Advanced pain management

Advanced pain management in the community

Western Radiology is a community focused radiology and intervention service with branches across the metro area. The experienced team of doctors at Western Radiology delivers a comprehensive service encompassing medical imaging, cardiac assessments, advanced interventional procedures and oncology services. Branches are set up and operated akin to a hospitalbased radiology practice in terms of the breadth and depth of items, speed and availability. Western Radiology provides uniformity across all locations, with the latest technology and standardisation of service items, making referring and interfacing both predictable and convenient. Quality, first, is the overarching principal at Western Radiology. Services are delivered with a focus on improving patient conditions around availability, efficiency and fast turnaround. This extends to meeting referring physicians’ needs along the same criteria, with additional emphasis on accessibility to radiologists and building strong working relationships. Comprehensive pain management solutions: Uniquely, Western Radiology provides an extensive list of pain management interventions and cutting-edge therapies, several of which are normally only provided in a hospital setting. Pain Management Injections:

Facet Joint Injections

Lumbar Epidural Injections

Selective Nerve Root Block (Cervical and Lumbar Nerve roots)

Sacroiliac Joint Injections

Greater Occipital Nerve Blocks

Pars Defect Injections

Sacrococcygeal Joint Injections

Rhizotomy – Facet Joints, Morton

Neuroma, etc

Radio frequency Ablation of

Morton’s Neuroma. Dr Ashish Chawla On Pain Management Image-guided injections are common procedures performed in symptomatic patients not only to decrease pain severity but also to confirm the pain generator, also to avoid or delay surgery. A critical factor in pain management is the correlation of clinical symptoms with imaging findings. Radiologists at Western Radiology with expertise in MR imaging and knowledge in pain management strategies, can distinguish active pain generators from incidental abnormalities. Moreover, their detailed knowledge of cross-sectional anatomy and patterns of contrast flow inform the planning and execution of safe and effective needle placement under image guidance.

Dr Daniel Wong Daniel on Rhizotomy: Radiofrequency procedures have been around since the 1950s and used for treating various chronic pain conditions. These minimally invasive non-pharmacological and non-surgical percutaneous treatments employ an alternating electrical current with oscillating radiofrequency wavelengths to eliminate or alter pain signals.

Service delivery standards:

Availability – same/ next day appointments.

Urgent bookings available daily on demand – Fracture, DVT, ectopic pregnancy etc.

Urgent reports delivery – within half to one hour, including verbal feedback from radiologist.

Normal reporting turnaround time – 4-24 hours.

Electronic images & reports delivery – HealthLink (into desktop software), InteleViewer and Web-portal via PACS (includes availability at specialists and hospitals). Reporting – detailed, subspecialised reporting with fellowships including: Neuroradiology, Musculoskeletal, Advanced Body, Oncology, Breast & Thoracic and Intervention. Billing – all Medicare rebatable services including image-guided interventions are bulk billed. *excludes MRI

(08) 9200 2777 (08) 9200 2778

reception@wradi.com.au www.wradi.com.au

Cancer care grows

GenesisCare is at the centre two major private cancer centre developments – one south of the river, the second north.

Last month the sod was turned on the building of a $17 million facility at St John of God Murdoch Hospital. The new facility is the result of a partnership between Centuria Healthcare, SJG Murdoch and GenesisCare. The building will be developed and owned by the Australasian real estate funds manager, Centuria Healthcare, expanding its existing healthcare presence in Western Australia. It is thought the facility will have capacity to treat up to 1,000 cancer patients a year and it will be fully integrated into the Murdoch hospital. The facility will also offer theranostics and nuclear medicine services molecular imaging equipment such as PET-CT and SPECT-CT. Over the Narrows Bridge at Hollywood Private Hospital, a partnership between Ramsay Health Care and GenesisCare will see, for the first time, patients at Hollywood having access to onsite radiation therapy with medical and radiation oncologists, haematologists, surgeons, radiologists, nurse specialists, clinical trial researchers, allied health and mental health professionals all on the one campus. The Hollywood centre will have a state-of-the-art linear accelerator, the Elekta Versa HD with the Brainlab ExacTrac Xray System, capable of delivering advanced stereotactic radiotherapy (SRT) and stereotactic radiosurgery (SRS). The centre will have a strong focus on prostate and breast cancer, aligned with

Michael Salter (St John of God Murdoch), Cr Nicole Robins and Melville Mayor George Gear, Dr Shane Kelly (CEO, St John of God Health Care), Ms Eva Skira (Chair of Trustees SJGHC), Ben Edwards, CEO, SJG Murdoch), Dr Tee Lim (radiation oncologist and future head of Murdoch facility) and Louise Coffey (Acting GM GenesisCare). Top: The Hollywood centre

Ramsay’s nurse care coordinators and specialist breast nursing service, including partnering with the Breast Cancer Research Centre WA for additional dedicated breast care nursing support.

Short-stay or managed?

Short-stay models of care for major orthopaedic surgery was canvased during a webinar and panel discussion organised by Australian Orthopaedic Association (AOA) and the Australian Ethical Health Alliance (AEHA). Participating in the discussion were private health insurers Medibank Private and Bupa. Possible business models and funding pathways were discussed. The webinar comes after it was announced that Medibank Private has acquired a 49% stake in the East Sydney Private Hospital. Reports indicate the insurer will initially invest $8.8 million to fund capital investment and operational costs required for the hospital to scale its short-stay model of care. AOA President Dr Andrew Ellis said his organisation remained “deeply suspicious of for-profit private health insurers who wish to enter the ownership of private surgical facilities or hospitals. They do this for business development reasons but under the guise of enhancing care in ‘doctor-led’ models. Out-of-pocket expenses are the smallest element in this move, as the majority of fees are paid by the commonwealth through the MBS. The real reason is to disrupt established hospital groups, and encourage alternative methods of care by offering fee incentives to surgeons to participate in managed care in health insurer-owned vertical business structures. To gain surgeons’ and patients’ trust, the health funds must act in transparent ways in developing business models such as these and declare incentives they offer participating doctors and hospitals. They seem to genuinely wish to contribute to health reform, and in this setting, we welcome collaborative discussion and action."

Problem with iron

A global study led by researchers at UWA has addressed the rising use of intravenous iron therapy in anaemic patients during major surgery and found there is little benefit. The RCT is the first to rigorously test a procedure, which has become routine practice. Up to half of patients undergoing major surgery have anaemia and over the past decade, hospitals around the world have given intravenous iron to these patients in advance of their operation. Professor Toby Richards said results of the PREVENTT trial showed that although iron therapy did produce a response there was no benefit in the patient’s outcomes of blood transfusion, major complications or length of stay in hospital. However, one significant finding was that giving iron after surgery did improve anaemic patients’ recovery. Yet another UWA study with researchers and clinicians from Fiona Stanley Hospital have found that pre-screening patients before surgery to determine those with anaemia or low iron was vital in reducing surgery costs and improving patient outcomes. The research has been published in Anaesthesia. Adjunct Research Fellow Kevin Trentino said industry had been hesitant to use preclinics before surgery to identify low blood counts, because of a perception they were costly and required significant resources. “In this study we analysed the results of an anaemia screening clinic set up at Fiona Stanley Hospital in 2016 in which 441 patients having bowel cancer surgery received

blood screening before surgery,” he said. “We found, contrary to common belief, the benefits of pre-screening far outweighed the costs.” Fiona Stanley Hospital Consultant Anaesthetist Dr Hamish Mace said while some blood loss in surgery was inevitable, minimising the resultant transfusion and the associated risks were important for clinicians. “By increasing the patient’s haemoglobin before the operation, our patients were given a major boost going into surgery,” Dr Mace said. “Pre-operative treatment with iron also led to an increase in patients’ red cells after the operation, giving them a buffer to avoid transfusion."

DREAM comes true

UWA’s DREAM trial, under the watchful eyes of Professor Anna Nowak, has published results that show a combination of chemotherapy and immunotherapy treatments can yield positive results for patients with advanced mesothelioma. They reported in The Lancet Oncology that the study was the first reported trial to test the combination of an immune checkpoint inhibitor with chemotherapy drugs. Trials were conducted in nine hospitals around Australia involving 54 patients for cancer surgery. Almost half the patients had a substantial shrinkage in their tumour, and patients lived longer than would be expected for chemotherapy alone. The antibody treatment continued for up to 12 months. However, once the antibody was stopped the majority of patients then had disease progression. Professor Anna Nowak said there was a strong unmet need to improve available therapies in mesothelioma and the results of this trial suggested chemoimmunotherapy could become a valuable treatment in this disease.

WA and opioid deaths

The new edition of Penington who were considered unsuitable

Institute’s Australia’s Annual Overdose Report is sobering reading for WA with 227 West Australians dying of unintentional overdoses in 2018 – an all-time high for the state. The rate of unintentional overdose deaths in WA increased from 6.4 per 100,000 people in 2012 to 8.8 per 100,000 in 2018 – close to double the mortality rate for melanoma across all of Australia in the same year. WA also had more overdose deaths from different types of drugs including stimulants, prescription opioids, heroin, benzodiazepines, and anti-depressants. The report also reveals that, for the first time, WA had the highest rate of heroininduced overdose deaths per capita, overtaking Victoria. WA also saw the biggest increase in unintentional deaths involving benzodiazepines.

VR for spinal rehab

Virtual reality (VR) is being put to the rehab test by people with spinal cord injuries as part of a project by researchers at Curtin University’s School of Occupational Therapy, Social Work, and Speech Pathology. Interactive, home-based VR simulation or ‘serious game’ is being used to improve upper limb function. The VR program uses cooking a virtual steak as a functional rehabilitation activity for people with cervical spinal cord injuries. Lead researcher A/ Professor Marina Ciccarelli said virtual tasks included seasoning, frying, flipping and transferring a steak from pan to plate, which when done repetitively over time helped improve the participant’s control and range of upper limb movements. Daily progress in the VR game could be remotely measured and reviewed by their therapist, and the level of challenge adjusted as needed. SpinalCure Australia, the Minderoo Foundation and Applecross Rotary supported the project by helping fund the purchase of the VR headsets. Armadale GP Dr Ramya Raman has been awarded the Business Events Perth / City of Fremantle Aspire Award to present her work on postnatal recovery at the World Organisation of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) Asia Pacific Region Conference.

Autism researcher Dr Gail Alvares and digital health professional Ms Bec Nguyen are the recipients of the Telethon Kids Institute Aspire Award, which is coordinated by Business Events Perth.

Speech pathologist and Curtin University researcher Dr Sharon Smart has won an Aspire Award. Sharon is one of the only speech pathologists in Australia actively researching tongue tie and the impact it has on feeding skills and speech production in infants and children.

Business Events Perth / Perron Institute Aspire Award has been presented to Dr Alex Tang who is researching brain stimulation and imaging.

Bioinformatics researcher Dr Saskia Freytag and diabetes researcher Dr Elizabeth Johnstone are joint winners of the Business Events Perth / Perkins Institute Aspire Award. Dr Freytag leads a research program on causes of severe epilepsy. Dr Johnstone was recognised for her work on the pre-clinical profiling of a potential kidney disease drug called DMX-200.

Victorian GP Dr Karen Price has been elected President of the Royal Australian College of General Practitioners (RACGP), with her term set to take effect from the close of the RACGP’s Annual General Meeting on 30 November 2020.

It’s always a gut feeling

A passion for people, a thirst for knowledge and a love for music have been some of the drivers for UWA’s executive dean Professor Jon Watson’s career.

By Ara Jansen

For Professor Jon Watson, faith can be found in the quiet contemplative pews of an Anglican church listening to a choir. Faith can also be found when the amps are turned up to 10 in the cover band he founded, Jonny and the Optics. A lover of modern and classic music, Jon reckons Bob Dylan’s recent Rough and Rowdy Ways album is his best since the 80s.

Equally, faith can also be found in medicine. The recently arrived Executive Dean of the Faculty of Health and Medical Sciences at the University of Western Australia has faith in many things related to his profession, including a great belief in the power of people, their work and their stories. Born and raised in the UK, Jon gained his Master of Arts at Cambridge and then went to Oxford to study medicine. During those six years he met some of the “finest minds of my life” as five Nobel winners worked along one corridor. The collegiate system was also strong and exposed him to new friends, colleagues and contacts from all over the world and who have ended up working across the globe. He worked in Britain’s National Health System (NHS), including Queen’s Square and Hammersmith Hospital and his mission was to be a clinical academic. Early on, his interests included the study of hepatitis C, for which he gained his PhD. He also decided that gastroenterology was where his greatest interest lay. By the mid-1990s Jon – and many of his colleagues – had become disillusioned with the NHS and decided it was time to get out. He’d finished his registrar training and was working in a liver transplant unit. People told him he was mad when he agreed to take a job in Ballarat, Victoria, and move his family of three small children across the world. Call it a gut feeling, he signed on for two years and they stayed for seven. Culture shock was absent because everyone was so welcoming. Jon pursued his work as a gastroenterology specialist and says it was wonderful opportunity because he learnt so much but also had the opportunity to do some teaching. He then spent two years at John Hunter Hospital in Newcastle and then at

University Hospital Geelong before being appointed as Clinical School Director for Deakin University’s School of Medicine in 2011 and Dean and Professor of Medicine at Deakin in 2014.

He has also served as a board director for the Postgraduate Medical Council of Victoria and as Board Chair of the National Centre for Farmer Health in Hamilton, Victoria. He’s a member of the

National Examining Panel of the Royal Australasian College of Physicians. Earlier this year Jon and his wife made the move west as he was appointed Executive Dean of the Faculty of Health and Medical Sciences at UWA. His children live and work in Melbourne.

“I’m not sure I actually planned any of this out,” he says. “I feel like I took these opportunities as they came along. I kept up my clinical practice until arriving here. It has been a great privilege seeing patients. But I also don’t want to be the bloke in the office no one ever sees. I don’t want to be asking my colleagues to do things I wouldn’t do myself.” While administration and leadership are a critical part of his new role, he will also remain active in research thanks to several grants the university has received. “I’ve already learnt so much because everyday someone comes into my office and tells me what they are working on. I’m always interested and fascinated. I do one clinical day a month because I don’t feel like I am ready to give that away. “It’s a privilege to see patients and some of them I have been seeing for 25 years. I think I have seen something like 11,000 patients over 20 years.” Jon’s mum was a nurse but there were no doctors in his family. Being blessed with a relentlessly enquiring mind, he didn’t know how he could put it to best use until he found medicine.

“It can be frustrating, stressful and fascinating, but it’s never boring! I’m a very social person and I really like being with people. The reason I chose gastro was the mix of physician training. I liked the problem-solving part of being a physician, I like helping people and I like the procedural work. “In life you just keep reinventing yourself. Interesting things keep coming along. I trust my gut and I keep doing them, using the transferable skills I have to move forward.”

More than ever before, Jon says having a medical degree, being a doctor or a specialist doesn’t mean that’s where you stay. He believes having that experience is transferrable into so many different, allied and related fields for a career. That can include working on boards or working in or helming an NGO. “The practice of medicine is of great interest to me since I qualified in 1989. There are so many places you can go and I think that’s worth considering when we look at how we train in medicine in the future.

It’s always a gut feeling

continued from Page 11

It’s not so much about knowledge but it’s about giving students the skills for their next 30 years. Medicine remains popular as a career choice, but it’s also less popular probably because of the lifestyle. “Another area is that medics have much less autonomy. You could argue that doctors in the 1970s and 1980s had too much autonomy. There were more doctors who ran their own show. Now, many work for larger organisations. “The relationship between a doctor and the patient is sacrosanct and many professions have lost that. I hope we never lose it. You are here to be the advocate for the patient so sometimes you also have to work against the system. Doctors find it hard to work with economic imperatives and financial issues. This brings them into conflict and it’s a conflict that’s difficult to solve these days. “Despite all that, I don’t think I would have done things any differently. I still believe it’s an enormous privilege to help patients and teach students and doctors of our future.”

Jon says at institutions such as UWA and Deakin, there are about 3000 to 4000 applications for 150 to 200 places in medicine each year. That’s proof enough that demand isn’t tapering off and that the profession is still attracting each generation’s brightest minds. Besides a great GP is “worth their weight in gold”. Jon stepped into his new job in February, just as the pandemic hit. He’s seen it as an opportunity and wanted the university to be front and centre of investigations, trials and expert advice. UWA has played a key role in advising state and federal governments on COVID-19 strategy through the Group of Eight Universities’ panel of research experts and are actively involved in treatment trials through their COVID-19 Research Response Hub in collaboration with colleagues from major health services and other universities. Authorities have been co-operative and helpful in terms of fast-tracking applications for ethics approval and approval for clinical trials, he said. They are not involved in making vaccines.

Brought up as an Anglican who enjoyed singing in the church choir, Jon has managed to make his way to St George’s Cathedral to enjoy the choir and sit quietly for moments of reflection.

“I think reflection is especially important. Most of us are not good at work life balance.”

When Jon wanted to take a walk on the wild side he’d be singing with Jonny and the Optics, who were unashamedly lost in the ’70s. Known for performing in very loud suits – one featuring a test pattern and the other lime green with daisies – Jon will be looking for a new band to sing with here when his gut tells him the time is right.

Read this story on mforum.com.au

Q&A with...

Dr Omar Khorshid, Orthopaedic Surgeon & National President of the Australian Medical Association

MF: With COVID-19 dominating the health agenda and government budgets, what will be the national AMA’s focus for the next 12 months? OK: We’re struggling to talk about anything other than COVID at the moment and it’s clear that it will remain a significant focus of the AMA for some time yet. Australia has done very well by world standards in tackling the spread of the virus, but we are not out of the woods. Governments will continue to need strong medical advice, particularly in the face of unrealistic and potentially dangerous calls to open up the economy before it is safe to do so. We need to get the balance right, recognising that without a strong health response to COVID-19, we will not be able to get our economy back on track at all.

However, although COVID-19 is urgent, the AMA needs to be setting the agenda. The AMA is a trusted voice, and we will be using that trust to call for action on other pressing issues in our health system. We need a stronger, better health system that places disease prevention as its key focus, with the investment needed to make a real change. The AMA is advocating for 5% of the health budget to be allocated to preventive health. Integrated quality General Practice must be the gateway to the entire health system, further supported by digital health technology such as telehealth. The AMA has just released a detailed policy on this, and we will be prosecuting it. Our public hospitals need increased and certain funding so they not only cope, but flourish. We need to end the days of public hospital doctors working dangerously long hours due to being short staffed and underresourced. The AMA believes we need a detailed reform agenda for our private health system – and again, we have developed a series of detailed policy proposals for government that can be actioned now. Finally, for the most vulnerable people in our society, including those in the aged care sector, we will remain relentless in raising these issues with the Aged Care Royal Commission and beyond, so that we see lasting improvement.

MF: In this context, what can the AMA offer its members by way of support and advocacy? OK: Members join the AMA for our policy advocacy. They want to work in a health system that supports them to provide quality care for their patients. Our job is to prosecute a policy agenda that supports this – and the above areas of focus are just the beginning. Doctor independence, whether in a government-run system, a privately insured and funded model, or in the context of a nationally regulated scheme, is critical. MF: The pandemic response has seen agile collaboration between the public and private health sectors. What is needed to continue that co-operation once the public health threat of COVID-19 subsides?

OK: No part of the health sector will remain unscathed by the time the threat of COVID subsides. Waiting lists for surgery will be longer, the viability of many private sector practitioners and organisations will take years to recover, and the community will have suffered greatly. We also know that the Treasury coffers will have been exhausted and that health will be under the expenditure microscope. If we are to have a healthy economy in the future, we will need a healthy society. This will require investment and reform. We can’t afford to cut our way to a healthy future. In order for the type of collaboration we have seen during COVID-19, stakeholders will need to understand that life will not return to normal in the foreseeable future and that it is in everyone’s mutual interest to work together if we are to meet the needs of our patients. MF: What are we getting right and wrong in our national response to the pandemic? OK: So far, Governments have largely listened to the medical advice that they have been given, and National Cabinet has been an excellent vehicle to support a nationally coordinated response, although cracks are beginning to show.

Australia also got onto the front foot in tackling the virus with a broad lockdown. You must get ahead of COVID, otherwise it will win every time. As we see a second wave, there is a concern that Governments are being too slow to act, focusing too much on daily infection numbers. By the time these rise beyond an acceptable threshold, policy makers are already two weeks behind the eight ball. We are seeing some divergence in approach among jurisdictions. Some have eliminated the virus and have been forced to close their borders to those jurisdictions that are taking a different approach and continue to report new infections. Depending on what happens in Victoria and, to a lesser extent in NSW, governments need to revisit the elimination debate, otherwise communities may suffer a diabolical cycle of restriction easing followed by lockdowns. We also know that healthcare workers are at significant risk of COVID-19, making up a significant proportion of infections in the Victorian outbreak. This has exposed problems with access to PPE on many fronts. PPE guidelines have been too weak to properly protect healthcare workers and there have problems with the supply and, probably more critically, the distribution of PPE. Ultimately, the best protection from COVID-19 for healthcare workers and the community is the achievement of zero community transmission. This will require Government to continue to take tough decisions on restrictions and to be realistic about the extent to which we can open up again while the threat of the virus hangs over us.

The community needs to play its part as well – we all have to change the way we live and how we interact with each other.

We have not done enough to protect our vulnerable populations in aged care facilities, and they have suffered as a result. There has been too much of a blame game and not enough planning and support for this sector. While this hardly comes as a surprise, given the evidence before the Aged Care Royal Commission, this failure highlights just how far we have yet to go in addressing the systemic problems in our aged care system. We know what needs to be done, we need Governments and operators to heed the advice, and quickly. MF: The generalised economic pain of the pandemic is impacting on an already fragile private health insurance industry. How important are these funders to the national health system? OK: Even before the impact of the COVID-19 pandemic, private health insurance was in trouble. Membership has fallen continuously for the past 20 quarters and the government’s recent reforms have not reversed this decline. Younger people continue to drop their private hospital insurance, while people over 65 years are taking it up in increasing numbers, further jeopardising the stability of the system. Demographic shifts have created a trend which places upward pressure on premiums for those who maintain their insurance, leading the Australian Prudential Regulation Authority to state that private health insurance is in a ‘stable but serious condition, with that stability under threat’. The AMA is concerned that the likely financial impact resulting from the COVID-19 pandemic including unemployment, underemployment and a slowing economy, will result in even more young people giving up their insurance, increasing pressure on an already unstable system. The unique balance between the public and private sectors makes the Australian health system one of the best in the world. In 2017- 18, 66% of elective surgeries (that is almost 1.5 million surgeries) occurred in private hospitals. Without our private system, our public hospitals will not cope with the increased demand. Just last year (September 2018 to September 2019) health funds subsidised more than 100 million services, paying $21.4 billion in benefits.

MF: How can the AMA and the medical profession support that industry? Is that something the profession and the AMA should even have to worry about? OK: The AMA believes that all contributors want the Australian private health system to be effective, high quality, provide value, and to be inclusive. But we recognise the problem and its severity – the current policy

Q&A with Dr Omar Khorshid

continued from Page 15

settings for PHI no longer work. However, we also recognise that the government is pivotal in the health insurance equation. It is behind so many of the policy levers that must be adjusted swiftly to reverse these trends and restore value and confidence into our private health insurance system. The AMA has outlined a few policy prescriptions for private health insurance. We support moves to restore the premium rebate, at least for younger Australians and low-income workers. Premiums need to be within reach of average Australians – otherwise we will have a two-tier system. The minimum amount returned to members for every dollar going in varies from anywhere between the high 70s to above 90%. This must be standardised, and it must be higher than the industry average right now. The Lifetime Health Cover loading must be reviewed, particularly the starting age. People are staying in university or TAFE longer, starting families later, and facing mortgage pressures more intensely. The starting age is supposed to be a signal to get into insurance, but it’s now at a point of locking younger people out. It’s vital that people have transparency around their out-ofpocket costs. Gaps are the biggest bugbear for most people about their private health insurance. In fact, less than 3% of medical services are billed outside a no-gap or known gap arrangement, but that’s no comfort to those patients who find out that they’re not covered when they need it. That’s why the AMA has developed our Informed Financial Consent guide, to help doctors and patients work through all the issues before treatment starts. We’ve also called on the government private health website to do more. It must help patients understand that each fund pays a different benefit for the same MBS item, and what their health fund will pay. The AMA has been at the table on all the discussions about private health insurance. We have been at the table to consider alternative clinician-led models of care. We will stay at the table to achieve the best outcomes for the system and our patients. It’s only by all the players in this equation working together, all of us giving some ground and pursuing reform, that we will succeed. MF: What are the issues that pose the greatest challenge for the national AMA organisation, which has undergone a volatile period of financial and membership duress? OK: The AMA is financially strong as its membership base. At a time when membership bodies are finding it difficult to maintain membership, the AMA’s membership penetration would be the envy of many. Like any other organisation, the AMA works hard to ensure that its budget is balanced each year. This year we have seen the re-organisation of some parts of the Federal office, with a strong emphasis on prioritising expenditure towards our key advocacy areas. MF: How can the AMA attract more members?

OK: AMA members have told us that they value our advocacy work highest, and at the national level we will focus more than ever on strong advocacy that delivers tangible benefits to our patients and our profession. Most doctors have little comprehension of the breadth of issues that the AMA deals with and the many threats to the profession

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that are resolved before most doctors realise they exist. The AMA needs to refocus its communication strategies with members and other doctors, so that all doctors are aware that they have a strong representative body in their corner that is actively listening to its members and committed to achieving the best possible outcomes in conjunction with other medical groups including Colleges. The AMA is the peak representative body for our profession – the challenge is to become an organisation that all doctors aspire to join. MF: Do you think there are too many disparate ‘medical voices’ trying to be heard in the political sphere? With medical advice based on evidence leading governments’ decision-making during the pandemic, will this change the advocacy style of doctor groups in the future? OK: The pandemic has in many ways strengthened the AMA’s position in the political sphere. The AMA has proven to be a calm and authoritative voice, both with governments and the community. We have been a strong voice for the community and the profession, and governments have listened to our advice.

The reality is we are truly separate from government, and we are the only body that represents all the profession and its specialties. The challenges ahead for the health system are ones that will affect all specialties, and all doctors – no matter what stage of their career. Although there are many other voices, the AMA is the strongest and most respected body representing doctors and will continue to advocate as the peak body in this rapidly changing environment. MF: What interested you about the AMA national leadership that made you want to stand for election?

OK: I have watched many Federal Presidents of the AMA over the past 20 years and have seen the capacity of the AMA to deliver on a national stage. At the same time, I have observed the need for the medical profession to lead a reform agenda to deal with the current and future demographic and economic challenges that face our health system. If we want to enjoy access to a health system that is based around individual doctors and patients making decisions that are best for that patient, then we must be willing to fight for it. That means being willing to challenge some of the sacred cows and defining what we think are the critical aspects of a sustainable, high quality health system. We cannot rely on the political class to deliver a health reform agenda and if we do nothing, it is inevitable that the solutions others come up with will be unacceptable to the medical profession. MF: What did you learn from your time as president of the AMA WA that will keep you in good stead as national president? OK: As AMA WA President, it was very clear to me how important the AMA is to any conversations with the public about health care. There is an enormous amount of respect for doctors and for the AMA in the community and that respect can be used to advocate for changes that can improve the lives of thousands or millions of people, as opposed to the one-on-one interactions that we have as individual doctors.

I also observed how little choice you get in terms of the advocacy issues of the day and how difficult it can be to set the health care agenda. The AMA must be strategic in terms of its advocacy agenda but also nimble in order to ensure that we remain relevant to members and effective in achieving change in a chaotic world.

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The long-haul

The devastation caused by the long-term symptoms of COVID-19 is redefining how we should view the virus.

James Knox reports.

It is not often one can say something has genuinely ‘changed the world’ without a modicum of hyperbole yet in the case of COVID-19, it has, with quarantines, social distancing and isolation measures enacted to mitigate the spread of the disease having become the new normal across the globe. For those who have contracted the virus, the disruption can be devastating both in the short- and long-term, particularly if they have been unfortunate enough to suffer from a constellation of debilitating symptoms over weeks and months. As COVID-19 spreads, so too does the collective knowledge of the long-term effects of the disease and the difficulties faced by ‘Long COVID’, the long-haulers. Approximately 10% of COVID-19 cases will go on to experience prolonged illness. The British Medical Journal defines post-acute COVID-19 (Long COVID) as a continuation of symptoms three weeks from the onset of first symptoms and chronic COVID-19 after 12 weeks of symptoms. In the early days of the pandemic, a worst-case scenario of a COVID-19 patient would be something like a patient in intensive care, on a ventilator, isolated from their family, gasping their last breath. Whilst the same exercise for a mild case of COVID-19 may conjure an image of someone with flu-like symptoms, soon to recover in a matter of weeks.

For the long-haulers, they may start with a mild case and instead of the symptoms subsiding, they persist and can persist for months or indefinitely. Long COVID According to UK’s Professor Paul Garner, for those unfortunate enough to suffer through Long COVID, they are stricken by a diverse constellation of symptoms, of which he can speak from personal experience. Prof Garner offers a unique perspective on Long COVID as not only is he suffering from it, he is the Director of the Centre for Evidence Synthesis in Global Health at the Liverpool School Tropical Medicine and the Co-ordinating Editor of the Cochrane Infectious Diseases Group, whilst earlier in his career he was an epidemiologist in Papua New Guinea and a doctor in the NHS. Ironically, Prof Garner’s Long COVID journey began on a teleconference with Dr David Nabarro, one of six Special Envoys to the World Health Organization who are assisting the COVID-19 response. “During a teleconference with Nabarro he mentioned COVID-19 had a doubling time of three days and anybody who felt a little bit unusual needed to self-isolate. And I thought ‘I don't feel quite so well’. I didn’t feel dreadfully unwell, didn’t have a temperature, headache or a cough for the first few days and then the illness crept up on me,” Prof Garner said.

“Within five days, a sort of emergent headache came and then on day six or seven of being symptomatic, I had absolute utter fatigue, my heart was racing, I thought I had myocarditis, I felt dizzy, sweaty, yet I did not have a temperature. “I felt I was passing out, I laid down and I actually started passing out on the bed. I thought I'd die, then came around two hours later after this sort of two-hour sleep. I then went through weeks of feeling a bit groggy but not feeling too bad, then suddenly coming out from nowhere, I had the feeling of a cricket bat hitting me around the head and flooring me completely

for a day or two and then getting back up again. And this went on for 12 weeks. It just didn't stop. “Every time there was a new symptom, it would be deafness one day or pains in my legs and calves or occasionally a bit of a cough other days – I never really knew what I was going to get. “This was going on at a time when everybody was saying the illness only lasted two weeks and, of course, there was me with all this going on. “It was extremely frightening as it also messes with your mood. Everybody gets this wrong about mood saying, ‘oh, of course, you're going to be depressed because you're unwell, locked up and the world's going mad outside’. “I could be almost in tears in the morning with emotion that I didn't know where it came from, then completely happy and almost manic wanting to go out for a walk in the afternoon. It does mess with your head and people don't get that.” Eventually Prof Garner’s symptoms became less severe, though he was left with significant fatigue, which was exacerbated by both physical and mental exertion.

“Early in the illness, around eight weeks, I felt so well. I thought I'd do some exercise and that led to post-exertional malaise – where you push yourself a little bit and feel all right then, bang, within 24 to 48 hours you are flat as a pancake, can’t move, all the symptoms come back for two or three days," he said. Anyone and everyone Co-morbidities, obesity and age are relatively accurate predictors of who may have an acute case of COVID-19, yet this is not the case for Long COVID, according to Professor Danny Altmann, an immunologist at Imperial College London. He told New Scientist: “There’s clearly something going on here. It is not their imagination or hypochondria. It doesn’t even seem to be linked to how severely they had the disease, as far as I can see.” Since mid-March, these symptoms have persisted for Prof Garner, who at the time was in his early 60s. He trained regularly and ran between 30-40km a week, with no co-morbidities prior to the onset of symptoms. “I spoke to doctors who didn't really know what to say or do, so I got in touch with chronic fatigue and myalgic encephalomyelitis people that I knew, and they were incredibly supportive. “I spent over three months trying to work out how to control the fatigue, such as how far I could walk, because I was so fit before, I was highly expectant that I could really hammer this disease out. I've had viral infections before and just jumped on the stationary bike and trained five minutes one day, ten minutes the next, 20 minutes the next and in a week I'm up and running again. “During Long COVID, I found out it wasn't just physical exercise, simply participating in Zoom calls used energy and if I used all this energy and went to bed drained, then I'd be floored sometimes for a couple of days afterwards. “My head was incredibly muggy because of the headaches and I couldn’t see or read very well.” Outliers When the pandemic was emerging, COVID-19 tests in the UK were in limited supply, which meant Prof Garner had to choose between being driven 80km to the nearest testing centre or be admitted to hospital, yet due to the non-critical symptoms, he chose to self-isolate rather than use up a precious test kit that a front line medical worker could have used or the bed of a critical patient.

The COVID long-haul

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However, this meant, that in his case and others in his situation were not even considered COVID-19 statistics. It was only when he went to a hospital for a suspected pulmonary embolism that he was tested as negative, further complicating his treatment. He has since taken an antibody test which has come back positive. “The policy of the UK at the time was to stay home. The only people who got admitted to hospital or even seen were people basically dying, with SATs below 80 or respiratory distress. I probably was very seriously unwell, but didn't realise or acknowledge it,” he said. “We've got thousands of people already used to self-treating who are not in the system – I am not in any government statistics, so I'm not counted as a case.

“It's taken me literally six months as a patient to access important information that can help me manage my condition and I've done it well as I've been banging on about it and people have sent me advice.”

As one of the co-founders of the Cochrane Collaboration, Co-ordinating Editor of the Infectious Diseases Group and the co-ordinator at the Centre for Evidence Synthesis for Global Health, it would be apt to describe him as someone who has dedicated his career to evidence-based research, yet during the worst of his Long COVID experience, he relied on support groups for the most upto-date information.

“People who had all these symptoms found solace in self-help groups, not their doctors. These self-help groups were usually about two to four weeks ahead of their GPs.

“I had problems with my speech, particularly when I got tired, so I contacted a friend who's in charge of rehabilitation in a London hospital and she said, ‘get yourself down to casualty, you may be having a stroke, you need an MRI’. “And I posted these symptoms on a Facebook group, and all of these people said, ‘Oh, God, I've been having that for months’. Then I would check in with the chronic fatigue or myalgic encephalomyelitis communities and they would say this is quite common.

“I'm not blaming the doctors, you know. What we need is not well known, but what we need is people to get the message out. These observations are important. Big studies in medical journals will be too late. By the time the medics have completed a longitudinal study, I'll be either recovered or dead.

“I do think the medical systems for collecting information and disseminating it are not fit for purpose at the moment because things are moving so rapidly, because everything is so new.” Getting the message out Prof Garner has unapologetically used his position to disseminate and legitimise Long COVID. While awareness of it is becoming more prevalent, he has heard too many stories of discrimination or outright dismissal by clinicians not to speak up. “I run the Cochrane Infectious Diseases Group and am known for my work on malaria and TB. I'm able to verbalise things in an accessible way. I have friends who say, ‘if I said what you're saying, people would just say I'm a 45-year-old non-medical woman and they wouldn't believe the kind of symptoms I come up with’. “At my age and, you know, as an old bugger, a white male in infectious diseases, maybe this is what I can do to help, by using this position to give this condition some more credibility in these crazy times. “Things are in such disarray with advice and particularly for somebody like me on the fatigue spectrum and because doctors have denied chronic fatigue and myalgic encephalomyelitis, they think it's all in your head, so that's been an additional barrier.

“Then there are people with Long COVID who have dysautonomia syndrome where their autonomic system is going haywire, they have incredibly high heart rates for no apparent reason. One of

the symptoms these people have is intermittent tachycardia, and if they do anything about it they are going to their GPs and casualty departments saying, ‘I've got a problem with my racing heart’ and these people are being diagnosed as having anxiety. “I know a psychiatrist who went to a casualty department with these symptoms and the casualty officer said, ‘oh, you're just anxious about being unwell and it lasting so long.’ Not so mild When the pandemic emerged the most acute cases were rightfully prioritised for hospitalisation and experimental treatments to reduce symptoms and hopefully bring patients back to recovery, whereas the so-called ‘mild’ cases were thought to recover without the need for intervention.

As the number of hospitalised and non-hospitalised cases have exponentially increased, so too has the understanding that a portion will go on to experience adverse symptoms for months, while the majority of the cases will experience some form of continued symptoms. For younger people, catching COVID-19 is viewed as a mere inconvenience because the mortality rate is low. Yet the mortality rate does not highlight

the actual risks, according to Mary-Louise McLaws, Professor of Epidemiology at the University of New South Wales and a member of the WHO Health Emergencies Program Experts Advisory Panel for Infection Prevention and Control Preparedness, Readiness and Response to COVID-19. “From an epidemiological and outbreak management perspective, the 20 to 39-yearolds have represented just more than 40% of all cases. And that's very disconcerting because while they may have non-hospitalised COVID, I wouldn’t label all of these cases as mild because that undermines their experiences and trivialises their potential for Long COVID,” she said According to Prof McLaws, people with less severe cases of COVID-19 who were in good health prior to the onset of symptoms may be more aware of the Long COVID symptoms compared with the acute cases where people had prior morbidities or risk factors.

“They may well have not been able to identify the difference between the Long COVID, post-discharge, compared with the very young

and fit people recuperating. The non-hospitalised COVID patients recuperating talk about profound fatigue, headaches, diarrhea, palpitations, breathing difficulties and heart problems. “One of the most important groups who must be protected from Long COVID are the 20 to 39-year-olds, because we wouldn't want them to go into their middle age having any of these symptoms. “It has been estimated that symptoms can drag on for more than three weeks in 80% of people and the six-week recovery period is for a group who bounce back rapidly. However, for a lot of people, while they may no longer be infectious, they may not be well enough to consider that they're back to normal health.”

Mixed messages The focus on acute cases was exacerbated by the public health messaging, which at the time was focused on reducing the spread of the virus and balancing the demands on the health care system, yet inadvertently minimised the non-hospitalised cases, Prof McLaws said.

“In Australia and overseas we have sent lots of incorrect messages to the community. We've used the term mild and that makes people think that they don't have to worry about COVID, that they'll just bounce back like they've got a mild flu. The authorities have used the rhetoric for not wearing a mask unless you've got symptoms, which is only 50% of the real story. “When the chief medical officer of every state and territory was using that rhetoric, it made me very concerned because we don't send health care workers onto a ward without a mask and they don't have symptoms. “Once you start using rhetoric as if it's a concrete truth, it's very hard for leaders to walk that rhetoric back. The rhetoric of a ‘mild’ COVID for the majority disrespects the insidious nature of this disease as a serious issue, particularly for the young who need to get back their quality of life and productivity. “It also sends a message to the medical fraternity that they may not appreciate the signs and symptoms of post-COVID and may think there's a different cause rather than it being directly associated with COVID, for instance fatigue, because extreme fatigue is sometimes thought of as a mental health issue rather than actually being a part of a post-recovery condition associated with this inflammatory disease.”

A return of sports, of sorts

Olympic athletes have had a truncated preparation for the now 2021 Olympics in Tokyo but it’s their mental fitness that will see them through.

James Knox reports.

When the ubiquitous pandemic landed in Australia, the control measures incrementally encroached on almost all aspects of Australians’ day-to-day lives. However, the nation’s sports leagues stubbornly continued when most other nations decided to take their bats and head home. Although professional sports leagues are back, albeit with compressed seasons, limited crowds and isolation ‘bubbles’ and hubs, Australia’s Olympic team has not been so fortunate.

In early 2020, as the world became acquainted with COVID-19, the organisers of the Tokyo Olympics were doggedly moving forward with the Games, declaring on March 2 that the event was continuing as planned. On March 11 the World Health Organisation labelled the outbreak a pandemic, leaving the organisers of the biggest sporting event with a difficult choice to make.

It was the Canadian and Australian Olympic committees that essentially forced the hand of the organisers by declaring on March 22 they would not be sending their athletes to the Games. On March 24, the organisers acquiesced to the pressure and delayed the Olympics until 2021. Yet, for the hundreds of future Olympians in Australia and the thousands around the globe, they were in the difficult situation of having to train for what could be the pinnacle of their careers while balancing the demands of each of their respective countries’ various control measures.

All in the mind It may seem overly simplistic to drill down to a single characteristic that defines an Olympian, or a professional athlete for that matter, but if one were to be identified, mental fortitude would certainly be core of what ultimately drives them to the pinnacle of their chosen sport. And it is this strength of mind that has kept Australia’s Olympic hopefuls focused during the containment measures, according to Dr Carmel Goodman, Medical Director of the Western Australian Institute of Sport (WAIS). Dr Goodman explained to Medical Forum that once governmentmandated restrictions were put in place, WAIS implemented remote training plans to maintain their athletes’ conditioning and continue their preparation for the Olympics. As WAIS runs a variety of programs, each of their athletes had different requirements for the remote training, such as for those who compete in team and contact sports such as water polo, and individual endurance sports such as cycling.

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A return of sports, of sorts

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According to Dr Goodman, the remote training programs for each of their athletes varied from massively disrupted to relatively uninterrupted depending on the program, however, upon returning to WAIS, most of the athletes had surprisingly maintained their conditioning and skills and were able to quickly get back to their normal levels.

“With this level of athlete, within a week or so, they can regain their skill level,” she said. “Motivation was not as big of an issue as I expected it to be. The athletes managed surprisingly well, from physical and mental points of view. We know they managed well from a physical point of view because of the fitness tests we conducted when they came back to their training environments.”

Managing the maintenance The athletes who had their regular training disrupted were provided with alternative training plans, yet this led to an unexpected increase in injuries, Dr Goodman said. “I was seeing a higher incidence of overall injuries. For instance, the swimmers and the water-based athletes who had started jogging or running experienced more lower limb injuries because they were not used to running or cycling. “On the otherhand, the rowers, perfectly maintained their training because they could train at home on rowing machines.” In response to these injuries, WAIS’s exercise physiologists, coaches and Dr Goodman carefully assessed each of their athletes training programs and capacities to identify and recommend individual cardiovascular and strength loads for each athlete so they could maintain their strength and fitness.

Peak performance Although it may seem intuitive for Olympic athletes to increase their training to peak for the Games, Dr Goodman explained WAIS athletes are always close to their peak, which means that although the Olympics have been delayed 12 months, their training regimes have not. “It is not like everything is geared towards the Olympics and then there is a significant tapering period. During the years between the Olympics, all the athletes are vying for selection and must be at their best almost all the time.

“Then there is local, national competitions and overseas competitions. It's not like four years of training goes towards the Olympics, it is a continual cycle of performing and tapering.” “When I looked after the Australian women’s hockey team [Dr Goodman was the team doctor of the Hockeyroos] there was maybe a period of a few weeks at the end of each year that they would have off. “At any stage during those four years, they would be match-fit to play in an Olympic Games. The athletes are always training almost at a level that they could go

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straight into major competitions because the Olympic selection is happening all the time.”

The mental game Although the mental fitness of an athlete can be their greatest strength, it can also be a weakness and something clinicians need to be mindful of, particularly during the current pandemic, Dr Goodman said.

“We are now seeing considerable mental challenges for a lot of the interstate athletes who are really battling because they can't see their families due to the border restrictions in Melbourne and Sydney. “Throughout this situation, that is perhaps one of the biggest issues we are dealing with, from the athlete’s personal point of view.”

Read this story on mforum.com.au

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Effects of lockdown

Not all the effects of COVID-19 are physical. How have the public health measures impacted on body and mind? Professor Jim Codde wants to find out.

COVID-19’s acute health impacts are increasingly better understood for infected individuals but the secondary health impacts (e.g. mental health, health service demand, lifestyle factors, stress, and domestic violence) for the wider, uninfected community are less so. Similarly, while the economic impacts of the global shutdown will be acute for the next 12 months, the financial effects are likely to continue for several years, exacerbating the health and social consequences. While quarantine and isolation can reduce disease infection rates, there are also significant, associated psychological and mental health effects that impact on mental wellbeing. A recent systematic review found that time spent in infectious disease quarantine resulted in negative psychological outcomes, including insomnia, depression, anxiety, post-traumatic stress, and emotional exhaustion. Additionally, where parents were quarantined with children, the mental health toll increased with one study reporting that no less than 28% of quarantined parents warranted a diagnosis of “trauma-related mental health disorder”.

Psychological wellbeing and mental health have been shown to be associated with levels of physical activity, sedentary behaviours, diet, and quality of life. Therefore, any changes in either mental health or associated lifestyle behaviours may impact negatively on one another. The COVID-19 lockdown period provides an ideal environment in

which to study these impacts. The restrictions placed on movement outside the home and other physical distancing measures changed the way West Australians worked, socialised, shopped and exercised.

While some restrictions are still in place, many have been lifted. It is essential to collect retrospective data now while the experience is still fresh in the minds of the community. WA research survey To examine these questions, researchers at the University of Notre Australia are inviting West Australians over the age of 18 years to complete an online survey to provide insights on how the COVID-19 lockdown impacted on their “body and mind” and what issues may persist. The WHO released health promotion material about the importance of “staying physical at home”, “healthy eating” and “looking after our mental health” as part of their #HealtyAtHome program during the COVID-19 lockdown period. Other countries, including Australia, focused more on the importance of social distancing, personal hygiene and social isolation in their messaging while largely failing to provide strategies for maintaining optimal physical and mental health. The study’s outcomes will help inform development and delivery of health promotional activities at state and local government level should WA be impacted by a second wave of the virus or similar emergency. This state-government funded survey can be found at: https://notredame.syd1.qualtrics. com/jfe/form/SV_2i6cRGer71duajP and takes about 20 minutes to complete.

– References on request