MIC CAVAZZINI: Welcome to [IMJ On-Air] from the Pomegranate health studio. The Internal Medicine Journal and this podcast are brought to you by the Royal Australasian College of Physicians. I’m Mic Cavazzini, but your host today will be the IMJ’s subeditor for hepatology, Professor James O’Beirne. He’s Director of Gastroenterology & Hepatology at Sunshine Coast Hospital and Health Service and conducts his research through the University of the Sunshine Coast.
Before I hand over to him, let me give you an outline to today’s research paper, published online in October’s IMJ on the Hepatocare model for “Improving palliative and supportive care in advanced cirrhosis.” Median survival for patients with advanced cirrhosis is around 2 years and quality of life is poor. But these patients are rarely referred to palliative care services as shown in three different single centre studies from Canada and the USA published in the last decade. Among patients with cirrhosis who were removed from the transplant list, such referrals occurred variously in 11, 17 or 27 percent of patients. The Canadian researchers also found that for only 28 percent of patients had documentation regarding resuscitation orders.
It’s been speculated that hepatologists working towards a curative goal are uncomfortable bringing up the prospect of palliation. Meanwhile there is survey data from Californian liver transplant providers indicating that two significant barriers to referral were knowledge of appropriate criteria and a belief that such services were limited to end-of-life care. And as we’ll hear, there is also a significant resourcing issue; the availability of time in the liver clinics to start this conversation and then of palliative care physicians to meet the need.
The try and reduce these barriers, clinicians at Royal Brisbane Hospital developed a model they dubbed Hepatocare. Clinicians from the regular liver clinic would identify patients with deteriorating health and quality of life, usually with the insight of the Clinical Nurse Consultant most familiar with the patients.
The team would apply a modified version of the Supportive & Palliative Care Indicators Tool that included cirrhosis-specific indicators such as the existence of treatment-resistant ascites or hepatic encephalopathy persisting for more than 6 months; or a second episodes of variceal bleeding within 12 months. Those patients who met a threshold score were referred to Hepatocare, and the same nurse would continue to accompany a palliative care specialist on subsequent visits.
Over the year 2017, the model was piloted model in 30 consecutive patients to the liver clinic, and compared to a control cohort receiving standard of care who retrospectively would have met the Hepatocare referral criteria. The impact of the intervention was assessed on three outcome measures; first, whether this model of care did in fact increase the rate of referrals to palliative care in this patient cohort and advanced care planning. Second, whether participation in the program reduced incidence of unplanned admissions, length of patient stay and rates of polypharmacy. And finally, whether the referral criteria developed for Hepatocare effectively identified patients at risk of functional decline.
Today we’ll hear from palliative care physician Alison Kearney who was first author on the paper, hepatologist Richard Skoien who was principal investigator and clinical nurse consultant Olivia Cullen. But first, Professor O’Beirne tells us what prompted him to share this paper with the podcast audience.
JAMES O’BEIRNE: So I think I'll just start by saying that I'm delighted to be discussing this paper today. I've had a long interest in palliative care in the setting of chronic liver disease and, and you know, I remember probably more than ten years ago at the British Association for the Study of the Liver was the first time in the plenary session, I saw a paper presented about palliative care and liver disease. And I remember at the coffee break afterwards, a lot of physicians saying that this didn't really have a place in a modern liver conference because liver disease was all about saving lives and palliative care was not really something that was important. But it is important. It was a pleasure to handle this paper as the editor, and I'm delighted to welcome three of the authors of this paper. And we're going to discuss the finer points of both this paper and in the wider context of palliative care in the setting of cirrhosis and liver disease generally. So welcome, Richard, Welcome, Alison. And welcome, Olivia. So, Alison, first of all, congratulations on publication of this paper, which I think is in this month's edition of the IMJ. Can you tell me, why do you think the topic of specialist palliative care is so important in cirrhosis?
ALISON KEARNEY: Well, thank you, James. I'm Alison Kearney. I'm the Clinical Director of Supportive and Palliative care here at Royal Brisbane. The need for liver patients is clear to our team and, I think, to all of the workers here at Royal Brisbane. The patients are young they have a high symptom burden, they're very unpredictable in their trajectory. So we really felt that palliative care was not getting involved in a timely fashion to help these patients both with decision-making and symptom-management. So I really feel that this is a very important step forward in us providing care, especially for the patients who generally have missed out on a specialist palliative care service with non-malignant conditions. I think the teams are generally very comfortable at referring patients who have cancer which is not amenable to systemic or palliative treatment. But the great number of patients with cirrhosis who still have significant symptom burden were really missing out.
JAMES O’BEIRNE: Absolutely, I think we'd agree with that. And I just wondered if—we'll discuss the model of care that's described in the paper shortly—but just for the listeners, where do we start from? What do you think palliative care looks like in most places for patients with cirrhosis? Or what does it not look like, I suppose?
ALISON KEARNEY: Yeah, I think the before our project, it was pretty much being referred patients in the very last stages of life. So we were getting to see distressed families and patients who had days to live. And really, at that time, the impact of our service while we could afford them a good peaceful death, really the patients are not benefiting from any of the rest of what we would hope is good palliative care. Which as we know, is much more than just those last few days of life, we would really hope to work with treating teams to optimize patients who have significantly longer to live.
JAMES O’BEIRNE: Absolutely. You've described the need and you've described sort of what palliative care can offer. So Richard, can I turn to you and say that, how did the model development can you describe the model of care that’s illuminated in the paper for us?
RICHARD SKOIEN: Thanks, James, I'm providing the hepatologist perspective. I’m a staff specialist here at the Royal Brisbane Hospital. And in terms of the model of care, this was a quality improvement study and was looking at a model of care that we introduced to try to address some perceived deficiencies. And really, it was a sense—and if we go back over the last decade I'm sure you'll agree with this—we had a sense that everybody was working hard, and everyone was busy, and everyone's doing their best. And I think we were concentrated so much on doing the best we could for their liver diseases that we ignored the rest.
And many of my colleagues from interstate and overseas would agree that we thought we were doing a pretty good job of helping these people with very sort of complex diseases. But really, I had the sense that we weren't doing as much as we could, and as Alison has already said, we were regularly faced with patients who developed complications or had an unexpected death andd we hadn't involved palliative care at all for these patients. And I thought, we probably could be doing better than that. Many people are familiar with palliative care getting involved when it's time for dialysis to finish or oncological treatments that are the second or third line have run out and when patients really get to the stage where they have ceased to have effective treatments.
Liver disease is not really like that. We are constantly reacting to complications that occur. And as you know, some of those patients get admitted and that that last admission. And they have this unpredictable disease trajectory. So I wanted a model of care that would give patients support and give patients the opportunity as outpatients to make decisions about their lives and the care they would receive. But not lose sight of the fact that we were still actively treating these patients and many of these patients could be considered for transplant.
So it was having a an integrated multidisciplinary model that could run alongside and not particularly threaten the hepatologists who were doing their job. And that was a bit of a struggle, I’ve got to say, with our colleagues to try to get that on board. And as you've already said, many of our colleagues would think well, “you know, palliative care doesn't have a role in a chronic disease that we're trying to fix people”.
But yeah, so the model of care was a separate clinic that actually ran alongside and had a multidisciplinary team of a dedicated experienced palliative care physician, a highly experienced liver nurse who knew these patients well and then also a clinical pharmacist who could help with medications.
JAMES O’BEIRNE: Brilliant segue into the role of Olivia because you were the CNC in the model of care. And I have to say, my liver nurses are superb and I couldn't function without them. So it's really true that knowing the patients and knowing their needs is great. It brings a lot to the patient, they really appreciate it. But I'm interested your role within the clinic, you must have learned a lot about palliative care of patients, generally, I would imagine.
OLIVIA CULLEN: Yeah thanks, James. Hi everyone, I'm Olivia Cullen. I'm one of the clinical nurse consultants in the liver clinic here at the Royal. It’s been a wonderful experience for me to be involved in this model. And prior to the model, I realized that I was trying to do a lot of this work myself but didn't have the medical support. I was quite stressed. These patients had our contact numbers and would ring me and I'd be trying to liaise with the GPs or make community referrals myself. So this has just been a game-changer for us.
I think you're right, it doesn't always happen, but most of the patients have a pre-existing relationship with myself, especially the HCC patients, because that's a major role, I coordinate HCC treatments. And it's really invaluable, that pre-existing relationship, because it creates a really sensitive transition to palliative care. And I introduce the concept of Hepatocare long before we need to get there, so it doesn't come as –it's not a major shock when we're finally there. And they know that I'm there as well, so it's almost like they’re just coming to see me again. But. “Hello, here's my friend, Dr. Alison Kearney that I told you about”. And it works really well.
JAMES O’BEIRNE: You're the bridge, if you will, between one and the other. And you're right, sometimes when you make a referral to palliative care it does sometimes feel like you're cutting the umbilical cord sometimes. And we often keep people in clinic, conscious that as hepatologists we don't really have a lot to offer in that space. So I think you've eliminated really well the benefits of the model. But going back, Richard, to the types of patients, can you describe what the patients look like? What are the diseases and severities, et cetera?
RICHARD SKOIEN: Well, by definition, they all have what we call advanced cirrhosis. And this is a term that we’ve started to use more frequently to identify those patients who've got complicated cirrhosis. And we've traditionally classified this according to what their MELD score or the Child's-Pugh score might be. In terms of the patients who we studied, we had some selected criteria that were developed as part of his model of care. Now we had used modified criteria from a palliative care indicators tool that was already published. And I adapted those a little bit to make them a bit more clinically relevant to our patients. They have patients who have complications—recurrent complications or chronic complications of encephalopathy or recurrent variceal bleeding, infections like SBP, or progressive renal injury is another important one. But there was a holistic criterion that were used as well, which was just progressive disease despite optimal care and/or indication for transplant is there but they can't be transplanted for one reason or another.
The age wasn't particularly important, it was whoever met those criteria. So we could have some quite young patients or they could be older patients. The disease aetiologies would be variable, we didn't have a specific disease etiology in mind in terms of the cause of their cirrhosis. And we didn't have a cutoff really for patients in terms of Child’s-Pugh score or MELD, which would be traditional thresholds to get past to get onto to a palliative care referral. And I think that was mostly based on the fact that, that—two things; Firstly, before the model in those patients aren't typically referred even when they get quite advanced disease, and also patients who have lower scores can still have bad complications of disease. And it didn't seem to me that we were finding that it was just the patients with high MELD scores, who were dying or who needed the help of the supportive and palliative care unit. And that's certainly what our research found as well is that the MELD score or childcare score wasn't necessarily a predictor of whether they'd be alive in 12 months.
JAMES O’BEIRNE: Thank you. So Alison, all have you given a good idea of the need for this model of care and how it actually works. So what were the headline results? What did you find?
ALISON KEARNEY: Well, the study did show, first of all, that referral to palliative care didn't increase mortality. You know, a lot of people were concerned that when we referred patients that their prognosis would be very short, and perhaps we would be extra generous with prescribing, which would in fact lead to increased mortality. Tthat was not shown to be the case. We are certainly not suggesting for one moment that referral to our service would be a prognostic advantage, but at least we can say from this tiny number of patients, it was at least neutral. So that was one thing.
And the other thing was really about the rates of advanced care planning, which were poorly addressed in the business as usual model but really was one of the core tenets of our clinic to try and get decision makers, and some plans for where people wanted to be looked after as we got more unwell. Clearly, patients when they come in encehalopathic, who don't have a decision maker—that's a common problem in acute hepatology service—and we really tried to address that and get some resuscitation plans and advance health directives. And I think we were really quite successful.
The patients took a little while to get—I mean, that’s quite a confronting conversation for any patient. But I think having Olivia and her rapport and trust with the patient population and their families certainly helped for us to try to align patients’ expectations with what was actually feasible. And I think the other key thing was that we did manage to avoid excessive aggressive treatment at end of life for a lot of our patients. And you'll see that the death rate at home or in palliative care unit is significantly higher than for the business, the cohort population, where most of those patients sadly died in the acute setting. So I think, really, there was some really quite tangible outcomes. Other things that we did measure but which we haven't put in the paper were things like some quality of life and symptom assessment tools, but they're very small numbers. So we really did concentrate on those bigger, more measurable findings for the paper.
MIC CAVAZZINI: Not sure if I missed it, but did anyone at any point describe the number the patient numbers that the distribution of cohorts?
RICHARD SKOIEN: I think I mentioned that, that we had two consecutive cohorts or two cohorts of 30 patients, 30 consecutive patients presenting to clinic who were recruited for each cohort. The criticism but also, I think, a benefit of our study is that we used a historical cohort. And it really meant that we weren't biasing the management these patients are getting under standard of care. As I said, this study started out as a sense that we just weren't doing enough, and lo and behold, we found out that 20 percent of patients were being offered palliative care involvement, and those who were, it was often not meaningful in terms it was only added in the terminal admission in the last days of life.
So we a randomized control trial would certainly have been better, but it—I wasn't confident that seeing all the things I hoped Hepatocare would show that I, as a physician doing standard of care management wouldn't start embracing those things myself, which would have been good for our patients, but I think it would have, it would have overstated what our standard of care is really like. And what I wanted to see was, warts and all, what our standard of care management was, like for the for the year right up until we introduced Hepatocare.
JAMES O’BEIRNE: Well, I think you're right, retrospective control groups are always difficult. But I agree that doing a randomized trial of this model of care would be—I think, ethically, might be quite difficult on a number of levels.
RICHARD SKOIEN: Yeah, I only ever drafted it for ethics as retrospective control cohort and an intervention cohort. It was consented for those reasons. So I really felt that we were probably withholding good care for patients if we were if we were randomizing people to standard of care at that stage. I mean, I wouldn't think that the care that people were getting in the 12 months up to Hepatocare’s introduction would have been any different if you're if you're working in Brisbane or in Sydney or Melbourne or indeed overseas.
JAMES O’BEIRNE: Absolutely. And Olivia, you'll probably be able to speak to this, I guess, because—we we're very good, I think, in hepatology clinics in dealing with ascites and encephalopathy and things like that. And increasingly, I will ask people about meaningful things like sleep, cramps, fatigue. These are sort of things that often are glossed over in a busy medical consultation. But, can you talk a little bit more about this global symptom assessment that takes place in the palliative care setting?
OLIVIA CULLEN: Yeah, so, first of all, we run the clinic altogether. So it's run on a Wednesday morning, we see five to six patients. And myself, Alison and our clinical pharmacist all sit in on the clinic. We certainly do address sleep, cramps, itch, nausea, pain, mood, appetite. And I say to them, “if we could fix one thing today and make your life better, what would that be?” And that, kind of, starts off to get into a discussion about what's really worrying them at a time.
JAMES O’BEIRNE: Yeah, as hepatologists, or maybe I'm just speaking for myself, but I don't often ask questions I can't answer. Certainly with fatigue and sleep issues where I don’t have a lot of tools in my in my box for that. So it tends to get glossed over and so I think this is really, really important for holistic patient care, to be honest.
OLIVIA CULLEN:: Yeah, we're very honest with the patient—so there's many things we can't solve. But we have a lot more time in this clinic to be don't having a busy hepatology clinic. They're not rushed, they're not under pressure. There's plenty of time to sit, the family have very encouraged to join the patient. It's as much looking after their loved ones as it is the patient themselves. And it's just a feeling—I see these people come in, especially to the first encounter, very stressed, very emotional, and we know when they leave, I can see a noticeable change in that person. There's a light heartedness when they walk out, and I can visibly see that we've reduced some fear and anxiety.
JAMES O’BEIRNE: Richard, you wanted to add something there?
RICHARD SKOIEN: Yeah, I just, I just think the flip side of that—and I'm sure you've, experienced this as well, James—is that dealing with all these problems in a liver clinic, when you dealing with other things (a) there's not the time and I think people often perceive they don't have the skills to do this. And I think we sometimes feel guilty and bring people back more frequently than we can actually do much for them, because we feel we can't do much about those other symptoms, and Hepatocare was a really great way of dealing with that. Knowing that a large burden of problems that patients find really important, as Olivia has just said, are actually being directly addressed.
And we were also conscious of the fact that we didn't want the palliative care part of the patient's care to be confronting and, and coming up against in conflict with hepatology care. And we and this model allowed us to be quite flexible, so when patients are doing quite well, but they've got really important liver-specific complications that we're treating, they come into the clinic more frequently to see me. But when from the lver side of things they're doing about as well as I can manage them, but they've got these other issues, they might see the Hepatocare team more frequently. And it just meant that our unit was able to use its resources much more effectively as well.
JAMES O’BEIRNE: And do you think that flexibility and that communication and addressing the whole of the patient pathway and problems is what translated into the, let's be honest, a quite massive reduction in unplanned admission days?
RICHARD SKOIEN: It's a little bit hard when you have a retrospective control cohort that that's, that's an admitted problem. But there was a reduction. We've done a further analysis a couple of years down the track with one of our fellows and we found actually, the admission days and inpatient bed days reduced even further. So, I think you're right, I think we actually got a bit better at working out when patients had interventions or other operations or admissions that they wouldn't need or wouldn't be a benefit for them. But also just the perspective that we're able to feed back to treating teams about where this person's disease is at and the fact that they are being well-managed and handled and supported in an outpatient setting. So they didn't need to spend all this extra time in hospital.
JAMES O’BEIRNE: And I just wanted to get down into some of the nitty gritty of the paper and just some questions that came out when I was when I was reading it. There was a relatively low level of patients with alcohol-related liver disease who were currently drinking in the cohort. Was there a reason for that or was it just a quirk?
RICHARD SKOIEN: Yeah it’s an interesting observation because what you would think that this cohort would be fairly advanced and they're back to drinking again, to be so advanced—we didn't find that. You know, I think the percentage of ongoing active alcohol use was in of teens less than 20 percent. It was quite similar between the two groups, the control cohort and the and the intervention cohort. But one of the explanations was, these were consecutive patients, we didn't select the patients other than those on a consecutive basis who actually met criteria, we wanted to be an unbiased view of 30 consecutive patients in each group. And it just happened to fall out that way. But hopefully, what it also says is that our teams are relatively good at trying to adjust those modifiable risk factors as best we can. And yet the patients still have quite advanced disease despite that intervention with a majority not drinking, not having active ongoing alcohol use.
JAMES O’BEIRNE: And talking about compliance, one of the things that I thought was really interesting was you had a pharmacist in your clinic. The role of deprescribing, which I think is one area of the modern management of hepatology where we really need to focus on because maybe you can remember or remind me what was the average number of medications that these patients will take.
ALISON KEARNEY: There was an awful lot of polypharmacy in this patient cohort. 25 of between 27 had polypharmacy and hyper polypharmacy was in 20 of the 27 with a median of 13.5 medications taken by patients when they were referred to our clinic. So there was a significant interactions and pill burden experienced by these patients. And we were able, with the help of our pharmacists to, offer advice regarding deprescribing. Clearly that is an area which can be difficult, and we would always try to consult with their treating hepatologist and the GP, regarding deprescribing.
And some patients were super keen, were very keen to try and minimize the amount of medicines they were taking. Whereas others were reluctant because they had been told these were essential, lifelong medications. But I think within encouragement and discussion and weaning of medications we were able to show that deprescribing could be done safely and effectively.
JAMES O’BEIRNE: And again, it's one of those things that really feeds into what you were saying about having time in the clinic, because it certainly takes less time to prescribe a medication than to deprescribe a medication. So I think that was one of the major facets of the model of care and one which I've struggled with in the outpatient department when I've tried to deprescribe. It's sometimes a longer conversation than you have time for. So, congratulations on that. I noticed that one of the relatively commonly deprescribed drugs as beta blockers. And I wondered for people who manage patients with cirrhosis, how you how you manage that sort of tension between getting rid of a medication, which is often difficult for people to take in terms of side effects, versus the risk of bleeds or whatever with the prescribing the beta blocker.
ALISON KEARNEY: Yes, deprescribing the beta blocker was often one of the more controversial discussions that we would have. And certainly we were declined by a hepatologist on a few occasions that we thought would be helpful for issues with fatigue and postural hypotension. But I think at end-stage cirrhosis when patients are having so many troubles with self care and blood pressure dropping and falls, we really do reach a time where ongoing beta blockade is not helpful, especially when patients are having renal impairment as well. I think that's really the turning point that we really need to think what are we actually achieving by continuing to suppress that axis.
JAMES O’BEIRNE: Richard, you want to make a comment?
RICHARD SKOIEN: Yeah, and it's worth noting that, that beta blockers were only ceased in seven of the patients and I guess in patients, as Alison says, they've got refractory ascites, and kidney injury. And this is a study cohort from 2017. It's not uncommon for us, these days, in those patients to fairly routinely cease beta blockade and in those patients. And so to some extent, perhaps we were catching up, the palliative care were setting the pace in terms of stopping medications that were harmful in those patients. But it was always done on a case-by-case basis and I think it's an important part of the model.
JAMES O’BEIRNE: So I'm going to be fairly challenging the address the elephant in the room. You're clearly very lucky to have somebody like Alison who's interested in palliative care and cirrhosis. And, you know, our palliative care team locally, and I'm sure around the country also want to help but they're really busy. You know, I would love to have a model of care like this for the patients here on my hospital. But frankly, it's not feasible. So how can we—what can we do? Olivia, you've clearly learned a lot about how to manage this patient group. So is this a role for hepatology CNCs? Should they be trained in palliative care and advanced care planning?
OLIVIA CULLEN: Yeah, James, I really think they could be an excellent job for a nurse practitioner for sure, with some sort of minimal contact with the specialists maybe once a week where you could run things by them.
ALISON KEARNEY: And so if I can just add, I am employed by the Department of Gastroenterology. So this is supernumerary to my palliative care time. So I think that is an important part of the model is that I'm paid two sessions a week by gastroenterology. So it's not detracting from my other palliative care work, that's just a part of the model.
JAMES O’BEIRNE: Perfect, I'd actually, I'd wonder whether you're going to do some cost effectiveness, because if you're reducing bed occupancy days, then it's a worthwhile investment, I would imagine, and I'm thinking about how you might roll this model out more widely.
RICHARD SKOIEN: So there are two issues and that the first is, you know, how do you actually pay for that? And if the experience is replicated in other units you can generate money to allocate to these sorts of services. As Alison says, the business case was made for money in the budget, in the gastroenterology budget to pay for her sessions on the basis of cost savings. It started out with seed funding, just to employ Allison for the for the year.
The second thing is, do you have enough palliative care physicians or do you have a locally employed palliative care physician in your hospital who could spare a session. That's the other issue and that's something that is a bigger conversation that Alison might like to comment on in terms of training numbers and in the place of palliative care in hospitals these days. But certainly, we had to take a hiatus after this pilot program of about a year where the Heaptocare clinic had to stop, because we had to make the business case to then reemploy Alison.
MIC CAVAZZINI: Can I just pick up on that business case? And actually to flag that figure in the paper that you made a savings of your estimated savings of $800 per bed day. So who's seeing that? That's the gastroenterology department that’s seeing that, and is it the gastroenterology department that then has to decide whether to invest that in a palliative care specialist?
JAMES O’BEIRNE: If only it were that simple, Mic.
MIC CAVAZZINI: In terms of suggesting to listeners how to make this argument within—you know, which administrators are you making the business case to and how to draw the bow together?
RICHARD SKOIEN: Yeah, it's a complicated discussion. But the first step is show how many bed days you're using under your current standard of care management, and then show what you can be using. And then I think we're bound to replicate the analysis to see that we're still having those ongoing benefits. But obviously, this is a hospital-wide discussion where the people who are paying for the beds actually have to be involved. It's a discussion with your unit itself to see where you’re allocating money in the budget, and so we think that's worthwhile? But it affects everybody from emergency all the way through to sort of discharge planners.
JAMES O’BEIRNE: I've always thought in my in my head that if you were training the hepatologist of the future they should do two sort of modules. One in intensive care and one in palliative care. And I think there are a lot of models around the world where intensive care trainees have to spend some time in palliative care to sort of—you know, these are transferrable skills, which we'll be using every day in the management of our patients.
RICHARD SKOIEN: There was an interesting survey of liver transplant fellows in United States who almost universally recognized they felt completely underskilled in the prescription of analgesics for patients and also having discussions about advanced care planning with patients. So it's a huge area of need. Many of the other models in in this area trying to fit palliative care into hepatology have looked at training existing staff in palliative care. And those models have had variable success. I think if you're lucky enough to have someone like Alison, in your hospital then that, I think, is optimal, because you have the ability to prescribe and the specialist skills that that someone like Alison brings to the clinic.
But having a multidisciplinary team and having experience with the nurses as the as the nexus between all those different services, I think is critical and certainly there’s a lot of skills that that have rubbed off on hepatologists as well as other members of the team in gastro that we're now able to employ. And I think in terms of inpatient care as inpatient teams, we are better at managing these patients. You know, it's almost universal that patients who are admitted routinely will have an resuscitation plan in place at the time of their admission, even if we're not expecting that to happen. Because things unfortunately do.
MIC CAVAZZINI: Many thanks to Alison Kearney, Olivia Cullen and Richard Skoein for sharing their fantastic work with us. Thanks also to James O’Beirne for contributing to the podcast on top of his editorial work at the Internal Medicine Journal. Members who donate their time like this are the life and blood of the Royal Australasian College of Physicians.
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This podcast was produced on the lands of the Gadigal people of the Yura nation. I pay respect to their storytellers who came before me and wish you a restful Gooray’murrai. In Darug language this refers to the warm and wet season we associate with November and December. I’m Mic Cavazzini, thanks for listening.