Transcript

MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini for the Royal Australasian College of Physicians. As you’ll have seen from the title, today’s episode is a birthday celebration. That’s right, the podcast was launched in June 2015 so we’re marking the ten year anniversary. I’ve been behind this microphone for nine of those years, which is quite a sentence. But it has been a real privilege to work for the RACP and in a small way contribute to the collegiate environments that helps you do your work and stay well.

Today I’m going to do a Pomegranate retrospective and highlight some of the standout episodes from the last ten years. If you’re a recent subscriber, this might help you navigate the back catalogue of more than 130 episodes. But before I do, I want to share some fun facts or rather, some fun stats. Over those many episodes we’ve had about 340 guests on the show. Not just physicians of every flavour, but also GPs and critical care specialists, surgeons and nurses, patient advocates and carers, academics and public servants.

Over the year 2024 alone there were 119,000 downloads of all episodes. It’s hard to say how many listeners that represents, though any single episode gets between 5000 and 6000 downloads in a year. Some of our oldest episodes have had three or four times that number since they were published. As you’d expect, most listeners are within Australia at 68 per cent of the audience and another 8 per cent from Aotearoa-New Zealand. But there are listeners in over 150 countries around the world. The US and UK come next on the list, but would you believe that Canada is pipped out by Iran, and then Germany, Japan and India round out the top ten. A full 14 per cent of listeners are located outside the traditional anglosphere. So, a special shoutout to those individuals who have tuned in from Lithuania and Albania, Ethiopia and Mali, Oman and Kazakhstan, Myanmar and the Cook Islands. And honestly, thanks to every single person who has listened over the years.

Okay, let’s get stuck into the Best of Pomegranate Collection. I’ll assume that you’re able to pretty easily scroll back over the past two years, so I’ve focused on episodes that were published before mid 2023. I’ll start first with a spread of some of the clinical topics we’ve covered. We’ve done episodes on the diagnosis and prevention of acute coronary syndrome; on managing severe asthma or avoiding drug interactions from polypharmacy; and on precision therapies for melanoma and rarer cancers. One of the all-time most downloaded episodes, was number 22: titled “Early days for medicinal cannabis”. You’ll remember that in that period around 2017-2018 there was a lot of talk about fast-tracking access to medicinal cannabis. Current RACP President, Professor Jenny Martin co-authored a College perspective urging that drug regulators and medical practitioners not abandon their commitment to evidence-based rigor just because of expectation from some consumers or industry groups. To add to that conversation I wanted to show that this caution wasn’t out of a sense of prudeness from physicians, but rather a duty of care towards their patients. I found a handful of medics who were closely positioned to trials of medicinal cannabis in various fields including palliative physician Professor Meera Agar, who has  been trialling the effects of the drug on stimulating appetite and enjoyment of food in patients nearing the end of life.

MEERA AGAR: We know that eating is not just a medical symptom, eating is part of our social life, our family life. You know, if you imagine sitting down, we do it without thinking every night with our families having dinner. Imagine if one member of your family was not able to participate or feel able to be part of that experience day in day out. That profoundly affects not just the wellbeing of that person providing food is one of the ways we show love in our relationships.

MIC CAVAZZINI: So, the delivery method in your trial will be as a vaporised cannabis flower bud. Why choose this delivery model rather than one of the more purified formulations, like dronabinol is pill formulation isn’t it?

MEERA AGAR: Yes, so, the prior studies did use dronabinol. Our concern was around the bio-availability of that product and eating is a spontaneous activity in that you need to have quite a rapid peak in THC so that’s why the vaporised route in terms of being able to get a rapid onset of that THC. But then also it to be quite rapidly removed from the body so that you don’t have THC hanging around when you’re not trying to actually get appetite stimulation was the theory.

And most studies in this area have not taken any pharmacokinetic data so that we have no idea when the drug is ingested what actually happens in the person’s body in terms of absorption, the peak levels, and how that relates to the change in symptoms and when people are telling us that they’re experiencing side effects.

So, the product we’re using is one of the sort of moderate range THC products so that we’re hoping that that minimises the significant side effects but we need to remember that people with advanced cancer have quite altered metabolism of drugs due to the weight loss. They often have brain effects of their cancer and other drug interactions that make them more vulnerable to medication.

MIC CAVAZZINI: So far from saying that “These patients are approaching the end of life, we should let them take whatever chances they want”—they actually could be quite vulnerable to side effects that don’t emerge so much in the studies of healthy patients?

MEERA AGAR: I suppose our view is quality of life is so important. Often you have one chance to provide the right treatment without harms. The other challenge I think in people who are physiologically vulnerable is that if you do get a side effect it’s often very tricky to then reverse the new problem. So, my view is that people at the end of life deserve the best evidence to guide their care because you have often one chance to get it right and to do it really properly. And it has such huge effects on their lives and the lives of their loved one.

MIC CAVAZZINI: Alongside Professor Agar I also interviewed Associate Professor Peter Grimison, who’d found that cannabis helped quell nausea in some chaemotherapy patients but was on average not as effective as other first line medicines. Professor Sam Berkovic, who specialises in treating childhood epilepsy, told me that cannabinoids did help about 5 per cent of those patients refractory to other medications, but it was no game changer. And pain specialist Associate Professor Carolyn Arnold compared the analgesic effects of cannabinoids to codeine or tramidol while the potential harms could be worse.

One take away message from that podcast was just how vulnerable clinical practice is to all sorts of external forces. There are so many systems and human factors between the lab bench, the clinical research, the guidelines and then the translation of this into clinical practice.  One example of this was episode 41, which I called Targeting Diabetes because it focused on a debate going on in the USA at the time around the appropriate HbA1c targets for people with Type 2 diabetes. For two decades, the mantra for blood glucose management had been “the lower the better,” but in April 2018 the American College of Physicians allowed for less stringent targets than had been previously accepted. This prompted intense debate over which patients were actually at risk of low frequency adverse events from tighter glucose control. Here are comments from Auckland endocrinologst Dr Paul Drury, and from Professor Sophia Zoungas, who co-authored a strident editorial in response to the ACP along with diabetologists from around the world.  

PAUL DRURY: If you’re talking about an older frail patient, perhaps living alone an older, frail patient—perhaps living alone on an agent that can produce hypoglycaemia—who’s already had a fall or two—who’s had a vascular event–and is struggling to cope with their diabetes—then they should have a higher target because the hazard and risk of serious damage is high. If on the other hand, you have a young patient—age 40, 50 or 60—newly-diagnosed with a long life expectancy, otherwise healthy with no other comorbidities, and you’ve got them on metformin and possibly something else, why ever would you de-intensify? You would absolutely go for the best glycaemic control you can achieve without hypoglycaemia. But it really is horses for courses and I don’t remotely agree with the sort of blanket statement in the ACP, which I think it has not been thought through.

SOPHIA ZOUNGAS: So, I think they are just overgeneralising a small risk that applies to a particularly high-risk group of frail people with diabetes where, yeah, it would be more appropriate to be more modest and conservative in the targets. You know the paradigm really now is individualisation. It seems to me that the ACP are well behind the eightball from us where we were already doing this a decade ago.

MIC CAVAZZINI: And even the ACP makes this the first statement of their guideline—that clinicians should personalise goals for glycaemic control. So, if everyone’s agreed that personal factors are more important than numbers why the big drama about whether the target is specifically 7 per cent of 7 to 8 per cent?

SOPHIA ZOUNGAS: What you ask is a good question, and you may say we’re arguing semantics about where the numbers are, and should we be using numbers? But unfortunately monitoring glucose levels is all about numbers. People need to understand what a normal glucose range is and what they’re aiming for. If we take that away, then it’s —I use the analogy it’s like taking the tools that a pilot has to fly an aeroplane. If we don’t know what our numbers are, well, you know how are we flying our plane?

MIC CAVAZZINI: What’s a safe altitude to fly at?

SOPHIA ZOUNGAS: Correct. So, you know I think you can’t fly blind and you need to empower those individuals with diabetes and give them the skills the understand what the numbers mean. But also not create anxiety by being overly aggressive with targets or overly aggressively titrating therapy.

MIC CAVAZZINI: People always ask me how I come up with stories for Pomegranate Health. The theme for the episode I just mentioned had come from one of the trainees on the podcast editorial group who’d seen it discussed in the medical press. My reviewers are a motley crew of forty or fifty physicians who I bounce ideas off and send audio drafts to for feedback. I’m so grateful to all of these volunteers over the years who’ve dedicated their time, expertise and quiet a bit of patience for this armchair expert.

Sometimes I get suggestions mailed in from listeners and remember you can always write in to podcast@racp.edu.au. And in 2019 I was inspired by comments from a colleague to make sense of the shift in Australia’s cervical screening program, which went from two yearly pap smears to five yearly testing for infections of human papillomavirus. It was an intriguing conversation about how a public health decision of such magnitude could be made on the back of limited real-world, real-time data.

You don’t have to be a sub-specialist to become absorbed in this thin and winding path of healthcare implementation. Another episode with this character was number 70, titled Zeroing in on “the renal troponin” which was informed by an article in the College’s Internal Medicine Journal. Acute Kidney Injury makes a greater contribution to early mortality than myocardial infarction but the presenting features aren’t as overt as those of a heart attack, and serum creatinine levels rise only after substantial damage has already been done. A urinary biomarker for acute kidney injury would be very valuable in high-     risk patients, such as those undergoing major cardiac surgery or liver transplantation or those affected by sepsis.

A decade ago, two promising candidate proteins were identified, cell cycle arrest proteins which are expressed after acute kidney injury to downregulate cell proliferation. But this overexpression is not a clear on-and-off process and the area under the ROC curve of the integrated assay is about 0.83. That’s not a bad predictive value, but it’s a long way off the 0.96 value that a positive troponin assay has as a predictor of MI in a patient admitted with symptoms of a heart attack. Professor Rinaldo Bellomo AO of Austin Health and Monash Hospital has been testing the clinical utility of the commercially available Nephrocheck assay. Here is a snippet of our riveting interview. 

RINALDO BELLOMO:       Look, you’re absolutely right.  Troponin is in a league of its own.  And also it is associated with therapies that are clearly beneficial.  We’re nowhere around that.  Imagine, for example, not having chest pain when you have a heart attack and having a test that tells you that there’s been a heart attack when half of your heart muscle is gone.  And so, you lose the ability to develop a therapy, because everything’s already happened and it’s already finished. 

Giving an intervention late is like closing the stable after the horses have bolted. On the other hand, if you knew the horses were going to run out the stable, then you can close the door very quickly and you’ll be successful.  If you don’t have biomarkers, you can’t test the hypothesis that if you change the course of acute kidney injury, you change the course of the patient’s outcomes.  You’re never really in a position to test the therapy in a way that gives it a real chance of showing whether it’s efficacious or not.

MIC CAVAZZINI:               So as a parting comment, should our listeners go into work tomorrow and order a box of these assays in?  And, if so, which listeners are going to find it most useful, the intensivists, or –

RINALDO BELLOMO:       Yes, that’s a good question.  I think, at the moment, these remain research tools.  As they get understood more, probably belong to both the Emergency Department, the intensive care environment, and the nephrology environment.  But how, in what patients, and specifically when and so on, is still a matter of research.

But irrespective of this research, the fact that a subclinical or a sub-GFR-derived acute kidney injury exists, is a fact. There is a biological phenomenon where people with a variety of conditions release biomarkers in the urine, in a way that is normally not done by human beings, is a fact.  And that these patients are at greater risk of adverse events, compared to those patients that do not release these biomarkers, is a fact.  So there is a thing—it’s a biological event.  We can pretend that it doesn’t exist, but it’s probably best to pretend that it does exist, and then investigate it more clearly to understand it better.

MIC CAVAZZINI: The Pomegranate Health podcast doesn’t just do clinical themes but also career guidance. Episode 55 was a very practically-focused explainer on “Starting out in Private Practice”. With late-career rheumatologist Dr Lou McGuigan and some financial advisors, this podcast explored the challenges, rewards and the small print of going into business for yourself or with others. I was chuffed to see listeners leave feedback at the website like, “most insightful podcast I have heard for private practice specialists.”

It’s always humbling to interview the brilliant medics that come through the RACP. It makes me wish I’d listened to my mother and studied medicine rather than going down the rabbit hole of laboratory research. I thought a doctorate in neuroscience at the University of Oxford would unlock the secrets of the universe but I didn’t experience any Eureka moments there or in my postdoc at the ANU. And so, about 12 years ago I turned towards teaching and health commentary.

After a failed start as a newswriter, I taught myself to edit audio. I love the intimacy of the format and the scope that narrative journalism allows to explore nuance and feeling. This podcasting role at the RACP is a perfect fit, in that I’m equally interested in health policy and ethics as I am in the biomedical science.

One guiding document I use is the RACP’s Professional Practice Framework which lays out the standards of practice that make a well-rounded physician. Displayed in a schematised rosette are the domains I’ve just mentioned, each forming a petal of a different colour, then there are Communication, Quality and Safety, Leadership and teamwork, Cultural Safety and also Judgement and Decision-making.

This last theme was explored in Episode 32 on cognitive biases in diagnostic thinking. My job was made very easy by the talented hosts of another medical podcast, Doctors Nic Szecket and Art Nahill. They’re two general physicians from Auckland City Hospital who for six years put their heart and souls into the IM Reasoning podcast. I tried to distil all of that into a one episode reader’s digest of some of the more common forms of diagnostic bias; premature closure, the framing effect, the anchoring heuristic and so on.

NIC SZECKET: Yeah, so diagnostic momentum I see as a continuation of anchoring, the difference being that the diagnosis gets anchored from person to person. Framing isn’t just purely about handing over a diagnosis and expecting every other team subsequently to continue with that same diagnosis. Framing is the information that you emphasise when you’re handing over patients, what you decide to even just mention will affect the way that subsequently people think about that diagnosis. The way that you write a note, and that’s going to affect the diagnoses that are elicited in other people’s minds.

ART NAHILL: One of our juniors did a recent study on the framing effect and he sent out surveys to emergency room physicians and general physicians, both registrars or residents and consultants or attendings, and in it there were essentially two different scenarios. And one of the scenarios was framed very suggestively for pulmonary embolus, the other one had exactly the same clinical information in it but was not framed suggestively, and the results were pretty dramatic.

So, the survey asked people to list the top three things on the differential diagnosis and what they would do to investigate it. In the scenario with the framed pulmonary embolus, I think almost all respondents had pulmonary embolus on their differential diagnosis, whereas only, I think, a third in the non-suggested scenario had pulmonary embolus even anywhere on their differential. The second disease was interstitial lung disease. Again, one framed suggestively, one with the same clinical information framed non-suggestively and the drop-off was remarkable.

MIC CAVAZZINI: Episode 25, published way back in 2017, fell within a similar ballpark of ideas, that’s to say, Dealing with Uncertainty. First, you’ll hear a broad comment from Professor Ian Harris, a surgeon at Liverpool Hospital who authored the book “Surgery, The Ultimate Placebo.” And then I’ve spliced in a segment of my conversation with Associate Professor Louise Stone, a GP academic in Canberra familiar with managing patients who have medically unexplained symptoms.

IAN HARRIS: Yes, I think that there’s a natural intolerance to grey areas in humans. We have an aversion to uncertainty. Doctors falsely see this as a failing, because they think that unless they’re providing an intervention that they’re not treating the patients. And there’s this conflation between medical interventions and medical care. And you can care for someone very well without necessarily intervening. And probably on the other side, on the patient side, they’re falling for the same trap. They see everything as having a clearly identifiable unambiguous source that can be identified on a scan or a blood test, and can be addressed, and specifically targeted by a medical intervention.

MIC CAVAZZINI: In one of the BMJ journals, West and West say that there is too much reliance on protocols “because they absolve the clinician who follows the protocol correctly.” But these create a false sense that everything can be reached by a decision tree, yes or no. Whereas the opposite extreme, the “dirty option”, is to pass all the responsibility onto the patient. And while “this form of shared care remains fashionable,” they say “it is in reality an abrogation of responsibility. Something has gone wrong with the clinical relationship where clinicians quote figures, survival rates and probabilities of side effects at their patients.”

LOUISE STONE: I think that’s an interesting question. I tell my registrars is that autonomy is on a spectrum. You know, personally, if I’m unconscious, I don’t really want an anaesthetist waking me up and asking my opinion about which anaesthetic I’m going to use, you know? I want them to just be the doctor and do the job. We don’t talk about that much anymore, because it’s seen as patriarchal. But I think it’s very patient-centred when a patient says, “What do you think doctor?” or “I don’t know any more, it’s all too hard and too complicated”—to be able to be brave enough to stand up and say, “This is what I think.” And that’s not taking away power if the patient is begging you to take that power for them.

Particularly in paediatrics, parents tell me when a child is critically ill they actually don’t sometimes want to make that decision, they want to put their faith in someone and not think, “If I’d only made the other choice, if I’d only”—you know. I find that very hard. And I don’t think it’s discussed clearly about when you need to be the patriarch and stand up, and stand in for the patient when the patient’s not able to make a choice. It’s a very difficult place to be.

MIC CAVAZZINI: Now we’re talking about some fuzzier domains of professionalism, like participatory decision-making. One of the surprising stars of the Pomegranate Health back catalogue was episode 45 about Medical Fitness to Drive which has been downloaded around 15,000 times. Eleven of those listeners actually took the time to post comments at the website to say how it had helped them navigate such consultations in a non-confrontational way.

Episode 38 was all about communication; How to give patients the space to speak and also how to share ones own feelings with colleagues after confronting clinical scenarios. I was honoured to have an international guest join me from New York City, Dr Danielle Ofri who is an internist from Bellevue Hospital. She’s also a prolific writer, with her commentary on health systems and patient doctor interactions appearing in New York Times, the Lancet, the Washington Post, the Atlantic magazine and beyond. It was her bestselling book “What Patients Say, What Doctors Hear?” the inspired me to reach out and have her tell some of these striking stories in person.

DANIELLE OFRI: Typically we start an interview with, “What can I help you with today? What brings you here today?” And the patient will say “Well, I have this pain over here.” And then we doctors, we jump in right away, on average maybe 10 seconds, and we jump in with legitimate questions: “When did the pain start? When did it stop? What makes it better? What makes it worse?” because we want to find the origin of this pain. But of course, the patient may have had a second thing to say like, “I think I may have had a stroke last week,” but we’ll never get to that, because we dive right in. And it’s really this dogged detective instinct that in essence backfires, because we interrupt the patient, and they may never get back to the most important thing. So, you can see the genesis of medical error right there in those first 10 seconds, and we doctors divert the dialogue in the area that we want to go.

MIC CAVAZZINI: I found quite amusing in the book your insistence on testing this out on yourself with a stopwatch.

DANIELLE OFRI: You know, I wondered, “How long would patients actually talk if I let them speak?” And so, I found one study that actually looked at that. A Swiss study where they let the patients talk until they naturally stopped, and checked the stopwatch. And on average, it was 92 seconds. Not the tsunami that we all were fearing. But you know the Swiss—reserved, precise, diplomatic. They don’t necessarily have the gab for loquaciousness that maybe Americans have. So, I tried it out myself. And what’s interesting, the first patient talked maybe 30-some odd seconds, it wasn’t too bad, but he was pretty healthy, and the second patient also less than a minute.

But then came my patient Josephina Garza, which is not, of course, her real name. A patient with a host of aches and pains, anxiety, depression, irritable bowel, she has an elderly mother to take care of and an unsupportive boss. And I thought “Boy, we’ll be here forever.” But I made a promise to let every patient talk, so I said to her, “How can I help you?” and turned on the stopwatch. And she said, “Every single thing hurts, from my nose to my toes,” and she reeled off every symptom, her tongue was burning, and she had pains up and down her elbows, and she just went on and on, and every time I said “Anything else?” there always was. Finally, she came to the end. I checked the stopwatch, it was about four minutes and 10 seconds, right—not four hours.

My interns will come and say, “The history’s not so good, the patient was a poor historian. And I always say “Oh, would they make a better architect, or social worker?” And the idea is that the burden is on them to tell the best story, as opposed to the burden being on us, or shared by us, as being good listeners. And there’s really interesting research on how the quality of the listener directly affects the quality of the storytelling, because as the person’s telling a story, and they sort of catch that their listener isn’t with them, well then they circle back and they tell the plot again, and eventually the story falls apart and peters out. And I believe that’s us, the doctors. We kind of look like we’re paying attention, but we’re busy typing into a computer, and so that alone already detracts from the ability to look at the patient, see how their face is responding to the questions, catch the body language. And so, we’re not actually hearing what the patient says.

MIC CAVAZZINI:                We sometimes make the distinction between soft skills and hard skills, but these domains of practice often go hand in hand. One good example of this was a story I titled “Genomics for the generalist” where two of my guests gave brilliant explainers about the applied science, while a clinical geneticist and a genetic counsellor talked about the ethical minefield that comes with it. What does a clinician do about incidental findings, particularly where no treatment can be offered? Or when advising couples who carry genes for a genetic disorder about risks of passing that on, how to navigate the variable understanding or tolerance of genetic risk without being too paternalistic.     

Perhaps the most fraught area of patient communication relates to instances of medical injury, which I explored in episodes 74 to 76. What do patients and their families want to hear from their treating doctors to demonstrate remorse and accountability? And how might institutional advice often given to medics “to say sorry, but don’t admit liability” interfere with the authenticity of that apology, perhaps even making litigation more likely. By contrast, “no fault” compensation schemes like that found in New Zealand can facilitate apologies and help generate a sense of restorative or distributive justice.

I’ll share with you some comments on how medics themselves deal with the anguish of having contributed to medical injury. Few people have described this experience as philosophically as Minnesota ruralist David Hilfiker did in his 1984 essay “Facing our Mistakes”. I tried to contact Dr Hilfiker but he had retired from public life with declining cognitive health. In his place, I asked my colleague and part-time thespian Michael Pooley, to read these words.

The most gut-wrenching part of Hilfiker’s essay includes reflections on a grievous error that he had made decades before. One of his patients, Barbara Daily, had come in with a hunch that she was pregnant, but four pregnancy tests over six weeks turned up negative. Clearly the pregnancy had terminated but hadn’t been followed by a miscarriage. There was no need to send Barbara on a long drive to an expensive specialist consult, so she was booked in for the D and C procedure in the familiar theatre of the country practice. Once she was anaesthetised and Dr Hilfiker got to work with care. It was only as he began removing the pieces of foetal tissue, unusually pink and healthy, that he realised with horror that he had aborted a living foetus.

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MICHAEL POOLEY as DAVID HILIKER:     “Although I was as honest with the Dailys as I could be in those next months… I never shared with them the agony that I underwent trying to deal with the reality of the events. I never did ask for their forgiveness. I felt somehow that they had enough sorrow without having to bear my burden as well. … it was my responsibility to deal with my guilt alone… How can I not feel guilty about the death of Barb's baby?... 

Even the word "malpractice" carries the implication that one has done something more than make a natural mistake; it connotes guilt and sinfulness.…[This results] in an intolerable paradox for the physician. We see the horror of our own mistakes, yet we are given no permission to deal with their enormous emotional impact…Although mistakes are not usually sins, they engender similar feelings of guilt. The only real answer for guilt is spiritual confession, restitution, and absolution. Yet within the structure of modern medicine there is simply no place for this spiritual healing… there is no place for real confession; "This is the mistake I made; I'm sorry."

How can one say that to a grieving mother, to a family that has lost a member? It simply doesn't fit into the physician-patient relationship. Even if one were bold enough to consider such a confession, strong voices would raise objections.  The nature of the physician-patient relationship makes such a reversal of roles unseemly…

Little wonder that physicians are accused of having a God complex. Little wonder that we are defensive about our judgments. Little wonder that we blame the patient or the previous physician when things go wrong; that we yell at the nurses for their mistakes; that we have such high rates of alcoholism, drug addiction, and suicide. At some point we must bring our mistakes out of the closet… We need to find healthy ways to deal with our emotional responses to those errors. Our profession is difficult enough without our having to wear the yoke of perfection.”

MIC CAVAZZINI: I’d better wrap up for now, but I hope that this podcast has inspired you to dig through the extensive back-catalogue of Pomegranate Health. In a month or so I’ll put out another sampler touching on the professionalism domains of cultural safety, healthy policy and systems, physician wellbeing and also a few easter eggs from the history of medicine. There are too many people to thank here for their support of the podcast over the years. Both the physicians who have contributed as guests or reviewers and also the staff who have greased the wheels to keep it ticking over. I’m going to list as many as I can remember at the webpage racp.edu.au/podcast, then click through to this episode.

You might notice that the web page has undergone a bit of a redesign. It’s now a bit easier to navigate and will be even better when we get a search term function built in. But the easiest way to scroll and search really is using a pod browser app on your phone. Do yourself a favour and download Apple podcasts, Spotify, Castbox, or any other such aggregator and then search for Pomegranate Health. To get notified of new releases by email you can subscribe to a mailing list from the web page.

Please send any feedback or ideas to podcast@racp.edu.au. Thanks to all those listeners you have written in at various times, it’s nice to know someone is listening. Pomegranate Health is produced on the lands of the unceded Gadigal people of the Yura nation. I pay respect to their elders past and present. My name’s Mic Cavazzini. I’ll catch you very soon.