medicJUNE 2020 SAVOLUME 33 NUMBER 3

The new normal Practising medicine during and after the pandemic

POST-OP COMPLICATIONS – THE HIDDEN PANDEMIC • VALE SENIOR MEMBERS • POLIO’S PERMANENT REMINDERS • THE DEANS’ LISTS Dr Jones & Partners is pleased to introduce Dr Malalagama, Dr Paterson and Dr Moon

Dr Geethal Malalagama and Dr Helen Moon join our experienced team of drjones.com.au/ radiologists. Dr Malalagama has a keen interest in Neuroradiology, Abdominal imaging and more broadly in CT and MR imaging. Dr Malalagama also holds doctors a position at the Flinders Medical Centre.

Dr Helen Moon has a special interest in trauma imaging and delivering medical student education. Dr Moon additionally holds a position at the Royal Adelaide Hospital.

We also warmly welcome back Dr Felix Paterson, who has recently returned from Hobart after completing his second year of Nuclear Medicine training with Calvary Lenah Valley (I-MED) and the Royal Hobart Hospital. Dr Paterson will work across both radiology and nuclear medicine, with a special interest in Oncology, PET, Nuclear Medicine and Neurology.

We are delighted to have Dr Malalagama, Dr Moon and Dr Paterson join our specialist doctor team.

Enquiries & Bookings: CRICdrjones.com.au/, 1800 875 290book For all enquiriesdrjones.com.au/ &online-referring bookings call 1800 875 290 2 | medicSA Doctor Led • PatientFocused • Quality Driven drjones.com.au Contents 5 President’s report Australian Medical Association (South Australia) Inc. 6 Editor’s letter Level 1, 175 Fullarton Road, Dulwich SA 5065 7 Moving house PO Box 134 North Adelaide SA 5006 9 Partners in protection Telephone: (08) 8361 0100 10 Hidden figures – SA doctors look to reduce Facsimile: (08) 8267 5349 post‑op complications Email: [email protected] Website: www.amasa.org.au 13 On the frontline Executive contacts • SA President faces COVID-19 committee President • Speaking for GPs – Profiling Dr Danny Byrne Dr Chris Moy: [email protected] • Questions on notice – experts’ perspective on medicSA SA’s performance Editorial • A specialist’s story Editor: Dr Philip Harding Managing Editor: Karen Phillips • Future perfect – a care model for the next pandemic Cover image • Consultants on call – the known and unknown Feverpitched, iStock outcomes of telehealth Advertising [email protected] 29 Caring for the most vulnerable – the special cases of Aboriginal communities and palliative patients Production Typeset and printed for the AMA(SA) by 33 Sock it to ’em – embracing the campaign for Douglas Press Pty Ltd. doctors’ health ISSN 1447-9255 (Print) 34 On the Dean’s list – leading SA’s medical schools ISSN 2209-0096 (Digital) Disclaimer 50 Vale – remembering Dr Peter Hetzel and Dr Andy Czechowicz Neither the Australian Medical Association (South Australia) Inc nor any of its servants and agents will have any liability in any way arising from information or advice that is contained in medicSA. The statements or opinions that are expressed in the magazine reflect the views of the authors and do not represent the official policy of the Australian Medical Association (South Australia) unless this is so stated. Although all accepted advertising material is expected to conform to ethical standards, such acceptance does not imply endorsement by the magazine. All matter in the magazine is covered by copyright, and must not be reproduced, stored in a retrieval system, or transmitted 42 in any form by electronic or mechanical means, photocopying, or recording, without written permission. Images are reproduced with permission What will COVID-19 bring? under limited license. These Victorian boys of the 1930s suffered from one of the worst diseases to afflict Australian children: polio. Decades after they survived the pandemic itself, they would be forced to bear other symptoms related to polio, including worsening fatigue and new pain, that no one expected – and that today’s doctors are still learning to recognise and diagnose. South_agency, iStock © South_agency,

medicSA | 3 Dr Divya Sabharwal General practitioner South Australia

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210mmx297mm_SA Medic_MAY20.indd 1 13/5/20 1:20 pm REPORT

Not remotely normal

ne evening during the height effects of reduced social connectedness of the physical distancing and mental health stresses, compounded restrictions, my wife and I by unheard-of economic challenges. received a text query from our Doctors are not only at the front line Odaughter, Natasha, who was alone in of caring for patients in this new society; her bedroom from which happy music we are struggling with the changes, too. was thumping and computer-generated With this is mind, #CrazySocks4Docs President’s flashes were seen emanating from the came as a timely reminder that we gap under her closed door. When my doctors are human and that we must report wife Monika decided to respond with consider both our own mental health a vocal answer, she was met with two needs and those of our colleagues. Only happy but abrupt text communications Dr Chris Moy then can we genuinely heal our patients. from my daughter: ‘I’m busy’ followed Much like my daughter’s attitude by ‘I’m at a party’. towards her virtual party, one factor It’s been a strange and intense that has created an unexpected positive five months for us all. I guess a psychological element during this time pandemic will do that. has been the ‘can do’ approach that has While we doctors have experienced dominated over the naysayers. Contrast varying degrees of anxiety and this with the pervasive air of negativity, exhaustion in facing both the health cynicism and pettiness that can be threat of COVID-19 on our patients found when some decision-makers or and ourselves, and the impacts on our community members find reasons not to businesses, there has been an inspiring change things for the better. spirit of community permeating our With this in mind, I point to the profession. In a column published article on page 10 regarding the need in the Sunday Mail in late March, I to reduce the genuinely extraordinary asked South Australians to be kind, and appalling number of patients who generous and big-hearted. I have to say suffer and die from post-operative that with few exceptions, the people complications. This is the third most of this state have come through. In frequent cause of death worldwide, with giving evidence to Legislative Council COVID-19 Response Committee in late 4.2 million people dying within the first May, I reported that if South Australia 30 days of surgery each year. Australia was a footy team, the newspaper report does no better; in addition to reducing could have summarised performances harm to our patients, it is estimated that in the early stages of this critical game even a 15 per cent reduction in post- as ‘all played well’. operative complications would lower We as the medical profession – for costs by $1.2 billion a year – a relevant which the AMA is the only voluntary statistic in our debt-affected post-COVID organisation representing all doctors – world. Implementing changes to reduce … one factor that should feel a significant level of pride in these complications seems to be not a our parts in the effort. And as I write this ‘can do’ but a ‘must do’. has created an in mid-June, South Australia is one of the Led by organisations such as the unexpected positive safest places in the world to be. AMA, doctors around the world have Yet still we function within what made such a difference in confronting psychological element is being termed ‘the new normal’. the virus so far. I hope that, for the sake during this time has Handshakes and hugs have been of our patients, we can continue this removed from our social encounters spirit so that health in South Australia been the ‘can do’ and may never return. A return to continues to adapt and ‘do’. And, as a approach that has emphasising hand washing, harking result, we can extend this current mood back to the times of polio, is an irony in of each of us playing our part into the dominated over the our supposedly first world society. And quiet satisfaction found in careers of naysayers … physical distancing is leading to the twin contribution and service.

medicSA | 5 EDITORIAL

ost South Australians will appointed Governor of New Zealand, a role remember the name of Edward in which he had a long-running conflict MGibbon Wakefield because of his with Wakefield who by then had assumed role in setting up the South Australian high political office in that country. Edward colony in the early 19th century. Those who Gibbon, whose difficult and chequered life don’t know that will have noticed there are is itself a very interesting story, spent his many places in the state named after him, last years in New Zealand but never visited including a port, a river, numerous roads South Australia. and streets (including the one in which I Then, while at an international live) and most recently a hospital. However, conference earlier this year (when such Wakefield Hospital has recently forsaken things were possible!) I mentioned some that name, having moved to new premises of this story to a New Zealand colleague, at Calvary Adelaide. who told me that the two largest private Editor’s Last year while on holiday in hospitals in Wellington are Calvary and letter Christchurch, New Zealand, my wife and I Wakefield, the latter indeed named after were intrigued to discover Wakefield’s name the said Edward Gibbon. The connections to be well-known, a legacy of his role in the continue – and if, as has been suggested, Dr Philip Harding settlement of the surrounding Canterbury Australia and New Zealand form a ‘travel area in the 1840s. When we travelled on to bubble’ in emerging from the pandemic, the North Island, further evidence emerged this may be a subject worth exploring on of his involvement, along with other the other side of the pond. members of his family, in the establishment of Wellington. Wakefield’s interests in colonisation, developed during a period of imprisonment for abducting an heiress with a view to marrying her, extended well beyond Australasia to involve Canada and other parts of what was then still the British Empire. Another interesting link was that George Grey, the fourth Governor of South Australia, had also twice been

New board member for AMA(SA)

trategy and governance expert including the introduction of a new Megan Webster has joined the electronic courts management system. SExecutive Board of the AMA(SA). In 2015, Ms Webster has served as Ms Webster has more than 15 years Chair and Deputy Chair of the Board of experience as a senior executive in of Regional Development Association ‘In what have been an extraordinary few months, our Board has worked hard the South Australian Government. (RDA) Adelaide. Other appointments to support and provide a platform for Her background also includes law, include roles with the University of the Council, our members and AMA(SA) human resource management, social Adelaide Alumni Council, University of staff to perform their essential services,’ policy (health, higher education Adelaide Council Selection Committee, ‘Megan’s experience expands the and employment), government Cure for Cystic Fibrosis Foundation, and capacity of our group to address the relations, strategic communication the State Records Council. range of important and in some cases and governance. ‘This has been a year like no other, and unparalleled issues on our agenda in Ms Webster has been an advisor to its challenges have tested organisational 2020 and beyond,’ Dr Nelson said. premiers, and as the first Executive responsiveness and agility as we’ve not Ms Webster joins radiologist Director of Leadership and Governance seen before,’ Ms Webster said. Dr Nelson, accountant Andy Brown, for the South Australian Public Sector ‘I hope to contribute significantly to anaesthetist Dr Guy Christie-Taylor, led sector-wide employment, leadership the good governance of the AMA, so the along with Councillors Dr Chris Moy development, induction and culture AMA(SA) Council can focus its attention (President), Dr Michelle Atchison change programs. on important matters of policy. (Vice-President) and Dr William More recently, she led extensive Dr Nelson welcomed Ms Webster Tam (Immediate Past President), changes in the South Australian Courts, to the Board. on the Board.

6 | medicSA NEWS

AMA(SA) COUNCIL

Office Bearers President: Dr Chris Moy Vice President: Dr Michelle Atchison Immediate Past President A/Prof William Tam Ordinary Members Dr Daniel Byrne, Dr Matthew McConnell, Dr Penny Need, Dr Clair Pridmore, Dr Rajaram Ramadoss, Dr John Williams, Dr David Walsh Specialty Groups Anaesthetists: Dr Simon Macklin Above: AMA(SA) President Dr Chris Moy and fulltime and part-time office and Skills Training Dermatologists: Dr Patrick Walker staff at the temporary Dulwich premises. Emergency Medicine: Vacant General Practitioners: Left: The fire at AMA House caused an Dr Bridget Sawyer estimated $5 million damage. Obstetricians and Gynaecologists: Dr Jane Zhang Ophthalmologists: Dr Edward Greenrod New home for AMA(SA) Paediatricians: Dr Patrick Quinn Pathologists: Dr Shriram Nath Physicians: Dr Andrew Russell MA(SA) staff have begun working Dr Mead thanked Adelaide dentist Dr Psychiatrists: Prof Tarun Bastiampillai in temporary premises at Dulwich Bill Verco, who offered the Dulwich offices Public Health Doctors: following the fire that caused quickly and on helpful terms to support Dr Nimit Singhal extensive damage to AMA House AMA(SA) and his medical colleagues. Surgeons: Dr Peter Subramaniam Ain May. AMA(SA) President Dr Chris Moy said The fire, which was believed to have been the fire would not influence the AMA(SA)’s Radiologists: Dr Jill Robinson deliberately lit, caused about $5 million essential work during the pandemic. Regional Representatives damage to the building. Significant structural ‘Our thoughts are with the medical Northern: Dr Philip Gribble, damage has required the AMA(SA) to vacate practitioners and others who lease these Dr Simon Lockwood the offices for at least nine months. suites,’ Dr Moy said. ‘We understand that Doctors in Training Representative AMA(SA) CEO Dr Samantha Mead said the fire will have a distressing impact on Dr Hannah Szewczyk staff began working in the offices on Level 1 their capacity to help their patients in what Student Representatives at 175 Fullarton Road on 22 June, after having are already extremely challenging times worked from their homes since 26 March. for everyone. University of Adelaide: Dr Mead said it was a ‘fortuitous by- ‘From an AMA(SA) perspective, we are Mr Jack Rumbelow product’ of having staff work from home extremely relieved that the fire has not Flinders University: Ms Matilda Smale that the fire caused minimal disruption to caused any injuries. Property can be repaired. AMA(SA) Executive Board AMA(SA) operations. Buildings and premises can be rebuilt. But Dr Michelle Atchison, ‘Staff had transferred their computers if there is anything that this pandemic has Mr Andrew Brown, Dr Guy Christie- and other equipment to their homes weeks demonstrated, it is that people and their Taylor, Dr Chris Moy, Dr John Nelson, before the fire, and were set up at home and health and wellbeing must and do come first. accustomed to working outside the North ‘The AMA(SA) is determined that A/Prof William Tam, Adelaide office,’ Dr Mead said. our work in serving patients, members, Ms Megan Webster ‘We have visited the office to work with health practitioners, the government Federal Councillors assessors and to mark what needed to be and communities across South Australia A/Prof William Tam (State Nominee) cleaned as a priority, so we have everything throughout the pandemic will continue.’ we need at Dulwich,’ she said. ‘It was Dr Chris Moy (Area Nominee SA/NT) distressing and disappointing to see the AMA(SA) staff will be based at Level 1, 175 Dr Matthew McConnell (Specialty waste and realise the impact the fire will have Fullarton Road, Dulwich, until further notice. Group Nominee: Physicians) on the businesses that leased other suites in All phone and fax numbers, email addresses and AMA House.’ the PO address remain the same.

medicSA | 7 Lung cancer services expand in Elizabeth Stereotactic Body Radiation Therapy (SBRT) Now available

SBRT is an advanced, high precision radiation therapy Our radiation oncologists technique that delivers ablative radiation doses while minimising dose to normal tissues.

For suitable patients, SBRT offers the following advantages: Improved oncological outcomes with: • Superior local control in early stage NSCLC due to higher (ablative) radiation dose compared with conventional Dr Kevin Palumbo radiation1 MBBS, FRANZCR • Comparable survival to surgery for early stage NSCLC and oligometastatic disease2,3 Greater patient convenience with: • Reduced radiation dose to surrounding healthy tissues resulting in less side-effects • Fewer treatment sessions - usually 4 - 8 attendances compared to 20 – 33 with conventional treatment Dr Marcus Dreosti • Faster treatment delivery times during each treatment BSc, Hons LLB, MBBS (Hons), session (20 minutes) FRANZCR

Patients potentially suitable for lung SBRT include: Pathologically confirmed primary NSCLC or lung metastasis that is: • Medically inoperable or • Patient has declined surgery High radiological probability of malignancy where Dr Phuong Tran MBBS, FRANZCR pathological confirmation is: • Technically not feasible/contraindicated or • Declined by patient • Stage T1/T2 (<5cm) and N0 • ≤ 3 synchronous metastases or oligoprogressive disease

Dr Laurence Kim Refs: 1. Ball D et al. Lancet Oncol 2019; 20: 494-503 2. Chang JY et al. Lancet Oncol MBBS, FRANZCR 2015; 16:630-637 3. Ball S et al. The Oncologist 2016;21:393-398

Calvary Central Districts Hospital 25 – 37 Jarvis Road Elizabeth Vale 5112 Tel: 08 7285 6400 | Fax: 08 7285 6401 [email protected] 8 | medicSA STATE NEWS

Personal protection An innovative AMA(SA) contract with a local medical device supplier is helping members access high-quality, locally made PPE in the pandemic.

he AMA(SA) has entered an agreement with leading Adelaide-based medical device manufacturer Austofix Tto support the local supply of TGA- approved masks for South Australian doctors and health workers. Austofix designs, manufactures and distributes world-class orthopaedic devices. Now, in response to the COVID-19 pandemic, Austofix has turned its attention to supplying masks tested in its purpose-built, TGA-approved device cleanroom technology and packaging facilities at Thebarton. AMA(SA) CEO Dr Samantha Mead said the dire threat posed by the pandemic required the AMA(SA) to explore innovative ideas and extraordinary measures to support members. ‘Austofix has presented us with an opportunity to help our members access the PPE they so desperately need while supporting a local company with a proven medical pedigree,’ Dr Mead said. ‘Across Australia and the world, doctors and healthcare workers have been forced to do their work without reliable PPE. Others have lost income as they stood aside to allow colleagues in AMA(SA) CEO Dr Samantha Mead and Austofix general manager Chris Henry with ICUs and elsewhere to have masks and Austosafe surgical masks. other equipment. ‘This agreement helps us help our and Victoria in early May, becoming could access quality products in times of members when they need it most’. one of the first local manufacturers to dire need. Austofix CEO Chris Henry said his produce and supply PPE to rigorous ‘We are relieved and delighted company had expanded into supplying ISO 13485 quality standards. to partner with a South Australian PPE in response to the nation’s most The high-level compliance makes company like Austofix, which can work threatening health crisis in recent times. Austofix one of only a handful of closely with our members to meet their Mr Henry said that as a manufacturer Australian suppliers able to offer specialised needs and create a secure sterile and non-sterile PPE. of orthopaedic implants for more than long-term supply option right here in 25 years - and with its own state of the ‘The clean-room facilities at SA,’ Dr Mead said. art clean room at Thebarton – Austofix Thebarton are certified to process ‘Austofix is a local company with was able to respond quickly and Class 3 implantable devices, so credentials in the medical sector that manufacture PPE when COVID-19 hit. diversifying to manufacture PPE was After receiving TGA approval relatively straightforward,’ Mr Henry is looking to contribute to better, safer to manufacture PPE on 23 March said. ‘We’re keen to continue to invest working environments for doctors and 2020, Austofix immediately secured in new manufacturing facilities other health practitioners.’ components through its existing here in Adelaide to expand medical Mr Henry said Austofix would pursue international network of medical device manufacturing.’ international markets, particularly in suppliers. It shipped its first ‘Austosafe’ Dr Mead said it was important that the Middle East and Asia, when local

© Sarah Reed/Newspix masks to hospitals in South Australia members, hospitals and health services demands are met.

medicSA | 9 IMPROVING CARE

The hidden pandemic Urgent attention to the many unseen costs of post- surgery complications will be even more vital in a post- COVID health system, writes Professor Guy Ludbrook.

urgery is an essential component perioperative care even further. The of healthcare. It is necessary for Summit recommendations have a third of our disease burden, become even more relevant and must be reflected in 2.5 million surgical implemented to enact change. Sprocedures annually, and will be SYSTEMS IMPROVEMENT required to expand substantially in Systems thinking – understanding the future years to maintain the health important elements and how they best of Australians. work together – was a key focus of the Access to safe and effective care for Summit. In healthcare – as explained Professor Guy Ludbrook addresses the patients undergoing these procedures, by Louise Locock in 2003 – systems National Summit however, is unlikely to continue thinking means ‘thinking through without rapid action. We know already from scratch the best process to achieve that postoperative complications are aligns with the views on quality of speedy and effective care from a patient common, and that mortality after the Australian Commission for Safety perspective, identifying where delays, and Quality in Health Care. Similarly, surgery is the third leading cause of unnecessary steps or potential for error death worldwide. Further, without the movie Moneyball showed how the are built into the process, and then Oakland A’s baseball team, faced with attention, this problem will worsen, redesigning the process to remove them by up to 10 per cent annually by 2047, large budget challenges, introduced a and dramatically improve the quality ‘Sabermetrics’ systems approach and as Australia’s population ages and of care’. co-morbid disease increases. These applied economic principles to baseball Designing an end-to-end, high-quality figures are mirrored internationally, and was rapidly successful. Ensuring system based on relevant evidence has making this a real – but very much all elements (players) were good at the been commonplace in non-healthcare hidden – pandemic. individual important activities (such as industries for decades. reaching first base rather than hitting NATIONAL SUMMIT WHAT DOES INDUSTRY DO? the occasional home run) combined to The impact on patients’ health McDonald’s founders Richard and produce the desired outcome (winning) and wellbeing, and the cost to health Maurice McDonald understood 70 and quickly led to high-value outcomes services, means that continuing to years ago the importance of high- (victories cheaper than those more turn a blind eye to this situation is no quality end-to-end food service – established teams could manage). longer an option. This was confirmed including personnel, space, machinery Importantly, industry shows us that at a National Summit in March this and workflow – without weak links. even large, established organisations year, opened by Federal Health Minister Interestingly, their approach of such as Nestlé can rapidly reform their Greg Hunt and his South Australian minimising unnecessary variation business: the Nespresso transition from counterpart Stephen Wade, instant coffee was achieved when 85 experts from around rapidly through small-scale Australia, NZ, the UK and the US demonstration, led by teams met in Adelaide. Their roadmap with change-management for the future, The Hidden skills, then followed by Pandemic of Post-Operative widespread adoption. Complications - Meeting Report, highlights how systems changes HEALTHCARE are essential, provides principles INDUSTRY to underpin future activity, and These analogies have provides 34 recommendations direct and immediate on actions to provide high-value relevance to surgery and care. Further, it provides a ruler perioperative care. against which to judge current Firstly, we know the and future care. impact of end-to-end system Since March, of course, we improvement. have experienced the COVID In medicine we frequently pandemic, with its tragic focus on individual, logically consequences on people’s Medical journalist Dr Norman Swan mediating a Summit impactful surgical or health and livelihoods, panel including (from left) Professor Ludbrook, British perioperative elements such as and on the economy. This anaesthetist Professor Michael Mythen and Professor Katina medical devices (for example, suddenly jeopardises access D’Onise, Wellbeing SA’s Executive Director, Prevention and robots) or new medicines to safe effective surgery and Population Health (such as analgesics). We

10 | medicSA IMPROVING CARE

often struggle to prove large benefit, Lastly, we need to understand • Primary care groups are already especially across centres, in part because the measures of success, which will discussing elements such as early risk individual excellence can be undone by include: and comorbidity assessment any weak link. There is also the issue of • Consumer feedback and experiences • Commissions now exist to assist siloed thinking, in part as result of our (measured against consumers’ jurisdictions with starting innovation disjointed healthcare structures and preoperative understanding of the and demonstrating excellence funding, such as for general practice, risks and benefits of proposed surgery • Partnerships with key organisations, private specialist and public hospitals. against their own goals) such as University College London, Stakeholders are insulated from each • Relevant endpoints, built bring expertise in large data other and, not surprisingly, frequently into standards management and modelling, risk fail to effectively understand or engage • High-value (outcome and cost) assessment, A.I. and economics. with each other. measures, accompanying all activities, We can and must urgently implement excellence through a new system There is, however, observational initiatives and improvements of perioperative care. The impact evidence that end-to-end systems in the system. can be measured frequently and thinking is effective in surgery and In Australia alone, it is estimated carefully. Subsequent iterations and perioperative care. The large National that even a 15 per cent reduction in new elements, such as enhanced Emergency Laparotomy Audit (NELA) postoperative complications will reduce primary care, can be added and their in the UK struggled to demonstrate costs by $1.2 billion a year. I suspect this impact measured. the impact of individual high-quality is a modest target. Advanced recovery A hospital partnering with one or elements (such as ICUs and consultants work at Royal Adelaide Hospital, in two others as Centres of Excellence can in theatre). However, the few centres effect a new end-to-end model, showed demonstrate small-scale high value and with a geriatric service demonstrated closer to an 80 per cent reduction in allow adoption over time, an approach a three-fold reduction in mortality. key complications and re-admissions, fundamental to implementation Undoubtedly geriatrics is essential for and costs, suggesting rapid impactful change is feasible. science. Use of clinical trials tools high-quality perioperative care of people and standards will ensure validity in the relevant age group. However, EXCELLENCE IS FEASIBLE, NOW of the findings. in my view, it is more likely that this It has taken the recent COVID crisis to A table of very senior healthcare phenomenon reflected centres with show us that rapid change in healthcare personnel at the Summit stated the resources and foresight to develop is possible. Remote access to patients; explicitly that someone should grab high-quality end-to-end systems, the rapid implementation of change the opportunity ‘by the b..ls’, no doubt magnifying the benefit of individual using teams skilled at, and designed paraphrasing another successful high-quality elements. for, innovation; and application of business enterprise’s catchphrase – Secondly, we must understand what high-acuity care in non-traditional ‘Just Do It’ (carefully). activities are important. The Summit settings with rapid staff upskilling; are If we don’t, now, who will? This is a report highlights the following as simple examples. Going back from what true pandemic – are we prepared to being beneficial: has worked recently, to the previous continue to live with the consequences? pattern of stagnation and resistance to • Genuinely understanding the The Summit’s roadmap for the future change, would be a lost opportunity. consumer’s wishes and expectations, has been released and is available at The large established business of https://thehiddenpandemic.com so the selected care is likely to achieve surgery and perioperative care faces a their desired outcome sudden challenge of cost and quality Dr Guy Ludbrook is Professor of • Early consistent and formal risk post-COVID, but has the opportunity to Anaesthesia at Royal Adelaide Hospital, and needs assessment – there is improve rapidly because: Head of Acute Care Medicine at the increasing evidence of the benefits • The roadmap on priorities and University of Adelaide and a practising of elements such as lifestyle change activities exists1 anaesthetist in the public and private (such as exercise and smoking) and • The end-to-end pathway exists, sectors, with postgraduate education in optimisation of comorbidities, but developed by the collective both business and economics. He will good lead times are needed professional Colleges2 discuss the Hidden Pandemic report, • Mechanisms to enhance decentralised • Individual elements of excellence and Advanced Recovery, in a (remotely care through community and primary are proven (cost and quality), and delivered) keynote address at the Evidence- care settings readily implementable – for example, Based Perioperative Medicine (EBPOM) remote preoperative care3 and • The pathways start with primary care meeting in London on 02 July 2020. advanced recovery3 1. https://thehiddenpandemic.com • Pathways and models of care must • Evidence exists for key quality 2. http://www.anzca.edu.au/about- be explicit, match patient needs, and endpoints: readmissions or days- anzca/perioperative-medicine 2 be based on evidence – pathways , at-home4 are reliable, available 3. https://bmcanesthesiol. and evidence for specific activities indicators of the quality of in- biomedcentral.com/articles/10.1186/ (in context), are now frequently hospital care s12871-015-0057; https://topmedtalk. adequately developed for jurisdictions • Electronic tools such as EMRs, and libsyn.com/topmedtalk-silent- to adopt My Health Record will assist data pandemic-of-surgical-complications • Visibility of decisions, goals and collection and analysis 4. https://bmjopen.bmj.com/ plans, as well as progression through • Validated electronic tools exist for content/7/8/e015828 the pathway, must be recorded and risk and comorbidity assessment – 5. https://riskcalculator.facs.org/ available to all stakeholders. e.g. NSQIP5 RiskCalculator/

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Mid-game review: ‘all played well’

AMA(SA) President Dr Chris Moy’s statement to the South Australian Legislative Council COVID-19 Response Committee on 21 May 2020 provided a careful but optimistic view of South Australia’s reaction to the coronavirus pandemic.

Dr Chris Moy during one of many media would firstly like to ask that and the principles of physical interviews during the pandemic all of my statements today are distancing, which have been so critical viewed through the lens of an in reducing the spread of COVID-19. front–line stakeholders providing ‘ appropriately wary doctor who My first practical involvement health services. doesI not feel that we can ‘count our regarding COVID-19 was when I This principle, I believe, became chickens before they hatch’ in the face contacted Chief Public Health Officer critical – because what has become of an infectious threat that still poses so Professor Nicola Spurrier on Monday, obvious is that dealing with a pandemic many uncertainties, and which we have 27 January 2020, following calls from is not a theoretical exercise, it is a been fighting for only a few months, GPs concerned about lack of PPE to be practical one which must consider the with the likelihood of this continuing able to carry out tests for ‘coronavirus’. practical issues of the front line. for some time to come. I proposed an idea of my father: to have a By listening and working well together However, I believe that South stand-alone testing unit such as the one with other groups, and with the support Australia has placed itself in the best in Westmead, Sydney. of and input from AMA(SA): position possible, even when compared I also suggested a need for resources • SA Health worked well to support with other states, and certainly when to support General Practitioners, which the close-knit Chinese community compared to other parts of the world, were beyond and at odds with what and the community of doctors in to have the greatest control of its I felt were inadequate and problematic South Australia, which mobilised destiny in re-emerging from a required Commonwealth resources at that time. early to implement measures such constriction of society, while ensuring as self-isolation before national the greatest chance of the protection of advice to do so the health of the community. …what has become • SA Health developed specific signs Again, without counting our chickens, for practices and clinics which were I can tell you that the way that the obvious is that dealing clearly superior to those in other states pandemic has been handled in South with a pandemic is not • SA Pathology developed an Australia, and our position on such a theoretical exercise … information sheet on how to take things as the reopening of elective a swab for coronavirus surgery, have been discussed with some An SA Health information session • On my urging, SA Health developed an envy in other states. for GPs supported by AMA(SA) was all-in-one flowchart for the frontline I believe that this has occurred due held on 30 January and attended by management of suspected coronavirus to several very much interdependent Professor Spurrier, the Director of the cases, which other states later factors here: Communicable Disease Control Branch, requested • recognition that decisions must be Dr Louise Flood, and the Clinical Service • SA Heath created an important based on science and evidence Director SA Pathology, Dr Tom Dodd. position of GP Liaison (Dr Danny • a follow-on understanding that you Despite a very tense meeting where Byrne and Dr Emily Kirkpatrick) which must give health experts the room to quite a few frustrations were voiced, has acted as the bridge between SA make the right decisions particularly by GPs of Chinese extraction Health and frontline GPs • a willingness of groups at all levels who had been managing so well the • from the GP Liaison office have come to work together and, instead of first group at high risk of bringing daily update and information emails bickering, just get on with the job for coronavirus to SA: individuals who had for GPs the sake of the community … travelled to or returned from China. • GP Webinars have been staged to • which, in turn, has allowed calm, Professor Spurrier (and SA Health) ensure GPs have the latest information clear, consistent communication took this on the chin and, instead of and can ask the questions and address to the community so that trust dismissing concerns and reverting the issues that for a while were has developed … to siloed thinking, chose to take all changing every day. • to which the public has responded well concerns seriously and work in a in a willingness to accept restrictions genuinely collaborative way with all ... continued on page 14

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Pandemic practising As ‘first responders’ during the pandemic, GPs have agilely introduced dramatic changes to their usual systems, writes Dr Bridget Sawyer.

very GP in South Australia had patients in addition to the financial to rapidly adapt to the changes support allowing us to keep our ECOVID-19 imposed on the way we practices running. consult, prescribe, provide home visits I found telehealth care to be a and care to aged-care facilities. No one valuable adjunct to routine face-to-face would describe it as an easy experience. consulting. The benefit of assessment Notwithstanding the difficulties, our via a video consult far outweighed that Dr Bridget Sawyer state public health response has been of a phone consult; it is so much more acknowledged country-wide as being valuable to see both your patient and to be seen to be part of the provision of of high quality, well-coordinated and their surroundings. holistic GP care. effectively led thanks to our state AMA Our GP practice maintained both While there have been difficulties routine consultations and video/phone President Dr Chris Moy, SA Health’s in the last few months there have also director Dr Tom Dodd and Chief Public consultations throughout the period of been advantages. I have welcomed Health Officer Professor Nicola Spurrier. lockdown. Those patients seeking face- the ease with which my specialist Keeping abreast of the constantly to-face consultations waited in their cars colleagues have assisted in my patient changing public health advice has been and were screened via phone call before care with phone discussions, and demanding but important because of a decision being made as to whether it reviews of imaging, ECGs or pathology the imperative of providing the most was appropriate to enter the building. up-to-date advice to patients who This was not perfect, despite best efforts, reports. Online learning has been looked to us as a reliable source of but overall it worked well. Most patients quickly embraced to speed us towards information and support. The consistent welcomed the opportunity to be in the necessary Quality Assuring and informative daily emails provided contact with their trusted GPs and were Continuing Professional Development by SA Health and the GP liaison team, very grateful for ongoing care. (QACPD) points. together with the weekly webinars I hope that telehealth, in some The COVID-19 pandemic has required hosted by AMA(SA), Royal Australian format, will be available through us to review the way we practise. These College of General Practice (RACGP) and Medicare in the future to complement changes are here to stay and this may Adelaide Public Health Network, have the hands-on care that we provide. be more valuable in the long term been a very valuable resource. I would I have been disappointed that some than we think. If, overall, we are all like to take this opportunity to thank have seen telehealth as a business more respectful of each other in the those involved in providing those emails opportunity as opposed to a means to future, in which ever medical discipline and webinars. ensure the ongoing wellbeing of the we work, that will be a positive and Further, the introduction of vulnerable, chronically ill, house‑bound important result. telehealth item numbers was an or disadvantaged. It’s not care to enormous contribution, allowing GPs be provided by any provider at the Dr Bridget Sawyer is chair of the AMA(SA) to provide the required care to our patient’s convenience, but it does need Committee of General Practice.

despite some of the most massive • the outstanding testing regime Mid-game review ... disruptions and realignments in the by SA Pathology, not only in ... continued from page 13 health system occurring with urgency – numbers but in the employment of the public takeover of private hospitals, innovative models These are a collaboration of SA Health, and the banning and then reinstatement • the closure of interstate borders AMA(SA), RACGP and Adelaide PHN of elective surgery – all occurring much • the combination of excellent and are attended by up to 700s GPs more smoothly and ahead of other leadership and the willingness of all groups to work together in a and practices which have been key states, many of which are still very in supporting GPs across the state in depoliticised way in just getting the job much at sea. responding to COVID-19. done for the sake of the community To end, I’d like to provide you with The good working relationships • the calm, clear communication have extended to the SA Health CEO the points that I gave to a newspaper to the community who have Chris McGowan, the Minister for Health reporter about the main reasons for responded brilliantly. Stephen Wade, the Premier Steven South Australia’s good results so far: Again, while not counting our Marshall, and also the Shadow Minister • the early efforts of the South chickens, if South Australia was a for Health Chris Picton. Australian Chinese community led footy team, for this first big game Constructive effective dialogues by a core group of GPs of Chinese the newspaper report would be behind the scenes have led to calmness extraction that ‘all played well’. 14 | medicSA ’ ???????????

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The good doctor

Nearly three decades as a South Australian general practitioner made AMA(SA) Councillor Dr Danny Byrne the logical choice as SA Health’s GP Liaison during the pandemic.

s a six-year-old Mildura Australia’s response to the schoolboy, Danny Byrne was COVID-19 pandemic. told by his mother, time and He has never questioned A younger Danny Byrne when Chandlers Hill time again, that he should be his calling. He married fellow Surgery was named the RACGP Australian Practice Aa doctor when he grew up. The young student Linda Foreman of the Year Danny never questioned the advice; at the beginning of his Since then, the RACGP has named rather, he recalls now, it became part of sixth year at medical school. They Chandlers Hill Surgery Australia’s who he was and who he would become. lived ‘a poor students’ life’, young and best practice in 1999 and South With his mother a nurse and father financially struggling, long hours and Australia’s best in 2010. In 2019, patient an entomologist, perhaps he would hard work, but, he says, enjoyable and feedback earned it the Number 1 have explored medicine as a career even challenging. He and Dr Foreman later rating among Australian practices without his mother’s urgings. Maths and worked together at Chandlers Hill for on health appointment booking the sciences were his favourite subjects 20 years before she left for a full-time site HealthEngine. at school, and even in art he was most role in palliative care. They have two ‘Over the years – and no thanks to fascinated by the discovery that yellow daughters, Sophie and Henrietta, now me – it’s become stronger and stronger,’ and blue together formed green. forging their own careers in arts and Dr Byrne says of the practice. ‘When But because of his mother’s insistence, anthropology respectively. I joined it had four consulting rooms; Dr Danny Byrne now ‘can’t remember now we have 11 rooms with 18 GPs, and ‘Finally you get to practise what you not wanting to be a doctor’; nor can he nurses and physiotherapy. We do minor learned academically,’ Dr Byrne says of remember ever considering a medical surgeries and iron infusions and skin his intern years. ‘Medicine really needs career beyond general practice. ‘Yet lesions. It’s a real medical home now.’ that apprenticeship model – I feel very I didn’t know what it meant to be a Dr Byrne says the hub model is one sorry for this year’s “pandemic” students doctor,’ he recalls. ‘I’ve never been a development he has supported in who have been forced to spend months patient, never had a stitch or broken recent years because of the time and just on bookwork.’ my arm. cost-saving benefits for patients; it He maintained his passion for general ‘Doctors were doctors, and I didn’t won’t be long, he says, until a patient know anything else. That seemed fine practice through the specialist rotations, will receive treatments such as to me.’ conscious that as a GP he would need chemotherapy and ultrasounds at their It is a calling that took him through ‘some knowledge about each one, but regular GP surgery. He has also watched medical school at the University of not a huge amount about any one’. as GPs are increasingly able to sub- Adelaide and then his internship, to the During the Family Medicine program, specialise, so they can provide services then-Family Medicine Program, during he was fortunate enough to spend time such as Type 2 diabetes treatments at which he moved every three months at The Parks, where GPs such as Paul Chandlers Hill that previously required – not every year, as current training Pers, Gavin Beaumont and Oliver Frank visits to the Flinders Medical Centre’s programs demand. showed him what to do and how it Endocrine Clinic. At the end of the program he was should be done. He has also been an early asked to join Chandlers Hill Surgery, ‘When you go to different practices and appreciative adopter of the where he has spent most of the past during your training, you can see what technological ‘efficiencies’ such as three decades. He has also spent a lot they’re like, how they’re different My Health Record and electronic of time educating GP trainees. Most and what’s important to you,’ he says. prescriptions that are transforming recently, in April, he was seconded to a ‘Chandlers Hill Surgery was a great Australian medicine; at the same time, critical role in SA Health as part of South practice with a really good reputation.’ he recognises their value is limited by

16 | medicSA the red tape that often limits the transfer present with and discuss mental health of documentation such as referrals issues – especially men – he says there between sites. ‘Medicine is often the are never enough resources devoted to easy bit,’ he says. ‘Working the system is mental health, or to the role GPs play often the hard bit. Everyone wants to do in helping patients receive the care the best by their patients, but if you don’t they need. know the ins and outs of the referral Now, in early June, with South system, it’s the patient who suffers.’ Australia’s success in battling the virus Over time, his own interests have demonstrated on a curve that ‘replicates developed with his patient cohort. (his) anxiety levels’, Dr Byrne is back He used to spend most of his time in his rooms at Chandlers Hill. He’s ensuring he had the latest information accustomed to the 25-minute trek on paediatrics and obstetrics at his south from his inner-city home each fingertips; now, consultations are mainly day; scarcely notices the drive if the about diabetes, heart complications and Spotify track or podcast sufficiently palliative care. captures his attention. He serves his ‘As a GP, your patients choose you. colleagues and his community as an And then, if they like you, they stay with AMA(SA) Councillor. He’s looking you. They age and you age,’ he says. ‘Any forward to returning to Adelaide Oval AMA(SA) Councillor Dr Danny Byrne doctor who’s been 25 or 30 years in the to watch the Crows. And, over the long one practice probably has those regular, term, he wants to perform the kind of ‘But the status of GPs now is lower. The loyal patients who’ve grown older mentoring role that doctors Beaumont, financial remuneration is lower. GPs with them.’ Frank and Pers did for him, ensuring are undervalued. Less satisfying is the increased that junior doctors want to be GPs and ‘This is an issue of having the best prevalence of mental health issues are trained to become good ones. ‘I’m patient care and rewarding that care. among GPs’ patients. Although he is happy with my career and position and We know patients get better faster when pleased that more people are willing to the life it’s given me,’ Dr Byrne says. good GPs are involved.’

RAH trial aims to test COVID-19 vaccine

esearchers from PARC Potential participants will undergo a Clinical Research at the Royal 45-minute screening session, including Adelaide Hospital are calling a review of their medical history and a for volunteers to screen for a blood test, to assess their suitability. Rpotential COVID-19 vaccine trial. PARC Clinical Research’s Professor Royal Adelaide Hospital Clinical Guy Ludbrook says early screening immunologist Dr Pravin Hissaria has already begun, to allow the trial to says people over the age of 18 are begin as soon as possible after the trial is encouraged to apply for a possible confirmed and the vaccine is available. trial that could result in an historic He says clinical trials on the medical breakthrough. development of new vaccines, ‘COVID-19 has had a devastating medicines, medical devices and systems impact on the world and that is unlikely of coordinated care – the focus of to change until we can find a permanent PARC Clinical Research efforts – have solution,’ Dr Hissaria says. repercussions across the health system, ‘A number of vaccines are showing including in avoiding post-operative PARC Clinical Research’s Professor promising results in animal models, complications (see page 10). Guy Ludbrook so we are excited at the prospect ‘The cross-fertilisation of vaccine of beginning human trials in research with PARC’s role in innovation Adelaide and including others in this is important, timely, and relevant,’ ‘By starting the initial screening exciting journey.’ Professor Ludbrook says. ‘We want process now, we will be able to start the Researchers are seeking about 100 South Australia to lead the way on the trial as soon as possible.’ healthy Adelaide-based adults who development of a COVID-19 vaccine, so Professor Ludbrook says the trial is would be interested in joining the first we would encourage anyone looking likely to run for six to nine months. phase of the vaccine trial that may start to play a part, to put their hand up and More information is expected to be later this year. get involved. available in coming weeks.

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Professor Nicola Spurrier Dr Tom Dodd Dr Samantha Mead Dr Danny Byrne In the room where it’s happening

ow has South Australia number of repatriated Australians –  SA appears to be one of the few emerged as a role model the South Australian Indian Medical places in the world where science and for how best to respond Association supported this by providing evidence led (virtually) every decision to a pandemic? medicSA GPs speaking nine different languages relating to a response. How did that Hasked some of the medical decision- – making it so much easier for us to happen and what difference did it makers what succeeded and what manage the various health issues make to the situation we’re in? they’ve learned. encountered by this group. NS: From a population perspective, Joining the conversation are: TD: There was a focus on solid our biggest hero is SA Pathology, which • Chief Medical Officer Professor and consistent problem-solving was able to ramp up testing so quickly. Nicola Spurrier (NS) methodology to many challenges Testing and case isolation were key • SA Pathology Clinical Service with short time frames. This approach to getting on top of the pandemic. Director Dr Tom Dodd (TD) was founded on good, whole-of- Even in the early days, SA Pathology was doing COVID-19 testing on every • AMA(SA) CEO Dr Samantha Mead (SM) system communication. respiratory swab. • SA Health GP Liaison and AMA(SA) SM: Coming into February we were We have also been fortunate to have Councillor Dr Danny Byrne (now urging the public to be alert, but academics at SAHMRI provide evidence- returned to private practice) (DB). not alarmed. based reviews on key topics (e.g., impact There were some questions that some In March it was clear that the spread of school closures on the pandemic). deemed outside their field of expertise. of the virus had to be slowed. The term At a national level, we have been  What was the mood in the health ‘flattening the curve’ became part of supported by a truly amazing group system in February, and how has our everyday vernacular. It was clear we of mathematical modellers who that changed over time? needed to move to shut down events have provided detailed jurisdictional NS: Our mood has always been very like the Grand Prix and yet there was a modelling to support our public health positive, at the beginning with a great reluctance to do so. actions. I have been surrounded by a deal of comradery and people willing to April saw significant changes to the wonderful team of public health and pitch in and do the hard yards. In April way we live and interact. Clear unified clinical experts including Dr Evan it was clear that we were starting to get messaging, community compliance and Everest, Dr Chris Lease, Dr Mike Cusack, on top of the numbers, and we had the a high-level of coronavirus testing all Dr Louise Flood, Dr Paddy Phillips and, health system in a relatively good place. lead to a sense of calm. at critical times, Dr Chris Baggoley. It was also clear that the SA community TD: In terms of pathology, SA Pathology May saw reasons to quietly celebrate were on board. May and into June has was prepared for a pandemic with perhaps been more difficult, but not with no new coronavirus being detected immediate testing capacity for 20,000 unexpectedly so. Keeping up messaging in the state. tests. SA Pathology rapidly responded to people to get tested and keep physical DB: In February in General Practice to the PPE shortage for GPs by setting distancing is still important, but perhaps the mood was fine. We were aware up the drive-through collection stations not so obvious for our community as we of the few cases overseas and – in fact, South Australia was one have had no new cases for such a long the interesting developments in China. of the earliest places in the world to time. We knew that making decisions In early March we had the Festival and do this. about lifting restrictions would be hard Fringe and WOMAD. It was only in SM: Scientific evidence in Australia is and that has been the experience. mid to late March that things began generally well received and the health A real bright spot for many of us was to become more real, more scary, and profession is trusted. Australians overall supporting the quarantining of a large more anxious. understand that the benefits of scientific

18 | medicSA COMBATTING CORONA

breakthroughs outweigh any deleterious In South Australia, we had early and Once the national consistency kicked effects. This general philosophy made broad testing and contact tracing. This in it was much easier to promote Australians willingly comply with was critical to establish the extent consistent messaging. the strict social changes necessary to of the spread and assist with case  What was the importance of testing protect the wider community. In the identification as well as contact tracing to SA’s response? health system there was an enormous and isolation The World Health Organisation amount of collaboration and things that NS: SM: Toilet paper aside, people on the urged countries to test, test, test to would normally take months to enact or whole were respectful of each other, control the virus and testing has been change were happening within hours. compliant with the health messaging the backbone of South Australia’s DB: We had excellent leadership from and courageous in time of great change response. We would not be in the Prof Brendan Murphy on the national and stress. The national response to position we are in today if it weren’t scene, Prof Nicola Spurrier locally and dealing with the virus was calm and for the quick and innovative response Dr Tom Dodd at SA Pathology. I presume clear, and we had the support of the from the team at SA Pathology. In early the politicians listened because this nation to bring about necessary change February, our laboratories established was a real crisis unfolding before our to save lives. local testing and we added the eyes with alarming real-time evidence DB: The response of the community novel coronavirus testing to routine from China, Iran, Italy and elsewhere of was outstanding. The Australian psyche respiratory infection testing through what was possibly going to happen here. was tuned in to saving the lives of GPs. While this not only made it a It was not a slow, unfolding issue like our elderly and most vulnerable more efficient and streamlined process global warming and climate change that rather than the economic cost. It was for GPs, it also meant we could rule can be manipulated and ignored - it was very gratifying to see. out any incidental links to COVID-19 real-time crazy real.  What were the flaws in the within the community. Once our testing  What were the strengths of the Australian and SA responses? capabilities were improved, we wanted Australian and SA responses? NS: Given that we have done so well, to make it easier for South Australians to get tested. We introduced a We shut the international borders I am not sure we can really find many NS: domiciliary service, dedicated COVID-19 early and so ‘turned off the tap’ of new flaws in the SA response, but we have clinics, and were among the first in cases. This was complemented early certainly learned things along the the world to establish a drive-through by requiring quarantine for interstate way. We had lots of concerns with clinic. While initially our testing was travellers. As the numbers have PPE supply in the beginning, mainly targeted to people who met the clinical dropped across Australia, we have been because of our reliance on overseas criteria, we were very excited to launch pleased to be able to drop some of these manufacture. Some states had trouble a testing blitz in mid-April to gauge the requirements. As noted above, the SA ramping up their testing to pandemic level of infection within the community. response was exceptional because of levels and there have been supply chain The blitz reiterated in my mind that the very early, high testing rates. While issues with pathology reagents. Our we had very little COVID-19 within some states have now caught up, our relationships with GPs have improved the community, which was a pleasing testing strategy has put us in our current over time and has been really helped by result. Overall, the extent, accessibility great position. This has been backed up having Dr Danny Byrne and Dr Emily and innovation of SA Pathology’s with meticulous contact tracing and Kirkpatrick employed in SA Health to testing throughout the pandemic has quarantining of close contacts. We also facilitate GP liaison. been world-leading and left us in very moved early to call-out hot spots such TD: There were no flaws, but good stead. as the Barossa, limiting travel into and it is interesting to note that out of this area and ramping up testing Australia is very dependent on TD: This was very important to establish locally. The management of the Adelaide many international medical supplies. the extent of the spread and assist with Airport was also a highlight – it showed SM: There was a real fear that there case identification and contact tracing the importance of partnering with major would not be enough PPE to protect and isolation. companies such as Qantas. Turning doctors and other healthcare workers.  If you could change one action back a flight from Sydney one evening I am pleased to see that Australian between 27 January and 9 June, was certainly not without stress but was companies have come on board to make what would it be? done with close weighing up of public quality locally produced PPE to ensure DB: Close the international arrivals to health risks. We have also maintained there is fit- for-purpose equipment in all countries. We were quick on China a very strong partnership with our the future. and Iran but too slow on Italy and US. colleagues in SAPOL. This has been of DB: Easy to say this in hindsight but we And cruise ships - no way next time. key importance in terms of writing and did not have enough PPE for the whole They must be the first to shut down! rewriting the Directions, and of course health system. I think General Practice SM: I guess this depends on what state enforcing the Directions. SAPOL has has to realise that they need to be of Australia you live in. If you asked done a tremendous job with a relatively self-sufficient and better prepared on a someone in NSW, they might refer to light touch. local individual level. The few practices the disembarkation of 2,600 passengers TD: Australia and South Australia that had their own prepared stored PPE from the Ruby Princess cruise ship. were fortunate because of a strong supplies were at a major advantage. From my point of view it became clear government response at both levels The thought that you can just rely on that we knew we had to stop many of of government, including closing government is not realistic any more. the things we enjoy, like sport or dining our borders and implementing The other issue in the early days was social restrictions. the mixed messages from each state. ... continued on page 21

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A specialist’s story

The COVID-19 pandemic has hit every South Australian doctor in unique – but also shared – ways. AMA(SA) Councillor and haematologist Dr Shriram Nath provides his perspective.

came to know about coronavirus decreased while phone consults when it was announced in increased. Some of my patients wanted faraway mainland China. I felt to discuss with me ‘flatten the curve’ that pandemics similar to the and ‘R-value’. One of my elderly, long- Dr Shriram Nath Icoronavirus had been contained within term patients told me on the phone China in the past and that this would that he and his wife had been ‘read initially a technology challenge but occur with the coronavirus, too. Every the riot act’ by his children so they became the norm of the day. Gaining year the Chinese New Year changes and were remaining within the confines knowledge without the hassle of travel a new virus emerges and subsides. Life of their home awaiting for things to was welcome. outside China seemed to be going on improve. Returning Ruby Princess Private hospitals struck agreements at a steady pace. I had no idea what is cruise passengers and close contacts with government for nursing staff going to hit me in the coming days. I had of COVID-19 on the aeroplane to and beds. But individual private no prior experience to prepare me for Adelaide narrated their experience of practitioners and practices such as the ship and the quarantine process. the change. pathology and radiology services There was anger and helplessness – but In early March 2020, the pandemic were not included in the agreements. started to spread beyond the shores also hope. Once the curve started to The only employment option was of China. I received an email from the flatten, everyone saw the reason for to enrol in the SA Heath COVID-19 organisers of a thrombosis conference their efforts. health recruitment drive for private to be held in Singapore in May 2020, practitioners, and possibly gain telling me that the conference had ... the only employment if required during been cancelled due to the coronavirus. employment option the pandemic. Various medical I started to realise that the virus was indemnity insurance companies going to affect me and change my life. was to enrol in the were contacted to clarify the status Soon, Australia’s Prime Minister SA Heath COVID-19 of treating public patients in private announced that air flights from various hospitals. SA Pathology was given a parts of the world were being cancelled. health recruitment Various experts appeared on television drive for private lifeline by the government during the pandemic, which was a relief. Clinpath and radio, predicting what the path practitioners ... forward would be. Businesses were Laboratories joined the battle with COVID-19 testing. ‘We are in it together’ closed as virus cases came to light in Meanwhile, for us, even though Australia. I realised I was in the health patients were not in the clinic, was the sentiment. sector, running a small business. Will I administration tasks and time The lack of personal protective survive the pandemic? Will my business remained the same. Arranging equipment (PPE) led to the and its two staff survive? Preparations follow-up radiology, blood tests, and closure of elective theatre lists. started, searching for masks. Everything appointments with other specialists, Opthalmology clinics were closed. was in short supply, even (especially) hospital admission and getting back to Medical practitioners and practices toilet paper. The practice had difficulty the patient on the phone was a different were exploring the government’s sourcing masks and hand wash. ‘Social experience. Telehealth and phone JobKeeper allowances and cash-flow distancing’ and ‘flatten the curve’ consults had become the new norm support programs. dominated our language. and possible because phone lines were Taking rounds in hospitals was People listened to the Prime Minister working. No electricity shortages were different. Temperature checks were and the Chief Medical Officer. They noted. Stamps were not in short supply. performed on doctors as we entered, stayed home, postponed going to their Australia Post was used to send follow- stickers stuck on our clothes, visitors General Practitioners. Community up blood test forms to patients. restricted. PPE equipment like masks blood tests decreased. Diagnosis Conferences were cancelled. Zoom/ was kept under lock and key as they of haematological problems was Microsoft team meetings became were in such short supply. Everyone was postponed, along with that of other a norm. Listening to international aware that they must save PPE. Some problems. Sitting in the doctor’s chair speakers in my pyjamas (because of hospital coffee shops were closed by was a different feeling. The number time differences) was not so boring. their franchise owners. Others offered of patients turning up to the clinic Multidisciplinary meetings were takeaway, so we could inhale vital

20 | medicSA caffeine but not sit in the coffee shop South Australia continues to record no and share a discussion with a colleague. new cases. Social distancing applied to travelling I have adopted the motto ‘The aim in lifts, with two per ride. Consultation of 2020 is to survive, and all the rest is was limited to having the patient in a bonus’, as a famous person said. My the room and using technology to business, staff and I survived March, include relatives in the discussion. April and May largely due to the support Theatres were empty with only of my patients, and colleagues; my GP; emergency operations and procedures my family and my faith. ‘Australia is a being performed. lucky country’ is making sense for the And all through this, there was first time. With luck and continued the fear of the unknown. The fear of good management, we will remain so. contracting COVID-19 and not able to deliver health care was always on AMA(SA) Councillor Dr Shriram Nath my mind. is a clinical haematologist consulting at Now, as I write this, the situation Adelaide Haematology and in hospitals, has improved, restrictions are being and also works at Clinpath Laboratory relaxed, people are feeling a lot better as in Adelaide.

Australians. In January we faced an has put us in a very good position for any In the room where unknown future and we had to make further outbreaks in the future. it's happening ... changes quickly to protect the health of SM: Rather than learned I would our community. I didn’t expect such a ... continued from page 19 say reinforced. It reinforced that our positive response from the community. health system can be nimble and work out, but slowing the spread also meant I have been overwhelmed at the letters collaboratively to ensure massive change slowing the economy and there was a and emails of thanks I have received in minimal time. pivotal time when we could have closed throughout the pandemic. DB: Not for me to say but I really hope SA things down earlier. TD: I appreciated the collegiate approach Health learned that bringing in Liaison  If there is one outstanding benefit of all involved, from members of the GPs (Dr Emily Kirkpatrick and me) was to have emerged from the pandemic, public to the people required to make a very clever move and they would do what is it? essential health decisions very quickly. the same again next time. The positive NS: The health system has worked SM: I have learned a lot. The past couple feedback from grassroots GPs to the remarkably well together throughout the of months made me reflect on how service we provided has been humbling pandemic. From weekly webinars with stretched for time I had been. Moving and overwhelming. GPs through to daily communication from meeting to meeting or children’s  How strongly should the AMA push across the public and private sector and sporting events meant that I was for a national Centre for Disease Residential Aged Care Facilities, the constantly on the go. Everyone being Control (CDC)? engagement, cohesion and cooperation forced to use technology to get things across all sectors involved has been a done has been a real positive. TD: South Australia’s success benefit not only internally but to all highlights the important role of the SA DB: We can act quickly and rationally South Australians. I hope we continue Communicable Diseases Control Branch. when we must if we have the right to work in a much more aligned and people in charge. I also learned that SM: Australia is the only OECD country consistent approach from here on in. some people still wanted to do ‘business without a national centre for disease TD: The creation of the GP liaison role in as usual’ with committees and meetings, control. In the case of coronavirus, SA Health. which was just not OK in a crisis. How we seem to have taken control of the spread of this virus despite not having SM: It is understanding that we can we all reacted personally when we were a CDC and so there might be those move quickly by whatever means to genuinely in a crisis is understandable – who say 'why is a CDC necessary?'. But enact change for the greater good. it brought out the best in most people. for me having a CDC is a no brainer. DB: For General Practice, the use of What has the SA health system learned? After witnessing what has occurred telehealth. It seemed like 10 years of NS: During the pandemic, the health globally because of coronavirus lobbying and wish-lists for common- system was forced to adapt rapidly and it would seem inexplicable to not sense use of telehealth came into respond very quickly to an ever-changing establish a body to, among other things, being overnight. situation. These are the characteristics gather data to predict and monitor  What have you learned – about that we want to take forward into our public-health threats, and accelerate yourself, about the system, about business as usual approach as we build information flows. human behaviour? a dynamic and world-leading health DB: The AMA should be lobbying for a NS: The system – covered above system. From our hospitals to our CDC now – and as strongly as possible. and below. Communicable Disease Control Branch, A pandemic will happen again, and we I have been amazed at the cooperation, the system has learned to work very well need better national coordination from generosity and compliance of South together and the excellent work so far the start next time.

medicSA | 21 COMBATTING CORONA

A model for future pandemics Orthopaedic surgeon Professor Ted Mah is determined that the challenges endured in this pandemic will provide lessons for the future.

he worst of the pandemic may conducted by phone and junior doctors local manufacturers that rushed to be over but there is more to do to continued to train. produce PPE in response to government overcome time lost for patients But cancelling elective surgery had subsidies were likely to be stuck with an and to evaluate the COVID-19 caused ongoing problems that would oversupply. ‘Once all our hospitals are Tstrategies for future emergencies, says continue for months and possibly years. fully stocked with PPE, Australia should the Head of Orthopaedics at Northern ‘Because of the restrictions in donate surplus PPE to other areas of Adelaide Local Health Network providing clinical services for patients, need, places like Africa, parts of Asia or (NALHN), Professor Ted Mah. there is much longer waiting time,’ Pacific Islands,’ he suggests. Professor Mah says that having Professor Mah says. ‘Nothing has Managing the private health managed contingencies from shortages changed in the public hospitals. The fact insurance fall-out associated with mass to potential infections among staff, you don’t see 50 patients a day in a clinic unemployment will also be an issue, medical teams now have a solid doesn’t mean they’ve gone away. They Professor Mah says. He suggests some blueprint for future pandemic responses are just backed up in the hospital queue. people will stop paying for private ‘We already have a lengthy waiting health insurance, while others without – one he’s keen to share with colleagues. time for the Orthopaedic Outpatients insurance will defer treatment because ‘This won’t be the last pandemic Department even before the COVID-19 they can’t afford it. we experience and there is a lot we crisis started, and now, after four ‘People will rush to have surgery can learn. We need to identify what months, we have even more people before their private health cover expires, works and what doesn’t, and to create on the waiting list. Patients still need but they are unlikely to renew their a template as a way to safeguard the treatments irrespective of COVID, private cover,’ he predicts. ‘There’ll be future,’ Professor Mah says. and this is the social price that our fewer people who can afford to take on With careful planning and community has to pay.’ private health insurance, if they have lost management of personal protective Imported supplies such as their employment. equipment (PPE), emergency medications were limited by air ‘The government could consider orthopaedic surgery had continued transport restrictions, creating further providing some tax concessions for throughout the pandemic, he says. delays in ramping up elective surgery, people paying private health fund to Outpatient consultations were Professor Mah says. At the same time, prevent job losses in private health

22 | medicSA COMBATTING CORONA

providers and reduce the burden on • Day-case surgeries where possible, Team 3 – later became the Modbury public hospitals. aiming for early discharge and single- team. Initially this was the standby ‘The government should also consider staged surgeries (clean) team. increasing the Medicare rebate. At the • Surgical interventions if their Interns – all interns attended hospital moment, patients have to pay a gap documented effects are superior to daily and rotated with the RMOs for because the rebate has not kept up with non-operative management. Benefits cover shifts. inflation over the past 20-plus years. and harms discussed with patients. Where allocated OT sessions were ‘After the JobKeeper scheme finishes Elective lists cancelled, consultants came to the later in the year, why don’t we consider Only Category 1 or time-expired cases, hospital to provide leadership and putting some of that money into health with a surgical review committee to to support Junior Medical Officers care?’ screen and prioritise cases. where possible. Registrars to remain in their current rotation until 2021 BATTLE BLUEPRINT Outpatients to ensure they achieve the required • Waiting rooms redesigned to follow Professor Ted Mah and his colleagues clinical experience. developed what they call an ‘Orthopaedic distancing rules Surgery Pandemic Blueprint’ that he’s • Patients screened and relatives advised PPE keen to share to support preparations for not to accompany patient to the All gowns, masks, face shields, wipes future outbreaks. consulting rooms unless absolutely and alcohol gels were kept in secure areas. Supplies of PPE were initially low Key plans included: necessary • Most consultations conducted by but weekly ordering was implemented • Promote and ensure staff and patient based on demand and increased safety phone • Consultants rostered to Outpatients manufacturing, which meant the • Inform staff about evolving clinical shortage was short-lived. guidelines and assess institutional Department (OPD) (either in person Nursing staff capacity or on phone) to provide immediate advice on treatment plans and reduce Nursing staff used appropriate • Develop clear policies for airway the need for patients to return to OPD. PPE when required and ensured management in known or suspected • All registrars to treat trauma/ they maintained their hand hygiene. COVID-19 patients emergency referrals/patients via Where possible, they carried out • Maximise patient wellbeing to allow telephone consult, with consultant duties while maintaining distancing. early discharge advice where possible The arthroplasty education sessions • Establish rotating teams that • Clinicians advised to use splints rather that nurses run with physios were communicate regularly but can work than plasters or backslab. temporarily cancelled. in isolation Medical staff teaching • Enable senior consultants to support Older patients from residential care Patients with suspicious symptoms Weekly Zoom teaching sessions and advise junior medical officers such as coughs were swabbed for replaced face-to-face from March 2020. • Engage department staff for meetings COVID-19 in the Emergency Department Face-to-face teaching resumed with and teaching via videoconferencing and treated as planned if indicated. relaxing of restrictions, but with physical • Postpone elective surgery and plan for Those confirmed with COVID-19 were distancing and Zoom as an option. phased return transferred to the COVID-19 designated Working from home • Introduce telephone and telehealth hospital (the RAH). Staff working from home were consults where appropriate Teams asked to provide brief logs or • Aim to continue acute orthopaedic Surgical teams were split into three descriptions of their activities, e.g. admissions where possible (these rotating teams that would communicate telephone consultations, telephone were only slightly reduced from across teams by phone, Zoom or supervision/teaching, mandatory pre‑COVID). Microsoft Teams. training, professional development and research, etc. Emergency procedures Two teams performed different duties The following measures were introduced and one team remained at home, ready Telehealth for emergency surgery: to step in if a member of one of the other From late May 2020 telehealth • A protocol for senior consultants to teams was exposed to COVID-19. These templates commenced, including prioritise surgery cases first thing in teams were rotated. approximately one third face-to-face, the morning Team 1 was responsible for one third telephone consultation, and • Clear policies for airway management ward rounds and in-patient care, one third telehealth in all orthopaedic in known/suspected COVID-19 emergency theatres. outpatient departments. patients Team 2 was responsible for the Waiting lists • Dedicated COVID-19 or modified Modbury Private Hospital and Lyell Phased return of elective surgery operating room: 1) away from high McEwin Hospital outpatient clinics. planned, including potentially traffic areas; 2) with few people Clinics were reduced and mainly outsourcing procedures to appropriate present during anaesthetic induction conducted by phone. Team 2 triaged private hospitals to help to clear and extubation; 3) negative pressure all emergency department referrals in the backlog. where available (positive pressure and the mornings. Health and Wellbeing air conditioning switched off) The overnight registrar could All staff was reminded to rest well, eat • Independent flow pathways for traffic be from Team 1 or Team 2 - daily well and practice vigilant hand washing, in and out of designated COVID-19 handover was via Zoom at 7.30 am with social distancing and if appropriate use operating theatres consultant input. gloves, gowns and masks.

medicSA | 23 COMBATTING CORONA

Loud call for telehealth

COVID-19 has finally released the telehealth genie from the bottle.

ith some recalibrations where appropriate is here to stay. measurements, as well as photographs, and a newfound impetus Everyone will fight for it, including the which can feed directly into the app to develop technology, the consumer groups that are behind it. to be sent to their doctors in real time telehealth innovations ‘I think people see now that it’s and securely. Wintroduced during the pandemic could ridiculous to make people come in ‘In addition, we’ve implemented have great benefits for patients and for consults that could be handled via technology to send prescriptions change the way health is delivered, says video or over the phone, which is what electronically – we’re just waiting for the AMA(SA) President Dr Chris Moy. Medicare requirements have artificially legislation to be finalised.’ Dr Moy represented the AMA forced for so long.’ At the same time, he says, there federally on the initial 2010 Department However, Dr Moy says, there have will need to be regulatory changes to of Health and Ageing Telehealth been problems, primarily because the prevent the unethical behaviour that Advisory Group and is a Clinical Medicare items were created quickly to has already emerged: pop-up telehealth Reference Lead for the Australian Digital respond to immediate need. services including those promoted by Health Agency. He says that progress on ‘Because there had been no progress pharmacies that advertise telehealth achieving a Medicare rebate for video with these items, we weren’t ready services solely to provide prescriptions. consultations had largely stalled for with the technology,’ Dr Moy says. ‘The ‘These cases represent a perverse 10 years due to hesitancy within the crisis has forced this and that’s been “tail wagging the dog” and totally Department of Health. a good thing.’ contradict the principle of doctors only ‘COVID-19 forced the hand of the He says that while video technology prescribing based on clinical need,’ Dr Federal Government in implementing apps such as Zoom, Skype Facetime and Moy says. ‘The telehealth item numbers temporary Medicare rebates for WhatsApp do not yet technically meet will have to be adjusted to minimise telehealth services,’ Dr Moy says. privacy requirements, the introduction this inappropriate and unconscionable ‘Telehealth consultations were never of telehealth item numbers will prompt behaviour, to ensure telehealth is meant to replace face-to-face – you developers to produce appropriate used only as a part of providing can’t set a broken arm or lance a boil via health apps that will be easy for both high‑quality care. telehealth. But during the pandemic, practitioners and patients to use and ‘It’s the 21st century. We have the it reduced the possibility of COVID-19 connect with each other. technology. But we also have many spread by decreasing physical contact ‘In the future,' he says 'you can expect patients suffering from chronic and reserving face-to-face consultations to see family practices using software illnesses. Telehealth will be particularly for when they were necessary. and apps that enable their patients important for people with mobility or Otherwise, if a patient came into a clinic to consult much more seamlessly transport challenges or people living with the virus, you would have to close with their doctors electronically – in rural areas. It will also help reduce the whole place and isolate all staff. while ensuring improved privacy and infections if COVID-19 remains a threat ‘Now that patients have had their eyes security – so that they’ll get a message to community health. opened to the advantages of telehealth telling them that the doctor is about to ‘We should encourage people to only – especially those with mobility call them. come in if they want to or have to, while problems such as the aged or those with ‘Patients may even be able to ensuring the highest quality of health disabilities – the option to use telehealth take their blood pressure and other care. That’s the future.’

24 | medicSA ???????????

The lighter side of telehealth

Dr Michelle Atchison has found that telehealth has produced some unusual consultations – including at Bunnings.

sychiatry had been a major many consultations while people telehealth would know, the number of up-taker of telehealth before are driving somewhere in their car. close-ups of nasal passages, ears and the coronavirus and was That is okay, (kind of), until the recent under-chins is incredible. One sensible using it to good effect to give consultation where someone propped patient used a selfie stick and I would Pconsultations to rural and remote areas. their phone up on the dashboard have to say it gave a very good picture. The coronavirus took us all by surprise, and tried to say it was alright to do a Telehealth also allows the doctor with a rapid uptake of telehealth for Facetime call as they were driving! I to consult in a different way. We are all consultations. I think it took some have had consultations while people all far more aware of our hair (which patients by surprise as well! As is the are out walking their dog, digging in the was a problem when we couldn’t go case for many doctors, I have had to garden or cooking. Having a psychiatric to hairdressers) and what is behind us use the telehealth platforms that were consultation where I later find out the on a videocall. Unlike Zoom, none of easily accessible and which patients person is walking through the shops, the platforms I was using have virtual felt comfortable with. This has meant a especially Bunnings, has become backgrounds, so having my familiar number of consultations by Facetime, common. Many patients have had to office painting behind me I hope gave Skype and WhatsApp. retreat to a car, or one to a caravan in some sense of connection back to my Not all consultations have gone their yard, to have privacy for their calls. office for patients who were missing to plan. As time has gone on, it has While the nice part of telehealth video coming in. I have been very grateful that seemed as though some patients have consultations is that I often am able I can wear my ugg boots to work in this forgotten the meaning of a consultation. to walk around a person’s house or a recent cold snap with no judgement. A number of times I have called, only look at their dog or children, there are At least I have had more on than to take the patient by seeming surprise. some sights that can’t be unseen. One just my bra! (We do remind patients the day before woman finally worked out how to use by text that they have an appointment). Facetime, only for me to see them sitting AMA(SA) Vice President Michelle Atchison During this COVID time I have done there in only their bra! As anyone doing is a psychiatrist in private practice.

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The greatest relief Innovative support has helped consumers of palliative care in the pandemic.

hey say it takes a village to raise or by generalist palliative care,’ a child and, equally, it often Dr Holden says. takes a community to make ‘Some of the issues identified by the end-of-life experience patients and carers in a state-wide Tcomfortable for terminally ill patients workshop last year include the need and their families. for access to services, particularly Palliative Care Clinical Network Clinical And for this to happen, there need after-hours support. Patients and their Lead Dr David Holden to be seamless support and transition families are looking for easier access between services –not always easy given to resourcing to help them support the such as GPs, nurse practitioners, and the complex web of federal, state and loved one in the site they want to be.’ palliative care community nurses. community services involved. Dr Holden says the committee is ‘In telehealth, for example, That’s why the new Statewide building on collaboration between particularly with the restrictions and Palliative Care Clinical Network the state and federal governments limitations around visitation during Steering Committee, formed in late in the $7.65 million Agreement on COVID-19, we’ve seen extensive uptake 2019, includes clinicians, community Comprehensive Palliative and Aged of telehealth to provide support Care and the state government’s service providers and consumers, with for patients with an emphasis on $16 million palliative care election a strong co-design focus to improve the supporting rural colleagues. Face-to- commitment. SA Health is expanding consumer experience. face visits still occur but these have community outreach services to provide Palliative Care Clinical Network been supplemented and replaced with a 24/7 service and a phoneline to help Clinical Lead Dr David Holden says the telephone and video telehealth. 19-member committee, created under clinicians access specialist support has been created. ‘Caring-at-home kits have also been the auspices of SA Health’s Commission developed, and fact sheets for on Excellence and Innovation pharmacological and non- in Health (CEIH), has the pharmacological symptom consumer links necessary to management have been ensure service providers can particularly helpful in rural offer the seamless support settings where 24/7 services are people need. difficult to provide.’ Dr Holden says there is Dr Holden says the Rural opportunity for the committee Support Service, SA Health, to improve the experience CIEH and AMA(SA) have been and outcomes of palliative very supportive in advocating for care for consumers, carers a consumer-focused approach to and the community, whether at home, in residential care palliative care. or assisted living, or in the ‘I am also thankful that there hospital system. is an approach to palliative ‘What you find is that by care that considers not only the taking the consumer lens, it medical needs but the broader community aspects – for example, helps us collaborate around a common Dr Holden points to recent research through advance care planning and goal,’ he says. by Palliative Care Australia that found grief and bereavement support,’ Dr Holden says the committee has that community support for advance started a co-design process that uses care planning, which captures a person’s Dr Holden says. creative design thinking from the end- values and beliefs to inform medical ‘There is a lot of great work to be user’s perspective to develop a cohesive, decision making, is valuable for the thankful for around palliative care. interdisciplinary service plan. Sub- individual and the family and creates There are still some significant committees focus on factors such as economic benefit for the community. issues to tackle, though, including grief and bereavement, core medicines, ‘There is growing recognition around workforce and education, not only in Aboriginal palliative care and rural the need to support palliative care,’ he the specialist services but recognising support services. says. ‘In a short time we’ve seen some the role of palliative care in the whole ‘There is a recognition that specialist great examples of collaboration in this health system … (and) that different palliative care has an important role in space and there has been a range of new community members will require supporting generalist palliative care, supports to improve the experience different levels of support from but most is provided in the community of consumers, families and clinicians different services.’

medicSA | 27 Your mental health matters

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28 | medicSA COMBATTING CORONA

Planning has been centralised within government, with insufficient Protecting the vulnerable involvement of the primary health care services on the ground, with local public Close attention has been paid to managing the needs health and socio-cultural knowledge, of vulnerable Aboriginal communities during the which should be informing the planning processes. pandemic, write Shane Mohor and David Scrimgeour. This reluctance of government to engage with and respond to Aboriginal organisations is exacerbated by the fact ustralia, and South Australia processes to appropriately manage that the Aboriginal Health Division in particular, has done patient flow with physical distancing, within SA Health has been cut back in well with the public health triage and to identify suspected cases recent years, leaving it under-resourced response to the global and facilitate timely testing. and unable to provide the direction Apandemic of SARs-CoV2. There were some initial difficulties and leadership required (despite Border closures, widespread in obtaining personal protective valiant efforts by the overworked testing, active contact tracing, and equipment (PPE) from Primary Health personnel involved). measures to limit viral transmission Networks, but the Aboriginal Health A South Australian Aboriginal have flattened the curve to the extent Council of SA (AHCSA) worked with SA Communities COVID-19 Action Plan is that in South Australia, at least for Health to ensure a direct supply of PPE yet to be finalised. When completed it the time being, there is apparently no from the state’s stockpile to Aboriginal will provide a state-wide framework, community transmission. community-controlled health services. but it is critical that detailed planning Three months ago, with the initial AHCSA has also worked with progresses now at the regional/local community level. While this has wave of infections, there were legitimate these services to assist with planning happened to some extent (mainly concerns that Aboriginal communities and training to ensure that best- within the Aboriginal community- would suffer disproportionately from practice infection control policies controlled sector with little government the pandemic. are implemented. involvement) there are no detailed High levels of poverty, overcrowded Like many other primary health care response plans outlining support housing and homelessness in a highly services, Aboriginal health services requirements and clearly defined roles mobile population increase the risk of increased their use of telehealth. In and responsibilities. widespread transmission, and higher fact many Aboriginal health services rates of chronic diseases and other co- Importantly, this includes detailing had been using forms of telehealth for morbidities increase the risk of severe the role played by SA Health and the years (especially in remote communities disease and death. State Control supporting agencies where there may not be a GP on-site The spread of COVID-19 in Australia to enable a rapid, effective outbreak at all times), but without the benefit has meant that, so far, these fears have response. And while remote of Medicare rebates, so the recent not been realised, with no cases yet communities are a priority, given the introduction of telehealth rebates was reported in Aboriginal people in remote potential for a greater health impact viewed by these services as well overdue. or very remote parts of Australia, and no from an uncontrolled outbreak, this Another important development has Aboriginal deaths from COVID-19. work also needs to be undertaken in been the introduction of Point-of-Care However, the vulnerabilities remain. non-remote Aboriginal communities. testing for COVID-19 in some Aboriginal With the easing of restrictions, This local-level planning is especially health services. This is a response to the cases of COVID-19 will inevitably urgent as we move to ease restrictions recognition that in more remote areas, re-emerge and there is the possibility for the general population as well waiting for a swab result can take a week of the introduction of the infection as easing restrictions for Aboriginal into Aboriginal communities, with or longer, with the patient often unable communities, which are part of the potentially devastating consequences. to adequately self-isolate during this Biosecurity Act Determination. The The current period of quiescence in period and potentially infecting many ability to manage a COVID-19 case the pandemic at least allows steps to others if positive. rapidly to prevent and contain an be consolidated to minimise the risk of The Commonwealth Government has outbreak will be critical in supporting this happening. funded a national program to establish communities to manage these risks and The Aboriginal health sector, and Point-of-Care testing in selected rural to minimise future outbreaks. other Aboriginal organisations, were and remote Aboriginal health services, Without a more effective and inclusive proactive early in the pandemic in including in South Australia. This has response from the South Australian introducing preventive measures. Some reduced the waiting time for swab Government involving Aboriginal Aboriginal community organisations in results to about an hour. leaders and organisations, there is South Australia introduced restrictions Despite these positive developments, ongoing potential for a significant on travel to and from their communities many Aboriginal health services mortality rate from COVID-19 among before the Commonwealth Government continue to have legitimate concerns South Australian Aboriginal people. amended the Biosecurity Act to further that more remains to be done, and Black lives matter here, too. support these restrictions. to express frustration that there has South Australia’s Aboriginal health been an inadequate response from Shane Mohor is CEO and David services moved quickly to update their state government departments to Scrimgeour a Public Health Medical Officer pandemic plans ensure policies and these concerns. at the Aboriginal Health Council of SA.

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Collaboration the legacy of COVID-19 The ‘one for all’ attitude that doctors are demonstrating must be a lesson from the crisis.

s a profession, surgery has a information in future. reputation for being highly Doctors from all over competitive (not to say the world were looking cut‑throat). beyond self-interest, AYet South Australia’s COVID-19 sharing data and response has brought the profession strategies in on-line in the state together in a rapid and forums across multiple constructive way to protect the local time zones for the community, says vascular surgeon Dr common good. Peter Subramaniam. And while there From the vantage point as a medical have been stories about Surgery in the pandemic has demanded co-operation lead in the surgery program at Central the theft of personal between all health practitioners Adelaide Local Health Network (CALHN), protective equipment as well as a vascular surgeon in private (PPE) and hoarding, he says that for the in surgery but also across all medical practice, Dr Subramaniam has a bird’s eye most part, the crisis had ‘brought out the specialties and community care,’ he says. view of the impact of the pandemic on best in people’. ‘We have now experienced something the profession. Surgeons had generally accepted, that other countries experience all He admits it has been personally with good grace, the hit to private the time: infectious disease with no challenging on many fronts: as one of practice caused when elective surgery antibiotics to treat it, no health care many clinicians contributing to rapid was suspended to preserve a precious facilities. We have everything but, as decision-making in the South Australian PPE supply in anticipation of a surge a community, we are reeling because public health system, as a private of demand. we have never been in [a pandemic practitioner, as the father of teenage Surgery at CALHN rapidly developed situation] ourselves – we have just read children at university and senior school, a simple algorithm to find the balance about it. and as a son whose 91-year-old father between essential and non-essential ‘Now we have some experiences, we lives in Malaysia. surgery: surgery would be conducted if it need to do something with it. I am very Yet, he says, there is cautious optimism interested in the impact this has on the were in the best interests of the patient, about the COVID-19 response. next generation of doctors, nurses and if it could be conducted safely for the South Australia’s health care system, health care workers.’ patient and the staff, and if it were of already in a strong position before the Dr Subramaniam hopes a sense of community value. crisis, would be even stronger, he says. interdependence across the community Meantime, private surgical practices ‘What we have realised is that will become the new norm, along with a had kept their doors open where we (surgeons) have a reputation as commitment to ongoing improvements possible, providing reassurance as much competitive individuals - but when to systems, rapid access to scientific as clinical care in physical consultations the chips are down, as they have been, data – and continual handwashing. we’ve been able to band together, easily and via telehealth to patients who ‘I think the crisis has brought out and with a sense of a common goal,’ Dr needed it. the best in in the medical profession,’ Subramaniam says. Yet some difficult decisions had been he says. ‘People have died in Australia, ‘For us in CALHN, we were on a necessary, nearly spelling the end for thousands have died across the world; process of financial recovery. We had many private and small community I think it is a big cliché to say this, but put some measures in place to make us hospitals before governments waded those deaths should not be without some more accountable and, in some respects, in with emergency support packages learning for all of us…. we have realised COVID-19 has accelerated that process. to preserve the delicate public/private how capable we are to deal with it and It has given us unity of purpose; it has ecosystem on which Australian health that’s a strength. brought us together – not only surgery care depends. 'There is a quote that really impressed in CALHN but as a medical community This was thanks in no small part me from the President of the World and not just within Australia but to lobbying by the AMA, Health Organisation, just after America internationally.’ Dr Subramaniam says. withdrew funding. He said: “This virus is He says the crisis has highlighted the ‘We are now reflecting on how to bring a very dangerous virus because it infects interdependence of health, community us together, and when we are through the space between us”. and financial systems in a way that this, how we retain some parts of that ‘That is true – but here, we’ve done well would encourage people to better share thinking to develop a “new normal” because we have supported each other.’

medicSA | 31 AMA supporting DiTs during COVID-19 response The AMA has been working to ensure that both patient and trainee safety is at the forefront of any decisions during the COVID-19 response.

he Federal AMA has been talking As the situation with COVID-19 status of Colleges’ responses to the to medical colleges and regulatory has altered, a pragmatic and flexible COVID-19 pandemic. Tauthorities about how to support approach to medical education and The resource summarises publicly doctors in training (DiTs) and mitigate training has been required. Among the available information from individual the impact that COVID-19 will have on concerns for DiTs has been ensuring College websites about changes to, medical education and training over the that those who are asked to work and the current status of, assessments, next 12 to 18 months. outside their usual clinical area/role or education and training, selection into training and wellbeing. It includes links State and Territory AMAs and the scope of practice are given appropriate to College COVID-19 webpages and to AMA Council of Doctors in Training induction procedures, supervision (AMACDT) have been supporting pages targeted at trainee wellbeing. and PPE. DiTs in highlighting and addressing This resource provides information in Similarly, DiTs have sought industrial issues as they arise. the following areas: reassurance that consideration must Given the rapidly changing For specialty trainees environment and competing priorities be given to the level of work, stress, • examinations surrounding the impact of the COVID-19 difficult clinical treatment decisions • career progression virus, the burden on doctors in training and large numbers of ill patients which • exam, course and other fees and the implications for education, may impact their wellbeing, along with • special COVID-19 leave training and clinical care have required the health and wellbeing of all frontline • wellbeing careful consideration. Some trainees healthcare workers. For prevocational trainees have had their exams cancelled The AMACDT quickly developed • application processes for training. and disruptions to other training an online resource to help specialty For more information go to the activities are likely. trainees stay up to date with the AMA website.

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medicSA | 33 The paradox of isolation A ‘nobody left behind’ approach is guiding pandemic strategies at Flinders University.

t’s a commonly observed paradox ‘It does present enormous that intense social dislocation opportunities for learning, not only in associated with the global COVID-19 terms of the technical elements about pandemic has simultaneously been personal protective equipment, but also Ia force to bring communities together. about culture and people responding to That is exactly what has happened adversity,’ Professor Craig says. ‘These with the 4,000 staff and students are the important things that ultimately at Flinders University’s College of make for good doctors and clinicians. Medicine and Public Health, says its ‘Our medical program students Vice President and Executive Dean, continued their Year 3 and 4 placements Professor Jonathan Craig Professor Jonathan Craig. – that hasn’t been the case across Across campuses ranging from Mount the state or the country. But we felt and engaged medical graduates. We Gambier to Nhulunbuy in the Northern very strongly that if we are a publicly want our staff inspired to support our Territory to the expansive multilayered funded institution and we expect students to graduate with the best campus at Bedford Park, a sense of that the community in the future possible degree, we want to do great common purpose and creativity has would be cared for by our graduates, research, and we want students to get a forged stronger bonds. those graduates should be trained to great education. The university adopted a three- cope with every possibility. And that ‘And social vision – we expect our pronged strategy to ensure that includes pandemics. ‘There are probably about 20 things graduates, our young doctors to be everyone would graduate as planned; trained to the best possible standards first, acting swiftly to move the where we are going to be better and stronger than previously; for example, that they deliver the best care.’ curriculum online – achieving in two The community theme is one weeks the agility and flexibility they had the partnerships we’ve had with our student members are probably even that has directed Professor Craig’s been developing for two years. decision-making throughout his life. Second, the university sought to stronger than they have been.’ Equally, he says, the staff He is internationally celebrated for act on the advice from public health community has flourished throughout his work in paediatric nephrology authorities. Third, it developed creative the pandemic. and epidemiology – particularly approaches to supporting both staff ‘One of the challenges is that we in kidney disease in children and and students. are a very spread-out College but in a Indigenous communities. ‘With the onset of the pandemic, Zoom or Teams meeting, everyone is ‘I chose paediatrics because if you work and life in general was a very scary communicating whether your office is are going to invest in something, why place for many people, so we set up in the same corridor or in Nhulunbuy. wouldn’t you invest in kids?’ he asks. communities of practice. The primary (For example) the community of ‘There is potential to shape their consideration was, “nobody left behind”,’ educators started with a relatively small entire trajectory and I wanted, very says Professor Craig. group and then blossomed to include 70 broadly, to be like the senior clinical role The College worked with parents staff who met three times a week for an models I was profoundly impressed by.’ and students edgy about the climbing hour – it’s basically sharing innovations With his previous appointments at the infection rate in Australia in early they had brought to their teaching.’ Children’s Hospital at Westmead and in March, encouraging them to ‘keep the Professor Craig says the COVID-19 the School of Public Health at Sydney faith’ because once borders were closed, response reflected a broader Flinders University, as well as his position in the there would be no quick way back. University philosophy: people, culture, Flinders College of Medicine and Public In late May, the whole university innovation, excellence and social vision. Health, he’s recently chosen to influence returned to campus, with the College on ‘Everybody within the College has community outcomes through teams track to deliver on its promise that no a sense that they are supported and and team building. It’s about the people, student would be left behind. that cared for,’ he says. ‘Culture is he says. ‘At no point did we withdraw our also critically important – a culture ‘This is a position that enables you to placements and we were always of diversity and inclusion; one that invest in a large number of people, both committed to graduation and that supports gender equity, supports the academic staff and students, who can commitment looks like it is going to be rights and voice of Aboriginal people make the sort of difference you as an fulfilled,’ Professor Craig says. and whereby people are treated individual could never have,’ he says. He says that while nobody wants a positively irrespective of where they ‘I think that if you start off in a career pandemic, if you are in the business of went to school and what their various in health it is all about the health of training the next generation of doctors, family lineages might have looked like. individuals and about communities – it makes sense to use any new challenge ‘Around excellence, we do aspire that’s the predominant reason why we as a learning opportunity. to produce Australia’s most capable do what we do.’

34 | medicSA Jigsaw pieces beginning to fit Adelaide Medical School Interim Dean Professor Cherrie Galletly is finding the right places for the right pieces in her new role.

s a psychiatrist who intelligent, very motivated specialises in working with students’. But given the people with schizophrenia unprecedented challenges and other psychoses, and of the COVID-19 shutdown, Professor Cherrie Galletly Apost-traumatic stress disorder (PTSD), it is a job that could have the Interim Dean of Medicine at the tested the mental health of a less academic requirements of the program]; University of Adelaide, Professor Cherrie well-equipped professional. Professor that there wouldn’t be a year who would Galletly, is accustomed to turning crises Galletly is also Chair of Psychiatry, a miss out and I’m very confident we’ll into a strategy. position supported by the University of achieve that,’ Professor Galletly says. Since graduating as a psychiatrist in Adelaide and Ramsay Health Care (SA), ‘We’ve managed to adapt to meet Dunedin, New Zealand and moving to and Director of Mental Health Research the Australian Medical Council Adelaide, Professor Galletly has turned and Training in the Northern Adelaide (AMC) requirements, and our final- a ‘knack’ for helping people with some Local Health Network. year program adaptations have been of the most complex mental illnesses ‘In a response to the COVID-19 approved by the AMC. This was an into a stellar career, combining research pandemic, Australian Government enormous accomplishment.’ into the neurosciences and clinical restrictions and in compliance with the She says having a six-year program psychiatry, academia, private practice University of Adelaide response, the model for school leavers – with and parenthood. Adelaide Medical School had to reinvent students completing the pre-clinical She continues to be excited by the the wheel in five weeks to accommodate teaching, skills and simulation before prospect of working with severely ill online teaching across all years of our undertaking three full years of clinical people, buoyed by their courage, and the medical program, finding a way for placement – has given the Adelaide opportunities to help them move from the small group, apprenticeship-style Medical School some breathing room in a ‘pretty terrible situation to a pretty learning to work with Zoom and social dealing with the COVID-19 pandemic. reasonable situation’ with medication, distancing,’ Professor Galletly says. Holding barrier exams in fifth year to individual support, and community and ‘People have learned how to do Zoom allow the sixth-year students to focus on family rehabilitation. tutorials and online lectures – they’ve preparing for internships also ensures There’s also the prospect of a major done all the things they’ve needed to students will be well-equipped for the leap forward in the understanding of do to get a medical program online in a workplace – in everything from conflict schizophrenia and psychoses through very short time. in the workplace and bullying, ethics, imaging, brain networks and genetics. ‘The online teaching and the and how to handle difficult situations to ‘I feel that we are on the edge of a new methods of assessments we’ve protecting their wellbeing. major paradigm shift or a breakthrough developed – I think many of those will Professor Galletly says the Faculty in the area of psychoses,’ Professor improve the MBBS. There has been a lot of Health and Medical Sciences under Galletly says. ‘It hasn’t come yet – I’m of innovation and change; there have Executive Dean Professor, Benjamin hoping it comes in my lifetime. been advantages.’ ‘It’s like all the bits of a jigsaw and they Final-year student placements will Kile, is running on all cylinders, with a don’t quite fit together and you feel like be fewer and longer – 12 weeks versus strong commitment to a collaborative you are just missing some major part of the traditional four to six weeks – and teaching style. it, or that you are looking at it the wrong the graduates will have had different The school’s leading medical program way and one by one we’ll tease out the experiences but will be no less well- continues to attract the brightest different causes. It is an exciting time.’ equipped, she says. Fifth-year students minds, and is expected to be further Professor Galletly’s new role as will be able to sit their barrier exams, strengthened with the move to a new Interim Dean has required her to including the Objective Structured Bachelor of Medical Studies and Doctor bring many pieces of her background Clinical Examination (OSCE) – even if it of Medicine from 2022. and expertise into the ‘jigsaw’ that has to be done by Zoom. ‘We are coming out of this with all is academic leadership. She is ‘We did guarantee to our students that of our students having had a different enthusiastic about a position that each year of students would progress to experience, perhaps adapted, but still allows her to work with ‘lovely, highly the next year [providing they satisfy the an excellent degree,’ she says.

medicSA | 35 MEDICAL EDUCATION

Light at the end of the tunnel? back with open arms – thank you! It and will come after, who will not have JADE PISANIELLO could not have been an easy process. the disruption and disappointments STUDENT NEWS: Although our current placements we have had, it remains a privilege ADELAIDE UNIVERSITY are perhaps not akin to what many to be a member of this cohort. While of us had planned during fifth-year next year will be challenging in its own SWOTVAC, which is of course the best way, we have proven we can rise to hroughout the six years of reminder of how lucky we all our to be the occasion. medical school, every student in this position at all. Tis told by their seniors that Scrolling through my social media there is light at the end of the tunnel. feed, I see none of my cohort sipping All those nights and days spent in wine along the south coast of Italy, or Barr Smith or the RAH library would swimming in the Bahamas. While I eventually be rewarded with sixth year. am saddened that we have missed out If a picturesque city had a hospital, it on these experiences, I am heartened wouldn’t matter how far from South every day when I see my peers on the Australia that city might have been, you ward or over Zoom tutorials. We have could bet that a sixth-year student from undertaken this journey together, for this state was ‘completing’ their Dean’s six years of highs and lows. We have Elective from the closest beach or bar. watched each other grow and develop Sadly, given the current global and we have supported each other It’s never been more crisis, the vast majority of my cohort through the fear and uncertainty of of soon-to-be-interns have had their the past few months. This month, we important to stay in touch. overseas adventures cancelled. have begun our applications to begin For updates on AMA(SA) news and activities, Initial disappointment was quickly our medical careers as interns. Already our paths are beginning to diverge, but please follow us: outweighed by fears over the future Facebook: @AMASouthAustralia I look forward to what the future holds of our placements and our ability Twitter: @ChrisMoyAMASA for every one of us. to graduate, as placements were Instagram: @amasamembers Really, the joy of medical school is suspended and teaching paused. It was LinkedIn: Australian Medical Association (SA) not confined to one single year, or a with a great sense of relief that all sixth single overseas elective. Cliché though To ensure you receive future ‘bumper’ (June years returned to placement recently, it may be, the joy is in the people you and December) editions of medicSA, please and this was only strengthened by an share it with. I’ve come to realise that provide your name, phone, postal address assurance from the AMC that we will all the days spent studying or on the and preferred email address to: be graduating on schedule, despite the wards were spent alongside friends [email protected]. disruptions. To the many University that I know will remain friends for the faculty staff members who assisted rest of my life. This is not the year I If you are a member, check for our Informz newsletters in your inbox. with this process and clinicians at had planned, and while I will look with these sites who welcomed students some envy to those who came before

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It’s time to talk complexities that surround sex and sex Women’s Health West explore this LIAM RAMSEY work are superficial. further in their literature review ‘The STUDENT NEWS: We don’t unpack the complex social health status and health inequities of FLINDERS UNIVERSITY and cultural factors that interplay with women, including transgender women, sex. We don’t discuss that sex is really who sell sex services in Australia’. It is crucial to a person’s holistic wellbeing, implicit that this portion of our society arents talk about the birds and and that it comes in many different requires our advocacy for their health the bees with their kids, so why forms. We certainly don’t discuss how needs, and therefore this must be part Paren’t doing that for our medical it can be used as a profession and be of our medical education. It is through students? Medical schools have empowering for people. We often discuss broadening our learning that we become increasingly large curriculums to best adverse consequences of sex such as better doctors and service providers. train our fresh-faced doctors for the sexually transmitted and blood-borne Awareness of intersectionality in our diversity within Australia. Nevertheless, diseases, but that is where it ends. society, helps us to identify stigma and gaps emerge when moulding these Sex is very complex, and that’s why also highlight where there is a need competent doctors, often in areas sexual health is its own speciality. It is for for more education. We have a duty to such as public health advocacy. We this reason that it is important we teach provide safe and equitable healthcare have improved the focus on some students about the nuances of sexuality, to these groups of people. We have vulnerable groups in our population, gender and sex work. It is essential to a moral responsibility to provide but the discrimination that affects sex safely educate and combat stigma which compassionate and decent care, and workers and gender-diverse people can progress to discrimination, which challenge pre-existing bias or stigma in our society persists in our medical impairs utilisation of healthcare services we have been taught to hold. I have education framework. for sex workers and gender diverse witnessed many missed opportunities people in Australia. to appropriately care for patients who We certainly don’t discuss sex workers’ It’s vital that we engage in productive identify as LGBTQIA+ or work in sex health and sexual violence and the discussions about sex worker health at work – opportunities to validate them, medical implications. We don’t learn university. It identifies and challenges strengthen the community’s opinion about various sexual interactions and societal stigma and simultaneously of us as a profession and provide how people engage in sex. We don’t delve educates us, to be able to provide the personalised care. into issues around sex and consent, best care for all our patients. Sex work is Sexuality, gender identities, sexual or counselling around these issues. still not decriminalised nationally and orientation and their nuances may Sessions run by SHINE SA offer excellent in SA it remains an offence under the not seem as if they belong in medical information for students, but often those Summary Offences Act 1953. education, but they do. They are relevant attending are not the ones that need to Engaging with health services can in not only reproductive health and hear it. Not everyone will become sexual be increasingly distressing for sex mental health, but the overall holistic health physicians, but everyone will treat workers, especially if they are met health of the individual. We need to see someone having sex. with judgement, even if unintentional. this emphasised in medical education Despite being trained in the Stigmatised subgroups of people have and curriculum. It’s imperative we do anatomy, physiology and pathology of worse health outcomes and higher this, so we provide everyone the care reproduction, our understanding of the levels of distress. Dr. Graham et al, and they deserve. We are growing!

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medicSA | 39 COUNCIL NEWS

change to be made at the upcoming been well received, with proposed Annual General Meeting, and had the recommendations to be included in a opportunity to hear from one of the report, now being drafted, seen as an teams running for the elections, Dr important way forward. Discussions Chris Zappala and his running mate, Dr focused on developing constructive Ines Rio. partnerships with other representative The AMA(SA) has had a significant organisations to achieve the aims of and important role during the early and the Summit. escalation phases of the pandemic. The CEO Dr Samantha Mead detailed the President thanked Council members unfortunate level of damage sustained in who supported the AMA with technical the AMA House fire. All AMA artefacts advice and who responded with rapid have been professionally cleaned and decision-making during uncertain have been able to be preserved. Dr Peter Subramaniam times – especially early in the pandemic Doctors in Training representative Councillor lockdown. The President particularly Dr Hannah Szewczyk advised Council acknowledged the input of the doctors about the impact the pandemic travel AMA(SA) Council Meeting in training and medical student restrictions and border closures are representatives of Council in responding June 2020 expected to have on the resident to the pandemic crises. Dr Moy observed doctor workforce in both country and ue to the COVID-19 pandemic that the federal and state healthcare metropolitan hospitals. Council was restriction and the AMA House systems responded as a single, updated on the impact of COVID-19 fire, the June meeting was held unified entity, which was crucial to a D on regional services and, in particular, in the ‘new normal’ of the Zoom virtual successful response to the challenges of platform. Under the watch of the Chair, the pandemic. the emergency department of the Vice-President Dr Michelle Atchison, an The President updated the Council Port Lincoln hospital, which will need informal (but hard fought) competition on progress made on e-prescriptions significant upgrades to meet post- for best virtual Zoom back-drop and the expedited process for COVID requirements. broke out. assessing patients' driving licences Council was advised that current Council was advised that Federal when appropriate. GP hospital contracts will expire in elections will be held electronically The AMA(SA) Culture and November but that contracts have been following a necessary constitutional Bullying Summit was noted to have extended because of the pandemic.

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40 | medicSA New telehealth assessment to support non-urgent patients

A Ambulance service is Options for care may include: strengthening its management of • ambulance transport to hospital – STriple Zero calls, using experienced either urgent or non-urgent SA Ambulance’s Clinical Hub Operations paramedics to provide low acuity callers • referral to the patient’s GP, Manager Kate Clarke with Clinical with clinical assessment. GP Locum Service or another Telephone Assessment team leaders Sarah The new Clinical Telephone primary health service Evreniadis and Nick Marks Assessment service will initially • referral or ambulance transport focus on a defined cohort of low to a Priority Care Centre • home-based care. Clinical telephone assessment will: acuity patients. • streamline their access to the most Why is this change being made? The management of urgent Triple appropriate care SAAS receives hundreds of Triple Zero Zero calls will not change and urgent • support the utilisation of non- calls every day, with many not requiring cases will continue to receive an emergency pathways of care an emergency response. However, non- emergency ambulance response. • leave more ambulances, crews and urgent patients often wait longer for an other emergency resources available However, callers with low acuity ambulance and are also most likely to be for more urgent patients. conditions may be transferred to a delayed on hospital ramps. specialised paramedic telehealth In addition, a hospital emergency For more information on Clinical clinician, who will conduct a detailed department is not always the most Telephone Assessment, visit http://www. clinical assessment and recommend the appropriate place for people with less saambulance.com.au/ProductsServices/ most appropriate care for the caller. serious conditions. CTAClinicalTelephoneAssessment.aspx

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medicSA | 41 Polio’s permanent reminders The late effects of a disease that ravaged Australia are still felt, but little understood, write Dr Nigel Quadros and Michael Jackson.

olio is no longer a challenge in The barriers faced by polio School-aged boys await their Salk polio vaccinations Australia, yet its ageing survivors survivors when interacting have a different perception with the medical profession include other medical conditions necessary of the disease than do others their doctors’ lack of experience of to exclude include hypothyroidism, anaemia, cardiac disease, diabetes Puntouched by the disease. Polio survivors their condition, the attribution of their mellitus, chronic infections, renal and report a range of symptoms that are symptoms to other causes, or in some liver disease, sleep apnoea, depression, related to late effects of polio (LEoP) cases, a denial of the existence of LEoP. anxiety and stress (4). in addition to secondary, age-related, In early 2020, Polio Australia Weakness in LEoP is mainly attributed health comorbidities. conducted a nationwide survey of polio to motor neuron dysfunction, but The significant health barriers faced by survivors. Of the 734 respondents, other causes of new weakness must be ageing Australian polio survivors are the 133 were South Australian. Among the excluded: inflammatory demyelinating result of LEoP symptoms and those of its SA cohort: disease, multiple sclerosis, Parkinson’s subset post-polio syndrome (PPS) – and, • 69% of those who experienced LEoP disease, cerebrovascular disease, most importantly, a health care system had problems when discussing health myasthenia gravis, amyotrophic lateral in which health professionals do not care needs with their doctors sclerosis etc. Muscle weakness is recognise the conditions and their needs. • 81% respondents were aged 70-89 assymetrical in pattern, and involves LEoP manifests decades after an years polio affected and unaffected muscles. initial polio virus infection, in some who • 52% were male Clinical signs include fasciculations, developed acute and residual paralysis, • 67 % live in a metropolitan area muscle cramps, and atrophy. • 68% report one or no other chronic as well as in some who had the non- Biochemically elevated serum creatinine health condition paralytic form of poliomyelitis (1). kinase may be noted (5). The most common symptoms, variable • 32% would like to join a support group. Pain manifests as muscle pain Three in five respondents felt their both within and between individuals, – described as deep and acheing general practitioner (GP) had sufficient include (2): or superficial and burning – and knowledge of LEoP, while only one in • new and worsening weakness overuse pain caused by improper body four felt that the GP was willing to learn • central and peripheral fatigue biomechanics leading to soft tissue, about it. Almost 50% of those surveyed • myalgia muscle, tendon, ligaments and bursa expressed low confidence in the ability • sleep difficulty injuries. Assessment involves other of new GPs, new specialists including • cold intolerance. conditions that could be producing anaesthetists, and new allied health Australia was declared polio free pain such as degenerative disc professionals to manage LEoP. by the World Health Organization in and joint disease, radiculopathies, Polio Australia has provided free 2000; hence, many younger health spondylolisthesis, scoliosis, spinal canal professional education workshops to professionals have little or no experience stenosis, fibromyalgia etc. (6). more than 1,300 health professionals in management of acute poliomyelitis GP knowledge and understanding across Australia to reduce these and its long-term effects. This creates an Exercise - general recommendations education barriers. education void between the ageing polio are low resistance, high repetitions survivors who are well educated on their GP’S MANAGEMENT OF and frequent rest periods of sufficient condition, and the health professionals SURVIVORS duration to allow recovery from muscle with little or no experience in managing Elderly polio survivors present with fatigue (7). their impairments. a constellation of symptoms due to Falls - ageing polio survivors are Yet many Australian medical impairment caused by LEoP as well at an increased risk of falls compared professionals, whether aware of it or not, as secondary health conditions; the to the general population due to have likely treated a local polio survivor. delineation between the two is difficult. problems maintaining balance, The community antipathy experienced Addressing major symptoms of LEoP weakness in knee extension and a by polio survivors during childhood is The most common symptoms of fear of falling (8). Osteopenia and not forgotten and has consequences: LEoP are fatigue, increased or new osteoporosis are common in affected some are reluctant to share their history muscle weakness, muscle and joint limbs, thereby increasing the risk of of polio, others deny that their childhood pain, and new difficulties in activity of fragility fractures (9). condition is returning to challenge their daily living (3). Medications - commonly function again, and others do not realise Fatigue has multiple aetiologies and prescribed medications such as statins, they had polio at all. prior to being attributed mainly to LEoP, beta blockers, CNS depressants,

42 | medicSA benzodiazepines, local anaesthetics and • Discussing with the muscle relaxants may worsen fatigue patient - and weakness; their usage requires  healthy lifestyle with careful evaluation of risk versus benefits. exercise, weight In some instances, dose reduction is loss and stress necessary (10). management Anaesthesia and surgery - special  fatigue and activity anesthetic considerations are needed activity strategies when treating patients with history of  effective pain poliomyelitis due to increased likelihood management of altered respiratory function, chronic  lower falls risk  treatment options pain syndromes, cold intolerance, for secondary aspiration, and altered sensitivity to LEoP knowledge that polio survivors expect of several health medical/surgical anesthetic agents (induction agents, professions (2020 Polio Australia Survey) conditions including inhaled anesthetics, neuromuscular anaesthetic use agents, opioids and regional and general • Referring to skilled allied health skilled health professionals with a special anaesthesia medications). A discussion professionals, rehabilitation medicine interest in this condition. with the anesthesiologist is advisable to physicians, neurologists, respiratory The reference list is available at: provide safe care (11). physicians as individual patients need https://www.poliohealth.org.au/ In 2020 the RACGP endorsed a • Directing to PolioSA (www.poliosa. ama-sarefs/ LEoP information brochure, and org.au) for local support, and to Polio more information is available at www. Australia (www.polioaustralia.org.au) Dr Nigel Quadros is Senior Consultant poliohealth.org.au. A GP education for polio resources. Rehabilitation Medicine at the Queen module on LEoP is in development, and A thorough understanding of LEoP is Elizabeth Hospital and Hampstead a LEoP pathway has been requested of necessary to treat ageing polio survivors. Rehabilitation Centre, Michael Jackson HealthPathways South Australia. The GP plays a pivotal role in managing is Clinical Health Educator for Polio Establishing a GP management plan these patients and can promote their Australia. Co-author Brett Howard (now Key components of a plan for GP care health and wellbeing by being aware of deceased) was President of PolioSA and would include: the condition and seeking advice from Vice-President of Polio Australia.

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medicSA | 43 FROM OUR PARTNERS

Preparing for the ‘new normal’ Adelaide law firm Norman Waterhouse has recommendations for the doctors who face changes to their work practices during the pandemic.

Lincoln Smith Sathish Dasan Ganesh Krishnan

s the Federal and State For example, a request from an among employees to simmer or remain Governments ease employee who is the parent of a school- unresolved. When employees are restrictions in relation to aged or younger child, or who is 55 returning to work to the employer’s COVID-19, it is important years or older, may only be refused on premises, it is an ideal time to start Afor employers to consider how they ‘reasonable business grounds’, which fresh with employees and implement are transitioning from the COVID-19 include that new working arrangements teambuilding exercises and workplace pandemic and adjusting to the ‘new would be too costly, the changes may training, such as conflict resolution and normal’, as well as being prepared if a result in a significant loss of efficiency appropriate conduct training. second wave of COVID-19 occurs. or productivity, or customer service There are also socialising factors There are areas employers should would suffer. to consider. As employees return be aware of as they adjust and the dust If employers consider that it is to workplaces, and restaurants and settles, as well as lessons learned from appropriate for their employees to pubs reopen, there is a natural desire how businesses have managed during continue working from home, the these unpredictable times. arrangement should be outlined in a to socialise, including in workplace written flexible working agreement. functions. Employers should have FLEXIBLE WORKING appropriate drug and alcohol policies ARRANGEMENTS To ensure uniformity, this agreement in place and ensure that employees are Many employees have, either by should align with your organisation’s aware of the behaviour expected of them choice or at the direction of their flexible working arrangement policy, ‘post COVID-19’, such as maintaining employer, worked from home during which explains its position on the period social distancing and practicing the COVID-19 pandemic. It is likely that of the flexible arrangement and any many employees prefer the flexibility review, employees’ duties and hours of good hygiene in accordance with of working from home and employers work, work health and safety guidelines, government guidelines. may receive more requests for flexible and requirements for maintaining Employers should also be pro- working arrangements. confidentiality of information. active and understand that improving Section 65 of the Fair Work Act 2009 REINVIGORATING workplace culture starts at the executive (Cth) enables certain employees to WORKPLACE CULTURE level. They should understand that some request a change to their working Due to the rapid onset of restrictions, employees may struggle with returning arrangements, depending on whether it may be that the time away from the to the workplace, especially in a full- certain circumstances apply to them. office allowed any workplace tensions time capacity. It’s advisable to consult

44 | medicSA FROM OUR PARTNERS

with employees before their return, ORGANISATIONAL have sudden adverse impacts, similar to including discussion of: RESTRUCTURE the impacts of the pandemic. • safety measures and procedures now Many businesses will have had to Business continuity preparation in place, such as social distancing review their operations, financial is imperative if a business is going in the office, regular cleaning of streams and sustainability, especially to effectively manage any of these communal areas and individual in consideration of access to situations and emerge ready perform workplaces, limiting the number of JobKeeper payments. as its customers need and expect. people at in-person meetings, and From such reviews, organisations To ensure you have a robust internal encouraging video and teleconference should consider whether they can business continuity plan: meetings when possible increase business efficiencies through • review your IT systems and ensure changing IT platforms, processes and • encouraging employees to use their your company’s information is staff members’ duties. A restructure sick leave and not come to the office if protected may be advisable; this could include an they have cold or flu symptoms (which • review employment contracts to examination of employees’ employment are similar to COVID-19 symptoms) ensure they allow for flexibility contracts and position descriptions and that duties are appropriate and • what will happen if an employee to determine whether certain duties necessary contracts COVID-19 or is found to have are no longer needed, if they should • review leave balances been in contact with someone who be outsourced, or whether certain has COVID-19 roles and duties can be merged. If an • review or implement an emergency • what an employee should do if employer undertakes a restructure, it plan they are a high-risk person or is imperative that they consult with • ensure human resources policies and lives with someone who is a high- affected employees. guidelines are robust and flexible • if needed, introduce training that will risk person (including if they are LESSONS LEARNED improve your workplace culture. immunocompromised), and whether COVID-19 has affected all industries they will be able to continue working across Australia. But the reality is that a from home crisis or unexpected disaster can affect For more information please contact • making services such as Employee any business at any time. For example, Sathish Dasan on 8210 1253, Lincoln Access Programs (EAP) or other an unexpected event such as a fire, an IT Smith on 8210 1203 or Ganesh Krishnan (internal or external) counselling attack, the death of a senior employee – on 8217 1395, or email Lincoln on available to staff. or even a second wave of COVID-19 – will [email protected].

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medicSA | 45 Experts for your financial health.

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Connecting to Country South Australian programs are reinforcing the benefits of relationships with Country.

or thousands of years, Aboriginal Framed around the South East people and communities have Aboriginal Focus Group’s Weaving understood, experienced and the South East Seasons Calendar, celebrated a spiritual connection the program enables participants Fwith their ancestral lands and waters. to contribute to environmental Aboriginal people see themselves as sustainability and experience the belonging to Country and every aspect of benefits of connecting to Country. This themselves and their life as holistically is modelled on a successful program run interconnected with Country. This with headspace Mount Gambier in 2017. Moogy’s Yuki Scar Tree at Kalangadoo connection is distinctly personal; In July 2019 a participant group set Country is regarded like a family off for Kalangadoo to view the Yuki scar Mr New says programs such as the member. The relationship with Country tree – a Yuki is a traditional style bark ‘Walking the South East Seasons with is interdependent, reciprocal and canoe carved from a red gum. In 2010 Nature in Mind’ provide important sustained through cultural knowledge. Elder Major Sumner (Moogy) and Uncle opportunities for connecting to Country Connection and re-connection to Cyril Trevorrow had spent six hours in and learning about the significant Country are significant determinants a cherry picker carving the canoe from relationship between Aboriginal of health and wellbeing for Aboriginal the bark; the finished Yuki measured people and Country. people; they form part of Aboriginal four metres and was cured on a smoky He refers to the South Australian peoples’ sense of belonging and self- fire. Three months later it was floated Government’s ‘Joint Statement of determination. at Lake Leake near Mount Gambier and Action: Connection to Country’, which Building on this long-standing later in 2010 it was floated as part of states that Connection to Country is traditional knowledge and evidence the National Water Craft Conference on underpinned by leadership, healing, base, an increasing body of western Darling Harbour, Sydney. learning, promoting places of cultural evidence is demonstrating significance, sovereignty, that connection to family and promotion of traditional community, land and sea, and languages and culture’. culture and identity is integral ‘Previous participants have to Aboriginal health and commented that the program wellbeing. Numerous studies provides opportunities for being also confirm the benefits that in nature, that make you feel arise from Aboriginal people’s happier, more peaceful, better reciprocal relationship with for being involved,’ Mr New says. Country through Connection to ‘Other reports suggest that the Country initiatives. Connection experience stimulates energy, to Country centres on the creativity and learning and relationships between Aboriginal provides opportunities to make people and their Country, and new friends and be surrounded by includes activities that reinforce other likeminded people.’ and support relationships with Nel Jans, Coordinator at The July trip also incorporated a 3 physical, cultural, social, economic and the South East Junction, says some km walk around the perimeter of the spiritual environments. participants have since engaged with In South Australia, there are many Mt Burr Rock Shelter Forest Reserve, other Junction Programs and Connection programs and initiatives that promote which ended with a cultural session to Country walks. Others have the significant mental, physical and with Aboriginal Elder and South East commented that the experience inspired social health and wellbeing benefits of Aboriginal Focus Group member, Doug them to try non-guided Connection to Connection to Country. Nicholls. The cultural session included a Country experiences. In March 2018, the South East smoking ceremony, didgeridoo playing ‘This has been particularly important Junction (Mental Health Activity and and discussion about the rock shelter amid the recent COVID-19 situation,’ Resource Centre Inc., in Mount Gambier, site. A visit and song from a flock of she says. ‘With many community Millicent and Penola) and Natural about 15 yellow tail black cockatoos activities and facilities on hold, some Resources South East started ‘Walking finished the outing. ‘Being out on- program participants have done their the South East Seasons with Nature in Country, immersed in the environment own walks. This demonstrates a sense Mind. The program – led by Aboriginal with like-minded people is great for of resilience and self-empowerment Elders – provides a unique perspective of anyone’s mental health!’ says David New, for protecting personal wellbeing, First Nations culture and connections to Aboriginal Engagement Officer, Natural likely strengthened by what was learnt the region. Resources South East. through the program.’

medicSA | 47 REFLECTIONS

50 things every doctor should know

In 2018, Michael Sorkin, an American architect and designer, wrote 250 Things An Architect Should Know. (https://www. readingdesign.org/250-things) To a non- architect the list is whimsical and inspiring. There are items on his list that are technical and others that are philosophical, but the inherent message is that there is more to a profession and life than is taught in textbooks.

Inspired by 250 Things, presented here are 50 Things Every Doctor Should Know. You may have your own ‘things’ to add! 1. The fundamentals of chemistry. 2. The fundamentals of physics. 3. Basic statistics. 4. The scientific method. 5. The Dunning Kruger Effect. 6. What to refuse to do, even for the money. 7. The importance of ‘measure twice, cut once’. 8. How to ask for and accept help. 9. Who to go to in an emergency. 10. Whose shoulder to cry on. 11. When to say, ‘I don’t know’. 12. When to stand up in the face of criticism. 13. When to stand up for your patient r Troye Wallett is a GP and does and when to argue with them. not presume to know what doctors 14. How to celebrate small victories. Dshould know. He presents this list, in a spirit of amusement and whimsy, for 15. Conversation starters for consideration and pondering. He loves to three‑year‑olds. hear from people so if there are any items you think need to be on the list, please email him 16. How to make a duck from a glove. at [email protected]. Let’s collaborate to make the list ‘250 Things’, like 17. What makes babies laugh. the architects. 18. The power of therapeutic touch. 19. The placebo effect and how to use it effectively and ethically.

48 | medicSA ???????????

20. Germ theory and the importance of 36. Why patients come to see them. hand washing (obviously!). 37. Why patients really come to see them. 21. Gauging and managing risk. 38. That a patient knows more about 22. When to walk, and when to run. themselves than their doctor does. 23. How to bring calm to a stressful situation. 39. A deep understanding of fear and how 24. How to recognise and treat a it deafens, blinds and drives people. pneumothorax on the side of the road 40. How to be a gracious team member. with no medical equipment at hand. 41. The preferred warm drink 25. How to stop a bleed of colleagues. (especially epistaxis). 42. The difference between sympathy 26. CPR. and empathy. 27. Safely dealing with sharps. 43. How to give and receive 28. QWERTY. constructive feedback. 29. The power of compound interest. 30. The power of compounding 44. How to deliver a 20-minute teaching their interests. session with no notice. 31. How to cultivate a growth mindset. 45. How to say ‘no’. 32. Their own blood pressure 46. When to say ‘yes’. and fasting glucose. 47. How to give. 33. Where to obtain a healthy snack. 48. How to receive. 34. How to cook a healthy meal in less than 15 minutes. 49. What their mood enhancers are. 35. The allergy season in their city 50. The realisation that their own life or town. comes first.

medicSA | 49 VALE

The heart of the matter

Dr Peter Stuart Hetzel AM KStLJ MD, BS MSc, FRCP, FRACP, FCSANZ

1924 – 2020

‘A true gentleman’

minent cardiologist Peter cardiopulmonary Hetzel was instrumental in bypass using a establishing cardiopulmonary modifier pump. Dr Peter Hetzel bypass (open heart) surgery During his period at Eat the Royal Adelaide Hospital (RAH) Rochester, there were from 1960. two places in the world where open These teams supported Dr Sutherland The younger son of Kenneth and heart surgery was being conducted, and in cardiothoracic surgery and the Elinor Hetzel, Peter was born in London they were less than 150 km apart. initial open heart surgery in 1960. Valve on 8 November 1924, while his father In late 1956 Peter took up a position replacement followed in 1963. Cardiac was on a scholarship from his medical as a research registrar at the Brompton surgery was very successful and went practice in Adelaide. The family Hospital in London, where he worked on to great strengths. In December 1962 returned to Adelaide in 1925. Peter and with Paul Woods, and continued an article was printed in the Medical his brother Basil attended school at his research in cardiac output and Journal of Australia entitled ‘Initial Kings College (now part of Pembroke) intracardial pressures. He returned experiences with open heart surgery’ by and later St Peter’s College. He began with his family to Adelaide in 1958 and Dr Sutherland, Dr Hetzel, Dr Waddy and his medical studies at the Adelaide took a position as part-time registrar at anaesthetist Dr Pauline Daniels. By the Medical School in 1943, graduating the RAH while also performing clinical in 1948. mid-1960s 25 per cent of all Australia’s work in his father’s rooms on North After an intern year at the RAH, Peter cardiac surgery was performed Terrace. Peter also had an honorary won a surgical research position at the at the RAH. visiting appointment to the Women’s Institute of Medical and Veterinary Peter continued as a clinician, and Children’s Hospital to help manage Science (IMVS), investigating fluid teacher and researcher for many children with congenital heart disease. balance problems and potassium years. He was very supportive of After much discussion, particularly loss and using Dextran as a plasma younger cardiologists and assisted in with Dr Darcy Sutherland in 1959, Peter substitute, and earned his MD. He then the introduction of new techniques joined the Mayo Clinic in Rochester, wrote a submission to South Australia’s of investigation and intervention. He Minnesota, working there for five Department of Health on how cardiac retired as Director of the CPIU in 1985 years as a clinical researcher. He surgery could be further developed in and returned as a visiting medical was involved in the development of Adelaide. State Cabinet approved the officer on five sessions until 1989, the cardiopulmonary bypass pump, proposal within a month. continued in private clinical practice techniques for measuring cardiac In January 1960 Peter was appointed until 2002, and provided medico-legal output, and intracardiac measures Director of the Cardiopulmonary assessments until 2018. and shunts. Accurate diagnosis of Investigation Unit (CPIU) at the RAH. Peter was a dedicated family man. intracardiac defects and physiology was The CPIU had four components: He married Margaret (nee Mackie) crucial for the success of intracardiac • cardiac investigation in 1954 and they had four daughters surgery and the development of these (led by Peter) – Diana, Philippa, Penelope and techniques was an exciting time. • respiratory investigation Catriona. He was keenly interested At the Mayo Clinic, Peter was part of (led by Dr Michael Drew) in staff affairs; as president of the a team that began experimental work • cardiac perfusion South Australian Salaried Medical in cardiopulmonary bypass in 1954 – (led by Dr John Waddy) Officers Association (SASMOA) he using dogs – and results were published • medical electronics helped initiate superannuation for the in 1955. In 1956, they began performing (led by Mr Neville Martin). visiting medical staff.

50 | medicSA Additionally, Peter was an active parishioner of Scots Church on North Terrace, chairman of the Board of Presbyterian Girls’ College (now Seymour College) and a great supporter of the Uniting Church. He was chairman of the RAH Heritage and History Committee for 12 years from 2006. Peter was a true gentleman. He was of a very even temperament, always pleasant and supportive of his colleagues, students, and the nursing and ancillary staff. He was a pleasure to work for and with. He is missed by many. Cardiologist Dr Leo Mahar was a colleague and friend of Dr Hetzel.

An oral history that records an extended and fascinating interview with Dr Peter Hetzel in 2006 (OH 172/35) is available from the State Library of South Australia at https://archival. collections.slsa.sa.gov.au/oh/ OH172_35.pdf. The information in the oral history helped prepare this obituary. Dr Hetzel (seated far right) enjoyed cricket while in Rochester.

medicSA | 51 VALE

Renaissance man Dr Andrew Stanislaus Czechowicz M.BS, FRANZCP, FRACMA, FACRM, FAFRM (RACP), Grad Dip Health Admin.

1940 – 2020

‘An eternal student’

ndrew Stanislaus Czechowicz, I use it in a positive way universally known as Andy, as ‘living is learning’. was born during the Second Andy had numerous World War, at Vilnius, then interests and insatiable Aa Polish city where his father Gustaw curiosity. When faced practised medicine. Towards the end with a new subject or of the war the family was forced to issue he tried to find Dr Andy Czechowicz at a conference at Adelaide Oval flee the impending occupation by the out everything that Soviet army, and Gustaw took his wife was known about it. He in 1962. He remained an active member Wiktoria, his three sons, Andrew, Leon, applied this approach to every aspect of and was granted Life Membership of the and Romuald, and Wiktoria’s parents his professional career. AMA in 2017. Similarly, he was active in west across Europe. At the end of the Although Andy had many interests, the affairs of the RANZCP. war they found themselves in a refugee there was never any doubt he would He was always involved in psychiatric camp in the American zone in Germany. specialise in psychiatry. Family legend education and training, and in addition In 1950 they were among the great wave has it that he proclaimed this as a to active involvement with his College of 182,159 displaced Eastern Europeans small boy. He trained in psychiatry at had academic status with the University sponsored by the International Refugee the Glenside Hospital at a time when of Adelaide and Flinders University. Organisation (IRO) who arrived in a dramatic transformation was taking Whatever his administrative role, he Australia between 1945 and 1954. They place in the practice of psychiatry always remained clinically active. His were placed at the Willaston refugee and provision of mental health care interest in psychiatric rehabilitation led hostel and then settled at Gawler. in South Australia, and nationally to him becoming a Fellow with the new Gustaw had to work at a variety of as the Australasian Association of College of Rehabilitation Medicine in basic jobs to support his family and Psychiatrists (AAP), evolved into the 1981, and his interest in herbal remedies never had the opportunity to practise ANZCP, now the RANZCP. led to his co-authorship of the book medicine in Australia. He did, however, The transformation in South Herbal Remedies: Harmful and Beneficial found a medical dynasty. Two of his Australia was triggered by the arrival Effects in 1989. sons and two of his grandsons practised of Professor William ‘Bill’ Cramond in Andy was immensely proud of his medicine, and a great-granddaughter 1963. He dragged psychiatry into the Polish heritage and served on many is now studying medicine at 20th century. On his graduation Andy committees, usually as Chairman. As Flinders University. became a leader in the application of a member of the Polish community he Andy’s Australian education began the new methods and was continually was the President of the Committee that at the Good Samaritan Convent School active in the education program for established the international SA Violin at Gawler. Starting with no English, he trainees in South Australia. Competition, which ran for a number of won the English prize in grade 7 and He held senior positions in years. He was awarded the Centenary began his high school education at health administration from the Medal ‘to recognise people who made Christian Brothers College in Adelaide beginning of his career. In 1977 he a contribution to Australian society or on a scholarship. He again excelled and was appointed as the Superintendent government’ on the nomination of the gained a Commonwealth Scholarship to of Hillcrest Hospital, and in 1980 Polish Community. fund his medical education. the Superintendent and CEO of the Andy was always sought out by Polish Andy was an eternal student. This Glenside Hospital. Australian patients, not only because term is often applied in a pejorative Throughout his career he was actively of his knowledge of the Polish language sense to describe someone who involved in formal professional affairs. but because he understood the culture protracts formal education rather than As a student, he joined the BMA (SA and the impact of the migration graduating and facing the real world. Branch), which merged with the AMA experience on their lives. He had a great

52 | medicSA interest in Aboriginal mental health; he was the visiting psychiatrist to the Anangu Lands 1976–1979 and continued to care for Aboriginal patients throughout his career. In recent years he had a great interest in adult ADHD. I had many useful and interesting conversations with him because some of the troublesome changes in personality and behaviour found in dementia also suggested parallels with ADHD. Andy and his life partner, Maryla, were great travellers for business and pleasure and had friends around the world. They went to France to attend the wedding of a young woman doctor who had lived with them as an exchange student. She Dr Czechowicz with Dr Ludomyr Mykyta in 2015 at the 50th anniversary celebration of their medical kept close contact with them for school graduation, and being honoured as a 50-year member of the AMA(SA) by then-President the rest of Andy’s life. On their A/Prof William Tam in 2017 travels Andy took hundreds if not thousands of photographs turn to me and ask, ‘Uncle Andy is being Royal Australian Air Force. He died with ever-more expensive cameras. facetious isn’t he?’. surrounded by his family and friends Andy was a proud and loving His battle with oesophageal cancer to the sound of The Last Post, which father and grandfather and enjoyed took about four years. Maryla and was being broadcast as he took his interacting with children. He was Uncle his children - Gus, Lydia, and Sophie last breath. Andy to our daughters and many other provided loving and exemplary Andy was a public servant for all children of relatives and close friends, palliative care. I called them ‘Team his professional life. The sobriquet as is the custom with Eastern Europeans Czechowicz’ and was proud to be an ‘Renaissance man’ was first applied and Australian Aboriginal people. He associate member. to another famous Pole, Nicolaus had a way with children. Camping on He died on Anzac Day, five days short Copernicus. Andy, like the astronomer, Hindmarsh Island they would discover of his 80th birthday. One of his great was a man of many parts. dragon bones which Andy would interests had been military history, and describe in great seemingly scientific if he had gone down a different path, Dr Czechowicz’s fellow graduate and detail, until one of the children would it would have been as a member of the friend Dr Ludomyr Mykyta

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medicSA | 53 DISPATCHES

TEMPORARY OFFICES date as soon as possible. Please contact HELPFUL HINTS FOR AMA(SA) Claudia Baccanello on 8361 0109 or Are you having trouble logging on to at [email protected] if you have You’ve read Please note that due to the fire that update your details, renew your tax- any questions. caused extensive damage to AMA deductible membership for 2020, or 120 years’ experience House in North Adelaide on 6 May, Reference to the AMA(SA) Constitution print your tax invoice? Here’s a simple helping medical AMA(SA) staff are now working from has confirmed that appointments to tip to help: professionals temporary premises in Dulwich. 10 times your our Council extend from one AGM to • Head to: members.amasa.org.au If you wish to visit our office, please the next, so that the terms of existing • Username: your email address Medico-legal advice come to Level 1, 175 Fullarton members of Council and the President 24/7 emergency Road, Dulwich. and Vice-President will continue until • Password: whatever you have set support Our phone numbers and email the AGM can be re-scheduled. this as. weight in addresses remain the same. Our postal If you have a question about To access your tax invoice: address remains PO Box 134, North Risk education learn to manage Adelaide SA, 5006. nominating, please contact the Chief • log into your SA Membership Portal your risk Email: [email protected] or Executive Officer, Dr Samantha Mead, as above on 8361 0109 or at journals for [email protected] • click on ‘My Payments’ tab Phone: 8361 0100 CEO@ amasa.org.au. Earn Qantas Points1 • click on ‘AMA Membership Fee’ next on your MIGA to the relevant date insurance WE’RE HERE FOR YOU GALA DINNER AND • click on the PDF icon to download a this career. The AMA(SA) thanks members for AMA(SA) ANNUAL AWARDS copy in PDF format. providing ideas, views and feedback, Each year, the AMA(SA) presents two You can also update your contact details and payment information using and for alerting us to matters of awards at the Gala Dinner: the AMA(SA) concern, during the COVID-19 this portal Award for outstanding service in pandemic. Your involvement has been With 120 years as a specialist medicine and the AMA(SA) Medical essential to ensuring we have been Educator Award. It deserves insurer to the medical profession, able to respond appropriately as issues emerge and continue to affect doctors, Due to COVID-19, the 2020 Gala Dinner protect yourself with the experts health practitioners, the wider health was cancelled and the awards will not sector and communities. be presented this year. expert in medical indemnity insurance.2 MEMBER BENEFITS FROM HOOD SWEENEY STAY CONNECTED DO WE HAVE YOUR CORRECT For a competitive quote, The AMA(SA) is working closely with MEMBERSHIP DETAILS? Our preferred accounting and SA Health and other organisations to financial planning provider Hood protection. call 1800 777 156 or visit If your contact details, place of communicate the latest information to Sweeney has extensive expertise in employment or membership category www.miga.com.au doctors and health practitioners across the health and medical industries, South Australia, and to ensure that has changed recently, perhaps because you’re no longer a student, you’re and is passionate about supporting emerging concerns are addressed. AMA(SA) members. If you have issues or queries about your working part-time, or you’ve recently membership, please email Rebecca at retired, please let us know so we can For information about the generous [email protected] or phone update your details. discounts and benefits available 8361 0108. If you’ve been a student member but to you as an AMA(SA) member, or are no longer a student, please let us to speak with a specialist adviser, know so we can upgrade you to a full please phone 1300 764 200 or email AMA(SA) ANNUAL membership. You’ll then have access to [email protected] GENERAL MEETING AND a range of additional state and federal MAY COUNCIL MEETING benefits, including the Medical Journal Due to the pandemic, the Annual of Australia (valued at more than $400) General Meeting (AGM) of the AMA(SA) and the AMA List of Medical Services was not held at AMA House as and Fees (valued at $499), which are previously scheduled on 7 May 2020. not available to student members. The experts in medical and The Board of AMA(SA) decided Some interns forget to provide new ACCESSING VITAL PPE that an online format was not professional indemnity insurance. email addresses to replace their suitable for an AGM, during which The AMA(SA) is partnering with student contacts. If you’re currently Doctors, Eligible Midwives, Healthcare Companies, Medical Students all participating members must South Australian company registered as a student member be able to provide questions and Austofix to help members source and you’re now an intern, please  A business must be a Qantas Business Rewards Member and an individual must be a Qantas Frequent Flyer Member to earn Qantas Points with MIGA. Qantas Points are offered under the MIGA Terms and Conditions (www.miga.com.au/qantas-tc). comments and have their involvement high‑quality PPE. Qantas Business Rewards Members and Qantas Frequent Flyer Members will earn 1 Qantas Point for every eligible $1 spent (GST exclusive) on payments to MIGA for Eligible Products. Eligible Products are Insurance for Doctors: Medical Indemnity let us know and we’ll change your Insurance Policy, Eligible Midwives in Private Practice: Professional Indemnity Insurance Policy, Healthcare Companies: Professional Indemnity Insurance Policy. Eligible spend with MIGA is calculated on the total of the base premium and membership recorded. The postponement was For information about how Austofix fee (where applicable) and after any government rebate, subsidies and risk management discount, excluding charges such as GST, Stamp Duty and ROCS. Qantas Points will be credited to the relevant Qantas account after receipt of payment for in line with the South Australian membership category. an Eligible Product and in any event within 30 days of payment by You. Any claims in relation to Qantas Points under this offer must be made directly to MIGA by calling National Free Call 1800 777 156 or emailing [email protected] can meet your PPE needs with its  Insurance policies available through MIGA are underwritten by Medical Insurance Australia Pty Ltd (AFSL 255906). Membership services are provided by Medical Defence Association of South Australia Ltd. Before you make any decisions Government’s Consumer and Business If you have any questions about your ‘Austosafe’ products, please call about any of our policies, please read our Product Disclosure Statement and Policy Wording and consider if it is appropriate for you. Call MIGA for a copy or visit our website at www.miga.com.au © MIGA March 2019 Services advice. membership please contact us at Austofix senior sales consultant We will inform members of the revised [email protected]. Robert Caprile on 0419 261 924.

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MIGA019 AMASA MedicSA 210x297 DJ V1.indd 1 8/5/19 12:05 pm You’ve read

120 years’ experience helping medical 10 times your professionals Medico-legal advice 24/7 emergency weight in support Risk education learn to manage journals for your risk Earn Qantas Points1 on your MIGA this career. insurance

With 120 years as a specialist It deserves insurer to the medical profession, protect yourself with the experts expert in medical indemnity insurance.2 For a competitive quote, protection. call 1800 777 156 or visit www.miga.com.au

The experts in medical and professional indemnity insurance.

Doctors, Eligible Midwives, Healthcare Companies, Medical Students

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

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MIGA019 AMASA MedicSA 210x297 DJ V1.indd 1 8/5/19 12:05 pm FOR YOU, YOUR COLLEAGUES AND ALL SOUTH AUSTRALIANS WE ARE STRONGER IF YOU ARE WITH US WE ARE LOUDER IF YOU SPEAK THROUGH US OUR INFLUENCE IS GREATER WHEN MORE OF YOU ARE BEHIND US

The AMA(SA) is proud of its long and proven history of supporting South Australia’s doctors, and as a trusted advocate for the medical profession and the health of all South Australians.

Our value has never been more evident than in fighting COVID-19, when we’ve been pivotal in: • Contributing to plans to stop the spread of COVID-19 • Introducing telehealth MBS and electronic prescribing • Providing financial and mental health support for doctors • Advocating for adequate PPE • Supporting Doctors in Training and medical students.

Decisions are made by those who show up. Support the organisation that supports you. Join Now! sa.ama.com.au [email protected]

56 | medicSA 08 8361 0108