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Pomegranate Health

Pomegranate Health

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Pomegranate Health is an award-winning podcast about the culture of medicine. How do doctors make difficult clinical and ethical decisions? How can one communicate better with patients? How can health delivery be made more equitable and efficient? You’ll hear from clinicians, researchers and advocates. Every episode is developed with the guidance of RACP members, to inspire excellence in practice.

On each episode page there is a MyCPD link for Fellows to log credits for listening. Please also check out all the other Online Learning Resources @ RACP which include eLearning courses and recorded lectures. Why a pomegranate? The fruit has featured on the coat of arms of the Royal College of Physicians since 1546, and then that of RACP almost four hundred years later. The pomegranate is an ancient symbol of sanctity, fertility, and regeneration in all the major religions.

Search for 'Pomegranate Health' in Apple Podcasts, Spotify or any Android podcasting app. You can also subscribe to our e-mail alerts list to find out when each new episode is released. Discuss any episode in the comments section, and send your feedback or ideas to podcast@racp.edu.au.

Listeners also recommend

IMReasoning: In-depth examination of diagnostic error and bias (NZ)
Pediacast CME: Continuing medical education for quality paediatric care (US)
Essential Ethics: Clinical ethics from the Children's Bioethics Centre at RCH Melbourne (Aus)
Onthewards: Covers every topic of interest to junior doctors (Aus)
Emergency Medicine Cases: Case-based discussion of key practice in EM (Can)
PEM Currents: Up-to-date practice and tech in paediatric emergency (US)
Broome Docs: Shared tips and experiences for rural generalists (Aus)
Key Literature in Medical Education: From the Royal College of Physicians and Surgeons of Canada
Don't Forget The Bubbles: Lively and comprehensive paeds talks and blog (Aus)

Latest episodes

Ep65: A New Script for Global Public Health

Intellectual property law has influenced pharmaceutical development and marketing for at least 25 years ago. But it’s not clear whether this is actually the best model for stimulating innovation and addressing the most important global health problems. Closer to home, we also discuss a solution to the jurisdictional conflicts in responding to the pandemic.

Ep64: Big Pharma and the People’s Vaccine

The COVID-19 pandemic has stimulated a frenzy of vaccine development never seen before, but also examples of hoarding, price hikes and vaccine nationalism. We discuss where the intellectual property rules have come from and where exceptions are sometimes made for public health emergencies.

Ep63: the WHO’s Biggest Test

During the COVID-19 crisis there has been some criticism of the World Health Organisation as to whether it declared a pandemic soon enough or covered up for China’s failings. In this podcast we examine the role and responsibilities it shares with its member states and where the straining points have been.

Ep62: Essential Ethics in Adolescent Health

Two more case studies from the Essential Ethics podcast tackling the question of when refusal of treatment should or shouldn’t be accepted by a medical team, and how much autonomy does an adolescent have. Featuring clinicians from the oncology department at the Royal Children’s Hospital, Melbourne.

Ep61: Delirium Part 2- Prevention and Management

Delirium can be precipirated by a host of environmental triggers that are highly modifiable. Anything that contributes to a person’s disorientation and discomfort can increase the likelihood of a delirium episode. While a lot of these factors are compounded in elderly and frail patients, delirium can be reversed in a majority of patients by non-pharmacological means.

Ep60: Delirium Part 1- Detection and Causes

Delirium is an acute disturbance of consciousness, attention, cognition or perception. It’s associated with an increased risk of falls, dementia and high dependency care, and all of this adds up to higher mortality. About a third of patients admitted to ICU or approaching the end of life, experience delirium. But it’s notoriously underdiagnosed, so in this episode we talk about the presentations and detection of delirium. We also go through some of the medical and iatrogenic risk factors.

Ep59: Essential Ethics in Paediatrics

When can a child be said to have cognitive capacity and bodily autonomy? For those who don’t, where does the guardianship of the parent to give way to that of the medical professionals? These questions and more are discussed in two case studies from the Essential Ethics podcast, produced within the Children's Bioethics Centre in Melbourne.

Ep58: Billing Part 2—Compliance and the Free Market

Almost 500 million Medicare rebates are processed every year and for the most part these are claimed appropriately. But non-compliant billing could be costing the health system over 2 billion dollars annually. The vast majority of this comes down to lack of education about the MBS. Department of Health has an elaborate, and sometimes controversial way of identifying misuse of the system. Government regulation also influences the market for private medical fees as does supply and demand of certain specialties.

Ep57: The Art of Telehealth

COVID-19 has disrupted delivery of routine healthcare in many ways. Consulting patients by video or phone can be a way to keep patients safe, but many doctors are nervous as they adopt it for the first time. In this podcast we go over some of the bureaucratic and tech support questions that clinicians have been asking during the current crisis. We also discuss the art of building trust with new patients, and conducting a physical examination through telehealth.

Ep56: Billing in Byzantium

Australia has one of the best value health systems in the world, but also some of the most complicated health regulation that ties together public and private payers. This creates some traps for well-intentioned providers and loopholes for the less well-intentioned.

Ep55: Starting out in Private Practice

When doctors are starting out in private practice, they typically do so within the safety net of an established practice, and typically renting a room in exchange for an agreed portion of the consultation. The next levels of complexity involve setting up a business for oneself, or partnering in a group practice. In this podcast we discuss the personal and financial challenges, and also how to build awareness and trust in the community.

Ep54: My Health Record in Practice

Australia’s personal health record has been around for seven years, but it’s been hard getting health providers to upload data the MyHealth Record routinely. The uptake differs wildly between primary, secondary and tertiary care, so in this podcast we visit each of these settings and hear what the different expectations are of this new tool, what are the benefits gained, and how well it fits into the workflow of a consultation.

Ep53: Marrabinya—a hand outstretched

Marrabinya is a Wiradjuri word meaning “hand outstretched.” It’s the name of a service in the Western New South Wales Primary Health Network which financially supports Indigenous Australians to attend specialist consultaions. Aboriginal and Torres Strait Islander Peoples currently receive specialist medical care 40% less often than non-indigenous Australians. The Marrabinya staff explain how socioeconomic factors and institutional biases even in these settings can accumulate to prevent Aboriginal patients from receiving the care they need.

Ep52: Opioids Part 2- Regulation and Marketing

This episode looks at influencers of opioid prescribing. First we ask which are the opioids most commonly leading to dependence and why are they prescribed. Then we discuss the mixed messages that prescribers are getting from guidelines and pharmaceutical regulation, not to mention promotional campaigns by pharmaceutical companies. In Tasmania these influences have be countered by education, regulation and real-time prescription monitoring.

Ep51: Getting off the Opioids- Part 1

Australia and New Zealand have seen a fourfold increase in opioid use over the last thirty years. Most of this prescribing has been for chronic non-cancer pain, but there is little evidence to support this indication. In this podcast we’ll discuss some of the latest studies that provide evidence against the efficacy of opioid use for chronic non-cancer pain. We explain how to identify patients that have developed dependence on or addiction to opioids and how to wean them off this medication. And we describe an alternative approach to therapy that involves breaking maladaptive pain associations in the nervous system.

Ep50: Rural Medicine in NZ- Congress 2019

In this episode we hear three perspectives on rural medicine in New Zealand-Aotearoa, recorded at the RACP Congress in Auckland. New Zealand doesn’t have the same extremes of remoteness of Australia, but it does have a rugged landscape that results in small and scattered communities. The populations which are disproportionately under-serviced and in worse health, are not necessarily the most remote, and the demarcations fall much more starkly along lines of socioeconomic status.

Ep49: Training in the Bush Part 2—Remote WA

Remote settings in Australia only have 11 percent as many specialists per capita as major cities and this means that pathology is often more advanced by the time it’s diagnosed The medicine can be confronting but the training experience is great and rewarding. In this episode we visit Broome, two and a half thousand kilometres from tertiary facilities in WA, and find out what it’s like to train as a generalist up there.

Ep48: Training in the Bush Part 1—Country NSW

A third of Australia’s population is classified as regional or remote, but as it’s such a big place it’s hard to provide comprehensive heath care all over. In this episode we visit the country town of Dubbo which services a catchment of 130,000 people across Western NSW. While need in this area is high, Dubbo presents an example of strong clinical leadership and training across many specialties.

Ep47: Complex Adolescent Transitions—Congress 2019

Adolescence is a turbulent time as teens are faced not just with changes to their bodies, but to their moods and thought patterns as well. Young people with complex needs such as diabetes, transplant management or intellectual disability are the least likely to received dedicated transition support. The three speakers in this podcast explain that improving this transition process doesn’t require going way above and beyond regular practice, it just needs a little more coordination. And all the medical care in the world needs to fit in with the lifestyle that every young adult aspires to.

Ep46: The First 1000 Days—Congress 2019

This episode was recorded at the 2019 RACP Congress in Auckland. The three speakers dealt with the profound influence that the early years of life have on life-long health, wellbeing, behaviour and socioeconomic outcomes. Together, these speakers demonstrated that the consequences of childhood disadvantage are borne not just by individuals and families but by all of society, and conversely that a community approach must be adopted to ameliorate this. The lectures were framed by the launch of an RACP position statement on early childhood titled “The Importance of the Early Years.”

Ep45: Medical Fitness to Drive

Clinicians are drawn into the question of driving fitness in two main ways. The more clearcut is when a patient presents with a medical assessment form. The other is when they detect a new or worsening condition in a patient who is already licenced. Clinicians are expected to warn their patients off driving, and to potentially report them to the DLA if this advice isn’t being heeded. In this podcast we hear about some of the diagnoses that should raise red flags, and how to discuss cessation from driving with patients.

Ep44: Cervical Screening–Less Is More

Pap testing has been one of the most successful public health interventions in history. But in Australia, that classic cytology test now plays second fiddle to HPV testing and New Zealand intends to follow suit by 2021. The most noticeable shift is that the interval between screens will now be five years rather than two. And women will enter the program at age 25 instead of 18. This episode will answer some questions that women and health professionals might have about the renewed cervical screening program.

Ep43: What’s in a Name? - Disruption Part 2

This is the second of two podcasts about “digital disruption” in healthcare. We discuss autonomy in decision-making, and how access to health data is important to individuals. We’ll also hear about the cultural baggage attached to words like patient and consumer.

Ep42: The Value Proposition - Disruption Part 1

“Digital disruption” is what happened to the taxi industry at the hands of Google Maps and Uber or to the music industry with the onslaught mp3 files and digital sharing platforms. Democratizing technology is changing delivery of healthcare too and the expectations of consumers. What is the role of physicians in this brave new world?

Ep41: Targeting Diabetes

Glucose-lowering medications have been the mainstay of managing type 2 diabetes for 20 years. But a recent polemic between diabetes organisations has prompted an examination of specific targets for blood sugar in different patients. This episode explores the debate, and also summarises the use of new drug classes that don’t just lower blood glucose but appear to provide cardiovascular benefits directly in sicker patients.

Ep40: Rebooting CPD Part 2—Feedback and Audit

From 2019, there will be only three categories of activities in the RACP’s CPD framework, encouraging Fellows to participate in performance review and outcome measurement alongside more traditional educational activities. In this episode, two New Zealand Fellows discuss what they’ve learned about this ‘strengthened CPD’ approach since it was nationally implemented there four years ago.

Ep39: Rebooting CPD Part 1—Origins

In this episode we put continuing professional development (CPD) under the microscope, particularly the regulatory changes on the horizon. The Medical Board of Australia is emulating shifts already made by the Medical Council of New Zealand and regulators in Canada, the U.S. and the U.K. In some cases, this ‘revalidation’ movement has been fiercely opposed by doctors. But where did it come from, and why is CPD even necessary after you’ve already done 10 to 15 years of medical training?

Ep38: Making a Connection

An empathic connection and good communication between physician and patient can promote better outcomes. In this episode of Pomegranate Health, you’ll hear where major breakdowns in communication occur, and some remedies to improve this. We also discuss why some media report a ‘crisis of compassion’ in healthcare, and how empathic reflection can help both doctors and their patients.

Ep37: Ethical Dilemmas—Congress 2018

As medicine becomes more sophisticated, discussions about clinical ethics become more common. It’s now possible to support life in dire clinical circumstances, but physicians are not always sure if this is the right thing to do. This episode centres around ethical decision-making in two case studies. The first describes a three-year-old boy with a severe neurodegenerative disorder, whose parents are desperate to try an expensive experimental drug. The second is about a man ravaged by bowel cancer who has spent months on life-sustaining care.

Ep36: Acute Coronary Syndrome Part 2—Secondary Prevention

This is the second of two episodes about ACS, and deals with secondary prevention and adherence to therapy. One-fifth of people given a diagnosis of acute coronary syndrome (ACS) have another ischaemic event with six months of discharge. For secondary prevention, guidelines recommend pharmacotherapy, cardiac rehabilitation and lifestyle management. However, many patients are discharged from hospital without best-practice care, setting a trend for inadequate therapy long-term. Cardiac rehabilitation also needs to be modernised and personalised to keep patients engaged.

Ep35: Acute Coronary Syndrome Part 1—Diagnosis

Chest pain and other symptoms suggestive of acute coronary syndrome (ACS) make up the majority of presentations to hospital, but no more than 17 per cent of patients end up having the diagnosis confirmed. Diagnosing acute coronary is complex, and should be guided by the 2016 guidelines of the Cardiac Society of Australia and New Zealand. This podcast outlines how ECG is used to diagnose ST segment elevation myocardial infarction, and which life-threatening differential diagnoses to look for. The role of high sensitivity troponin assays is also discussed, in the differentiation of non-STEMI and unstable angina, and also in risk stratification of patients for safe discharge.

Ep34: Diagnostic Error Part 2—Systems

In Episode 32 of Pomegranate Health, we discussed cognitive error in diagnostic reasoning. On this episode, we take a look at systems pressures that increase the likelihood of medical error, crystallised by the recent prosecution of U.K. National Health Service (NHS) paediatrician Dr Hadiza Bawa-Garba. Almost half of diagnostic errors are due to a combination of systems errors and individual cognitive error. Obvious systems effects come into play in understaffed acute care units; if a clinician is forced to see too many patients without enough time to make careful examinations or reasoned decisions, errors become more likely. The stepping stones of ordering, receiving and reviewing diagnostic tests and scans also allow much opportunity for error and delay. Guests on this episode discuss mechanisms to improve efficiency.

Ep33: Early Days for Cannabis Therapy

Cannabis is a plant rich with potential therapeutic compounds and centuries of cultural resonance. However, only a few of the claimed medical effects of the plant have been proven by rigorous clinical trials in people. These include spasticity and pain in multiple sclerosis, chemotherapy-induced nausea and vomiting and some cases of epilepsy. But for many other conditions, systematic reviews have concluded that meaningful clinical recommendations cannot be made. In this episode, we explain how important it is to separate the effect of various cannabinoids in a systematic way, and why well-regulated research and prescribing will be safer for patients.

Ep32: Diagnostic Error Part 1—Cognitive Bias

This is the first of two episodes about errors in diagnostic reasoning. Misdiagnosis or delayed diagnosis occurs in 10-15 per cent of acute presentations, although fortunately only a tenth of these lead to serious consequences. But of concern is the fact that this figure hasn’t changed in three decades, despite progress in clinical knowledge. Cognitive errors result from jumping to conclusions on the basis of intuition and incomplete information. There are a hundred different types of such bias. On this episode, the most common types will be discussed, as well as strategies to force a more considered process of diagnostic reasoning.

Ep31: Ngā Kaitiaki Hauora

‘Ngā Kaitiaki Hauora’ translates as ‘guardians of health’. This podcast emerged from a meeting near Auckland organised by the RACP’s Māori Health Committee in November 2017. Members of various medical colleges and institutions came together to share perspectives on the delivery of health care to New Zealand’s population of Māori and Pacific Islander people. This conversation comes in the context of the Wai 262 claim, which is forcing a re-examination of the Crown’s obligations to the Māori population under the Waitangi Treaty of 1840.

Ep30: Being Human

Figures about burnout, depression and suicide are often reported on in the health workforce. These rates are typically twofold higher than they are in the general population, according to studies from New Zealand, Australia and around the world. Causes often given for psychiatric distress in the medical profession are the gruelling hours, the pressure of perfection, the unforgiving culture and the stigma associated with mental health issues. This episode examines how the system affects the individuals within it, and what can be changed for the better.

Ep29: Drug Interactions and Deprescribing

Drug-drug interactions might be responsible for a million hospitalisations in Australia every year. They have become more frequent over the decades, as more medications reach the market. More than half of people over the age of 75 are on five or more prescriptions—a state referred to as polypharmacy. This episode examines some of the systems that have led to current rates of polypharmacy, and some strategies for deprescribing. We also discuss a review from the Internal Medicine Journal on the common drug interactions physicians should be most concerned about.

Ep28: Transitions to Fellowship

Transitioning from trainee to consultant marks an exciting and daunting and step in a clinician’s career. Suddenly you take on responsibility for everyone on the ward—both patients and other staff. While the clinical skills have been hammered in over years of training, the ‘hidden curriculum’ can be harder to pick up. This episode captures the experience of striking out as a leader, manager and mentor to others. At the same time, recognising limitations and knowing when and how to seek help is all important.

Ep27: Severe Asthma

For years the management model for asthma has been empirical. The more serious the disease, the more the dose of controller therapy is increased. But this doesn’t work for everyone and a more rational approach involves identifying one of three distinct pathological pathways. This episode describes emerging diagnostic tools therapies such as monoclonal antibodies that are targeted to specific disease phenotypes.

Ep26: Dealing with Uncertainty – Part 2

Uncertainty is a frightening but unavoidable fact in every speciality. In the second of a two-part series, we look at the stigma and disorientation experienced by patients with medically unexplained syndromes, and some behavioural interventions for functional disorders. Since treatment outcomes are never guaranteed, we also discuss how a patient’s expectations must be managed from the beginning of a consultation, and the importance of long-term coping strategies.

Ep25: Dealing with Uncertainty – Part 1

Uncertainty is a frightening but unavoidable fact in every speciality. In the first of a two-part series, we examine the culture within the profession and general public that expects nothing less that perfection in medicine. We also ask whether hospital training might shelter younger doctors from the experience of complex, chronic conditions, and how much the simplicity of protocol can be relied upon.

Ep24: Social Medicine – Themes from Congress 2017

At May’s RACP Congress, there was great interest in sessions examining the moral obligations physicians have to society. On this episode of Pomegranate, three speakers from these panels reflect on some of the themes raised at the event.

Ep23: Managing Autism in the ED

People with autism spectrum disorder can become very agitated when experiencing pain, as they often have trouble making sense of their own emotional and physical states. Many also have difficulty communicating, and are thus difficult to assess in the emergency department. This episode covers techniques to calm distressed patients with autism and make medical assessments.

Ep22: Transitions to Retirement

It’s common to avoid thinking about retirement, and the idea can sometimes come as a shock—professionally, personally, or financially. This month, we speak with physicians both in and out of retirement, as well as two psychiatrists whose research focuses on medical professionals’ identity.

Ep21: Genomics for the Generalist – Part 2

This is a two-part series looking at how modern genomics is changing clinical practice. In our second episode, we consider genetic risk, the ethics of consenting patients, and gene-targeted treatments in cancer research.

Ep20: Genomics for the Generalist – Part 1

This is a two-part series looking at how modern genomics is changing clinical practice. In our first episode, we look at the differences in gene-testing technologies and their practical utility in clinical practice.

Ep19: Health, Disease and Death in the Early Colony

A history of health in the early Sydney colony. From disease epidemics and panic, to crude remedies and overcrowded cemeteries.

Ep18: Integrating Health and Social Care

Sir Harry Burns and Dr Ruth Hussey OBE are public health physicians involved in “whole-of-system change” in Britain’s health and social care. They were invited to Australia in 2016 to advise NSW Health on such delivery models; this episode of Pomegranate features a special lecture presented at the RACP during their trip.

Ep17: Better Practice in Paeds

EVOLVE is the RACP’s initiative to minimise clinical practices not supported by the current evidence base. This episode takes a look at the recently published list of low-value practices in general paediatrics and some alternatives that can be adopted.

Ep16: Mind the (Gender) Gap

While more than half of all medical students and trainees are women, they make up only about 30 per cent of registered physicians. On this episode, guests discuss challenges for equity in medicine, and how role-modelling and leadership may offer strategies to support the next generation of women doctors.

Ep15: Methamphetamine – Beyond the Hype

Crystal methamphetamine, or ice, has been sensationalised in the media over the past decade. This episode puts straight some of the facts and figures about ice use, and talks about the damaging stigma of the media narrative.

Ep14: Fever of Unknown Origin

With the evolution of diagnostic technologies, the diverse conditions that underlie pyrexia of unknown origin (PUO) are changing. This episode explains how to rationally investigate patients with persistent fevers, and alleviate their anxiety throughout the process.

Ep13: A Fresh Start for Disability Services

As the National Disability Insurance Scheme (NDIS) rolls out in New South Wales and Victoria, this episode examines the impact it has had for recipients and their carers.

Ep12: Perspectives on Aboriginal and Torres Strait Islander Health

In anticipation of NAIDOC Week, this episode focuses on Aboriginal and Torres Strait Islander people’s health in Australia.

Ep11: Adolescent Health Adds Up

For physicians in Australia and New Zealand, there has been no specific training to meet the needs of adolescents—until now.

Ep10: Evolving Your Practice

Costly or prolonged treatment doesn’t always translate into better outcomes for patients. In response, the College has launched EVOLVE.

Ep9: The Gut Microbiome and IBD

Understanding the gut microbiome offers potential new insight for treating a number of diseases—gastrointestinal and otherwise. But what’s the evidence base? This episode is presented in partnership with the Internal Medicine Journal.

Ep8: Obesity Inside Out

Obesity can seem like what strategists call a 'wicked problem'—a problem with so many parts that it's impossible to solve. But some things are changing.

Ep7: The Art of Supervision

Supervision shapes the next generation of physicians. This month, a mix of Fellows and Trainees considers different aspects of being a supervisor and why they find the process worthwhile.

Ep6: Antibiotic Resistance – Are We All Doomed?

In a new article on antibiotic resistance, Prof Peter Collignon says he is actually optimistic about the future. This episode is presented in partnership with the Internal Medicine Journal.

Ep5: Physician, Heal Thyself

Most preventive health messages focus on diet, exercise, and stress reduction. But are doctors taking this advice for themselves?

Ep4: Stem Cell Therapies Today

This month we’re presenting an overview of stem cell research—looking at ongoing clinical trials for stem cell therapy around the world, and the current treatments available in Australia and New Zealand.

Ep3: Law at End-of-Life

Doctors may have gaps in their knowledge of end-of-life law. In this episode, the last of our end-of-life series, we review the relevant legal frameworks.

Ep2: Cultural Humility

Treating a dying person goes beyond understanding their disease. In the second of a three-part series, we examine the importance of family and culture in end-of-life care—from the ICU to the neonatal unit.

Ep1: Recognising Death

End-of-life decision-making is a hard topic to discuss with patients, but it might be the most important conversation we’re not having.