In episode 59 we shared a sampler of the Essential Ethics podcast from the Children's Bioethics Centre , at the Royal Children’s Hospital, Melbourne. A couple of cases studies were presented to help us define “the Zone of Parental Discretion” – a space in which decision-making about a child’s medical care is conceded to parents even if it’s not optimal clinical management. Today’s thought experiments come from the oncology department. First, we’re asked to consider when an adolescent should...
Aug 11, 2020•42 min•Ep 62•Transcript available on Metacast In the previous episode we discussed the presentations and screening of delirium, as well as the risk factors. Just as important as these medical and iatrogenic precipitants are a host of environmental triggers that are highly modifiable. Anything that contributes to a person’s disorientation and discomfort can increase the likelihood of a delirium episode. While a lot of these factors are compounded in elderly and frail patients, it’s important not to be fatalistic. Delirium can be reversed in ...
Jul 09, 2020•34 min•Ep 61•Transcript available on Metacast Delirium is associated with an increased risk of falls, dementia and high dependency care, and all of this adds up to higher mortality. About a third of patients admitted to ICU or approaching the end of life experience delirium. But it’s notoriously underdiagnosed, so in this episode we talk about the presentations and detection of delirium. We also go through some of the medical risk factors, including dementia, infection and metabolic disorders like hypercalcaemia. But even more common than t...
Jul 08, 2020•32 min•Ep 60•Transcript available on Metacast The ethical questions that come up in paediatrics can appear overwhelming to begin with. When can a child be said to have cognitive capacity and bodily autonomy? For those who don’t, where does the guardianship of the parent to give way to that of the medical professionals? When might treating one child have implications for the resources available to others? And what about not treating or vaccinating a child, if that’s what the parents want? All of these issues are tackled in the Essential Ethi...
Jun 15, 2020•35 min•Ep 59•Transcript available on Metacast In this episode we continue the discussion from Episode 56 about medical billing in Australia. Almost 500 million Medicare rebates are processed every year and for the most part these are claimed appropriately. But non-compliant billing could be costing the health system over 2 billion dollars annually. The vast majority of this comes down to misunderstanding of the conditions around MBS items, according to our guest Loryn Einstein of Medical Billing Experts. Every year the Department of Health ...
May 11, 2020•44 min•Ep 58•Transcript available on Metacast COVID-19 has left few people around the world unaffected, and health practitioners are among those at the top of the list. Their daily and intimate service to public inevitably puts them at risk of catching the virus, while social distancing precautions can compromise the work that they do. Dreadful as the viral disease is, the bigger consequences of the pandemic may be on the disruption to routine healthcare . Consulting patients by video or phone can be a way to keep healthcare ticking over, b...
Apr 23, 2020•36 min•Ep 57•Transcript available on Metacast Australia has one of the best value health systems in the world, but also some of the most Byzantine health regulation. Between the federal Medicare scheme, the state hospitals, the private health insurers and the patient, it’s not always clear how a provider should invoice their services. To explain some of the fundamentals our guest is former nurse and lawyer, Margaret Faux of Synapse Global Medical Administration. She also describes areas of ambiguity in the legislation and the Medicare Benef...
Mar 11, 2020•43 min•Ep 56•Transcript available on Metacast This podcast is about one of many pathways in medicine; private practice. It’s a pathway that presents many opportunities, but also personal and financial challenges. When doctors are starting out in private practice, they typically do so within the safety net of an established practice, and perhaps only for part of the working week. In a simple model, they would be renting a room in exchange for an agreed portion of the consultation fees, to cover administration costs. The next level of complex...
Feb 05, 2020•41 min•Ep 55•Transcript available on Metacast How many times have you thought “things would be so much more efficient if we had shared electronic health records?” Australia, now has the My Health Record covering 90% of the population with individual profiles. It is proposed that this will improve safety especially for people with chronic and complex health care needs. It could reduce medication mismanagement and duplication of pathology and diagnostic imaging tests and help improve health literacy among the public. And at the point of care ...
Dec 09, 2019•42 min•Ep 54•Transcript available on Metacast Marrabinya is a Wiradjuri word meaning “hand outstretched.” It’s the name of a service in the Western New South Wales Primary Health Network which financially supports Indigenous Australians to attend specialist consultations. Aboriginal and Torres Strait Islander Peoples receive specialist medical care 40% less often than non-indigenous Australians. It’s easy to imagine communities out in the red desert and blame culture clash or the tyranny of distance, but most Indigenous Australians live in ...
Nov 12, 2019•33 min•Ep 53•Transcript available on Metacast In the previous episode we talked about the science of pain, opioid analgesia and dependence. Now we look at the influence of culture, regulation and marketing on opioid prescribing for chronic non-cancer pain. First we ask which are the prescription opioids most commonly leading to dependence and why are they prescribed. Then we discuss the mixed messages that prescribers are getting from guidelines and pharmaceutical regulation. Ever-relaxing indications for pharmaceutical subsidies can nudge ...
Sep 16, 2019•34 min•Ep 52•Transcript available on Metacast The dramatic headlines about the opioid crisis are all-too familiar by now. Australia and New Zealand have followed the lead of the US, and seen a fourfold increase in opioid use over the last thirty years. Most of this prescribing has been for chronic non-cancer pain, but systematic reviews will tell you that that there are no decent trials that would warrant use for this indication. In this podcast we’ll discuss some of the latest studies that have actually followed pain patients long-term, an...
Sep 04, 2019•32 min•Ep 51•Transcript available on Metacast New Zealand doesn't have the same extremes of remoteness of Australia, but it does have a rugged landscape that results in small and scattered communities. And there is a strong rural identity, though the fraction of the population classified as rural is now around 16 percent. As you'll hear, the populations which are disproportionately under-serviced and in worse health, are not necessarily the most remote. The demarcations fall much more starkly along lines of socioeconomic status, a...
Jul 21, 2019•26 min•Ep 50•Transcript available on Metacast A third of Australia's population is classified as regional or remote, but as it's such a big place it's hard to provide comprehensive heath care all over. In the previous episode, we heard about an important referral centre in country NSW, but this episode takes us to Broome, a small town that's two and a half thousand kilometres from tertiary facilities in Perth. On average, remote settings like this only have 11 percent as many specialists per capita as major cities and th...
Jul 11, 2019•32 min•Ep 49•Transcript available on Metacast A third of Australia's population is classified as regional or remote, but since it's such a big place it's hard to provide comprehensive heath care all over. As a result, chronic disease gets treated later and mortality is 1.3 time higher than it is in major cities , according to the Australian Institute of Health and Welfare. There are only 42 percent as many specialists per 100,000 population in regional areas as there are in major cities , but research shows that these experie...
Jul 03, 2019•36 min•Ep 48•Transcript available on Metacast Everyone knows that adolescence is a turbulent time. Teens are faced not just with changes to their bodies, but to their moods and thought patterns as well. They might also be saying goodbye to familiar carers in the paediatric department, and in Episode 11 we heard how important it is to ensure a smooth transition to adult services, which tend to be more anonymous. This is especially true for young people with special needs such as diabetes, transplant management or intellectual disability, tho...
Jun 05, 2019•29 min•Ep 47•Transcript available on Metacast This episode was recorded at the 2019 RACP Congress in Auckland and deals with the profound influence that the first 1000 days of life have on lifelong health, wellbeing, behaviour and socioeconomic outcomes. Professor Richie Poulton outlined the influential Dunedin Multidisciplinary Health and Development Study, which has followed over 1037 participants since 1972. All sorts of measures have been taken throughout the participants' lives, but Dr Poulton showed the incredible predictive powe...
Jun 04, 2019•38 min•Ep 46•Transcript available on Metacast Australia and NZ are made up of sprawling cities and far-flung towns, and driving is often viewed as a fundamental freedom. It can be hard for clinicians to challenge that freedom with patients who they consider unfit to drive safely. And harder still to deal with the consequences if a patient does have a crash. Clinicians are drawn into the question of driving fitness in two main ways. The more clearcut is when a patient presents with a medical assessment form. It's the Driver Licencing Au...
Apr 17, 2019•42 min•Ep 45•Transcript available on Metacast Cervical cancer is the fourth most common cancer in women worldwide, but it's almost entirely preventable. Incidence in Australia and New Zealand has fallen by half since national Pap testing programs were implemented almost thirty years ago, and it now it sits between 6 and 7 cases per 100,000 women. But this rate has been at plateau for over a decade , and Pap cytology now plays second fiddle to HPV testing. In December 2017 Australia seconded the Netherlands to adopt this as the primary ...
Feb 12, 2019•41 min•Ep 44•Transcript available on Metacast This is the second of two podcasts about "disruption" in healthcare . We hear from members of the RACP Consumer Advisory Group about the way they see the power balance in health service delivery and how to increase participation. Consumer advocate Jen Morris discusses autonomy, and all the subtle aspects of informed consent. Another factor which can give the public a greater sense of agency in their care is access to health data. Consumer expectations are different to what they were tw...
Dec 18, 2018•36 min•Ep 43•Transcript available on Metacast In this and episode 43 we revisit the theme of 'disruption' from the 2018 RACP Congress. Disruption is what happened to the taxi industry at the hands of Google Maps and Uber. Or to the music industry with the onslaught mp3 files and digital sharing platforms. Democratizing technology is changing delivery of healthcare too and now permits remote consultations, automated dispensing, or even algorithmic diagnostics. The public also has access to more information, and even today, "Dr...
Dec 16, 2018•36 min•Ep 42•Transcript available on Metacast Glucose-lowering medications have been the mainstay of managing type 2 diabetes for 20 years, but in April this year a polemic erupted around specific targets for blood sugar. The American College of Physicians recommended less stringent control than had been previously accepted, and invoked fierce criticism from other diabetes organisations around the world . It all comes down to the interpretation of four key trials between designed to show a link between intensive glycemic control and improve...
Nov 20, 2018•36 min•Ep 41•Transcript available on Metacast From 2019, there will be only three categories of activities in the RACP's CPD framework, encouraging Fellows to participate in performance review and outcome measurement alongside more traditional educational activities. Performance review can include collegiate exercises like peer review of case outcomes, or surveys of patient experiences. Multi-source feedback is one sophisticated example that has been trialled by the RACP. Outcome measurement typically refers to clinical audits of case ...
Sep 26, 2018•30 min•Ep 40•Transcript available on Metacast In this episode we put continuing professional development (CPD) under the microscope, particularly the regulatory changes on the horizon. The Medical Board of Australia is emulating shifts already made by the Medical Council of New Zealand and regulators in Canada, the U.S. and the U.K. In some cases, this 'revalidation' movement has been fiercely opposed by doctors. But where did it come from, and why is CPD even necessary after you've already done 10 to 15 years of medical trai...
Sep 25, 2018•31 min•Ep 39•Transcript available on Metacast An empathic connection and good communication between physician and patient can promote better outcomes. In this episode of Pomegranate Health, U.S. physician A/Prof Danielle Ofri discusses where breakdowns in doctor-patient communication occur—often in the first 10 or 20 seconds of a consultation . Dr Ofri, author of What Patients Say, What Doctors Hear , suggests ways for physicians to listen better, to be understood and promote adherence. Some media also report a 'crisis of compassion&ap...
Jul 15, 2018•32 min•Ep 38•Transcript available on Metacast As medicine becomes more sophisticated, discussions about clinical ethics become more common. It is now possible to support life in dire clinical circumstances, but physicians are not always sure if this is the right thing to do. There are questions about quality of life and best interests of the patient, questions about cognitive competence to make such decisions for oneself or questions about equitable distribution of limited resources. This episode was recorded at the RACP Congress in May and...
Jun 13, 2018•41 min•Ep 37•Transcript available on Metacast This is the second of two episodes about acute coronary syndrome (ACS). In part one , the discussion focused on diagnostic workup of acute coronary events. This episode deals with secondary prevention and adherence to therapy. One-fifth of people discharged with a diagnosis of ACS have another ischaemic event within six months, and the risk of dying increases the second time round. There is an established strategy for secondary prevention of ACS that includes pharmacotherapy, cardiac rehabilitat...
May 23, 2018•33 min•Ep 36•Transcript available on Metacast Chest pain and other symptoms suggestive of ACS make up the majority of presentations to hospital. 11 to 17 per cent of patients presenting to ED with such symptoms end up having the diagnosis confirmed. But follow-up studies of discharged patients show that up to six per cent of diagnoses are missed , and inappropriately discharged patients have a twofold higher mortality rate than those who are admitted. The 2016 guidelines of the Cardiac Society of Australia and New Zealand were developed to ...
May 03, 2018•29 min•Ep 35•Transcript available on Metacast In Episode 32 we discussed cognitive error in diagnostic reasoning. On this episode, we take a look at systems pressures that increase the likelihood of medical error, crystallised by the recent prosecution of NHS paediatrician Dr Hadiza Bawa-Garba. Almost half of diagnostic errors are due to a combination of systems errors and individual cognitive error. Obvious systems effects come into play in understaffed acute care units; if a clinician is forced to see too many patients without enough time...
Mar 19, 2018•36 min•Ep 34•Transcript available on Metacast Cannabis is a plant rich with potential therapeutic compounds and centuries of cultural resonance. At this moment in Australia, media accounts are full of patient stories and lab data suggesting benefit from cannabis for scores of different conditions, while politicians discuss laxer regulation of the drug and a new lucrative industr However, only a few of the claimed medical effects of the plant have been proven by rigorous clinical trials in people. Nabiximols is the only medicinal cannabis pr...
Jan 30, 2018•36 min•Ep 33•Transcript available on Metacast 
