Mind over matter Aged & palliative care |
November 2023
CVD risk & falls, neuroimaging, sensory loss, pain & palliative care
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Cathy O’Leary | Editor
One for the ages In many ways, we have to sort out what is inevitable and what is not.
When Queen Elizabeth died last year at the age of 96, two words on her death certificate caused quite a stir among some gerontologists and ageing experts. The certification of cause of death read simply ‘old age.’ Critics pointed out that old age is not a disease and should not be used as a cause of death. Some objected on the basis that it legitimised ageism and ignored the multiple causes of ill health in later life – and even detracted from treatment and prevention. In the debate that followed, the use of other terms on death certificates was reported, such as “the frailty of old age,” or even a past practice of recording the death of an elderly person without an obvious medical cause as being “taken by a visitation of God.” As many writers have commented in various adaptations over centuries, there are two things certain in life – death and taxes. That said, while we might not be able to keep the taxman at bay, advances in science and medicine are helping to push back average life expectancy and delay death. But it is not all about the numbers. Quality of life in later years is arguably just as important, although sometimes harder to measure. In many ways, we have to sort out what is inevitable and what is not. And that’s where research and treatments in dementia and Alzheimer’s disease come into their own, because those conditions are not always a given. This month we look at ways to keep our brains and bodies from ageing prematurely, so that any extra years of life are not just for the record books but actually worthwhile.
SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission. DISCLAIMER Medical Forum is published by Medforum Pty Ltd (Publisher) as an independent publication for health professionals in Western Australia. Neither the Publisher nor its personnel are medical practitioners, and do not give medical advice, treatment, cures or diagnoses. Nothing in Medical Forum is intended to be medical advice or a substitute for consulting a medical practitioner. You should seek immediate medical attention if you believe you may be suffering from a medical condition. The support of all advertisers, sponsors and contributors is welcome. To the maximum extent permitted by law, neither the Publisher nor any of its personnel will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors and do not represent the opinions, views or policies of Medical Forum or the Publisher. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the Publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Competition and Consumer Act 2010 (Cth) as amended. All advertisements are accepted for publication on the condition that the advertiser indemnifies the Publisher and its personnel against all actions, suits, claims, loss or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Medical Forum has no professional involvement with advertisers other than as publisher of promotional material. Medical Forum cannot and does not endorse any products.
MEDICAL FORUM | AGED & PALLIATIVE CARE
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CONTENTS | NOVEMBER 2023 – AGED & PALLIATIVE CARE
Inside this issue 20 30
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FEATURES
IN THE NEWS
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Editorial: One for the ages – Cathy O’Leary
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News & views
Cover story: Alzheimer’s answers still elusive Habit of a lifetime – alcohol and age Close-up: Dr Michael Page New stroke targets
LIFESTYLE 56 Supporting women performers 58 Art re-imagines the blues 59 Wine review: Cape Mentelle
In brief 2023 Surgical Audit Challenging social drinking norms – Sarah Rusbatch
36 Testing PPE 41 Reflections on life – Dr Joe Kosterich
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Dr Greg Witherow from Perth Orthopaedic and Sports Medicine Centre is the lucky winner of our September doctors dozen wines from Arlewood Estate.
PE M E N T E L L
DOCTORS DOZEN
This month we have more premium wine to win, from Margaret River winery Cape Mentelle, which is reviewed by Dr Craig Drummond on page 59. We also have a swag of double passes, courtesy of Sony Pictures, to see the action epic Napoleon, starring Joaquin Phoenix, which opens in cinemas on November 23. For your chance to win, use the QR code on this page or go to www.mforum.com.au and hit the competitions tab.
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EDITORIAL TEAM Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Production Editor Jan Hallam 08 9203 5222 jan@mforum.com.au
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Supporting hearing and vision in residential aged care Prof Hamid Sohrabi & Dr Carly Meyer PhD
Dementia: when does neuroimaging play a role? Drs Aden McLaughlin, Shoba Ratnagobal & Richard Warne
Journalist Eric Martin 08 9203 5222 eric@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Graphic Design Ryan Minchin ryan@mforum.com.au
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New CVD risk assessment guidelines Dr Michelle Ammerer
Getting to the heart of falls risk Mr Abadi Gebre
Ensuring quality end-of-life care Dr Charles Inderjeeth
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Managing pain in older adults Dr Rajiv Menon
Can we help heart-sink patients if we have heart-sink systems? Dr Siobhain Brennan
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When words matter Dr Michael Gannon
Colleges the backbone of quality medicine Dr Sanjay Jeganathan
A village required to treat AF Dr Justin Ng
Integration of mental health services vital Dr Mike Verheggen
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NEWS & VIEWS
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Liver cancer vaccine hope Dr Ankur Sharma, Laboratory Head at Harry Perkins Institute of Medical Research, has been awarded a CSL Centenary Fellowship valued at $1.25 million over five years for his work in the development of a vaccine for liver cancer. Dr Sharma has discovered how liver cancer cells grow together in a similar way to the rapidly dividing cells of a human embryo, which allows them to resist treatment. He is now trialling ways to analyse these cells and determine which liver cancers may respond to immunotherapy, including the development of anticancer vaccines which could one day help doctors to manage cancer as a chronic disease. While the similarities in how cells behave were previously known, Dr Sharma’s research identified the role of the microenvironment in which they existed. “We know that cancer cells are very plastic and some of the cancer cells could behave like embryonic cells,” he said. “My research has shown that the tumour microenvironment mimics the features of embryonic development, a phenomenon I term the ‘onco-fetal ecosystem.” His research suggests that as patients age, they tend to see more cell mutation. This is particularly marked in the case of liver cancer, given the organ’s ability to regenerate. “If we understand these phenomena, we will be able to target fetal-like reprogramming and may be able to
Your say on RGs Doctors are being asked to comment on plans to recognise rural generalist medicine as a specialty. Formal recognition is getting closer with the Australian College of Rural and Remote Medicine and Royal Australian College of General Practitioners encouraging doctors and the community to take part in the public consultation on the second stage application. The Rural Generalist Recognition Taskforce chaired by the National Rural Health Commissioner Adjunct Prof Ruth Stewart and senior College representatives are driving these efforts. The second stage application assessment is being undertaken by the Australian Medical Council for the Medical Board of Australia. 4 | NOVEMBER 2023
prevent cancers,” he said. “We want to make vaccines that deplete the microenvironment where cancer seeds are thriving.” He hopes this could turn the patient’s immune system against the cancer cells, eventually killing them. “Over the next five to 10 years, we aim to develop vaccines against fetal-like cells and show proof of principle in clinical trials that we could prevent cancer in high-risk patients,” he said. “I think in the next 20 to 30 years, we might be managing cancer like a chronic disease, where instead of killing cancer cells, we might be trying to manage the cancer in its smallest form, so it does not evolve and become resistant to treatment.”
ACRRM president Dr Dan Halliday said that the stage two national consultation was the last critical milestone before the final assessment and referral through governance bodies for determination.
until Tuesday 12 December and can be accessed at: www.medicalboard.gov.au/News/ Current-Consultations.aspx
“It is expected that building the RG workforce will address the current $6.55 million underspend that currently exists,” he said. “With recognition comes the opportunity to create a single national rural generalist quality standard which is transparent, safe, purposedesigned, and easily understood by systems, patients and doctors.”
COVID-19 has become the first infectious disease to rank in the top five causes of death for more than 50 years. It was ranked the third leading cause of death in 2022, behind heart disease and dementia in the Australian Bureau of Statistics annual figures.
RACGP president Dr Nicole Higgins said the recognition would value the additional skills and scope provided by rural and remote doctors, and help to build a strong workforce. The public consultation is open
COVID’s deadly stats
“This marks the first time an infectious disease has appeared in the top five leading causes since 1970, when influenza and pneumonia was ranked fifth,” said ABS’s Lauren Moran. continued on Page 6
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Two WA Health staff who helped lead the State’s COVID-19 emergency response made the King’s Birthday Honours List – Dr Clare Huppatz and Liz MacLeod.
Fiona Stanley Hospital medical intern Alexander Armanios recently won the Young Scientist of the Year award at the 7th World Congress on Controversies in Breast Cancer meeting in Dubai.
Perth paediatric anaesthetist Professor Britta Regli-von Ungern-Sternberg is among 27 new fellows elected to the Australian Academy of Health and Medical Sciences. The chair of paediatric anaesthesia at UWA has led research to make surgery in children as safe and pain-free as possible.
St John of God Bunbury Hospital obstetrician and gynaecologist Dr Diane Mohen has retired from medical practice, after a career spanning 40 years, initially in general practice before moving to Bunbury in 1996 to provide services at the hospital.
St John of God Health Care has announced the appointment of Professor Peter Bremner to its Board. He is a respected thoracic physician and professor for respiratory medicine at SJOG Murdoch Hospital.
Two WA Country Health Service teams have been named finalists in the 2023 Palliative Care in WA Awards. The East Kimberley Palliative Care team and Fitzroy Crossing Hospital were recognised for their work in Aboriginal communities.
6 | NOVEMBER 2023
NEWS & VIEWS
Vale Dr Rod Moore Dr Rod Moore, one of the first doctors in Australia to graduate in the area of sports medicine, died last month after a battle with cancer. He was considered a trailblazer in sports medicine, being the first doctor in Western Australia to set up an integrated multidisciplinary sport medicine practice, Sportsmed, which opened at Murdoch in 1990 and expanded to St John of God Subiaco in 1999. Dr Moore was doctor at the South Fremantle Football Club and the inaugural West Coast Eagles doctor, earning respect as a passionate and dedicated mentor who was also highly involved in the training of the next generation of sport medicine doctors. As the Eagles’ club doctor for 26 years, he was known for his attention to detail and empathy which helped to fast-track many players on the road to recovery from injury. He had held many other roles, including once-president of MDA National.
continued from Page 4 “Broken down by sex, we saw that COVID-19 was the third ranked cause of death for males (5,484) and the fourth ranked cause of death for females (4,375). Those who died from COVID-19 had a high median age at death of 85.8 years,” she said. Dementia remains the leading cause of death among women and the second leading cause of death for men. Stroke and lung cancer rounded out the top five leading causes of death. Overall, there were 190,939 deaths recorded in 2022 – 20,000 more than the previous year.
Telehealth on wheels WA Primary Health Alliance has commissioned telehealth technology provider Visionflex to deploy telehealth carts to residential aged care homes to connect GPs and other healthcare providers to patients living in these facilities across WA. The technology is expected to improve access for aged care residents to primary care services, reduce travel time for health professionals, facilitate better management of chronic conditions, increase early intervention, and potentially decrease hospital admissions, especially after hours. The telehealth carts are equipped with a video call platform and Bluetooth-enabled devices
including pulse oximeter, blood pressure cuff, digital stethoscope with headphones, and a highdefinition examination camera. The platform allows clinicians to live monitor residents’ vital signs and manage imaging for wounds and skin conditions, with data integration into practice management software and uploaded to My Health Record. About 150 aged care homes have expressed interest in securing equipment, and it is expected that the first 75 carts will be in use within the next few months.
Stroke drug could offer more A new drug being trialled for stroke in Perth could also help people with Parkinson’s or Alzheimer’s. Argenica Therapeutics, a WA-based biotechnology company developing therapeutics to reduce brain tissue death after stroke and other brain injuries, said preclinical research findings showed possible benefits for diseases such as Parkinson’s and Alzheimer’s. The data is from the laboratories of Argenica’s Chief Scientific Officer, Professor Bruno Meloni, who is Head of Stroke Laboratory Research at WA’s Perron Institute, and Associate Professor Ryan Anderton from Notre Dame University. One of the hallmarks of Parkinson’s is the accumulation of aggregates of continued on Page 8
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Scanning for heart problems The WA Country Health Service is using innovative technology to help stamp out rheumatic heart disease in the Pilbara. WACHS Pilbara is partnering with Menzies School of Health Research to take part in NEARER SCAN – Non-Expert Acquisition and Remote Expert Review of Screening – using echocardiography images from child health and antenatal clinics to evaluate the implementation of a novel diagnostic tool to screen for RHD in at-risk children and pregnant women. Chantelle Pears, WACHS project nurse coordinator for NEARER SCAN, said RHD was a serious disease involving damage to one or more of the four small heart valves and disproportionately affected Aboriginal and Torres Strait Islander people in WA. Using portable heart ultrasound technology, the handheld echocardiography devices can be used in community settings to scan the heart to help detect evidence of RHD. WACHS is supporting eight healthcare workers, including five Aboriginal health staff, to undertake non-expert echocardiography training for the study. Supported by a team of experts, they will take part in training sessions, including theoretical, hands-on and face-to-face training to perform RHD screening echocardiograms in the Pilbara. Ms Pears, pictured, said the technology would help to increase equitable access to effective and culturally safe RHD care. “We have a real opportunity to change the landscape of how RHD is detected, diagnosed and managed in the Pilbara,” she said. The project will also support upskilling country clinicians.
continued from Page 6 the protein alpha-synuclein (α-syn) in neurons. This neural protein plays a role in the transfer of information between neuronal cells and in the immune response in non-neuronal cells Professor Meloni said the results confirmed that ARG-007, also known as R18D, reduced both cellular uptake and aggregation of α-syn. “Importantly, additional data recently generated also confirms a dosedependent inhibitory effect of ARG007 on α-syn aggregation,” Professor Meloni said. “The data demonstrated that as the dose level of ARG-007 increased, so too did the inhibitory effect on α-syn aggregation. “The combination of both sets of data suggests that ARG-007 may also be beneficial for Alzheimer’s disease, as clinical data is beginning to emerge regarding the presence of α-syn pathology in patients with that disease. “It strengthens the scientific hypothesis that ARG-007 may have broader neuroprotective therapeutic potential. with possible application in a range of neurodegenerative diseases, including Alzheimer’s and Parkinson’s.” 8 | NOVEMBER 2023
On your bike for cancer Doctors have once again made up a significant chunk of the almost 2000 riders who helped raise millions of dollars for cancer research in WA last month. A record $8,674,649 was raised by the nation’s biggest charity bike ride, the MACA Cancer 200 Ride for Research. The money will go to the Harry Perkins Institute of Medical Research to support investigations into the hardest to treat cancers. Nearly 2000 riders set off from Optus Stadium on a 200km two-day ride to Mandurah and back over one weekend. Perkins director Professor Peter Leedman said vital new cancer research would be supported by funds from the ride. “It is made possible because West Australians want to make a difference for cancer patents. The fact that Australia’s biggest charity ride is in WA says a lot about the giving spirit we have here,” he said. MEDICAL FORUM | AGED & PALLIATIVE CARE
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Cervical screening self-collection increases choice and supports better outcomes Self-collection of a sample for HPV testing is now available to those eligible for cervical screening. This change is helping to increase participation in the National Cervical Screening Program. Women and people with a cervix aged 25 to 74 years have the choice to collect their own vaginal sample for HPV testing using a swab or have a healthcare provider collect a cervical sample using a speculum. Dr Sarah Smith, GP Liaison at King Edward Memorial Hospital, said that both cervical screening options are accurate, safe and effective and that recent data showed that more than 18% of all HPV screening tests in WA are self-collected. “A cervical screening test using a self-collected vaginal sample is just as accurate for the detection of HPV as a clinician-collected sample taken from the cervix during a speculum examination,” said Dr Smith.
“By offering the choice of selfcollection, we remove some cultural and personal barriers that may discourage some people from screening. “Self-collection provides a more acceptable option for many groups that are less likely to request a screen, including Aboriginal and Torres Strait Islander women, culturally and linguistically diverse women, gender and sexually diverse people, people with disabilities, women who have experienced sexual violence and those with a previous negative cervical screening experience. “The role that healthcare providers play in offering choice to their patients will help enable early detection of pre-cancerous cell changes and reduce the risk of progression to cervical cancer.”
options, including which collection method is most appropriate for each person and their personal circumstances. Talk to your local pathology provider to: • confirm you have the correct collection device for selfcollected vaginal samples • confirm handling and processing arrangements for self-collected vaginal samples, including arrangements to refer samples to another lab, where necessary • order self-collection devices, pathology request forms and patient information sheets. There are many resources and free online learning available for clinicians and patients from the WA Cervical Cancer Prevention Program, including resources to help guide discussions with women from Aboriginal communities and women who may have experienced female genital cutting.
Healthcare providers are best placed to talk with their patients about cervical screening testing
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NOVEMBER 2023 | 9
When words matter Dubbed the “MeToo of childbirth,” more than 4000 submissions have been made to the NSW Select Committee on Birth Trauma, with claims that many women have experienced some form of “obstetric trauma” or “obstetric violence.” But many doctors are alarmed by the language and messaging. Perth obstetrician Dr Michael Gannon responds.
In June this year, the Legislative Council in New South Wales established a Select Committee into birth Trauma. Highly regrettably, point 1(a) in the terms of reference used the term ‘obstetric violence’. I have met, trained and been trained by some brilliant obstetricians in Australia, Ireland and Britain. I have met some of lesser talent. But in 25 years, I have not on even a single occasion seen use of ‘physical force intended to hurt, damage, or kill someone.’ The use of the term ‘obstetric violence’ is offensive and stupid in equal measure. It surely goes to the highly ideological motivation of the inquiry but reduced the opportunity for obstetricians and midwives to more meaningfully and less defensively explore the significant psychological and physical morbidity felt by a lot of women after their births. Antenatal education that focuses
too heavily on ‘normal’ birth leads to unrealistic expectations. In my experience in taking care of women in public and private hospitals across three countries, those who are most likely to feel traumatised by their birth are those who received treatments or if you must ‘interventions’ they had little understanding of. Quality antenatal education gives women and their partners accurate information about the differences between spontaneous and induced labour. It explains to women how often augmentation of labour is indicated, i.e. many patients are managed almost identically to those being induced after prelabour rupture of membranes (PROM) without labour or in the context of a wandering, spurious or ineffective spontaneous labour. Robust antenatal education includes information on the instances in which antibiotic prophylaxis is indicated, the pros
Bone-brain link for Alzheimer’s? WA-led international research has raised a possible link between osteoporosis and the risk of developing Alzheimer’s disease. Findings from a collaboration involving Professor Minghao Zheng’s bone and brain research group at the Perron Institute and UWA, and Professor Ralph Martins’ Alzheimer’s research group at Edith Cowan and Macquarie universities, suggest that bone loss as people age may result in the release of a factor that affects brain function. 10 | NOVEMBER 2023
and cons of different analgesia options, and a basic understanding of the maternal and fetal indications for assisted vaginal delivery, be that vacuum extraction or forceps. It is also important to understand the reasons why 10 to 15% of patients have an emergency caesarean section. Good antenatal care provides information on the likely length of inpatient stay and the physical, psychological and pastoral supports offered to families in the days, weeks and months after birth. Obstetrician-led care can result in lower ‘trauma’ rates as patients are far more likely to be informed about treatments e.g. induction of labour, elective and emergency caesarean section, and operative vaginal delivery. The rate of thirdand fourth-degree tears is much lower. There is not a shared language when it comes to ‘birth trauma’. There is an organisation called
The study involving several national and international institutions investigated the association between levels of sclerostin, a protein mainly produced by bone cells, and amyloid beta load in the brain measured by PET-scanning, which is one of the major hallmarks of Alzheimer’s. Study leader Dr Jun Yuan, from Perron and UWA, said increasing age was a known risk factor for both Alzheimer’s and osteoporosis. “Also well-observed clinically is the correlation between people with osteoporosis and a tendency to develop Alzheimer’s in later life,” Dr Yuan said. “There has, however, been a lack of clear understanding of whether bone-derived factors are associated with MEDICAL FORUM | AGED & PALLIATIVE CARE
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in childbirth, which include an increased incidence of advanced maternal age at first birth, obesity, chronic disease, affective disorder and assisted reproduction. With reduced family size, a higher proportion of births are in primigravidae, which are inherently more difficult. Our courts have no sympathy for deviations from best practice care. The insurance costs incurred by those private hospital operators who deliver maternity care continue to escalate. We should avoid the fantasy that birth was ‘better’ a generation or two ago. But we must also concede that improvements in maternal and perinatal morbidity and mortality have come at a cost. Many treatments that mothers and babies receive are uncomfortable. Importantly, they are not always well-explained. Birthrights in both Australia and Britain. The Australian ‘chapter’ has long focused on the difficulty women have in accessing accurate evidence-based information and support when they pursue Vaginal Birth After Caesarean (VBAC). In Britain, women are far more likely to receive care where a midwife is lead clinician. Birthrights in that country has a keener focus on pelvic organ prolapse, urinary and faecal incontinence, and inadequate analgesia in labour as consequences of a culture of promotion of vaginal birth. These differences are notable and relevant, but in no way diminish the fact that a significant minority of women in developed countries have much physical and psychological healing to do after their births.
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists has invested much energy in promoting understanding of so-called ‘nonstandard birth plans.’ But best practice care of women in the 21st century, whether that be provided by midwives, GP obstetricians or specialist obstetricians, will by extension occasionally involve multidisciplinary teams which include anaesthetists, paediatricians and psychiatrists. Comparable countries with midwife-led care, e.g. New Zealand, do not have vastly lower caesarean section rates.
Listening to patients, understanding their motivations, and recognising differences in culturally and linguistically diverse communities are all extremely important. Levels of anxiety in the community continue to escalate. Expectations continue to grow. None of this removes the ethical and professional duty of maternity care providers to lend a listening ear and to continue to strive to provide the best possible care for mother and baby. ED: Dr Michael Gannon is an obstetrician and gynaecologist at St John of God Subiaco Hospital and chair of the WA Perinatal and Infant Mortality Committee.
We should understand the drivers behind increasing morbidity
the brain changes in Alzheimer’s disease. This latest research indicates that sclerostin has a potential negative impact on the brain, playing a role in agerelated cognitive decline.” Dr Yuan said a link between sclerostin and amyloid beta deposition in the brain of older adults with high risk of developing Alzheimer’s indicated that elevated levels of sclerostin in the blood were a promising biomarker for early detection of this disease. “This is the first study pointing to direct evidence of bone impact on Alzheimer’s disease and will draw further attention to the importance of the two-way interaction between bone and brain, known as the bone-brain axis.”
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Dr Jun Yuan
NOVEMBER 2023 | 11
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Alzheimer’s answers still elusive A lot of hope – and hype – surround the immunotherapy drugs flagged to treat Alzheimer’s disease. The jury is out on their real-life benefit, while the push continues for earlier diagnosis.
By Cathy O’Leary
12 | NOVEMBER 2023
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COVER STORY The need for effective treatments is undeniable. Unless there is a medical breakthrough to seriously dent the predicted increase, the number of Australians living with dementia is expected to tip over 500,000 within two years. And the big contributor will be Alzheimer’s disease, the most common form of dementia accounting for up to 70% of cases, as well as being the number one cause of death in Australian women, and the second biggest cause in men. So, pressure is on to find ways to treat existing disease, as well as pick up very early symptoms that might be amenable to change, assuming effective drugs have come online. Immunotherapies are already used to treat cancer, and some researchers believe that by clearing amyloid plaques from the brain, these drugs might be able to slow down Alzheimer’s disease. But speakers at a recent webinar for Australian doctors have tempered some of the enthusiasm, arguing the results from trials are not conclusive, nor is there enough evidence that amyloid removal is the holy grail of Alzheimer’s prevention or treatment. The event, hosted by health commentator Dr Norman Swan, was run in association with the WA Primary Health Alliance and several local Primary Health Networks, and featured two WA-based doctors. They discussed not only latest advances in Alzheimer’s treatment – including the antibody drugs donanemab and lecanemab – but also the imperative to pick up and treat early dementia. Professor Amy Brodtmann, lead of cognitive health initiative in the Department of Neuroscience at Monash University, said beta amyloid was still a primary hypothesis but many older people could have it in their brains and it might mean nothing. “We’ve gone through huge stages, initially this was thought of as a senile disease that was a part of normal ageing, then it was thought to be a vascular degeneration in the
“Possibly 20% of people over the age of 60 had mild cognitive impairment, and not all were in the category that had been used in the drug studies. The studies have included people with mild cognitive impairment with amyloid protein, as well as people with early or mild dementia...” brain, and then these two proteins tau and amyloid were considered important,” she said. “The amyloid hypothesis as the driver, the trigger, and the reason for cognitive decline is certainly still one that is promoted by many. There are also people who think there are a lot of reasons for the brain failure that results in Alzheimer’s and dementia. “When we look at the pathology, people don’t have just one pathology in their brain. They have amyloid and tau, and Lewy bodies that don’t just have to be seen in Lewy body dementia, and they have lots of vascular disease, particularly if they’re in their 70s and 80s. “So, to think there’s just one protein that’s causing everything is a little simplistic.” Professor Leon Flicker, an expert in geriatric medicine at UWA and executive director of the WA Centre for Health and Ageing, told the webinar that about 30-40% of older people had amyloids in their brain and most of them would die without ever getting dementia. “The median age of onset for dementia, or Alzheimer’s dementia, is about 82-83 years of age, so this is a condition of older people, and quite old people. “The Alzheimer’s pathology would only explain about 40% of those people. About 25% is due to vascular, and about 15-20% is due to another protein TDP-43, and the alpha-synuclein is about 12%. So, the amyloid pathology
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doesn’t explain the dementia of the majority of older people.” Dr Swan said that despite some uncertainties about the link between beta amyloid and Alzheimer’s, there was a lot of focus on ways to ‘hoover’ it from the brain with drug treatments. Dr Brodtmann added that after two decades of failures, there had been recent success in removing amyloid, particularly with donanemab. “But one of big issues is that the clinical benefits of the removal of amyloids seems fairly minor, and it’s difficult to know if it’s clinically significant. And in addition, we know that all of these drugs so far are associated with increased brain atrophy, which is concerning because we’ve always said that brain atrophy is a marker of brain degeneration. So this would suggest potentially that they’re degenerating faster. “At the last couple of meetings where these drugs have been presented, people have said the (results) are proof of the amyloid hypothesis, but if it was proof then if you had no amyloid in the brain you shouldn’t continue to decline, and you shouldn’t continue to dement, yet people are.”
Selective studies Professor Flicker said another issue was that possibly 20% of people over the age of 60 had mild cognitive impairment, and not all were in the category that had been used in the drug studies. “The studies have included people with mild cognitive impairment with
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Alzheimer’s answers still elusive continued from Page 13 amyloid protein, as well as people with early or mild dementia,” he said. “But It’s very difficult to extrapolate those results to a general population. “These are people with nothing else wrong with them, (the studies) have screened out people with vascular damage, or co-morbidities, so they’ve picked a group which would be the best group for the drug early on, and it’s not clear how you would actually get that group on treatment generally.” Dr Brodtmann said while there were
many trial drugs in the pipeline, there was unlikely to be a single magic bullet.
on GPs because the belief was that you had to get in early otherwise it was too late for the drugs to work.
“There is a lot going on in the brain, there’s not just one protein, so we’re going to need a cocktail of drugs, just like we have for treating any other complex disease,” she said. “There’s no cancer that is treated with one drug, and HIV isn’t treated with one drug.”
Dr Brodtmann said that clinically the diagnosis was based on a patient’s presentation and function, so it was still on their history and impairment. Amyloid PET scans in non-research setting were very new, and mostly difficult to order.
Dr Swan suggested that even if proven drugs were found, this was where the rubber hit the road for general practice, because there were calls for earlier diagnosis when drugs could be potentially more effective. That put pressure
“Blood biomarkers are exciting, and we can measure brain derived proteins in a simple blood test, but they’re very expensive and not that scalable,” she said. “However, we don’t understand blood biomarkers’ clinical utility yet.
“GPs are seeing patients more frequently than a specialist would, and they can detect red flags that family members have picked up... some are comfortable at organising brain imaging, but there are limits that different practitioners can order.”
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COVER STORY
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COVER STORY
We know they correlate with the diagnosis of different dementias in very selected populations who have been followed for months or years by research services. “We just don’t know that if you were to take 1000-2000 patients and do a blood test, how good that would be at picking up someone who has current cognitive decline? “We know that the test for amyloid correlates well with amyloid in the brain, but we also know you can have amyloid in your brain and be totally fine. So, we still need to learn more about their actual real-world utility.”
comfortable at organising brain imaging, but there are limits that different practitioners can order.” Dr Simon Torvaldsen, chair of the AMA WA’s Council of General Practice and experienced in aged and palliative care, told the webinar that resources were finite, and picking up early cases was not easy to do.
Early diagnosis remained a key goal, using available tests as well as tapping into the vital role of GPs.
“GPs are pretty good but we’re not miracle workers,” he said. “We’re pretty good at picking up people once they’re functionally impaired and they’re at the point where they need support or to be considered for some of the drugs we already have.
“GPs are very good at this, because they’re seeing patients more frequently than a specialist would, and they can detect red flags that family members have picked up,” Dr Brodtmann said. “Some GPs are
“But if we’re talking about picking up people at the very early stages, you’re talking about screening programs, and that’s very resource and time intensive. In my practice, the last time we checked, it’s
Role of GPs
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got something like 3000-4000 patients over the age of 70. “There are opportunity costs, because if we spend the time and money and resources to do this, what other things are we not doing? “It’s a fallacy that resources are unlimited, and from my point of view as a GP, the treatment and pickup rates, and the outcomes have to be worth the investment, and governments will have to put some money in, which they’re notoriously reluctant to do.” Dr Torvaldsen argued that to have functional and accessible general practice, it needed to be viable, including having longer consultations so that issues could be picked up rather waiting for screening.
continued on Page 17
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Alzheimer’s answers still elusive continued from Page 15 “If we’re talking about these blood tests, who is going to select which patients, and what other things might miss out?” Professor Flicker said 90% of people will present with dementia that is of Alzheimer’s-type but that is not the pathology – only 40% of that diagnosis is explained by Alzheimer’s pathology – and that was one of the great misnomers.
Scaling back drugs “When people are old and get dementia, which is usually of the Alzheimer’s dementia type, it’s all mixed pathology. When I’m looking at someone with dementia, all the co-morbid conditions are equally as important, and we may have to look at de-prescribing. “One of the problems is that we spend 15 years teaching doctors to prescribe, and we teach deprescribing in an afternoon and I’m
“One of the problems is that we spend 15 years teaching doctors to prescribe, and we teach de-prescribing in an afternoon and I’m sure my GP colleagues will know how hard it is.” sure my GP colleagues will know how hard it is. “If someone is on a bunch of medications, started by different specialists and GPs, you’re trying to work out how you can stop some of them, and that requires a great deal of time. But it’s a really rewarding part of trying to get someone thinking better.” Dr Torvaldsen agreed it was very hard to de-prescribe, and GPs struggled to do it in general practice and in aged care facilities. “It’s quite difficult when drugs have been started in hospitals, for
reasons that are not always clear in the discharge summaries – if we ever get to see them – and with an anxious family saying, ‘oh no, the specialist started them on that, you can’t stop it’. There is the fear that if we stop their medication and they have a stroke next week, we know who’s going to get blamed. “It’s very easy to start medication but it can be very difficult to stop it.”
Prevention for all Professor Flicker also stressed the importance of prevention – targeting the usual recommendations of exercising, not smoking and losing weight. And the whole point about promoting preventive measures was that it is for everyone rather than trying to pick people at risk of dementia. “It is a classic example of the preventative paradox – you are better off trying to move the whole population a little bit along the curve, rather than trying to work out who is at risk and getting them to do something, because then it will all have dementia effects.” Dr Torvaldsen said enormous amounts of time, effort and money were at stake with Alzheimer’s diagnosis, particularly if considering widespread use of PET scans and other tests. “I pose the question, what if we put even a fraction of those resources into things that we know are going to make a difference, and for half the cost, we’ll get just as much bang for the buck.”
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NOVEMBER 2023 | 17
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NEWS
COVID legacy on surgery deaths WA’s annual audit into surgery-related deaths has found a sudden rise in reported cases in the past two years and explores the possible side effects of COVID.
By Cathy O’Leary
A sharp increase in the number of deaths under the care of a surgeon in Western Australia over the past two years has been linked to COVID-19, possibly because of delays in treatment. The Western Australian Audit of Surgical Mortality, established as a voluntary audit in 2002, is a peer-reviewed investigation of the care associated with surgery-related deaths, to improve patient safety and quality of care. The review includes patients who, for whatever reason, did not end up having surgery. It is funded by the WA Health Department and has protection under federal legislation. Participation in the audit became a mandatory requirement of the Royal Australasian College of Surgeons in 2010. Overall, its audit of more than 2900 surgery-related deaths in the past five years identified 18 which had adverse events that caused the death of a patient and were considered definitely preventable. Last year, WAASM recommended an ongoing review of the impact of COVID on deaths under the care of a surgeon.
18 | NOVEMBER 2023
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NEWS Its 2023 report, released last month, said a standout observation this year was the increase in the number of reported deaths in 2021 and 2022 compared to the previous four years, when numbers had been steadily falling. In 2018, 584 deaths were reported to the audit, falling to 562 in 2019 and 556 in 2020. But in 2021, the number of deaths rose to 616 and last year they reached 626. The increase of 40-50 patient deaths for each of 2021 and 2022 was an abrupt reversal of the progressive and almost uninterrupted decline in surgical deaths since WAASM started more than 20 years ago. The report said that while it was possible the increase was an annual variation, it seemed a large change that was inconsistent with the longterm trend, particularly because it was seen across two years.
COVID effect An explanation was that the increased mortality was a consequence of COVID, either directly or indirectly. The increased mortality seemed to be confined to emergency admissions and included patients who had surgery as well as those who did not end up having an operation. “The spread of COVID-19 in WA was different to elsewhere. In WA, the number of reported COVID-19 infections and hospitalisations throughout 2020 and 2021 was very small, only starting to rise in March 2022,” the audit stated. “The first death of a surgical patient with COVID-19 was reported to WAASM in March 2022. Thus, it is unlikely that the increase in mortality in 2021 was directly related to patients having an active COVID-19 infection.”
adversely impacting high-risk patients, or patients may have been reluctant to go to hospital even when they had acute surgical symptoms. Another possibility was that patients who contracted COVID outside of WA may have been asymptomatic after quarantine but had an unknown legacy effect from COVID. Likewise, there were possible explanations for the increase in surgical deaths among emergency admissions in 2022, when there were 31 deaths documented in COVID-positive patients, slightly more than half the overall increase in deaths. “While it is possible that WAASM did not capture all COVID-19 positive surgical patients who died, there may be another COVID-19related explanation for why the increase in the number of deaths was greater than the number infected,” the audit stated.
Microvascular impact? “The 2022 WAASM report noted that COVID-19 infection impacts microvascular circulation. Other conditions that have a similar impact, such as smoking and diabetes, are well-known to be associated with greater surgical risk and poorer outcomes. The same is true if a patient’s immune system has been disturbed.” Emergency surgery was also carried out in patients who had recovered from acute COVID infection but had known symptoms of long COVID. “There are minimal data on the potential surgical risks for patients with long COVID, but it is likely that elective surgery would have been postponed while emergency surgery proceeded,” according to the audit.
The audit suggested the increase in surgical deaths in 2021 could be a secondary consequence because access to routine community medical services was reduced or delayed, leading to patients presenting as emergency admissions with medical comorbidities that were poorly managed.
“It is possible that some deaths were a consequence of previous COVID-19 infection in asymptomatic patients who appeared to be fully recovered and were managed under this assumption. If, however, such patients had a hidden legacy of microvascular circulation or immune system impairment, their surgical risk may have increased.
Patients might have undergone surgical interventions for underlying pathologies that had progressed to the extent that non-surgical intervention was impossible,
“At the time, there were no data regarding surgical risk in asymptomatic post COVID-19 patients with or without symptoms of long COVID.”
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Commenting on the audit as a whole, its clinical director, surgeon Dr James Aitken, said there had been some important developments in the past year which had implications for the program. The Australian Health Practitioner Regulation Agency had introduced the concept of CPD Homes. Previously, surgeons completed the RACS CPD program and reported their compliance to the Medical Board when renewing their membership. Unless selected for audit by RACS, there was no confirmatory check. With the advent of CPD Homes, this had changed. The onus was now on RACS to report CPD compliant surgeons to the Medical Board. One of the RACS CPD requirements was that surgeons complete their WAASM/Australian and New Zealand Audit of Surgical Mortality obligations in a timely manner.
Timeliness “When the RACS CPD year closes on December 31 each calendar year, there are always surgeons with outstanding surgical case forms,” Dr Aitken said. “RACS will be unable to report as compliant those surgeons who still have SCFs outstanding.” Dr Aitken said WAASM’s report last year had included a section that reviewed its data over the first 20 years, and this had prompted two national reports. “The first, was a longitudinal analysis of national data using standardised mortality ratios, which showed a progressive and highly significant fall in deaths under a consultant surgeon, and this was observed in all states and across all specialties,” he said. “It is difficult to think of any change to surgical care over the last 10 years that has had such a universal impact.”
NOVEMBER 2023 | 19
Habit of a lifetime – alcohol and age The sober truth is that Older Australians’ love affair with alcohol is impacting their health and their behaviour.
Eric Martin reports
20 | NOVEMBER 2023
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FEATURE Even though there is evidence that Australians’ consumption of alcohol has declined over the past two decades – predominantly driven by people under 30 – there are growing concerns about the health implications of drinking for our ageing population.
“While young people seem to be going in the opposite direction.”
This comes with evidence of increasing use and related harm among older age groups who may have maintained those high-risk drinking patterns learned over a lifetime.
“For most people, when you feel sick the last thing you want to do is have a drink of alcohol. But these days, we're getting so good at managing and screening agerelated illness with medications that this natural slowdown has been countered to some extent,” she said.
Recent estimates using data from 2018 show that the total intangible costs of alcohol were $48.6 billion that financial year, and with the addition of hard data such as 5219 deaths, about 127,000 hospitalisations ($2.1 billion), $3.1 billion in costs to the justice system, and $2.4 billion in traffic accidents, the total estimated social and economic cost of alcohol in Australia was $66.8 billion. Professor Tanya Chikritzhs, lead for the Alcohol Policy Research team at the National Drug Research Institute based at Curtin University, says the impact of the nation’s love affair with alcohol continues to be reflected on the rates of accidents and falls, selfharm and violence. “While the proportion of alcoholcaused crashes still hovers between 26% and 30% Australia wide, that is predominantly dictated by broader societal policy and practice such as the legislation around drink driving or the minimum drinking age, and the extent to which that's policed and enforced,” Professor Chikritzhs said. “Unfortunately, the proportion of injuries that are caused by alcohol also remains stable. ED presentations still hover around 30%, and that is directly linked to how much people are drinking. “And for some age groups, particularly older Australians, that percentage appears to be increasing, which is interesting because they seem to have brought their drinking patterns from youth and middle age with them. They haven't slowed down to the same extent as you would expect over the life course.
Professor Chikritzhs said that years of observation had shown that, normally, people drank less alcohol as they got older due to greater rates of ill health.
“As such, we have a situation where the last National Drug Strategy household survey told us that the group increasingly most likely to drink above the National Health and Medical Research Council guidelines was older people. “Older age groups are now drinking at greater risk than they have been in decades of drinking above low risk guidelines, yet more than 10 standard drinks a week is not good news for an ageing population.” And with that, there were serious healthcare complications associated with alcohol consumption in this age group, including ED presentations for injuries from alcohol-related falls and hospitalisations for long-term impacts.
U-shaped curve “There has always been what we call a U-shaped curve in terms of alcohol and hospitalisation, and it's not just true of younger people but of older people too,” Professor Chikritzhs said. “Alcohol is a neurotoxin, it's a central nervous system depressant and at high enough doses, it results in loss of consciousness. The brain will even start to use acetaldehyde, the metabolite of alcohol, as a fuel rather than glucose, which has major impacts on balance centres and contributes to the implication of alcohol in falls. “For a much older person who may suffer an alcohol-related hip fracture, they may end up in hospital for a month or longer and that could result in a downward spiral in terms of overall health. “And for some people, there's no coming back from that.”
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Professor Chikritzhs pointed out that polypharmacy use was an issue that could often complicate alcohol consumption for older Australians. “One of the fastest growing areas of health care expenditure is prescriptions, which is a major problem when it comes to alcohol,” Professor Chikritzhs said. “In the 60-plus age group, most people are taking two or more, or five or more pharmaceutical medications and very few people are heeding the instructions, which is that most medication is not to be taken with alcohol. “The irony is that in many cases, these people may already be on medications addressing health problems directly related to alcohol consumption. For example, hypertension is one of the biggest killers in the world today and is commonly treated with medication, yet alcohol is a major cause. “On top of that, we're notoriously bad at monitoring our own alcohol consumption and measuring how many standard drinks we've had, especially for beverages like wine, where you pour them into a glass but rarely measure the content.”
Low level pain Professor Chikritzhs explained that traditionally, when we think of alcohol and injury, we tend to think of high levels of alcohol consumption and intoxication, but it also exists at low levels. “For example, it's well-established that key impairments to a person’s ability to pay attention and reaction response time occurs even at a breath alcohol concentration of 0.02, which was the original limit for probationary drivers,” she said. “There is impairment in those key physiological and pharmacological pathways even at very low levels of alcohol, as well as key physiological differences between men and women, which are reflected in the guidelines for drinking.” Professor Chikritzhs said the NHMRC guidelines aimed to maintain a risk level of less than one in a 100 for adverse outcomes, and highlighted that at low levels of consumption, the risks started out as comparatively equal for both sexes.
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Habit of a lifetime – alcohol and age continued from Page 21 “It's currently the same for men and women at a low level because the additional risk-taking behaviours that tend to go with being male, and the physiological factors that make women more susceptible to the impacts, such as having less mass and more hormones, tend to cancel each other out at two drinks,” she said. “But starting just above that level, the harm for women accelerates much faster. And these factors are important as we age. For example, holding less water in the body can lead to more rapidly accelerating blood alcohol concentrations. “The other issue is tolerance. A person with an alcohol use disorder who drinks regularly will probably have a better physiological tolerance to the effects of alcohol than somebody who drinks heavily once a month.
“The person who drinks heavily once a month is more prone to injury, and the person who drinks at regular levels of exposure is more prone to chronic effects such as cancers, stroke and CVD. “And let's not forget, one of the greatest contributors to alcohol related injury is interpersonal violence. This is obviously a huge issue for young men and increasingly so for young women.”
Violence follows While the involvement of alcohol was not recorded, throughout 2020-21 there were 23,000 hospitalisations in Australia due to assault, and while most of these involved male victims (62%), 49% of female victims reported being assaulted by a spouse or domestic partner. Professor Chikritzhs added that alcohol was also frequently implicated in drownings and suicides. “We know that a lot of people who suicide successfully have consumed
alcohol at the time and, worldwide, it's about 50% of cases,” she said. “But establishing a clear relationship between alcohol and depression it is not just about monitoring an individual’s drinking in the moment, but looking at how regular exposure over time is having an impact on that person’s mental health.” She highlighted that the ‘goon bag,’ or cask wine, has had a long history of being a highly problematic beverage in Australia (especially the NT, QLD, and northern WA), not just for Aboriginal communities but also more broadly for certain socioeconomic groups, because it offered ‘the best bang for your buck.’ “And I mean high alcohol content at a very cheap price. Port was very popular as well for quite a while and we are also dealing with cleanskins. You can now buy wine at a cheaper price than bottled water,” Professor Chikritzhs said.
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disposable income not only provide greater availability but can also help insulate against more broadreaching financial impacts, which is probably true of other drugs as well.”
How GPs can help Professor Chikritzhs said that one of the most important things doctors can do to help their patients with alcohol-related issues was to have an awareness and understanding of the NHMRC drinking guidelines. “No more than 10 standard drinks a week – and if you can, recommend to your patients, especially if they like to drink, to take just a couple of days off – even one day off a week – which can make a big difference in terms of their tolerance,” she said.
“Interestingly, Australia tends to get higher levels of drinking at both ends of the social spectrum, but for different reasons.
generally less access to health care and other socioeconomic factors, they tend to suffer greater levels of problems from alcohol use.
At the lower socioeconomic end, you get higher levels of consumption – they tend to drink the cheaper beverages, and due to
“At the other end of the spectrum, those in higher socioeconomic groups drink heavily because they can afford to. High levels of
“And we are not just talking about physiological tolerance, but psychological tolerance, which is also important. Having a glass of alcohol is often the first thing we do when we come home from a hard day's work and need to de-stress, or deal with the kids. “And that often turns from one continued on Page 25
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GUEST COLUMN
Challenging social drinking norms It can be an uncomfortable conversation, but grey area drinking coach Sarah Rusbatch is encouraging doctors to raise alcohol use with their patients. Doctors play a crucial role in promoting overall health and wellbeing and part of this responsibility includes addressing issues related to alcohol. However, a reluctance to probe and the acceptance of social drinking can sometimes hinder an open and honest discussion with patients. The reluctance of doctors to delve into their patients' drinking habits can be attributed to a range of factors. One key factor is the fear of judgment and potential strain on the doctor-patient relationship. Doctors may be concerned that raising issues around alcohol consumption may alienate patients and lead to them avoiding medical care altogether. It is a delicate balance that doctors must strike, and it requires effective, compassionate communication. There is also a societal norm that accepts social drinking as an ordinary and even ‘healthy’ practice in moderation. However, moderate drinking can, and does, easily tip into excessive or problematic drinking. There is a fine line between responsible alcohol use and potential problem drinking, and patients may need help to understand these boundaries. The World Health Organisation now recognises there is no safe amount of alcohol.
How can doctors navigate these challenges? Empathy. Patients should feel comfortable discussing their drinking habits without fearing judgment. Physicians can create this environment by showing empathy and understanding and framing the conversation as part of their overall health assessment. Understand the risks. It’s vital for doctors to be well-informed about the risks associated with all levels of drinking. Armed with the latest research, they can provide patients with accurate information about the potential health implications of their drinking habits. This knowledge can empower patients to make informed decisions about their alcohol use, or to abstain entirely.
Normalise sobriety Doctors can play a key role in normalising sobriety. Encouraging patients to reflect on their drinking habits and arm them with sober support networks is vital. It's essential for patients to understand that there is a spectrum of drinking behaviours, and the goal can be abstinence without stigma or judgment.
Tipping points Patients need to be aware of the dangers of ‘social drinking’ that can spiral into problematic use
and the subsequent potential negative impact on their health, their relationships, and their life. It's important to counter the myth that drinking is a rite of passage and that excessive alcohol use is a ‘lifestyle’. More than eight glasses of wine a week is considered alcohol use disorder.
Sober networks This may involve referring patients to addiction specialists, therapists or support groups. Having a network of professionals who can guide patients through the process of change without judgment is important. Doctors play a vital role in addressing the subject of alcohol with their patients, even in the face of reluctance and societal norms. The key to success lies in open and non-judgmental communication, accurate information and a nuanced understanding of the spectrum of drinking behaviours. By encouraging an open dialogue and providing the necessary resources, doctors can help their patients develop a healthier relationship with alcohol. It's a challenge that, when met with empathy, will lead to better patient outcomes. ED: Sarah Rusbatch is one of Australia's first accredited grey area drinking coaches and a public speaker and author.
Habit of a lifetime – alcohol and age continued from Page 23 drink to two and so on – we all know it happens.” Professor Chikritzhs said that surprisingly, one of the facts that
her research uncovered was that very few medical doctors either knew about or believed the link between alcohol and depression, a situation that the research team attributed to cognitive dissonance.
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“One of the reasons we found why doctors don't ask their patients how much they're drinking, is because it causes them to have to reflect on their own alcohol consumption,” she said.
NOVEMBER 2023 | 25
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Presenting a united front Recently elected as president of the AMA in Western Australia, Dr Michael Page is the first pathologist to hold the post in decades. By Ara Jansen
You might never meet Dr Michael Page, but it’s likely that he’s an important part of the chain of your care. The 41-year-old is a chemical pathologist whose job involves monitoring bodily fluids like blood and urine to detect important changes in body chemistry. He’s likely to play a key role in diagnosing and monitoring patients with a wide variety of illnesses – from high cholesterol to rare genetic diseases. “The thing about pathologists is that some people have a perception that they are toiling away in a basement in little rooms with harsh light and no air, away from the outside world,” Michael says. He’s spent the last five years working for Western Diagnostic Pathology and definitely isn’t banished in an airless basement. “Communication skills and the ability to distil and explain complex ideas are simply some of the most important skills a pathologist needs. It’s incredibly important to do the job well.”
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“I saw the AMA as an avenue where I could raise these issues and perhaps see what I could do to contribute.”
Organised and focused, what attracted Michael to the specialty was the ability to solve often complex problems with limited information, sometimes quickly and on a tight timeline. He also enjoys having access to a lot of data in the lab – “you can answer a lot of questions through research and we have the capacity and the access”. “I enjoy helping GPs and other specialists to solve complex clinical questions. The depth of understanding of lab tests is something you can’t get anywhere else. When I’m able to help demystify a really unusual result or solve some otherwise obscure diagnosis it’s quite satisfying. “I fully accept it’s not everyone’s cup of tea,” says Michael who also loves films and music. “Some people see it as really boring. I get just as excited as anyone else in their job when I come across something really interesting, or a rare diagnosis. I really enjoy those moments.” In June, Michael was elected unopposed as the new president of the WA branch of the Australian Medical Association. He’s the first pathologist in 40 years to hold the role.
Making a difference His involvement in the AMA dates back 10 years and, he says, his motivation to run for office started by wanting to be a member of the
involved. I never aspired to become president but somewhere along the line it became my turn, I was in a position to say yes and I feel strongly about the mission of the AMA.” Being a pathologist in the president’s role will also give Michael the opportunity to raise the profile of pathology as a specialty and perhaps demystify it a little bit too. representative body for doctors in WA and making a difference. “I could see how many issues there were facing doctors, during and after their training and that the system just didn’t seem to care sufficiently about them,” he said. “I saw the AMA as an avenue where I could raise these issues and perhaps see what I could do to contribute. They were also an independent advocacy body, which was another reason I wanted to be
“It’s good to have a range of specialties in positions of leadership,” he says. “On the other hand, being from one of the specialties which is a little under the radar perhaps might give me objectivity around some of the issues affecting my colleagues in different specialties and forces me to think of issues that affect all doctors and what unifies us. “There are a lot of unifying factors that tie us together and make the organisation necessary. Some doctors have a view that their specialty field is so narrow that a broad-based organisation is less representative of them. “I believe those bigger external issues can only be represented by a broad-based organisation, such as the issue of increasing role substitution by non-medical practitioners. These sorts of developments are cost-saving but they also undermine the medical system to the detriment of patient care and undermine the whole profession.
Docs’ responsibility “Our mission relates to doctors and patients and if we don’t have a strong medical workforce, we don’t have the best patient outcomes. Someone in a healthcare team has to be responsible for the outcomes that the patient experiences – and
continued on Page 29
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CLOSE UP
Presenting a united front continued from Page 27 that’s the doctor. It’s the truth and that’s the truth across all specialities.” The son of a pharmacist, Michael did his medical degree at UWA after starting in pharmacy. “I had a vague interest in health sciences and my dad’s job seemed interesting,” says Michael. “I worked in hospital pharmacy in Graylands Hospital.” Eventually he found that pharmacy didn’t have the level of clinical involvement he wanted and having become interested in psychiatry while working at Graylands, decided to sit the entry exams for medicine. While he didn’t rotate through pathology as a student or a junior doctor at Royal Perth Hospital, Michael took up a research project which had a chemical pathologist on the team. Having never really heard much of the specialty, it was through this personal connection that his interest was sparked and set him on the path. He trained in chemical pathology at PathWest (Fiona Stanley and Royal Perth) and Western Diagnostic Pathology. He’s now also a senior lecturer at UWA and is working towards a Doctor of Philosophy through UWA Medical School. Michael serves on the Chemical Pathology Advisory Committee of the Royal College of Pathologists of Australasia and the Federal Council of the Australian Medical Association and is a Member of the Australasian Association of Clinical Biochemists and a Fellow of the Royal College of Pathologists of Australasia
Team player Michael also enjoys pathology because it’s a team job. Not only being part of the chain of exploration but working with at least three or four colleagues each day means a natural sharing of collective experience and wisdom. Within that team everyone has a different sub-specialty interest. Michael’s are pathology testing for the evaluation of cardiovascular risk and disease, including lipid
disorders and hypertension. He’s also the office DJ in charge of the daily music playlist in the lab. He takes requests but always has final veto power. Michael keeps himself fit by running and during the recent school holidays did plenty of walking around London, Crete and Italy with his wife Dr Sarah Strathie-Page (a dermatologist) and their two young sons. The trip – the family’s first big overseas adventure together – has helped him reconnect with his interest in photography. His favourite dishes to cook at home are Italian and Michael is pleased to report that his carbonara and amatriciana stack up favourably to the originals he tasted in Rome and Florence. The family spend most weekends together – a benefit of having two parents in specialties which rarely require out of hours work – and the
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boys are young enough that their schedules are not yet packed out with sport or other activities. “I enjoyed a lot of different specialities in my rotations. To me the most important thing is finding something you really enjoy, fit into as a person, are really comfortable with and that you feel like you are in the right place when you go to work every day. “It’s often said that people choose their specialties based on the people they meet in them rather than the actual work. I started medical school with people who had very fixed ideas on their specialty choices and it’s probably true that only a small percentage of them ended up in those specialties. You can have a great fascination about eyes or skin but until you work in the area you don’t know what you’ll find in the day-to-day.”
NOVEMBER 2023 | 29
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FEATURE
More than a stroke of good luck A roundtable of Australian stroke experts has developed new targets to boost lagging care standards, with life-saving messages for both patients and clinicians. By Cathy O’Leary
For WA stroke physician Dr Andrew Wesseldine, the mantra of “time is brain” for stroke is not used glibly. When someone has a stroke, millions of brain neurons are lost as every minute passes. That is why he welcomes bold targets to ensure people get earlier access to treatment following a stroke or transient ischaemic attack (TIA). The longer stroke is left untreated, the more brain dies, and the lower the chances of survival and recovery. In August this year, the Stroke Foundation, Stroke Society of Australasia, the Australian Stroke Clinical Registry and Angels Initiative met for the National Stroke Targets Roundtable to develop a set of proposed targets for Australian hospitals to meet by 2030. Experts argued that while there were many pockets of excellent stroke care in Australia – with progress in treatment options, assessment and access to specialist care – the time it took the average patient to access acute stroke reversal treatments and stroke unit care lagged behind that of other developed countries.
30 | NOVEMBER 2023
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FEATURE
In particular, the time it took for an Australian patient to receive clot-busting drugs (known as doorto-needle time) was significantly longer. An accepted international door-toneedle target is within 60 minutes of a patient arriving in hospital. In the United States, 68% of patients are treated within that time, and in the United Kingdom it is 61%, but in Australia it is only 32%.
New targets Australia’s new national median targets include endovascular clot retrieval door-to-puncture time of less than 30 minutes for transfers; thrombolysis door-to needle time of less than 60 minutes; door-indoor-out time for endovascular clot
retrieval of less than 60 minutes; and endovascular clot retrieval door-to-puncture time of less than 90 minutes for primary presenters. There is also a target that certified stroke unit care be provided to more than 90% of patients with primary stroke diagnosis. As well as holding the post of director of medical services at St John of God Hospital in Murdoch, Dr Wesseldine is WA State Stroke Director, with oversight of the Telestroke service which expanded in July this year to become a 24hour, seven day a week service for clinicians caring for patients with acute stroke symptoms. Stroke specialists are now available as the first point of contact to
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assist emergency clinicians in the diagnosis, assessment and care of acute stroke and transient ischaemic attack patients across the State. The extended service is part of phase two of the $9.7 million program which began in late 2021, and is aimed at helping to achieve faster diagnosis in regions where stroke specialists may not work or be readily available. Dr Wesseldine said stroke care was on a journey nationally, but the health system had a lot of challenges and one of them was around navigating that care.
continued on Page 32
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More than a stroke of good luck continued from Page 31 “Telestroke aims to facilitate the navigation of stroke and TIA patients. We’re working collaboratively with the Health Department and the health service provider to have a core group of clinicians who are happy to be the first port of call for a doctor in a regional ED who might have a stroke patient, or a TIA patient – and to be clear, they’re just as relevant,” he said. “There’s a lot of literature at the moment about TIAs, showing that no, a TIA is not a mini-stroke, it’s not a mini anything, it’s actually a big warning sign.
The recent Stroke Roundtable
and the way we’ll get better thrombolysis rates is to better inform patients about what to do, like calling an ambulance to get to hospital quicker, and that shifts the curve to the left.
“The kicker with stroke is that it’s about what you’re trying to save, and that’s what makes it a little different to a lot of other things – it’s like brain trauma. “For me, it’s about shifting the curve, from the onset of something, to the patient attending care and to finishing their journey – trying to shift that curve to the left by any means necessary.”
“If the ambulance is called at two minutes, not 20 minutes, that’s 18 minutes when they’re not losing brain function.” He said it did not mean giving patients thrombolysis without appropriate review, but it was about asking questions such as whether it was actually a stroke, whether the patient should go to the metropolitan area, and whether they needed stroke rehabilitation.
Common-sense medicine Dr Wesseldine said the best medicine was common-sense medicine, and if you could do something quicker without a lot of disruption, in the right patient at the right time, it could make a huge difference. The revised stroke targets were logical and reasonable, but the key was supporting clinicians. “I don’t want targets where you penalise people, it’s not about being punitive, it’s about targets that make sense for patients, and people doing the best that they can do for all West Australians having a stroke or TIA,” he said. “Time is brain, and brain death means disability, and disability is the difference, for example, between someone returning home by the weekend or not returning home at all because they can’t walk or talk, and they have to be looked after in a nursing home.” The focus was on working with stroke clinicians to get closer to the targets, while recognising that 32 | NOVEMBER 2023
WA State Stroke Director, Dr Andrew Wesseldine
some of the targets were very challenging. “For example, you’re never going to get a patient in Broome into vascular clot retrieval in less than probably six hours, so a 90-minute target is not fair,” he said. “However, if I can get them there in six hours rather than 12 hours, then that can make a monumental difference to their disability. “Targets are only as good as the people who are either using them or helping to support them. I view targets as conversation starters,
Dr Wesseldine said there had been an explosion in new treatments to treat stroke, but some of it could only be delivered in a place like Sir Charles Gairdner Hospital because of the number of cases that clinicians needed to see to remain competent and skilled.
Time is of the essence “Clot retrieval is an example of that. You couldn’t set up a clot retrieval service in Broome because you wouldn’t get enough patients to create the value. But if you base it at Charlies or Fiona Stanley, like we do, then you need to have a system scaffolded over that which expedites the patient in Broome to get down to Perth in as quick a time as possible,” he said. “We don’t have to ring five wellmeaning people to get through to
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FEATURE
the right person to talk to, which means that rather than a 10-minute delay, you’re on to them straight away. “It’s about creating a sense of urgency and making sure we have the right things at the right spot and at the right time. Some of the goals are realistic for Perth metro but not for other places. We’d never use targets to penalise, it’s about having goals so we become better at what we do.” Not everyone who has a stroke needs to have endovascular clot retrieval, but decisions needed to be made on which patients could stay at Midland hospital, for example, and who should go straight to SCGH. “We work with doctors and St John Ambulance on that, it’s a really collaborative conversation, and part of the reason for that is because you have to have a CAT scan to make a stroke diagnosis, so you’re limited by that,” he said. “We apply a basic scoring system in the field, using the patient’s story and their clinical state, and if they reach a certain score on the RACE scale then they’d be automatically bypassed to go straight to Charlies. It’s a lot of work to try to make the best decision in the moment, given the tyranny of distance and all the
other challenges going on in the system.
emergency – that’s absolutely the priority.”
“There’s lot of variables, and a 30-year-old with a complex migraine can look like they’ve had a stroke, but in fact they’ll respond to aspirin and not need to be transferred.”
But when stroke did occur, getting the right treatment as early as possible was the next priority.
In more than half of all Telestroke calls, the patient was able to stay exactly where they were, in regional or outer metropolitan areas. Dr Wesseldine said supporting local clinicians to keep looking after the patients and giving them advice was just as valuable as saying “put them on a plane and transfer them to Charlies.”
Prevention is better He also stressed that going back one step – to prevention – was where the biggest gains could be made. It was important to remind all West Australians of the common signs of stroke, and to think “FAST” – facial weakness, arm weakness, speech problems and time. “My number one priority is stroke prevention – getting people to have their blood pressure checked and on the right treatment for atrial fibrillation, and making people understand that sudden onset of weakness of the arm, or loss of speech or vision is a medical
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Sometimes it was the difference between a patient being left having some disability or no disability, or the difference in having a lot of disability or some disability, and at other times it was the difference between surviving or not. “We’ve treated people 12 hours after their stroke, and although they weren’t able to recover all the way to normal, they had a reduction in their disability, which is better than being treated at 24 hours or not at all,” he said. “The key thing in all of this is that no one wants to have a stroke, which is why you go back to prevention, because underneath all of this, we’re reacting to something you’d do anything to prevent. “But then when you do react you want to make the best decision using the best process for that individual patient at that time, and that is very challenging in a complex system. “Care navigation is hard, but it’s about refining and improving our system of stroke care in this State.”
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Colleges the backbone of quality medicine A faster, cheaper, and less collegiate system for IMGs—what could go wrong, asks Perth radiologist Dr Sanjay Jeganathan. About a year ago, the Commonwealth initiated a ‘rapid review’ of government processes regulating overseas health practitioners applying to work in Australia. The independent review by retired senior public servant Robyn Kruk seeks to improve how we assess international medical graduates, specifically registration and recognition of their skills and qualifications. Ms Kruk issued her interim report in April for comment, with her final report due anytime now. Among the interim recommendations are bureaucratic reforms to improve the applicant's experience – for example, by removing duplication and streamlining steps such as visas and criminal history checks – as well as policy proposals such as expanding the use of comparable health system pathways. This CHSP would be based on a government list of countries deemed to have a comparable health system and would ‘fasttrack’ applications, allowing emigrating doctors in these jurisdictions to gain registration without undertaking further assessments. Under the current system, specialist medical colleges play an essential role in the assessment of IMGs and determining suitability for registration by comparing their qualifications and training against those of Australian-trained specialists and fellows.
but the thinking behind some is flawed. A telling sign is the 30 or so mentions of ‘medical colleges’, without mention of any specific Australian or New Zealand specialist medical college or any attempt to distinguish between the different medical professions.
Sidelining colleges
Taking a one-size-fits-all approach like this fails to acknowledge the wide variations in doctor training across different specialities. Greater use of CHSPs may have some value in some specialities but it is unlikely to have any impact for others.
Ms Kruk believes the current system lacks consistency and is too slow and costly for applicants. Hence, she has recommended the so-called ‘equivalence assessments’ undertaken by the colleges be transferred to the Australian Medical Council, with the colleges continuing in an advisory role only. The interim report puts forward many reasonable suggestions 34 | NOVEMBER 2023
The Medical Council of New Zealand uses a CHSP list with 24 nations, including Australia, US, Canada and 18 European countries, with no Asian entries other than Singapore
and Hong Kong. The vast majority of IMG applications my college receives are from nations currently not on this CHSP list. In any event, we do not accept that comparability applies evenly across the health system. For example, the UK's health system may be broadly comparable to Australia's but it's not so in all specialities. It is disappointing the Kruk review has not to date meaningfully engaged with the colleges especially on the supply of services in rural and regional Australia. Instead of seeking our unique knowledge and insight, the report prefers to highlight a comment by an unnamed and uninformed WA Health official that ‘medical
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GUEST COLUMN
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GUEST COLUMN colleges have a vested interest in controlling the number of specialist practitioners practising in Australia’. The colleges do not control numbers. Training positions at various hospitals are created and allocated by state health departments, and not by specialist colleges. The colleges assess IMG applications fairly and transparently in accordance with the standards set by the AMC, the very body that Ms Kruk says should be in charge of assessments. Further, the number of IMG applications to be considered each year is controlled not by the medical colleges but government regulation and requirements. We just do the hard part: ensuring that any overseas-trained doctor is educated to the same standard and scope of practice as our Australian or NZ-trained doctors. Our members provide their time and expertise for these assessments at no cost to government.
The Kruk review is predicated on the Australian government's desire to address growing shortages of health practitioners, especially among GPs, and especially in rural and regional areas where the shortages are worst. We support that and the proposed changes to how we process IMG applications may be part of the solution, but it cannot be the long-term solution. At present the focus of various state and federal governments is to find an immediate solution to our health workforce issues and they seem oblivious to the fact that this is a global problem. In large part due to the actions of wealthier nations such as Australia and New Zealand, poorer countries are seeing large numbers of their specialist medical workforces being enticed into employment overseas, undermining the health systems of the poorer countries and leaving them even worse off. Our government should plan for a long-term solution. Our medical school numbers almost doubled over the past 15-20 years, but specialist training positions have not increased at the same pace. Each year, scores of young and capable locally trained doctors fail to find specialist training positions and waste more years in the vain hope of finding a training position in their chosen field.
Looking long-term Ultimately, we must be selfsufficient in health training, and to achieve this without lowering our enviable, world-class standards in healthcare and without putting patient safety at risk. To date, neither the Federal government nor the State governments have engaged with specialist medical colleges to seek the advice of the experts on how we could collectively work in addressing the workforce shortage. Machinations over the registration of IMGs need to be viewed in the light of other recent government actions related to education and training. These include concerns among State and Federal ministers over the medical colleges' accreditation of training sites – specifically decisions in which the accreditation of a site was withdrawn – and action by the Tertiary Education Quality and Standards Agency against colleges that award diplomas. MEDICAL FORUM | AGED & PALLIATIVE CARE
Taken as a whole, the narrative which appears to hold sway in government circles is one in which the medical colleges are portrayed as an impediment rather than a safeguard in the delivery of healthcare. The Government answer is to subject medical colleges to ever-greater levels of bureaucracy and over-regulation.
CPD changes We have read the same message in the Medical Board of Australia’s plan to open the continuing professional development market to a score of external providers, some of whom are likely to opt for a high volume/low service business model. The stated aim is to provide a CPD home for up to 30,000 medical practitioners who are currently without one, but that could have been achieved with greater certainty of outcome by asking the colleges to open the doors to their existing programs and directing the ‘homeless’ doctors to choose a program. Under the current regime, the fees we collect from CPD are reinvested into member and trainee services. A reduction in this income is bound to lead to a rise in general membership fees or a reduction in services. What would be the backlash if engineers, accountants, lawyers and company directors were forced to open their CPD programs to external market players in this manner? Once again, it seems as if the medical colleges are being singled out. What isn’t being understood by decision makers is that Australia has enjoyed the benefits of the highest standards of specialist medical workforce over many decades, and that did not happen by magic. It is the result of thousands of volunteer members of the colleges ensuring the standards are maintained. We need to be united in our efforts with strong advocacy on behalf of our patients and doctors who serve them with dedication. ED: Dr Sanjay Jeganathan is president of the Royal Australian and New Zealand College of Radiologists and the chairelect of the Council of Presidents of Medical Colleges.
NOVEMBER 2023 | 35
Putting PPE to the test A new service to test the effectiveness of personal protective equipment, and help keep health staff safe, is now available to all WA hospitals and universities. The state-wide service based at Royal Perth Hospital is currently focused on N95 particulate-filtering respirators but will be extended to independently check whether items such as face masks, face shields, goggles and gowns meet expected quality standards. The testing uses specialised equipment – Particulate Filtration Efficiency and Synthetic Blood Penetration Resistance testers – which were acquired using a COVID-19 Infrastructure Focus Grant. The grant was awarded to the project’s lead, Dr David Morrison, a senior bioengineer with the East Metropolitan Health Service's Centre for Implant Technology and Retrieval Analysis (CITRA).
“It can also be used to test other medical devices such as customised CPAP masks and will be a valuable resource for local innovators seeking to quality test their products, paving the way for increased research, innovation and commercialisation opportunities,” he said. “Most importantly, however, our healthcare workforce can enjoy greater peace of mind knowing that the PPE that is issued to them is providing them with the level of protection they expect.” Dr Morrison said the need for testing capability in WA was brought to the fore early in the COVID emergency when, despite enormous demand for protective equipment, existing stocks of reputable PPE were exhausted and alternative supplies of unknown quality were having to be sourced. During the height of the pandemic, the CITRA team – who undertakes
design, manufacture and testing of medical equipment and devices – was flooded with requests from stakeholders throughout the health sector to test medical equipment and PPE. “The problem was that nobody in Australia had the ability to adequately test these alternative supplies to ensure they met minimum standards of protection,” he said. “While assessing the equipment as best we could at the time, we also recognised the importance of having suitable testing infrastructure to reduce the vulnerability of our health system to supply chain disruptions, particularly during times of emergency.” In 2020, the CITRA team oversaw production of high-quality, locally made face shields that helped meet high demand for the items early in the pandemic.
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NEWS
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NEWS The shields were approved by the Therapeutic Goods Administration and met the high safety and quality standards required for hospital use.
Dr David Morrison and Dr Jenn Ha
Dr Morrison said the PPE testing service would be made available to WA hospitals, universities and innovators wanting to test or develop equipment for use in the health sector. Perth Children’s Hospital Ear Nose and Throat surgeon Dr Jenn Ha, who has worked closely with CITRA in the past on producing specialised ENT face shields and customised CPAP masks, provided important clinical input on the project. “Clinicians will ultimately be the ones using the equipment, so it is important that we get their input and perspective from the outset,” Dr Morrison said. CITRA’s enhanced testing capability also created the potential to gain new insights into minimising transmission of viral and other biological particles.
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NOVEMBER 2023 | 37
A village required to treat AF GPs play a vital role in the management of atrial fibrillation, writes Perth-based cardiologist and electrophysiologist Dr Justin Ng. Atrial fibrillation, the most common cardiac arrhythmia, affects millions of people worldwide. As an electrophysiologist specialising in arrhythmias, I can appreciate the complexity of the decisionmaking for this common arrhythmia particularly for general practitioners who, in recent years, have had an increasing role in the diagnosis and management of AF. Affecting more than one in four Australians aged 55 and over, AF is responsible for one in four strokes and, if untreated, can lead to other serious complications, including heart failure, cognitive impairment, reduced exercise capacity and a reduction in quality of life. A recent national survey commissioned by charity hearts4hearts revealed that one in three Australians were unaware of AF and its symptoms, and that’s concerning. We have readily accessible, effective management for AF, however the old adage ‘AF begets AF’ predominantly remains true, and the longer it takes to initiate appropriate management, the higher the risk of a complication and the more difficult it is to achieve long-term control. In the majority of cases, GPs should be able to make the diagnosis of AF. The challenge, however, lies in its often-elusive nature, as AF can be paroxysmal, making diagnosis a difficult task. Knowing which investigation to choose when trying to make a diagnosis of symptomatic AF whether it be a 12 lead ECG, a holter, an event monitor, a loop or an Alivecor monitor is invaluable. The management of AF is a team effort and GPs are often the first point of contact for patients with cardiac symptoms, making their role in early detection paramount. Many patients experience subtle 38 | NOVEMBER 2023
symptoms, including palpitations, shortness of breath, decreased exercise tolerance or fatigue, which may go unnoticed. GPs can recognise these signs and symptoms and initiate appropriate diagnostic investigations.
individuals to take an active role in managing their condition. Lifestyle modifications including weight management, smoking cessation and alcohol moderation are key elements that GPs can advise for improved outcomes.
One of the most significant contributions GPs can make is identifying and screening patients at risk of AF through routine checkups and targeted screenings.
To enhance care, GPs and cardiologists should embrace a model of shared decision-making. Together, customised treatment plans, incorporating the patient's preferences, comorbidities, and overall health goals can be created.
While the majority of new diagnoses of AF should be reviewed by a cardiologist to determine a long-term strategy, the waitlist to see a cardiologist can be long, making familiarity with the initial management of AF essential for the GP. Initiating anticoagulation where appropriate as well as having the confidence to start rate control is important. Ordering basic investigations such as electrolytes, FBP, thyroid function and an echocardiogram to assess LV function and valvular disease should help speed up the decisionmaking process. GPs are well-positioned to educate patients about AF and the importance of lifestyle factors, which have been shown to make a significant difference. Through patient engagement and counsel, they can empower
Open lines of communication and timely updates are essential in ensuring patients receive holistic care, particularly as atrial fibrillation is not a static condition, and often multiple changes in management are often required. It is vital for specialists to keep GPs informed about the latest developments in AF management to ensure timely and appropriate referral of their patient and achieve optimal patient care. By sharing information about risk factors, early detection, and preventive measures, organisations such as hearts4heart play a crucial role in raising awareness of heart conditions, and empowering people to take charge of their heart health and contribute to reducing the burden of heart disease.
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GUEST COLUMN
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GUEST COLUMN
Integration of mental health services vital More coordination is needed to bridge the gaps in WA’s mental health care system, argues psychiatrist Dr Mike Verheggen. The recent release of the Independent Review of WA Health System Governance is a significant occasion for the field of mental health care in Western Australia. While we at the Royal Australian and New Zealand College of Psychiatrists welcome the positive strides that have been made to embed lived experiences, clinical expertise and Aboriginal and Torres Strait Islander voices into the system, we also bear certain concerns. Firstly, let me acknowledge the significant progress that has been made. The commitment to a recovery-oriented mental health system is laudable and long overdue. As an organisation advocating for this approach for two decades, we are heartened to see the WA Government’s intent to align with this vision. Recovery, in essence, is about ensuring that individuals receive the help they need, when they need it and where they need it, without having to navigate a complex health system. The recent changes announced by the government take promising steps in this direction. However, as we delve deeper into the review’s findings, it is apparent that there are structural hurdles that must be overcome. Coordination remains a critical challenge. Without integrated mental health services operating in cohesion with each other, we risk perpetuating a system where West Australians continue to fall through the gaps in the mental health care landscape.
bedrock of achieving positive patient outcomes and realising the recovery model of care.
Fragmented services Our mental health system is fragmented, with people providing clinical services separated from people responsible for recovery, and different services with different pathways, access points, eligibility criteria and funding arrangements. As long as this fragmentation remains, individuals will continue to fall between gaps and be unable to access services – in practice, this means people being pushed out of acute treatment services in order to accommodate others who are more acutely unwell but remain too unwell or “too high risk” to be accepted by the next tier of services, so go without any care or support.
to improving accountability and service delivery within the Mental Health Commission and the Department of Health is welcome, more work needs to be done. The impact of a disjointed mental health system is not always visible to the public, but the consequences are acutely felt by those who require support. It creates unnecessary barriers that hinder individuals from accessing the mental health care they desperately need and has broader economic implications. We can’t afford to let there be further delays and complications for West Australians in need of timely assistance. ED: Dr Mike Verheggen is WA chair of the Royal Australian and New Zealand College of Psychiatrists.
This is what we refer to as “the missing middle” where there are supports available to the least unwell, treatment services for the most unwell but little care for those in between. Without establishing continuity between service delivery, clinicians, and sectors, we cannot support people to navigate the mental health system in a manner that is not intimidating, complex and dissuasive. We firmly recommend that service integration becomes a key priority for the WA Government. While their commitment
It is essential to understand that multidisciplinary care and timely access to appropriate assistance are the
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Dr Joe Kosterich | Clinical Editor
Reflections on life For all the health issues that we face, life expectancy in Australia continues to increase. According to the AIHW, a male born today can expect to live 81.3 years and a female 85.4 years. This is 30 years more that at the turn of the 20th century. Surprisingly the gender gap has widened from 3.7 to 4.1 years.
The key here is not that we have to work, but we need to be enjoying what we do. Sure, if you can continue to get paid to do what you enjoy – bonus!
Australians on average live six years longer than Americans and two longer than the British. This is excellent news and should be celebrated while at the same time we can strive for further improvement especially in quality of life. The question that we have not answered and often don’t even ask is why some people live better for longer. Yes, the basics do matter. Not smoking, doing regular exercise and eating sensibly all play a role. Studies on centenarians consistently show this. These studies also show that having fun, connections and purpose play a role too. We tend to ignore this as it is not a medical issue and there is no medical solution. It is interesting to look at those who are still active in their 70s and 80s to see if we can learn and apply any lessons. Tom Jones is touring at 83 as is Paul McCartney at 81. Jones told The Weekend Australian (September 21) “I would hate to retire”. He quotes Bob Hope describing enjoying what he was doing into his 90s. The key here is not that we have to work, but we need to be enjoying what we do. Sure, if you can continue to get paid to do what you enjoy – bonus! In the same paper, Gene Simmons (74) is quoted “If god or whoever is in charge gives you only 24 hours of life, what are you going to do with it? Are you going to go out there, try to do some good…”. He concludes that the best thing to do is to live life well. There is an adage which says that which can be measured will be. We can measure weight, cigarettes smoked or blood pressure. We cannot measure enjoyment, the value of a smile or touch of a hand. We cannot establish ‘guidelines’ or ‘best practice’ as what matters or is enjoyable to one person may not be to another. It is about what matters to us. Human beings are more than a collection of atoms and molecules arranged into cells and organs. We need to remind ourselves of this. Simmons is right – live life well!
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Supporting hearing and vision needs in residential aged care By Prof. Hamid Sohrabi, Clin. Neuroscientist & Dr Carly Meyer, Speech Pathologist Approximately 130,000 Australians are living with dementia in residential aged care, representing slightly more than half of all residents.
Knowing that it is the residential aged care staff who are primarily responsible for supporting residents’ sensory needs, we have drawn on behavioural science tools and frameworks to prioritise key behaviours to focus on the intervention, understand key barriers and enablers to carrying out these behaviours, and identify evidence-based strategies to support staff in enacting these behaviours.
The management of dementia is made more complex by the presence of other age-related health conditions, with two common ones being hearing and vision loss, affecting approximately 64% of residents (although hearing and vision loss are often poorly documented in aged care records). Sensory loss is frequently undetected in people with dementia as both conditions share common characteristics – namely, if not managed well, hearing and vision loss can both impair verbal and visual information processing resulting in communication breakdowns, which can be wrongly attributed to dementia. When sensory loss is identified, management can be complex and is often reliant on support from residential aged care staff and family members. Sensory loss, like dementia, can lead to social isolation resulting in loneliness, depression, and anxiety. The presence of both conditions can exacerbate these impacts, with previous qualitive research describing how hearing loss has emotional, social, and behavioural consequences for residents with dementia. It is important that hearing and vision functions are assessed regularly in residents with dementia to ensure that sensory losses are identified and effectively managed to limit their impact on the residents’ overall functioning. Acknowledging the importance of addressing hearing and vision loss in people living with dementia, the SENSE-Cog Europe team developed and trialled a sensory support intervention designed for people with dementia (and their informal caregivers) living in the community. The intervention comprised
Key messages Sensory impairment is common in aged care but often missed European research showed promising results from sensory support interventions A collaborative Australian project will pilot sensory support interventions in aged care facilities. hearing and vision assessment, the provision of hearing or vision devices (e.g. hearing aids, glasses), and support from a trained sensory therapist that focused on device adherence, communication training, home-based modifications to optimise sensory functioning, and referral to support services. Results from the field trial were positive, showing clinically significant gains in quality of life. However, results from the fully powered randomised controlled trial failed to replicate these findings. Secondary analyses from the trial are awaited.
How are we intervening differently? We received funding from the Medical Research Future Fund to adapt the original SENSECog intervention for Australian residential aged care facilities. Currently, no intervention exists that supports both hearing and vision loss in people living with dementia in residential aged care.
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We have funding to support the presence of a sensory champion in participating aged care facilities, who will seek to understand the hearing, vision, and communication needs and preferences of individual residents, provide information about relevant hearing / vision services, and carry out an audit of residents’ rooms to optimise them for hearing and seeing well. We will then work directly with residential aged care staff to support their day-to-day management of residents’ hearing and vision devices and their use of effective communication with residents. More specifically, we will train and support the aged care staff to routinely check that residents are wearing their devices in the morning and that they are cleaned and stored somewhere safe in the evenings. With respect to communication, we are encouraging staff to speak clearer, nearer, and slower to accommodate hearing loss; and to make text brighter, bigger, and bolder to accommodate vision loss. Our team will be implementing the intervention in two or three residential aged care facilities in 2023-24 and evaluating the impact of the intervention on resident and informal caregiver quality of life and overall wellbeing, as well as staff use of sensory support behaviours, resident use of hearing and vision devices, continued on Page 44
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Dementia: when does neuroimaging play a role? By Aden McLaughlin, Shoba Ratnagobal & Richard Warne, Radiologists Dementia refers to a group of acquired brain disorders, typically affecting adults, characterised by progressive decline in cognition. Dementia is defined in the DSM-5 as a substantial cognitive decline in one or more of the following domains: complex attention; executive function; learning and memory; language; perception; and social cognition. That decline must be sufficient to interfere with independence and be unrelated to a treatable medical or psychiatric disorder. The Australian Institute of Health and Welfare estimates over 400,000 Australians are currently living with dementia, a figure predicted to more than double before 2060. The current prevalence estimate is equivalent to 15 people with dementia per 1,000 Australians, increasing to 84 people with dementia per 1,000 Australians aged 65 and over. Dementia disproportionately affects women, with >60% diagnosed being female. Dementia is the second overall cause of disease burden in Australia, second only to coronary heart disease. Early diagnosis allows the individual to plan for the future, and accurate diagnosis can assist with treatment. Most dementia is caused by neurodegenerative disease, with Alzheimer’s disease (AD) the most
Key messages Structural imaging (CT and/or MRI) is used to exclude dementia mimics and reversible causes of worsening cognition, particularly when cognitive decline is rapid, the patient is young or there are associated clinical signs and symptoms of other pathologies such as stroke MRI brain offers a sensitive assessment of the burden of coexistent chronic microvascular disease and can detect the typical imaging findings of specific neurodegenerative processes. Functional imaging with SPECT or PET can be helpful in distinguishing the common neurodegenerative diseases and is used when clinical assessment in conjunction with structural imaging is unclear. common, accounting for 60 – 80% of dementia and often co-existing with vascular dementia in a mixed dementia pattern. Frontotemporal dementia (FTD), dementia with Lewy bodies (DLB), and Parkinson disease dementia (PDD) are also some of the most common neurodegenerative diseases encountered in clinical practice. These conditions have overlapping clinical syndromes and imaging phenotypes, with diagnosis often difficult to make.
Fig 1. Normal adult brain (1a - c) T2/ FLAIR sequences with comparison cases of Frontotemporal dementia (2d), Alzheimer's disease (2e) and chronic small vessel disease (2f).
When evaluating a patient with worsening cognition, neuroimaging (CT and/or MRI) plays an important role in the diagnostic work-up. For example, in the setting of a rapid decline in cognitive function, if the patient is young or there are
Hearing and vision in residential aged care continued from Page 43 hearing and vision function, and quality of patient-provider communication. Importantly, using health economics methods, we will evaluate the cost-effectiveness of the intervention. 44 | NOVEMBER 2023
This project is being led by Professor Piers Dawes at the University of Queensland in collaboration with multiple universities, Brightwater Care Group and Hearing Australia.
Centre for Hearing Research at University of Queensland – References available on request Author competing interests – the authors are involved in the research described
ED: Prof Sohrabi is director of the Centre for Healthy Ageing at Murdoch University and Dr Meyer is Senior Research Fellow, MEDICAL FORUM | AGED & PALLIATIVE CARE
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CLINICAL UPDATE Early diagnosis of these potential dementia mimics is important for their appropriate management and a low threshold for imaging should be maintained.
Fig 2. Normal FDG PET (1a - d) compared with the typical regional hypometabolism (green areas) of Alzheimer's disease (2e - h).
Fig 3. MRI arterial spin labelling (a), FDG PET (b) and T1 weighted MRI sequence (c) demonstrating typical features of Alzheimer's disease.
associated neurological signs and symptoms, screening neuroimaging with CT offers a rapid and easily accessible tool to exclude acute intracranial pathology, such as stroke, potentially reversible conditions such as subdural haemorrhage and metastases, with all of these more frequently seen in an ageing and comorbid population.
Using more advanced neuroimaging in the work-up of patients with suspected dementia in a general practice setting is less clear with practice guidelines varying on their recommendations. However, many local and international guidelines on the evaluation and management of adult patients with cognitive impairment recommend the routine use of structural imaging (CT or MRI) to exclude reversible causes and potential dementia mimics. While there is overlap in the imaging phenotypes of AD, FTD, DLB and PDD, there are often specific differences that can be detected using both MRI and nuclear medicine imaging, contributing to the overall diagnosis. MRI can offer an excellent assessment of chronic microvascular disease burden, which often coexists with and contributes to the underlying neurodegenerative process and can also detect the typical
imaging findings of the specific neurodegenerative processes. Advanced MRI techniques such as arterial spin labelling (ASL), whilst not routine, can offer a functional assessment by quantifying regional blood flow, which is tightly linked to regional metabolism, with the typical neurodegenerative processes demonstrating distinct patterns of regional metabolic impairment. Functional brain imaging using the nuclear medicine modalities of single photon emission computed tomography (SPECT) and positron emission tomography (PET) can demonstrate regional reduced perfusion and metabolism respectively. These modalities are often used when diagnosis based on structural imaging and clinical assessment is unclear and there are atypical symptoms. ED: Dr Ratnagobal is a radiologist and nuclear medicine specialist; Drs McLaughlin and Warne are radiologists. Author competing interests – nil
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New CVD risk assessment guidelines – how should our practice change? By Dr Michelle Ammerer, Cardiologist, Subiaco The burden of cardiovascular disease in Australia remains high, every nine minutes someone has a heart attack. While CV mortality rates have been in decline for years, 2022 saw an increase of 9.1% compared to 2020. Early identification and management of risk factors in general practice remains fundamental to the prevention of premature mortality from cardiovascular disease. A new risk calculator can bring increased accuracy of risk prediction. Until this year we used Framingham risk calculator during our CV risk assessments – a calculator based on population data from America, which often miscategorised the Australian population, leading to patients being classified as low risk who go on to have a cardiac event. It is estimated by the Heart Foundation that a national switch to the Aus CVD Risk Calculator could benefit health outcomes for up to 8 million Australians.
Key messages There is now a CVD risk calculator calibrated for the Australian population which could benefit up to 8 million people Consider reclassification factors that allow for further nuanced and personalisation of risk, especially for those with results close to category thresholds How we communicate results are key to promoting the meaningful behaviour change required to improve outcomes.
Aus CVD Risk Calculator is validated for patients aged 30-79 and allows for more nuanced risk prediction. The Heart Foundation is currently working with GP EMR providers to ensure easy access to the calculator. Until then, it can be accessed online at www.cvdcheck.org.au A CVD risk assessment should be undertaken on all patients between 40 and 79, those over 35 with diabetes and over 30 for Aboriginal and Torres Strait Islanders. This represents an expansion of those we should be considering for CV risk assessment.
The Aus CVD Risk Calculator was developed from the PREDICT – 1 equation and calibrated for the Australian population. This calculator allows for more sensitive risk prediction, utilising additional information known to influence risk, including socio-economic status.
moderate to severe kidney disease should proceed directly to being classified as high risk.
Reclassification factors – what are they and how do we use them? Additional to the new risk calculator, we can also consider reclassifying patients up or down a risk category depending on other factors. Reclassification factors provide most benefit when a patient’s risk estimation lies close to a risk threshold and treatment decisions are uncertain.
New risk categories and how we help our patients understand what they mean. The new CVD risk categories are: • high (≥10% risk over 5 years) – prescribe pharmaceutical management of BP and lipids. • intermediate (5 to <10% risk over 5 years) – consider pharmaceutical management of BP and lipids. • low (<5% risk over 5 years) – pharmacotherapy is not routinely recommended. The purpose of undertaking a risk assessment is to empower patients to make the meaningful changes
Patients with Familial Hypercholesterolima (FH) and
Reclassification Factor
Down one Category
Up one Category
Calcium Score (low to intermediate risk patients only)
0
>99 or ≥75Th percentile
continued on Page 48
Family history of premature CVD
CHD or stroke in first degree female relative <65 or male relative < 55 years old.
Renal Function
• sustained eGFR 45-59 mL/min/1.73 m2 • persistent uACR 2.5-25 mg/mmol (men) or persistent uACR 3.5-35 mg/mmol (women)
Ethnicity
East Asian (Chinese, Japanese, Korean, Taiwanese, or Mongolian ethnicities)
People living with severe mental illness
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First Nation People, Maori, Pacific Islander or Southeast Asian (Indian, Pakistani, Bangladeshi, Sri Lankan, Nepali, Bhutanese or Maldivian ethnicities)
Defined as a current or recent condition requiring specialist treatment, whether received or not, in the 5 years prior to the CVD risk assessment.
NOVEMBER 2023 | 47
Getting to the heart of falls risk – CVD and musculoskeletal health By Mr Abadi Gebre, Edith Cowan University Around 33% of Australians aged 65 years and over fall each year, with one in five experiencing injuries such as fractures, accounting for one out of every eight days spent in hospital. Falls can also cause psychological trauma, with a loss of confidence to engage in physical activity, resulting in self-imposed mobility restrictions and loss of functional independence to perform daily routines. This poses a significant challenge, highlighting an urgent need to address the growing burden of falls, particularly considering the ageing population. Uncovering novel fall risk factors may allow for more effective and tailored prevention strategies. While transient events often associated with cardiovascular disease (CVD) such as hypotension, syncope and dizziness are among commonly recognised fall risk factors, atherosclerotic CVD is an underexplored potential risk factor. To address existing knowledge gaps, we conducted five studies, the majority using data from the Perth Longitudinal Study of Ageing in Women.
Structural measures of subclinical CVD: injurious falls The primary cause of CVD is atherosclerosis, which begins early in life and progresses for
decades before cardiovascular symptoms appear. Atherosclerosis leads to structural and functional alteration in major arteries including abdominal aorta and carotid arteries, typical of subclinical CVD. Measures of subclinical CVD (e.g. abdominal aortic calcification (AAC) carotid atherosclerosis), are associated with decline in muscle strength — an independent fall risk factor. However, the contribution of subclinical CVD to the risk of falls was unclear. We demonstrated for the first time that AAC, a marker of generalised atherosclerosis seen in more than 70% of older women, was linked to a 39% higher risk of injurious fall-related hospitalisation over 14.5 years. This is important because
routine osteoporosis screening, undertaken for fracture risk detection can also detect AAC and fall risk. We also showed that AAC was related to a higher risk of fractures at multiple skeletal sites. The presence of fatty build-up in any of the carotid arteries, was also associated with a 44% higher risk of injurious falls in older women. These two studies indicate the potential of subclinical atherosclerosis to provide a warning signal not only for CVD, but also for fall risk.
Subclinical CVD biomarkers: injurious falls High-sensitivity cardiac troponin (hs-cTnI) is a lower-cost and
New CVD risk assessment guidelines continued from Page 47 required to prevent future cardiac events. We know that how we discuss risk categories with patients can make a dramatic impact on what they do when they leave the consult. Using frequency-based language for example, “15 out of 100 people like you will have a heart attack 48 | NOVEMBER 2023
over the next 5 years”, combined with a visual aid, can help patients with a variety of health literacy levels to understand the meaning of their risk assessment. The online Aus CVD Risk Calculator includes a visual aid to enable more meaningful discussions.
shown to have a greater impact than one session alone. Focusing on the positive benefits of treatment and lifestyle changes has also been shown to lead to the greatest impact with patients. Author competing interests - nil
Repeating the advice and discussion over a few consultations has been MEDICAL FORUM | AGED & PALLIATIVE CARE
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Key messages Falls are the primary cause of injury-related hospitalisations, leading to a substantial loss of functional independence in daily routines Older women with CVD are previously unrecognised high fall risk population.
By Mr Peter Ammon Foot Ankle & Knee Surgery
Subclinical CVD may serve as an ‘amber light’ signalling a future risk of harmful falls, offering an opportunity for implementing early fall prevention interventions.
readily available marker of myocardial injury related to fatal and non-fatal CVD events. There were limited studies reporting an association between subclinical CVD biomarkers and falls, however we lacked evidence whether hs-cTnI was linked to injurious falls. For the first time, we demonstrated elevated subclinical levels were associated with a 46% higher risk of fallrelated hospitalisation. This suggests hs-cTnI may serve not only as a biomarker for CVD, but also for injurious falls.
Clinical CVD: injurious falls Although some cross-sectional studies reported the association between self-reported CVD and falls, there was limited evidence on whether CVD was related to injurious falls.
Plantar fascia origin
We found prevalent clinical CVD was associated with a 29% greater risk of fall-related hospitalisation, with cerebrovascular disease being the primary driver, linked to a 51% higher risk of injurious falls. This indicates individuals with CVD are an under-recognised high fallrisk population, warranting the need for consideration of cardiovascular health during fall assessment. Our studies are not without limitations. Due to the observational nature of the studies, a causal relationship cannot be claimed. The studies were based on older women, limiting generalisation to other populations. Overall, these works present a valuable opportunity, as fall prevention interventions are not often initiated until an individual experiences a fall, by which point the damage has already occurred. It is important to inform individuals with CVD that they may have a higher fall risk and could benefit from undertaking fall screening. Currently, limited clinical guidelines exist on the best approaches for fall prevention in individuals with CVD, however, there is a consensus on the need for tailored fall-prevention strategies. Recommendations include a comprehensive exercise program including aerobic, resistance, and challenging yet safe balance exercises. Lifestyle changes such as quitting smoking and adopting a diet rich in vegetables are also advised to improve cardiovascular health and reduce fall risk. – References available on request Author competing interests the author was involved in the research described
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Ensuring quality end-of-life care By Dr Charles Inderjeeth, Geriatric Medicine, SCGH & Osborne Park With an ageing population, the delivery of specialised, realistic, individualised care for this group should be the goal. The rational integration of palliative care into aged care is a necessity, having considerable implications for patient wellbeing and healthcare provision efficiency. The aim is to provide holistic, patient-centred care enhancing the quality of life and respecting individual dignity. However, several barriers have been identified impeding the realisation of these principles including a lack of sufficient training in palliative care for healthcare professionals and limited public knowledge and understanding of the benefits and goals of palliative care. Early initiation of palliative care is important. It should not merely be viewed as an end-of-life care plan, but an ongoing process, commencing from the point of diagnosis of life-limiting illnesses. Early incorporation of palliative care improves patient quality of life, effectively manages pain and symptoms, and fosters improved communication about care preferences. Taking a proactive approach can help prepare patients and their families for impending health changes, reducing the frequency of aggressive treatments pursued near death and unwarranted hospital admissions. Effective communication is the bedrock of successful palliative care. Establishing trust and rapport with the patient and their family is paramount. Encourage open and honest dialogue about the prognosis, treatment options, and potential outcomes. Discussing end-of-life preferences early can help avoid misunderstandings and conflicts later. Use plain language and be ready to answer questions patiently.
Interdisciplinary approach Palliative care is a comprehensive, interdisciplinary field comprising
Key messages Palliative care in aged care settings is a multifaceted and demands sensitivity, empathy, and a patient-centred approach Early initiation of care, utilising an interdisciplinary team approach, and tailoring treatment plans to individual patient and family needs and preferences are vital Holistic care that addresses physical, psychological, social and spiritual domains improves patient comfort and can increase both patient and family satisfaction with the care given.
various health professionals including doctors, nurses, care aides, and social workers collaborating to address not just the physical pain and symptoms, but also the psychological, social, and spiritual challenges that confront patients. Encouraging active family participation can significantly enhance patient comfort and overall satisfaction with care. Palliative care is not a one-size-fitsall approach. Begin by conducting a comprehensive assessment, considering not only medical issues but also psychological, social, and
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spiritual dimensions. Engage in open conversations about endof-life wishes. Understand the patient's goals and expectations and completion of Advanced Care Directives and Goals of Care are essential. Some may prefer to remain at home, while others might opt for a care facility. Ensure that the care plan aligns with their desires and wishes and belief systems.
Pain & symptom control No patient at the end of their life should have to endure pain and suffering. Effective symptom management is central to care. Tailor interventions to the individual, considering their medical history and preferences. Combine effective pharmacological and non-pharmacological approaches. Medications should be titrated carefully to provide relief while minimising side effects. Additionally, consider complementary therapies such as massage, music or aromatherapy to enhance comfort. Ageing adults and their families may experience a range of emotions, including anger, denial, anxiety, depression and grief. Addressing continued on Page 53
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Managing pain in older adults By Dr Rajiv Menon, Anaesthetist & Pain Medicine Physician, Joondalup Pain in older adults has historically been under-diagnosed and undertreated. Previous (now-obsolete) teaching principles for medical students included the idea that as patients age, and particularly if they develop cognitive decline, they may feel less pain. It is now accepted that the older adult population has a higher prevalence of experiencing pain (>50%). There are numerous potential factors for this, including an increased presence of degenerative/inflammatory diseases in the spine and major joints, increased prevalence of disorders that may cause neuropathic pain (eg. diabetes, cancer, stoke), and other conditions such as peripheral vascular disease that can contribute to the pain experience.
There is also an increased risk of more than one of the above factors being present in the older adult population. The corollary is that there may be a perception that pain is ‘expected’ with ageing, and therefore less likely to be reported. When assessing pain in the older adult population, we must consider the presence of neuropsychological co-morbidities that can interfere with normal reporting of pain and reduce the ability for external observers to perceive the patients’ pain. These factors include mental state alterations (e.g. depression or anxiety) and altered cognitive states (acute or chronic). Application of screening tools such as the DASS-21 and the MoCA (Montreal Cognitive Assessment) can be helpful in identifying such issues, and these patients may
benefit from further geriatric or psycho-geriatric assessment. Analgesic pharmacotherapy forms a key part of managing pain in the older population, with specific factors to consider. The older adult population is more likely to experience adverse effects from these agents. A reduced physiological reserve, higher risk of organ dysfunction that may affect drug metabolism, and lower thresholds for complications such as respiratory depression are all potentially complicating factors. These patients are often already on multiple medications for other comorbidities, with an increased risk of drug interactions. It can be difficult to find an effective dose of a given agent
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Key messages Pain that is refractory to standard (and escalating) treatments may indicate underlying exacerbating neuro-psychiatric factors (eg. Anxiety, depression, cognitive decline). Maximising non-pharmacological strategies can reduce the need for strong analgesia and associated side effects. Interventions may be a better tolerated alternative to regular strong analgesia in older adults. that does not cause unwanted or intolerable side effects. A “start low, go slow” approach, with careful titration is a reasonable strategy. Combining more than one agent at lower doses may lead to less side effects compared with a single agent at higher doses. Setting clear functional goals at the outset (e.g. improved sleep, improved mobility, or specific functional goals such as walking a certain distance) may help the patient achieve a satisfactory outcome without necessarily requiring a complete cessation of pain.
Given the potential pitfalls associated with the use of stronger analgesic agents, it is key to maximise non-pharmacological strategies. This is often better done with the involvement of an allied health team experienced in the management of chronic pain and musculoskeletal conditions, including physiotherapy, occupational therapy, and clinical psychology. Potential treatments in this category can include pacing, activity modification, the use of assistive devices, graded exercise therapy, distraction, mindfulness, and emotional regulation. While these strategies are unlikely to work in isolation in the management of strong pain, even a modest effect may allow for a reduction in medication dosing that can make a significant positive impact on the patient’s function. When the above strategies have been inadequate, or poorly tolerated, it is worth considering interventional techniques. These include corticosteroid injections, targeting common sources of pain including the epidural space, spinal facet joints, sacroiliac joints, and other large joints (e.g. hip, knee and shoulder).
More advanced techniques such as thermal radiofrequency ablation or cryoablation can be used to provide a more prolonged duration of effect. These techniques (generally performed under sedation, by an interventional pain specialist) can offer equivalent or better pain relief than pharmacotherapy, with fewer systemic side effects. They are generally well tolerated with a low risk profile. They are also helpful in the older adults unable to have a surgical solution for their pain due to the presence of other co-morbidities. They are often used in an inpatient setting to allow patients in an acute pain flare to mobilise and be discharged home. Other co-morbidites must be taken into account when considering interventions (e.g. antiplatelet/ anticoagulant medication). These factors can be mitigated with careful assessment and work-up, and the procedures are best done in a hospital setting with the input of a specialist anaesthetist. Author competing interests – nil
Ensuring quality end-of-life care continued from Page 51 these psychological aspects is integral to holistic care. Social workers and counsellors can provide emotional support and facilitate discussions about endof-life emotions. Encourage family involvement and provide resources for grief counselling and support groups. Consider spiritual needs, offering access to chaplains or religious leaders if requested.
Ethical considerations Navigating ethical dilemmas is a reality in palliative care. Practitioners should be well-versed in ethical principles, including autonomy, beneficence and nonmaleficence. Be prepared to guide patients and families through challenging decisions, such as withholding or withdrawing lifesustaining treatment.
Get a second opinion from a colleague when in doubt or when there is family conflict. In some rare situations, consult with an ethics committee or seek legal advice when faced with complex ethical questions. Always prioritise the patient's best interests and respect their autonomy over all else. There comes a point when giving the patient the best quality of death is the most realistic and important consideration. Palliative care is a dynamic process. Regularly evaluate and adapt the care plan to address changing needs and goals. Patient comfort is the goal. Maintain open communication with the patient and their family, addressing any concerns promptly. As the end-of-life approaches, consider shifting the focus of care from curative to comfort-oriented. In summary, effective palliative care in aged care centres on three key
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principles: early initiation of care, utilising an interdisciplinary team approach and tailoring treatment plans to individual patient and family needs and preferences. Holistic care that addresses physical, psychological, social, and spiritual domains improves patient comfort and can increase both patient and family satisfaction. The focus should be on adding life to years rather than years to life. As we continue to champion the cause of providing optimal care for our ageing population, let us consider these key messages not only in our routine clinical practice but also as springboards for continued research, ongoing education, and public awareness initiatives in this vital area of healthcare. Author competing interests – nil
NOVEMBER 2023 | 53
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• Comprehensive expertise in adult and paediatric neuroradiology. • Consultant radiologist experience at public, private and teaching hospitals and universities. • Involvement in multidisciplinary team meetings across Perth. • Premium acute stroke imaging service.
Please contact our customer relations team for more information or email assist@perthradclinic.com.au perthradclinic.com.au 54 | NOVEMBER 2023
MEDICAL FORUM | AGED & PALLIATIVE CARE
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CLINICAL UPDATE
Can we help heart-sink patients if we have heart-sink systems? By Dr Siobhain Brennan, GP & GP Liaison (Silverchain & SJGHC) As a GP and a GP liaison working in the outer suburbs, I often reflect personally and professionally on the barriers to healthcare for the patients in the community I care so much about.
confused on a recent visit, and I want it communicated efficiently with me. A key feature identified repeatedly is the federal-state divide in funding, resulting in fragmentation, duplication and accountability issues.
Previously our healthcare system was admired by other nations, but less so recently. There are many complex reasons why, and certainly ours is not the only OECD health system currently heaving under the demands of an ageing population with increasing disease complexity (not helped by the pandemic). Over the past 20 years in general practice, I have witnessed a gradual devaluation of primary care, which I believe has contributed significantly to the challenges we now face. The result of this malaise can be seen in the most recent Deloitte GP Workforce Report which indicated a potential shortfall of 11,392 GPs by 2032 if significant reforms are not implemented to prevent this. Deloitte expects that the demand for GPs by 2032 will be up by 35% from today. In 1985, 40% of doctors in Australia were practising GPs, and RACGP data shows only 13% of medical students today identify general practice as their intended speciality. Given the economics of health care and the clinically and financially important role of primary health care in maintaining the wellbeing of the nation for the lowest cost, this decline is alarming. Beyond statistics, the impact is individual and personal. What does this mean for my senior patient who cares for her adult child with disability? Will she and her adult child be able to get the care they need by 2030? Will they be able to get a GP appointment to have their infections treated in a timely manner to prevent hospitalisation? Will GPs of the future have time to listen to her realistic concerns? We know that supporting patients with complex disease prevents morbidity, mortality and hospital admissions. But will there be
Many health carers in the community want to have consistent clear lines of communication between the different services and their GP, but there is little infrastructure to enable that and most providers muddle along the best they can. Ongoing reforms in electronic records must look at how to integrate well with GP networks.
Key messages An ageing population needs a viable primary care system Better integration with in-home and other services is critical Technology has potential to facilitate better care.
enough GPs in the community to support parents when they need it? And what can we do to elevate the primary care system for optimal patient outcomes and create satisfying work for GPs? It is critical to improve the networking and collaboration of primary care with in-home care for the most vulnerable, in palliative care, wound care, chronic disease support, and allied health services. These collaborative models will be vital for our ageing population. If these models are developed to connect and integrate with GP services, we will see improvements to outpatient care to rival the efficient Danish health system. My elderly patient may cope well at home if she has the support of in-home care. As her GP, I don’t need to be the person that changes her dressing, or gets her to her appointment, but as the coordinator of her care, I need to know if the visiting team found her
MEDICAL FORUM | AGED & PALLIATIVE CARE
Patients with chronic disease have been identified in the Strengthening Medicare Taskforce reforms as needing much greater support, and the role of general practice in preventing hospital admissions has been clearly identified. The current change to voluntary patient registration is a step towards improved care coordination and support for primary care providers and for these patients. With the current health care reforms federally, we have an opportunity as healthcare professionals to advocate for a new, digitally connected, more collaborative approach to health care, but we can only do that if primary care and general practice remain strong and attractive to support care coordination. We can all (hospitals and primary care) open our thinking beyond bricks-and-mortar facilities but must take a whole-person approach to care. We must ensure the digitally enabled platforms we are building benefit the patients and efficiently connect the health care system and professionals that serve them. Author competing interests – nil
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MUSIC
Collective spotlights women Two Perth musicians have created an arts organisation to inspire the next generation of performers while also championing female composers through the ages.
By Ara Jansen As a young musician Stephanie Nicholls was blessed to have great mentors and opportunities to perform. Now she and close friend Tresna Stampalia have founded a collective to pay their musical knowledge and experience forward for female musicians in Perth. Called Mirabilis Collective – Mirabilis being a Latin adjective meaning wondrous and remarkable – the not-for-profit supports emerging female musicians and fosters diversity and inclusion. Stephanie (oboe and piano) and Tresna (flute) have shared friendship and creative collaboration since university. Their journey together has included performing in orchestras, 56 | NOVEMBER 2023
chamber music ensembles and Australian touring musical theatre productions. Early in their careers, the pair were mentored by exceptional musicians. Stephanie says this invaluable experience has not only shaped their music careers but has instilled in them a profound understanding of the importance of creating opportunities for others. “When Tresna and I left university, we had a lot of opportunities to perform,” Steph says. “Now, we have had a lot of women leaving the profession because they have decided there’s not a career here. Or maybe it just becomes a hobby. We are losing a lot of talent because of this.
“Tresna and I have built thriving freelance careers through diverse performance opportunities. With Mirabilis Collective, we’ve established an organisation where women can gain experience in concert preparation and collaboration, fostering a cohesive environment for collective growth and learning. We like to think of our organisation as intergenerational women performing genre-defying music. That’s what I love about it.” The chamber music group have also chosen their repertoire a little differently as they exclusively perform classical, contemporary and world styles written by women. A Mirabilis Collective performance will likely have a classical piece
MEDICAL FORUM | AGED & PALLIATIVE CARE
MUSIC
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A feature of a Mirabilis Collective concert is that they are an hour in length and no piece is longer than six minutes. Not only is this a perfect introduction but is designed to encourage people to dip their toes into the world of chamber music as they hear some familiar pieces alongside music new to their ears. The multi-generational group ranges in age from 21 to performers in their 50s. They have started working and mentoring students from UWA’s Conservatorium of Music. “We’re learning as much from these students as they are from us, which I think is wonderful. We get their perspective on style and programming.” Mirabilis Collective’s focus in their first year was to present their concert series. The next step is to add workshops and master classes, as well as continue to book other performance opportunities for different sized groups within the collective. Both Tresna and Stephanie have strong backgrounds in education, so they plan to leverage that experience for the group. They’ll also be setting up a network of sponsors called The Remarkables with the aim of commissioning and funding new works by local female composers. Tickets for Mirabilis Collective’s final 2023 show are available at www.mirabiliscollective.com
sitting next to a re-imagined Kate Bush, Regina Spektor or Joni Mitchell song. This year’s concert series called Her Voice Resounds has included one performance featuring music written or inspired by women named Emily including poet Emily Dickinson’s work put to music, songs by Australian Indigenous songwriter Emily Wurramara and folk-rock songs by Emily Saliers of Indigo Girls. The final concert in the series on November 21 is The Ties That Bind, which will explore the deep bonds of sisterhood and friendship. It features music written by Lili Boulanger, Clara Schumann, Annie Lennox and Katie Noonan. “We’re putting the spotlight on the oftenunderrepresented work by women,” says Stephanie. “The idea for Mirabilis Collective was influenced by work I completed for the Australian Music Examination Board when writing their current oboe syllabus. It was important for the syllabus to have better representation from women composers and include music outside traditional ‘dead white male composers’. “I found an exciting array of female composers dating back through to the 1700s and 1800s whose works are now featured. It’s now possible for students sitting high level exam programs for the AMEB to present a program of varied genres composed entirely by women. “I wondered why we didn’t know about these composers – some of them are amazing. I discovered music by a Brazilian woman who wrote sambas in the early 1900s and learnt more about South African singer Miriam Makeba. Women from all over the world and all styles have been writing music for a long time and it’s time for that music to be heard.” MEDICAL FORUM | AGED & PALLIATIVE CARE
Movie give-away He came from nothing and conquered everything. From acclaimed director Ridley Scott, Napoleon is a spectacle-filled action epic which details the checkered rise and fall of the iconic French Emperor Napoleon Bonaparte, played by Oscar-winner Joaquin Phoenix. This month, courtesy of Sony Pictures, we have 15 double tickets to Napoleon, which opens in cinemas on November 23. Go to mforum.com.au
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VISUAL ARTS
Art reimagines the blues Painter Emma Thomson loves the ocean, the beach and the colour blue, so it makes sense her work combines all three.
By Ara Jansen Indigo, azure, cornflour, aqua, navy, midnight. Name a kind of blue and Emma Thomson has probably used it liberally in her paintings. Blue is Emma’s favourite colour and she uses every tone and hue to colour her calming and highly realistic seascapes. She spends a lot of time by the water, watching and taking it all in, hypnotised by the blues. “I feel like I could go to the beach every day for 20 years and it would still be different each time – and I would never lose interest in seeing it at different times of the day,” says Emma. “I’m deeply connected to the ocean and love exploring the coastline, observing colours and wave formation. I’m particularly drawn to how the light interacts with the water, creating an endless array of hues and shadows constantly in flux. I’m also fascinated by the energy and movement of the ocean, from the crashing waves to the calming stillness on a summer’s evening. “I use photos I take as a guide and don’t usually mess with them too much. I like that people recognise 58 | NOVEMBER 2023
their local beaches in the work. People also commission me to paint their family on their favourite beach or their dog.” She works in Wash House Studio, an old, renovated wash house at the back of her Mt Lawley home, which she shares with husband Kim and their two teenagers. Willow the grey cat and a miniature dachshund aptly named Pablo Picasso are always lounging about the studio, while music of all genres is a constant companion. A full-time painter for the past five years, the bubbly artist has been painting or drawing all her life. Emma started her professional career as a graphic designer, majoring in illustration and her first job was designing patterns for kids’ clothes. It took a lot of artistic investigation to settle on this style as the one which makes her happiest and content. “It was a process and not a fast one. I painted everything from abstracts to portraits. It was frustrating. I remember one day I went to Rottnest and I came home thinking I was going to paint a beach scene. I loved it and realised this was it. I kept going. That was about eight years ago.”
She paints all day while the kids are at school, accepts the odd bit illustration and social media work and says it’s a blessing to be disciplined about her work. Like her personality, Emma’s work exudes a natural joy and says one of the biggest compliments she can receive is that the work makes people feel calm. Painting is like her therapy and it’s what helps her feel calm when the busy of life is whirling around. Represented by Darlington’s Juniper Galleries, she’s been part of numerous group shows there as well as taking commissions. She’s active on TikTok and has a lot of fun sharing her process and journey. “My intention is to create paintings that not only capture the beauty and power of the ocean but also evoke an emotional response, inviting the viewer to connect with the natural world in a deep and meaningful way.” www.emmathomsonart.com
MEDICAL FORUM | AGED & PALLIATIVE CARE
The times they are a-changin’ M IU
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These famous words from Bob Dylan are very applicable to this great Margaret River winery over this past year. Cape Mentelle was one of the earliest wineries in the region, with 16ha of vines planted in 1970 by the visionary David Hohnen. His Cabernets were central to the recognition of Margaret River as a quality Australian wine region when they won the Jimmy Watson Memorial Trophies in 1983 and 1984.
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WINE REVIEW
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In 1990 the property was purchased by the international giant LVMH (Louis Vuitton Moet Hennessy) and over their three decades of ownership plantings have grown to 145ha. Now, in January this year, LVMH sold Cape Mentelle to the huge Endeavour Groups subsidiary Paragon Wine Estates, which owns Eastern States wineries, this being their first venture into WA. Interestingly, Woolworths Group demerged from Endeavour in 2021, but is still a major shareholder. I suspect that Cape Mentelle marketing will largely be through their Dan Murphy's retail outlets. I am certain that the outstanding quality of the wines will continue. For this article I reviewed two wines – their flagship varietals, Chardonnay and Cabernet, and both were as always of excellent quality.
Review by Dr Craig Drummond Master of Wine
Cape Mentelle Margaret River 2021 Chardonnay (rrp $60) A classic Margaret River Chardonnay. Good outcome for a challenging vintage, with a cold wet spring and hot dry summer, then rain and high humidity at harvest. Winemaking included whole bunch pressing to barrel, with solids, wild fermentation, then into French oak (25% new), and left on yeast lees for 10 months with frequent stirring. The resulting wine leaps from the glass with vibrant, inviting aromas of peach skin and cashew nut. An amalgam of great fruit integrated with quality oak. Leads onto a palate packed with flavours of grapefruit and white peach. Textural and structured, with a linear acidity and a mineral core. A touch of butterscotch from malolactic fermentation. Has a long and clean finish. Great drinking now and will reward for a further 6-8 years.
Cape Mentelle Margaret River 2020 Cabernet Sauvignon (rrp $60) The product of a very good vintage. Warm/dry conditions, low yields giving concentrated fruit, and minimal bird strike. Selected vineyard batches were treated individually in the winery – de-stemmed and lightly crushed, fermented with selected yeasts before being basket pressed and the blend assembled within six months of harvest. Maturation was for 15 months in the barrel (26% new French oak). The result is another great Margaret River Cabernet. Ruby red in colour with a purple meniscus suggests youth and longevity. Nose displays rich cassis Cabernet characters, with integrating oak. Palate is ripe, succulent, with flavours of blackcurrant, blueberry and Spanish black olive. Superb oaky characters. Tannins supple, fine and long. A very balanced and complete wine. This wine will evolve and drink well for 10-12 years.
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MEDICAL FORUM | CARDIOVASCUL AR HEALTH
medical forum CLASSIFIEDS FOR LEASE
DUNCRAIG Highly Sought Rare Medical Suite + Unique opportunity as long term tenant retiring + 98sqm medical consulting suite + Ample parking + 3 consulting rooms + Opposite Glengarry Hospital Asking Rent $34,300 pa + GST & Outgoings For further details please contact Rob Selid 0412 198 294
MURDOCH Murdoch Health & Knowledge Precinct Suite 3.10, 44 Barry Marshall Parade, Murdoch • Superbly located ‘A Grade’ suite within master-planned medical community • 195 m2 brand new tenancy • Corner suite, abundant natural light • 2 under cover car bays • Fit-out contribution available • Suite may accommodate 4/5 consulting rooms, reception/waiting area, kitchen/breakout area, store records room, and other zones. Be part of this brand-new complex and make your enquiry today. Contact Paul Farris 0424 888 778 or paulf@rfre.com.au
HILTON 44 Victor Street, Hilton • Well located whole building in a thriving Neighbourhood Commercial Hub. • 93.2 m2* m2 lettable area. • 3 consulting rooms, reception/waiting room, multiple toilets plus shower, store and tearoom. • Abundant on-site parking. • Ready for your practice now. Contact Paul Farris 0424 888 778 or paulf@rfre.com.au
FOR SALE CANNINGTON GP practice for sale in Cannington: Established for past 30 years in Cannington on Albany highway right across Carousel shopping Centre. Excellent opportunity. Current owner need to move due to changes in their business model and also moving to another state. Great negotiable deal. Call 0408 928 916 for confidential inquiry.
Contact Andrew, classifieds@mforum.com.au or phone 9203 5222 to place your classified advert
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RURAL PLACEMENTS
HARVEY Treendale Medical Group – GP Positions • DPA Area’s and MMM5 Available • FSP GP’s are welcome to apply • Busy & well established Medical Group with 4 Location in the South West of WA • Full time & Part Time GP Positions in Treendale & Harvey • Fully computerized and accredited modern practice with nursing and admin support • Well supported with large team of experienced GP’s • Situated in the beautiful South West Region surrounded by coast and forest and close to tourist areas in the south of WA • Only 1 ½ hrs from Perth • Family friendly working hours and no on call or hospital cover required • 65 – 70% of billings depending on experience Please forward CV and enquiries to Kylie Wilson kyliew@harveymed.com.au
METRO PLACEMENTS
DUNCRAIG Duncraig Medical Centre GP required Full time patient load available. Flexible hours seven days Excellent remuneration – $200 to $300 per hour. Predominantly private billing practice Modern fully computerised practice (Best Practice) Please contact Michael on 0403 927 934 or michael@duncraigmedicalcentre.com.au
CHURCHLANDS Seeking a locum GP who is able to work Tuesdays, Thursday and Fridays for the months of June, July and August No afterhours consulting Remuneration is negotiable Herdsman Medical Centre is a busy, family orientated, accredited Practice Well Equipped Treatment Room Clinipath adjacent Privately Owned/Mixed Billing Friendly Registered Nurses and Experienced Administration Support For further information please Email: karen@herdsmanmedical.com.au
ALKIMOS Jupiter Health Alkimos A wonderful and exciting opportunity for a VR-GP has arisen to join our experienced, friendly and supportive team. We are a modern purpose-built practice based in the heart of a growing community, with 7 consult rooms and a large treatment room. • Mixed Billing • Pathology onsite • Excellent reputation with patients • Modern, well-maintained equipment • Established and expanding patient demographic • Close-knit and supportive team culture • Allied health rooms available onsite • Open 6 days a week (Sunday-Friday) • Efficient admin and nursing staff • Own dedicated consulting room • Free parking For more information or expressions of interest please send an email to Emma at p.manager@jupiterhealthalkimos.com.au
COMO
Opening for VR GP - F/time or P/time Full Private List available now from retiring GPs FRACGP essential Up to 70% private billings Unique opportunity to join our family orientated practice in one of Perth’s fastest-growing suburbs. Enjoy working for a doctor-owned, non-corporate, well supported, and accredited practice. Please contact the Practice Manager on 6165 2444 or email: reception@comogp.com.au
GLEN FORREST Glen Forrest Medical Centre GP Position The doctors at our practice enjoy clinical autonomy and practising on their own terms. There are no KPI’s or numbers of patients per hour. Our friendly, supportive administration team are there to assist with in-house IT and management of accounts. We use Best Practice software. We have a purposebuilt treatment room and separate procedure room for Mirena’s etc with a great team of nurses to support you. Glen Forrest Medical Centre provides quality and comprehensive care to our patients including minor surgical procedures, women’s health (Mirena/ Implanon/IUCD), men’s health, IV fluids, iron infusions, mental health, paediatrics, adolescent health, complex medical comorbidities and palliative care. Please contact Maria Clark on 08 9298 8555 or email mariac@gfmc.com.au
PERTH Breast Clinic seeking VR GP Perth Breast Clinic is seeking an enthusiastic VR GP to join our expert team of breast physicians, 1 – 2 days per week. Located in the Mount Hospital Medical Centre, Perth Breast Clinic offers a comprehensive service for women, from breast screening and diagnosis through assessment of symptoms, diagnosis and management of breast cancer and benign breast disease. The clinic is led by our specialist breast physicians who work as part of a multidisciplinary team comprising radiologists, surgeons, pathologists, oncologists, nursing and support staff. We offer • Comprehensive training and mentorship by highly experienced breast physicians • Flexible work hours, 1-2 days per week • Mixed billing, low service fee • Onsite parking Requirements • AHPRA registration / Medical Indemnity insurance • Previous experience in women’s health • Advanced communication skills For further information, please contact Tasha Pratt by email tasha.pratt@healthscope.com.au or phone 0477 961 871
BENTLEY Burton Street Family Practice Unrestricted VR GP required for well-established privately-owned mixed-billing practice With an interest in all areas of general practice, you are expected to share our mission to provide high-quality care for the whole family in a coordinated fashion. Serving a diverse patient demographic, we aim to manage chronic illness to avoid complications and acute issues and reduce the need for hospital presentation and admission. You are provided clinical autonomy and supported by a strong team of Australian trained GPs, nursing and administrative staff. AGPAL and WAGPET accredited, we offer the opportunity to be involved in teaching medical students and GP registrars. Please apply to burtonst@burtonst.com.au or call 08 9458 4558 BURSWOOD/CLAREMONT 75% OF BILLINGS!! GP positions available in accredited mixed-billing clinics in Burswood and Claremont. Looking for VR GPs and non-VR GP’s on a full time/part-time basis for weekday and Saturday afternoon sessions. Fully computerised with on-site pathology and RN support. Please contact Dr Ang on 9472 9306 or Email: info@thewalkingp.com.au
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
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medical forum CLASSIFIEDS
EDGEWATER GP FT/PT Edgewater Medical Centre is an accredited, mixed billing, medical practice in Edgewater, Western Australia and seeking a General Practitioner to join our friendly, patient focused team. Work place: You will be working with a dedicated and professional team of administration, nursing and health staff supporting GPs within this busy practice, providing a full range of medical services. The focus is on personal care, attention and expertise. Role: As an experienced GP, this role will allow you to provide high quality primary health care services to the community, in keeping with best practice standards. Essentials: • Applied knowledge, skills and experience in general practice • Unrestricted VR GP qualification • Full Australian Work Rights What’s in it for you: • State of the art equipment, technology & facilities • Supportive team • Doctor owned practice • Nurse Support • Onsite Pathology • No call outs– Week Day 8-5 roster • Free parking onsite • Flexible arrangements • 70% of billings • Initial Guaranteed payment of $150.00 per hour in first 3 months For a confidential discussion, please contact Cecelia – (08) 9306 1899 or CeceliaC@edgewatermedical.com.au
BULL CREEK MetroGP Requires a VR GP Unrestricted for Part-time Position: As an experienced GP, this role will allow you to provide high quality primary health care services to the community, in keeping with best practice standards. Essentials: • Applied knowledge, skills and experience in general practice • Unrestricted VR GP qualification • Full Australian Work Rights What’s in it for you: • Supportive and Experienced Admin team • Doctor owned practice • Nurse Support • Onsite Pathology • Flexible arrangements • AGPAL Accredited Practice • Located near FSH and SJOG Murdoch • Mixed Billing (mainly Private) If you are interested please contact our Practice Manager for further information on 9332 5556 or email: adminmetrogp@metrogp.com.au
CURRAMBINE Shenton Avenue Medical Centre has a great opportunity for a General Practitioner to join a very well established practice. • Wonderful, friendly staff. • Experienced doctors. • Very large existing and loyal patient base. • Mixed billing practice. • 75% of billings. • Non-Corporate. • On-site services including Pathology, Physiotherapy, Podiatry, Dietitian • Fully accredited practice. If you are interested in this exciting opportunity please contact Phil at phil@medibizz.com.au BULL CREEK Bull Creek Medical – VR GP opportunity We are seeking full time or part time VR GP to join our friendly team. It is a mixed billing well established practice providing quality health care for many years. It is located closer to world class public and private hospitals and near by top public and private schools. Flexible working hours and terms and conditions are negotiable. If you are interested in this exciting opportunity, contact practice manager via email: admin_pm@bullcreekmedical.com or call on 08 9332 0488
ATWELL Require VR GP’s Unrestricted for Part-time Positions: As an experienced GP, this role will allow you to provide high quality primary health care services to the community, in keeping with best practice standards. Essentials: • Applied knowledge, skills and experience in general practice • Unrestricted VR GP qualification • Full Australian Work Rights What’s in it for you: • Supportive and Experienced Admin team • Doctor owned practice • Nurse Support • Onsite Pathology • Flexible arrangements • AGPAL Accredited Practice • Located near FSH and SJOG Murdoch • Mixed Billing (mainly Private) If you are interested please contact our Practice Manager for further information on 9332 5556 or email: adminmetrogp@metrogp.com.au
BALCATTA Clinical autonomy The role would suit a new Fellow or GP who wants to curate their own patient base with a guaranteed minimum offered for 3 months. Work in a fantastic environment – a non-judgemental, respectful and safe space with a supportive nursing and admin team. Enjoy an innovative, modern practice with the latest equipment and software (BestPractice). Choose your hours – our clinic is open from 8am to 7pm Monday-Friday, 8-1pm Saturdays. Get to know your colleagues with quarterly team-building activities Sub specialise – for the right applicant, we’re happy to support your special interest. Central location - 15 minutes from the CBD, extensive parking available. Contact: PracticeManager@balcattafamilypractice.com.au or call Debbie on 08 6478 3955
Gosnells Healthcare Centre has a great opportunity for General Practitioner to join a very well-established practice. GREENWOOD Kingsley Family Practice We are seeking a part time or full time GP to join our well established, busy practice. You will work in a highly equipped AGPAL accredited practice, alongside GPs with extensive specialised skills, including skin cancer surgery (including flaps and grafts), cosmetic medicine, ultrasoundguided musculoskeletal PRP injections, IUD insertion, ENT operating microscope use, and much more. The practice itself is highly equipped, including on-site ECG, spirometry, ABI machine, ultrasound, digital dermoscopy imaging, ambulatory BP monitoring and a full time chronic disease management nurse. Mixed billing, offering our GPs 70%. All appointments privately billed on Saturdays. For more information please email kingsleypractice@gmail.com or call our Practice Manager Tracy Weare on (08) 9342 0471
The role would suit a new Fellow or GP who wants to curate their own patient base with a guaranteed minimum offered for 6 months. Wonderful, friendly practice Experienced Doctors Very Large existing and loyal patient base Mixed billing practice Enjoy an innovative, modern practice with the latest equipment and software (Best Practice) 70% of billings- plus attractive relocation package Choose your hours, Our Clinic is open from 8am-5pm Monday-Friday. On-site services include Pathology, Physiotherapy, Podiatry, Dietician Fully Accredited practice DPA Replacement Provider Number available Safety Net of $150 per hour for 6 months
If you are interested in the exciting opportunity please contact Phil at ceo@spectrumhealth.net.au Gosnells HealthCare Centre 2227A Albany Highway, Gosnells WA 6110
Contact Andrew, classifieds@mforum.com.au or phone 9203 5222 to place your classified advert
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
medical forum CLASSIFIEDS
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Opening October in WATERFORD New patients welcome
Hillarys Medical Centre is a very busy practice located 15mins from the Perth CBD along the coast. We have a strong focus on family & preventive health medicine. We are a team of 10 doctors with excellent administrative and nursing support staff. We have been in Hillarys for 20 years with dedicated GP owners. We pride ourselves with providing exceptional health care to our community of Hillarys. We have a modern purpose built well equipped 3 bed treatment room and 10 consulting rooms with quality equipment as well as a spacious staff & meeting room. We are also able to offer secure remote access and secure onsite parking. Pathology & Pharmacy are within our complex. There is a high-income potential as we are mainly a private billing practice. We would also encourage doctors to develop their own special interests
Positions available for suitably qualified Doctors and Nurses To apply please contact: practicemanager@parkmedicalgroup.com.au
To book your appointment
Call ☎ 9452 9999
or book via
or on-line via
www.parkmedicalgroup.com.au Park Centre, U2, 779 Albany Highway, East Victoria Park Victoria Park Central, U24, 366 Albany Highway, Victoria Park Waterford Plaza, 230 Manning Road, Karawara
Our patient base is varied as well as a strong family base practice including women’s & mens health, skin cancer medicine, iron infusions, aviation medicine and more. Our nurses are committed to support for care plans & health assessments. We are a 7 day a week (Mon to Thur 8am to 7pm, Fri 8am to 6pm, weekends 8.30 to 12.30pm) we have a variety of sessions available and the opportunity to share a Saturday roster with your fellow GP colleagues, with nursing support. We would require: Current unrestricted registration with AHPRA as a general practitioner Current medical indemnity insurance Full Australian working rights and No DPA restrictions For confidential discussion please phone Dr Rod Parker 0447 117 013 or Dr William Thong 0403 171 061 or by emailing admin@hillarysmc.com
General Practitioner Join our friendly Health Services team to provide quality care and make a difference in Curtin Community’s health and well-being at our Bentley campus. Part-time and full-time contractor/temp opportunities available Excellent working conditions and room facilities Administrative and Nursing support provided JOB REFERENCE Are you a caring and experienced General Practitioner? Join our friendly and collaborative team of general practitioners, nurses, medical receptionists, and a Practice Manager to make a difference to our Curtin Community’s health and well-being within our busy Medical Centre at our Bentley campus. Our Medical Centre is a well-established and fully equipped practice with a total of 7 consulting rooms, a procedure room, treatment, and onsite pathology. The Centre is open Monday to Friday between 8:30 am and 4:30 pm. It is well-served by public transport and has ample parking. We offer mixed billing (70% bulkbill) with flexible consulting hours. Our GPs are fully supported by a practice manager, registered nurses, administration staff and a mental health nurse practitioner. Our Medical Centre has high volumes of patient demands and full-appointment books during semesters. This is a large and diverse patient base offering lots of interesting work, plus walk-ins, opportunities for Healthcare Plans Health Assessments, and procedures.
Make tomorrow better
BENEFITS 70% of the billing/mixed billing Work full-time or part-time with flexible hours. You choose! Excellent working conditions and room facilities Walk into a full & immediate patient base, OR create your own, with walk-in presentations Best Practice software in use throughout the practice REQUIREMENTS MBBS or equivalent Current AHPRA registration as a General Practitioner Vocationally Registered (VR) No restrictions To learn more about this opportunity, please contact Nandita Nadkar, Team Leader on 08 9266 7345. For more information about our university, please visit www.curtin.edu.au Applications close: 15 December 2023
curtin.edu.au
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
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medical forum CLASSIFIEDS Positions - Stress Test Supervising Physician Perth and suburbs
Northbridge Medical Centre is looking for a VR General Practitioner to join our well-established private billing medical practice located between Perth CBD and Mt Lawley Owned and operated by doctors High patient load Taking over existing patient base from relocating GPs Full Time or Part Time Position available now 65% billings with minimum of $150/ hour for the first 6 months Joining a team of 6 Doctors with supportive Nursing, Management and Marketing team AGPAL accredited, well equipped and fully computerized with Best Practice software Doctor’s parking available Requirement: MBBS or equivalent, Vocational Registration / Fellowship, current AHPRA registration
Are you seeking a workplace focused on best practice and excellence in clinical care? At Perth Cardiovascular Institute we believe in providing more than just a diagnostic imaging service. Our team are committed to delivering an excellent patient experience along with clinically robust findings in a timely manner. Senior staff perform as leaders and assist with training, mentoring and development of less experienced team members. Much of our time is dedicated to ensure our trainees develop superior skillsets to tackle even the most difficult of cases. We foster an environment that promotes asking questions, seeking feedback and sharing of knowledge. We have world class, internationally renowned cardiologists within our group that support and develop individuals. Our cardiologists are approachable to discuss patient findings and encourage and enable team members to manage patients. In completing our daily duties we go above and beyond expectation with clients repeatedly providing outstanding feedback from their contact with us. If you wish to know more about the role, feel aligned to the way we do things and are excited by the unique opportunity Perth Cardio offers then we would be thrilled to hear from you.
Please contact Adam Lunghi on Phone (08) 6314 6881 or info@perthcardio.com.au If you are looking to practice quality medicine in a supportive environment, please contact Dr Alex Koh on 0408 037 290 for a confidential conversation or email at Alex@northbridgemedical.com.au
District Medical Officer Christmas Island – Serving the local community Full time Ongoing Vacancy | Package is $400K+ and negotiable The Indian Ocean Territories Administration (IOTA) is currently seeking a motivated and suitably qualified professional to join our enthusiastic and multidisciplinary team as a District Medical Officer (DMO) within the Indian Ocean Territories Health Service (IOTHS) based on Christmas Island. The IOTHS delivers a primary and acute health care service in two of Australia’s most remote and most spectacular settings Christmas Island (CI) and the Cocos (Keeling) Islands (CKI). The IOTHS includes a 24 hour eight bed hospital and primary care facility on CI and clinics on Home and West Islands in the CKI. The IOTHS is committed to “Working with our communities to keep us healthy for the whole of our lives”. The DMO works in a team and is primarily responsible for delivering comprehensive medical services to the community of Christmas Island using a culturally appropriate approach. The DMO provides general practice services and inpatient care as required, after hours’ emergency medical care and preventative health care. Our ideal candidate will have demonstrable and substantial experience working effectively in general practice in a rural and remote cross cultural environment, recent experience working in an Emergency Department and the ability to work independently, make sound medical judgements and manage the emergency environment. In addition, the successful candidate will be
committed to working collaboratively to deliver quality health outcomes and have excellent communication skills including experience in preparing reports. The successful candidate must hold a current ALS2/REST certification or equivalent, will be registered, or be eligible for full registration, as a Medical Practitioner with the Australian Health Practitioner Regulation Agency (APHRA) and hold a post graduate qualification. Further the successful candidate will hold a current driver’s license transferable to the Indian Ocean Territories, a valid Western Australian Working with Children Check and provide proof of vaccination or immunization as required by the IOTHS. For an application pack outlining how you can apply, please contact the IOTA Human Resources Team at IOTHRTeam@infrastructure.gov.au and quote position number 109318.
Applications close 4.00PM (Christmas Island local time) (CXT) (UTC+7), 9 November 2023
NEXT DEADLINE: For Classifieds, contact Andrew Bowyer – Tel 9203 5222 or classifieds@mforum.com.au
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Atrium Homes is a multi-award winning building company with a proud, rich history of creating luxury homes over the past 50 years. Our in-house design team is here to help create a home that truly represents who you are and where you want to be!
Current show homes for viewing: The Long Island – 6 Colin Street, Dalkeith Open Sat/Sun 1-5pm, Wed 2-5pm Tony Galante 0413 952 172 | Meg O’Brien 0418 910 309 The Edge – Mount Pleasant Open by appointment only Ben McCarthy 0402 349 224
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An Investment in Quality | Since 1972
An amazing lifestyle opportunity for GPs Our beachside practice in Albany is looking for new GPs
FRACGP preferred, flexible arrangements Relocation assistance offered Large and diverse patient base, mixed billing
Your own spacious room Fully computerised and Doctor owned No on call or after hours
For a confidential discussion about your next career move, call Jean at 0400 605 529 or email jean.paradise@breckenhealth.com.au