Medical Forum May 2020 - Public Edition

Winning Ways WA STEPS UP IN COVID ERA

Women’s Health issue | Recurrent UTIs, Fibroids, Pelvic Pain, Endometriosis

MAJOR PARTNER

May 2020 www.mforum.com.au

More specialty expertise.

More doctors protected.

We’ve got your back.

Dr Chris D Ch i M Merry ry Cardiothoracic Surgeon Western Australia

As a respected doctor, you stand by your reputation and our reputation is built on protecting yours. The fact is, no medical indemnity insurer has more resources or expertise to safeguard your reputation than Avant. With Avant, you’ll have the support of award winning Avant Law, Australia’s largest specialist medico-legal firm. And more doctors on staff delivers

the unique support and understanding that only a peer can provide. The depth of our experience and expertise gives us knowledge of your specialty that’s simply unmatched.

We’ve got your back.

Don’t risk your reputation. Talk to us today about Professional Indemnity Insurance.

1800 128 268 avant.org.au/practitioners *

IMPORTANT: Professional indemnity insurance products are issued by Avant Insurance Limited, ABN 82 003 707 471, AFSL 238 765. The information provided here is general advice only. You should consider the appropriateness of the advice having regard to your own objectives, financial situation and needs before deciding to purchase or continuing to hold a policy with us. For full details including the terms, conditions, and exclusions that apply, please read and consider the policy wording and Product Disclosure Statement, which is available at avant.org.au or by contacting us on 1800 128 268.

3030.5 04/20 (0811)_MF

EDITORIAL BACK TO CONTENTS

Jan Hallam | Managing Editor

A little ray of sunshine Your faith in us finances our independence.

Our promise is to keep delivering.

Pulling this edition of Medical Forum together has been an uplifting experience, which has, frankly, stunned us.

Firstly, there’s the exciting discoveries every journalist craves – new voices standing up and being counted; wise heads reminding us that times change but our values mustn’t; steady hands leading West Australian work that will contribute to the global good; and doctors all over protecting the interests of their patients when not only their patients’ anxieties are at an all-time high, but their own as well.

These stories may or may not make headlines anywhere else, but for our community of readers they are heartening, reaffirming and (we like to think) important.

On the second count, simply being able to publish this print edition has been humbling because it couldn’t have happened without the support of the WA medical community – our readers and advertisers – who have backed our endeavours to deliver uniquely local and independent content.

There’s not an individual or group among us who hasn’t been impacted by the measures to stop the pandemic from decimating our citizens and health system. The signs are good that the pain caused to lives and businesses has been worth something and that we have some cause for hope when the future is still far from clear.

We are committed to keep telling your stories, air your concerns and recount your joys any way we can. You will see overleaf some new digital innovations we are hoping to trial.

This is a time to test the temperature of new communication waters and we are lucky to have on our small team, people (yes, younger than me) who have the skills, agility and, let’s face it, the fearless enthusiasm of youth to lead these digital projects.

However, we know, from our surveys, that you find comfort in our printed edition, which gives heart to this old dinosaur. So, the MF team will, with your continued support as readers and as advertisers, keep the presses rolling anyway we can.

Your faith in us finances our independence. Our promise is to keep delivering.

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

DISCLAIMER Medical Forum is published by HealthBooks as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants will have any liability for the information or advice contained in Medical Forum.

The statements or opinions expressed in the magazine reflect the views of the authors. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the publisher or its contributors for the promoted product, service or treatment.

Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Trades Practices Act 1974 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser.

EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers.

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 1

CONTENTS | MAY 2020 – WOMEN'S HEALTH ISSUE

Inside this issue 10

6

16 To our readers and supporters

INSIDE THIS ISSUE 6

Close-up: The art of medicine Dr Jennie Connaughton

10 Q&A: Obstetrician Dr Pierre Smith COVID-19 COVERAGE

12 Leadership: Professor Fiona Wood 16 Research: Professor Gary Geelhoed In the time of COVID

20 General Practice 22 Secure doctor communication 24 Telehealth LIFESTYLE

39 Wine review: Chateau Tanunda

12

We have big plans, but they’re not possible without you. In these uncertain times, we intend to expand our coverage of the local and national medical scene with regular digital-only content, via our website and regular emails.

All we’re asking from you is to engage with them so we can demonstrate to our advertisers the value of supporting these ventures. Like our print magazine, the digital-only content will be the same evidencebased and unbiased quality that Medical Forum is known for and it will be free.

We will soon be emailing you a readership poll and it’s vital to us that you open it and take a few minutes to let us know what you would most like to read regularly and what is of most significance to you.

– Dr Martin Buck

CONNECT WITH US /medicalforumwa

/medical-forum-wa-magazine

/MedicalForum_

info@mforum.com.au

2 | MAY 2020

www.mforum.com.au

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

CONTENTS

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

Clinicals

ADVERTISING Advertising Manager Gary Sullivan (0403 282 510) mm@mforum.com.au EDITORIAL TEAM

5

The New CST: When Medicare doesn’t come to the party Dr Bridget Cooke

30

Managing endometriosis Dr Mini Zachariah

31

Management of fibroids Dr Rae Watson-Jones

32

Acute management of persistent pelvic pain Dr Cliff Neppe

36

Diet for fertility and pregnancy Dr Joo Teoh

36

WA Health COVID-19 response Dr Jelena Maticevic

37

Recurrent UTI Dr Trenton Barrett

38

Gastrostomy and children with intellectual disability A/Prof Jenny Downs

Managing Editor Ms Jan Hallam (0430 322 066) editor@mforum.com.au Journalist James Knox (08 9203 5222) james@mforum.com.au Clinical Editor Dr Joe Kosterich (0417 998 697) joe@mforum.com.au Clinical Services Directory Editor Karen Walsh (0401 172 626) karen@mforum.com.au GRAPHIC DESIGN Thinking Hats studio@thinkinghats.net.au INDEPENDENT ADVISORY PANEL for Medical Forum John Alvarez (Cardiothoracic Surgeon), Astrid Arellano (Infectious Disease Physician), Peter Bray (Vascular Surgeon), Pip Brennan (Consumer Advocate), Joe Cardaci (Nuclear & General Medicine), Fred Chen (Ophthalmologist), Mark Hands (Cardiologist), Kenji So (Gastroenterologist), Alistair Vickery (General Practitioner: Academic), Olga Ward (General Practitioner: Procedural), Piers Yates (Orthopaedic Surgeon)

Guest Columns

CONTACT MEDICAL FORUM Suite3/8 Howlett Street, North Perth WA 6006 Phone: Fax: Email:

08 9203 5222 08 6154 6488 info@mforum.com.au

www.mforum.com.au

4

Values in the time of COVID Dr Michael Watson

27

Maternal alcohol use and child outcomes Prof Carol Bower & Dr Colleen O’Leary

MAJOR PARTNER

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 3

Values in the time of COVID In times of intense duress, values will see us through, writes infectious diseases physician Dr Michael Watson.

If you had to choose just one core value to see you through the SARS CoV2 pandemic, it has to be Respect (empathy + compassion i.e. understanding and kindness).

It is only when our whole community truly understands and lives the core value of Respect that we will see calm, sensible and measured responses to the SARS CoV2 epidemic.

The prevention strategies that we recommend and implement must pass the Respect test (understanding and kindness) and if they don’t, then those strategies themselves will pose a far greater risk to our society than the SARS CoV2 virus ever could.

Our community has come to understand the importance of physical distancing (“social distancing”) to help prevent the spread of this infection, but it’s essential that we don’t become more “distant” socially and that we respond with strong social cohesion.

Social cohesion must underpin all of our activities and relationships in our community. There is no substitute for hearing a loved one’s voice and seeing a smiling face, so regularly pick up the phone and video call family and friends.

When everyone lives the core value of Respect, we will not only be safe but we will also feel safe.

As doctors, we will bear an enormous responsibility in the coming months not just for our patients, but also for our families and for the entire community. While there is no conclusively proven cure or vaccine to offer patients yet, we should not fool ourselves into believing that we have nothing to offer.

4 | MAY 2020

Outstanding supportive care is what we can and must deliver. This will not only save lives. It will save our community.

Outstanding supportive care is what we can and must deliver. This will not only save lives. It will save our community.

If we always use the Respect test (empathy + compassion) and apply this to every policy, procedure and treatment we implement, we will have made an outstanding contribution to our society during this crisis.

We are no strangers to caring for people with incurable diseases. We know how to care for patients and their loved ones with deep Respect (understanding and kindness).

We must ensure that we focus on Respect when managing patients with the SARS CoV2 virus.

We know that at the heart of our endeavours the focus must be on delivering patient and family focused health care. Respect is demonstrating deep empathy and compassion for patients and their families by always trying to fully understand their needs, and to do our best to meet those needs.

It will be crucial to ensure our health care system allows families to stay connected through a respectful and safe approach to visiting, and through innovation.

Video conferencing technology is possible for every patient so family members can remain fully connected with their loved ones in their time of need. We must ensure that we provide this for all of our patients.

Now more than ever it is vital that families understand the wishes of their loved ones, and that those wishes are made known to health carers through Advance Health Directives and Enduring Power of Guardianship roles. These forms and processes are readily available through the Office of the Public Advocate https://www. publicadvocate.wa.gov.au/. We must encourage all of our patients and their families to complete these processes as soon as possible.

Finally, it is OK for us all to feel a little fearful at the moment.

There is indeed good reason to.

However, it is not OK to give in to fear. When we give in to fear it robs us of our most important human value, Respect. We then stop being empathetic and compassionate to our fellow human beings.

Doctors are key community leaders during this pandemic and we must show courageous and respectful leadership.

It is essential that we all review and question policies and procedures that seem to fail the Respect test, (no matter who has mandated them). There is usually a more respectful option, it just needs some thought and innovation!

There is a safe way forward for everyone in the era of SARS CoV2.

It is to deeply Respect our fellow human beings, at all times, and in all ways.

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

OPINION

BACK TO CONTENTS

MAJOR PARTNER

The New CST: When Medicare doesn’t come to the party We are now two years into the new cervical screening test and it has been mostly smooth sailing, However, there are a few areas where there are episodes which are rejected by Medicare resulting in private billing and a cost to the patient.

The three main groups are:

Screening in the under 25s The new screening program covers women from the age of 25 (and not from two years after first intercourse as previously) until an exit CST at 70-74 years. Medicare will not rebate a CST for women under the age of 24 years and 9 months UNLESS: 1. Follow up of previous abnormality (high grade); 2. Symptomatic – unusual vaginal bleeding, unusual discharge or dyspareunia (see note below); 3. Early debut.

CO-TEST for symptoms Bleeding: Post coital (specify if one or more episodes); Postmenopausal; Persistent and/or unexplained intermenstrual bleeding; Unexplained endometrial bleeding; Spotting/irregular/ breakthrough bleeding (not on hormones, OCP); PV bleeding.

Discharge: Abnormal, unexplained, unusual; Bloodstained, malodorous; Postmenopausal.

Abnormal appearing cervix: Dyspareunia ONLY IF accompanied by abnormal bleeding.

Dr Bridget Cooke Head of Cytology

About the Author Dr Bridget Cooke is head of cytology at Clinipath Pathology. She studied medicine at the University of NSW and held appointments as staff specialist pathologist at the Royal Prince Alfred and Prince of Wales Hospitals.

Dr Cooke has particular interests in breast, ophthalmic and respiratory pathology as well as cytology, especially fineneedle aspiration cytology.

Early recall by the NCSP We are aware that women are receiving recall letters from the National Cervical Screening Program (NSCP) before the appropriate time e.g. recall at just under two years instead of five years. If requested, CST will be rejected by Medicare and the patient will be billed privately.

If the patient presents, it is suggested that you check the previous history and check that the recall is appropriate. In the instance above, if previous Pap smears were normal and the previous CST was negative for HR HPV, the CST should be repeated at five years and not two years.

Main Laboratory: 310 Selby St North, Osborne Park

www.clinipathpathology.com.au

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 5

Look and listen – the art of medicine Dr Jennie Connaughton has been practising for more than four decades and has now found the kind of medicine that’s closest to her heart.

She tells Ara Jansen how she got there.

It was a nine-year-old girl who did it. She is entirely to blame – in the best possible way – for setting Dr Jennie Connaughton on the path which has led her to practising medicine with the principles and attitudes which resonate most loudly with her soul.

The child in question had been living in an Indian shelter for homeless girls for almost two years when the Perth doctor met and spoke to her in 2008.

“I asked her what life on the street had been like and what coming to the shelter had meant to her,” Jennie remembers. “She turned on like a little button explaining how much better and safer her life was.

It felt like she had given me a job, to support the group whose shelter had given her safety and security.”

Up until that point, the Perth GP had a long history of practising with a focus on women’s health.

While there was little doubt she had found her niche, Jennie says it took her much longer to discover a way to work in medicine which felt most naturally aligned with her beliefs.

A life-long love for culture and language has led Jennie to understand that her work is more than diagnosing an ailment. She sees communicating effectively with people from different cultural and language groups being just as important. At her core, she loves the stories as much as the science.

“When I work with people with cultural differences, I have to pay close attention to what someone means with their words and how 6 | MAY 2020

I say things,” she says.

“When someone has lived a more traditional life, as a western-trained doctor, it can be a challenge to be aware of what’s really important to them and how to make the relationship work.”

When she turned 50 in 2003, Jennie decided to stop metropolitan GP work, move to Sydney and begin doing locum work in rural and remote Australia.

Power of culture “I was learning a lot and it was affecting me greatly. I was working with people who spoke many languages and was learning so much about medicine, about Australia and about Aboriginal culture. That made me feel very differently about doing medicine. I felt very privileged.

“When I was young, I was really interested in languages and other cultures. I was lucky enough to be able to take time off medicine and travel a lot. At the time, the common image of a doctor was very much a young white male.

While I knew that wasn’t correct, it had a strong effect for a long time.

“During medical school, we only saw a limited view of what being a doctor could be. I was never interested in running the business of a medical practice. It took a while to realise there are a million possible ways to do medicine.

That’s the luxury of it – we can do so many different things and be so many different kinds of doctor.”

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

CLOSE-UP

BACK TO CONTENTS

CLOSE-UP

Now sixty-six and “very much not retired”, Jennie Connaughton has found her kind of doctoring. It includes doing four-to-six-week stints at Wyndham Hospital, a tiny hospital in the Kimberley, in the state’s far north. It also allows her to spend time in the bush, connecting with nature, which is one of her passions.

with the women and children who benefit from this work.

“It’s important to be able to assure donors in Australia that their contributions are having a significant impact in India. Collecting donations, given so generously, is a big responsibility,” she says. “When I started CINI Australia in 2009, I needed to do so many things that I had no idea how to do and it meant doing a whole lot of things I had no background in.

Working with a small but dedicated team of people, Jennie loves that they often use their collective training to solve problems presenting in their patients. It’s very different medicine to working in a big city.

“In a city you are quite anonymous, but in a small town, while people are respectful and don’t bring their issues to you at the supermarket, they know who you are. Medicine is complex up north and you must pay attention to the whole person.

Talking problems over with the other doctors is essential. It’s complex medicine that demands one to be really thorough.

“I have two lives – one in the Kimberley and one in the city.”

That life in Perth is spent as founding director of CINI Australia, raising money to support programs in West Bengal. The Child in Need Institute (CINI India) was established in India in 1974 and is recognised as a leading authority on mother and child nutrition and health in the country.

“I had never wanted to speak in public or run an organisation, but now I’m doing it all. It’s fantastic!

I feel fortunate to be a part of such positive change in India. The difference it’s making for those most in need is inspiring.”

Jennie at work in India

Empowering communities CINI Australia supports a range of its community programs which work at grassroots level to empower women and improve health, nutrition, education and protection for children in their local communities. These programs use local knowledge and skills to empower the community to care for their own.

Jennie spends up to two months in India each year visiting CINI, assessing progress and meeting

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

The first time Jennie went to India, she was a disillusioned, 20-yearold student following the hippy trail overland to Europe. She spent a few months with the Child in Need Institute. It was then a very new organisation working with profoundly malnourished children in Kolkata.

A local pediatrician taught her “the things that mattered about medicine”. That wisdom was: people can really do a huge amount to improve their own situation and health when given the right information and support. continued on Page 8

MAY 2020 | 7

Look and listen – the art of medicine continued from Page 7 “It’s about autonomy and empowerment. Women with little schooling were running clinics and teaching other women about health, hygiene and nutrition.

Doctors have so much great information, it’s important to share it in a way people can use it for their benefit,” she says. “CINI has been doing that for a long time and has had a big impact on a huge number of people. They continually review what they are doing to make sure it really is helping people.

“In India, compassion is still valued, which I think is often missing in the way we work here. We have become so functional and hurried, believing it produces a better outcome.

Lasting change “To me it’s about being a partner in change and not encouraging dependency but building knowledge. This builds people’s understanding of their body and empowers them to speak up for what they need. That’s what helps create lasting change.”

It wasn’t until decades later, after working as a city GP, that Jennie circled back to CINI in India. She says while she may have done other things in the meantime, including raising a family and working as a doctor, she never forgot that early experience.

While it didn’t drive her back to India sooner, the kernel of something always sat in her heart, patient and waiting for the right time.

Jennie founded CINI Australia in 2011 and to date it has raised more than $500,000 from donations. In Australia that sort of money doesn’t always go a long way in a budget.

In India it has a huge impact. It has funded projects such as reaching 250 families affected by HIV, and development in 25 villages. Over the next five years, community development programs will grow from reaching 70,000 to an estimated 140,000.

“Those programs work with women and children and local services and local government to create change in their community – that’s about both behaviour and system change.”

8 | MAY 2020

Jennie in the Kimberley

Jennie considers herself to have the “unbelievable good fortune” to be part of something which has positive and lasting effects. She also believes there’s a lot more exchange to be had between her work in both countries.

“It’s about listening to the community. This idea has stayed with me for a long time and remains the foundation of my work. It wasn’t until I was older that I had the space and freedom to make it a priority. I have always believed that community participation is what makes a real difference to people’s wellbeing.”

In 2008, 35 years after that first Indian trip when Jennie was barely out of her teens, she returned to India. She had no great agenda in mind, other than wanting to reconnect with something which had been so important to her all those years ago.

Clarity of children What she saw, impressed her. It was CINI’s profound understanding of the needs of children in terms of their safety and health and their broad sense of what matters. That and the conversation with a nineyear-old girl convinced her this was the next step in the evolution of her practice of medicine.

“I felt it was an opportunity to be part of something really good.

An Australian dollar can make a massive difference when you’re not setting up infrastructure or buying staff cars.

“There are a lot of things in the world that are negative and not working. This is really good work. It makes sense and builds independence. Basically, it gives communities the skills to change their own future.”

Jennie sees working in Wyndham and India as parallel stories in two areas of need. Each day she gets to practise medicine and learn more about language, culture and people. She loves both, for their unique elements and their similarities.

“I used to think with medicine that I would do something amazing or create something astounding.

But I’ve learnt it’s about doing the thing in front of you really well. I don’t know how to make massive improvement in Indigenous health but as a doctor, my job is to do the best I can with the person in front of me and ask for help when I don’t know.”

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

CLOSE-UP

We were made for you

Still with an ordinary health fund?

Time to switch to the fund created for doctors Dr Nicola Ward Orthopaedic Surgeon Doctors’ Health Fund member since 2017

Doctors’ Health Fund was created exclusively for the medical community and their families. We provide simple, yet comprehensive hospital and extras covers, offering excellent quality and value.

Our Top Cover Gold hospital uniquely pays up to the AMA list of medical services and fees, minimising your potential out-of-pocket costs.

Our Prime Choice Gold hospital is comprehensive gold level cover, with very competitive premiums.

We have generous extras benefits and give you complete choice of allied health provider.

Plus we provide exceptional member service, with a satisfaction rating of 95% for 2020. *

GET A QUOTE

1800 226 126 doctorshealthfund.com.au Join in just 5 minutes

* Doctors’ Health Fund Member Satisfaction Survey 2020.

Private health insurance products are issued by The Doctors’ Health Fund Pty Limited, ABN 68 001 417 527 (Doctors’ Health Fund), a member of the Avant Mutual Group. Cover is subject to the terms and conditions (including waiting periods, limitations and exclusions) of the individual policy.

DHF 287_5/20

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 9

Q&A with...

Dr Pierre Smith, Obstetrician, Mt Lawley

MF: A little bit about you! What drew you into obstetrics?

PS: My first clinical rotation in medical school was through obstetrics. I enjoyed it, found it easy to understand and had a good rapport with the team I was assigned to. There is also something spiritual about the birth of a baby that still amazes me.

MF: COVID-19 has changed the way many doctors are practising.

Have you seen anything quite like this situation and how has it impacted on you?

PS: I worked in South Africa at a time when the number of HIV/AIDS patients increased rapidly. It caused anxiety but was a lot easier to deal with than COVID-19. This pandemic seems to be a once in a generation occurrence and its rapid spread makes it very hard to contain.

Even though I have not yet seen any woman with COVID-19 (that I am aware of anyway), it has already had a major impact on how we work.

We have had to split our practice into three teams working alternate shifts from our consulting rooms at SJOG Mt Lawley and SJOG Subiaco. This has caused significant disruption for both staff and patients but we are happy that we can still work and care for our patients. We spend a lot of our time implementing social distancing, changing appointments and wiping down surfaces after every patient visit.

MF: Are there any indications that the virus impacts pregnant women more severely than the general population?

PS: There is currently no evidence that it does. Our knowledge, however, is limited to small case series and case reports. There are 10 | MAY 2020

theoretical concerns in pregnant women due to their reduced lung function, increased oxygen consumption and changed immunity.

associated with natural and/or c-sections? Is decision making altered in any way around these issues due to COVID-19?

MF: Obstetricians and midwives are important to every pregnant woman in routine circumstances, how important are those antenatal ‘visits’?

PS: Unless there are contraindications, a vaginal birth is safer for mother and baby. The virus does not appear to spread vertically and amniotic fluid in women infected with COVID-19 tested negative for the virus.

PS: The current system of antenatal visits used in Australia and around the world is based on long-term evidence. Women who do not attend antenatal visits are at increased risk of pregnancy complications including maternal death and stillbirth.

Controlling the COVID -19 pandemic is very important, but it has to be carefully balanced with the potential harm of reducing antenatal visits. I see women less frequently in the first and second trimesters and have reduced the visit frequency of low-risk multiparous women in the third trimester.

MF: Good communication, too, is a mark of good obstetric care. How has the messaging changed during these times?

PS: Because the number of consultations has been reduced, communication is more challenging.

Consultations take a lot longer in order to deal with COVID -19 related concerns and there are less consultations to establish trust and rapport and fit in essential elements of care.

We rely heavily on our receptionists and midwives to assist and complement our care. Electronic communications such as email, text messages, Facebook and our website are utilised to assist us in this regard.

MF: Babies will continue being born. Are there any higher risks

The risk to staff is more difficult to quantify. During a vaginal delivery, women have one-on-one care for several hours as opposed to the shorter but more intensive care received during a caesarean section.

MF: Hospitals have put in place protocols about visitors. What is happening in the labour ward in regards to clinical and family support?

PS: Currently, only one support person is allowed into the birth suite/theatre and that person is the only one who can stay with, or visit, the mother and baby after the birth.

This has caused tears and increased anxiety among patients, which was heightened after media reports suggested that birth partners could be banned from Australian birth suites and theatres.

Support people were banned from birth suites in two hospitals in New York for a couple days but it was quickly reversed after an executive order by the governor of New York banned that practice.

I cannot believe that any administrator in Australia would ever implement that and that doctors and midwives would allow that to happen here (provided that that support person is not symptomatic or known to be infectious.)

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

Q&A

BACK TO CONTENTS

Q&A

MF: With anxiety levels heightened for new parents, what is your advice to them?

PS: Whilst it appears that children under one year of age are more likely to get a more severe form of COVID-19, the absolute risk is still very small. Social distancing is very important as was practised by many parents prior to the COVID-19 pandemic. Wash your hands, do not touch your face and practise social distancing.

MF: Is the joy of a safe delivery a bit more heightened for you and your team in the COVID-19 world?

PS: I think the opposite is true as no one is quite sure what is happening and what to expect in the next few months. COVID-19 has placed a bit of a dampener on everything but the birth of a baby provides a different perspective and reminds us that life goes on!

Read this story on mforum.com.au

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 11

FEATURE

Leadership in the COVID era In times of crisis, we need good leadership but what are the hallmarks of a good leader?

Among the multitude of issues that will be sifted and picked over once COVID-19 becomes a mitigated virus (please the science gods) is leadership and how its execution affected the way societies, systems, teams and individuals coped during and after the crisis.

Health leadership at this time has been firmly fixed at the centre of the decision-making, not just within the system but for the entire global response to the pandemic. And it has shown its colours, sometimes in unexpected ways and in unexpected quarters.

Last November, the Doctors Health Advisory Service WA hosted the national annual doctors’ health conference in Fremantle. Among the keynote speakers was burns surgeon and researcher Professor Fiona Wood, no stranger to effective crisis leadership.

In the context of the conference, her address was about the importance of developing a good work culture and thriving teamwork to enhance the wellbeing and productivity of team members – the essential focus of every successful leader. In the context of the response to COVID-19, those elements are critical.

The 2002 Bali bombings and the response in particular of the Royal Perth Hospital burns unit, of which Prof Wood was head, has formed much of her thinking around the topic of leadership.

Strength in numbers “No one can create a good culture and team on their own. We all bring our training and knowledge to work every day. But it doesn’t stop some 12 | MAY 2020

of the things we see on a daily basis,” she said.

“If you ask me to talk about Bali, I'd have to swallow hard and stiffen my back. I know that over the years I've accumulated trauma and I know that even though I consider myself an extraordinarily resilient individual, I’d even say I’m bulletproof, there is an element of clay feet in that.

“I know that I cope because I work with an extraordinary group of people.”

Prof Wood talked passionately about medicine being a privilege and one to share. In order to do that consistently and be proud of the work achieved personally and collectively – “bringing your best selves to work each day”— it was important to practise self-care.

“It’s the simple things such as family connection, good food, exercise that help me look after my wellbeing so I can bring my best self to my patients and colleagues.”

In 1991, she was appointed director of the Burns Service of Western Australia.

“On Friday, I was the registrar. On Monday, I was the boss. I was a bull at a gate and, I confess, I still am, and I found myself heading a multidisciplinary team that had been established by Dr Harold McComb and taken over by Dr Robert Wheeler.

“It was a very tight team and I was striving hard on my life’s big opportunity, introducing something new almost daily. And we were changing things. This was the start of the spread of skin cells. We were changing how we skin graft and

how we did dressings, how we were mobilising, telling patients they couldn't lie in bed.

Understanding teams “All these things were happening and I thought it was fantastic. I've got a team, and I was leading and change was happening, but it was happening without any insight from me.

“By 1993, I hadn't understood that the elastic between me and the rest of the team was stretching to the point where it wasn't able to rebound anymore. The social worker of the team chased me down the corridor, and I was doing the classic walking talk. I got to the door, and she said ‘no, you're going to sit down’.

“I thought, Oh, God, this is something really bad. She sat me down and said, ‘we can see you're passionate about this. We understand you really want to change things for the better but, as spokesperson for the team, I’ve come to tell you we don't know what you're doing. We can't explain to patients’ relatives what's going to happen to their loved ones anymore.

We've been doing it the same way for so long and now we're not. How do we understand?’

“It was a really good lesson for me, both in leadership and team building, because there is absolutely no point having a team of people around you and not respecting what they do.

There is no point bringing people to the table then ignoring what they say and not actually allowing them to be the best selves that they can be.

“One of my coping strategies

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

Jan Hallam reports

BACK TO CONTENTS

FEATURE is learning from today to make tomorrow better because if I look at someone and tell them we will do everything we can, only to fail and they die, then how am I going to get up tomorrow and do it all again?

It’s by learning and changing what we can change and always moving forward so that we honour these people’s suffering.”

Prof Wood introduced that idea to the team.

Leaders listen “We built the team in a much more purposeful way around nursing, allied health, the medical teams and the aesthetic teams, linking those teams to infectious diseases, ICU, pain. Each team member is highly skilled in their area and each has a voice and a leadership role within the context of the team. “There’s no point in building such a team and then do what you want anyway.”

When Bali victims started arriving at RPH the Sunday night and early Monday morning, the extent of the disaster and workload was apparent.

“We had a meeting in the RPH boardroom with everybody involved from theatres to ICU to the wards.

Everybody put a plan on the table. Everyone went away. Three hours later, we came back and we executed the plan.

“I had worked hard on flattening the leadership pyramid but, in those weeks, I had been questioned very little, to the point that some nights I would go home and feel really isolated. I felt like I was on my own in that everything I asked, people said yes, even at home, which was particularly weird.

“I put my head down and kept going, but I felt like the pyramid had shrunk to a needle point.

When we reflected after the three weeks, and colleagues who had come from other hospital or states were returning, I stood back and thought, well, we discussed it and everyone said it was clear what had to be done and there wasn't time for everybody to be involved in the decisions that had to be made.

“That acceptance was built on the respect and the cohesion which had developed years before.

“So, leadership is dynamic and needs to be responsive to situations. continued on Page 15

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 13

You’ve done more documenting than David Attenborough for this career.

It deserves expert protection.

120 years’ experience helping medical professionals Medico-legal advice 24/7 emergency support Risk education learn to manage your risk Earn Qantas Points1 on your MIGA insurance

With 120 years as a specialist insurer to the medical profession, protect yourself with the experts in medical indemnity insurance.

2

For a competitive quote, call 1800 777 156 or visit www.miga.com.au

The experts in medical and professional indemnity insurance.

A business must be a Qantas Business Rewards Member and an individual must be a Qantas Frequent Flyer Member to earn Qantas Points with MIGA. Qantas Points are offered under the MIGA Terms and Conditions (www.miga.com.au/qantas-tc).

Qantas Business Rewards Members and Qantas Frequent Flyer Members will earn 1 Qantas Point for every eligible $1 spent (GST exclusive) on payments to MIGA for Eligible Products. Eligible Products are Insurance for Doctors: Medical Indemnity Insurance Policy, Eligible Midwives in Private Practice: Professional Indemnity Insurance Policy, Healthcare Companies: Professional Indemnity Insurance Policy. Eligible spend with MIGA is calculated on the total of the base premium and membership fee (where applicable) and after any government rebate, subsidies and risk management discount, excluding charges such as GST, Stamp Duty and ROCS. Qantas Points will be credited to the relevant Qantas account after receipt of payment for an Eligible Product and in any event within 30 days of payment by You. Any claims in relation to Qantas Points under this offer must be made directly to MIGA by calling National Free Call 1800 777 156 or emailing clientservices@miga.com.au Insurance policies available through MIGA are underwritten by Medical Insurance Australia Pty Ltd (AFSL 255906). Membership services are provided by Medical Defence Association of South Australia Ltd. Before you make any decisions about any of our policies, please read our Product Disclosure Statement and Policy Wording and consider if it is appropriate for you. Call MIGA for a copy or visit our website at www.miga.com.au © MIGA March 2019

14 | MAY 2020

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

SIMPLE_DA_MIGA042

Doctors, Eligible Midwives, Healthcare Companies, Medical Students

FEATURE

BACK TO CONTENTS

Leadership in the COVID era continued from Page 13 There's leadership potential in everyone and everybody can lead in their aspect. I really believe you can have a team of leaders, in fact, I think a team of leaders is a very solid structure because it has the input of a range of experts.

Agile leadership “We need this sort of dynamic leadership, not just in situations of extraordinary stress and challenge, but we also need it on a day-to-day basis.”

Prof Wood said that understanding this type of dynamic leadership and the capacity of the team helps the individual parts feel more supported in times when “it’s not always sunshine and roses”.

And that, in turn, leads to building a culture on the foundations of respecting the value of the individual and the power of the sum of those parts.

“If people believe they have a voice and are listened to; if they are encouraged and inspired to develop their skills and feel personally good about doing that; these people will enjoy what they do. The whole team starts to move forward and a healthy culture is created.”

Fiona sounded a warning note that teams and culture needed constant

nourishing if they were expected to respond swiftly to change.

She recounted the experience of bringing different burns teams together when Fiona Stanley Hospital was opened. A shopping centre explosion put staff to the test with some very unwell people in ICU. “There were the Fremantle guys, there were the Royal Perth guys and there were staff from all over the world. We had spent 20 years building a model of care in our intensive care and then all of a sudden it hit us like a freight train.

“We were a team that worked together, we weren’t going to give this patient over and disappear until they were better.

Respect & kindness “So, we all had to step back and start to build again with mutual respect and kindness. We were in a new environment and the wheels were wobbling. I felt it caught me out because I had to change, the paradigm had to change. It felt like I was back in 1993, yet with a vastly different level of understanding of how to actually engage in changing the capacity of this team.

“We had to bring the team back together and readjust in this new environment. So, it was again, a wake-up call for me.”

Respectful communication is,

unsurprisingly, an important element to successful leadership. Equally important is managing negativity.

Fiona’s team culture is what she describes as a “whinge-free zone” and it’s a lesson she learnt from a colleague as the unit was preparing to move from RPH to FSH. “My colleague Suzanne, who's the deputy director, had clipboards for those who had a complaint. It was divided in two – one side had space for the problem, the other side had space for the solution. She’d hand them over and says, ‘don't forget both columns.’

“Now it doesn’t work all the time, but in the vast majority of instances, if you give people an opportunity to solve the problem, support them to find a solution, the whingeing falls away.

“Some of the ideas might not be practical, but the benefit is in the discussions and engagement with people and the problem can actually be solved. The digital innovations we've come up with were born from whingeing.”

Prof Wood thinks leadership grows in people in times of crisis and brings out the best in a team.

“If you've got people at the table who have got information, opinion, data, then you are cognitively and intellectually trained to be able to solve a problem at that level, a higher level, not just defaulted to the way you always do things.

“That's really quite challenging. It may be that what you were going to do is the right way, but you owe it to the team to pull it apart and demonstrate why, so that everyone else believes you are right as well.

“It is all about dialogue, discussion and understanding, knowing that if you need to respond in a different way, you've got the cohesion to back change.

The spray-on skin is one of the innovations resulting from Prof Wood's work.

Picture courtesy Avita Medical www.avitamedical.com

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

“Everybody gets up in the morning wanting to do the best they can and to go to sleep at night knowing they have done that, all within a framework of support and kindness.

That's when we've achieved the culture of teamwork that we should all strive for.”

MAY 2020 | 15

FEATURE

Research in the COVID era Local researchers are contributing to ways of combating the COVID-19 pandemic.

Western Australia has, so far, been relatively isolated from the COVID-19 pandemic, allowing clinicians and researchers time to prepare for what could come, while also offering the opportunity to push for a collective, world-first research effort to understand the virus.

With no definitive treatment and a vaccine being projected to be anywhere from 18 months to years away, the best defence is risk mitigation, particularly through an understanding of how the virus establishes itself in hosts. There has been substantial variation in susceptibility of impact with some cases experiencing little or no apparent effect while other cases have been fatal.

By understanding these individual variations, researchers hope to develop effective treatments and vaccines for COVID-19 and also help in preparing for another coronavirus pandemic.

The clinical and research response, organised by the WA Health Translation Network (WAHTN), comprises six major research institutes, five universities, public and private hospitals, the WA Department of Health and PathWest.

accurate patient data supported by biological samples that can be relayed in a de-identified manner for all researchers and scientists.

Such a multidisciplinary, multiinstitutional clinical and research response demonstrates the capability of translation networks to leverage tangible outcomes.

According to WAHTN executive director Professor Gary Geelhoed, although his organisation may be the fulcrum around which the response revolves, it is the collegiality of the clinicians and researchers to be so open and collaborative in such a short period of time that has made the response in WA so unique.

“With the advent of the COVID-19 crisis, we were a rallying point to bring together all the research and researchers with weekly meetings including as many as 50 researchers and representatives from all of the groups involved,” Prof Geelhoed said.

WA was well positioned to respond as the population was large enough to provide meaningful data, while the medical and research community was small enough to be well connected and collaborative.

Building on blocks

Part of the response is the WA COVID Research Response (CRR), which proposes “a harmonised platform of integrated research to clinical care…bringing together researchers, scientists and clinical trial teams under the WAHTN as ‘one voice’ in collaboration.”

Part of the response will support existing trials, including one that is specifically designed to anticipate pandemics, with Prof Geelhoed emphasising the global REMAPCAP trial that is currently being run in 13 countries and in more than 50 research hospitals, including Royal Perth Hospital.

The immediate core objective is to build a platform for real-time

REMAP-CAP is a randomised controlled trial of different treatment

16 | MAY 2020

modalities for patients in intensive care due to community-acquired pneumonia. It is unique as it is an adaptively designed trial where the treatment interventions are simultaneous rather than sequential as usually found in traditionally designed trials, allowing clinicians to continuously adapt optimal treatments based on real-time data.

Although the REMAP-CAP trial was initially focused on communityacquired pneumonia, it has been adapted to include COVID-19 domains and has since been named as a key clinical trial for COVID-19 by the Chief Medical Officer in the United Kingdom.

“Much of our effort is to ensure this trial is supported completely and also rolled out to other hospitals as a matter of equity. There are promising treatments that may help and these trials will allow people access to these potentially effective or even lifesaving treatments. So, while we are talking about research, there is a very practical clinical application,” Prof Geelhoed said.

While an existing trial such as REMAP-CAP could provide clinicians with new treatment modalities, so too could new trials, specifically designed for COVID-19.

“If we see trials very early on that tick all of the boxes, in the sense that the group has the capability to do it and there is an immediate impact, we will move to fund them as early as we can,” he said.

The WA Government has provided $3 million for COVID-19 research and has also moved the Guardianship and Administration Amendment (Medical Research)

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

James Knox investigates

BACK TO CONTENTS

FEATURE

Executive Director of the WA Health Translation Network, Prof Gary Geelhoed

Bill, which will allow researchers to include incapacitated adults in research – meaning the most critically ill individuals without the capacity to consent can now be included in potentially life-saving trials, with the consent from a guardian or next of kin.

Follow the data The first pre-clinical phase of the WA COVID Research Response (CRR) will focus on data and biospecimen collection required for REMAP-CAP and future clinical trials. The Department of Health’s REDCAP database was configured to interoperate with a bespoke system called the Clinical Data and Analytics Platform (CDAP), which is based on the World Health Organisation’s (WHO) International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) rapid response protocol for clinical trials: the Severe Acute Respiratory Infection (SARI) database.

The SARI database was developed in expectation of the COVID-19 pandemic and is currently in use in more than a thousand hospitals imputing COVID-19 data.

To get this far, so quickly and effectively, has taken a mammoth effort from everyone involved, says the co-lead of the CRR, Professor Toby Richards from the University of Western Australia and Fiona Stanley Hospital, who specialises in designing clinical trials.

“Western Australia has watched what's happened in Europe and, luckily, over the past month, we have been able to put together a cohesive response to enable high quality research to investigate potential treatments and cures,” Prof Richards said.

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

An adaptive clinical trial, such as REMAP-CAP, was beneficial in a pandemic scenario as the real-time findings could provide clinicians with adaptable treatment modalities, depending on individual’s responsiveness to interventions, he said.

An example of how an adaptive clinical trial in this situation could be represented by a wedge or a cluster randomisation, comparing treatments between hospitals, rather than the traditional approach of group selection and randomisation.

“This is an opportunity where patients can help doctors. If we've got a choice of two drugs and we don't know which is the best treatment, then some patients may be offered inclusion into one drug trial and another group of patients offered the other. We can work out what the best treatment is over the continued on Page 18

MAY 2020 | 17

FEATURE

continued from Page 17 course of these patients’ admission ready for the next group of patients to present.”

Prof Richards is keen to emphasise the CRR will be complementary to frontline clinicians’ workflow with COVID-19 cases.

“The secret of research is not to hide it, rather it’s to ensure that it’s so easy to do that everyone prefers to do it,” he said.

“We’re working closely with emergency department physicians to help them design a template and a workflow that incorporates the research and actually makes their life easier. At the same time, we're collecting data for the WHO [SARI] database and contributing that data to other Australian and international databases.”

Despite the WA Government COVID-19 research funding, Prof Richards said it will only go so far and more state, federal and private funding of the CRR is needed.

“We’re running on coffee fumes, love and dedication at the moment.

At the very least, we need some baked beans to feed the staff,” he said.

“Many people are involved working

round the clock. There's a lot of people giving an awful lot of time above and beyond for this.”

While WA has, so far, avoided COVID-19 cases inundating hospitals, Prof Richards sees this as an opportunity to be ready for whatever the pandemic may bring, even if this means going beyond what is ultimately required.

“Are we doing the right thing here?

Should we invest in it? Should we be setting up clinical data and biological sampling as a platform?

The answer is overwhelmingly yes.

Should we be setting up head-tohead trials of drugs? The answer is yes.”

One of the proposed trials is the Australasian COVID-19 Trial (ASCOT), which could potentially assess pharmaceutical interventions such as lopinavir/ritonavir and/ or hydroxychloroquine efficacy in clinical, virological and immunological outcomes in cases of COVID-19.

As for patients who may be reticent to participate in an experimental trial such as the CRR, Prof Richards is keen to stress they will not only be assisting clinicians and researchers in understanding COVID-19, they will also be guaranteed access to the best, most cutting-edge treatments.

“They may or may not work, but a lot of thought has gone into the reason why we're trialling them,” he said.

“If a patient is in trouble, the quality of care and the attention to detail is unsurpassed. And importantly, money spent on clinical research is money well spent because it's normally rewarded four to fivefold more back to society.”

Clues for the cure With the data and bio-specimen collection underway, the next phase is to study the samples stored in the recently activated biobank at the Fiona Stanley Hospital Campus.

Since 2018, WAHTN has been working towards the formation of a centralised and standardised biobank framework in WA. However, the emergence of COVID-19 has expedited this program with the first freezers being turned on at Harry Perkins Institute of Medical Research.

Biobanks are essentially biorepositories equipped to store and process bio-specimens, such as DNA and blood samples, to enhance and advance health and medical research.

One of the organisations that has focused its efforts on COVID-19

WE HELP YOU GET ON TOP OF BUSINESS SO YOU CAN GET ON WITH CARING FOR THE COMMUNITY Talk to the ANZ Health Banking Specialist Team that understands your needs.

Visit anz.com/health or contact your local State Health Director, Megan Carter, on 0411 140 781.

© Australia and New Zealand Banking Group Limited (ANZ) ABN 11 005 357 522.

18 | MAY 2020

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

Research in the COVID era

BACK TO CONTENTS

FEATURE

is the Australian National Phenome Centre (ANPC), led

by Professor Jeremy Nicholson, ProVice Chancellor for Health Sciences at Murdoch University.

According to Prof Nicholson, the ANPC is focusing on predicting who is most susceptible to being acutely affected by COVID-19 and identifying who will be a good or a bad responder to drug trials, providing researchers and clinicians with real-time evidence of what is and isn’t effective so they can adapt their treatment strategies.

The ANPC intends to analyse biobank specimens for biomarkers that help stratify patients and subtypes to assist in choosing the most appropriate therapy – a type of prognostic modelling in a clinical trial situation.

“The ultimate aim is to make almost real-time, multivariate metabolic analysis with feedback to doctors on the ward, advising what is working and what is not. COVID-19 will challenge us in different ways as an epidemiological scale problem, but we also have a patient. The clinical meets epidemiological in a

way that we haven't seen before,” Prof Nicholson said.

Individual differences With so many unknowns surrounding COVID-19, the analysis conducted at ANPC could lead to a deeper understanding of the individual differences in cases, such as if previous exposure to a coronavirus is protective or harmful.

Although certain risk-factors, such as older-age groups and co-morbidities, are rightly being disseminated as part of the public health messaging, these are speculative causal relationships, which is what the CRR researchers, Prof Nicholson and the ANPC hope to decipher.

These risk-factors could be caused by myriad possibilities, according to Prof Nicholson.

“Some may relate to genetics; some duration in relation to previous immunological competencies and exposures; some will obviously be relevant to underlying physiological fitness and co-morbidities.

“You could argue that the social conditions in places such as Italy, where young people live with their older relatives, is a big potential exposure factor for older relatives, which is one of the reasons why

it might have spread much faster.

Every country is going to have a different demographic, genetic and microbiological backgrounds.

Prof Nicholson explained how microbiome variation could potentially be a component leading to susceptibility and ultimately the potential for recovery.

“Symbiotic bacteria do a lot of good things for us. We vary hugely in our microbiome compositions. With 90% of our immune cells in the gut lining, the microbiome tunes our immunological status.

“Given that, when you die of this disease, you die in a sort of cytokine storm where all the immunological signals are going crazy, it would be surprising to me if [microbiome variation] didn't have some effect.

“The important thing to understand is the variance of proportion.

What's the biggest contribution to variation? Is it genetic? Is it microbiological? Is it previous [exposure]? Is it social?

“This is quite a challenge of the traditional analytical understanding of human biology as well as it is for actually generating something that's useful to medicine.”

Telehealth – Do you need help with setup?

New telehelp™ complete setup and service package is available now!

Save your valuable time and we can have you on Telehealth within a few days.

No lock in contract, fees are based on a percentage of billings.

SIP/H.323 connectivity to legacy videoconference equipment

Easy setup and training if required and full IT Support

Our videoconferencing services on secure telehelp™ servers

Telehelp website and email address

Dedicated telehelp™ practice manager and admin support

Office365 and Practice Management Software subscriptions

Individual Fax Numbers for sending prescriptions to GPs, patients and pharmacists

Healthlink messaging

Billing and support from our CPA if required Affordable rates and no lock-in contract

Please contact us to discuss more in detail.

Telehelp is a family business founded by a locally trained psychiatrist and a professional accountant and I.T. Specialist.

Contact us now to get started on Telehealth.

Ph 08 6119 8008 Fax 08 64447414 Email inquiries@telehelp.com.au

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 19

FEATURE

GPs in the COVID era The pandemic has hit the community hard and its health lifeline, general practice, has felt its pain.

No single individual or branch of medicine has been untouched by the pandemic and our governments’ responses to it.

In general practice, the opening of the telehealth sluice gates has fundamentally changed how GPs are treating patients. It has also affected how many patients they are seeing over the threshold of their surgeries.

And while, in the short-term, telehealth has been a safer way of at least triaging patients with flu-like symptoms, it is raising concerns in the GP ranks, given its limitations and the fear the pandemic has created in the community, that there will be a dangerous spike of unmanaged chronic disease symptoms in a few short months.

It is a message that now needs to be heard from the chief medical officers and politicians during their daily media briefings.

Infectious diseases clinician Dr Nick Coatsworth (who also happens to be a UWA medical graduate) was the first to highlight the issue when he was on media duty over the Easter weekend. He reassured the public that there was an extremely low chance of COVID infection for those requiring a doctor or pathology visit for their chronic conditions. He urged people not to neglect their general health.

It is an issue that worries Armadale GP Dr Ramya Raman.

“There is a lack of chronic disease

20 | MAY 2020

management right now because patients aren't coming to us for their follow-ups as they normally would.

We must brace ourselves for a spike of poorly managed diabetes, COPD, polypharmacy issues in elderly patients, falls, hip fractures to all sorts of cardiovascular health,” she told Medical Forum.

distancing rules but still having a consultation per se, making sure we are recording all the essential vitals, administering the vaccine and monitoring post vaccine administration. The response from our patients has been overwhelmingly positive with this set up,” she said.

“All of which, may, of course, lead to many more people occupying a lot of hospital beds.

“With this current pandemic and the dynamic changes our health system has seen, I think my colleagues would agree that general practice is not going to be the same moving forward.”

“We are grateful for the introduction of telehealth but there are challenges and, I can tell you, that I am certainly missing my face-toface consults with patients.”

While fear of COVID-19 keeps some people from visiting their doctor, despite surgeries taking pains to limit numbers in waiting rooms, it is a complex reality facing GPs and practice owners and it may take some time to reel in.

With so much media talk, speculation and the all-too-real financial and social impacts of the tough public health measures, the science of treatments and vaccine may be the few things that are able to cut through.

However, in the meantime, there must be some semblance of business as usual for general practice.

Ramya said the practice for which she works, Skye Medical Armadale, has started outdoor flu vaccination clinics, which are giving her and her colleagues a chance to eyeball some of their patients they hadn’t seen in a while.

“We're minimising patient contact and maintaining the social

As a GP with special interest in women’s health, Ramya is aware of the potential impact of family domestic violence (FDV), especially in this current environment of social isolation, job losses, financial stresses and health concerns.

It would be a sad reflection of society’s failure to stamp on FDV if it were to be considered a chronic disease, but like mismanaged diabetes in the time of COVID, there is great fear that it is increasing and going unreported.

Because of the subtleties of presentation, it is hard to prove that isolation, fear and mounting tensions alleviated by alcohol and substance abuse has caused a spike in FDV incidents in WA. Though some reports from China, during its severe lockdown, indicated that FDV had increased by 30%.

“It is a complex area because people don’t tend to come in with FDV as the presenting symptom. Certainly, mental health concerns like anxiety and depression, have spiked in general practice in the past four weeks.” Ramya said.

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

Jan Hallam reports

BACK TO CONTENTS

FEATURE “Self-isolation, stresses around finances and job losses, restrictions in movement, worries about children and elderly parents are some of the challenges. It's all about the anxiety and stress that generate these concerns and the aftermath of these.

“There is also an increase in alcohol and substance abuse because people are staying at home and it adds up to family and domestic violence, particularly when there are already predisposing factors.”

Ramya says some of the flags for possible FDV is a person presenting with multiple physical symptoms and symptoms of anxiety and depression or poor sleep.

“What the RACGP is advocating so strongly for is to keep FDV in the back of GPs minds when they are seeing patients. The conversation is subtle and may start with an update on what is happening at home. Or noticing a bruise and inquiring what had happened, these gentle probes may help a patient to open up.

“Family medicine is complex and dynamic. GPs are often dealing not just with one family member; we are

usually are seeing the entire family.

Certainly, women don't present these things symptoms initially.

“It's up to me to keep a log of the emotional, physical or financial concerns that they have, the relationships that they are holding with their families, identifying any potential risks the kids may have.

I usually document how old the kids are, what is the relationship within the family; is it a mixed family dynamic? Who else is living at home?

“And importantly, it’s ensuring that I make a follow-up plan with them because it is a safety measure. This is by far the most important thing, for women to feel safe, and we must work with patients to ensure they have a safety plan in place in case things go bad.

“Knowing how to manage these situations; how to refer a patient to the right place using the right resources, is essential. That is the message the RACGP wants heard.

The College’s White Book is an excellent resource and it is regularly updated, and 1800 Respect is also an excellent resource.”

“There are some incredible resources alongside the White Book and 1800 Respect – Relationships Australia and Lifeline and there is a 24-hour FDV helpline for both men and women (https://mccwa.org.au/ fdv.html). I also see a role for safety apps and frequently recommend the Daisy, Sunny and Girls Gotta Know apps to my patients.”

For Ramya, her role as the trusted family doctor is what makes her get out of bed every day and go to work.

“Listening to your patient, giving time to your patient and validating their disclosures and protecting their privacy is a responsibility but it is also privilege and the foundation of general practice.”

ED: Dr Ramya is a GP with special interest in women’s and children’s health.

She is a medical educator at WAGPET and the School of Medicine, University of Notre Dame, Fremantle. Ramya is also an elected council member on the RACGP WA Faculty.

Read this story on mforum.com.au

COMPREHENSIVE COMMUNITY RADIOLOGY Western Radiology, high-quality imaging and intervention services available across Perth.

With a focus on state of the art equipment, procedures and scans we deliver a higher standard of care in the community.

Daily appointment availability at each branch, direct access to our clinical team and affordability set us apart.

Catering for GPs and specialists with: Comprehensive vascular, interventional and cardiac services.

Plus level-2 interventions: C-Spine, Epidural, Rhizotomy, P.R.P., plus oncology procedures.

Cardiac MRI, CT Coronary Angiogram & Calcium Scoring.

Staff are highly trained, experienced and service focussed.

Results available online, with 24 hour turn-around. A strong, growing list of radiologists and a policy to bulk-bill all Medicare rebatable items rounds out an exceptional service.

9200 2777

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

9200 2778

www.wradi.com.au

MAY 2020 | 21

FEATURE

Communication in the COVID era

Now more than ever, outstanding communication between health professionals is needed to help us to problem solve, innovate and adapt to the threat of the SARS CoV2 virus.

I think there is a real need for a multifunction mass communication platform i.e. a secure unified communication platform that includes all doctors. This platform should be funded and controlled by doctors to benefit all doctors, their patients and our whole society.

In addition to a unified communication platform there also needs to be a plethora of small, boutique ICT applications which promote highly specialised information sharing and gathering amongst specific groups of health care professionals.

Government responses to the SARS CoV2 threat (the “social distancing” regulations) have resulted in the prohibition of many traditional forms of doctor communication such as face-to-face clinical meetings (including morbidity and mortality meetings) and scientific and clinical conferences where doctors have been able, in the past, to share important stories (case studies and research) that help us all to learn from our experiences.

We are now forced to use electronic media to meet and to discuss confidential clinical cases. Many doctors have turned to free email and video conferencing applications.

Many of these applications lack the security features necessary for safe discussion of clinical cases and raise legitimate concerns about patient privacy.

22 | MAY 2020

They also lack the sophistication to allow for the extremely high level and ultra-efficient communication needed to combat this virus.

Of even greater concern to me is the use of mass social media platforms whose servers are based outside of Australia and have a track record of data breaches.

I would encourage doctors to consult with their medical defence organisations before using these forms of free mass electronic social media to discuss their patients.

Whilst they are free and easy to use, it is disrespectful to our patients to discuss confidential information in an online forum where privacy is questionable.

If we look to the ICT marketplace to find a mass communication platform which is multi-functional, secure and has servers in Australia, we can either look at pulling together pieces from multiple different sources or a single integrated solution.

There are many excellent standalone platforms which provide outstanding individual services such as commercial business grade video conferencing on its own or dedicated file sharing platforms, but there are currently very few secure, fully integrated business grade solutions that are available at affordable prices.

Having researched this extensively when setting up a telehealth business in the past, the product that now stands out to me is Microsoft Office 365.

Many doctors already use Office 365 in some form. Office 365 gives us the potential right now to allow

for secure connectivity between doctors. It is just a matter of catalysing this connectivity.

My organisation Valued Voice is currently exploring options to help facilitate the connectivity of doctors and I would greatly value people’s thoughts on this. There are many ICT and social media gurus in our profession, so now is the time to share your ideas!

What values do we need?

Of course, in any system there must be a way to ensure that people work together to promote the common good. In the traditional model this has been achieved through lengthy legal agreements with vast numbers of rules and regulations which can stifle the communication process.

I believe we only need one rule.

Everyone must live the value of Respect (empathy and compassion i.e. understanding and kindness).

This means Respect for each other, for our patients, for our whole society (including our society’s leadership) and most importantly respect for ourselves.

Respect is NOT political correctness (a series of artificial rules to try to dictate some form of ‘ideal’ conforming behaviour). Respect is a genuine heartfelt desire to try to understand how others feel, and to be kind to them. Respect allows for genuine mistakes and it promotes people’s better understanding of human behaviour so we can all work together to help each other be safe and feel safe.

Respect means respecting people’s individual privacy, their individual rights and their human dignity.

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

How can doctors safely communicate in the SARS CoV2 era? Dr Michael Watson examines some options for this critical need.

BACK TO CONTENTS

FEATURE What would be the ideal system?

I have used the Office 365 platform as an example (there may be others out there, but this is one I have researched in depth) and propose three levels of communication; 1. An emergency channel (similar to a mayday channel or Channel 16 on marine radio). This function could be filled using email.

Email should be reserved for critical communications about emergency situations and for key updates on the SARS CoV2 situation. Your email box will NOT be full in this new ideal system as it will only be for critical communications!

2. A health business channel which is for collaborative health communications of a semi-urgent or elective nature on health-related topics. This type of communication could principally use Microsoft Teams.

Collaborative groups are readily established with file sharing, video conferencing and many other sophisticated business tools to promote high level, efficient collaboration on health issues.

3. A secure doctor’s social media platform. The mainstay of this could be Yammer which is a sophisticated and secure social networking tool which will allow doctors to share information of a private nature, debrief on personal experiences or organise virtual social groups (many of whom used to meet in person but are no longer lawfully allowed to do so with the new social distancing regulations). I think this type of social communication will be essential for the health and wellbeing of doctors in the coming months and years.

almost always auto correct their communication behaviours in favour of Respect. This is particularly true when we have respectful and respected moderators.

Freedom of speech and freedom of scientific ideas should be promoted within this ideal system and the bullying of individuals who are trying to respectfully put forward alternate viewpoints should not be accepted.

Respectful questioning of the policies of the day is a healthy part of our democracy and should be encouraged. However, public disclosure of scientific conjecture should be discouraged so all communications within this ideal health communication network should be held in the strictest confidence.

In my experience, groups of ethical individuals (such as doctors) will

Valued Voice is a public health advocacy organisation. We aim to promote the health (the broadest WHO definition) through the promotion of the value of Respect.

I have found that promoting Respect has solved many seemingly insoluble clinical and public health problems and I think that respectful communication is at the heart of the solution to this new deadly virus.

If you are interested in helping to promote respectful communication between doctors, please call me on (08) 9386 3839 or email me at michael@valuedvoice.com.au . I will keep you updated on the progress of this exciting idea!

The ICT nuts and bolts?

There are also many boutique ICT platforms being developed to help

WE ARE OPEN FOR BUSINESS AND WE OFFER TELEHEALTH A/Prof Harsha Chandraratna, Dr Bill Gong and Dr Andrew Kiyingi are available and keen to support your patients during this time of COVID-19.

We are able to see any urgent surgical cases. We can also see elective cases to be assessed and prepared with a view to proceeding to surgery the moment elective surgery recommences.

Through the use of champions, of course!

Moderating communication?

Who is Valued Voice?

Where to from here?

A simple written agreement which reminds people to behave in a respectful way towards each other, our patients and society as a whole would be an essential feature of the network.

How do we catalyse doctor communication?

I think we need to recruit moderators and leaders who will help to bring doctors together to promote high level, respectful communication. Once started, groups of doctors will naturally recruit and select their own facilitators or moderators and form new groups.

fight the SARS CoV2 virus. I have seen some spectacular enhanced surveillance tools, plans for the development of SARS CoV2 related clinical decision support software and patient monitoring tools and many, many more. It is ripe for more investigation.

We are able to see patients either in person at our rooms at Subiaco, Murdoch, Booragoon or Mandurah or via Telehealth.

FOR ENQUIRIES/BOOKINGS: Ph (08) 9332 0066 Fax (08) 9463 6202 Mob 0401 809 255 (Dr Chandraratna) Mob 0413 149 758 (Dr Gong) Mob 0404 758 539 (Dr Kiyingi)

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 23

FEATURE

Telehealth in the COVID era It’s a technology that has been around for 20 years, but now telehealth has come into its own.

The all-encompassing COVID-19 pandemic has disrupted the world like nothing before it, yet it’s the pressure on primary health services and public health systems that have been most disrupted.

of dedicated video conferencing systems was prohibitive – over $30,000 a unit – whereas now, these tools are free (Zoom, Skype, FaceTime etc) if you have a compatible device.

With stringent stay-in-place, quarantine and social distancing orders in place, the role of telehealth has never been greater, which has been reflected in the Federal Government providing $100 million of Medicare funding for bulk-billed telehealth consultations.

Distance between a clinician and patient may have been the initial primary rational for telehealth, but this is no longer the case, says Professor Anthony Smith, Director of the Centre for Online Health at the University of Queensland.

The telehealth system, essentially video and some telephone consultations between clinicians and patients, could prove to be extremely effective in treating at-risk patients by reducing the possibility of community transitions of COVID-19, while offering a new paradigm of treatment that is potentially more convenient and cost effective.

Although telehealth has been in use in Australia for almost two decades, the take up has not been representative of the system’s potential, but this is changing, particularly in primary health.

The questions we need answers for are: Will telehealth become the new normal for primary care delivery?; and will the disruptive forces of COVID-19 be an opportunity for clinicians and the public to fully embrace its benefits?

Slow start Twenty years ago, telehealth was primarily used for specialist consultations on an ad-hoc basis, particularly with patients in rural or remote locations. Then the cost 24 | MAY 2020

Prof Smith has been researching and designing telehealth services for more than 20 years: “Telehealth has proven to be useful for everyone, regardless of location. We have established telehealth services to support patients living only a few kilometres from their hospital.

“These people may normally find it difficult to attend their appointment because of frailty, other physical or mental health issues, transport costs, or lack of family support.

Telehealth technology has changed this significantly.”

Although the uptake of telehealth has been slow and fragmented in Australia, Prof Smith said this wasn’t without good reasons.

“The lack of funding to support the costs of doing telehealth for patients and providers; availability of technical infrastructure, such as high-speed telecommunications and interoperable video-conference platforms; absence of revised workflow procedures; appropriate education and training; limited general public awareness; ineffective or no change-management processes, as telehealth is a disruptive process.”

Change management A salient determinant for acceptance of disruptive technologies is effective change management, he said.

“Some clinicians seem to adopt telehealth quickly, while others are resistant. It’s important to consider change-management strategies which support clinicians and patients during this process.

“Learning from experience is important. We often find that once clinicians have been involved in telehealth, the process is much more acceptable to them.

“It’s also important to acknowledge that telehealth is not appropriate for all consultations. There will always be a need for appointments that require a physical assessment or specialist procedure which can’t be done remotely. Of course, the decision to do telehealth should be based on the clinical requirements.”

Telehealth & COVID-19 With the unprecedented disruptive changes due to COVID-19, such as social distancing, there has been a rapid adoption of telehealth, which has validated the benefits of the system for clinicians and patients alike, Prof Smith said.

“Patients can access services more conveniently from their own home.

Vulnerable patients, such as those aged over 70 with chronic health conditions, can have a telehealth appointment rather than waiting in a busy medical centre, among other people who potentially have the virus or other communicable health conditions. While clinicians are able to assess and manage patients without the risk of infection.”

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

James Knox reports

BACK TO CONTENTS

FEATURE Finding the funding As part of the COVID-19 funding package provided by the Federal Government, amendments have been made to liberate the delivery of telehealth.

“We have seen major changes to Medicare funding guidelines such as the removal of geographical limits and the introduction of special telehealth MBS items for GPs to consult directly with their patients via telephone or video conference, and MBS telehealth items for nursing and allied health services,” Prof Smith said.

“Currently, there is no stipulation on distance which means that a clinician can consult with a patient who is in the same suburb.

“Questions have been raised about the inability to charge a gap fee for primary care telehealth items. This is an issue currently being considered by various professional colleges and the health department.”

Privacy problems The susceptibility of some videoconferencing systems’ data management and encryption could lead to potential privacy issues.

FaceTime and WhatsApp offer endto-end encryption, while Zoom has ‘incomplete’ end-to-end encryption – in essence, it is not secure. Skype has no encryption at all.

“The issues of privacy and security have to be resolved at the same time we focus on the integration of telehealth into mainstream health services. Many common platforms such as Zoom and Skype are used for telehealth appointments, and while the risks are low, they do need to be recognised,” Prof Smith said.

While privacy via videoconferencing applications could be problematic, Prof Smith says it comes with similar risks to other methods of communication.

“It is important patients are informed of the risks of whatever platform is being used. We have to remember, though, that other communication methods – telephone conversations, email messages and fax transmissions – can potentially be intercepted, but the occurrence is extremely rare,” he said.

“Clinicians need to be trained to use telehealth, including the guidelines around privacy and security.”

Barriers to entry While the need for expensive, dedicated video-conferencing systems for telehealth has decreased, and the proliferation of smart phones and tablets has made telehealth more equitable, there will still be disadvantaged users.

“Fortunately, we are seeing more widespread access to mobile phones and Internet connectivity across Australia,” Prof Smith said.

“However, we must remain mindful of patients who may not have the necessary technology for a telehealth consultation.

“One way of addressing this is by providing telehealth facilities in community health centres, so patients can access these services without the need for extensive travel. As training is important for clinicians, it is equally important

to raise awareness of telehealth amongst the general public.

Tele-future Will telehealth become a staple of primary health care? Although Prof Smith cannot say definitively if this will be the case, he believes its benefits during the COVID-19 pandemic will demonstrate how effective it can be for routine consultations.

“My vision is that we have access to a comprehensive health service which includes telehealth as a routine service modality. There’s no reason to switch off a valuable service which delivers easier access and greater convenience to health services.”

He provided two use-cases where telehealth is advantageous: • Triaging patients and determining best pathways for care – we should quickly see a proportion of appointments that don’t require physical contact changed to telehealth.

• An opportunity for GPs and specialists to be more connected and improve continuity of care and enhancing training opportunities through shared case management.

Prof Smith said research funding urgently required to escalate the critical appraisal of telehealth in Australia. “Now is the ideal time to compare telehealth with conventional face-to-face services,” he said.

“We need to explore new telehealthenabled models of care with a particular focus on barriers and enablers; workflow procedures which are replicable; education and training requirements; funding implications and user experience.”

Message for GPs Ultimately, telehealth’s uptake is dependent on clinicians who believe in the value of it for them, their patients and their practice.

“The more familiar GPs are with telehealth, the easier it is to explain its basics. It’s important for GPs to reassure their patients that telehealth is an ideal way to help assess conditions. In some cases, it may be necessary to have a face-toface appointment.”

The COH have produced a number of telehealth guides to support clinicians and patients: https://coh.centre.uq.edu.au/quickguides-telehealth MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 25

COVID-19 doesn’t hamper our extraordinary care!

Cardiology Telehealth Consultation

D

DR MICHAEL DAVIS

Providing ongoing care in the safest possible manner for patients and colleagues is our utmost priority during these unprecedented times. To ensure the risks of COVID-19 are minimised for both patients and staff, Perth Cardio has transitioned to Telehealth video consultations for ALL consult clinics.

This is one of the many COVID-19 safeguards we have in place to continue delivering outstanding care with minimal interruption or delay to your patients.

To book a Telehealth appointment with any of our leading cardiologists, visit perthcardio.com.au/telehealth or call 6314 6833

MOUNT HOSPITAL HOLLYWOOD PRIVATE HOSPITAL JOONDALUP HEALTH CAMPUS MURDOCH HOSPITAL  SJOG BENTLE Y

26 | MAY 2020

|

ESPERANCE

|

KIMBERLE Y

|

MIDLAND

|

MT L AW L E Y

|

ROCKINGHA M

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

Maternal alcohol use and child outcomes New research is closing in on maternal alcohol use disorder and its implications for a spectrum of adverse child health outcomes, says Prof Carol Bower and Dr Colleen O’Leary.

In a recent paper using recordlinked data in WA, the effects of maternal alcohol-use disorder were found to be experienced by the majority of exposed children, rather than a vulnerable subgroup of this population.

Over half (55%) of nonIndigenous children and 84% of Indigenous children of mothers with an alcohol-use disorder had at least one adverse biological and/or social outcome.

The outcomes examined were intellectual disability, cerebral palsy, being small for gestational age, birth defects, preterm birth, stillbirth and infant mortality, poor educational outcomes and school attendance, contact with the justice system

and contact with child protection.

These outcomes had earlier been examined and reported separately, but this was the first time they had been examined jointly.

The research used routinely linked administrative and research data to identify the outcomes in the offspring of women with and without a record of an alcoholrelated diagnosis, who gave birth in WA between 1983 and 2007.

The exposed cohort was defined as births to mothers with an alcoholrelated diagnosis recorded in the hospital morbidity, mental health or alcohol services datasets. The comparison cohort was infants of mothers with no record of an alcohol-related diagnosis,

frequency-matched to the exposed cohort on maternal age within Indigenous status and year of child’s birth.

The exposed cohort consisted of 13,969 non-Indigenous and 9,535 Indigenous offspring; the comparison cohort consisted of 40,302 non-Indigenous and 20,533 Indigenous offspring.

Analyses were conducted separately by Indigenous status and adjusted for the matching variables and other relevant co-variates. The effect of timing of the recorded alcohol exposure in relation to pregnancy was also examined. continued on Page 29

Temporarily suspended

B

reastScreen WA has temporarily suspended routine breast screening from Monday 30 March 2020.

This is to limit the transmission of COVID-19 (Coronavirus) and prioritise the wellbeing of • All women with cancelled appointments will be contacted, as soon as possible.

• No new bookings can be made at this time.

• We will recommence screening as soon as we are advised it is safe to do so.

• Any clients who have been called back for additional tests (assessment) by BreastScreen WA will be assessed as soon as possible.

• Women have been asked to contact their GP if they have concerns about their breast health, or develop new symptoms.

Thank you for your understanding at this time.

Further information on the suspension of service is on BreastScreen WA’s website.

If you have any queries please email breastscreenwa@health.wa.gov.au

www.breastscreen.health.wa.gov.au or phone 13 20 50 MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

Mar ‘18

BACK TO CONTENTS

GUEST COLUMN

MAY 2020 | 27

28 | MAY 2020

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

GUEST COLUMN

Maternal alcohol use and child outcomes continued from Page 27 The adjusted odds of a child of a mother with an alcohol-related diagnosis having any adverse outcome was over 2.5 times greater than for the comparison cohort for both Indigenous (OR 2.67; 95%CI 2.50-2.85) and non-Indigenous (OR 2.67; 95%CI 2.56-2.78) groups.

The highest odds were seen when the alcohol-related diagnosis was recorded during pregnancy (OR 4.5 for non-Indigenous; OR 5.18 for Indigenous). When the maternal alcohol-use disorder was recorded before or after pregnancy the odds of an adverse outcome two- to fourfold greater than in the comparison cohort, for both Indigenous and non-Indigenous groups.

This study adds new information about the magnitude and breadth of the negative impacts of maternal alcohol use disorder on offspring,

with the majority of exposed children being affected.

This underscores the need for multiple agencies to coordinate identifying alcohol-use disorder and providing support in pregnancy, early assessments and interventions for the child, and long-term support for both mother and child. Indigenous designed, led and delivered programs will need to be embedded in these multi-agency approaches.

It is important to point out that not all women with an alcoholuse disorder will have a record of such in administrative datasets and, furthermore, there will be many women consuming alcohol who do not have an alcohol-use disorder, but the fetus may still be exposed to prenatal alcohol with its attendant risks.

Assessment of alcohol use in every pregnancy and for every woman is essential, followed by

brief intervention and motivational interviewing or referral for more intensive intervention as indicated.

Resources for health professionals are available on the FASD Hub (https://www.fasdhub.org.au) to assist them in asking and advising about prenatal alcohol exposure, including a set of videos and resources for GPs entitled ‘GPaskthequestion’ (https://www. fasdhub.org.au/fasd-information/ understanding-fasd/alcohol-use-inpregancy/gpaskthequestion/).

– References on request ED: Both Prof Bower and Dr O’Leary are researchers at the Telethon Kids Institute

Read this story on mforum.com.au

At SKG Radiology, we know your patient’s welfare, as well as your own, is very important to you. We recognise the continuing need to provide the same great quality service across our practice, so we are bulk-billing all Medicare rebateable services*, during this time of crisis.

Telehealth Referrals are accepted now.

Visit www.skg.com.au/referrers/skg-radiology-telehealth/ to find out more. * Valid for current green Commonwealth Government Medicare Card holders.

When y o u d ep e n d o n th e r igh t r e su lt, t h e cho i c e i s cle ar , S K G R adio lo gy.

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 29

Managing endometriosis

By Dr Mini Zachariah, MBBS, MD, FRCOG, FRANZCOG Endometriosis is defined as the presence of endometrial-like tissue outside the uterus, which induces a chronic, inflammatory reaction. The prevalence ranges from 2-10% within the general female population but up to 50% in infertile women.

Symptoms include infertility and cyclical and non-cyclical pelvic pain, dysmenorrhoea, dyspareunia, dysuria and dyschezia. It is generally accepted that no correlation exists between the severity of such pain symptoms and the extent of disease.

Since there is currently no cure, treatment focuses on reducing endometriosis-associated pain and improving fertility requiring a multidisciplinary approach.

As a chronic disease, endometriosis requires a lifelong management plan that maximises medical treatment and avoids repeat surgical intervention. For women with pain from presumed endometriosis, empiric medical therapy with NSAIDs and hormonal suppression with combined hormonal contraceptives or progestogens is an acceptable strategy because these treatments are low risk.

In known endometriosis associated pain, clinicians are recommended to prescribe hormonal treatment as it reduces endometriosisassociated pain. The options include continuous use of hormonal contraceptives, Mirena IUS, progestogens, or antiprogestogens. Women who wish to conceive can use the NSAIDs alone.

For women with severe symptoms not responding to the above therapies, a trial of gonadotropinreleasing hormone (GnRH) analogue with add-back hormonal therapy is recommended. Where deep endometriosis pain is refractory to other medical or surgical treatment, consider prescribing aromatase inhibitors in combination with oral contraceptive pills, progestogens, or GnRH analogue.

Long-term pain management is complex and early involvement of 30 | MAY 2020

hormonal suppression is ineffective in the management of infertility.

Key messages Endometriosis is common and more so in infertile women Primary surgical treatment improves pregnancy rates in stage I/II endometriosis, but ART has a major role Early involvement of a multidisciplinary team is crucial to avoid repeat surgery.

a multidisciplinary team including pain specialist, physiotherapist and psychologist with relevant expertise is crucial.

Surgical Treatment When endometriosis is identified at laparoscopy, surgical treatment is recommended, as this is effective for reducing endometriosisassociated pain.

In symptomatic or expanding endometriomas, laparoscopic cystectomy is recommended. For asymptomatic or small ( 5 cm) endometriomas, the lesions are left in place because surgical excision can decrease ovarian reserve.

Medical therapy does not treat endometriomas.

For women with bothersome symptoms suggestive of deep endometriosis or extrapelvic lesions, medical therapy with hormonal suppression is appropriate. Surgery is indicated for women with ureteral or bowel obstruction or women whose symptoms do not improve with medical management.

Women with suspected or diagnosed deep endometriosis should be referred to a centre of expertise offering all available treatments in a multidisciplinary context.

Treating Infertility Couples presenting with infertility should complete evaluation for contributing male and female factors followed by an assessment for the need for primary laparoscopic surgery. Address potentially treatable infertility factors first. Medical treatment with

Women with infertility and symptoms suggestive of endometriosis, who have not had primary surgical treatment, are candidates for primary operative laparoscopy. Primary operative treatment is associated with improved pregnancy rates in women with stage I/II disease and reduced pain symptoms compared with diagnostic laparoscopy alone.

Repeat surgery does not improve fertility. For women with endometriosis who have no symptoms other than infertility, surgical treatment to improve fertility is not indicated.

Women with infertility and an asymptomatic endometrioma typically proceed with Assisted Reproductive Technology (ART).

Surgical removal is indicated for large endometrioma (>5cm) that is limiting oocyte retrieval during ART or is symptomatic. Ovarian surgery to remove the endometrioma can reduce ovarian reserve as assessed by anti-Mullerian hormone (AMH) levels.

Women with minimal to mild endometriosis (Stage I/II), under age 35 years can be offered a trial of natural conception or continued infertility treatment with ovulation induction and intrauterine insemination (IUI). Those with advanced endometriosis (Stage III/IV) or over age 35 years of age with Stage I/II endometriosis are suggested to proceed directly with ART. Women with non-reversible infertility factors (e.g., significant male factor component, decreased ovarian reserve) are recommended to proceed directly with ART. The impact of endometriosis on ART outcomes is variable.

Mild endometriosis (i.e., Stage I/ II disease) does not appear to negatively impact ART results in contrast to Stage III/IV disease. – References available on request Author competing interests – nil

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

CLINICAL UPDATE

BACK TO CONTENTS

CLINICAL UPDATE

Management of fibroids

By Dr Rae Watson-Jones, Obstetrician and Gynaecologist, Mt Lawley

SUDDEN SENSORINEURAL HEARING LOSS; AN OTOLOGIC EMERGENCY

Fibroids are common and have presence in up to 80% of women. They are monoclonal benign tumours arising from smooth muscle cells in the myometrium.

They can be single or multiple, small (under a centimetre) to massive (over 10cm). The exact aetiology is unknown.

They are hormonally responsive. Symptoms are usually experienced by women in the reproductive years. AfroCaribbean women seem to have the highest ethnic prevalence but women from all ethnicities are affected.

Treatment depends on the symptoms experienced.

Many women are asymptomatic and the fibroids are an incidental finding on imaging for another reason. Such women can be reassured that they do not need treatment.

Ultrasound is usually sufficient for imaging, but if the fibroid is large or rapidly growing, an MRI pelvis should be considered to rule out any features of sarcoma. If sarcoma is suspected, a gynaecology oncology opinion should be sought.

The most common symptom arising from fibroids is menorrhagia. The usual treatments for menorrhagia such as tranexamic acid, levonorgestrel IUD, endometrial ablation and hysterectomy can be offered. Women need to be warned that conservative treatments for menorrhagia have a lower success rate than if fibroids are not present.

Ullipristal (a selective progesterone receptor modulator) was a medical treatment for fibroids but has been withdrawn from the market due to cases of severe liver failure.

Myomectomy is, in general, a fertility-sparing operation and should be reserved for large fibroids 6cm and above.

Laparoscopic myomectomy has been complicated by the withdrawal of laparoscopic motorised morcellators from the market. Morcellation can cause small fibroid chips to disseminate throughout the abdomen, which may result in unintended seeding of a malignancy.

Some surgeons have developed personalised techniques for in-bag morcellation but as the instruments and equipment are not widely available, in addition to the litigious aspects, most large fibroids are removed via an open procedure. Women undergoing this procedure should have elective Caesarean delivery prior to the onset of labour in any future pregnancy.

Uterine artery embolisation can be an effective treatment for fibroids where available. It avoids the need for surgery and general anaesthetic and generally can be done as a day procedure. It causes reduction in the size and volume of the fibroid, which can relieve symptoms.

Submucosal fibroids can be effectively treated via hysteroscopic morcellation. Commonly used devices do not use energy which greatly increases the safety of the procedure.

Author competing interests – nil

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

Anne Gardner

Andre Wedekind

Post Dip. Aud., BSc

M.Clin.Aud., BHSc (Physiotherapy)

Sudden sensorineural hearing loss (SNHL) affects 5-20 per 100,000 people per year. frequencies occurring within three days.

It may be accompanied by aural fullness, tinnitus, vertigo and sound distortion.

SNHL generally occurs unilaterally but, after the initial insult, patients are at an increased risk of loss in the contralateral ear and ipsilateral relapse.

Suspected aetiologies are genetic causes, viral infections, autoimmune diseases and vascular insults. A lack of good diagnostic

meningitis, diabetes mellitus, syphilis) have broader health implications for the patient, warranting thorough investigations in all cases for reasons beyond hearing recovery alone.

Many aetiologies cause irreversible damage to the outer hair cells and cochlear support structures. In some cases, further damage can be prevented by timely diagnosis and treatment of the underlying condition.

The most common medical treatment for idiopathic sudden SNHL are systematic corticosteroids. There is some evidence for the additional inclusion of hyperbaric oxygen therapy. Intratympanic steroid injections have been used successfully in some cases as a salvage treatment following initial unsuccessful systemic steroid treatment.

Hearing recovery may not occur, can be complete or partial. The likelihood of recovery varies with a number of factors. Better recovery rates are seen at milder levels of hearing loss, in cases of low-frequency sloping hearing loss, and in cases without vertigo.

An urgent ENT referral is needed in cases of suspected sudden SNHL. The greatest recovery is seen if oral corticosteroids are administered within a week of symptom onset.

Long-term rehabilitation options look at treating the residual symptoms of sudden SNHL. Monitoring of hearing is recommended at two, six and 12 months to document recovery and guide aural rehabilitation (hearing aids or cochlear implants).

Physiotherapy may be required for vestibular rehabilitation, and a structured tinnitus management program may be required for persistent tinnitus distress.

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

MAY 2020 | 31

Acute management of persistent pelvic pain

By Dr Cliff Neppe, Obstetrician and Gynaecologist, Joondalup When first approached to write on the above topic, Coronavirus and the strain it is placing on our health systems was not even a consideration.

Given that the last place a patient currently wants to present is to a hospital emergency department, hopefully this will help to provide you with some tools to assist you and your patients through their acute flare of their persistent/ chronic pelvic pain (PPP). I have prepared this with the benefit of various meetings I have attended with pain specialists as well as using the excellent article published in the O&G magazine, Winter 2019 Vol 21 No 2.

PPP is caused by a complex combination of visceral and musculoskeletal pain, central sensitisation and pelvic floor

32 | MAY 2020

Key messages PPP affects 15-20% of women Flare-ups can be managed in the community Identify and manage triggers

hypertonicity, often accompanied by evolving psychological dysfunction. It affects 15-20% of women.

Acute exacerbations (flares), which can last days to months, are often occupied with significant fear and anxiety relating to escalation of pain. They are often triggered by menstruation, constipation, UTI/ bladder pain and pelvic muscle spasms.

We should aim to prevent unnecessary investigations,

admission and surgery and focus on identification and treatment of specific triggers while providing validation, reassurance and education to patients.

Management principles need to include excluding acute intraabdominal pathology, recognition and management of likely triggers of the flare, appropriate analgesia with the avoidance of opioids, assessment of psychological stressors and self-harm risk, acknowledgement of the patient’s pain, education and emphasis on self-management and appropriate follow-up.

Long-term management involves a multidisciplinary team approach including laparoscopic gynaecologist, pain specialist, psychologist, physiotherapist and referral pathways to psychiatry,

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

CLINICAL UPDATE

BACK TO CONTENTS

CLINICAL UPDATE functional gastroenterology as well as colorectal surgeons.

For acute presentations, history should focus on symptoms suggestive of pelvic muscle spasm; pain of sudden onset, unilateral or bilateral location, pain worse with movement, pain referring to anterior thigh, tender lower back or gluteal region, periods of overactivity or stress. Mental health assessments as well as medication history and prior services engagement is essential.

Examination should focus on excluding peritonism, deferring speculum examination unless warranted (PV bleeding or D/C) and bimanual examination of the uterus and adnexa for localised tenderness or masses. Acute spasm of the pelvic floor muscles will be evident in most women with PPP and often vaginal examination will not be tolerated.

Investigations should only be performed to support clinical findings. Urine dipstick to exclude pregnancy and UTI, bloods and imaging only if clinical evidence of alternate pathology. If indicated, pelvic ultrasound is the best imaging modality to define acute pelvic pathology.

Targeted acute management needs to include treatment of acute pathology as indicated, explanation of the likely trigger for the flare where it is known such as acute pelvic muscle spasm.

Address reversible causes such as constipation, UTI, dysmenorrhoea and hypertonic pelvic floor.

Non-pharmacological management should include heat packs as well as mindfulness and deep breathing.

A stepwise pharmacological approach is advised: • Simple analgesia – oral paracetamol with either oral or PR diclofenac • For anxiety and pain related to central sensitisation, Pregabalin 25-75mg • For pelvic floor spasm PV/PR diazepam 5mg (in a fatty base – compound pharmacy made) • For painful bladder symptoms – Ural or 500ml water with a tablespoon of bicarbonate soda • For constipation – mild: Movicol two sachets daily with up to four sachets daily for moderate; add dulcolax mane until bowel movement; severe: two microlax enemas with three dulcolax

tablets and eight sachets of Movicol in 1L of liquid over 12 hours • For dysmenorrhoea – Diclofenac 100mg PR • Opioids increase central sensitisation when used regularly and should be avoided where possible when acute pathology is excluded • If required consider, Tramadol 50-100mg, Tapentadol IR 50mg.

The acute exacerbation of PPP can be a frustrating encounter for both the patient and clinician, frequently resulting in unnecessary intervention that yields little information or clinical improvement.

By directing acute management at diagnosing and treating triggers, providing education and instituting multi-disciplinary team follow-up allows for outpatient management and avoids admission and its associated problems.

The author acknowledges Drs Thea Bowler, Michael Wynn Williams, Susan Evans, Jayne Berryman and Natalie Kiel of the Mater Mothers Hospital in Brisbane Author competing interests – nil

COVID -19 PANDEMIC RESPONSE Western Cardiology acknowledges that the COVID-19 outbreak has resulted in uncertainty for our patients and referrers.

We wish to advise that in an effort to ensure ongoing access to high quality and safe cardiovascular care we have made a number of changes to our service delivery.

During the pandemic response we will be BULK Cardiology testing in the metropolitan area.

BILLING all Medicare rebated

Easy access to Cardiology Consultation via Telehealth is available.

Our Cardiologists remain available for face to face consultation as required.

We continue to provide a NO GAP service for in-patient care.

Ph (08) 9346 9300 A/h 9382 6111 Chest Pain Centre 0411 707 017 E info@westerncardiology.com.au

www.westerncardiology.com.au

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 33

34 | MAY 2020

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

MAY 2020 | 35

Is the Mediterranean Diet good for fertility and pregnancy?

By Dr Joo Teoh, Obstetrician, Gynaecologist & Fertility Specialist, Perth There is strong evidence that the Mediterranean Diet (MD), which consists of plant-heavy, unprocessed fish and poultry, has many health benefits. Early research has found that the diet has a protective effect for cardiovascular diseases and certain cancers.

A healthy diet enhances the fertility potential by improving the quality of the gametes and optimising the intrauterine environment for nurturing the embryos. It improves the overall health of individuals and perhaps helps fight against adverse impacts from the environment Recent evidence suggests this diet improves fertility potential for both men and women. The beneficial effect is seen not only in groups with metabolic syndrome, but also in the general population. For instance, using a MD scoring system, females who have the highest adherence to the diet have been found to have a 66% lower chance of having ovulation problems and a lower risk, by 27%, of having other factors affecting their fertility.

Women with a higher MD score have a better chance of conceiving in IVF (29.1% vs 50%) and

Key messages The Mediterranean diet has benefits in reproduction A good diet can help prevent complications in pregnancy Good nutrition provides the optimal nourishment for fetal development. successfully giving birth (26.6% vs 48.8%). Likewise, men with a high MD score have the best semen quality in all measured parameters.

‘Western’ diet and fast food high in carbohydrates, processed and red meats, and sweetened drinks are associated with longer time periods to conception, and lower semen quality.

Laboratory studies have shown that MD improves the immune response in certain systems in the body, e.g. the gut cells. In the current environment of a viral pandemic, a healthy diet may have a protective effect against the infection.

In the 1918 influenza pandemic, the birth rates were reported to be significantly reduced. A study in Taiwan stated that the birth reduction was due to reduced

conceptions and embryonic loss during the first month of pregnancy, rather than through late-first-trimester loss. We are yet to learn the full picture of COVID-19. Reassuringly so far, there are no adverse outcomes being reported in early and mid-trimester pregnancies.

In pregnancies, adequate carotenoids intake has been shown to prevent pre-eclampsia and preterm delivery. A better diet quality, highly similar to MD, is associated with less likelihood of restricted growth. It is also beneficial for the development of intelligence of the babies. MD decreases the chance of gestational diabetes, macrosomia and emergency caesarean section.

In Singapore, a study has shown that vegetable and fruit-focused diet reduced likelihood of preterm-births.

Like other environmental exposures, diet in pregnancy has also been shown to affect the epigenetic imprinting of the offspring, potentially affect their phenotypes for future generations.

Author competing interests – the author has written a book on this subject

WA Health COVID-19 response

By Dr Jelena Maticevic, Public Health Registrar, HDWA The novel coronavirus, officially called SARS-CoV-2, causes the disease COVID-19. Since emerging in December 2019, it has captured the world’s attention. Western Australia’s health response is guided by the national approach developed through the Australian Health Protection Principal Committee (AHPPC), which receives advice from Communicable Diseases Network Australia (CDNA).

Preparedness and response to 36 | MAY 2020

COVID-19 is underpinned by the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19), an adaptation of the Australian Health Management of Planning for Pandemic Influenza (AHMPPI).

The Chief Health Officer oversees the health response, of which there are three main ‘arms’: the Public Health Emergency Operations Centre (PHEOC); the strategic Pandemic Clinical Service and

Operational Response (PCSOR) ; and the operational State Health Incident Control Centre (SHICC) .

Travel restrictions, border measures and quarantine advice implemented by government early in the response have provided time for the WA health system to prepare. This includes engaginging with health and non-health sector stakeholders to identify key actions required before and during the response.

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

CLINICAL UPDATE

BACK TO CONTENTS

CLINICAL UPDATE

Recurrent UTI

By Dr Trenton Barrett, Urologist, Nedlands Recurrent urinary tract infection (rUTI) is defined as two or more UTIs over six months, or three or more UTIs over 12 months. The recurrence can be reinfection (clear sample after treatment, recurrence often with a different organism) or persistence (no clear sample, same organism). Non-antibiotic prophylaxis should be considered to reduce the risk of antibioticrelated complications or resistance.

While any UTI in a male is a red flag event and may indicate abnormal structure or function of the urinary tract, UTIs in women are very common. In young women there is often no clear predisposing factor.

Even with rUTI, a large portion of patients may be young, immunecompetent women with structurally normal urinary tracts. In one study, 27% of young university-age women with their first UTI experienced at least one recurrence within the following six months. Recurrence is more common as women age. In women over 55 some 53% report UTI recurrence.

First line therapy for a symptomatic UTI is a single course of appropriately targeted antibiotics. If the infection recurs, there may be a role for

In WA, planning for and responding to the impact of COVID-19 on hospital services is informed by clinical working groups. Planning considers a variety of scenarios to enable services to manage business continuity, as well as the demand from COVID-19.

This includes strategies for patient triaging, the establishment of COVID clinics, stewardship of resources and cohorting of patients.

Surge capacity is a key element of planning, particularly if the COVID-19 burden on the health care system coincides with the influx of annual influenza cases.

Laboratory capability for COVID-19 testing in WA has been prioritised.

Specimen collection initially occurred at identified specimen collection centres. As the situation evolved and

Key messages Recurrent UTIs are more common in women, increasing with age Long-term antibiotic prophylaxis can cause resistance Consider non-antibiotic prophylaxis.

prophylaxis after the active infection is treated.

Long-term antibiotic prophylaxis with rotating low-dose antibiotics over six months is effective but can damage the intestinal flora and promote the development of bacterial resistance.

Non-Antibiotic prophylaxis A simple option is urinary sterilisers such as methanamine (Hiprex). This is a urinary steriliser that is converted to formaldehyde in the urine. It does not lead to bacterial resistance and has a low side effect profile. There is some evidence that it is effective as a short-term non antibiotic prophylaxis where the urinary tract anatomy is normal. It works best in acidic urine so is often taken in combination with vitamin C while avoiding urinary alkalinisers.

shortages of key laboratory reagents loomed, community testing moved to COVID clinics, supported by domiciliary collection services in the Perth metropolitan area.

Testing suspect cases occurs within the limits of the current case definition. A surveillance system has been implemented to assist the detection of cases and close contacts, protect vulnerable groups through early case detection and detect any community transmission.

Primary care services are key to managing the response.

Engagement includes ongoing liaison with clinicians and peak bodies about implementing infection prevention control measures including phone triage of patients, recommendations

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

Another option are drugs that replenish the bladders glycosominoglycan (GAG) layer such as hyaluronic acid plus chondroitin (e.g. iAluril). This is an intravesical therapy that replenishes the GAG layer in the bladder, which is a natural defence against UTI. Meta-analysis has shown a reduction in 2.6 UTI episodes per patient per year with these agents. These results are likely conservative because in all but one study the comparator was prophylactic antibiotics not placebo.

Vaginal estrogen replacement can be beneficial in postmenopausal women without specific contraindications.

Emerging vaccines and immunotherapies show promise.

Uromune is a vaccine for recurrent UTIs administered sublingually as a spray, with two pumps every 24 hours over three months. It contains a suspension of inactive whole bacteria (E coli, K pneumoniae, P vulgaris and E faecalis). This isn’t available in Australia, but multiple studies show up to 90% of patients who had previously suffered rUTI reported a reduction to 0-1 UTIs over the 12 months after starting treatment.

Author competing interests - nil

for the use of personal protective equipment (PPE), developing guidelines, and providing public health advice and education.

Guidelines, protocols and factsheets to guide health professionals will continue to be developed throughout the response.

Key non-health sector stakeholders play a crucial role in a response of this nature, ranging from care for people in self-isolation or home quarantine through to supporting recommendations to ‘flatten the curve’ by physical distancing. It is essential the community is engaged and empowered throughout the health system’s response and health professionals continue to provide compassionate care, promote factual information and dispel fear.

MAY 2020 | 37

Gastrostomy can help children with intellectual disability

By A/Professor Jenny Downs, Telethon Kids Institute Research led by the Telethon Kids Institute analysed linked administrative, health and disability data from Western Australia and New South Wales and found children with intellectual disability who underwent gastrostomy experienced fewer all-cause hospitalisations, including fewer hospitalisations for epilepsy, than before undergoing gastrostomy.

The rate of hospitalisations for acute respiratory illnesses was not impacted.

Gastrostomy insertion began in the early 1980s and has become more common since 2000, particularly for children with severe intellectual disability who often experience difficulties taking in adequate nutrition, fluids and medications.

Parents spend long periods feeding their child, which can cause considerable strain. Gastrostomy can address this problem.

Yet, while a common procedure, the evidence of its health outcomes is sparse.

The progress of hundreds of children from WA and NSW born with intellectual disability between 1983 and 2010 and, who later underwent gastrostomy, adjusting for time because hospitalisations generally reduce as children grow older, was tracked.

These children experienced about 30% decrease in hospitalisations for all causes by five years postprocedure. This was more so for children who were under age three at gastrostomy insertion, possibly due to improved nourishment and intake of fluids allowing for improved growth.

Epilepsy-related admissions also declined by approximately 50% by five years post-procedure. More consistent delivery of anti-epilepsy medications may be one of the reasons for this.

There was no improvement for hospitalisations for acute respiratory illnesses. This is possibly because even if you remove the 38 | MAY 2020

Key messages Carefully assess the child’s history of hospitalisation, swallowing function and gastro-oesophageal reflux Discuss clinical indications, potential for complications, and implications for quality of life.

Post gastrostomy, monitor feeding regimens and any continued gastro-oesophageal reflux to reduce the risk of respiratory illnesses from continued aspiration.

oral ingestion of food and liquid, children with severe disability may still struggle with swallowing their own saliva or experience reflux, which can lead to respiratory issues.

Gastrostomy has the potential to improve overall health and quality of life for children and families. However, there can be complications, and some families

prefer to avoid more medicalisation and keep the pleasure of eating for their child as long as possible.

It’s not a black and white decision and very careful and detailed discussions between clinicians and families is needed.

However, for those who do choose gastrostomy, we’ve seen benefits for children and their families. As well as better health, nutrition and easier to deliver medications, there is opportunity for greater independence when the child is able to feed away from home and feeding times are less frustrating for both child and caregiver. Each of these factors can support general health, mental health and quality of life.

The author acknowledges the input of Professor Lakshmi Nagarajan and Dr Andrew Wilson, both from Perth Children's Hospital Author competing interest. The author was involved in this research

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

BACK TO CONTENTS

CLINICAL UPDATE

WINE REVIEW

BACK TO CONTENTS

Review by Dr Martin Buck

Chateau Tanunda – no wonder It is not often that you get to review wines from a family owned Australian winery that has been in production in the Barossa, whose history spans the 19th, 20th and 21st centuries.

Owned by the Geber family, the ‘Chateau’ has had a rebirth with some iconic wines made with traditional techniques and fruit from some of the oldest vineyards in the country. Historic wineries such as Chateau Tanunda are part of our wine DNA and reflect how far we have come from our European winemaking roots. These bold and elegant wines are worth preserving.

Chateau Tanunda 2019 Single Vineyard Eden Valley Chardonnay This Chardonnay is a lightly oaked wine with eight months of mostly seasoned oak after traditional whole-bunch basket pressing and barrel fermentation. The result is a complex wine with some lime and oak aromas, a soft fruit driven palate with a nutty finish. A stylish wine with interesting complexity.

Chateau Tanunda 2017 Grand Barossa Shiraz This is a wine made from small batches sourced from multiple local terroirs to extract the characters of the sub-regions. Matured in oak for eighteen months, it is a balance between bold fruit and delicate tannin flavours. There are great dark berry flavours with peppery spice and leather combined with subtle, balanced tannins. This wine is a great reflection of all things Barossa.

MEDICAL FORUM | WOMEN 'S HEALTH ISSUE

'S EWER REVI

PICK

Tanunda The Old Cooperage 2017 Grenache Grenache is one of my favourite varieties and there a none better than those from heritage vineyards in the Barossa. The Old Cooperage 2017 Grenache is a limited single vineyard wine from the Stonewell sub-region which has been given the full small parcel process – basket pressed, small fermenters and eighteen months of seasoned oak.

The result is a handsome, mediumbodied Grenache with a lifted cherry, raspberry and liquorice nose, following on to juicy palate full of perfumed fruit and soft, fine tannins.

This is truly a majestic Grenache and ticks all my boxes!

Chateau Tanunda 2017 Terroirs of the Barossa Ebenezer District Shiraz Shiraz and Barossa are a perfect match and these last two wines celebrate the rich history of that combination. Ebenezer District Shiraz is from the northern Barossa and is a big 15.5% bold red wine. Deep purple-red in colour with intense fruit aromas and a hint of lavender, it’s a big wine that still has amazing finesse with seamless, fine tannins. A wine that will develop beautifully over many years of cellaring.

MAY 2020 | 39

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

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

We take this very seriously too.

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

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

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

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

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

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