privileged, and redistribute resources on a more equitable basis?
SHARE
Professionalism is all about trust: as professionals we should increase (not decrease) trust in our profession. Good doctors, who communicate well, are competent, and make sure they respect all comers increase trust. Lousy communicators with terrible skills and biased attitudes clearly decrease trust.
So, shouldn’t we all share the benefits AND the responsibility of the system? Shouldn’t we all be accountable?
Bluntly, should there be an AHPRA for politicians, bureaucrats and managers who reduce trust in healthcare by overpromising and underdelivering? It causes harm, not only to the doctors, but also to the public who receive substandard care from burned out, overworked, disillusioned and depressed clinicians.
Stop it. It’s not fair.
TELL THE TRUTH
If “the way we do things around here” is clearly different to written policies, fix the policies. Otherwise, you are just lying.
WATCH FOR TRAFFIC, HOLD HANDS AND STICK TOGETHER
Stand up for your colleagues. Be an upstander, not a bystander. If necessary, take a leaf out of the book of the psychiatrists, and walk away from systemic abuse.
And while we are at it, don’t tell me some fancy new digital product “is what consumers want” if every single consumer you’ve spoken to is a well-educated, well-resourced, white Australian.
I have never yet been in a
committee with a consumer who can’t read. It’s time we optimised the system for the people who really need it. I bet the system would become simpler and easier to navigate. So, stand up for your own rights, and for those who have no voice.
LIVE A BALANCED LIFE
Learn some and think some and draw and paint and sing and dance and play and work
every day some. There is still a role for self-care. It is just not the antidote to systemic abuse.
BE AWARE OF WONDER
I think I have the best job in the world. When I lose that perspective, as I definitely did recently, I take my rage into the garden and bury it. Rage and frustration and bitterness destroys my health and my effectiveness. When I go back to the
coalface, into my consulting room, I meet people I deeply respect. There I find the purpose, meaning and wonder in the privilege of care, and I recharge. Thinking of patients, including doctor-patients, gives me the strength to stand up against systemic abuse. It gives me the courage I saw in the NSW psychiatrists. Doctors deserve better than the disdain and disrespect that has become
commonplace in our health system. It is my hope that the seniors in the system defend that right for our junior colleagues, who are much more vulnerable to bullying, harassment, scapegoating, overwork and disrespect. We are the only ones with the power to defend them, and they deserve better.
So, for those of us who get to be “in the room where it happens”, expect kindness, and hold everyone accountable for
demonstrating it, in their words, their policies and their behaviour.
Otherwise, we are part of the system where the most junior, and the least privileged are deeply vulnerable.
And that is unacceptable.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
Indication5: SHINGRIX is indicated for the prevention of herpes zoster (HZ) and post-herpetic neuralgia in: adults 50 years of age or older, and in adults 18 years of age or older at increased risk of HZ. Contraindication 5: Hypersensitivity to the active substances or to any component of the vaccine.
This medicinal product is subject to additional monitoring in Australia. This will allow quick identification of new safety information. Healthcare professionals are asked to report any suspected adverse events at www.tga.gov.au/reporting-problems.
References: 1. Weinberg A, et al. J Infect Dis. 2010;201(7):1024–30. 2. Centers for Disease Control and Prevention (CDC). Prevention of herpes zoster: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2008 June;57(RR-5):1-30. 3. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook, Australian Government Department of Health and Aged Care, Canberra, 2022. Available at: immunisationhandbook.health.gov.au [Accessed August 2024] 4. Gidding HF, et al. Epidemiol Infect. 2003;131(3):1085–9. 5. SHINGRIX Approved Product Information.
For information on GSK products or to report an adverse event involving a GSK product, please contact GSK Medical Information on 1800 033 109. GlaxoSmithKline Australia Pty Ltd. ABN 47 100 162 481. Melbourne, VIC. Trade marks are owned by or licensed to the GSK group of companies. ©2024 GSK group of companies or its licensor. PM-AU-SGX-JRNA-240011. Date of approval: September 2024.
For Australian Healthcare Professionals
Go back to basics: women aren’t safe
If we don’t advocate to the point of pain, half the population will keep living in danger
Ispend all day advocating for patients. That is general practice. We advocate for the wellbeing and rights of our patients and most of us will see it as a fundamental duty.
I am advocating every time I call a specialist or hospital angry, frustrated from long wait times for appointments, or delayed care, or unsafe discharges, or “GP to follow up” recommendations, or denied referrals.
I am advocating every time I write a passiveaggressive-aggressive-largely-aggressive letter to bullying workplaces, specifically noting I have recommended involvement of the Fair Work Commission.
I am advocating every time I support a patient’s request to get a second opinion. I am advocating when I offer (unfairly) divisive clinical services like medical terminations of pregnancy.
Every time we arrange an interpreter, even though the consult will be harder and take longer, we are advocating for the patient’s right to their language and culture.
Every time we protect the confidentiality of an at-risk teen and refuse to disclose irrelevant information to their overbearing parent, we are advocating for the needs of the child. Whether you call it that or not, we are absolutely advocates.
During my specialist GP training many years ago, I was offered advice that forever changed the way I practised. A senior GP said: “Give your patients the kind of care that you would want your parents to get.”
Thereafter, I held back not one iota in advocacy for my patients.
I have no interest in colluding with problematic people and systems or pandering to unsafe doctors with dangerous egos.
As GPs, we take ownership of our patients – and how can I treat people and families for decades if I don’t care enough to advocate for their needs and rights?
I have to advocate for my patients and believe that some other doctor is out there advocating for my family. I do what I need to, in order to make sure my patients and I share in safety, respect and trust.
One of the best things about GPs is that we’re often advocates for each other, too.
My LinkedIn feed, text messages and emails
are full of inspiring GPs advocating for the sustainability of general practice, or Medicare rebates that are actually worth the work we do.
There are GPs leading massive advocacy to control the climate crisis, the single biggest threat to human health. You want to be a good doctor, but you don’t want to vocalise and act on behalf of the environment, that’s too much? How? How’s that fair or logical?
There are doctors out there, fighting the fight for all of us, even when so many will quietly sit in the corner afraid to voice and support, or worse, are completely indifferent.
And … isn’t that feminism, too? Aren’t some of us risking our reputations and personal safety and unfair comments and offensive judgments in our efforts of advocacy for all women?
Haven’t we said this again and again and again – that we are not fighting to force subscription to our lifestyles by others – we are fighting for the choice.
I don’t mean superficial choices such as colour in gender norms, or the right to retain our name after marriage (although yes, obviously freedom in these choices is essential). I mean the choices you can make when you have the right to basic education and literacy, and advanced education to bear a
high-paying job, financial independence from early womanhood and the right to be heard. The right to safety does not exist today for women. It does not exist.
Do you understand the anger? The tears, the frustration, when women tell you that we are still fighting for the right to safety?
I don’t have freedom in decisions, I don’t meaningfully have choice, if I am still afraid to walk to the car alone at night in the staff carpark. I am a high-achieving, high-earning, English-speaking doctor who even still is not given the privilege of safety. And if it impacts even me, imagine the threat to safety borne by all the women who are less privileged.
And by the way, if you think it’s “not all women” who worry about their safety, let me firmly tell you: boy, you are wrong.
Have I veered off on a tangent?
No. If we are still fighting for women’s rights as basic as safety, then we are failing. We are not advocating hard enough, frequently enough or dangerously enough.
We’re all feeling it – unsettled, that the world is moving backwards. There are pockets of certainty and comfort within the large and increasing spaces of conflict and division and danger. This is a very worrying state to be in, right now.
,As GPs, we take ownership of our patients – and how can I treat people and families for decades if I don’t care enough to advocate for their needs and rights?
There’s a reason the 2025 International Women’s Day (March 8) theme was “Accelerate Action”, to “highlight the urgent need to drive gender equality through bold, decisive actions rather than slow progress”. There is a clear, obvious, universal threat to women’s safety.
Surely you must know how hard it is to put my name at the end of a piece like this, aware that I have many roles and responsibilities, even if I preface with the cop-out disclaimer that “views are my own”?
Please don’t sit back, allowing a numbered few to do the heavy lifting when it comes to fighting for our rights and for fairness. I beg of you. Make your advocacy strong and loud. Be brave in your advocacy.
The braver you are, the braver I can be.
The braver we are, the safer we are.
Dr Pallavi Prathivadi is a Melbourne GP, member of the Eastern Melbourne PHN Clinical and Practice Council, and GP Lead of the RACGP Academic Post cohort support and education program. She holds a PhD in safe opioid prescribing and was a Fulbright Scholar at the Stanford University School of Medicine. She is studying creative writing at Harvard University’s Division of Continuing Education.
There are doctors out there fighting the fight for all of us
Dr Pallavi Prathivadi
LEARNING
Dr Imaan Joshi
The menowars ... that weren’t
The So Hot Right Now menopause conference generated some heat, but also some light
When I attended the So Hot Right Now event recently, it was largely to support an O&G colleague (Dr Talat Uppal) and a GP colleague (Dr Angela Kwong).
As a longtime follower of some of the international speakers – Drs Mary Claire Haver (O&G), Kelly Casperson (urologist) and Vonda Wright (orthopaedic surgeon) – and being aware of the controversies they’d been involved in on social media, I admit I wasn’t sure what to expect.
I went in prepared to say NO to woo and the use of prescription medications in a nonevidence-based way.
Instead, I found myself inspired for myriad reasons with relatively little to arouse my scepticism.
It seems timely to write about this just after International Women’s Day, with statistics showing women live to around 83 years yet their healthspan, even in the developed world, is closer to 63 years.
What is healthspan? The concept dates at least back to JFK who said in 1963 that it was “not enough for a great nation merely to add to the years of life. Our object also must be to add new life to those years”.
The healthspan gender gap includes some statistics that we are all taught in medical school without much focus on prevention: women are twice as likely to suffer from osteoporosis as men and are more likely to have incontinence, which increases falls risk; these together increase the risk of frailty and inability to live independently into our old age.
There is inequality between the genders in health even if you don’t talk about hormones, which this conference was primarily about: menopause and the many ways in which we are failing our female patients globally, in large part because we were never taught about menopause and life beyond it.
As a former accredited O&G trainee, it was eye-opening for me to think back to my decade in training and remember the intense focus on reproduction, including fertility and health in pregnancy, and the neglect of other aspects of a woman’s life, such as perinatal anxiety, postnatal depression, health and fitness while breastfeeding and then menopause and the decades beyond this crucial life stage. Attendees at the conference were 99% female, unsurprisingly; but among them
was great variety: O&Gs, psychiatrists who work with women affected by perinatal anxiety and postnatal depression, nutritionists and dietitians as well as pelvic floor physiotherapists and of course, specialist GPs.
I’ve written about my own experience with perimenopause and the struggle I had getting help for it – not because my GP didn’t want to help, but because neither he nor I picked up on these symptoms, which began around age 43, because they were atypical, as they can be in women of colour.
So, I suffered for years until I tried MHT last year. It’s not perfect, and it is a work in progress, but I’m better than I was and I’d hope to be able to give women better help than I got due to lack of knowledge and information.
It was wonderful to listen to Drs Haver, Casperson and Wright talk about issues we’ve not really talked about much in Australia, with a strong focus on: “What else besides MHT do we need to talk to our patients about?”
Dr Haver, who is an O&G by training but who seems to do mostly menopausal health now, was an engaging speaker who declared her conflict of interest (including selling supplements in the US, but not here) and talked about wanting to age differently from her mother, who recently had a serious fall.
Dr Casperson reminded us to examine patients when needed, as often what’s thought to be a UTI isn’t.
It reminded me of my experiences with
female patients over the years with genitourinary syndrome of menopause that leads to so much misery for so many women – many of whom are not even examined before being treated for presumed UTIs, often for months on end, even when their urine is sterile. In one case I picked up a vulval cancer; she and her male GP had not examined her for a year due to embarrassment.
She spoke too about the safety of vaginal oestrogen even in women with a history of breast cancer.
Just recently I had another breast cancer survivor whose male oncologist again said no to vaginal oestrogen, despite my providing her with the latest research on its safety in breast cancer survivors for longterm use. Given her frustration and the impact on her life, I suggested it might be time to consider a second opinion.
Dr Wright for me was the highlight, with her focus on bone density in women, which she would like to improve so we don’t all end up “in my OR, where I have to put metal in you”.
She’s an oncology nurse turned orthopaedic surgeon who focuses on multidisciplinary teamwork for women who want to age well and remain independent all their lives.
For those of us who’ve been doing this a while now, in (I admit) a somewhat ad-hoc fashion, the conference, organised by Sydney northern beaches GP Ceri Cashell, was a reminder to work on better systems to serve
As GPs we are often in a rush, but it is easy to remind patients to eat well, get enough protein, ditch the yoyo dieting and lift weights. ,
our patients and to focus more on all the other things besides MHT to consider.
As GPs we are often in a rush, but it is easy to remind patients to eat well, get enough protein, ditch the yoyo dieting and lift weights. Even if it seems impossible to fit in with the rest of their lives, it’s all worth making space for.
As with smoking cessation, I need to allow enough time at the initial consultation to go over diet and exercise in more detail and to ask about mood changes as well as the physical changes we all know to ask about. Then at review, we ask again. And we ask. And we ask. And we nudge if that is needed. All told, it was an unexpectedly wonderful day, despite the fact that it was Ramadan and I was not eating.
Yes, there was also some more controversial talent; but as qualified healthcare practitioners, I’d like to think we are able to look for our own evidence or ask the speakers to cite their references.
The point of medical conferences is provide evidence, established and emerging, and ask some questions that we don’t ask in the everyday flow of medicine.
Ultimately it was a multidisciplinary meeting of practitioners who were there to learn what they can do better to help women and to establish a referral network. I walked away feeling hopeful, excited and full of ideas to help myself and my patients.
Dr Imaan Joshi is a Sydney GP; she tweets @imaanjoshi
There is inequality between the genders in health even if you don’t talk about hormones
Bird flu: Don’t panic, but do get the flu vax
If it is a pandemic, we are preparing well, says one immunisation expert
MARIELLA ATTARD
Australia does not yet have the strains of bird flu causing problems in the US and Europe.
But birds fly, people travel and we’re understandably nervous.
The virus has spread from wild birds to poultry, cattle, rats, farm cats, indoor cats and, rarely, humans.
So, are we looking at a pandemic?
“All the elements are there for it to happen. At the moment it hasn’t, and let’s hope that continues,” Dr Gary Grohmann, board member of the Immunisation Coalition and adjunct professor at the University of Sydney, told The Medical Republic.
Australia has not had a homegrown case of avian flu strain – influenza A virus subtype H5N1 clade 2.3.4.4b. – causing so much concern overseas. (The bird flu detected on Victorian poultry farms is H7N8.) And we are keeping an eye out, with a dedicated high pathogenicity avian influenza (HPAI) preparedness taskforce coordinating industry, wildlife, health, environmental and scientific activity to stay on top of this biosecurity risk.
“It’s a potentially serious situation, and we just need to keep monitoring, keep preparing, and not panic; neither the farming community nor the community at large,” Dr Grohmann said.
“Even though we’re an island with borders, birds fly and so we can truly expect more bird flu to come to Australia.
“Whether it spills over into humans we’re yet to see but I think we have to anticipate that and do pandemic planning – or epidemic
planning at least – for that eventuation, which I think the department of health is doing really well. So far, so good.”
A DoHAC spokesperson told TMR that it has had a “strategic stock of filled and finished pre-pandemic vaccines in the national medical stockpile to support the immediate response to the threat of avian influenza H5N1 strain, with enough doses to “support an initial response to a pandemic by vaccinating frontline workers and priority populations” since 2023. Plus, there’s money in the kitty ($22.1 million) to increase this amount as the situation demands.
The Commonwealth had an arrangement with CSL Seqirus for long-term supply and to “scale up its manufacturing operations into full pandemic response mode to allow for more general population level vaccines to be made available – if they are needed”, the spokesperson said.
“Each year, the Commonwealth Department
of Health and Aged Care seeks advice from CSL Seqirus, the WHO Collaboration Centre and other experts to inform the selection of the antigen strain to be held in bulk, which can be manufactured into a filled and finished vaccine if required.”
The vaccines in stock were for an H5 strain that was well matched to the global H5N1 2.3.4.4b strain causing concerns the spokesperson said.
The stockpile also included antiviral medicines (oseltamivir and baloxavir) to be used if there was an outbreak, they said. Finland has been giving the Seqirus vaccine to people at risk – those who work with livestock, laboratory workers, those in contact with the infection – since June 2024, after the outbreak on mink fur farms caused by clade 2.3.4.4b genotype BB resulted in the death of many animals. At the time, there were no cases yet of H5N1 in humans in Finland.
Dr Gary Grohmann
“Even though we’re an island with borders, birds fly and so we can truly expect more bird flu to come to Australia.”
Canada bought 500,000 doses of the vaccine this month. The country had its first domestically acquired human case in November. A teenager, now recovered, was made critically ill by the same H5N1 strain found in wild birds and Canadian poultry farms – clade 2.3.4.4b genotype D1.1.
“Highly pathogenic avian influenza A(H5N1) virus infection acquired in North America can cause severe human illness. Evidence for changes to HA that may increase binding to human airway receptors is worrisome,” investigators wrote in a letter to the NEJM. But Canada has the action right on its doorstep. According to the 19 February American Medical Association Update, two people were hospitalised recently, bringing the number of known cases to 70.
“To put this in perspective, up until now, we had only seen two hospitalisations total in the US. The majority of people who have had confirmed bird flu here have had mild cases,
Regular flu vaccines may provide some cross protection against these bird viruses
some with conjunctivitis as their only symptom, and have fully recovered,” AMA vice president of Science, Medicine and Public Health,
from the newer 2.3.4.4b clade.
“The circumstances are a bit different [here],” Dr Grohmann said. “That’s an option [vaccination] the
Dr Andrea Garcia
“The majority of people who have had confirmed
[the US] have had
influenza vaccines were not completely matched to viral strains because of the time it took to manufacture them, they would still save lives,
vaccines. It almost certainly will have a little bit of effect against one of these other bird flu types. It won’t be dramatic, but it will be some
So it’s really important to keep up their vaccinations to covid and flu. It may not protect them against the new virus coming in, but it
to start giving people the bird flu vaccine here just yet, according to Dr Grohmann.
At the time of writing, Australia has only had a single case – in a returned traveller in Victoria last year, a two-year-old child with the H5N1 clade 2.3.2.1a, which is different from those causing outbreaks in the US.
In our region, a toddler died this month from the H1N1 strain in Cambodia, though the clade was not reported. Cambodia has had 18 cases, half of them fatal, confirmed since early 2023, including
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the more people that are vaccinated, the better,” Dr Grohmann said. “Every so often, we’re going to get a pandemic. And we’ve seen a pandemic in 2009 we’ve seen the coronavirus pandemic, we’ve seen pandemics in ‘47 and ‘58. Nineteen-sixty-eight was the H3 pandemic. We’ve seen HIV. We need to understand that there are not two certainties in life, of death and taxes. There are three – death, taxes and pandemics.”
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When treating long covid, begin at the beginning
Mitigate the acute infection and reduce the risk of lingering symptoms, an Australian expert says
RUBY PROSSER SCULLY
Some simple steps can help mitigate long covid and treat its symptoms, according to the head of the long covid clinic at St Vincent’s Hospital in Sydney.
With 750 million covid survivors globally, more awareness of the treatable traits would help address this public health problem, respiratory physician Associate Professor Anthony Byrne told delegates at the Immunisation Coalition ASM in Melbourne last month.
GPs played an important role at every stage in the long covid journey, from identifying high risk patients to diagnosing long covid and treating it and comorbid conditions, Professor Byrne said.
HOW TO DIAGNOSE?
The first step in combating this public health problem was diagnosing and mitigating the infection when it occurred, said Professor Byrne, whose
multidisciplinary long covid clinic was one of the first and has seen more than 1000 patients in its three years.
“When that patient calls you and says they’re covid-positive, have a think about giving them treatments that might reduce the chance of them getting long covid, rather than waiting for three months for them to tell you that they’re still sick,” he told TMR
One barrier to diagnosing long covid was that patients and clinicians alike often didn’t think of linking a prior infection to current symptoms.
He recommended PCR tests to confirm the covid diagnosis, and said he gave patients with chronic illnesses PCR request forms in advance to prevent diagnostic delays.
Some data suggests antivirals such as nirmatrelvir/ritonavir (Paxlovid, Pfizer) cut long covid rates by a quarter compared with no treatment. Metformin also appears to help.
Among patients who took the drug for two weeks at the time of diagnosis, 6.3% had long covid a year later compared with 10.4% of those who didn’t take metformin.
Similarly, inhaled steroids with budesonide reduced the risk of long covid while also treating symptoms in the acute phase of the illness, such as cough, Professor Byrne told the meeting.
One challenge in diagnosing long covid was that there were more than 200 symptoms described in this population, he said.
But the simple definition is the presence of these symptoms at least three months after infection that is not otherwise explained.
,Associate Professor Anthony Byrne
“Although there’s not one biomarker or one test, the diagnosis of long covid should not be hard.”
complex, with one or more comorbidities. This complexity played a role in patients not getting diagnosed and sometimes being dismissed by healthcare professionals, Professor Byrne said.
But of the patients Professor Byrne and colleagues saw in their clinic, “99% of them who think they have long covid have long covid”.
“So the diagnosis is not in question. What’s in question is how much blame, if you like, to allocate to long covid, and how much to allocate to their poorly controlled diabetes or their chronic pain syndrome or their sleep apnoea that’s undiagnosed, etc, etc.”
WHO’S AT HIGH RISK?
Mitigation strategies such as metformin or inhaled corticosteroids were particularly important in patients at a high risk of long covid.
The most common symptom, by far, is fatigue. But mild cognitive impairment (brain fog), breathlessness (with or without cough), pain (including chest pain) and mental health problems (with or without sleep disturbances) are frequent complaints.
“Although there’s not one biomarker or one test, the diagnosis of long covid should not be hard. It involves taking a history, knowing the patient, knowing what they were like before and what they’re like now. That’s what GPs do all the time, particularly if they’ve got regular patients,” he told TMR
Another challenge is that many patients were
This included those who were un- or undervaccinated, had severe acute covid infection (which included hospitalised patients or those with more than five symptoms), were older, female or who had comorbidities (such as hypertension, diabetes, or who were immune suppressed or had autoimmune disease).
More surprising risk factors included stress at the time of infection and low self-esteem. Professor Byrne has also seen a high number of patients with ADHD.
Doctors can also use a new long covid risk calculator, CoRiCal, which can be found on the Immunisation Coalition website: https://corical. immunisationcoalition.org.au/longcovid.
The most common symptom of long covid, by far, is fatigue. But brain fog, breathlessness, pain and mental health problems are also frequent complaints
Treatable Traits
• Respiratory
- Asthma and COPD
- Infectious/inflammatory bronchitis & pneumonia
- PE and microvascular clotting
• Cardiac
- Myocarditis/pericarditis
- Ischaemia & cardiac failure
- Arrhythmia & POTS
• Sleep
- Insomnia & hypersomnolence
- OSA
- PLMS
• Mood Disorder
- Anxiety/depression
- Panic disorder/PTSD
• Autoimmune
- Polyarthritis and myalgia
- Inflammatory pain syndrome
- SLE-like disorder
• Neuropathic
- Painful neuropathy
- Radiculopathy
- PLMS
• Immunodeficiency
- Recurrent infections
- Reactivation of chronic viruses
Associate Professor Anthony Byrne “The message is: don’t just throw up your hands. It’s important to believe patients.”
HOW TO TREAT
Infection with SARS-CoV-2 can cause sweeping changes to the body.
“We see, in the severe spectrum, lung alveolar injury and diffuse alveolar damage on autopsy. SARS-CoV-2 destroys type II pneumocytes and causes inflammation, and then you have this cytokine storm and viral replication,” Professor Byrne said.
“Within the vascular system, we see thrombosis, and we see dysfunction
and damage on the alveolar level and coagulopathies. Then within the airways, we see problems with inflammation and problems of dysfunction within the airways.”
The good news was that GPs could address “treatable traits” in long covid individually, Professor Byrne said.
“It’s helpful to compartmentalise the condition,” he said.
“So, have an approach to fatigue ... Look at their sleep hygiene, do some simple tests for
One Healthcare System Towards
Speakers include:
thyroid, iron, diabetes, think about mental health, think about confidence and think about things that you can act on and treat.”
Professor Byrne said he would evaluate conditions in order of life-threatening, important and then annoying and disabling causes.
For example, long covid patients had a high risk of cardiovascular events: “That chest pain could be cardiac – it probably isn’t – but you’ve got to do the usual things and make
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sure that it’s not a heart attack, that it’s not unstable angina, and that it’s not a pulmonary embolism,” he said.
Patients will often have presented to hospital or other specialists, so test results may already be available.
“They’ll turn up to an emergency department for chest pain and the ED doctors will do an ECG, troponin [test] and chest X-ray, they’ll be fine, and [doctors] will send them on their way, but they have still got chest pain, scratching their heads and thinking ‘Okay, well, that’s good. I’m not dying, apparently, but I’ve still got terrible chest pain that I’m worried about’.”
It was also helpful to consider the lungs and not just the heart when a patient complained of breathlessness, Professor Byrne said, noting the lack of spirometers compared with ECGs in many GP surgeries.
“In evaluating breathlessness … we do identify lots of our patients that have subsegmental mismatch defects on V/Q scanning that are not found on CT pulmonary angiography, and we see these patients get better with anticoagulating them, as you would expect,” he said.
“We see a lot of myocarditis and pericarditis when it’s looked for, and we also see a lot of anxiety and panic disorder, and the interplay with that and small airway dysfunction, asthma, dysfunctional breathing.
“The chest pain is really interesting. Sometimes it can be because of pathology, such as PE – often it’s not – and we see pleuritis, and
CLASSIFIEDS
we see a neuropathic-type syndrome in these patients, with presumably nerve injury as the potential cause of their pain.”
Patients with long covid often had normal lung function when tested, but there were some with evidence of small airway dysfunction when oscillometry was used, Professor Byrne said.
Those patients, according to early data from their clinic, tended to improve over six months when put on inhaled steroids.
And it was important to remember that this was a respiratory virus, he told TMR
“It does cause recrudescence and new onset asthma … and occasionally there’s infected bronchitis and pulmonary embolism.
“Sometimes you can get this organising pneumonia that needs steroids to treat in the post-acute period of time,” he told the Melbourne audience.
Patients were at an increased risk of bacterial, fungal and other infections in the acute and post-acute phase.
“Venous thromboembolic disease is also seen in the acute phase, but we commonly see this in our long covid population.”
There are resources for long covid on the Australian Lung Foundation website, and St Vincent’s Hospital offers an online program for mental health anxiety and depression that patients can take.
The Covid-19 Yorkshire Rehabilitation Screening Tool can also be used to assess how a patient views their symptom severity after
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the infection compared with before. Long covid patients often had comorbidities, such as diabetes, sleep apnoea, ADHD, rheumatoid arthritis and COPD, and the infection often worsened these conditions.
Managing and trying to improve these chronic conditions was an important job for GPs, Professor Byrne said.
In many long covid cases, multidisciplinary care was required. While it was complicated in general practice to manage this, GPs could make use of complex care plans, he added.
There was some data to suggest that long covid patients often improved after 24 months, but Professor Byrne said he still saw patients who were persistently unwell beyond that.
“It results in airway, vascular and nerve injury, organ dysfunction, and it leads to reduced quality of life. And those symptoms have real impacts on social functioning and economic and professional roles in these patients.”
For patients at the St Vincent’s Hospital Sydney clinic, at least one in three can’t work or are working in impaired capacity at least six months after their infection. Many have seen multiple other specialists, which is costly and difficult, and are “very debilitated”, he said.
In general, data suggested that long covid patients frequently presented to GPs and other healthcare services, which was an important distinction to the long-term consequences of influenza infection, he said.
Ultimately, keeping long covid in mind and
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treating it seriously at the time of infection would improve the situation for individuals and the public health consequences of long covid downstream.
“Many patients that I see two or three months later that actually were PBS eligible for antivirals did not get them because their prescriber or GP thought that they were fine, and they were at low risk of needing hospitalisation.”
Professor Byrne said clinicians should keep a close eye on eligibility criteria for metformin and Paxlovid in the acute setting as it was frequently updated.
Patients were eligible for Paxlovid if they had been previously hospitalised for covid, and private script was always an option for this and metformin, he said.
“There’s probably some reducing efficacy over time, and in some patients – and there is data to support this – remdesivir intravenously is probably better.
“If there’s the capacity and the willingness to use that for a high-risk patient, I would have a lower threshold for bringing a patient in, giving them three days of IV remdesivir, even if they don’t have hypoxic respiratory failure if they’re at a high risk of long covid for other comorbid condition reasons.”
Stigma still surrounds this condition, and people often aren’t listened to by the medical professionals they see, Professor Byrne said. “The message is: don’t just throw up your hands. It’s important to believe patients.”
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In the meme-bers lounge
Now you can smell your telehealth patients, too
A new medical system fixes a significant gap in the telehealth clinical experience by incorporating smell.
“Nostril Navigator” was developed by olfactologist Professor Candid and his team.
“We’re all used to speaking with patients over the phone,” Professor Candid told Humoural Theory, “and most of us are now well versed in videoconferencing software.
“Our new product Nostril Navigator just takes things a little further, creating what you might call a more three-dimensional experience.”
The system uses sensors that recognise a multitude of organic molecules and turns them into electrical signals which are then transmitted via nasal spray directly into the doctor’s nostrils.
“Smell can provide an awful lot of clinical information,” the Professor explained.
“And I do mean awful, sometimes.
The AI collates enormous quantities of data about the patient, their personality, lifestyle, medical history and relationship they have with their doctor and synthesises all of
this into one unique scent providing a subconscious gateway into clinical decision-making.
“It’s probably easier if I give you some examples. This morning I spoke with an amiable, energetic patient who just needed a repeat script. Nostril Navigator gave him a carefree ocean-breeze smell laced with freshly cut grass.
“However, a grumpy, self-entitled 59-year-old that I don’t particularly get on with smelled of a warm vet’s flannel soaked in cognac and bits of bacon.
“It can get pretty dark, too. A dissocial patient with the triad of Machiavellianism, narcissism and psychopathy who has spent most of his adult life in and out of jail smelled like a shovel, a set of jailors’ keys and an overcoat caked in blood.”
It’s hoped that the system will allow patients to connect emotionally with their doctors in a virtual space like never before.
“But new and inexperienced doctors should be aware that it works both ways, and the only smell that’s easier to detect than abject fear is errant bullshit,” Professor Candid added.
The dogged pursuit of stress relief
The dog in the picture below is called Fred. His owner is a senior member of the staff at The Medical Republic, and he is quite probably the most loveable canine on the entire planet.
When Fred first visited our urban-chic inner-city office a year or so back, he quietly padded up to each team member for a cuddle and a pat, and, having dispensed with the formal introductions, proceeded to deliver a massive dump in a conspicuous location.
To this day, the memory of Fred’s chutzpah provides an endorphin boost sufficient to get all of us through the trials and tribulations associated with the pursuit of quality medical journalism.
And it turns out you don’t have to be a trouper like Fred to do diligent doggy duty – a mere 15 minutes of friendly interaction with a positive pooch is enough to reduce stress levels, according to a study published in PLOS ONE.
We have researchers at Thailand’s Chiang Mai University to thank for this latest investigation into the benefits of “canine-assisted intervention”.
The researchers recruited 122 Thai university students and six healthy, people-friendly dogs for the study.
The participants were given 15 minutes to play with one of the dogs then asked to report how stressed they felt before and after the interaction. They then had their blood pressure and heart rates measured, as well the levels of the stress hormone cortisol in their saliva.
To see whether the dogs were also benefiting
from the exercise, the team measured cortisol levels in their saliva and poo before and after meeting the students.
Unsurprisingly, the students reported feeling less stressed after playing with the dogs, and their heart rates and cortisol levels decreased.
For the canines, however, cortisol levels in the dogs’ saliva were unaffected by the interaction while levels in the dogs’ poo actually increased.
Thankfully, the researchers say that, based on the dogs’ behaviour, this result was more likely to be because they were excited rather than stressed.
