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.

You might have seen some fuss recently about the ten-year anniversary of this podcast, and in July we published a retrospective sampler of episodes from the back catalogue that you should go back and listen to if you’ve only subscribed recently. There are a few more samples I’d like to share with you to capture the full spread of themes that Pomegranate Health has to offer. Later you’ll hear about a great initiative in Indigenous Health, the complexities of medical billing, starting your own private practice and gender bias research and delivery of care. But I want to start with a fun segment attempting to answer the question I get asked all the time about why the podcast is named after a fruit. This was first published in episode 106 alongside an interview with the host of the great medical history podcast This Medical Life. But I’m going to play a revamped 7 minutes here, and you can see all the colourful pageantry I describe in the show notes at racp.edu.au/podcast.

So, the ye olde pomegranate that you see in our podcast tile is, actually copied straight from the coat of arms of the RACP. It appears there on a shield held aloft by an emu and a kiwi, the legendary flightless birds of Australia and Aotearoa-New Zealand. The College was founded in 1938, after a brief prelude as the Association of Physicians of Australasia. Prior to this our more esteemed physicians might choose to become members of the Royal College of Physicians, London. The RCP shield design is meticulously described in its official Grant of Arms as “A sable border with half a golden fleur de lis. From the top a flesh-coloured arm with an ermine cuff out of a cloud, argent and azure, with the rays of the sun in gold. The hand feeling the pulse of another arm, on top of a golden pomegranate.”

As explained in the journal of the London College, all these colours and motifs have a recognised symbolism in heraldry, except for the pomegranate. We can presume, however, that it was an homage to the College’s founder, King Henry the VIII. That’s right, the College was created by a Royal Charter in 1518, after Henry was petitioned by his personal physician Thomas Linacre to do something about rampant malpractice and quackery. But as you might suspect, the middle-eastern pomegranate was not grown in England and had never been represented in English heraldry before then. It actually made its entry through Henry’s marriage to Katherine of Aragon in 1510. Her personal crest was a crowned pomegranate and it infiltrated the palaces in many forms, often intertwined with the red and white Tudor rose. As recently as 2023 an amateur metal detectorist in Warwickshire uncovered a unique gold pendant in the shape of a heart decorated with these botanical symbols and the letters H and K.

But the pomegranate isn’t typical of Aragon either, flanked as it is by the Pyrenees mountains. In fact, it’s known as the Apple of Granada, the capital of Andalucia on the mediterranean. Today, the fruit is represented everywhere throughout the city, in reliefs and fountains and mosaics and today even bollards and manhole covers. That’s because pomegranate trees thrived down there after they were brought over from Syria with the Muslim conquests in the late 7^th Century. But their rule of several hundred years was coming to an end with the reconquista. The last stronghold of the Moor’s was Granada, under the Nasrid Sultan, Muhammad XII, known to the Europeans as Boabdil. Katherine’s parents, Queen Isabella of Castile and King Fernando of Aragon, had demanded its surrender, and when Boabdil refused, their forces besieged the city. Eight months later, Boabdil capitulated, and handed over the keys to Granada at huge ceremony on the 2nd January 1492. There’s a vibrant representation of this moment painted 400 years later by Franciso Pradilla that you’ll find in the show notes.

And interestingly, the scene was also described in the journal of Christopher Columbus like this; “After your Highnesses won the war of the Moors who reigned in Europe, finished it in the great city of Granada, where this present year 1492 on the 2nd January I saw the royal banners of Your Highnesses planted, by force of arms, on the towers of the Alhambra, which is the fortress of the city, and I saw the Moorish King come forth from the gates of the city and kiss the royal hands of your Highnesses.” Who knows if he was actually there, or just flattering the royal power couple who had bankrolled his little boating adventure that departed in August of the same year.

Now, there’s some debate as to whether the name Granada is itself is a nod to the fruit. By most accounts pomegranate comes to us from Latin, pomum granatum. That’s an apple with grains or seeds. But some suggest it’s a corruption of the word garnatum, which is where we get the name of the gemstone garnet. And I suppose pomegranate seeds also glisten a deep red? The city of Granada was, in fact, known by the Moors as Medina Garnata, or originally Garnata al Yahud, given the population of Jews living there when they took over. But I’ve also read that in Arabic, Gar-anat means “hill of pilgrims” so it’s possible that this is all just an elaborate linguistic coincidence.

What we can say more confidently is that the pomegranate was absorbed by the house of Aragon as a symbol of its conquest but also of Katherine’s own personal connection to Granada. She was only 6 years old when the city was handed over, but she received her extensive education there before being sent off to England at age 15. That was marry Henry’s older brother Arthur, who died five months later of a respiratory infection. By the time Katherine married Henry at age 23, she was already a seasoned diplomat. The pomegranate motif also has a long tradition in religious art that would have made it an appropriate symbol for the Catholic princess. There’s a famous Botticelli painting from this period called Madonna of the Pomegranate, with the Virgin Mary holding the fruit alongside the baby Jesus. An article in the British Medical Journal explains how the motif is understood to evoke the resurrection, life everlasting, and also motherhood and fertility.

Similarly, in the 10^th Century Persian epic Shah-nameh, the divine prince Esfandiyār becomes invincible by eating a pomegranate, and then goes on to complete heroic labours that allow the prophet Zoroaster to spread his faith. In Judaism too there are references to the pomegranate’s power; in particular that it has 613 seeds, one for each of the commandments in the Talmud. And all this probably goes back to the Greek myth of Hades and Persephone. When she was abducted by the lord of the underworld, her mother, Demeter despaired. Being as she was the goddess of harvest, this brought an endless winter to the land and she appealed to Zeus for intervention. Hades told Zeus he would only allow Persephone to leave if she’d not eaten any of the enticing food of the underworld. As it happened, Persephone had cracked and eaten just six pomegranate seeds. So, Hades agreed to release her for half the year, a month for each seed, and this was made manifest through the arrival of spring and summer. Hence the ideas of fertility and reincarnation.

Whatever the origin story, by the 1600s there was a popular encyclopedia of heraldry produced “by the study and industry of John Guillam, late pursuant at armes.” In its entry for the pomegranate as associated with the city of Granada it is written, “This fruit is holden to be of profitable use in Physick, for the qualifying and allaying of the scorching heat of burning Agues, for which end the juice thereof is reckoned to have a very sovereign virtue”. And there may be a grain of truth in all this too, given more recent evidence that polyphenols within the pomegranate are associated with improved cardiovascular and metabolic health, as well as antioxidant, anti-inflammatory and even anticarcinogenic activity.

So that’s the roundabout story of how this fruit made its way from ancient myth into English heraldry and then onto this podcast. But there’s still one more twist to the story. I said that the Royal College of Physicians was likely honouring its founder Henry VIII. The problem is that the RCP only filed its blazon with the Royal College of Arms in 1546, which is after Henry’s somewhat turbulent divorce from Katherine in 1533. Remember all that fuss with the pope and the six wives? Awkward.

So how could this have come about? One editor of RCP’s journal made this speculation, “As the physicians of 1546 would not have been so rash as to purposely remind the irascible Henry VIII of his first wife, the choice of the pomegranate as a compliment to royalty could only have been made when the physicians first received their charter in 1518.” So, it sounds like the crest sat in someone’s drawer for two decades before being submitted to the College of Arms. Now that’s not something that could ever happen at the RACP.

Thanks for indulging this historical excursion- I can’t really help myself when curiosity gets the better of me. If you like such detours episodes 51 and 52 have some dazzling quotes from across the ages about the mystical power of opioids dating right back to the Hippocratic texts. In episode 63, titled “The WHO’s biggest test” I started by explaining how global health coordination started in 1851 in response to the third great cholera pandemic, when twelve imperial states came together in Paris for the International Sanitary Conference. The main question they wrangled over, and still an issue today, was how border closures and quarantines could be legally enforced so as not to conflict too much with trade. And making episode 121 on precision oncotherapy I learned that the histochemistry protocols that underpin staging of cancer in tissue, have actually been around for 150 years and have a bizarre crossover with the paintings of Vincent van Gogh.

It's hard not to think about history when one visits the RACP’s physical home at 145 Macquarie St, Sydney. The sandstone terrace had been built in 1848 for then media mogul, John Fairfax down the road from the first hospital in New South Wales. It never escapes me that this really is the heart of the Sydney colony, just a stone’s throw from the rich cove that the Gadigal clans called Warrane. To me this makes all the more poignant the RACP’s stated commitment to health equity for First Nations people in particular.They are so often marginalised within systems and institutions that subtly privilege patients who can advocate for themselves in a certain way. I’ve published a few episodes on cultural safety for Aboriginal, Torres Strait Islander, Maori and Pacifika patients.

But the story I want to share with you was recorded in late 2019 in Dubbo, about 400 km west of Sydney on Wiradjuri country. I turned up to the Holiday Inn conference room thinking I was just going to be interviewing the CEO of Marrabinya, an Aboriginal designed and led support service. Instead, I was sat at a table with nine regional link staff who assist patients to connect with specialist care. Here are just a few of their observations about implicit bias and other friction points. You’ll hear from Possum Swinton, Kym Lees and first up, Desley Mason.

DESLEY MASON:         Yes, experiencing it personally myself.  Of course I’ve got issues with my liver, a fatty liver and they say, “Are you heavy drinker?”.  And I said, “Sorry sir, I don’t drink”.  My last drink was 30 years ago”.  I never was a heavy drinker at all, it might have been once a month.  And that’s what I assumed it was, I was a full-blown alcoholic.  And that’s the hurtful part of it.

POSSUM SWINTON:  And I think another thing to get through to specialists and that too is how isolated some of our communities are, how much harder it is for them to get to these appointments. So, if they can try to ensure that they, you know, if they’ve got an appointment not to change it.  Sometimes I know it can’t be helped.  But can you really look at where that person’s coming from, and what it’s taken for them to get to where they need that help?  If you’re going to have to change anybody or put anybody back on the list, can it be somebody who can access it more easily than our clients?

KYM LEES:       Or you have like a hospital that puts a client sitting there waiting for surgery, the hospital will say “No, we’re not going to operate today.  We’re going to operate tomorrow”.  Comes that day, they put it back again.  They put it off, put it off, put it off.  We supported someone down there for about a month, waiting for surgery. So, it was about $2,000 for a week that we were supporting them to stay down there.  It’s very frustrating, because they’re away from home.  They’re away from family.  But you can’t go home because if he did go home, he’d be put back for another year for an operation.

POSSUM SWINTON:  What do you do? Yeah.

DESLEY MASON:         Because a lot of the people from out at Weilmoringle and Goodooga, they don’t have public transport.  So, they rely on family members to get them to and from appointments.

MIC CAVAZZINI:         And the family member that’s come along has given up a day of work.

DESLEY MASON:         That is correct.

POSSUM SWINTON:  Yeah, you can’t always guarantee they’re going to be able to take you again later on.

MIC CAVAZZINI:         And what’s it like going to ‘the Big Smoke’ for these clients?

MELISSA FLANNERY:  Scary.  It’s scary for me.  I won’t drive there, no way.

DESLEY MASON:         And one client that lives in Dubbo, she won’t go to Sydney by herself, because she’s terrified.  She’s terrified of getting off the train, and if something’s going to happen, or terrified of getting lost.  A lot of Aboriginal people, and I’m one of them, don’t know how to catch buses and trains in Sydney.  How do you do that?

DONNA JEFFRIES:       You need an Opal card first.

DESLEY MASON:         Well, if you say Opal card to me, I’d look for Lightning Ridge to go look for an opal. 

MIC CAVAZZINI:                 It was very humbling to be trusted with these stories for the staff at Marrabinya, just as on other occasions I’ve been honoured by the confidence of patient advocates and carers. In Episode 23 I spoke to the grandmother of a boy with autism who had accompanied him many times to the emergency room until he grew too strong for her to manage. Meanwhile in Episodes 60 and 61, I recorded the testimony of a man whose elderly partner had experienced alarming bouts of delirium in medical care. In both of these episodes, the consumer voice added great insight to the advice presented by the same specialists who had treated their loved ones. 

Remember how in the last sampler I referred the nine domains that contribute to the Professional Practice Framework? So we’ve just heard about cultural competence and communication. Equally important are the teamwork and professional behaviour that help support physician wellbeing. I’ve tackled this topic a few times in different ways. In Episode 30 titled “Being Human” I interviewed cardiologist Dr Geoff Toogood, who has become a powerful advocate for the greater recognition of mental health distress among doctors after experiencing his own battle with depression. In episode 101 titled “Setting the Standard for Workforce Wellbeing”  some inspiring clinical leaders shared initiatives to combat burnout in their own workplaces.  And in episode 83 you can hear about injecting good vibes into a colleague’s day or reassessing your career options when you feel like you’re at a dead end.

Speaking of career pathways, in 2020 I dedicated an entire episode to “Starting out in Private Practice”. This was inspired by a New Fellows welcome seminar I attended where veteran rheumatologist Louis McGuigan gave a presentations on this subject alongside some financial advisors invited by the College. There were helpful tips on how to structure a business and allocate one’s time, but it started with a bit of a pep talk on deciding when you’re ready to step out on your own, and staring down some of the stereotypes of private practice as being a bit boring or stuffy.

LOU MCGUIGAN:            Well, when I was training the general reputation is was private practice is what you do when you can't get a real job so to speak. Well, that’s what it was 30 years ago. It’s not so much now because the real jobs have contracted quite a bit and it’s very difficult, often, to get a staff specialist job and academic jobs are very few and far between. But being in a hospital is very, very useful because you learn to look after really sick people and you learn what it’s like to get on with other members of a team.

The difference is that you're sort of constrained in what you can do and if you ever want to buy a piece of equipment or something like that you have to go through an administrative process. Now, that’s fair enough and that suits some people but it doesn’t suit others. I wanted to do my own style of practice.

The other thing I thought was I could work here for a long period of time and then be stuck at this level forever more. And I wanted to go out and see a lot more patients and test myself against the market so to speak to see whether I was good enough.

MIC CAVAZZINI:               And you told the New Fellows that it was natural to feel a bit daunted by stepping out of the public system. Take us through some of those questions you can ask yourself to know when you're ready to get over that imposter syndrome, perhaps.

LOU MCGUIGAN:            OK. Well, if you're at a stage when you're a registrar and you go and see a consult and you think, “This is really hard, I'm not quite sure what's going on here.” And then your boss comes along and they find it hard too and you think well, “If I find it hard, and they find it hard,” —you're ready. You're up to the stage where you're good enough to be a consultant. Nobody ever knows everything but you’ve got to be wise enough to know what you know and what you don’t know, when to ask for help and where to get it. Don’t be put off by saying, I'll never be able to run money, I'll never be able to work out to get staff. You can always learn the business.

Now, you may not want to step out by yourself to start with, you may want to step out into a group, you may want to do some locums et cetera. But once you go out there and you think I like this flexibility, I like the fact that I can run my own business, I like the fact that I can do my own style of medicine, then you know you're up to it.

MIC CAVAZZINI: In making Pomegranate Health, often the stories of particular interest to me are those that reveal the expression of clinical practice is influenced by human biases and bigger systemic drivers. For example, the strange public-private patchwork that funds healthcare in Australia can unwittingly influence certain practices or behaviours. We heard in Episode 85 how disability funding through the NDIS is only available for autism of level 2 and above. The knock on effect of this is that paediatricians rarely give a diagnosis of ASD1 anymore when they think their patient needs assistance and there aren’t enough school-based supports out there as a safety net.

In Episode 56 titled “Billing in Byzantium” , lawyer and medical billing advisor Margaret Faux described how a few billion dollars at least are inappropriately billed to Medicare every year, a ‘leakage’ rate of 10 to 15 percent of total expenditure. Most of this inappropriate billing is not due to overt fraud, but simply confusion at the tangled thicket of legislation and item numbers that have grown in last 50 years since Medicare was created.

Once legal case study she unpacked in her doctorate was that of Dr Suman Sood, a GP abortion doctor who in 2006 was charged with 96 counts of Medicare fraud. She had bulk-billed a procedure while charging for additional services alongside it, which in theory breaks the rules of Medicare. But those rules are far from clear.

MARGARET FAUX: So, Dr Sood’s case just struck at the heart of some of the things I was investigating, so obviously, I went down that path and looked at it in a lot of detail. So, she was prosecuted and found guilty of criminal fraud. And what she did was she bulk-billed a termination of pregnancy, and on the same day, she, separate to that, charged a fee called a counselling and theatre fee. There was no question that the counselling took place. There were good records that the counselling services were being provided by appropriately-trained nurses and that they were doing their job well.

So the question for the court was they had to determine the meaning of three ubiquitous words in the entire scheme; “in respect of.” What is in respect of a professional service? Where does it begin and end? And if you don’t define it, you cannot assume.

MIC CAVAZZINI: Maybe we should spell out that in this case, the item number, 35643, talks about and only talks about “Evacuation of the contents of the gravid uterus by curettage or suction curettage.” Full stop.

MARGARET FAUX: Correct, Thank you. That’s it. Full stop. That is what it says. So on what basis will Dr Sood have thought that counselling is part of that, that the costs of running operating theatres is part of that? Now, what’s interesting about that, is that operating theatre costs have been charged separately in this country since the ’90s. That’s what health funds do and that’s a part of activity-based funding in the public system—it’s always separate.

I think that the outcome of that case has actually just made things a whole lot more confusing for us. And Justice Adams, who was one of the justices on the Court Of Appeal, dissented in the strongest terms as to the majority decision of the court, and he basically said, “You are asking doctors to interpret law, which they have neither the knowledge or skills or training to do, when even ex post facto, three Supreme Court Judges don’t agree”. And he said that it is unfair to put the doctors in that position and render them liable to criminal responsibility, particularly where there’s nowhere to go for them to find out the answer, prior to embarking on that course of conduct.

MIC CAVAZZINI: And so you and the dissenting appeals court judge have the opinion that by ruling against Dr Sood, it’s actually weakened the significance of those words—that anyone can actually trust what’s written down in black and white?

MARGARET FAUX: Correct. How can you trust what’s written down in black and white? In fact there is a lot of under-billing is something, a strong theme coming out of my PhD. A lot of doctors just are constantly reporting. They don’t claim things if they’re not sure, or they can’t be bothered, so there’s a lot of that. And what it does is it pushes doctors to not bulk bill too. Because they think “Well, I’m just not going to bulk bill, it’s too risky.” And that pushes up out-of-pocket costs. 

MIC CAVAZZINI: This theme of how billing influences practice also came up in Episode 69 about Gendered Medicine. The way that consultations are paid for by Medicare favours short appointments and quick solutions, which isn’t going to work for complex chronic conditions. Endometriosis is an example that sometimes has psychosocial drivers behind it has well as biological ones, but instead practitioners have more financial incentive to conduct one excision after another even after no further clinical benefit can be attained. My guest on that episode, Professor Zoe Wainer, who has published research on sex differences in the predictive value of oncological markers. In our conversation she explained how gender bias has affected the rigor with which clinical testing of pharmaceuticals takes place.

ZOE WAINER:    OK, so Stilnox, or Zolpidem as it’s known, is a sedative medication. In, I think it was 2014, in America, they undertook driver safety studies on it because they were noticing a pattern of people having car accidents after having had it previously, and they wanted to work out exactly what the half-life of it was and was it impacting. What they found in that study was that 12 and 24 hours afterwards women had almost twice the amount of Stilnox in their blood than men did. And so, effectively, they should be on half the dose. Which actually makes sense, because, if you think about it, it’s acting at similar receptors to alcohol, and we know there’s a different dose response in women with alcohol, so why wouldn’t there be with these drugs that act at the same receptors.

So, America put in place requirements that the companies actually change the recommendations for the dosage for women. Australia has not done that, and remains silent on it. So that for me is one interesting observation. And in fact, there was the tragic death of Phoebe Handsjuk in Victoria and the coroner’s case into that found that that was potentially a contributing factor. She had Stilnox in her blood and, had those recommendations been in place, that may have assisted in preventing that tragic death.

MIC CAVAZZINI:               Even aside from the specific pharmacokinetics of that particular drug, we know that women metabolise drugs differently and that’s been known for a long time. But there isn’t any regulatory requirement to test different doses and so on?

ZOE WAINER:    So, in the wake of Stilnox findings in America, the NIH has put in place a requirement for researchers to include equal numbers of male and female cell lines, or male and female animals, and they retrospectively put additional money into existing research projects to allow them to do that. We are not yet quite that strict in Australia. But the pushback I hear around research about it costs too much to double, because you have to effectively double the numbers to get appropriate population size to be able to disaggregate and compare. It actually costs an enormous amount to get a drug to market and have it fail based on complications based on negative side effects in women. And there is plenty of evidence to demonstrate that that’s exactly what happens. I think there was a study that showed that eight out of ten drugs to market at a certain point in time had to be pulled from market because of the negative side effects in women, and they had not disaggregated in their initial studies. So, I’m firmly of the belief that you need equal numbers of men and women and I think it’s to the point that we started off our conversation in terms of you actually need to understand the difference. It’s not about just understanding what happens in women and just understanding what happens in men.

The other one that comes to mind when you’re raising that is actually hip replacements and joint replacements. And several conversations I’ve had with companies about the fact that, of course, they adjust for size. But of course, in something like a hip it’s not about size, it’s actually about women’s anatomy and men’s anatomy is very different. We stand differently, we walk differently. And there are quite clearly documented more poor outcomes in women with certain hip replacements as a consequence of that because it actually erodes at the bone and doesn’t sit as well and function as well as it does in men. And I’m actually surprised the drug companies and device companies haven’t seen this as a marketing opportunity, to be a first mover in market to say we actually cater for both sexes. But they just don’t seem to have grasped that yet.

MIC CAVAZZINI: The first episode of that series on Gendered Medicine  was equally eye-opening. I spoke to Associate Professor Sarah Zaman, an interventional cardiologist who talked about the delays in diagnosis and treatment of myocardial infarction in women. And then in part 2 I had a conversation with deputy editor at the Guardian, Gabrielle Jackson about her provocative book Pain and Prejudice. This explores the idea that women’s subjective reports of pain get diminished by the centuries old trope of hysteria and also how shame around sexuality interferes with good health literacy.

Now we’re dipping into another domain of the Professional Practice Framework described as Health Policy, Systems and Advocacy. In 2022 I helped with a high profile campaign by the College with an episode I called “Healthcare in a volatile climate”. And of course, what bigger policy and systems issue have we faced in recent years than the COVID-19 pandemic.I tried to approach the issue from an angle that I hadn’t seen covered elsewhere in the media, so in episode 63 I asked an academic to score the global response to the initial outbreak through the lens of the International Health Regulations. This convention was supposed to guide surveillance, preparedness, and the implementation of trade embargos and border closures, but kind of went out the window in the panic. I followed that story with two somewhat bolshy episodes that instead looked at the way that free trade treaties, corporate capture and so-called “vaccine nationalism” might stand in the way of development and dissemination of vaccines and other drugs.

There are plenty of other great stories in the Pomegranate Health back catalogue you can browse by clicking on the Episode Archive at our website racp.edu.au/podcast. It’s even easier to search for specific terms using a pod browser app like Spotify, Castbox, Apple Podcasts, and so on. If you prefer YouTube, we’re now streaming from the College’s channel which has the handle @TheRACP or web address youtube.com/user/RACP1938. I really want to thank my colleagues Adoni Patrikios, Erin Gillin, Angie Ruperto and Abhilash Bajpai for getting this up and running, tidying up the webpage, and pushing the marketing on social media in recent months. As I mentioned last time, ten years of Pomegranate Health could only be possible with the support of many other College staff, and scores of physicians who have contributed as guests or reviewers. I’ve thanked as many as I can remember at the episode notes under the main webpage racp.edu.au/podcast.

I’ve said it before, it really is an honour to be able to showcase the talent and dedication that makes up the physician community in Australia and Aotearoa-New Zealand, to thousands of listeners around the world. According to download metrics Pomegranate Health ranks among the top ~7% or so of all 123,000 podcasts hosted on the Buzzsprout platform we use, which isn’t bad for little old RACP. I’d love to push it up into Joe Rogan territory though, so please keep sharing it with your friends and colleagues and send any feedback at all to the email address podcast@racp.edu.au. I’m Mic Cavazzini. I hope to hear from you.