The Medical Republic

The number of spinal fusions performed in Australia has skyrocketed over the past few decades, with the number of privately funded procedures far outstripping those done in the public system. 

Spinal fusions, which help stabilise the spine by surgically joining two or more vertebrae together, can be used following traumatic injury, or to help correct scoliosis in children. But the most common use for spinal fusions is in degenerative conditions of the spine.   

This episode of The Medical Republic Podcast explores when this procedure should be considered, and why we are seeing such a large increase in the number of these procedures being performed. 

Dr Ashish Diwan, director of the Spine Service at St George Hospital in New South Wales, says there are several considerations to be weighed before undertaking a spinal fusion, including the duration, intensity and frequency of back pain; whether other treatment options have been tried; and what the patient wants.  

Dr Diwan has sympathy for GPs with patients who are considering undergoing a spinal fusion, which is far from a straightforward decision: “It's like trying to get married. If you're in doubt, don't do it.” 

The decision not to do surgery can be equally challenging, according to Dr Diwan. 

“There is also an incredible lack of evidence as to what you do for a person who continues to suffer. The alternatives [drugs, spinal cord stimulators or radiofrequency ablations] are not very clear … none of them stack up when you start dealing with people who have pain of a chronic nature.” 

There are many reasons for the spike in the number of spinal fusions being performed, according to Professor Ian Harris, an orthopaedic surgeon and researcher from the University of NSW. 

“There is an aging of the population, but [now] there are more so called ‘indications’ for spine surgery,” he tells the podcast. “The techniques of doing them have developed in a way that there's now lots of different ways you can do spine fusions.” 

Several reasons also exist for why more privately, rather than publicly, funded procedures are being done. But Professor Harris feels the inclusion of MRI scans on the MBS is glaringly obvious one. 

This presents a fine line to walk between using imaging to rule out potential pathologies and jumping at shadows and operating unnecessarily on age-related changes. This reinforces the need for clear discussions with patients about any imaging findings. 

“Just having a scan doesn't hurt anyone. It's what you do with the results that can harm people.” 

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Future overlords or really helpful assistants?

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Does an app a day keep the doctor away or make them worried?

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Voluntourism is an enticing form of travel: exotic locales, cultural immersion, serving needy populations with your skills – all wrapped up in your four weeks’ annual leave. 

Not so fast. Before packing your passport and mosquito net tune in to The Medical Republic podcast to hear from two guests who might make you reconsider. 

Dr Andrew Browning has been doing fistula surgery in Africa through the Barbara May Foundation for around 25 years. He says its life changing for patients who start to live normal lives again after the deeply distressing injury caused by obstructed labour. However, Dr Browning says a donation that funds local health workers may better support outcomes than a short-term volunteering stint. 

“When you're there for a short term the people don't know you, you don't know them. You don't know the culture, you don't know the way things work or don't work.  

“The people there are very polite, very long suffering and will put up with you for the time that you're there. Then as soon as you leave, they just go back to their normal ways,” Dr Browning says. 

But if you're still keen Dr. Browning said there are some spaces for shorter term volunteers if you have specialised in obstetrics, gynecology or midwifery. 

“Around 40% of these girls have been suicidal or attempted suicide with this injury, a hundred percent of them are depressed. And when you treat them they just turn back to be normal, happy citizens,” Dr Browning said. 

It’s the kind of heroic work that many doctors dream of, says rheumatologist Dr Rob Baume. After a bout of professional burn out, Dr Baume considered medical voluntourism but ended up not buying a plane ticket after all. 

“When I did a bit of more research, I found that unless you have a specific specialties such as anesthetist or an obstetrician, you need to sign up for nine months. The other part of the equation is that I don't speak the language. Then there’s also the cost, the health risks and the risk to your life,” he said. 

Instead of volunteering himself, Dr. Baume has just raised $1 million for healthcare  in developing nations through his charity, Twice the Doctor. 

Dr Baume said that research by Dr Greg Lewis shows that if a doctor wants to make maximum impact on the world, it doesn't matter which specialisation they do.  

“What matters is that you give a fair bit of your income to third world causes,” Dr Baume said. 

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The latest episode of The Medical Republic podcast is a special insight into female parts across the age spectrum.

We speak first with Associate Professor Melissa Kang who was, for 23 years, the iconic Dolly Doctor in Dolly magazine – the Australian teen-girl’s bible for many decades.

Professor Kang said that teenagers want to know how to navigate the health system and that young women are keen to talk about sexual health but need the GP to raise the topic first.

“Research has also told us that young women want GPs to bring up the difficult topics. They want GPs to introduce the topic of sexual health or sex or intimacy,” she said.

Professor Kang said that creates a bit of a mismatch because GPs often feel that those topics are too personal and sensitive.

“They are waiting for patients to bring it up themselves, whereas young women are saying, “No, we want GPs to do it!”. So, as doctors, we do need to create that space,” Professor Kang said.

We also talk about whether young women’s health concerns have changed over the last few decades. Professor Kang said that young women have more health knowledge these days but that some concerns are enduring.

“The stigmatization of their bodies and their sexuality. I don't think that has changed an awful lot over the decades that I've been working with young people as a doctor,” she said.

Dr Talat Uppal, our second guest, also that even midlife women experience taboo and shame about their bodies and that their health concerns are often minimised. She said that if a woman says she's having pain, even from a point of view of ischemic heart disease, they are more likely to be “fobbed off” by doctors than men.

“It never sees this to amaze me how much women put up with prior to seeking care or sometimes they've sought care but they have not been proactively managed as well as we would hope,” Dr Uppal says.

As a gynacologist and obstetrician, Dr Uppal opened her a multidisciplinary team based care clinic, in Sydney. The team draws on a range of expertise including a GP, colorectal specialist, nurse practitioners and physiotherapists.

Women’s Health Road cares for women health across their lifespan; from teenage girls with menstrual problems right through to older women with prolapse.

“It genuinely gives me joy when I see the difference in quality of care that the woman has access to, which has not been from what just I could do personally, rather, it has been the contribution of all the other tenanted clinicians in our team,” she says. 

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Do you struggle to keep your practice running like a well-oiled machine?  

Our line-up of experts today share insights on how to earn more profit, retain staff, cover your risk and level up your practice management. 

Guests include an accountant, lawyer and cybersecurity guru. We also hear from a health economist and a GP who has scaled their clinic to good financial and patient reward. 

Their advice includes how to optimise billing, hours of operation, and the value of a monthly review meeting with your team.  

Our guests also delve into technology solutions to cover your biggest cybersecurity risk and using social media to recruit staff that are a perfect match. 

Can a general practice prioritise clinical excellence and still make money? Listen to The Medical Republic podcast and find out what the experts say. 

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Resources: 

Guide to health privacy, Office of the Australian Information Commissioner. 

You can listen and subscribe to the show by searching for “The Medical Republic” in your favourite podcast player.  

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When the choice is between writing a script for pain killers and a 45 consultation about weight management, which one do you choose?

According to Associate Professor Kade Paterson, University of Melbourne, scripts for pain killers and referrals to orthopaedic surgeons are unnecessarily common for patients with osteoarthritis (OA).

Professor Paterson says everyone who has osteoarthritis should be offered some sort of therapeutic exercise that suits them, and his fitness focus is backed by evidence.

“We see very positive outcomes from the three approaches - exercise, weight management and education. All have been shown to be clinically effective at reducing both pain and function,” Professor Paterson says.

Professor Kim Bennell is director of the Centre for Health, Exercise and Sports Medicine at University of Melbourne. She says that the kind of language clinicians use with OA patients is important. Focusing on the person, rather than the joint, is shown to be clinically effective in improving a patient’s willingness to take up exercise, she says.

Resources:

OA treatment resources from the Centre for Health, Exercise and Sports Medicine.

“Using language that talks with optimism about the effective, different treatments out there,” is a small change that is relatively easy to make says Professor Bennell.

General practitioner Dr David King also advocates for non-drug and non-surgical treatments to be prescribed first. He’s on the RACGP’s project team for the Handbook of Non-Drug Interventions (HANDI).

“HANDI is designed to be a similar resource as a pharmacopia for drugs - just like when we look up, say Australian Medicine Handbook, we can get an idea of the indication and the dose of the non-drug intervention and any contraindications and size of benefits,” he said.

Guests also discuss when ACL surgery is best, why young girls are at risk and what gets in the way of a doctor trying non-drug treatments first.

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There’s been a swell of advocacy lately around breast density, which increases cancer risk while reducing the sensitivity of mammograms. 

The FDA in the US has recently mandated that women be notified by mammogram providers if they have dense breasts, giving them the opportunity to arrange supplemental testing.  

But BreastScreen Australia’s 2020 position statement does not recommend the routine recording of breast density or the provision of supplemental testing for women with dense breasts.  

Professor Vivienne Milch, the government’s medical advisor on screening policy, and Professor Bruce Mann, a breast surgeon and researcher, are two of our guests today in the Tea Room – the last Tea Room before we become The Medical Republic Podcast and go from weekly to fortnightly episodes.  

We also talk to two patients about their experiences with breast density and cancer, who find the lack of notification baffling – and a little bit 1950s.  

Dr Sandy Minck, a GP by training and a breast cancer survivor, said she was “dumbfounded” by the BSA position statement. 

“As a consumer I'm outraged. As a health professional, I'm dumbfounded. I just don't understand it.” 

Professor Milch says the program will conduct an evidence review on supplemental screening for women with dense breasts some time this year, although there is no guarantee of a policy change. 

“We're aware of the growing momentum of advocacy and of also some women's desire to know their breast density,” Professor Milch says, adding that different states have different policies.  

“Western Australia has been telling women about their breast density for some time, and then there are pilots in some services in [Queensland and South Australia]. 

“We may or may not have a policy change. But we'll be looking at the evidence.” 

Professor Bruce Mann, who works with the Roadmap to Optimising Screening in Australia (ROSA) project, says there is enough evidence to justify a change to BSA’s screening regimen. 

“As women and the community becomes more informed, there is a danger that what is offered by BreastScreen will be seen as insufficient,” he said, which will lead to women opting out of BreastScreen and going private.  

“What we don't want in this country is a two-tiered system where those who know and can get the best, do, and everyone else gets what's offered to them. That's what we are working to avoid. 

“If you can show that by doing something different you are finding more cancers, fewer cancers are being diagnosed between screening rounds, and the stage, the size and the nodal status of cancers that are diagnosed is moving in a favourable direction, I believe that's sufficient to encourage implementation with a planned review in 10 years when the mortality information's there.” 

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South Australia’s long covid clinic loves GPs and keeps them close.

Dr Angela Molga is a clinical pharmacologist and geriatrician at the long covid clinic at Royal Adelaide Hospital.

“We engage the GPs very early on, from the moment we receive the referrals. The patients are kept updated on the length of the waitlist and we also send them out resources specifically around self-rehabilitation,” she says.

Dr Molga says the average age of the patients who were seen in the South Australian clinic last year was 47 years old.

“These were previously healthy people. Little contact with the healthcare system, but now have multiple chronic issues. They have to change their lifestyle significantly, and then this also impacts their mental health,” she says.

Also on The Tea Room medical reporter Cate Swannell shares the nitty gritty details of the long covid parliamentary inquiry report.

Although long covid fails to get a mention in the federal budget Cate says the long covid parliamentary inquiry is pushing for $50 million. She says the RACGP has welcomed the recognition of GPs in the report.

“They also have pointed out that many recommendations reflect what the RACGP has been calling for, for a long time. Particularly around data collection and research,” Cate says.

Cate says the report seemed to hinge on the establishment of a national Centre for Disease Control which we saw confirmed in this week’s federal budget.

“They're also talking about expanding the list of eligibility for antivirals and there is a call for the establishment of a multidisciplinary advisory body to oversee the impact of poor air quality and ventilation on the economy,” Cate says.

Join The Medical Republic at an interactive live webinar that will equip you with the knowledge and tools to treat long covid patients.

Ask questions about including diagnostics and assessment, guidelines, billing and item numbers, and how to create a long covid clinic in a community practice.

The expert panel include doctors treating long covid in family practices, leaders of tertiary care teams, clinical researchers and public health specialists.

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What do you get when you cross advice from a health economist with that from a leading physiotherapist? Increased revenue and a better patient experience, say our guests on today’s episode of The Tea Room.

Scott Willis is president of the Australian Physiotherapists Association and a proud Palawa man. He says better results come from general practices who genuinely embrace allied health as part of the team.

“If you have social events, invite them. Let them be part of your strategy of the practice. They might sometimes see things from a different angle and add value to where practice is heading,” he says.

Mr Willis also says the business relationship amplifies when it wraps around the needs of the patients.

“The number one thing is that both parties – GPs and allied health - believe that it's a partnership to make the patient journey better. I know it's a business transaction in terms of hiring a space or having some type of input within general practice, but it has to be viewed as more than that,” he says

Tracey Johnson, health economist and CEO of Inala Primary Care, also favours multidisciplinary team care for patients. She also has a robust economic rationale for engaging allied health within a general practice.

“Given the rents that people are now paying in this sector, it will be incredibly hard for you to survive if you don't have onsite allied health or pathology or pharmacy that you are subleasing to,” she said.

Ms Johnson says that many doctors work part time and that hot-desking their rooms makes perfect economic sense.

“Some doctors might work from 8:00am in the morning until 2:30pm and pick their children up from school. So, bring in some allied health who might to use those rooms from 3:00pm until 7:00pm. You get more utilization around those rooms, more marginal return, and generally things come together better for the patients as well,” she says.

For more tips on how to optimise your allied health arrangements listen to the full episode.

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Professor Rob Moodie describes himself as “an eternal optimist”. He needs to be. 

A long and distinguished career in public health has seen Professor Moodie tackle the “big four” industries – alcohol, tobacco, junk food, and fossil fuel – and these days he’s added a fifth to the list, gambling. 

Those industries and corporate multinationals make up a large slice, but by no means all, of the commercial determinants of health – defined by Professor Moodie and his colleagues as “the products and practices of some commercial actors—notably the largest transnational corporations—[that are] responsible for escalating rates of avoidable ill health, planetary damage, and social and health inequity”. 

In a recent series in the Lancet, Professor Moodie, Professor Anna Gilmore from the University of Bath in the UK and other colleagues set out to define, conceptualise and frame an argument for paying attention to the commercial determinants of health and rebalancing the distribution of the profits of capitalism. 

Are Professor Moodie and his colleagues talking about the overthrow of capitalism? 

“We’re talking about a much more responsible form of capitalism,” he tells TMR. 

“[At the moment] these corporations, don’t pay the costs of their production and their consumption. Individuals and states pay the costs. And that means that money can't be spent on other things like education or other forms of healthcare.  

“They can completely externalise all the negatives, and they leave it for the rest of the society to pick up, literally what they’ve left behind. And that makes them more powerful.” 

Doing nothing to correct the balance of power between corporations and society could be catastrophic, says Professor Moodie. 

“We've grown up with an expectation, literally, that life expectancy will continue to increase, that our lives will get longer and better as we go grow older and that we'll have a happier society,” he said. 

“That notion of a fair go was built into our ethos, but it’s been disappearing over the last 15 to 20 years.  

“We've watched all these indexes that are going the wrong way, whether it's around childhood education, childhood development, sustainability, biodiversity, press freedom, peace index, quality of life index, quality of death index – in Australia we used to be really up there. 

“This has been worn away.” 

We need a shift in our mindset and where we look for inspiration, says Professor Moodie. 

“We could go to the wrong place,” he said. 

“The US is not a place to go for overall policy inspiration. We need to look to northern Europe or Scandinavia, where there's a commitment to the society as a whole, and what that produces.  

“The greater the equality, the better the health, and there's a dictum that says if you want to live the American dream, go to Denmark.” 

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With so much to learn in so little time, managing LGBTQI+ patients isn’t yet high on the priority list at medical schools.  

Dr Asiel Adan Sanchez is a GP and clinical tutor at the university of Melbourne. He knows first-hand that clinical environments can be off putting for people who are queer, trans and gender diverse. He’s also created a solution for that called Wavelength: a learning tool that builds clinician skills and makes general practices safer for LGBTQI+ folk. 

Dr Sanchez gives a quick masterclass on the simple and practical ways to take away the awkward interactions that occur in many medical environments. They say a very common example is when taking a sensitive history and asking about gender affirmation procedures.  

“A lot of clinicians really struggle with asking those questions and often the language that they use is quite inappropriate. ‘Have you had the operation?’ for example. A patient might get this question all the time outside, in the real world, and if you don't explain to the patient what the rationale behind asking those questions is, it can be really distressing for them,” says Dr Sanchez. 

Dr Sanchez provides a graduated approach to inquiring about gender affirmation surgery, after building rapport through simple ways such as using correct pronouns.  

“I often tell medical students to fall back on the skills that they already have around cultural competency to build that rapport with the person. For example, you might be talking about work and family and what the patient does at home. Then you can ask ‘By the way, are there any pronouns that you'd like me to use?’ And that's an organic and simple approach,” they say. 

Wavelength training module is now managed by the Australian Medical Student Association (AMSA), which is advocating to incorporate the content into Australian medical school curricula. 

Medical student Sophia Nicolades has researched the LGBTQI+ health curriculum gap. They found that, on average, there were between zero and two hours across the whole medical degree dedicated to LGBTQI+ health. 

“We also found that the groups with the poorest healthcare outcomes were also the least present in our curricula – those being trans people, intersex people, bisexual people, and those with intersectional experiences such as First Nations people and folks with disability,” Mx Nicolades said. 

Dineli Kalansuriya, medical student and chair of AMSA Queer, is also working to improve the medical curricula at Australian universities.  

“We would also love for some practising doctors to take part in the Wavelength module and let us know if they feel that it's relevant, if it's representative of the presentations that they've been seeing as well,” she said. 

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Struggling to hang on to doctor staff? This episode offers more than a few gems of wisdom from the most unlikely location. 

Today, The Tea Room travels to Crystal Brook, a rural town 200 kilometres north of Adelaide. There we meet Dr Richard McKinnon co- owner of Crystal Brook Medical Practice – a small-town clinic that is anything but small. After 35 years in this farming community, he knows the hacks to running a thriving practice that allows plenty of time to play golf. The secret, it appears, is knowing how to retain registrars. 

“The current generation, quite rightly and no criticism at all, won't go to single-doctor practices, they won't go to two doctor practices and they probably won't go to three doctor practices. Because it's all about work life, balance and lifestyle,” Dr McKinnon says. 

At Crystal Brook Medical Practice registrars are “really looked after”, says Dr McKinnon. 

“They don't do any more on-call than I do. They're very well supported. And if they want to go and play netball in winter and they're on call, I'll cover them and they'll cover me when I want to go sailing. And the ones we like and who like us tend to stay,” he said. 

Providing great training is another major drawcard for registrars. At Crystal Brook they get hands-on experience assessing and treating conditions, like gout and polymyalgia rheumatica, which in a city clinic would be normally referred to another specialist. 

“I think rural GPs will do more procedures perhaps than our city colleagues because you don't want the patient have to travel 200 kilometres for treatment. And if you're not kind of putting patients at increased risk then we will do those treatments and try to encourage and teach the registrars coming through,” he said. 

Dr McKinnon sees an over reliance on “sophisticated investigations” in current training approaches in large hospitals. He believes this can compromise clinical acumen and the confidence to diagnose and treat some patients. 

“You go to Medical School, in my case for six years of medicine, then four years post-graduate. Basically you've done 10 years training. If you then don't use your clinical acumen, well, it just breaks my heart,” Dr McKinnon said. 

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